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Regul. Mech. Biosyst., 2021, 12(2)
Regulatory Mechanisms
in Biosystems
ISSN 2519-8521 (Print)
ISSN 2520-2588 (Online)
Regul. Mech. Biosyst.,
2021, 12(2), 251–259
doi: 10.15421/022134
Current issues and gaps in the implementation of rabies prevention
in Ukraine in recent decades
I. F. Makovska*, T. M. Krupinina**, V. V. Nedosekov*, T. M. Tsarenko***, Y. A. Novohatniy****, A. S. Fahrion *****
*National University of Life and Environmental Sciences of Ukraine, Kyiv, Ukraine
**Poltava Oblast Center for Diseases Control and Prevention of the Ministry of Health of Ukraine, Poltava, Ukraine
***Bila Tserkva National Agrarian University, Bila Tserkva, Ukraine
****Oblast Center for Diseases Control and Prevention of the Ministry of Health, Kyiv, Ukraine
*****Friedrich-Loeffler-Institut, Greifswald-Insel Riems, Germany
Article info
Received 16.03.2021
Received in revised form 25.04.2021
Accepted 28.04.2021
National University of Life and Environmental
Sciences of Ukraine, Heroiv Oborony st., 15,
building 3, Kyiv, 03041, Ukraine.
Tel:+38-093-833-19-77.
E-mаіl: iryna.makovska@nubip.edu.ua
Poltava Oblast Center for Diseases Control
and Prevention of the Ministry of Health
of Ukraine, Vatutina st., 35a, Poltava, 36039,
Ukraine. Tel: +38-067-799-96-85.
E-mail: krupinina@ukr.net
Bila Tserkva National Agrarian University,
Soborna st., 8/1, Bila Tserkva, 09117, Ukraine.
Tel.:+38-068-353-63-69.
E-mail: taras.m.tsarenko@gmail.com
Oblast Center for Diseases Control and
Prevention of the Ministry of Health,
Herzen st., 31, Kyiv, 04050, Ukraine.
Tel.:+38-073-406-60-42.
E-mail: y.nov.oni@ukr.net
Friedrich-Loeffler-Institut, Federal Research
Institute for Animal Health, Südufer 10,
Greifswald-Insel Riems, 17493, Germany.
Tel.:+49-038-351-70. E-mail: anna.fahrion@fli.de
Makovska, I. F., Krupinina, T. M., Nedosekov, V. V., Tsarenko, T. M., Novohatniy, Y. A., & Fahrion, A. S. (2021).
Current issues and gaps in the implementation of rabies prevention in Ukraine in recent decades. Regulatory Me-
chanisms in Biosystems, 12(2), 251–259. doi:10.15421/022134
Ukraine remains the only country in Europe where rabies is widespread among animals and humans. Annually
there are about 1,600 rabies cases in animals in Ukraine and sporadic cases in humans have been registered despite the
conducting of preventive measures. Therefore, the aim of the study was to inspect the failures in rabies prevention, indi-
cate the top reasons for human cases and highlights the risk of animal attacks in view of their species and geographical
distribution in Ukraine during 1996–2020. The following archival state materials were used for analysis: from the Minis-
try of Health of Ukraine and from the annual reports of oblast departments of the State Service of Ukraine for Food
Safety and Consumer Protection. In general, more than 84,000 people (187.4 per 100,000 of the population) were af-
fected by bites or harmful contact with animals every year, among them, 2,155 people were victims of rabid animals.
