Rabies: Scientific Basis of the Disease and Its Management

Rabies

Second Edition

Alan C. Jackson

Queen’s University, Kingston, ON, Canada

William H. Wunner

The Wistar Institute, Philadelphia, PA, USA

Academic Press

Table of Contents

Cover image

Title page

Foreword

Preface

Contributors

Chapter 1: The History of Rabies

Publisher Summary

1 INTRODUCTION

2 REMEDIES FOR DOG RABIES FROM THE EARLY AND MIDDLE AGES TO THE 18th CENTURY

3 RABIES IN THE NEW WORLD

4 THE EARLY ROLE OF WILD ANIMALS IN THE SPREAD OF RABIES

5 DEVELOPMENT OF THE FIRST-GENERATION RABIES VACCINE

Chapter 2: Rabies Virus

Publisher Summary

1 INTRODUCTION

2 RABIES VIRUS STRUCTURE

3 RABIES VIRUS REPLICATION

4 LIFE CYCLE OF RABIES VIRUS INFECTION

5 VIRUS CELL-TO-CELL SPREAD – PERPETUATING THE VIRUS LIFE CYCLE

6 STRUCTURE OF RABIES VIRUS PROTEINS IN RELATION TO FUNCTION

Chapter 3: Molecular Epidemiology

Publisher Summary

1 INTRODUCTION

2 METHODS AND DEFINITION OF TERMS

3 VIRAL TAXONOMY

4 ASPECTS OF RABIES PATHOGENESIS AND EVOLUTION REVEALED BY MOLECULAR EPIDEMIOLOGY

5 CONCLUSIONS AND FUTURE TRENDS

ACKNOWLEDGMENTS

Chapter 4: Epidemiology

Publisher Summary

1 INTRODUCTION TO CONCEPTS

2 THE EPIDEMIOLOGY OF HUMAN RABIES

3 ROUTES OF RABIES VIRUS TRANSMISSION TO HUMANS

4 RISK AND PREVENTION OF RABIES FOLLOWING AN EXPOSURE

5 EPIDEMIOLOGY OF RABIES IN MAMMALIAN POPULATIONS

6 DISSEMINATION OF CANINE RABIES AND EVIDENCE FOR PERIODIC CYCLES

7 CROSS-SPECIES TRANSMISSION (SPILLOVER) OF RABIES VIRUS

8 SPATIAL SPREAD AND EPIDEMIOLOGY OF WILDLIFE RABIES

9 CONTROL OF RABIES DIRECTED TOWARD MAMMALIAN RESERVOIR HOSTS

Chapter 5: Rabies in Terrestrial Animals

Publisher Summary

1 INTRODUCTION

2 HOST RANGE AND SUSCEPTIBILITY

3 TRANSMISSION

4 CLINICAL COURSE

5 DIFFERENTIAL DIAGNOSIS

6 VIRAL EXCRETION AND PUBLIC HEALTH IMPLICATIONS

7 RESERVOIRS AND OTHER LYSSAVIRUSES

8 RABIES IN DOMESTIC ANIMALS

9 WILDLIFE RESERVOIRS

10 OTHER ANIMALS AS RESERVOIRS OR SIMPLY SPILLOVER HOSTS?

11 CONCLUSIONS

Chapter 6: Bat Rabies

Publisher Summary

1 INTRODUCTION – GENERAL CONSIDERATIONS ON BAT RABIES

2 BAT RABIES IN THE NEW WORLD

3 BAT RABIES IN THE OLD WORLD

Chapter 7: Human Disease

Publisher Summary

1 INTRODUCTION

2 EXPOSURES, INCUBATION PERIOD AND PRODROMAL SYMPTOMS

3 CLINICAL FORMS OF DISEASE

4 INVESTIGATIONS

5 DIFFERENTIAL DIAGNOSIS

6 THERAPY

7 RECOVERY FROM RABIES

8 RABIES DUE TO OTHER LYSSAVIRUS GENOTYPES

Chapter 8: Pathogenesis

Publisher Summary

1 INTRODUCTION

2 EVENTS AT THE SITE OF EXPOSURE

3 SPREAD TO THE CNS

4 SPREAD WITHIN THE CNS

5 SPREAD FROM THE CNS

6 ANIMAL MODELS OF RABIES VIRUS NEUROVIRULENCE

7 RABIES VIRUS RECEPTORS

8 BRAIN DYSFUNCTION IN RABIES

9 RECOVERY FROM RABIES AND CHRONIC RABIES VIRUS INFECTION

10 SUMMARY

Chapter 9: Pathology

Publisher Summary

1 INTRODUCTION

2 MACROSCOPIC FINDINGS

3 PATHOLOGY IN THE CENTRAL NERVOUS SYSTEM

4 PATHOLOGY IN THE PERIPHERAL NERVOUS SYSTEM

5 PATHOLOGY INVOLVING THE EYE AND EXTRANEURAL ORGANS

6 SUMMARY AND CONCLUSIONS

Chapter 10: Diagnostic Evaluation

Publisher Summary

1 INTRODUCTION

2 POST-MORTEM DIAGNOSIS OF RABIES IN ANIMALS

3 VIRUS ISOLATION

4 USE OF MOLECULAR METHODS TO DETECT VIRAL RNA

5 DIAGNOSIS OF RABIES IN HUMANS

6 RABIES ANTIBODY ASSAYS

ACKNOWLEDGEMENTS

Chapter 11: Rabies Serology

Publisher Summary

1 INTRODUCTION

2 INVESTIGATIVE SEROLOGY

3 SEROLOGIC METHODS

4 CHOOSING AN ASSAY

5 QUALITY ASSURANCE MEASURES

6 CONCLUSIONS

Chapter 12: Immunology

Publisher Summary

1 INTRODUCTION

2 MOLECULAR COMPONENTS OF A SPECIFIC IMMUNE RESPONSE

3 IMMUNE RESPONSES DURING RABV INFECTION

4 IMMUNOLOGICAL BASIS FOR POST-EXPOSURE VACCINATION EFFICIENCY

5 CONCLUSIONS

Chapter 13: Human Rabies Vaccines

Publisher Summary

1 INTRODUCTION

2 VALUE OF VACCINATION

3 NERVE TISSUE VACCINES

4 CELL CULTURE VACCINES

5 CONCLUSIONS

Chapter 14: Animal Vaccines

Publisher Summary

1 INTRODUCTION

2 ANIMAL RABIES VACCINES

Chapter 15: Next Generation Rabies Vaccines

Publisher Summary

1 INTRODUCTION

2 RECOMBINANT VIRUS VACCINES

3 DNA-BASED RABIES VACCINES

4 ORAL RABIES VACCINES DERIVED FROM PLANTS

Chapter 16: Public Health Management of Humans at Risk

Publisher Summary

1 INTRODUCTION

2 PRE-EXPOSURE VACCINATION

3 POST-EXPOSURE VACCINATION

4 ADVERSE REACTIONS TO CELL CULTURE VACCINES

5 INTERCHANGEABILITY OF VACCINES

6 RABIES IN CHILDREN

7 TRAVEL TO CANINE RABIES ENDEMIC COUNTRIES

8 RABIES CONTROL IN DEVELOPING COUNTRIES

9 EDUCATIONAL AWARENESS

Chapter 17: Dog Rabies and its Control

Publisher Summary

1 INTRODUCTION

2 THE BURDEN OF CANINE RABIES

3 HISTORICAL PERSPECTIVES ON DOG RABIES CONTROL

4 DOG ACCESSIBILITY

5 VACCINATION COVERAGE

6 THE EPIDEMIOLOGICAL THEORY OF DOG RABIES CONTROL

7 ORAL VACCINATION OF DOGS

8 AGE AT FIRST VACCINATION

9 DOG RABIES CONTROL IN WILDLIFE CONSERVATION

10 ECONOMICS OF DOG VACCINATION FOR RABIES CONTROL

11 DOG POPULATION MANAGEMENT

12 CONCLUSION

ACKNOWLEDGEMENTS

Chapter 18: Rabies Control in Wild Carnivores

Publisher Summary

1 INTRODUCTION

2 HISTORICAL ASPECTS OF RABIES CONTROL IN WILDLIFE

3 THE CONCEPT OF CONTROLLING RABIES IN WILDLIFE

4 INITIATION OF WILDLIFE RABIES CONTROL PROGRAMS

5 DIAGNOSIS OF SUSPECT WILDLIFE

6 VECTOR SPECIES BIOLOGY IN RELATION TO RABIES EPIDEMIOLOGY

7 TRANSPORTATION OF WILDLIFE

8 POINT INFECTION CONTROL: THE FIRST CALL FOR CONTROL

9 BAIT DEVELOPMENT FOR DELIVERY OF ORAL RABIES VACCINE

10 ORV INITIATION/CONSIDERATIONS

11 IMPORTANCE OF VECTOR HOME RANGE AND DENSITY FOR VACCINE BAIT DISTRIBUTION

12 LARGE-SCALE VACCINE BAIT DISTRIBUTION TECHNOLOGY

13 SURVEILLANCE PRIOR TO, DURING AND AFTER A RABIES CONTROL PROGRAM

14 VACCINE BAITING COSTS/BENEFITS AND COSTS OF RABIES CONTROL

15 VACCINE BAITING EFFICIENCY AND BAITING SUCCESS GUIDELINES

16 CONTINGENCY PLANNING

17 MODELING

18 CONCLUSION

Chapter 19: Future Developments and Challenges

Publisher Summary

