Epidemiological and clinical features of human rabies cases in Bali 2008-2010

Abstract

BackgroundPreviously thought to be rabies free, Bali experienced an outbreak of animal and human rabies cases in November 2008. We describe the epidemiological and clinical data of human rabies cases occurring in the first two years of the outbreak.MethodsWe analysed the patient records of all rabies cases from the Sanglah General Hospital in Denpasar, and district hospitals in Buleleng and Tabanan. A conventional reverse transcriptase polymerase chain reaction was developed to detect the rabies virus genome in saliva, corneal swabs, and ante- and post-mortem cerebrospinal fluid (CSF).ResultsThere were 104 human rabies cases in Bali during November 2008-November 2010. Patients' mean age was 36.6 years (range 3-84 years; SD 20.7), most were male (56.7%), and originated from rural districts. Almost all (92%) cases had a history of dog bite. Only 5.8% had their wounds treated and received an anti-rabies vaccine (ARV) after the bite incident. No patients received rabies immunoglobulin (RIG). The estimated time from dog bite to the onset of signs and symptoms was 110.4 days (range 12-720 days; SD 118.2). The mean length of medical care until death was 21.8 hours (range 1-220 hours; SD 32.6). Less than 50% of patients had prodromal symptoms. The most frequent prodromal symptom was pain or paraesthesia at the bite site (37.6%). The two most common central nervous system infection signs were agitation (89.2%) and confusion (83.3%). Signs of autonomic nervous system dysfunction included hydrophobia (93.1%), hypersalivation (88.2%), and dyspnea (74.4%). On admission, 22 of 102 patients (21.6%) showed paralytic manifestations, while the rest (78.4%) showed furious rabies manifestations. The case-fatality rate was 100%. The rabies virus genome was detected in 50 of 101 patients (49.5%) with the highest detection rate from post-mortem CSF samples.ConclusionsRabies is a major public health problem in Bali. Human fatalities occur because of a lack of knowledge regarding rabies risk, the poor management of dog bites, and the limited availability of RIG. Increasing public awareness of dog bite management, increasing the availability of ARV and RIG, and implementing an island-wide dog vaccination campaign will help prevent human rabies cases.

Human rabies: a descriptive observation of 21 children in Kinshasa, the Democratic Republic of Congo

“…This period was found to be similar to those described. 9,10,29 The signs and symptoms reported in this study were found to be similar to those described elsewhere.…”

“…Dogs have the main role in the transmission of the disease to humans as found in developing countries. 9,10,12,[21][22][23][24] Exposure in 19 cases (90.5%) was by stray dogs; similar to the situation reported in Ivory Coast.…”

“…Our result is similar to those reported in developing countries. 9,11 Pre-exposure prophylaxis with rabies vaccine has been recently recommended by WHO for children living in highly endemic regions. 27 This study shows that most children suffering from rabies did not receive proper first aid, rabies vaccination, or passive immunization post-exposure.…”

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“…In 2002, a patient developed rabies after exposure to a bat, the only case acquired in the United Kingdom in over a century [5]. In Canada, six of eight cases identified nationally since 1970 have been attributed to infections with rabies strains associated with bats [6].…”

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“…However, studies in the U.S. and South Africa have reported that the common anatomical site for dog bite injuries in children >6 years is to the lower limbs. 10,11 Ni M Susilawathi 9 et al study bites were most common in the lower extremities (59.3%), followed by the upper extremities (37.2%) and the head and neck (3.5%). Single bite cases were more frequent (72.9%) than multiple bite cases (27.1%).…”