Post-exposure prophylaxis (PEP) was prescribed annually, on average, for 21,434 patients (25.5% of all victims). Most
people were attacked by cats and dogs that had owners (71.5%). The frequency of the proportion of the risk of attacks by
rabid dogs on humans was (1:124), from cats (1:25), wild animals (1:7), and farm animals (1:2), but the largest general
proportion of animal attacks on people was from dogs – 838,635 attacks (77.7%). Thus, due to the permanently higher
level of contact with people, attacks by dogs remains more dangerous. Geographically attacks on humans by domestic
carnivores were observed most commonly in the east part of Ukraine due to the high urbanization of the region and the
high density of the human population. A large number of attacks by foxes was observed in the west part of Ukraine due
to the larger area of forests and fields. During the last 25 years, there have been 63 human rabies cases. The main sources
of rabies were dogs (24 cases) and cats (22 cases). The main causes of development of rabies were: failure to receive the
PEP due to the absence of a visit to a hospital after an attack of an animal (n = 38), failures in prescribing PEP (n = 15),
failure of PEP (n = 10). In conclusion, the gaps in the control measures against rabies are the lack of agreed coordination
of inter-sectoral links, the lack of significant efforts to raise public awareness and the lack of funding for prophylaxis
programmes for humans and animals. Our future research will be aimed at modelling the transmission of rabies from the
pet population to humans.
Keywords: epidemiology of rabies; rabid animals; dog bites; rabies exposure; rabies vaccines; spatial distribution.
Introduction
Rabies is a fatal viral disease that can be prevented by a vaccine
(Fooks et al., 2017, World Health Organization, 2018). Rabies is transmit-
ted to humans through contact with sick animals whose saliva contains the
virus. The main carriers of rabies for humans are unvaccinated domestic
carnivores that can get rabies (Rupprecht & Salahuddin, 2019; Klein et al.,
2020). Many countries have managed to get rid of rabies, the agent of
which is transmitted mainly through dog bites, or to significantly improve
the endemic situation (Franka & Wallace, 2018; Meyerhoff et al., 2021).
This success has been achieved primarily by the use of effective policies
and programmes that focus on campaigns for vaccination of dogs, public
awareness-raising, widespread use and availability of post-exposure pro-
phylaxis (PEP) (Calvelage et al., 2020; Meyerhoff et al., 2021). Although
mass vaccination of dogs is expected to be an important part of any effec-
tive strategy, the most important issue in preventing human rabies is the
vaccination of people living in rabies-endemic countries before and after
exposure (Baghi et al., 2019; Brookes et al., 2019; Gholami & Alamdary,
2020). In addition, human rabies occurs more than in 150 countries and
territories (Fooks et al., 2017; Fisher et al., 2018). Dog rabies produces
around 59,000 human deaths, more than 3.7 million people with disability
adjustments and $ 8.6 billion of economic damages every year around the
globe (Shwiff et al., 2013; Robardet et al., 2019; Yoder et al., 2019).
As reported by Hampson et al. (2015), the biggest component of the eco-
nomic burden relates to premature death (55.0%), under which direct
expenses for prevention measures (PEP, 20.0%) and medicines are in-
cluded in the PEP (15.5%), with limited costs for vaccination of animals
(1.5%) and extra expenses associated with livestock loss (6.0%). Besides
this, all consequences also combine losses correlated with the risk of hu-
man fatality, which leads to total economic damages caused by canine
rabies of $ 120 billion (Regea, 2017; Anderson et al., 2019). In Ukraine,
the prescribed course of anti-rabies vaccinations costs about $ 215 per
human, depending on the severity of the bite. In general economic costs of
treating rabies are enormous: the cost of the vaccine consumed annually
251
Regul. Mech. Biosyst., 2021, 12(2)
for humans is about $ 1 million, excluding rabies immunoglobulin used
for the combined course of vaccinations (Antonova et al., 2021). In addi-
tion, about $ 3 million during the last 10 years in Ukraine were lost due to
livestock rabies, while there are also considerable losses from funding
vaccination campaigns for wild and domestic carnivores which unfortu-
nately were ineffective (Kornienko et al., 2019; Taylor et al., 2021).
During the last few decades, more than 100,000 people (almost 210
per 100,000 population) turned to medical institutions for treatment of
animal bites annually. Every year, up to 23,000 people have been pre-
scribed rabies vaccinations (Kornienko et al., 2019; Polupan et al., 2021).