1 INTRODUCTION

2 PATHOGENESIS

3 EPIDEMIOLOGY

4 PREVENTION OF HUMAN RABIES

5 DIAGNOSIS AND THERAPY OF HUMAN RABIES

6 CONTROL OF ANIMAL RABIES

7 SUMMARY

Index

Foreword

Since the publication of the first edition of this book, Rabies, in 2002, there has been much progress in research on rabies virus and the other lyssaviruses and the disease they cause, i.e. clinical rabies. The reservoir and terminal hosts and their immune defenses, the pathogenesis of the disease in humans and animals, the natural history of the viruses in nature and the public health strategies and actions for prevention and control in developed and developing countries have also been the focus of intense research. The editors, Alan Jackson and Bill Wunner, recognizing this progress and seeing the continuing need to keep the subject ‘on the front burner’, envisioned this second edition and, we hope, envision further editions far into the future. The exciting content of this edition proves the foresight of the editors. Those of us who care about rabies virus and the other lyssaviruses and the disease they cause are grateful that the editors and the chapter authors have taken on the hard work to bring this edition to fruition.

Progress in research and, indeed, in public health disease prevention and control strategies and actions seems to be made in fits-and-starts – not smoothly across the whole subject, but concentrated in ‘hot spots’ that are often grounded in emerging technologies, personal interests of investigators and, most importantly, in changing disease threats. Although I am interested in every facet of rabies, from the viruses themselves, to their discovery and natural history, to their molecular biology, and in all aspects of the disease they cause, from its pathology and epidemiology, to public health disease prevention and control strategies and actions, as I read this edition I found myself exercising old biases and focusing on particular favorite ‘hot spots’. I am sure that others will see different ‘hot spots’, but for the moment here are my favorites:

• Pasteur – again and always – the father of the infectious disease sciences, who used rabies as the basis for so many lessons. Like so many other virologists and infectious disease scientists, I never get tired of Pasteur’s charge: ‘Dans les champs de l’observation le hasard ne favorise que les esprits préparés.’ ‘In matters of observation chance favors only the prepared mind.’ These words come from a speech Pasteur gave at the age of thirty-one as he was installed as Professor and Dean of the newly created Faculty of Sciences at Lille, well in advance of any of the discoveries for which he is best remembered. As I read this second edition I thought that Pasteur’s words are well aimed at the youngest, most forward-looking of rabies researchers.

• Modern history – my classmate, George Baer, has provided a comprehensive history chapter emphasizing the classical aspects of rabies history, a subject I never tire of. As I think about this, I like to reflect also on the modern history of the disease and the virus. I say this because as the generations turn over, newcomers to rabies research and public service can learn much from their predecessors, their pre-PubMed predecessors. In the 20th century there were many wonderful discoveries and discoverers that advanced our understanding of rabies: for example, Remlinger (1903) and the proof that rabies is caused by a virus; Negri (1903) and discovery of the Negri body; Goodpasture (1925) and the beginnings of rabies experimental pathology; Hoyt and Jungeblut (1930) and the utility of the laboratory mouse; Queiroz-Lima (1934) and the beginnings of the vampire bat rabies story; Kliger and Bernkopf (1938) and the adaptation of rabies virus to grow in embryonating chicken eggs; Johnson and Koprowski and their colleagues, over many decades making many practical discoveries; Constantine (1968) and the ecology of bat rabies in the USA; Kissling (1958) and early cultivation of rabies virus in cell culture; Kissling and Goldwasser (1958) and the application of immunofluorescence to rabies diagnostics; Davies and colleagues and Atanasiu and colleagues (1963) and the first negative contrast electron microscopic images of rabies virus; Matsumoto and Miyamoto (1965) and the first thin-section electron microscopy of rabies virus and the Negri body; Baer, Schneider, and others (1960s) and initial rabies pathogenesis studies; Dierks and Murphy (1968) and the first study of the nature of rabies infection in the salivary gland; Murphy and colleagues (1973) and comprehensive rabies pathogenesis studies in experimental animals; Shope and colleagues (1970) and the first identification of rabies-related viruses (Mokola and Lagos bat virus); Meredith and colleagues (1970) and the discovery of Duvenhage virus; Wiktor, Sokol, Wunner, Clark, Dietzschold, Obijeski, Flamand and others (1970s) and the first rabies molecular virology studies (RNA, proteins, replication); Wiktor, Koprowski, Smith and others (1978) and the development of panels of monoclonal antibodies to type rabies virus antigenic variants; Smith, Rupprecht and colleagues and the use of partial genomic sequencing to characterize rabies virus genotypes and to build the first phylogenetic trees; Schneider, Bourhy, Tordo, Grauballe, Nieuwenhuijs, King, Fooks, Dietzschold, Rupprecht and others (∼1977–1993) and the discovery and genetic characterization of the European bat lyssaviruses, EBL1 and EBL2; Fraser, Gould, Hooper and colleagues (1996) and the discovery of Australian bat lyssavirus; and so many other people and discoveries. This kind of list is dangerous in that I am sure to have left out many key discoveries and discoverers and, in so doing, I will have left myself open to justifiable criticism – nevertheless, I think it is important to recognize and remember these pioneers.

