Prof. dr. Anthony Fooks

Animal and Plant Health Agency (WHO Collaborating Centre for the Characterisation of Rabies and Rabies-Related Viruses, OIE Reference Laboratory for Rabies), New Haw, Addlestone, Surrey, KT15 3NB, United Kingdom. Tel: +44 (0) 208-415-2238. Email: Tony.Fooks@apha.gsi.gov.uk

Your experience with rabies:

What is your education? How long have you been working with rabies? Why did you start working with rabies?

I am educated with a 1st degree (BSc) in Microbiology, an MBA in business and a PhD in Virology. I began working with rabies in 2000 (17-years) when I accepted a job to lead the rabies team in the UK. In 2002, I was appointed director of a World Health Organisation Communicable Disease Surveillance and Response Collaborating Centre for the characterisation of rabies and rabies-related viruses and in 2006, I was appointed a Designated OIE Reference Expert for Rabies. I hold honorary Professorships at the Universities of Liverpool and London in the UK.

* Prof. dr. A.Fooks answers do not reflect the views of APHA or the UK government.

WORLD RABIES DAY

September 28th is the World Rabies Day (WRD), a day dedicated to rabies prevention. What is the role of the rabies scientific community in increasing awareness about rabies? What is its significance to you? Are you doing something to increase awareness about rabies?

I was pivotal along with some of the more experienced members of the Partners for Rabies Prevention (PRP) and Global Alliance for Rabies Control (GARC; 1st director, Dr Debbie Briggs) to initiate and develop WRD. We set this up to ensure rabies awareness was increased and to improve advocacy to governments, international organisations (WHO, FAO and OIE) and to other stakeholders. WRD provided a global platform to raise the awareness of rabies with simple messages to the public with respect to the risk of rabies from a dog bite.

Each year, my team has participated in a WRD event to increase awareness and to raise money for a given rabies charity. This year, the team is undertaking a cross-country run and raising money for the charity, Mission Rabies. I have also made a podcast about rabies, which will be posted to YouTube on Sept 28th.

Awareness:

Do you think people, in general, know what rabies is? Do you think there is a need to increase awareness among the general population?

The general population is not fully aware of all aspects of rabies. In rabies-free countries, individuals are not aware of the risks of bat-mediated rabies and also the risks from travel to rabies-endemic countries, which require prophylactic vaccination in many cases before travel.

Additionally, many physicians in rabies-free countries have rarely seen clinical cases of human rabies and there are some misunderstandings.

In rabies-epizootic countries, there is some ignorance in the general population with respect to the mechanisms of rabies virus transmission, animal hosts and what should be done in the event of an exposure to a ‘suspect’ rabies animal.

Physicians working in rabies-enzootic countries are aware of rabies and yet rarely have the tools (vaccines and immunoglobulin) to treat patients.

Burden:

The global burden of rabies is estimated to be around 60.000 death per year. Do you think the global burden of rabies might be higher?

The number of 60,000 cases is an estimate only and it can only be supposed that the number is an underestimate. My own research in collaboration with colleagues at the University of Liverpool in the UK and Malawi, demonstrated that clinical rabies in humans is often misdiagnosed.

Post-mortems are rarely undertaken in many rabies-enzootic countries and autopsy specimens are as a result not available for confirmatory laboratory testing.

In addition, I have anecdotal evidence of rabies patients in SE Asia being turned away from the hospital with the rationality that nothing can be done to treat the patient.

In these circumstances, the patient will die at home and the case will never be officially recorded as a rabies death. Lastly, in many countries in Africa, due to cultural and religious reasons, rabies still has a negative nuance if confirmed, especially in a child. For this reason, a family might prefer that rabies is not recorded on the death certificate.

Geographical burden:

Why is it a problem of mainly Asia and Africa? What countries experience the most number of rabies cases?

Rabies remains a disease of ignorance, poverty, and injustice.

In countries where rabies remains endemic, controlling the disease is not a human health priority. In many rabies-enzootic countries, rabies is neither a reportable nor a notifiable disease. Resource constrained veterinary services have no legal obligation to investigate ‘suspect’ rabies cases in animals and as a result the presence of rabies virus remains a threat to human health. The majority of human cases of rabies are reported from the Indian sub-continent, parts of Africa and SE Asia. In many of the countries of these regions, dogs are tolerated and not persecuted. This is in contrast to some countries in the Middle East where dogs are killed for religious and cultural reasons and the resulting number of human rabies cases is subsequently lower.

