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1.  Virology, Immunology and Pathology of Human Rabies During Treatment 
Background
Rabies is an acute fatal encephalitis caused by all members of the Lyssavirus genus. The first human rabies survivor without benefit of prior vaccination was reported from Milwaukee in 2005. We report a second unvaccinated patient who showed early recovery from rabies and then died accidentally during convalescence, providing an unparalleled opportunity to examine the histopathology as well as immune and virological correlates of early recovery from human rabies.
Methods
Case report, rapid fluorescent focus inhibition test, enzyme-linked immunosorbent assay, indirect and direct fluorescent antibody assays, reverse-transcriptase polymerase chain reaction, phylogenetic reconstruction, isolation in tissue culture, pathology and immunohistochemistry.
Results
The 9 year old died 76 days after presenting with rabies of vampire bat phylogeny transmitted by cat bite. Antibody response in serum and cerebrospinal fluid was robust and associated with severe cerebral edema. No rabies virus was cultured at autopsy. Rabies virus antigen was atypical in size and distribution. Rabies virus genome was present in neocortex but absent in brainstem.
Conclusions
Clinical recovery was associated with detection of neutralizing antibody and clearance of infectious rabies virus in the central nervous system by 76 days but not clearance of detectable viral subcomponents such as nucleoprotein antigen or RNA in brain.
doi:10.1097/INF.0000000000000624
PMCID: PMC4809748  PMID: 25405805
rabies; therapy; pathology; immunology; recovery of function; cerebral edema
2.  Willingness to Pay for Dog Rabies Vaccine and Registration in Ilocos Norte, Philippines (2012) 
PLoS Neglected Tropical Diseases  2016;10(3):e0004486.
Background
The Philippines is one of the developing countries highly affected by rabies. Dog vaccination campaigns implemented through collaborative effort between the government and NGOs have played an important role in successfully reducing the burden of disease within the country. Nevertheless, rabies vaccination of the domestic animal population requires continuous commitment not only from governments and NGOs, but also from local communities that are directly affected by such efforts. To create such long-term sustained programs, the introduction of affordable dog vaccination and registration fees is essential and has been shown to be an important strategy in Bohol, Philippines. The aim of this study, therefore, was to estimate the average amount of money that individuals were willing to pay for dog vaccination and registration in Ilocos Norte, Philippines. This study also investigated some of the determinants of individuals’ willingness to pay (WTP).
Methods
A cross-sectional questionnaire was administered to 300 households in 17 municipalities (out of a total of 21) selected through a multi-stage cluster survey technique. At the time of the survey, Ilocos Norte had a population of approximately 568,017 and was predominantly rural. The Contingent Valuation Method was used to elicit WTP for dog rabies vaccination and registration. A ‘bidding game’ elicitation strategy that aims to find the maximum amount of money individuals were willing to pay was also employed. Data were collected using paper-based questionnaires. Linear regression was used to examine factors influencing participants’ WTP for dog rabies vaccination and registration.
Key Results
On average, Ilocos Norte residents were willing to pay 69.65 Philippine Pesos (PHP) (equivalent to 1.67 USD in 2012) for dog vaccination and 29.13PHP (0.70 USD) for dog registration. Eighty-six per cent of respondents were willing to pay the stated amount to vaccinate each of their dogs, annually. This study also found that WTP was influenced by demographic and knowledge factors. Among these, we found that age, income, participants’ willingness to commit to pay each year, municipality of residency, knowledge of the signs of rabies in dogs, and number of dogs owed significantly predicted WTP.