• Molecular epidemiology – as Susan Nadin-Davis states in her chapter, molecular epidemiology has become a central theme in the study of virus-host relationships and the co-adaptation of particular hosts and particular virus genotypes. Phylogenic analysis is also providing powerful insight into the natural history of each virus genotype, especially now that we have a data-based global perspective. Recent discoveries of important ‘spillover events’ as particular virus genotypes have successfully jumped from one reservoir animal species to another are very important; appreciation of these events is largely dependent upon molecular epidemiologic approaches. Darwin lives – evolution continues…

• Taxonomy and strain characterization – extending from the genomic sequence analyses used in molecular epidemiology (above), there has been a remarkable application of phylogenetic programs that have uncovered the complex genetic structure of the lyssavirus genus. In the dendrograms, now including lyssavirus isolates from around the world, we can see the ancient rather insular econiches of various genotypes, especially the econiches constituted by the many bat species that serve as reservoir hosts. We can also see the evidence of the long-term radiation of particular genotypes into new niches. This is wonderful stuff for anyone interested in natural history of viruses. On a more formal level, that of the International Committee on Taxonomy of Viruses, some of the genomic information being placed in the genus-wide dendrograms may challenge our notions of the fine structure of the genus, but that is the way of taxonomy. In the end, the lyssavirus dendrogram makes sense. I am reminded of the extension of the Henle-Koch postulates, the elements of the proof of causation of specific diseases by specific microorganisms, by Alfred Evans. Evans’ extra criteria for the proof of causation were developed to deal with those viruses and viral diseases where the original postulates were found to be inadequate. Evans’ postulates add modern technologies to characterize molecularly viruses and also add improved approaches to the understanding of viral pathogenesis. The last of Evans’ ten postulates states, ‘And the whole thing should make biologic and epidemiologic sense.’ Clearly, the dendrograms outlining the phylogenetic relationships of the genus Lyssavirus ‘make sense’ from the perspective of understanding the natural history of rabies virus and the related viruses. And, we now can see how the lyssaviruses relate to the other member viruses of the family Rhabdoviridae and to the more distantly related member viruses of the order Mononegavirales. Wonderful!

• Terrestrial rabies in newly discovered reservoir host econiches – on one hand, here in the 21st century, we might think we should know about all the econiches occupied by lyssavirus genotypes around the world, but the lesson of recent discoveries is that the world still contains geographic and ecologic niches that hold secrets. In the past few years, three such secrets of particular interest have been unraveled:

1. rabies in non-human primates in Brazil

2. rabies-related viruses (lyssaviruses) in carnivores and bats in subarctic and arboreal zones of Eurasia

3. rabies virus in spotted hyenas in the Serengeti.

The latter, as noted by Alan Jackson in this volume, changes our view of the pathogenicity of the lyssavirus genotypes circulating in terrestrial mammals – the distinct genotype found in spotted hyenas in the Serengeti is not associated with fatal disease, but with subclinical infection, chronic viral carriage and long-term shedding. Much more must be learned about this genotype and this econiche.

• Bat rabies – Ivan Kuzmin and Charles Rupprecht have, in this volume, advanced in remarkable fashion our general knowledge about the natural history, population biology and epidemiology of bat rabies. At last we have a discerning assessment of the older literature on this subject and, for the first time, in my view, we are able to separate fact from fiction regarding rabies in diverse Chiropteran species. And, this subject is far from maturity: just in the past few years we have seen several additional lyssaviruses from bats added to our listings (e.g. Aravan, Khujand, Irkut and West Caucasian bat viruses). Everything we learn about bat rabies is important in guiding human and domestic animal disease prevention and control programs and in guiding bat conservation strategies. The notion that bats are the true ancestral reservoir hosts of rabies virus and other lyssaviruses, as reviewed so nicely by Ivan Kuzmin and Charles Rupprecht, suggests that the entrenched viral econiches are here to stay and that tangential means of disease control will have to serve the needs of public health while, at the same time, serving the interests of conservation. Perhaps this is a lesson for those dealing with many other zoonotic diseases.

• Pathogenesis and molecular pathogenesis – one reminder here that bears on many public health control strategies is that viral ‘exposure’ does not always lead to productive viral infection and a detectable immune response. As Alan Jackson states in his chapter on rabies pathogenesis, most of what we know about the events that take place during rabies infection has been learned from experimental animal models, too often employing fixed laboratory strains of virus and exquisitely susceptible hosts. We need more research employing models that more closely mimic street virus disease in humans and reservoir host animal species. Perhaps then we will be better able to understand the meaning of the presence of small amounts of viral nucleic acid, as detected by PCR, in feral hosts in the absence of progressive disease. Separately, we still have a long way to go to understand the neuroanatomical, neuropathological bases for the behavioral changes in animals with rabies. The mystery so nicely described by Richard Johnson in 1971 still faces us: ‘It is difficult to harmonize the dramatic clinical signs and lethal outcome of street rabies virus infection with the paucity of pathological changes in neurons. The greater localization to the limbic system with relative sparing of the neocortex provides a fascinating clinicopathologic correlate with the alertness, loss of natural timidity, aberrant sexual behavior and aggressiveness that may occur in clinical rabies. No other virus is so diabolically adapted to selective neuronal populations that it can drive the host in fury to transmit the virus to another host animal.’ Clearly, much more research is needed in this area.

• Diagnostics – the direct immunofluorescence technique has served as the cornerstone of rabies diagnosis for the past half century. What was in the days of my initial introduction to virology the most avant-garde diagnostic test in all virology is now the oldest standard test in common use. Charles Trimarchi and Susan Nadin-Davis, in this volume, capture very well the pros-and-cons for change. On the one hand, they point out that improved tests mostly employing PCR variations are available that can be performed more rapidly and at lower cost, and have increased sensitivity and specificity. On the other hand, there is much worry that such tests even when made foolproof in proprietary platforms run the risk of sample cross-contamination (false positives) and unforeseen technical glitches (false negatives) in the setting of the usual rabies labs around the world. While research continues, with a test as robust as the ‘home pregnancy test’ as the goal, it is no wonder that the WHO still recommends direct immunofluorescence as the gold standard post-mortem diagnostic test for rabies.

• Post-exposure rabies treatment – potent anti-rabies immunoglobulin (human or humanized) and potent vaccine regimens have a proven track record, yet there is a crucial need for new ideas, innovative approaches, all favoring cost-containment. Fewer than 1% of post-exposure treatments used in developing countries include modern vaccine and appropriately potent anti-rabies immunoglobulin. Limited availability clearly is a consequence of high costs. Stopgap approaches have been tried, but our real need is for revolutionary technological advances that are exportable to all rabies-endemic countries. This goal seems as far in the future as ever, but if research should be prioritized to deal with our most important problems, then here is the most important research target in the rabies public health enterprise.

