Six fatal cases of classical rabies virus without biting incidents, Iran 1990-2010.

BACKGROUND: Rabies is an endemic fatal zoonotic disease, commonly transmitted to humans through contact (bites and scratches) with infected animals. OBJECTIVES: During the years 1990-2010, six patients with the clinical symptoms of rabies (fever, tinnitus, buzzing, delirium and hydrophobia), with no history of a bite, were diagnosed by physicians in Iran. To obtain laboratory confirmation of rabies infection, different clinical specimens from each patient were sent to the World Health Organisation (WHO) Collaborating Center for Reference and Research on Rabies, Pasteur Institute of Iran. The first case was a 39-year-old male veterinary technician who entered his uncovered scratched hand into the mouth of a rabid bovine and became infected. Two years later, a herd of sheep being tended by a shepherd and his two sons were attacked by a rabid wolf. All three individuals were infected when they applied burnt thorny wool to the sheep's wounds as a bandage. Their hands were scratched and then infected through contact with the remaining saliva of the rabid wolf on the sheep's wounds. In 1994, two other human cases occurred through corneal transplantation from the same donor who had died with the clinical signs of food poisoning (according to his hospital record), which probably was a misdiagnosis of rabies infection. STUDY DESIGN: This is a case series study that describes human rabies cases without biting incidents. According to the WHO recommendation, human rabies cases are notifiable, therefore, in Iran, a rabies surveillance system has been established to follow these cases. During the last decade, six patients with no 'history of a bite' were hospitalised with growing symptoms of rabies. The data were collected from each patient by the physicians and transferred to the Ministry of Health and Medical Education of Iran, and to the WHO Collaborating Center for Reference and Research on Rabies, Pasteur Institute of Iran as the only testing laboratory. Thus, they came to the attention of the surveillance system. Ante-mortem diagnosis was performed on saliva, cerebrospinal fluid and blood samples that were collected from the first patient by the physicians. Fresh brain specimens from all patients were kept in a mixture of 50% glycerol in phosphate-buffered saline and transported on ice to the WHO Collaborating Center for Reference and Research on Rabies. RESULTS: For the first patient, rabies virus was investigated in saliva using the rapid tissue cell inoculation test (RTCIT) and the mouse inoculation test (MIT). Anti-rabies antibodies in this patient's serum and cerebrospinal fluid (CSF) were examined using the mouse neutralisation test (MNT). Fresh brain specimens from all patients were examined using the fluorescence antibody test (FAT) as recommended by the WHO laboratory manual in rabies as the post-mortem diagnostic test for rabies. Rabies infection was confirmed in all of the deceased patients. Anti-rabies antibodies were identified only in one patient's serum specimen. Testing also showed that the rabies virus isolated was the classic rabies virus (serotype 1), which is widespread in Iran. CONCLUSIONS: Prevention and control of this fatal disease require a sensitive surveillance system to follow 'suspected' animal and human rabies cases thoroughly through the improved reporting system, which contains the history of exposure, clinical examinations, symptoms and laboratory results. This study describes some notable human rabies infections and their transmission modes to prevent occupational accidents.

Rabies antibody levels in pregnant women and their newborns after rabies post-exposure prophylaxis.

BACKGROUND: Rabies is a fatal infectious disease and rabies post-exposure prophylaxis is the method of choice for prevention of human rabies. CASE SERIES: We report rabies antibody levels in cord blood and also in serum of pregnant women who were bitten by suspected animals to rabies and were immunized by purified Vero cell rabies vaccine (PVRV) and Human Rabies immunoglobulin (HRIG) serum. During the years of 2007-2010, six pregnant women by the age range of 22-35 years were admitted in treatment and prevention of rabies center in Pasture institute of Iran, in Tehran. Among them two cases were at first trimester, one at second trimester and three at third trimester of conception. The interval between biting with delivery was 5-265 days (mean 121 days). CONCLUSION: Results of immunoglobulin illustrate that levels of rabies antibody in maternal sera with the fetus are not equal and uniform but it is proved that baby will find efficient immunity as well with minimum protective level of 0.5 IU/ml in all cases except a newborn whom had been born just 5 days after the mother's immunization and in a shorter time than the appropriate immunization of the mother who had received her second vaccination courses.

Antibody persistence, 32 years after post-exposure prophylaxis with human diploid cell rabies vaccine (HDCV).

In 1975-1976 forty-five persons severely bitten by rabid wolves and dogs in Iran were treated successfully against rabies with HDCV. In this study contact was made with 26 of 45 above persons, 32 years after their initial treatment and all had rabies neutralizing antibody ranging from 0.3 to 2.69 IU/ml of serum. Of the 26 persons, 17 had received a booster dose of HDCV, 28 years ago and the remaining 9 persons, who had not received any booster since the initial treatment, were given one booster dose of HDCV. All 9 of these patients developed an anamnestic response after their booster inoculation. This study confirms the persistence of rabies neutralizing antibody in persons that received post-exposure vaccination with HDCV, 32 years previously. Furthermore, a single booster inoculation with HDCV resulted in anamnestic response in all individuals.