Historically, before 1970, dogs were a common reservoir and sources of
rabies in Ukraine, however, due to the increasing population of wildlife,
the main reservoir and source of rabies in Ukraine became red foxes
(Vulpes vulpes) (Botvinkin & Kosenko, 2004; Baker et al., 2020). As re-
ported by Makovska et al. (2020) from 2000 to 2019 foxes accounted for
88.3% of wildlife rabies cases and 36.5% of general rabies cases. Besides
these, domestic carnivores (including strays) were additional sources of
rabies. Cats accounted for 25.5% and dogs for 19.3%. The last high peak
of the incidence of rabies in animals was recorded in 2007 with the num-
ber of laboratory confirmed cases 2,932. Since 2007 the number of rabies
cases among domesticated companion animals has increased and in 2016
the number of rabies cases in cats was higher than in foxes (Drozhzhe,
2015; Makovska et al., 2018; Kornienko et al., 2019).
The difficult epizootic situation with rabies in animals poses a perma-
nent threat of complicating the epidemic situation in Ukraine. Based on
the results of epizootiological laboratory monitoring, there has been a pro-
nounced tendency with respect to human rabies infections: reduction of
manifestations of rabies among foxes and an increase among cats and
dogs. Thus, during 1997–2017, cats were the source of rabies for humans
in 39.6% of cases, dogs – in 29.3% and foxes – only in 20.7%, others –
8.7%, bats – 1.7%. The most meaningful factors of the increasing role of
domestic carnivores as a source of rabies for humans are low levels of
specific rabies prevention in domestic animals and the increased density of
the population of stray dogs and cats (Polupan et al., 2021). Among the
most important preventive measures which need to covered by monitor-
ring are problems of irresponsible pet ownership, stray dogs and cats, the
possibility of full immune prophylaxis of rabies (both in humans and
animals). Lack of reliable information is one of the main obstacles to
effective prevention and control of human rabies, not only at the global but
also at the national level (Grigoryan & Metlin, 2016; Acharya et al., 2020).
In this respect, the aim of our study is to indicate the problems, gaps
and failures in rabies prevention, investigation of the main reasons for
human rabies cases and highlighting the risk of animal attacks in view of
their species and geographical distribution on all territory of Ukraine du-
ring 1996–2020.
Materials and methods
In Ukraine, the function of the implementation of epidemiological
surveillance of rabies is entrusted to 24 oblast laboratory centres of the
Ministry of Health of Ukraine. The post-exposure prophylaxis prescripti-
on takes place at 726 units and 22 centres of rabies assistance (points of
PEP) operating under traumatological or surgical units of health facilities
of the Ministry of Health at rayon or oblast levels. First aid to those af-
fected by animals is provided at any health facility with further referral to
the PEP unit. Constant components of monitoring include recording the
number of cases when patients refer to healthcare facilities with injuries
resulting from animal attacks or from other dangerous contacts with ani-
mals. The number of cases is recorded by the species of animals that at-
tacked people. Information about post-exposure prophylaxis is taken into
account too. Monthly official statistical reports on cases of infectious
diseases in humans and animals are prepared. There is constant monitor-
ring of indicators of surveillance and exchange of information between the
Ministry of Health of Ukraine facilities and veterinary medicine facilities
regarding the epidemic and epizootic situation of rabies, the cases of ani-
mal attacks on people and the results of diagnosis of rabies in these and
other animals, the need for and results of quarantine of attacking animals,
PEP scope and other preventive measures. Monitoring involves the con-
stant exchange of information between different institutions. The relation-
ship between institutions that implement epidemiological surveillance,
medical care, and veterinary medicine is particularly close.
