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Letters |
1 Rabies and Wildlife Zoonoses Group, WHO Collaborating Centre for the
Characterisation of Rabies and Rabies-Related Viruses, Veterinary Laboratories
Agency - Weybridge, Woodham Lane, Surrey KT15 3NB
2 Institute of Virology, National Advisory Laboratory for Rabies, University
of Duisberg-Essen, Hufelandstrasse 55, D-45122 Essen, Germany
SIR, - Rabies is a fatal viral infection, usually acquired from a dog bite. Despite efforts in many regions, the virus remains endemic in urban dog populations throughout the world. By contrast, the UK has been free of terrestrial rabies since 1902, with a short period following the First World War when dog rabies was reintroduced. However, this has not resulted in a total absence of human rabies.
Since 1902 there have been 26 reported cases of human rabies in the UK (for details see Table 1). Of these, 24 resulted from infection while abroad. The two exceptions being a case from 1902, reported shortly before rabies was eliminated, and a rare case of rabies caused by infection with European bat lyssavirus type 2 (Fooks and others 2003b), which was probably caused by a bite from an indigenous bat. Where data are available, the median age of those infected abroad is 35 years old, with 68·4 per cent (n=13) being male. Furthermore, current molecular techniques enable epidemiological investigation of the infecting virus, which can support the evidence provided by the case history on the source of the infection (Johnson and others 2002, Smith and others 2003). The most significant observation from this group is that the majority of cases (16 of 26) resulted from dog bites in the Indian subcontinent (India, Pakistan and Bangladesh). For the UK, postcolonial migration and the emergence of this region as a holiday destination has resulted in rabies cases among foreign nationals visiting the UK and UK citizens who have visited the region often for very short periods. This is illustrated by the most recent report of a 37-year-old woman who was bitten by a dog while on a two-week holiday in Goa (western India). Postexposure prophylaxis, which would normally comprise antirabies immunoglobulin and vaccination, was not administered. Three-and-a-half months after returning to the UK the victim developed rabies and died in 2005 (Solomon and others 2005). A current public health challenge is to maintain awareness of the risks of rabies during foreign travel (Fooks and others 2003a).
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Like the UK, Germany has experienced cases of rabies acquired from travel to the Indian subcontinent (Table 1). Between 1981 and 2004, five rabies cases were reported, two of which were caused by bites from a dog and a fox within Germany itself. The three other cases were from dog bites received in India, also from a visit to Goa, and Sri Lanka (Ross and others 1997, Summer and others 2004). A sixth case occurred in December 2004, although at the time of death, rabies was not considered as the cause. The patient, a 26-year-old woman, was considered suitable as an organ donor. Six individuals received organs from the patient (lung, kidney, kidney/pancreas, liver and both corneas). Subsequently, three recipients developed encephalitis within six weeks of the transplant and died, with rabies confirmed by laboratory diagnosis as the cause of death. The patient who received the liver was given immediate postexposure prophylaxis and survived. The two recipients of the corneas were also treated and the grafts removed. Retrospectively, rabies was diagnosed in the donor from fixed brain samples and a history of a dog bite confirmed during a visit to India in October 2004. This incident followed a similar case in the USA earlier in 2004 (Srinivasan and others 2005).
Rabies, especially through contact with dogs, remains a risk to UK travellers in many regions of the world. Pre-exposure vaccination against rabies is highly effective and those who intend to travel to rabies-endemic areas should seek advice on the risks of exposure and the need for vaccination. The importance and effectiveness of thorough wound cleaning, irrespective of how trivial the exposure might seem, must be emphasised. This should always be accompanied by appropriate postexposure prophylaxis, even if the individual has been vaccinated against rabies. Finally, there is a constant need to raise awareness among clinicians to consider a diagnosis of rabies where a history of a dog bite and foreign travel, especially to Asia and Africa, is presented.
FOOKS, A. R., MCELHINNEY, L. M., POUNDER, D. J., FINNEGAN, C. J., MANSFIELD, K., JOHNSON, N., BROOKES, S. M., PARSONS, G., WHITE, K., MCINTYRE, P. G. & NATHWANI, D. (2003b) Case report: isolation of a European bat lyssavirus type-2a from a fatal human case of rabies encephalitis. Journal of Medical Virology 71, 281-289[Medline]
JOHNSON, N., LIPSCOMBE, D. W., STOTT, R., GOPAL RAO, G., MANSFIELD, K., SMITH, J., MCELHINNEY, L. & FOOKS, A. R. (2002) Investigation of a human case of rabies in the United Kingdom. Journal of Clinical Virology 25, 351-356[Medline]
ROSS, R. S., KRUPPENBACHER, J. P., SCHILLER, W-G., MARCUS, I., KIRSCH, W-D., WIESE, M., ADAMCZAK, M. & ROGGENDORF, M. (1997) Menschliche Tollwuterkrankungen in Deutschland. Deutsches Arzteblatt 94,A-34 -A-37
SMITH, J., MCELHINNEY, L. M., PARSONS, G., BRINK, N., DOHERTY, T., AGRANOFF, D., MIRANDA, M. E. & FOOKS, A. R. (2003) Case report: rapid antemortem diagnosis of a human case of rabies imported into the UK from the Philippines. Journal of Medical Virology 69,150 -155[Medline]
SOLOMON, T., MARSTON, D., MALLEWA, M., FELTON, T., SHAW, S.,
MCELHINNEY, L. M., DAS, K., MANSFIELD, K., WAINWRIGHT, J., KWONG, G. N. &
FOOKS, A. R. (2005) Paralytic rabies after a two week holiday in
India. British Medical Journal
331,501
-503
SRINIVASAN, A., BURTON, E. C., KUEHNERT, A. J., RUPPRECHT, C.,
SUTKER, W. L., KSIAZEK, T. G., PADDOCK, C. D., GUARNER, J., SHIEH, W. J.,
GOLDSMITH, C., HANLON, C. A., ZORETIC, J., FISCHBACH, B., NIEZGODA, M.,
EL-FEKY, W. H., ORCIARI, L., SANCHEZ, E. Q., LIKOS, A., KLINTMALM, G. B.,
CARDO, D., LEDUC, J., CHAMBER-LAND, M. E., JERNIGAN, D. B., ZAKI, S. R. &
RABIES IN TRANSPLANT INVESTIGATION TEAM (2005) Transmission of
rabies virus from an organ donor to four transplant recipients. New
England Journal of Medicine 352,1103
-1111
SUMMER, R., ROSS, R. S. & KEIHL, W. (2004) Imported case of rabies in Germany from India. Eurosurveillance Weekly 8. www.eurosurveillance.org/ew/2004/041111.asp#4. Accessed November 22, 2005
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