Rabia – zoonoză sau problemă de sănătate publică?

Rabies is an infectious viral disease of mammals caused by the rabies virus, a neurotropic virus of the genus Lyssavirus, family Rhabdoviridae, which is found in the saliva of infected animals. Other names for the disease are “mad dog disease” or “hydrophobia” (the Greek term for “fear of water”). The Greek word “lyssa”, used to refer to rabies, means “madness”, thus summarizing the dramatic nature of the symptoms^(1,2). The disease can spread to mammals (including humans) if there are breaks in the skin that allow the direct contact with infected fluids – saliva (bites, scratches). Subsequently, the rabies virus infects the central nervous system (brain and spinal cord), causing a series of initially nonspecific signs and symptoms. In exceptional cases, humans can be infected even without being bitten: either by handling an infected animal, alive or dead, or by inhaling the virus.

This usually occurs if the virus is present in very large quantities (e.g., in caves where bats live) or in the case of unsupervised children living in unsanitary areas (e.g., in the developing countries)^(2,3).

People living in disadvantaged areas with poor vaccination policies are at greater risk of contracting the disease from a rabid animal^(3,4). Also, handling certain wild animals, such as bats or raccoons, exposes people to infection. Contact with unpasteurized milk can also be a way of transmitting rabies, especially in children, but these cases are rare. Children are at a higher risk of infection due to certain risk factors, including bites from infected animals and accidental exposure to urine or other secretions from infected animals. It should be noted that children sometimes do not report the contact with a suspected infected animal, which can unfortunately lead to a delay in diagnosis.

The categories of people who are at greater risk of contracting rabies than the general population are^(4-7): travelers (especially the very young and the elderly), veterinarians, zoo employees, sanitation workers, cavers, laboratory technicians, people with open wounds in the neck or head area (as these can facilitate a faster transmission of the virus to the brain), transplant patients, those undergoing chronic immunosuppressive therapy (the immunosuppressed status of these patients favors the multiplication of viruses).

The first symptoms of rabies can appear within a few days to almost a year, but most symptoms appear four to six weeks after infection⁽⁶⁾. The symptoms may be similar to those of influenza, including weakness, discomfort, fever, cough, dry throat or headache⁽⁷⁾. There may also be stinging, burning, tingling, numbness, or itching at the site of the bite. These symptoms may last for several days. The symptoms then progress to brain dysfunction, anxiety, confusion and agitation. As the disease progresses, the person may experience delirium, abnormal behavior, hallucinations, hydrophobia (fear of water) or aerophobia (fear of air), muscle spasms in the face, neck or diaphragm (the muscle responsible for breathing), and insomnia.

The acute phase of the disease usually ends after two to ten days. Once the clinical signs of rabies appear, the disease is almost always fatal. Other symptoms that may occur are abdominal pain, paralysis (the only symptom in paralytic rabies, caused by vampire bat bites), large variations in body temperature, heart and respiratory failure.

Human rabies can be confirmed intravitally and post-mortem by various diagnostic techniques that detect the whole viruses, viral antigens, or nucleic acids in infected tissues (brain, skin or saliva):

• Direct fluorescent antibody test – a common, rapid test that detects the proteins that make up the rabies virus; the rest is done by taking a tissue sample from the potentially infected area.
• Polymerase chain reaction test – it detects the genetic material (DNA) of proteins in the rabies virus; it is very accurate and can be done from saliva, cerebrospinal fluid, or any other tissue.
• Histopathological examination – used to confirm the diagnosis in infected humans.

The treatment of rabies in its early stages involves the administration of rabies immunoglobulin and rabies vaccine within 72 hours of exposure. This post-exposure prophylaxis (PEP) can prevent the development of the disease in people exposed to the virus, so the rapid diagnosis and the immediate treatment of rabies are essential to increase the chances of survival for those affected. Educating the population about the risks associated with rabies and preventive measures is crucial to reducing the incidence of the disease.

After a person has suffered a potentially rabies-infected wound (e.g., dog bite), it is necessary to adopt the correct prophylactic measures as quickly as possible in order to prevent rabies^(10,11). The prophylactic measures that should be taken by a person who has suffered a potentially rabies-infected wound are:

• washing the wound thoroughly with soap and water for at least 15 minutes
• proper cleaning of the wound
• access health services as soon as possible, in order to assess the risk of rabies as quickly as possible and determine the need to start rabies vaccination and rabies seroprophylaxis.

A wound with potential for rabies may also have potential for tetanus, so the medical staff should also consider tetanus prophylaxis.

Complications of rabies may include: convulsions, fasciculations (short muscle contractions), psychosis, aphasia, autonomic instability, paralysis, coma and death.