Сonsolidated data from various sources were used to analyze prob-
lems and gaps in knowledge about rabies. Sources of primary data were
the following archival materials about human rabies cases reported in
Ukraine from 1996 to 2020; state statistical reporting from national reports
of infectious diseases in humans, information from epidemiologists’ re-
ports about investigations of human rabies cases and monitoring data for
rabies surveillance from the Ministry of Health of Ukraine. Information
about the human population was obtained from the State Statistics Service
of Ukraine. The data regarding visits to health facilities by patients who
suffered from animal attacks and the post-exposure prophylaxis scope
were available from national monitoring tables (2007–2019) with indica-
tors of epidemiological surveillance for rabies. Information on age, sex,
localization of injuries, incubation period, laboratory confirmation was in
some cases incomplete. Specific case descriptions were taken from the
above analytical references, reports of cases of rabies, data of oblast level
monitoring, scientific publications, personal experience. We also used
available data about the animals, wild or domestic, if they had an owner,
vaccination against rabies. The data included the number of attacks on
people by rabid animals, as well as the number of cases of using post-
exposure prophylaxis and implementation of other preventive measures.
The veterinary medicine oblast departments of the State Service of Uk-
raine for Food Safety and Consumer carried out epizootiology surveil-
lance of rabies in Ukraine. Data on the epizootic situation were obtained
from official annual reports of the oblast laboratories of veterinary medi-
cine and oblast departments of the state veterinary service for the period
from 2007 to 2019. Only laboratory-confirmed cases of animal rabies
were recorded.
All mentioned data were aligned and consolidated by time and geo-
graphic affiliation for visualization and analysis of the problem of rabies in
Ukraine. For spatial analysis free QGIS 3.4.6 (the USA, 2019) software
were used. The choropleth maps were created using projection CRS:
EPSG:102013 Europe Albers Equal Area Conic. Vector layers of Ukrai-
ne’s borders and oblasts were obtained using free spatial data Diva-Gis
(www.diva-gis.org/Data).
Results
In Ukraine, for the period 1996–2020, there were 63 cases of human
deaths from rabies. Among these 63 fatal cases, there were 51 adults and 12
children (aged from 3 to17). In terms of spatial distribution, human rabies
cases were observed in the majority of administrative oblasts of Ukraine
(Fig. 1).
Fig. 1. Dispersion of rabies cases in humans per oblast
during 1996–2020 according to the official statistical data
of the Ministry of Health of Ukraine
Frequency of reported cases varied between 1 to 7 cases per year.
The higher peaks were registered in 2007. There were no cases reported
252
Regul. Mech. Biosyst., 2021, 12(2)
for 2012, however, one person infected in 2012 died after a 3-month incu-
bation period, in 2013 (Fig. 2).
Fig. 2. The annual number of rabies cases in humans in Ukraine
according to the official statistical data of the Ministry
of Health of Ukraine (1996–2020)
In 62 out of 63 cases, there were typical clinical manifestations, and
rabies was diagnosed intra vitam, based on anamnesis of animal bites and
clinical signs and in the majority of cases (50) confirmed by laboratory
diagnosis (virus isolation: 13 cases; polymerase chain reaction: 30 cases,
histology: 7 cases). One case was only diagnosed post mortem by poly-
merase chain reaction. Anamnesis of animal bites is contained in the clini-
cal record of 58 cases with different species involved; scratching by un-
known animals in 2 cases; in the 3 remaining cases, there was no record of
an animal attack. Only 7 of the biting animals were tested for rabies, others
are known to have been killed following the attacks on humans without
having been investigated for rabies. None of the involved animals had a
record of rabies vaccination. The leading role as a source of rabies among
the 63 victims who died of rabies in Ukraine from 1996 to 2020 (Fig. 3).
was identified for dogs and cats.
Fig. 3. The proportion of animal species involved
in the 63 human rabies cases in Ukraine (1996–2020)
The majority (58.7%) of the dogs (16) and cats (11) involved in the
63 rabies cases had owners. There were also 19 cases of attacks on people
by stray dogs (8) and stray cats (11). We identified that dogs have increa-
singly become a source of rabies since 2003. Their proportion increased
from 0% for the first 5 years’ observation to 25.0%, 50.0%, 36.8%, 66.7%
respectivly in the following 5-year periods (Fig. 4).