Author Summary
Rabies is one of the most fatal viral diseases mostly transmitted through a bite of an infected mammal. In many parts of Africa and Asia, rabid dogs are the main transmitters of the disease to humans. In the Philippines, government enforced dog registration laws and government/NGO sponsored mass dog vaccination campaigns have so far been the cornerstone in successfully reducing the burden of disease in parts of the country. To further enhance the continuation of such programs, however, an introduction of affordable dog vaccination and registration fees to the public is vital and have shown to be an important strategy in other parts of the country. Our main objective here was to systematically assess how much money individuals were willing to pay for dog vaccination and registration in Ilocos Norte, Philippines. We also assessed whether the amount individuals were willing to pay was influenced by their demographic and knowledge characteristics. We conducted a cross-sectional study using a combination of cluster sampling, random sampling, and convenience sampling methods to identify study participants. We employed a specific elicitation strategy (bidding game) to elicit how much individual were willing to pay for such services. Our results indicate that Ilocos Norte residents, on average, were willing to pay 69.65 PHP (1.67 USD) for dog vaccination and 29.13 PHP (0.70 USD) for dog registration. The majority (86%) of respondents were willing to pay the stated amount to vaccinate each of their dogs, annually. We also found that willingness to pay was influences by age, income, municipality of residency, people’s willingness to commit to pay each year, number of dogs owned, and knowledge regarding rabies signs in dogs. This findings give policy makers some indication of how much people were willing to contribute financially towards dog vaccination and registration in particular and towards rabies elimination from Ilocos Norte, in general. Socio-economic and demographic factors, however, may need to be considered prior to the introduction of such fees to the public.
doi:10.1371/journal.pntd.0004486
PMCID: PMC4801174  PMID: 26999021
4.  Estimating the Global Burden of Endemic Canine Rabies 
PLoS Neglected Tropical Diseases  2015;9(4):e0003709.
Background
Rabies is a notoriously underreported and neglected disease of low-income countries. This study aims to estimate the public health and economic burden of rabies circulating in domestic dog populations, globally and on a country-by-country basis, allowing an objective assessment of how much this preventable disease costs endemic countries.
Methodology/Principal Findings
We established relationships between rabies mortality and rabies prevention and control measures, which we incorporated into a model framework. We used data derived from extensive literature searches and questionnaires on disease incidence, control interventions and preventative measures within this framework to estimate the disease burden. The burden of rabies impacts on public health sector budgets, local communities and livestock economies, with the highest risk of rabies in the poorest regions of the world. This study estimates that globally canine rabies causes approximately 59,000 (95% Confidence Intervals: 25-159,000) human deaths, over 3.7 million (95% CIs: 1.6-10.4 million) disability-adjusted life years (DALYs) and 8.6 billion USD (95% CIs: 2.9-21.5 billion) economic losses annually. The largest component of the economic burden is due to premature death (55%), followed by direct costs of post-exposure prophylaxis (PEP, 20%) and lost income whilst seeking PEP (15.5%), with only limited costs to the veterinary sector due to dog vaccination (1.5%), and additional costs to communities from livestock losses (6%).
Conclusions/Significance
This study demonstrates that investment in dog vaccination, the single most effective way of reducing the disease burden, has been inadequate and that the availability and affordability of PEP needs improving. Collaborative investments by medical and veterinary sectors could dramatically reduce the current large, and unnecessary, burden of rabies on affected communities. Improved surveillance is needed to reduce uncertainty in burden estimates and to monitor the impacts of control efforts.
Author Summary
Rabies is a fatal viral disease largely transmitted to humans from bites by infected animals—predominantly from domestic dogs. The disease is entirely preventable through prompt administration of post-exposure prophylaxis (PEP) to bite victims and can be controlled through mass vaccination of domestic dogs. Yet, rabies is still very prevalent in developing countries, affecting populations with limited access to health care. The disease is also grossly underreported in these areas because most victims die at home. This leads to insufficient prioritization of rabies prevention in public health agendas. To address this lack of information on the impacts of rabies, in this study, we compiled available data to provide a robust estimate of the health and economic implications of dog rabies globally. The most important impacts included: loss of human lives (approximately 59,000 annually) and productivity due to premature death from rabies, and costs of obtaining PEP once an exposure has occurred. The greatest risk of developing rabies fell upon the poorest regions of the world, where domestic dog vaccination is not widely implemented and access to PEP is most limited. A greater focus on mass dog vaccination could eliminate the disease at source, reducing the need for costly PEP and preventing the large and unnecessary burden of mortality on at-risk communities.
doi:10.1371/journal.pntd.0003709
PMCID: PMC4400070  PMID: 25881058
5.  Knowledge, attitudes and practices regarding rabies and exposure to bats in two rural communities in Guatemala 
BMC Research Notes  2015;8:955.