• New vaccines – following the advent of cell-culture-based rabies vaccines in the 1970s, there have been few major conceptual advances, at least in the downstream end of vaccine development, application and use. As Bill Wunner notes in his chapter, new generation rabies vaccines must be developed, which are inexpensive, stable, requiring one or at most two doses and, hopefully, even efficacious by the oral route of administration. Many rabies ‘immunogens’ have been developed using various molecular technologies, but it is a long way from expressing rabies virus proteins in vitro to the construction of a vaccine ready for clinical trials and field application. More needs to be done to expand the downstream vaccine development infrastructure that will yield the kinds of vaccine for use in rabies-endemic countries, as envisioned by Bill Wunner. Further, the differences in the goals for human vaccines versus domestic animal vaccines versus wildlife vaccines are clear enough, but there are common downstream technology and infrastructure development issues that suggest the need for further cross-fertilization.

• Public health organization and action, locally, nationally and globally – despite the work of the WHO over many years, there is still a notorious lack of surveillance and disease burden data for some rabies-endemic countries. At the same time dramatic decreases in human rabies cases have been reported in recent years in other countries, particularly in South America. This has followed implementation of programs for improved post-exposure treatment of humans and vaccination of dogs. As Deborah Briggs and B.J. Mahendra note in their chapter, under-estimating the importance of rabies leads decision-makers to perceive rabies as a rare disease, resulting from the bite of an economically unimportant animal (the dog) and therefore not worthy of much prevention and control funding. The fatalistic sense in some parts of the world that ‘rabies will always be with us’ adds to the perception. As T. Jacob John stated recently when reviewing two human rabies cases in Kerala State, Southern India: ‘The adage familiarity breeds contempt is apt here. Dogs are common, dog-bites are also common. People often do not take bites seriously. There are several factors involved in such negligent behavior: belief in pre-destiny or fatalism; non-perception of personal risk; lack of authentic information from public health agencies; availability of non-scientific remedies; inadequate health education in schools, etc. Needless to say, such tragic deaths are preventable.’ Surely, with the experiences gained in changing public perception about other diseases, such as AIDS and tuberculosis, social science research can contribute to solving this kind of problem as it impacts on rabies in developing countries. Additionally, in many countries, rabies falls in the crack between departments (ministries) of health and agriculture, adding to the problem of setting proper priorities, increasing public awareness and gaining appropriate political support.

• Enlisting a new generation of rabies research scientists and public health practitioners – seemingly the ghost of Pasteur, the nature of rabies as a global health problem and the nature of the research and public service work to be done should draw young would-be scientists and public health practitioners into the field like ‘bears to honey’. What a romantic calling to young people who want fulfilling careers! The questions and sense of purpose that have brought inquiring young people into my office over the years should be answered with career advice pertinent to careers dealing with all the zoonoses. In some instances, careers in rabies research and public service have been described in rather insular terms – for too long the rabies unit and its staff has stood alone down at the end of the hallway in many public health institutions. This has been a mistake, in my view: rabies belongs in the same career advice package as descriptions of careers dealing with all zoonoses, including Ebola hemorrhagic fever, West Nile virus encephalitis, Hantavirus pulmonary syndrome, SARS, avian influenza, and others that are identified as ‘new, emerging or re-emerging infectious diseases’. I think that this volume, reflecting the state of the art in rabies research and public service, is full of ‘hooks’ that should influence career decisions of the next generation of would-be scientists and public health practitioners.

This second edition of Rabies not only brings to the reader a wealth of new information representing the major advances in research on rabies virus and the other lyssaviruses and on the disease, rabies, it also provides an updated scientific base for guiding rabies prevention and control programs. Public health officials are on the front lines in global efforts to minimize the human and economic burden presented by the lyssaviruses. The practical application of research breakthroughs, such as improved vaccines and diagnostics, is the key to dealing with rabies as a global health problem. In this edition, we can see many remarkable advances in disease prevention and control programs in many developing countries. Even so, however, given the prevalence of rabies in many of the least developed countries of the world, we must continue with all facets of research and development, always thinking of least-cost, and develop the most practicable intervention strategies. There is still much to be done.

I would, in closing, like to express again my congratulations to the editors, Alan Jackson and Bill Wunner, for their vision in seeing the need for this second edition and for their hard work in bringing their vision to reality. I would also like to congratulate the authors for contributing such excellent chapters. I sense their love of the work and their fidelity to Pasteur’s pioneering leadership. As I think of the editors and authors, I conclude that the scientific base for rabies prevention and control, globally, is in good hands.

Frederick A. Murphy,     Department of Pathology University of Texas Medical Branch Galveston, Texas, USA

Preface

Globally, rabies continues to be an important disease of humans and animals and it is one of the deadliest human diseases. During the past five years since publication of the first edition of Rabies, there have been new developments in many areas on the rabies landscape. This edition takes on a more global perspective on rabies. Many new authors, who are leaders in their areas of expertise, offer fresh outlooks on their topics. Rabies has a very rich and lengthy history dating from antiquity. Pasteur’s first human rabies vaccination in 1885 followed centuries of terror associated with the disease and ineffective ‘treatments’ after bites by rabid animals. There were countless superstitions and misconceptions about the disease, many of which exist disquietly to this day in many parts of the world. Rabid dogs continue to be responsible for most human deaths, while wild carnivores, including foxes, skunks and raccoons, maintain sylvatic reservoirs and enzootic cycles of rabies virus infection. A new chapter on bat rabies has been added in this edition because of its importance. Bats are indigenous, quintessential reservoirs for lyssaviruses (rabies and rabies-related viruses) on a global basis and the associated virus variants are responsible for continuing human and veterinary mortalities in both developed and developing countries. Information on vaccines to control rabies virus infection has been expanded into three separate chapters. There have been considerable new developments in epidemiology and molecular epidemiology. New approaches to therapy of human rabies are discussed as well as issues involving organ and tissue transplantation. This edition describes recent successes in controlling wildlife rabies using a variety of innovative methods in the USA, Canada and Europe.

This new edition is again a truly multidisciplinary effort by contributors in the fields of medicine, veterinary medicine, virology, immunology, wildlife biology, epidemiology and geography, and we are very grateful for their efforts. We believe that this edition will again be very useful to medical and veterinary clinicians, public health officials, research scientists and students in their efforts to understand better rabies and to diagnose and prevent the disease worldwide. We are making progress, but much more work remains to be done on this ancient disease.

Alan C. Jackson and William H. Wunner

Contributors

George M. Baer,     Laboratorios Baer, S.A. de C.V., Hacienda Sta. Maria Xalostóc, Tlaxco, Tlaxcala 90250, Mexico

Deborah J. Briggs,     Rabies Diagnostic Laboratory, Department of Diagnostic Medicine/Pathobiology, College of Veterinary Medicine, Kansas State University, Manhattan, Kansas 66506, USA

James E. Childs,     Department of Epidemiology and Public Health and YIBS Center for Eco-Epidemiology, Yale University School of Medicine, New Haven, Connecticut 06510, USA

Sarah Cleaveland,     Centre for Tropical Veterinary Medicine, Royal (Dick) School of Veterinary Studies, University of Edinburgh, Roslin, Midlothian, EH25 9RG, UK

David W. Dreesen,     Department of Infectious Diseases, College of Veterinary Medicine, The University of Georgia, Athens, Georgia 30602, USA

Eric Fèvre,     Centre for Infectious Diseases, University of Edinburgh, Ashworth Labs, Edinburgh, EH9 3JF, UK

