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caoPRO/AH/EDR> Rabies – Greece: (North) re-emergence, human exposure
Summary
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Greece has been rabies-free since 1987 with no human cases since 1970.
During 2012 to 2013, rabies has re-emerged in wild and domestic
animals in northern Greece. By end March 2013, rabies was diagnosed in
17 animals including 14 red foxes, two shepherd dogs and one cat; 104
subsequent human exposures required post-exposure prophylaxis
according to the World Health Organization criteria. Human exposures
occurred within 50 km radius of a confirmed rabies case in a wild or
domestic animal, and most frequently stray dogs were involved.

Introduction
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The last animal rabies case in Greece, dates back to 1987 while the
last human case was reported in 1970. Here we describe the
re-emergence of rabies in both wild and domestic animals during
October 2012 to end March 2013 in northern and central Greece that was
associated with human exposure.

Rabid fox:

On 15 Oct 2012, a red fox (_Vulpes vulpes_) exhibited aggressive
behavior during daytime, threatening inhabitants of a west Macedonian
village in the area of Kozani. The animal was destroyed and
transported to the National Reference Laboratory (NRL) for Animal
Rabies at the Centre of Athens Veterinary Institutions Virus
Department, of the Ministry of Rural Development and Food as part of a
wild animal surveillance program for rabies organised and implemented
by the Ministry of Rural Development since April 2012 because of
documented presence of lyssavirus in neighbouring Balkan countries.
Four days later on 19 October, the brain samples tested positive for
lyssavirus by fluorescence antibody test (FAT) and molecular
techniques i.e. real-time RT-PCR and RT-PCR followed by sequencing.

Rabid shepherd dog and exposure of humans and domestic animals:

On 10 November 2012, in west Macedonia, near the Greek-Albanian border
in the area of Ieropigi, Kastoria, a shepherd dog, belonging to a
herdsman, bit the thigh of a passing-by hunter unprovoked. Two days
later, on 12 November, the dog developed an aggressive behaviour
attacking other dogs and sheep of the herd. It was consequently
destroyed and brain tissue samples investigated at the NRL in Athens
were positive for lyssavirus both by FAT and molecular techniques on
16 November.

Tracing of exposed humans and animals and first control measures:

An epidemiological investigation was initiated on 16 Nov 2012 by the
Emergency Response Center of the Hellenic Centre for Diseases Control
and Prevention (KEELPNO), Athens, in order to identify all individuals
who had had contact with the dog and possible exposure to the lyssa
virus. Seven people possibly exposed were interviewed. Besides the
hunter and the shepherd, three relatives of the latter reported close
exposure according to the World Health Organization exposure category
III i.e. dog bite and/or mucous membrane exposure to the rabid dog.
All five including the veterinarian who had sampled the animal
received human rabies immunoglobulin along with rabies immunisation
series. None of the exposed individuals has developed any symptoms of
human rabies so far.

Results from regular rabies surveillance November to March 2013:

In addition to the two animal cases described, and through the
enhanced surveillance instituted by the veterinarian authorities,
since November 2012 until end March 2013 we have identified additional
13 red foxes, one shepherd dog (20 December 2012) and one domestic cat
(28 February 2013) with laboratory confirmed rabies. In total 104
human exposures (category I: 1; 1%; category II: 21; 20%; category
III: 75; 72% and 7; 7% unknown) have been reported to KEELPNO
resulting in the administration of post-exposure prophylaxis according
to the WHO criteria.

Rabies situation in the Balkans countries:

Although Greece was declared rabies-free in 1987, reports of rabies in
wildand domestic animals exist for the neighboring countries. In fact
rabies appears to be prevalent in a number of reservoir species in
southeastern Europe and in countries north and east of Greece. Recent
phylogenetic analyses have shown a westward movement of rabies via the
movement of wild animals from Bulgaria to other Balkan countries
suggesting that this is a local event unrelated to the circulation of
phylogenetically distinct viral strains in Turkey. In addition, in a
previous study a distinct group of viruses identified in foxes in
Serbia provided evidence for southward movement of rabies from
Hungary, Serbia and Romania into Bulgaria . In another report that
compared the nucleoprotein sequence among animal rabies isolates from
three Balkan countries, including recent isolates from the years
2011-12, all strains belonged to the eastern European group
implicating wildlife movement in the transmission of rabies across the
region. However, more information is necessary regarding the
circulation of the virus and more genotypic data will assist in
establishing a pattern for the spread of disease. Only one
autochthonous human rabies case was reported in 2009 in the European
Union, in Romania, a person bitten by a fox.

Discussion
———
The reported cases of confirmed and possible human rabies exposure
after domestic or stray animal contact raise important public health
concerns: first, there is an urgent need for a prevalence estimate of
the virus circulation in wild animals in the area of northern Greece.
Such information will help guide immediate vaccination efforts
targeting wild animals that are reservoirs for the virus. It is likely
that the virus circulates largely in populations of red foxes as red
foxes are considered as the most important wild animal reservoir.
Second, there is an urgent need for an immunisation program for wild
animals. Experience from other countries has shown that rabies
elimination cannot solely rely on measures that include farm animals
or domestic pets such as compulsory vaccination and/or the control of
stray animal population. Reducing population density through culling
or sterilisation of the main wildlife reservoirs such as foxes has
been the most important factor in rabies elimination in these
countries.

Successive oral vaccination campaigns (supported by the European
Community) using bait vaccines have been successful in this regard in
recent elimination efforts in some European countries for example
Estonia but not in others e.g. Latvia and Lithuania. Third, all
domestic and stray animals especially in areas where sylvatic rabies
is prevalent should be vaccinated; since the majority of the bites
originated from stray dogs they should be targeted first. Unofficial
information about illegal importation of unimmunised hunting dogs
justify the implementation of strict border control, hygiene and
immunisation checks and appropriate quarantine during the importation
process of such animals according to relevant EU legislation. In
Greece, all imported dogs are checked for rabies immunisation with
appropriate documentation together with antibody titers and if
negative, entry to the country is not permitted. Other strategies
pertaining to hunting animals such as the prohibition of hunting with
dogs have not been discussed yet; nevertheless, the obligation to keep
dogs on a leash is recommended. Fourth, the public needs to be aware
about the potential for rabies exposures in areas where the virus
circulates in wild animals. Pre-exposure vaccination for high risk
groups is a priority in our targeted initial interventions.

The travel health department of KEELPNO is advising for preventive
measures e.g. avoiding contact with wild and domestic animals, special
attention for children exposure and pre-exposure prophylaxis only for
high risk groups (e.g. game wardens, hunters, veterinarians working in
the field) travelling to the affected areas; it also encourages the
use of post-exposure prophylaxis according to the WHO guidelines.
Currently, the risk of rabies to travellers to Greece remains
extremely low and so far only the northern part of the country is
affected. Fifth, healthcare workers need to carefully evaluate each
human exposure from a potentially rabid animal and take the
appropriate actions. Since the human rabies immunoglobulin is
expensive, a risk assessment as proposed by WHO should guide a
cost-effective approach in its administration.

Last but not least and since the disease was likely introduced to
Greece by rabid wild foxes crossing borders in the north of the
country, close collaboration with the neighboring countries is of
paramount importance especially with regards to control measures in
wild animals.


Communicated by:
ProMED-mail correspondent Susan Baekelnd

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