The reasons why rabies could not be prevented in the 63 human cases
were diverse, dominated by the animal bite victims not seeking medical
assistance (n = 38; 60.3%), while the remaining animal bite victims sought
medical assistance and died from rabies nevertheless (n = 25; 39.7%,
Table 1). A majority of the children among the rabies victims (11 out of
12) were in the group which did not seek medical assistance. Parents of
these children did not have any risk perception and did not bring the child
to a health facility, even though in 2 of these cases the parents were human
and veterinary medicine professionals. Seventeen people sought medical
assistance on the day of the animal's attack, 1 on the next day, 4 from the
third to fifth days, and 3 within a week (up to the 7th and 8th days).
The retrospective analysis findings indicate that all of these 25 patients had
to undergo all courses of vaccination which were conducted in Ukraine in
that period in accordance with the recommendations of the Ministry of
Health (Table 2).
As presented in Table 2, some requirements of the instructions until
2016 did not always correspond to the WHO position on rabies vaccines.
Particularly, it was regulated to start the post-exposure prophylaxis only in
the case of the animal showing clinical signs of rabies or disappearance of
the animal (without rabies immune globulin (RIG) or with RIG depen-
ding on the location, depth and number of injuries). Due to observance of
this practice the onset of vaccination was delayed, or vaccination was not
conducted. At the same time, for 15 patients the chance of survival was
lost, as the post-exposure prophylaxis was not carried out. The following
causes of rabies despite seeking medical assistance were reported: errors
during animal quarantine (9.5%); errors in diagnosis of rabies in animals
(3.2%); the refusal of PEP by the patient (6.3%); failure to prescribe post-
exposure prophylaxis (4.8%) (Table 1, Table 2). The remaining 10 pa-
tients out of 25, who applied to health institutions, received post-exposure
prophylaxis, but it turned out to be ineffective as was mentioned in Table 1.
Fig. 4. Changes in the role of different animal species as sources
of human rabies cases in ever 5-year period in Ukraine during 1996–2020
Table 1
The differentiation of the main reasons of rabies cases
in humans in Ukraine (1996–2020), %
Not seeking
medical
assistance
after animal
attacks
Error and risk underestimation while referring
for medical assistance after animal attacks
errors
during
animal
quarantine
errors in
diagnosis
of rabies
in animals
refusal of rabies
postexposure
prophylaxis by
the patient
failure to pre-
scribe rab ies
postexposure
prophylaxis
failure of rabies
post-exposure
prophylaxis
(PEP)
60.3
9.5
3.2
6.3
4.8
15.9
Among the reasons for post-exposure prophylaxis failures (n = 10;
15.9%): in 7 of these cases PEP was given without the use of RIG (pa-
tients No. 1, 2, 4, 5, 6, 9, 10); in 2 cases PEP failures were associated with
the violation of appointment regimen and consumption of alcohol (pa-
tients No. 3, 7); and in 1 case, it is associated with the ineffectiveness of the
vaccine (patient No. 8). The quality of the vaccine used in those cases has
not been verified. Post-exposure prophylaxis was ineffective in victims of
bites by foxes, by stray dogs and cats and bites by dogs and cats which had
owners, with localization rates: face, shin, hand fingers, hip, etc. The full
information regarding the PEP failures described in Table 3.
As can be seen from Table 3, the most common reasons for failure
were scheme breach, late start of course of vaccination and absence of
rabies immune globulin. In total, the analysis of visits by patients who
suffered from contact with animals and the provision of post-exposure
prophylaxis was carried out according to monitoring data for 13 years.