Chandra R. Gordon,     Rabies Diagnostic Laboratory, Department of Diagnostic Medicine/Pathobiology, College of Veterinary Medicine, Kansas State University, Manhattan, Kansas 66506, USA

Cathleen A. Hanlon,     Centers for Disease Control and Prevention, Atlanta, Georgia 30333, USA

Alan C. Jackson

Departments of Medicine (Neurology) and of Microbiology and Immunology, Queen’s University, Kingston, ON K7L 3N6, Canada

Departments of Internal Medicine (Neurology) and of Medical Microbiology, University of Manitoba, Winnipeg, MB R3A IR9, Canada

David H. Johnston,     Johnston Biotech, Sarnia, ON N7V 3B5, Canada

Magai Kaare,     Centre for Tropical Veterinary Medicine, Royal (Dick) School of Veterinary Studies, University of Edinburgh, Roslin, Midlothian, EH25 9RG, UK

Darryn Knobel,     Centre for Tropical Veterinary Medicine, Royal (Dick) School of Veterinary Studies, University of Edinburgh, Roslin, Midlothian, EH25 9RG, UK

Ivan V. Kuzmin,     Rabies Section, Centers for Disease Control and Prevention, Atlanta, Georgia 30333, USA

Monique Lafon,     Department of Virology, Pasteur Institute, 75724 Paris Cedex 15, France

B.J. Mahendra,     Department of Community Medicine, Mandya Institute of Medical Sciences, Mandya, Karnataka 571401, India

Susan M. Moore,     Rabies Diagnostic Laboratory, Department of Diagnostic Medicine/Pathobiology, College of Veterinary Medicine, Kansas State University, Manhattan, Kansas 66506, USA

Frederick A. Murphy,     University of Texas Medical Branch, Galveston Department of Pathology, Galveston, Texas 77555-0609, USA

Susan A. Nadin-Davis,     Centre of Expertise for Rabies, Canadian Food Inspection Agency, Ottawa Laboratory (Fallowfield), Ottawa, ON K2H 8P9, Canada

Michael Niezgoda,     Centers for Disease Control and Prevention, Atlanta, Georgia 30333, USA

Leslie A. Real,     Department of Biology and Center for Disease Ecology, Emory University, Atlanta, Georgia 30322, USA

Richard C. Rosatte,     Ontario Ministry of Natural Resources, Wildlife Research and Development Section, Trent University, Peterborough, ON K9J 7B8, Canada

John P. Rossiter,     Department of Pathology and Molecular Medicine, Richardson Laboratory, Queen’s University, Kingston, ON K7L 3N6, Canada

Charles E. Rupprecht,     Rabies Section, Centers for Disease Control and Prevention, Atlanta, Georgia 30333, USA

Rowland R. Tinline,     Queen’s GIS Laboratory, Department of Geography, Queen’s University, Kingston, ON K7L 3N6, Canada

Charles V. Trimarchi,     Wadsworth Center, New York State Department of Health, Albany, New York 12202-0509, USA

William H. Wunner,     The Wistar Institute, Philadelphia, Pennsylvania 19104-4268, USA

1

The History of Rabies

GEORGE M. BAER,     Laboratorios Baer, S.A. de C.V., Hacienda Sta. Maria Xalostóc, Tlaxco, Tlaxcala 90250, Mexico

Publisher Summary

This chapter provides an overview of history of rabies. For centuries, humans have felt terror after getting bitten by rabid dogs. But one has to take a mighty leap into the past to realize that until the 19th century, there was no accurate diagnosis of the disease in humans or animals, no isolation of the infectious agent, no animal control, and no human treatment. The role of wild animals in transmitting rabies was recognized by Celsus. Many of the histories of violent outbreaks in wild animals and the resultant human cases involved wolves. Canine rabies in most industrialized countries is reduced to almost nil, although the number of reported wildlife rabies cases has increased. The control of wildlife rabies is another matter, with no possibility of vaccinating the hundreds of thousands of animals needed to reduce the disease by needle and syringe. The oral vaccination method has resulted in the elimination of rabies in many Western European countries and eastern Canada, through the use of a variety of attenuated and recombinant rabies vaccines, and is also being used in raccoons and coyotes. Human rabies cases in the developing world are almost always transmitted by rabid dogs, but the situation in the developed world has changed radically.

1 INTRODUCTION

For centuries man has felt terror after bites by rabid dogs. Rabies is unique: one almost always knows when and where the bite occurred. But one has to take a mighty leap into the past to realize that, until the 19th century, there was no accurate diagnosis of the disease in man or animals, no isolation of the infectious agent, no animal control and no human treatment. The first written record of the disease comes from the Eshnunna code, 23rd century BC: ‘If a dog is mad and the authorities have brought the fact to the knowledge of its owner; if he does not keep it in, and it bites a man and causes his death, then the owner shall pay two-thirds of a mine of silver’ (Théodorides, 1986). So it is apparent that the connection between the bite and the danger of death was known even then. Some 1300 years later, Homer, in the 9th century BC compares Hector to a rabid dog (‘I cannot kill this raging dog’) and in Democritus, 5th century BC, one is able to read a description of the disease in the dog. Aristotle, in the 4th century BC, wrote in the ‘Natural History of Animals’, ‘…dogs suffer from the madness. This causes them to become very irritable and all animals they bite become diseased…’, although he considered that man was not affected by the disease.

Plato (4th century BC) used the word ‘Lyssa’ to describe erotic passion. Caelius Aurelianus (500 AD) suggests that Homer had the sufferings of a hydrophobic in mind when describing the torment of Tantalus in Hades, with water before him but not able to drink it. Many Greek or Latin classical authors knew of the existence of rabies; Xenophon speaks of it in his ‘Anabasis’, Virgil in the ‘Georgics’ and Ovid in his ‘Metamorphosis’.

Some early opinions, such as in the Talmud, suggested that rabies could be caused by witches’ spells or evil spirits (Rosner, 1974). Hekabe, the widow of Priam, king of Troy, was thought to be transformed into a raging dog. Avicenna, also known as Ibn Sina in the Islamic world, included the suggestion that rabies could arise through changes in ambient temperatures, the same general belief that the Romans held in attributing rabies to the star Sirius (from the Greek ‘Seirious’ meaning scorching or blazing, since it appeared with the sun in the hottest part of the year). The Romans adapted the Babylonian stellar system and called it the dog star or ‘canis’, with the hottest days of the year being ‘dies canicularis’ or dog days. Among others, Pliny (1st century AD) believed that this was a time when dogs were most susceptible to rabies, an idea which still persists in some parts of the world. Even in the 1st century, the optimism about curing rabies was not shared by Scribonius Largus, who affirms that a rabid patient is never cured, ‘Nemo adhuc, corruptum hoc male expeditus est’ (No one until now corrupted with this evil is freed therefrom).

Galen, the 2nd century doctor, contributed to the dehydrative cause of rabies, writing about ‘the extreme dryness’ that arises in the solid parts of the animal; he also believed that only dogs were susceptible and wrote that, ‘so great does the corruption of their humours become that their spittle alone, if it falls upon a man, can make him become rabid’.

