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Jpn. J. Infect. Dis., 63, 323­326, 2010 Original Article Human Rabies Epidemiology in Shandong Province, China Xianjun Wang*õ,ShujunDingõ, Zhong Li, Liansen Wang, Zengqiang Kou, Kaijun Feng, Lijuan Wang, Xianfu Wu1, and Charles E. Rupprecht1 The Institute of Communicable Disease Control and Prevention, Shandong Center for Disease Control and Prevention, Jinan, People's Republic of China; and 1Rabies Program/PRB, Centers for Disease Control and Prevention, Atlanta, GA 30333, USA (Received February 24, 2010. Accepted July 20, 2010) SUMMARY: Rabies has reemerged in China. National rabies surveillance is centralized and based mainly on six provincial stations, including one in Shandong Province, which are selected and moni­ tored by the China CDC. Data collection includes human rabies cases (diagnosed by local hospitals on the basis of signs or symptoms), documentation of post­exposure prophylaxis, primary laboratory diag­ nosis of suspect animal cases, and investigation of dog or other animal bites in viral transmission. Of the 408 human rabies cases reported during the period 20032007, most involved middle­aged male farmers bitten by their own unvaccinated dogs, with a seasonal peak in the autumn. These data provide key pointers regarding rabies prevention and control based upon an objective evidence­based framework. for human risk assessments. INTRODUCTION Rabies is an acute, progressive, and fatal zoonotic MATERIALS AND METHODS disease. Human rabies is associated with the rise of civilization, the growth of cities, and the domestication Data collection: Historical data concerning human of animals, especially dogs (1). Rabies in China can be rabies cases from 1956 to 2007 were obtained from the traced as far back as 556 BC in Master Zuo's tradition provincial reporting system. As regulated by the Surveil­ of the Spring and Autumn annals (2). Although sig­ lance Protocol in Shandong Province, any suspected hu­ nificant progress has been made in rabies control and man rabies case was investigated at the county or city prevention internationally, the annual human death health department level, with support from provincial toll, as estimated by the World Health Organization Center for Disease Control and Prevention (CDC), be­ (WHO), remains at more than 55,000 worldwide (3). fore inclusion in the national rabies database. Informa­ According to the Shandong provincial database, the tion from each investigation, such as exposure descrip­ German consul general in Qingdao died of rabies in tion (dog or other animal bite, injury site, and severity, 1930 (http://sd.infobase.gov.cn/bin [in Chinese]). Be­ according to the WHO standards), patient­related infor­ tween 1955, when rabies was designated a reportable in­ mation (age, gender, and address), wound cleansing, fectious disease in China, and 2007, a total of 5,055 hu­ and post­exposure prophylaxis (PEP) at the local clinic, manrabiescaseswerereportedwiththreemajorepi­ was documented. The forms and investigation report demics in Shandong Province. The first of these out­ were sent to the Institute of Communicable Diseases breaks occurred between 1956 and 1958, with a peak of Control and Prevention in Shandong. 803 cases in 1957, whereas the second epidemic occurred Diagnostic criteria: Human rabies cases were defined between 1978 and 1981, with 80300 cases each year. according to the national WS281­2008 Rabies Diagnosis The third outbreak occurred between 1987 and 1992, Criteria (7) and the Guidance on Rabies Prevention and with a peak of 610 cases in 1989. Human rabies cases Control (8). These guidelines cover the basic clinical gradually decreased in number to zero by 1996. This signs of rabies and the laboratory tests used for case general trend is consistent with the nationwide descrip­ confirmation. Human brain samples from necropsy are tions (46). Between 1997 and 2002, the cumulative rarely used to diagnose rabies in China, therefore other number of human rabies cases was reported to be as low samples, including saliva, serum, and other secretions, as 15, with a sporadic distribution throughout the were collected and sent to the provincial CDC for fur­ province, whereas 14, 64, 60, 133, and 137 human rabies ther laboratory diagnosis. Saliva was usually collected cases were reported in the period 2003 to 2007, respec­ from the suspected rabies patient on three consecutive tively. To better understand the dynamics of this dis­ days. ease, a provincial surveillance system was established Data analysis: Microsoft Excel and the chi­square test were used during the risk assessment. Frequency analy­ ses were performed using the SPSS statistical package, *Corresponding author: Mailing address: The Institute of version 10.0 (SPSS Institute, Chicago, Ill., USA). Communicable Disease Control and Prevention, Shan­ dong Center for Disease Control and Prevention. No 72 Jingshi Road, Jinan, China. Tel: {86­531­82679683, Fax: RESULTS {86­531­82679681, E­mail: xjwang62163.com A total of 5,055 human rabies cases were reported in õThese two authors contributed equally to this study. Shandong Province between 1956 and 2007, although 323 Table 1. Local distribution of human rabies cases in Shandong Province, 20032007 Year No. of cases Municipal/city County Township Village 2003 14 3 6 11 14 2004 64 8 20 59 64 2005 60 8 28 56 60 2006 133 121) 52 120 129 2007 137 14 64 116 136 Total2) 408 14* 84* 322* 398* 1): one with unknown origin. 