During this period (2007–2019), from 65,916 to 106,496 victims of ani-
mal attacks were registered annually. An average of 84,148 people (187.4
per 100,000 of the population) was affected by animals every year, among
which 2,155 people (4.8 per 100,000 of the population) suffered from
rabid animals. Post-exposure prophylaxis was prescribed annually, on
average, for 21,434 patients (25.4% of those who came for assistance after
animal attacks). Among them, 2,155 people were victims of rabid animals
as confirmed by the laboratory. By the end of each year, 14,619 patients or
68.0% of those who had been prescribed the vaccination completed the
course and were immunized, and 14.3% continued the course of the vac-
cination. The course of vaccination was stopped by doctors in 7.7% of the
11111
5
1
4
1
4
1
7
2
1
3
6
0
3
4
6
4
2
1 1 1
0
1
2
3
4
5
6
7
8
1996
1997
1998
1999
2000
2001
2002
2003
2004
2005
2006
2007
2008
2009
2010
2011
2012
2013
2014
2015
2016
2017
2018
2019
2020
Number of human c ases
24
22
11
5
1
0 5 10 15 20 25 30
Number of animal spe cies
Bats Unknown Fo xes Ca ts Dogs
253
Regul. Mech. Biosyst., 2021, 12(2)
cases after the laboratory exclusion of rabies in the animal or after the
quarantine period for animals was over. In 9.0% of cases, patients refused
to receive vaccinations or arbitrarily interrupted the course. 1.0% of those
who received vaccination were lost to surveillance, possibly due to chang-
ing residence. In addition, by 2015, for post-exposure prophylaxis, pre-
dominantly, a Cocav vaccine, 6 doses into the shoulder muscle under the
Essen regime (daily for 1 dose on 0, 3, 7, 14, 30 and 90th days) was used.
Since 2015, other vaccines for 6 and 5-dose prophylactic vaccination
(Indirab, Verorab, Rabipur) have been used more often (Table 2). Taking
into consideration the number of prescriptions of the combined course, the
annual need for rabies immune globulin was on average 69 L, and for
vaccines more than 110,300 doses. The amount of vaccine used in prac-
tice was almost 3,000 doses less than the total need because the vaccine
was not used in cases of refusal to vaccinate or after interruption of
courses. Since 2011, there has been a sharp decline in the use of the vac-
cine in combination with rabies immune globulin (Fig. 5).
Table 2
The type of rabies vaccines used for humans in Ukraine from 1996 to 2020 according to the official statistical data of the Ministry of Health of Ukraine
Name
of vaccine
Description
Years
of used
Manufacturer Base
Active ingredient/dose
activity, IU*/mL
Dose,
injection site
Mode of
administration
Delaying the start
of the PEP**
Cav
Rabies cultur e inacti-
vated dry vaccine for
human immunization
(Rabivac-Vnukovo-32)
Till 2004
Microgen,
Russia;
Bereh-service,
Ukraine
Primary culture
of the kidney
cells of Syrian
hamsters
Rabies virus
Vnukovo-32 strain/≥0.5
3.0–5.0 mL
by intradermal
7–12 days; booster
dose on the 10th, 20th
day after the main
course
Yes
Cocav
Rabies cultur e inacti-
vated concentrated
purified dry vaccine
From
1999
to 2014
Microgen,
Russia
Primary culture
of the kidney
cells of Syrian
hamsters
Rabies virus
Vnukovo-32 strain/≥2.5
1 mL i
ntramuscular
(deltoid area )
0, 3, 7, 14,
30, 90 days Yes
Verorab
Rabies vaccine for
human use, prepared on
cell cultures (inacti-
vated)
Since 2004
Sanofi Pasteur,
France Vero cell culture
Rabies virus, Wistar
Rabies PM/WI 38-
1503-3M strain (inacti-
vated)/≥2.5
0.5 mL
intramuscular
(deltoid area )
WHO: Essen regi-
men: 0, 3, 7, 14, 28
days. Zagreb regi-
men: 2,1,1 (0-2, 7, 21)
No
Indirab
Rabies, inacti vated,
whole virus Pitman
Moore
Since 2010
Bharat Biotech
International
limited, India
Vero cell culture
Rabies virus
Pitman Moore
strain/≥2.5
0.5 mL
intramuscular
(deltoid area )
Ministry of Health of
Ukraine 0, 3, 7, 14,
28, 90 days. Since
2016, WHO: 0, 3, 7,
24, 28 days
Yes, till 2016
Rabipur Rabies, inactivated,
whole virus Since 2016
Kyron Bering
Vaccines Pri-
vate, India
Primary culture
of fibroblasts of
chicken em-
bryos
Inactivated rabies virus
Fluru LEP strain/≥2.5
1 mL i
ntramuscular
(deltoid area )
WHO: 5-dose: 0, 3, 7,
24, 28 days (since
1997)
Abbreviated: 2,
1, 1 (0, 7, 21 days)
No
Notes: *IU – International Unit; ** – delayed start of the post-exposure prophylaxis means start of vaccinations with the appearance of signs of an animal’s disease or its disap-
pearance in accordance with requirements of “The instructions of the Ministry of Health of Ukraine”.