One widespread myth was that rabies was caused by a small ‘worm’ at the base of the tongue. A contemporary poet of Ovid (1st century BC), Grattius Falistcus, knew about the mythical origin of the sublingual ‘lyssa’ of rabid dogs that Pliny popularized; they believed that extracting the worms completely cured the dog. And as a preventive, this worm was also thought to possess magical curative powers in preventing the disease in the person bitten when it was injected, but only after having been carried three times around a fire. Prevention was also thought to be obtained by eating a cock’s brain. Other remedies included one coxcomb, some goose fat mixed with some honey, the salted flesh of a rabid dog, some maggots from the carcass of a rabid dog, etc.; and as many remedies existed for the local application of ‘preventers’, or for mixing them in drinks or food. Moreover, there were numerous talismans ‘capable’ of diverting rabid dogs from a person, such as a dog’s heart or placing a dog’s tongue in one’s shoes, or arming oneself with a tail of a weasel. But one of the most common ‘preventers’ of rabies has always been to pray for divine intervention (Figure 1.1), an evocation which many times was successful, for the variety of reasons later known.

Figure 1.1 A votive giving thanks to the holy virgin for saving the life of a boy from rabies: ‘We give you thanks, little virgin, for keeping my son from dying after he was bitten by a dog with rabies while playing with him, so when we saw that tragedy we called on you to perform the miracle of saving his life, and that’s the way it was.’ Soledad District, May 22, 1927. This figure is reproduced in the color plate section.

2 REMEDIES FOR DOG RABIES FROM THE EARLY AND MIDDLE AGES TO THE 18th CENTURY

The incurability of the disease has led to superstitions for centuries and one of the most celebrated is that of St Hubert, the 8th century evangelizer of the Ardennes and bishop of Liege (Belgium), most known because he was ‘patron of the hunters’ and protector against rabies (Tricot-Roye, 1926).

One writ from that time states:

This power was once demonstrated by a celebrated miracle, reported in the ‘Cantatorium’. One day, when St Hubert was preaching, a man afflicted with manic rabies entered into the church, his teeth gnashed, a bloody slobber ran from his mouth, his eyes emitted flames, he gave out some frightful roars, he launched himself like a maddened beast into the midst of the faithful, who fled in the most vivid terror. St Hubert faced him without manifesting the least emotion, extended his hands toward the unfortunate man and said: ‘May the Lord Jesus heal you’. Calm immediately reappeared on the convulsed features of the patient, his nerves relaxed. The saint wiped away the bloody slobber from the mouth; the sick man smiled and, himself, brought back to the sanctuary a part of those who had just fled from him with great fright. The cult of St Hubert extended to his being the patron against rabies as well as against ‘dullighedon’ or mental diseases. People bitten by dogs went to priests for the operation of ‘cutting’; the penitent presents the forehead to the priest, who then makes a tiny incision and raises a bit of skin in order to insert a small fragment of the stole that belonged to the great saint. This stole had come from heaven while St Hubert prayed on the tomb of St Peter in Rome. The forehead is then bound up with a black headband. It appears that between 500 and 800 cuttings per year were generally carried out. In addition, animals bitten by rabid dogs were ‘treated’ in the cult of St Hubert: a key that St Hubert received from the hands of the pope was heated to red hot and applied, glowing, to the animal’s wounds. This cauterization was supplemented by five to nine days of penitence imposed on the owner and by a diet of ‘blessed’ oat bread.

As early as the 1st century BC, Cicero called attention to hydrophobia – thirst and fear of water – and described the precautions to be taken as well as immediate cauterization of the wound or its suction (the latter being the hereditary privilege of the families of the ‘suckers of poison’). Cicero also stressed the preventive cauterization or extirpation ‘en bloc’ of the wound, the same that Galen, the 2nd century AD doctor of the gladiators and father of the medicine of humours, recommended in his turn. Celsus recommended, besides, a bathing, especially in sea water, the moment the disease made its appearance; the patient was suddenly thrown into the water, and if he did not know how to swim one should let him sink so that he swallowed some water, then he was taken out in order to be plunged in again. This saturation of water was to suppress the thirst and the hydrophobia. This heroic therapeutic measure remained in repute until the early part of the 19th century. In 1735, Shrewsbury (1952) cited two individuals who advertised their skills as successful ‘Dippers of Man and Beast’, charging high fees for immersing unfortunate victims of dog bites in the tidal waters of the River Severn. One advertised as follows: ‘William Bennet at the George Inn at Whitminster, six miles below Gloucester, Continueth to Dip Man and Beast…in the Salt Water, with Success’. Popular belief in the efficacy of ‘dipping’ was widespread.

There has been a plethora of herbal remedies used for rabies throughout the ages, from filbert nuts to hellebore, to rose oil, to camomile tea. The variety of these remedies may be seen in Nicholas Culpepper’s ‘Complete Herbal’, first published in England in 1649. In the last 350 years, 41 editions of this famous work have been published. A 1983 edition lists 40 plants, reputedly valuable in relieving the effects of bites and stings in general. Nine of these plants receive particular mention in the treatment of ‘mad dogs’ (Table 1.1).

TABLE 1.1

Herbal remedies recommended by Culpepper for the bites of mad dogs

aEspecially recommended for mad dog bites – Avicenna and Dioscorides quoted under balm. Compiled from lists in Culpepper’s Coloured Herbal (D. Potterton and E.J. Shellard, eds). W. Foulsham & Co, 1983.

During the Middle Ages, epizootics of rabies in dogs were reported in many countries. Not surprisingly, most reports came from Europe since much of the history of the disease comes from that part of the world. The first description of human rabies in China was recorded in the grey record ‘Zhou Chuan’ 556 BC: ‘The native Chinese chased and caught rabid dogs’. Another description of rabies appears in the book ‘Priceless Prescription’ by Sun Si-Miao, from the Tang Dynasty, 618 AD: ‘Starting from the end of spring to the beginning of the summer, nearly all dogs became rabid; warning must be given to the children and to the weak people to take sticks in hands to defend against attack by rabid dogs’. Still in 1931, there were 272 human cases in Shanghai, all but one transmitted by rabid dogs; canine rabies was eliminated there in 1949 (Lin Fangtao, personal communication, July 21, 1989). Rabies outbreaks in Europe appear to have been rare until the Middle Ages, with most cases caused by single dog bites. One of the first outbreaks was reported in Franconia in 1271, caused by wolves: 30 people died following bites by the rabid wolves (Steele, 1975). By 1500, Spain was reporting many rabid dogs. By 1586, outbreaks of rabies in dogs were reported in Flanders, Austria, Hungary and Turkey. By 1604, rabies was widespread in Paris. In the early 1700s, rabies was common all over Europe, especially in the central countries, in foxes and wolves. The first mention of the disease in Great Britain is in the laws of Howel the Good (Hywed Dda), in 1026, where it is reported that numerous dogs were suffering from ‘madness’ (King et al., 2004). It authorized any suspect dog to be killed, provided that clinical signs of rabies had been observed in the animal, i.e. a severely inflamed tongue and a frequent tendency to fight with other dogs. In the 1800s, rabies appears to have been widespread in Europe, especially France, Germany and England. An extensive outbreak in foxes occurred in the Jura Alps in eastern France beginning in 1803; this was reported as the largest outbreak ever seen, with hundreds of dead foxes seen in the surrounding foothills. Many people, dogs, pigs and other animals were bitten. In 1804, the disease appeared in the West German states and, by 1819, spread into the upper Danube and Bavaria; by 1825, it had entered the Black Forest (Steele and Fernandez, 1991). Fox rabies did not spread to northern Germany, unlike its spread from the Oder-Neisse line in the late 1930s (Duwer-Dohrmann, 1950; Starke et al. 1961; Seroka, 1977), which eventually covered almost half of France and even extended into northern Italy.

