Research Article: The Spatiotemporal Expansion of Human Rabies and Its Probable Explanation in Mainland China, 2004-2013

Date Published: February 18, 2015

Publisher: Public Library of Science

Author(s): Hong-Wu Yao, Yang Yang, Kun Liu, Xin-Lou Li, Shu-Qing Zuo, Ruo-Xi Sun, Li-Qun Fang, Wu-Chun Cao, Charles E Rupprecht.

Abstract: BackgroundHuman rabies is a significant public health concern in mainland China. However, the neglect of rabies expansion and scarce analyses of the dynamics have made the spatiotemporal spread pattern of human rabies and its determinants being poorly understood.MethodsWe collected geographic locations and timeline of reported human rabies cases, rabies sequences and socioeconomic variables for the years 2004-2013, and integrated multidisciplinary approaches, including epidemiological characterization, hotspots identification, risk factors analysis and phylogeographic inference, to explore the spread pattern of human rabies in mainland China during the last decade.ResultsThe results show that human rabies distribution and hotspots were expanding from southeastern regions to north or west regions, which could be associated with the evolution of the virus, especially the clade I-G. A Panel Poisson Regression analysis reveals that human rabies incidences had significant correlation with the education level, GDP per capita, temperature at one-month lag and canine rabies outbreak at two-month lag.ConclusionsThe reduction in the overall human rabies incidence was accompanied by a westward and northward expansion of the circulating region in mainland China. Higher risk of human rabies was associated with lower level of education and economic status. New clades of rabies, especial Clade I-G, played an important role in recent spread. Our findings provide valuable information for rabies control and prevention in the future.

Partial Text: Rabies is a viral zoonotic infection of the central nervous system caused by a lyssavirus, and its mortality rate is nearly 100% without proper post-exposure prophylaxis (PEP). As one of the most feared diseases throughout human history, rabies is widely distributed throughout the world with high mortality, leading to 55,000 human deaths each year [1]. China has the second highest rate of human rabies in Asia, where domestic dogs are the main source of infection and are the primary vector for human rabies. Towards the end of the last century, China encountered the third wave of human rabies since 1949 [2,3], and the reemerging disease was among the top three causes of human death due to infectious diseases in the country [4]. The rapid increase of domestic dog population and inadequate PEP for humans bitten by dogs were thought to be the important factors driving the high incidence of human rabies in mainland China [5–8]. However, data about the burden of canine rabies in China is limited given the lack of detailed data on the number of domestic dogs and comprehensive rabies surveillance among dogs in the country [9,10].

Rabies is considered one of the most dangerous but neglected diseases in developing countries, with the greatest burden in the poorest rural communities where 15 million people need PEP every year [28]. In China, rabies is thought to be under-reported or under-recognized, resulting in an under-estimation of the true disease burden [7].The State Council issued official notices in 2009 and 2012 underlining rabies control as a priority with control objectives between 2015 and 2020 [29,30]. Our study highlighted both the strengths and gaps in the rabies control efforts in China. Despite the decline in human rabies cases at the national level since 2008, especially successful control in historically high-incidence provinces, China has to face a new complication that rabies started to spread from high-incidence regions towards low-incidence regions, as evidenced in our statistical and phylogeographic analyses.



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