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Reemerging Rabies and Lack of Systemic Surveillance in People's

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Reemerging Rabies and Lack of Systemic Surveillance in People's Reemerging Rabies and Lack of Systemic Surveillance in People’s Republic of China Xianfu Wu, Rongliang Hu, Yongzhen Zhang, Guanmu Dong, and Charles E. Rupprecht Rabies is a reemerging disease in China. The high in- of the disease began only after 1885, with Louis Pasteur’s cidence of rabies leads to numerous concerns: a potential discovery of postexposure vaccination against rabies. In carrier-dog phenomenon, undocumented transmission of the 1930s, a rabies virus (RABV) 3aG strain was isolated rabies virus from wildlife to dogs, counterfeit vaccines, vac- in Beijing and was eventually developed into a vaccine for cine mismatching, and seroconversion testing in patients human immunization. In the 1950s, another RABV strain after their completion of postexposure prophylaxis (PEP). (CTN) was isolated in Shandong Province and was charac- These concerns are all scientifically arguable given a mod- ern understanding of rabies. Rabies reemerges periodically terized and attenuated as a vaccine for humans. However, in China because of high dog population density and low to date, no dog RABV isolates in China have been devel- vaccination coverage in dogs. Mass vaccination campaigns oped into animal vaccines. Few domestically licensed vac- rather than depopulation of dogs should be a long-term cines for animal rabies exist, according to the Regulations goal for rabies control. Seroconversion testing after vacci- for Veterinary Biologics in China (www.ivdc.gov.cn). The nation is not necessary in either humans or animals. Human disconnection between human and dog rabies in China re- PEP should be initiated on the basis of diagnosis of biting flects a lack of awareness of the concept of one medicine, animals. Reliable national systemic surveillance of rabies- or health without regard to species, in approaches to rabies related human deaths and of animal rabies prevalence is control in the public health system. urgently needed. A laboratory diagnosis–based epidemio- Although great progress has been made internation- logic surveillance system can provide substantial informa- ally in rabies control and prevention, >55,000 persons tion about disease transmission and effective prevention strategies. still die of rabies annually worldwide. In China, at least 108,412 persons died of rabies from 1950 through 2004 (3). A rabies epidemic occurs every 10 years in China (4). he record of rabies in Chinese history dates back to 556 Despite high human mortality rates, only ≈30 rabies virus TBC in Master Zuo’s tradition of the Spring and Autumn isolates have been recorded and partially characterized by annals. He wrote, “In the eleventh month, people in the cap- sequencing (3,5,6). Therefore, human rabies is mainly re- ital of Song were chasing a rabid dog. It entered the house ported without confirmatory laboratory diagnosis in most of Hua Chen” (1). Sporadic descriptions of overt clinical of China. Few statistics are available for dog rabies, indi- signs of rabies can be found in records of various ancient cating that a diagnosis and surveillance system for animal civilizations (2). However, robust scientific investigation rabies is not fully functional. Obvious inconsistencies exist in published results of human rabies diagnosis (6). China Author affiliations: Centers for Disease Control and Prevention, At- is now facing another wave of rabies outbreaks resulting lanta, GA, USA (X. Wu, C.E. Rupprecht); Academy of Military Medi- from the combined consequences of rapid economic devel- cal Science, Changchun, People’s Republic of China (R. Hu); Chi- opment, a profitable domestic pet industry, and continuing nese Centers for Disease Control and Prevention, Beijing, China family planning, resulting in increased numbers of family (Y. Zhang); and National Institute for the Control of Pharmaceutical pets. Reemerging rabies in China has led to a carrier-dog and Biological Products, Beijing (G. Dong) myth, strict pet population control policies, counterfeit vac- DOI: 10.3201/eid1508.081426 cines (low antigen, generating <0.5 IU of virus-neutralizing Emerging Infectious Diseases • www.cdc.gov/eid • Vol. 15, No. 8, August 2009 1159 PERSPECTIVES antibodies after administration), vaccine matching, se- result in neurophysiologic dysfunction. Also, virus persis- roconversion testing with an ELISA after completion of tence generally is life-long in infected hosts. The longest postexposure prophylaxis (PEP) in humans, virus–neutral- surviving presumed carrier dog lived for only 16 months; izing antibody titration in vaccinated animals because of in this dog, the tonsil was found to be the only organ from inferior vaccines, and other related issues. We discuss these