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Fatal cases of animal-mediated human rabies: Looking beyond sectoral prism to One Health
Authors: Folorunso Oludayo Fasina
Number of views: 195
This issue of Asian Pacific Journal of Tropical Medicine has
published a case report[1]. This report detailed an atypical fatal
case of fox-mediated human rabies. It once again reemphasized
the importance of zoonotic disease transmission by animals
(including wildlife), and a need to look introspectively in order
to consider innovative solutions aimed at reducing the burden of
zoonoses. Rabies continues to significantly impact human lives,
particularly in the Asian and Africa regions where fatal dogmediated
rabies in humans accounts for 96% of total rabiesassociated
global death annually (> 59 000)[2]. In the current case,
a fox (Vulpes vulpes) had attacked a man in a farm area in Qom,
Iran, inflicting injuries in the head and palms. The patient only
sought wound dressing without the necessary follow-up postexposure
prophylaxis. Ultimately, death supervene despite all
effort at late recovery[1]. This brings to focus the importance of
targeted but intense community awareness campaign on rabies
and other zoonoses, especially with regards to preventive and
mitigation measures that can reduce zoonotic burdens in atrisk
communities. Such activities have been tested with positive
outcomes in Moshi, Tanzania and elsewhere[3, 4].
Although Qom is a metropolis, south of Tehran, and it is the
seventh largest city in Iran with a human population of over 1.2
million, the Qom Province has four other cities. Perhaps these
cities may not be predisposed to cases of wildlife associated rabies
except in rare cases of stray wildlife. However, all other human
habitations in the province are classified as villages. It is a fact
that villages are suitable interfaces for human-wildlife-domestic
animal interactions. The wild cats, hyenas, wolves, jackals, desert
foxes and foxes (all potentials reservoirs for Rabies lyssavirus),
are among the rich fauna of Iran, inclusive of, in the low plain of
Qom[5], and these animals may likely be involved in territorialrelated
human-animal and wildlife-domestic animal conflicts.
Although, sources of aggression may include provocation,
entering the animal protected territories, possessiveness, response
to a painful injury, fear, maternal instinct, pursuant of prey, or
rabies-associated aggression[3], in the current case, the cause of the
fox attack was not stated. Based on reports, dog-mediated rabies
had predominated in Qom and other parts of Iran, but this should
not exclude the possibility of other forms of rabies transmission.
The current atypical case of fox bite associated rabies puts into
perspective, that other forms of rabies transmission, not dogmediated
rabies, is likely to happen. This present case should
elicitate more investigation on potential causes of human deaths,
especially when symptoms suggestive of rabies exist, even in the
absence of histories of dog bites. Perhaps, cases of atypical human
rabies have been underreported in previous circumstances.Previous work had mapped rabies at the human-dogs-wildlife
interface[6], and at such interfaces, control of zoonoses are
often complicated and complex. Interface communities should
be targeted for intense awareness campaign, mass vaccination
of domestic animals, the restriction of domestic dog-wildlife
interactions, movement control of reservoir populations (wildlife)
through barriers and other similar control measures[3, 6]. Where
cost associated with these measures overburden the subnational
government, subsidy system from the national authorities should
be instituted or portions of the eco-tourism funds should be
redirected at such measures.
Combating infection at source remains one of the best approach to
rapidly prevent escalation of infection, effectively detect pathogens
and efficiently respond to and curtail outbreak situations. Given
that health service deliveries are often delayed at subnational
levels (villages, wards and rural areas), these locations most times
also double as interfaces where the vast majority of rabies-related
morbidities and mortalities occur in Asia and Africa[2]. To achieve
the objective of timely and efficient delivery of health services
while at the same time utilizing cost-effective options, local public,
animal and agro-environmental health authorities need to define
One Health working arrangements that facilitate coordination,
communication and collaborations[7]. Institutionalizing such
platform at subnational levels should benefit the national health
systems and reduce the burden of zoonoses.
It is established that dogs account for up to 99% of all cases
of human rabies[2]; and with over 59 000 annual human deaths
related directly to rabies, an associated loss of 3.7 million DALYs
(disability-adjusted life–year: productivity losses due to mortality
or morbidity) and an estimated annual global economic cost of
dog-mediated rabies of US$ 8.6 billion (95% confidence interval,
2.9–21.5 billion)[2, 8], it is cost effective and discerning for nations
to implement carefully designed effective dog and cat vaccinations
annually to reduce the burden of human rabies and proceed
towards elimination target set for the year 2030[3,4,8].
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