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Wednesday, 8th of May 2013 Print

Abstract below; full text is at http://www.plosntds.org/article/info%3Adoi%2F10.1371%2Fjournal.pntd.0002209

Sixty cases of human rabies in international travelers were reviewed from 1990–2012. A significant proportion of the cases were observed in migrants or their descendants when emigrating from their country of origin or after a trip to visit friends and relatives or for other reasons (43.3%). The cases were not necessarily associated with long-term travel or expatriation to endemic countries; moreover, cases were observed in travelers after short trips of two weeks or less. A predominance of male patients was observed (75.0%). The proportion of children was low (11.7%). Cases from India and Philippines were frequent (16 cases/60). In a significant proportion of cases (51.1%), diagnosis was challenging, with multiple missed diagnoses and transfers from ward to ward before the final diagnosis of rabies. Among the 28 patients whose confirmed diagnosis was obtained ante-mortem, the mean time between hospitalization and diagnosis was 7.7 days (median time: 6.0 days, range 2–30) including four cases with a diagnosis delayed by 15 or more days. In five cases, a patient traveled through one or more countries before ultimately being hospitalized. Three factors played a role in delaying the diagnosis of rabies in a number of cases: (i) a low index of suspicion for rabies in countries where the disease has been eradicated for a long time or is now rare, (ii) a negative history of animal bites or exposure to rabies, and (iii) atypical clinical presentation of the disease. Clinical symptomatology of rabies is complex and commonly confuses physicians. Furthermore, failure in diagnosing imported cases in more developed countries is most likely related to the lack of medical familiarity with even the typical clinical features of the disease.

Author Summary

Rabies is readily diagnosed when it presents in the classic furious form. The paralytic and atypical forms can pose significant problems in diagnosis, particularly when found in rabies-free countries in travelers who acquired the disease abroad. We systematically reviewed the existing literature and collected 60 cases of rabies in travelers and expatriates from non-endemic countries and in migrants from endemic countries during their first migration trip or following subsequent trip to their origin country. We observed that the disease may have an atypical presentation and/or long incubation time resulting in delayed or missed diagnosis with adverse public health consequences including multiple transmissions of rabies via transplanted solid organs from a single infected donor whose diagnosis of rabies was retrospectively assessed or need for risk assessment in a large number of patient contacts. Rabies should be suspected, even when a history of animal bites is missing, in patients with encephalitis or paralysis who originate or return from rabies-enzootic countries, notably in male adult patients, in migrants visiting countries of origin, and in the context of travel to India or the Philippines. The analysis of three serially collected saliva samples and one skin biopsy taken from the nape of the neck offers the highest level of sensitivity when using appropriate molecular techniques for viral RNA detection.

Citation: Carrara P, Parola P, Brouqui P, Gautret P (2013) Imported Human Rabies Cases Worldwide, 1990–2012. PLoS Negl Trop Dis 7(5): e2209. doi:10.1371/journal.pntd.0002209

Editor: Charles E. Rupprecht, The Global Alliance for Rabies Control, United States of America

Received: January 28, 2013; Accepted: March 29, 2013; Published: May 2, 2013

Copyright: © 2013 Carrara et al. This is an open-access article distributed under the terms of the Creative Commons Attribution License, which permits unrestricted use, distribution, and reproduction in any medium, provided the original author and source are credited.

Funding: The authors have indicated that no funding was received for this work.

Competing interests: The authors have declared that no competing interests exist.