3 RABIES IN THE NEW WORLD

Even though the first reports of rabies in terrestrial animals in the New World came from Mexico in 1709 (Carrada Bravo, 1978), there are numerous descriptions of attacks by vampire bats on the Spanish conquistadores in the Mexican peninsula of Yucatan and south of the Darien strait (now Colombia) two hundred years earlier, where, in 1514, Fernandez de Oviedo wrote (Molina Solis, 1896) that many soldiers died after being bitten by bats. The native Indians discovered that burning the wounds with hot coals eliminated the danger. But the disease was most likely absent in dogs until the Spanish conquest. At the beginning of the 16th century, a 16th century manuscript from Ecuador states that: ‘In Quito, nor in any part of Meridional America, plague is to be found…likewise the disease of rabies in dogs is totally unknown….’ (America Meridional). In 1591, the viceroy of Mexico, Luís Velasco, published a book on ‘The Indies’ in which he states, ‘And thus the animals of the Indies never get rabies’. Smithcors (1958), too, states that there are no pre-colonial references to rabies in the Americas. Pferd (1987) and Varner and Varner (1983) cited by Childs (2002) mention that importation of dogs from Europe to the New World was known from the time of the second voyage of Columbus. The limited genetic diversity found among canine rabies isolates (Smith, 1989) suggests that the introduction of dog rabies into the New World is due to European colonization with the simultaneous introduction of dogs and their diseases (Smith et al., 1992). Rabies must have appeared in Mexico before 1709, the first date in which it was reported there in terrestrial animals. Later on, many countries in the New World reported the disease. Rabies was common in Virginia in 1753 (Steele, 1975) and ‘alarmingly frequent’ in Boston by 1768. George Washington, in his diaries, refers to rabies twice: on July 5, 1769 (Fitzpatrick, 1931) he wrote, ‘A Dog coming here which I suspected to be Mad I shot him, Several of the Hounds running upon him may have got bit. Note the consequences’ and, on Tuesday, August 28, 1786 (Fitzpatrick, 1932) he wrote, ‘A Hound bitch which like most of my other hounds appearing to be going Mad and had been shut up, my servant Will, in attempting to get her in again, was snapped at by her at the Arm. The Teeth penetrating through his Coat and Shirt and contused the Flesh, but he says did not penetrate the skin nor draw any blood’.

The first major epizootic in North America was apparently reported between 1768 and 1771, with foxes and dogs transmitting the disease to pigs and other domestic animals. In 1779, rabies was very common in Philadelphia and Maryland. Canine madness was raging all over the colonial states of North America in 1785, continuing until 1789. In 1797, the disease appeared in Rhode Island in an epizootic in dogs and the domestic animals they bit. The disease reappeared in the eastern states of USA in 1810 and in Ohio in dogs, foxes and wolves (Steele, 1975). Records of rabies cases are more complete in the last two centuries and newspaper articles attest to the burden that rabies inflicted and the widespread distribution of the disease; as examples, articles from New York City (Figure 1.2) and Indiana (Figure 1.3) cite human cases from dog bites. The case reported from Brooklyn, in which six persons were bitten and one died, also shows the way people in 1872 still held age-old beliefs about rabies cures: ‘When told that there was no efficacy in applying the dog’s hair to the wound, or in permitting the child to eat the animal’s heart and liver raw, he [the father of one of the children bitten…] was much troubled’. As is apparent, rabid dogs were biting people, other dogs and cats and livestock in urban and rural areas all over the USA. And it was not until twenty years later that Negri discovered ‘bodies’ in animal brains, making the diagnosis of the disease possible (Negri, 1903).

Figure 1.2 ‘The Horrors of Hydrophobia – Six Children Bitten by a Rabid Dog in Brooklyn.’ From the New York Times, March 8, 1872.

Figure 1.3 ‘His Pet Spaniel Killed Him. An Indiana Farmer The Victim of Hydrophobia.’ From the New York Times, July 1, 1891.

4 THE EARLY ROLE OF WILD ANIMALS IN THE SPREAD OF RABIES

The role of wild animals in transmitting rabies was recognized by Celsus in the 1st century AD. Many of the histories of violent outbreaks in wild animals and the resultant human cases involved wolves. One recent, notorious report of a wolf attack in Iran (Baltazard et al., 1955) is similar to reports of wolf attacks from the Middle Ages – and describes the anguish of an affected city:

…towards 1:00 in the morning…a large wolf entered the sleeping village of Sahane, on the international road from Teheran to Baghdad and Damascus…The part of the village along the road included only a few ghavehkanehs (inns), the filling station, the hospital., the police station, and a few houses or shops. Sahane…is a rather frequent stopping place…because of its location at the halfway point on the road, and on this night a dozen trucks and buses had stopped there…with the drivers sleeping inside the inns or outside because of the heat. The wolf came from the mountains bordering on the northeast, through the orchards and vineyards, where no habitation is found, but where, at this time, slept the guards in charge of watching the fruit. Going from one orchard to another towards the southwest, jumping the low dirt walls, or the thorn hedges, the beast attacked in succession 13 persons, the majority bedded down, which explains the number of bites on the head. Some few, awakened, fought with the wolf. One person, awakened with a start by the attack of the beast, was wounded on the cranium; 5 minutes later he was attacked again. This attack in the orchards and vineyards lasted more than two hours; from all sides the people cried and lit lanterns, and the drive was organized. But during this time the wolf had entered the village itself, and in the center of the village it attacked a blind beggar who slept in the street, entered the bazaar and here attacked another person inside a house where the door was left open; from there it jumped into a yard, then over the terrace of the houses where it attacked an old woman. Then it disappeared, and its itinerary became poorly determined…

As already mentioned, the first mention of rabies in the New World came at the start of the 16th century (Tellez Giron, 1977) from the description of men dying after being bitten by (vampire) bats (as early as 1514). Cattle epizootics attributed to vampire bats were reported during the 16th century in Guatemala (Licenciado Palacio al Rey D. Felipe II, 1576), during the 18th century in Ecuador and during the 19th century in Trinidad (de Verteiul, 1858). Although the first mention of the disease in terrestrial animals in North America was in foxes in Virginia in 1753, skunk rabies was also noted as early as the middle 1800s in the Midwest states. It appears to have been a most serious problem in the 1800s, so much that cowboys had to set up ‘phobey tents’ to keep from being bitten by rabid skunks at night (Charlton et al., 1975).