Background
Rabies is a fatal encephalitis caused by rabies virus, of the genus Lyssavirus. The principal reservoir for rabies in Latin America is the common vampire bat (Desmodus rotundus), which feeds routinely on the blood of cattle, and when livestock are scarce, may prey on other mammals, including humans. Although rabies is endemic in common vampire bat populations in Guatemala, there is limited research on the extent of exposure to bats among human populations living near bat refuges.
Results
A random sample of 270 of 473 households (57%) in two communities located within 2 Km of a known bat roost was selected and one adult from each household was interviewed. Exposure to bats (bites, scratches or bare skin contact) was reported by 96 (6%) of the 1,721 residents among the selected households. Of those exposed, 40% received rabies post-exposure prophylaxis. Four percent of household respondents reported that they would seek rabies post exposure prophylaxis if they were bitten by a bat.
Conclusions
These findings demonstrate that exposure to bats in communities near bat roosts is common but recognition of the potential for rabies transmission from bats is low. There is a need for educational outreach to raise awareness of bat-associated rabies, prevent exposures to bats and ensure appropriate health-seeking behaviours for bat-inflicted wounds, particularly among communities living near bat roosts in Guatemala.
doi:10.1186/s13104-014-0955-1
PMCID: PMC4302579  PMID: 25576098
Rabies; Bat bite; Health practices; Post-exposure prophylaxis; Guatemala; Rabies prevention; Vampire bat
6.  Bat Rabies in Guatemala 
Rabies in bats is considered enzootic throughout the New World, but few comparative data are available for most countries in the region. As part of a larger pathogen detection program, enhanced bat rabies surveillance was conducted in Guatemala, between 2009 and 2011. A total of 672 bats of 31 species were sampled and tested for rabies. The prevalence of rabies virus (RABV) detection among all collected bats was low (0.3%). Viral antigens were detected and infectious virus was isolated from the brains of two common vampire bats (Desmodus rotundus). RABV was also isolated from oral swabs, lungs and kidneys of both bats, whereas viral RNA was detected in all of the tissues examined by hemi-nested RT-PCR except for the liver of one bat. Sequencing of the nucleoprotein gene showed that both viruses were 100% identical, whereas sequencing of the glycoprotein gene revealed one non-synonymous substitution (302T,S). The two vampire bat RABV isolates in this study were phylogenetically related to viruses associated with vampire bats in the eastern states of Mexico and El Salvador. Additionally, 7% of sera collected from 398 bats demonstrated RABV neutralizing antibody. The proportion of seropositive bats varied significantly across trophic guilds, suggestive of complex intraspecific compartmentalization of RABV perpetuation.
Author Summary
In this study we provide results of the first active and extensive surveillance effort for rabies virus (RABV) circulation among bats in Guatemala. The survey included multiple geographic areas and multiple species of bats, to assess the broader public and veterinary health risks associated with rabies in bats in Guatemala. RABV was isolated from vampire bats (Desmodus rotundus) collected in two different locations in Guatemala. Sequencing of the isolates revealed a closer relationship to Mexican and Central American vampire bat isolates than to South American isolates. The detection of RABV neutralizing antibodies in 11 species, including insectivorous, frugivorous, and sanguivorous bats, demonstrates viral circulation in both hematophagous and non-hematophagous bat species in Guatemala. The presence of bat RABV in rural communities requires new strategies for public health education regarding contact with bats, improved laboratory-based surveillance of animals associated with human exposures, and novel techniques for modern rabies prevention and control. Additionally, healthcare practitioners should emphasize the collection of a detailed medical history, including questions regarding bat exposure, for patients presenting with clinical syndromes compatible with rabies or any clinically diagnosed progressive encephalitis.
doi:10.1371/journal.pntd.0003070
PMCID: PMC4117473  PMID: 25080103
7.  New World Bats Harbor Diverse Influenza A Viruses 
PLoS Pathogens  2013;9(10):e1003657.