Table 3
List and possible causes of post-exposure prophylaxis failures in 10 rabies victims in Ukraine (1996–2020)
Year Age
Source/rabies
test result
Localization
of injuries
PEP day
after attack
Drugs
received*
Incubation
period
Recommendations for vaccine
guidelines: category of injuries;
drug administration scheme
Possible causes
of PEP failures
1997 49 fox/negative
face, fingers,
forearms,
body
1
Cav
main treat-
ment course
30 days
Bad case; Rabies immune globulin (RIG)
+Cav 5.0 × 21 days. Revaccination on
10th, 20th, 35th days a fter main treatment
course
Scheme breach : RIG was not
administered (not available)
2001 11 home cat/
positive shin 2 Cav
3.0 х12+2 32 days
Light injuries; Cav 3.0 × 12 days. Revac-
cination on the 10th, 20th day after the
main treatment course
Inadequate assessment of the contact nature,
inadequate PEP course (without RIG). The
effect of acute respiratory infecti on when
receiving PEP is not excluded
2001 27 fox/no test data not
available 1
RIG, Cav
main treat-
ment course
data not
available
RIG +Cav 5.0 × 21 days. Revaccination
on the 10th, 20th, 35th day after the main
treatment cou rse
Scheme breach : did not show up at revacci-
nation on the 10th, 20th, 35th day. Alcohol
drinking during PEP
2003 44 stray dog/
no test shin 1 Cav
3.0 х12+ 2 105 days
Light injuries Cav 3.0 × 12 days, revacci-
nation on the 10th, 20th day after the
treatment cou rse
This category of risk does not include RIG
administration. No RIG administration due to
underestimati on of risk. Stitching the wound.
2004 32 fox/no test nose 2 4 Cocav 34 days
Category III b** RIG Cocav 0, 3, 7, 14,
30, 90
Scheme breach : RIG was not administered
2005 68
home dog/
no test
data not
available
5 4 Cocav 42 days
Category III a***
RIG + CoCAV 0, 3, 7, 14, 30, 90
Late PEP start. Sch eme breach:
RIG was not administered
2007 41 fox/positive
fingers
of the hand
5
RIG,
4 Cocav
27 days
Category III
RIG Cocav 0, 3, 7, 14, 30, 90
Late PEP start. Not enou gh RIG dose Cocav –
the next day Alcohol drinking during PEP.
2007 4
stray cat/
positive
hand fingers 1
RIG,
6 Cocav
103 days
Category III
RIG + Cocav 0, 3, 7, 1 4, 30, 90
Low immunizing power of the vaccine
2013 34 stray dog/
no test hip 8 2 Cocav
4 Indirab 150 days Category III The mode of joint use of
Cocav and Indirab is n ot regulated
Late start of PEP, Scheme breach:
RIG not administered (not available). Differ-
ent vaccines
2014 63 fox/no test face 1 4 Cocav 45 da ys
Category III
RIG + Cocav 0, 3, 7, 14, 30, 90
Scheme breach : RIG was not administered
(not available)
Notes: * – Cav, Cocav, Indirab – cultural rabies vaccines; the assertion that “vaccines from different manufacturers for the prevention of the same infectious diseases can be
interchangeable” does not apply to vaccines Cocav and Indirab; ** – category III b: any bite or slobbering of any localization made by a wild carnivorous animal or a bat; *** –
Category III a: slobbering of damaged mucous membranes, any bite in the head or face, neck, fingers of the hands, perineum, genital wide or deep bites of any localization,
multiple (2 or mor e) bites of a domestic animals.