Dogs are the problem:

Some people believe that if we eliminate rabies from stray dogs, rabies will no longer be a problem. Do you think targeting stray dogs is the way to go?

Unowned and stray dogs are not the only factor in the elimination of canine rabies. In the broader more holistic picture, rabies elimination from dogs will result in a concomitant reduction in the number of human rabies cases. Responsible ownership of dogs should include vaccination. Community owned, unowned and stray dogs might not be included in any pre-planned vaccination. Unowned and stray dogs can now be targeted using highly efficacious and safe oral vaccines in consumable baits.

Canine rabies elimination programmes should include the vaccination of unowned and stray dogs as well as the vaccination of owned dogs.

Transmission:

How is rabies transmitted? Do we have to worry about airborne transmission? Can we contract rabies by eating meat of a rabid animal or drinking unpasteurized milk? 

Rabies virus is typically transmitted in saliva from the bite of an infected animal. The bite from a rabid animal, especially dogs results in greater than 95% of human cases of rabies. Airborne transmission of rabies virus has been reported on rare occasions. In addition, on very rare incidents, it has been reported that rabies virus has been contracted from eating uncooked meat. Drinking unpasteurized milk from a rabies infected animal has not been reported to transmit rabies virus.

Pets:

Is rabies a problem in pets? 

Companion animals, mainly pet dogs and cats, are susceptible hosts for rabies and will transmit rabies virus, mainly in their saliva. Under responsible pet ownership, companion animals are routinely vaccinated against rabies and the risk from rabies is therefore greatly reduced. Companion animals participating in the non-commercial movement of pets as part of pet travel schemes must be vaccinated against rabies as a mandatory directive.

Research agenda:

What in your opinion should scientists focus their research on?
The principal research questions include:
1. Lyssavirus host switching events;
2. Antivirals that cross the blood-brain-barrier;
3. Immunity to rabies in bat species.

Sick bats:

Bats are the second most important source of rabies. How can you recognize a bat with rabies? 

Rabies infected bats show similar clinical signs as observed in other terrestrial mammals infected with rabies virus. Bats showing uncharacteristic behavior including flying in daylight, vocalizing, aggressive behavior and being unable to fly should be treated as ‘suspect’ rabies cases.

Other animals:

Certain animals are less at risk of contracting rabies, such as rabbits, squirrels or rats. Whys is that? What about rabies in non-mammals, such as chicken and birds? 

Most mammals can be infected with rabies virus however, not all mammals are considered as either maintenance or reservoir hosts as they are unable to transmit the virus to another host. Experimental rabies virus infection has been reported in birds, but naturally occurring infection of birds has been documented very rarely. An unsubstantiated article from India did report naturally acquired rabies infection in poultry. Under specific conditions, it is theoretically conceivable that cross-species transmission of rabies virus from dogs to poultry in highly endemic areas may be possible. Infection of birds with rabies virus remains to be fully confirmed and better understood.

Which types infect dogs:

Dogs are known to only transmit one type virus, type 1. Why are the other types not endemic in dogs? How does the virus persist in the dog population if dogs eventually die from rabies? 

Dogs transmit rabies virus and have been known to also transmit specific lyssaviruses. The virus persists in the dog population due to the high number of infected dogs, which transmit the virus to a naïve host before death.

Climate change:

Do you think that increased deforestation or climate change leading to increased forest-fire could increase rabies transmission by other animals, such as other canrnivores or bats? 

Other factors that bring naïve hosts into contact with rabies virus infected wildlife, including bats, will increase the possibility of a cross-species transmission event.

Personal experience:

Do you have a personal experience with a rabies victim? 

My team has been responsible for diagnosing all human cases of rabies in the UK. Since 2000, I have coordinated the testing and reporting of positive samples and have liaised directly with physicians managing these rabies cases. Once a human rabies cases has been confirmed in the UK, the medical team provide full palliative care for the patient.

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