Aquatic birds harbor diverse influenza A viruses and are a major viral reservoir in nature. The recent discovery of influenza viruses of a new H17N10 subtype in Central American fruit bats suggests that other New World species may similarly carry divergent influenza viruses. Using consensus degenerate RT-PCR, we identified a novel influenza A virus, designated as H18N11, in a flat-faced fruit bat (Artibeus planirostris) from Peru. Serologic studies with the recombinant H18 protein indicated that several Peruvian bat species were infected by this virus. Phylogenetic analyses demonstrate that, in some gene segments, New World bats harbor more influenza virus genetic diversity than all other mammalian and avian species combined, indicative of a long-standing host-virus association. Structural and functional analyses of the hemagglutinin and neuraminidase indicate that sialic acid is not a ligand for virus attachment nor a substrate for release, suggesting a unique mode of influenza A virus attachment and activation of membrane fusion for entry into host cells. Taken together, these findings indicate that bats constitute a potentially important and likely ancient reservoir for a diverse pool of influenza viruses.
Author Summary
Previous studies indicated that a novel influenza A virus (H17N10) was circulating in fruit bats from Guatemala (Central America). Herein, we investigated whether similar viruses are present in bat species from South America. Analysis of rectal swabs from bats sampled in the Amazon rainforest region of Peru identified another new influenza A virus from bats that is phylogenetically distinct from the one identified in Guatemala. The genes that encode the surface proteins of the new virus from the flat-faced fruit bat were designated as new subtype H18N11. Serologic testing of blood samples from several species of Peruvian bats indicated a high prevalence of antibodies to the surface proteins. Phylogenetic analyses demonstrate that bat populations from Central and South America maintain as much influenza virus genetic diversity in some gene segments as all other mammalian and avian species combined. The crystal structures of the hemagglutinin and neuraminidase proteins indicate that sialic acid is not a receptor for virus attachment nor a substrate for release, suggesting a novel mechanism of influenza A virus attachment and activation of membrane fusion for entry into host cells. In summary, our findings indicate that bats constitute a potentially important reservoir for influenza viruses.
doi:10.1371/journal.ppat.1003657
PMCID: PMC3794996  PMID: 24130481
8.  Ecological and anthropogenic drivers of rabies exposure in vampire bats: implications for transmission and control 
Despite extensive culling of common vampire bats in Latin America, lethal human rabies outbreaks transmitted by this species are increasingly recognized, and livestock rabies occurs with striking frequency. To identify the individual and population-level factors driving rabies virus (RV) transmission in vampire bats, we conducted a longitudinal capture–recapture study in 20 vampire bat colonies spanning four regions of Peru. Serology demonstrated the circulation of RV in vampire bats from all regions in all years. Seroprevalence ranged from 3 to 28 per cent and was highest in juvenile and sub-adult bats. RV exposure was independent of bat colony size, consistent with an absence of population density thresholds for viral invasion and extinction. Culling campaigns implemented during our study failed to reduce seroprevalence and were perhaps counterproductive for disease control owing to the targeted removal of adults, but potentially greater importance of juvenile and sub-adult bats for transmission. These findings provide new insights into the mechanisms of RV maintenance in vampire bats and highlight the need for ecologically informed approaches to rabies prevention in Latin America.
doi:10.1098/rspb.2012.0538
PMCID: PMC3396893  PMID: 22696521
culling; disease thresholds; longitudinal; Lyssavirus; chiroptera; Desmodus
9.  Genetic Characterization of Atypical Mansonella (Mansonella) ozzardi Microfilariae in Human Blood Samples from Northeastern Peru 
DNA sequence comparisons are useful for characterizing proposed new parasite species or strains. Microfilariae with an atypical arrangement of nuclei behind the cephalic space have been recently described in human blood samples from the Amazon region of Peru. Three blood specimens containing atypical microfilariae were genetically characterized using three DNA markers (5S ribosomal DNA, 12S ribosomal DNA, and cytochrome oxidase I). All atypical microfilariae were clustered into the Mansonella group and indistinguishable from M. ozzardi based on these DNA markers.