Centuries before the beginning of vaccine development in the late 19th century, literally dozens of different types of ‘treatments’ to prevent rabies had been recommended. It appears that Celsus (25 AD) first wrote about the treatment of wounds by searing them with hot irons or ‘cupping’ them to draw out the poison. In the first centuries AD, cautery became widely adopted (Baer et al., 1996) as part of the immediate treatment of bites by rabid dogs. Galen (131–200 AD) wrote about the need for prompt local treatment and advised that the wound be kept open to prevent ‘absorption’ of the poison. Early ‘treatments’, reviewed by Fleming (1872), include eating a cock’s brain or a cock’s comb pounded and applied to the wound and using grease and honey as a poultice. The flesh of a mad dog was sometimes salted and taken with food as a remedy. In addition, young puppies of the same sex as the biting dog were drowned and the person bitten ate their liver, raw. Other treatments (Pliny, 23–79 AD) included applying the ashes of the dog’s head to the wound, or placing a maggot from the carcass of the dead dog on the wound. Maimonides, a 12th century Talmudic scholar and physician, wrote a treatise on ‘Poisons and Their Antidotes’ at the request of Sultan Al Afdal, including a description of various ‘remedies against the bite of mad dogs’. Questions about the ‘source’ of the disease came from early times. Numerous doctors of the famous school of Alexandria (Egypt) in their writings localize the ‘hydrophobia’ sometimes in the stomach, sometimes in the brain; they wrote a book called ‘Kynolossus’ (rabies in the dog). Celsus, a learned man in the time of Augustus Caesar, belongs to the group of encyclopedists. From his complete work ‘De Artibus’ (‘On the Arts’), one chapter is ‘de arte medica,’ written between 25 and 35 AD. In it he describes rabies in man and affirms that the saliva of a rabid dog is infectious (‘autem omnis morsus habet fere quoaddam virus’); ‘virus’ in that and other Roman writings, was apparently a synonym for poisons of any kind. Many ancient writers refer to the ‘virus’ that caused the disease and its transmission by the ‘spittle’ of the dog. From the first century AD comes the ‘first recorded attempt at defining the cause of rabies and prescribing treatment’ (Neville, 2004). This comes in a poem entitled ‘On Hunting’ by Grattius Faliscus, a contemporary of Ovid (43 BC – 18 AD).

5 DEVELOPMENT OF THE FIRST-GENERATION RABIES VACCINE

It was not until 1804 that Zinke demonstrated that rabies could be transmitted by saliva (Zinke, 1804). He took the saliva from a rabid dog and brushed it into incisions that he had made on the foreleg of a young dachshund. The dog sickened on the seventh day; on the eighth day it refused food and water and ‘crawled into the corner of his cage’. By the tenth day rabid symptoms were obvious. There was no mention of it being a live agent, although Zinke wrote a series of articles on the pathogenesis of the disease and its ‘treatment’. Many of the studies carried out in the 19th century centered on ways to reproduce the disease by animal injection; during those early studies many routes were used in trying to achieve 100% mortality, since intramuscular and subcutaneous injections did not reach that level. Some of the routes used were intravenous, intraocular, intranasal and intraneural. As already emphasized by Théodorides, Galtier’s work on rabies was a crucial preamble to Pasteur’s work on the disease.

Galtier (1879) showed that the disease could be transmitted to rabbits by injection and by bite. Pasteur followed much of the rabbit studies that Galtier had initiated, citing them in detail in series of communications in his 1881 ‘Sur Une Maladie Nouvelle Provoquee par la Salive d’un Enfant Mort de La Rage’ [On a Disease Caused by the Saliva of an Infant that Died of Rabies]. Or, ‘un precieux travail de M. Galtier, professeur a l’Ecole veterinaire de Lyon, travail qu’il al’Academie des sciences…nous a appris: Ier que les symptoms de la rage du chien inoculee au lapin, n’apparaissent que de quatre a quarante jours après l’inoculation du virus; 2nd que le lapin mort de la rage ne presente pas de lesions anatomiques de l’ordre de celles ci-dessus indiquees; 3er que le sang des lapins morts de la rage ne peut communiquer la maladie’ [In a very precise work by Mr Galtier, professor of the Veterinary School at Lyon, presented in the Academy of Sciences, he has shared with us the following: first, that material from a dog with the symptoms of rabies, inoculated into rabbits, does not appear until the fourth or fifth day after the inoculation of the virus; second, that the rabbit that died of rabies does not show the lesions in the cells indicated; third, the blood of rabbits that died of rabies cannot transmit the disease]. Pasteur made two landmark discoveries, which eventually led to the famous vaccine that he developed: first, that the brain (and spinal cord) ‘housed’ the virus. (He had earlier written: ‘Le virus rabique, dit ce savant observateur, existe dans la bave, tout le monde le sait. Mais d’ou vient-il? Ou est-il elabore?…’ [Rabies virus, says the knowledgeable observer, exists in the spittle, the whole world knows that. But…where does it come from? Where is it produced?]); and, second, that injection of ‘virus’ material into the brain itself (‘…under the dura mater…’) (‘Je prende un autre exemple portant sur des lapins et par un mode d’inoculation different, celui de la trepanation’) invariably resulted in the paralysis and death of the animal from rabies.

This, of course, is what permitted the ‘fixation’ of the virus in two ways: ‘fixed’ in that it always caused the disease in the inoculated animal, and ‘fixed’ in that the incubation period was a standard 5–7 days after inoculation. Thus, it was not until the landmark studies of Pasteur (Figure 1.4) that the brain was recognized as a crucial organ in the pathogenesis of the disease and that the reliability of the serial intracerebral route for virus passage was recognized (this latter finding was immediately recognized for its importance, as confirmed by an article appearing in the front page of the New York Times a few weeks after Pasteur’s discovery (Figure 1.5) (Pasteur, 1881, 1884). After having developed his vaccine and used it on 50 dogs (‘…jeatais arrive a avoir cinquante chiens…’) with much trepidation he began – on July 5, 1885, with the assistance of Vulpian and Grancher – vaccinating young Joseph Meister from the Alsatian town of Meissengott (Pasteur, 1885). The boy had been repeatedly bitten by a dog, the guardian of a grocery store, and was covered in blood; the local physician diagnosed the dog as rabid because it had bloody foam over its mouth; later on the diagnosis was ‘confirmed’ as rabies by ‘pieces of wood in the stomach’.

Figure 1.4 Pasteur Removing a Saliva Sample from a Rabid Dog. A painting by Alfonse Marie Mucha. (Reprinted courtesy of the Institut Pasteur, Paris).

Figure 1.5 ‘Pasteur on Canine Madness. Paris Dispatch to the London Standard.’ The New York Times, March 16, 1884.

Meister had his wounds cauterized by phenic acid 12 hours after the bites; Pasteur began injecting Meister the next afternoon with rabbit spinal cords that had been ‘treated’ in ‘dry air’ in which the virulence ‘slowly disappeared’ (‘…la virulence dispairait lentement…’). The first cord was from rabbits killed on the 23rd of June (14 days‘ drying), the second from the 25th of June (12 days’ drying), and so on, with reduced drying times for each preparation, until the 16th of July, the 9th day in which cords were used that had only been dried one day. Pasteur had written about the need to dry the cords: ‘Si la moelle rabique est mise àl’abri de l’air, dans le gaz acide carbonique, àl’etat humide, la virulence se conserve…sans variation de son intensité rabique…’ [‘If the rabid spinal cord is kept from the air, and under the carbonic acid gas, away from humidity, the virulence is conserved…without any variation in its rabid intensity…’]. Meister survived and the world finally had a treatment for the disease which, for so long, had caused frenzy in people bitten