2): The total with * is the cumulative, not the aggregate number. Fig. 1. Location of Shandong Province in China and number of human rabies cases in Shandong Province, 19982007. only 14 of these occurred in the period 19982002 Fig. 2. Seasonal distribution of human rabies cases in Shandong (mean, 2.8 cases per year). The current epidemic began Province, 20032007. in 2003, with a total of 408 cases being reported in the period 20032007 (mean, 81.6 cases per year), which is 29 times the total for the previous 5 years. A total of 64 proximately half occurred in two localities, 34z cases were reported in 2004, with rabies­infected areas (142/408) in Linyi City and 14z (57/408) in Jining covering 57z (8/14) of municipal regions and 14z City. (20/140) of counties in the provincial jurisdiction. Simi­ (ii) Seasonal distribution: Of the 408 human rabies lar figures were reported in 2005 (60 human cases), cases studied, 55 occurred in November, 45 in October, whereas by 2007 rabies had spread to a much larger 46 in September, 45 in August, and 41 in July. Most area, with 82z (14/17) of municipal regions and 46z cases occurred in the second half of the year (259 cases, (64/140) of counties in the province reporting cases. All 64z),withonly63cases(15z) in the first quarter and rabies cases were fatal. Figure 1 shows that the number 86 (21z) in the second quarter (Figure 2). This seasonal of rabies cases in Shandong continues to rise, with 111 peak in Shandong could be linked to the harvest season, human rabies cases being reported in 2008. with migrating farmers returning to town for the har­ Rabies surveillance in China is centralized at national vest. As can be seen from the occupational analysis, and local levels. The fact that more rabies cases have about 82z of rabies victims were farmers. been reported in Shandong in recent years could be a (iii) Gender and occupational distribution: The result of the reporting system established, although the majority of the 408 human rabies cases (64z, 262/408) main reason is the low number of dogs vaccinated occurred in males, with male­to­female ratio of 1.8:1. against rabies. Indeed, rabid dogs were proposed to be Among the different age groups, 27z (109/408) of the main source of rabies infection in the 2003 outbreak cases occurred in the 5059 year age range (Figure 3). in Linyi City, although this proposal was not subse­ Male victims dominated all groups (Figure 4). By occu­ quently confirmed by a retrospective epidemiological pation, 82z (334/408) of cases occurred in farmers, fol­ study. lowed by 29 cases in young students, 18 in preschool Epidemiological characteristics: (i) Geographic distri­ children, and a few others. Most of the infected students bution: Although one of the 408 human rabies cases and preschool children came from rural areas. reported between 2003 and 2007 was from an unknown Human rabies exposures: (i) Hosts: Of the 390 human region, the other 407 human cases were distributed rabies cases with a known history of animal exposure, widely over 14 municipal areas, 84 counties, 322 town­ 94z (366/390) were attributed to dogs, 3z (11/390) to ships, and 398 villages or communities (Table 1). Ap­ cats, one case to an unknown wild animal, and 12 cases 324 Table 2. Human rabies cases post­exposure prophylaxis in Shan­ dong Province, 20042009 Wound treatment Vaccination Five Non­five No Yes Unknown No doses doses Unknown No. of cases 163 218 8 247 34 100 8 Table 3. Estimated incubation period of rabies cases reported in Shandong Province, 20042007 Incubation period 2004 2005 2006 2007 Total (z) Ã30 days 19 21 37 35 112 (30) Fig. 3. Age distribution of human rabies cases in Shandong Province, 20032007. 3160 days 20 9 31 32 92 (25) 6190 days 8 4 13 15 40 (11) 91180 days 10 9 27 18 64 (17) 0.5 year1 year 2 8 4 10 24 (6) 12 year 1 1 7 10 19 (5) À2years 4 2 5 13 24(6) Total 64 54 124 133 375 (100) hands (162/389, 42z), head (80/389, 21z), or lower extremities (71/389, 18z), and less frequently on the arms (26/389, 7z), trunk (4/389, 1z), or neck (3/389, 1z). (iii) Prophylaxis: Approximately 56z (218/389) of the exposures received basic wound care with clean or soapy water and disinfectants.

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