doi:10.4269/ajtmh.2012.11-0379
PMCID: PMC3435353  PMID: 22826497
10.  Prevalence and Diversity of Bartonella spp. in Bats in Peru 
Bartonella infections were investigated in bats in the Amazon part of Peru. A total of 112 bats belonging to 19 species were surveyed. Bartonella bacteria were cultured from 24.1% of the bats (27/112). Infection rates ranged from 0% to 100% per bat species. Phylogenetic analyses of gltA of the Bartonella isolates revealed 21 genetic variants clustering into 13 divergent phylogroups. Some Bartonella strains were shared by bats of multiple species, and bats of some species were infected with multiple Bartonella strains, showing no evident specific Bartonella sp.–bat relationships. Rarely found in other bat species, the Bartonella strains of phylogroups I and III discovered from the common vampire bats (Desmodus rotundus) were more specific to the host bat species, suggesting some level of host specificity.
doi:10.4269/ajtmh.2012.12-0097
PMCID: PMC3435358  PMID: 22826480
11.  Evidence of Rabies Virus Exposure among Humans in the Peruvian Amazon 
In May of 2010, two communities (Truenococha and Santa Marta) reported to be at risk of vampire bat depredation were surveyed in the Province Datem del Marañón in the Loreto Department of Perú. Risk factors for bat exposure included age less than or equal to 25 years and owning animals that had been bitten by bats. Rabies virus neutralizing antibodies (rVNAs) were detected in 11% (7 of 63) of human sera tested. Rabies virus ribonucleoprotein (RNP) immunoglobulin G (IgG) antibodies were detected in the sera of three individuals, two of whom were also seropositive for rVNA. Rabies virus RNP IgM antibodies were detected in one respondent with no evidence of rVNA or RNP IgG antibodies. Because one respondent with positive rVNA results reported prior vaccination and 86% (six of seven) of rVNA-positive respondents reported being bitten by bats, these data suggest nonfatal exposure of persons to rabies virus, which is likely associated with vampire bat depredation.
doi:10.4269/ajtmh.2012.11-0689
PMCID: PMC3414554  PMID: 22855749
12.  Bartonella spp. in Bats, Guatemala 
Emerging Infectious Diseases  2011;17(7):1269-1272.
To better understand the role of bats as reservoirs of Bartonella spp., we estimated Bartonella spp. prevalence and genetic diversity in bats in Guatemala during 2009. We found prevalence of 33% and identified 21 genetic variants of 13 phylogroups. Vampire bat–associated Bartonella spp. may cause undiagnosed illnesses in humans.
doi:10.3201/eid1707.101867
PMCID: PMC3381397  PMID: 21762584
Bartonella spp.; bats; Desmodus rotundus; Guatemala; bacteria; dispatch
13.  Epidemiologic Investigation of Immune-Mediated Polyradiculoneuropathy among Abattoir Workers Exposed to Porcine Brain 
PLoS ONE  2010;5(3):e9782.
Background
In October 2007, a cluster of patients experiencing a novel polyradiculoneuropathy was identified at a pork abattoir (Plant A). Patients worked in the primary carcass processing area (warm room); the majority processed severed heads (head-table). An investigation was initiated to determine risk factors for illness.
