Integration of human rabies surveillance and preventive measures in the State of Ceará, Northeast Brazil

Aim: To analyze the One Health approach regarding rabies surveillance, control, and prevention in Brazil’s Cear á State, exemplified by a detailed description of rabies cases that occurred over 18 years. Methods: We described in depth the history, case development, surveillance, and prevention measures of all cases of human rabies, 2004-2021. We analyzed patient charts and reviewed technical reports of the State Health Secretariat, in addition to analysis of personal notes from field missions. Results: All six cases occurred in rural areas. The affected people came from resource-poor communities. The state rapid response team performed comprehensive actions and seminars in collaboration with the Municipal Health Secretariats and other stakeholder groups. Patients and their relatives were not aware about the risk of wildlife-mediated rabies. A high number of wild animals (marmosets) kept as pets were collected in the communities. Only one patient presented at a primary health care center before the onset of symptoms but did not receive any post-exposure prophylaxis due to logistic problems. Even after onset of symptoms, in all cases, the suspected diagnosis was not rabies at first. In four cases, transmission occurred by marmosets ( Callithrix jacchus ), one by a hematophagous bat ( Desmodus rotundus ), and another by a domestic dog, though the identified viral strain was sylvatic. All patients died. Conclusion: Rabies in Cear á is a wildlife-mediated disease of the most vulnerable rural populations. There is a need for ongoing integrated surveillance and control measures, information and education campaigns, and professional training, especially focusing on wildlife-mediated rabies. An integrated One Health approach - as exemplified by the presented rabies control program in Cear á - is critical for human rabies elimination. with fever and pain in the arm but was taken to the local hospital only on the following day. The pediatrician prescribed antipyretic and analgesic drugs, and ice compresses. He did not ask about any history of animal contact. In the subsequent three days, the boy remained with moderate fever, and lack of appetite. On 26th February, he presented episodes of frequent vomiting. The day after, he was taken again to the local hospital. Another day later, his general condition worsened. Until now, diagnosis the diagnosis was dengue fever. On 29th February, the physicians suspected meningitis and transferred him to the reference hospital in the region in Barbalha municipality. There, rabies was suspected for the first time, and family members were asked about animal contacts, which was confirmed to be happened about 27 days ago. The Recife Protocol was implemented immediately, but the boy died on 12th March Intervention: The state rapid response team immediately conducted active case finding of individuals who had contact with saliva of the boy, or with the animal. The grandmother had contact with both, and on 4th March developed fever, nausea, vomiting, fatigue, and headache, but the diagnosis of rabies could be excluded. She was referred to the hospital in Jati and remained hospitalized, receiving post-exposure prophylaxis only administered on 7th March. The nursing technician and uncles had contact with the child's secretion, and seven children who were with him at the time of the aggression had contact with the marmoset. All exposed individuals underwent medical evaluation and received post-exposure prophylaxis. Educational video presentations and lectures were performed for schoolchildren. The primary health care teams assisted lectures on the epidemiological aspects of rabies, and post-exposure prophylaxis. During these lectures, the health professionals and also the population informed the rapid response team that several people, both in the rural and urban areas, would capture and keep wild animals as pets, mainly marmosets and capuchin monkeys. House-to-house visits in the community were carried out, to alert the population of the risk of keeping wild animals. A total of nine animals were collected (eight marmosets and a capuchin monkey) and delivered to the environmental authorities. The animals were microchipped and an oral swab was collected for antibody analysis, with negative result in all cases Case #6 (2016), Iracema municipality