which the virus was isolated (14). No data are available issues and suggest a new approach to prevention and con- concerning how long such carrier dogs survive. In healthy trol of rabies when the disease reemerges in an unprepared vampire bats, the duration of salivary excretion of RABV country like China. was reported to be 690 days after infection by an extremely high dose of RABV (8). Generally, persistent infections are Carrier or Asymptomatic Rabies characterized by an excess of viruses or virus antigens; free Typically, rabies is fatal once clinical signs develop. antibodies, which circulate without binding to antigens, Although persistent infections occur regularly for other vi- are difficult to detect. However, experimental carrier dogs rus infections, they have not been documented unquestion- and vampire bats presented high rates of virus-neutralizing ably in rabies, mainly because of the added complexity of antibodies in serum in these reports (8,14). From an evo- the disease’s relatively long incubation period. The carrier lutionary perspective, a carrier dog with normal behavior or asymptomatic rabies state was once considered to be im- does not pose an advantage for virus survival because bit- portant for public health, despite lack of adequate evidence ing when an animal is controlled by an aggressive brain is that the phenomenon actually exists. This concern has been the only major route for RABV to spread. Animal behavior raised repeatedly from the early 1930s until recently (7). change is fundamental for RABV survival/transmission. Reported carrier hosts have included vampire bats (8,9), Therefore, if carrier dogs exist, they are inferior to rabid cats (10), dogs (11–15), and hyenas (7). Because rabid dog dogs for disease transmission. bites are responsible for ≈99% of all human rabies cases in In a report by Zhang (17), 15 dogs that were diagnosed the world (16), the possibility of a carrier state or asymp- as positive by ELISA were confirmed to be negative by the tomatic form of canine rabies deserves serious evaluation. standard direct fluorescent antibody (DFA) method. Expla- Unfortunately, this possibility remains highly speculative. nations for these contradictory findings include misidenti- Although some investigators have questioned reports of a fication of infected dogs, detection of RABV early in the carrier state in dogs (17), an author reported RABV isola- prodromal course once it has reached the central nervous tion from brains of healthy dogs (6). Carrier dog RABV system after infection and incubation, and inadequate diag- isolates were even characterized at the molecular level in nostics. These phenomena, rather than the existence of car- 1996 (15). rier hosts, may explain historical reports of asymptomatic Similarly, reports of healthy-dog carriers were con- rabies in enzootic areas. secutively published in China in 1982 (18), 1999 (19), 2006 (20), and 2007 (21). Tang found that 5 (1.76%) of Rabies Diagnosis in China 283 healthy-looking dogs in Guangxi province were posi- A well-established surveillance system for infectious tive for RABV by reverse transcription–PCR (RT-PCR) diseases depends on reliable, laboratory-based diagnostic and virus isolation (5). Another study showed that 24 of 42 methods. Human and animal rabies cases in China have RABV isolates were taken from dogs or cats classified as been reported mainly on the basis of clinical presentations clinically normal (3). All animals from these studies were and retrospective epidemiologic surveys. Animal rabies is from areas experiencing rabies epidemics. rarely diagnosed in China. Human rabies diagnosis based All cumulative convincing data for more than half a solely on clinical symptoms is unreliable because human century from various parts of the world call into question rabies can be confused with Guillain-Barré syndrome, po- either the concept of a rabies carrier state or the quality liomyelitis, and other types of encephalitis (23). Similarly, of research indicating such a state. Other persistent virus rabies in animals is difficult to distinguish from canine dis- infections routinely occur in lymphocytes, monocytes, temper and other encephalitic conditions. Postmortem ra- macrophages, and dendritic cells through the viruses’ bies diagnosis should be routinely performed on rabid ani- curtailment of the host’s antivirus immune responses. Ex- mals, animals that have bitten victims, and human patients perimental RABV replication in murine bone marrow mac- who die after an animal bite. Antemortem diagnosis of ra- rophages and in human macrophage–like cell lines suggests bies in humans is challenging because of the disease’s long a mechanism of virus persistence (22). However, wild-type and variable incubation period. Also, distribution of virus RABV is highly neurotropic. If RABV persistent infection antigens,
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