Methods and Results
Symptoms of the reported patients were unlike previously described occupational associated illnesses. A case-control study was conducted at Plant A. A case was defined as evidence of symptoms of peripheral neuropathy and compatible electrodiagnostic testing in a pork abattoir worker. Two control groups were used - randomly selected non-ill warm-room workers (n = 49), and all non-ill head-table workers (n = 56). Consenting cases and controls were interviewed and blood and throat swabs were collected. The 26 largest U.S. pork abattoirs were surveyed to identify additional cases. Fifteen cases were identified at Plant A; illness onsets occurred during May 2004–November 2007. Median age was 32 years (range, 21–55 years). Cases were more likely than warm-room controls to have ever worked at the head-table (adjusted odds ratio [AOR], 6.6; 95% confidence interval [CI], 1.6–26.7), removed brains or removed muscle from the backs of heads (AOR, 10.3; 95% CI, 1.5–68.5), and worked within 0–10 feet of the brain removal operation (AOR, 9.9; 95% CI, 1.2–80.0). Associations remained when comparing head-table cases and head-table controls. Workers removed brains by using compressed air that liquefied brain and generated aerosolized droplets, exposing themselves and nearby workers. Eight additional cases were identified in the only two other abattoirs using this technique. The three abattoirs that used this technique have stopped brain removal, and no new cases have been reported after 24 months of follow up. Cases compared to controls had higher median interferon-gamma (IFNγ) levels (21.7 pg/ml; vs 14.8 pg/ml, P<0.001).
Discussion
This novel polyradiculoneuropathy was associated with removing porcine brains with compressed air. An autoimmune mechanism is supported by higher levels of IFNγ in cases than in controls consistent with other immune mediated illnesses occurring in association with neural tissue exposure. Abattoirs should not use compressed air to remove brains and should avoid procedures that aerosolize CNS tissue. This outbreak highlights the potential for respiratory or mucosal exposure to cause an immune-mediated illness in an occupational setting.
doi:10.1371/journal.pone.0009782
PMCID: PMC2841649  PMID: 20333310
14.  Spatial and temporal patterns of enzootic raccoon rabies adjusted for multiple covariates 
Background
With the objective of identifying spatial and temporal patterns of enzootic raccoon variant rabies, a spatial scan statistic was utilized to search for significant terrestrial rabies clusters by year in New York State in 1997–2003. Cluster analyses were unadjusted for other factors, adjusted for covariates, and adjusted for covariates and large scale geographic variation (LSGV). Adjustments were intended to identify the unusual aggregations of cases given the expected distribution based on the observed locations.
Results
Statistically significant clusters were identified particularly in the Albany, Finger Lakes, and South Hudson areas. The clusters were generally persistent in the Albany area, but demonstrated cyclical changes in rabies activity every few years in the other areas. Cluster adjustments allowed the discussion of possible causes for the high risk raccoon rabies areas identified.
Conclusion
This study analyzed raccoon variant rabies spatial and temporal patterns in New York that have not been previously described at a focal (census tract) level. Comparisons across the type of spatial analysis performed with various degrees of adjustment allow consideration of the potential influence of geographical factors for raccoon rabies and possible reasons for the highest risk areas (statistically significant clusters).
doi:10.1186/1476-072X-6-14
PMCID: PMC1853077  PMID: 17428324
15.  Potential cost savings with terrestrial rabies control 
BMC Public Health  2007;7:47.
Background
The cost-benefit of raccoon rabies control strategies such as oral rabies vaccination (ORV) are under evaluation. As an initial quantification of the potential cost savings for a control program, the collection of selected rabies cost data was pilot tested for five counties in New York State (NYS) in a three-year period.
Methods
Rabies costs reported to NYS from the study counties were computerized and linked to a human rabies exposure database. Consolidated costs by county and year were averaged and compared.
Results
Reported rabies-associated costs for all rabies variants totalled $2.1 million, for human rabies postexposure prophylaxes (PEP) (90.9%), animal specimen preparation/shipment to laboratory (4.7%), and pet vaccination clinics (4.4%). The proportion that may be attributed to raccoon rabies control was 37% ($784,529). Average costs associated with the raccoon variant varied across counties from $440 to $1,885 per PEP, $14 to $44 per specimen, and $0.33 to $15 per pet vaccinated.
Conclusion
Rabies costs vary widely by county in New York State, and were associated with human population size and methods used by counties to estimate costs. Rabies cost variability must be considered in developing estimates of possible ORV-related cost savings. Costs of PEPs and specimen preparation/shipments, as well as the costs of pet vaccination provided by this study may be valuable for development of more realistic scenarios in economic modelling of ORV costs versus benefits.
doi:10.1186/1471-2458-7-47
PMCID: PMC1852308  PMID: 17407559

Results 1-15 (15)