Rabies prevention is essential to reduce the risk of transmission of the disease to humans and animals^(10,11) through the following measures:

• Pet vaccination – vaccinating dogs and cats is essen­tial in preventing rabies. This is done by administering a rabies vaccine, which stimulates the animal’s immune system to produce antibodies against the rabies virus. Vaccination is carried out regularly, as recommended by the veterinarian, to maintain effective protection against the disease.
• Personal protection measures – to prevent exposure to the rabies virus, it is important to avoid the contact with wild animals or unfamiliar domestic animals and not to feed or touch them. It is also essential to supervise pets during walks and keep them on a leash to prevent contact with other animals. In the event of animal bites or scratches, it is necessary to immediately clean the wound with soap and water and consult a doctor.
• Public education – informing and raising awareness among the population about rabies and prevention measures are essential to reduce the risk of disease transmission. Information campaigns may include the distribution of informational materials, the organization of seminars and workshops, and the promotion of responsible behavior towards pets and the protection of public health.
• Control and monitoring of wild animal populations – authorities play an important role in preventing rabies by managing and monitoring wild animal populations that may carry the virus, such as foxes, bats or skunks. This may include capturing and vaccinating certain species of wild animals, reducing animal numbers through ethical methods, and constantly monitoring the cases of rabies recorded among wild animals.
• Voluntary vaccination of occupational groups at high risk of exposure to rabies is essential – veterinarians, sanitation workers, zoo employees, etc.

The use of pre-exposure prophylaxis (PrEP) is recommended only in well-defined populations where the risk of exposure is high (poor countries in Africa or Asia), the access to post-exposure prophylaxis is limited, and the control in animal reservoirs is difficult, mainly due to the high cost of rabies serum⁽¹²⁾. Fatal cases that can occur even after patients (especially children) receive post-exposure prophylaxis underscore the critical role of pre-exposure prophylaxis⁽¹³⁾. Delays in diagnosis and treatment initiation, as well as deviation from recommended protocols (wound hygiene, administration of rabies immunoglobulin or vaccine) are associated with increased morbidity and mortality. These have been correlated with an extended incubation period for the rabies virus, allowing viral propagation in the central nervous system and enabling it to progress unchecked⁽¹³⁾.

Mass media has reported numerous cases of rabies in recent months, including one fatal case, with infections in a wide variety of animals (cows, lemurs, deer), with many patients and their contacts seeking specific prophylaxis from emergency services. In most situations, the known prevention rules are being violated (direct contact with dead animals, failure to vaccinate animals, dangerous exposure to wild animals at the zoo).

At the “Sf. Parascheva” Clinical Hospital for Infectious Diseases, in Iași, Romania, the statistics show an increase in reported and vaccinated cases from 2020 to 2024, with a slight decrease in the last year. However, in 2025, 28 rabies outbreaks were confirmed, with 190 human contacts, a record so far (Figure 1).

There is a higher proportion of fully vaccinated patients compared to those who are partially vaccinated (Figure 2).

In 2023, we reached a total of 661 children aged 14 years old who presented with potentially rabies-related wounds at the Triage Unit of the “Sfânta Parascheva” Clinical Hospital for Infectious Diseases in Iași, most of them from rural areas, who were vaccinated (the complete schedule in most cases) – Figure 3.

A year later, in 2024, there was an exponential increase in the number of adults and children over the age of 14 from urban areas who came for vaccination (Figure 4).

In 2025 (January-August), there was a balanced ratio of urban/rural patients (Figure 5), with a few cases receiving media attention due to the particular nature of the animals involved (Figure 6).

The animals involved were:

• Dogs
• Rats
• Others (cow, lemur, fox, baboon, cat, bat, deer, jackal).

The patients’ contacts were also vaccinated, their number being impressive in some cases (as shown in Figure 7), which required additional financial efforts regarding the need for specific prophylaxis, including rabies serum, but also tetanus serum, given that there was a risk of concomitant tetanus infection.

A case admitted with a diagnosis of person exposed to rabies requiring the administration of rabies serum with specific immunoglobulin – KamRAB® (four vials on average) + Verorab® (vial I) + Tetavax® (vial I) – costs 5540 RON, which are not fully covered by the health insurance, having a significant financial burden on patients.

Therefore, the introduction of rabies serum into a national health program should be considered, thus ensuring the actual reimbursement of this medication, which is necessary in this condition with a 100% lethal risk. Beyond treatment, adults and caregivers of children at risk of infection should be aware of the danger posed by wild animals (in nature, at the zoo, or those that unwantedly populate urban areas), in order to take preventive measures.

Autor corespondent: Alice-Nicoleta Grudnicki E-mail: agrudnicki@yahoo.com

CONFLICT OF INTEREST: none declared.

FINANCIAL SUPPORT: none declared.

This work is permanently accessible online free of charge and published under the CC-BY.