254
Regul. Mech. Biosyst., 2021, 12(2)
Fig. 5. The number of people who received the prophylactic vaccination
courses during 2008–2019: blue colour – only vaccine; yellow colour –
vaccine and rabies immune globulin; green colour – the percentage
of combined courses (vaccine and rabies immune globulin)
On this curve, we can find a decrease in use of rabies immune globu-
lin during 2014–2016 and also less use of vaccines. In our investigation,
we identified that human rabies cases were confirmed in the period when
rabies was endemic in the territory of Ukraine with numerous of rabies
cases in animals. As we can see from the curve (Fig. 6), rabies cases were
registered each year and counted on average of 1,600 cases per year with a
peak in 2007 among animals.
Fig. 6. Dynamics of rabies cases among animals in Ukraine (1996–2020)
according to annual official reports from oblast departments of the
State Service of Ukraine for Food Safety and Consumer Protection
During 1996–2020 in Ukraine, there were about 37,338 cases of ra-
bies among 18 species of wild and 10 species of domestic animals. Most
of these cases were identified from domestic carnivores. However, most
often rabies was detected among foxes – 37.3%, and among other wild
animals – 2.9%. The share of rabid dogs was more than 19.3%, cats –
24.7%, farm animals – 15.8%. According to the results of epidemiological
surveillance for rabies during 2007–2019, the largest proportion of animal
attacks on people was from dogs (77.7%); the highest proportion of at-
tacking animals actually diagnosed with rabies virus occurred in cats
(32.9% of all rabid animals, Table 4).
Table 4
The comparison of the frequency of seeking medical assistance
by patients who had suffered from different animals species according
to annual official reports from oblast laboratories of Ministry of Health
of Ukraine (cases that have been analyzed 2007–2019)
Species of an imals
which attacks humans
Attacks by all animals
Attacks by rabid animals
total
average
%
total
average
%
Dogs
838,635
64,510
77.7
6,747
519
28.8
Cats
196,128
15,087
18.2
7,717
593
32.9
Farm animals
11,525
886
1.1
4,581
352
19.5
Wild predators
11,986
923
1.1
1,240
320
17.7
Bats
1,407
108
0.1
20
1
0.1
Rodents
14,430
1,110
1.3
159
12
0.6
Other
5,071
390
0.5
88
7
0.4
Total number of attacks
1,079,182
83,014
100
23,452
1,804
100
During 13 years among 1,079,182 analyzed cases of appeals for med-
ical assistance following animal attacks, 1 in 124 dog attacks on humans
was committed by rabid dogs (6,747 out of 838,635), so the risk of rabies
infection from dogs was 1:124 (Table 4). The risk of cats involved in
attacks being rabid was 1:25 (7,717 out of 196,128). Medical cases asso-
ciated with attacks of wild animals had a proportion of every seventh
biting animal being rabid (risk 1:7 – 4,397 out of 32,894). Among contacts
with farm animals, nearly every second case was found to be a contact
with a rabid animal (risk 1:2). It should be noted the majority of attacks by
cats and dogs involved animals that had owners (71.5%). The proportion
of stray cats and dogs involved in attacks was 27.4%. The largest number
of victims from animals was in 2008 (n = 106,496), and the smallest – in
2014 (n = 65,916). In general, the number of victims from attacks by
animals per 100,000 humans in the last decades was from 230.5 to 153.6
per year (Fig. 7).
Fig. 7. Number of victims from attacks by animals registered
in Ukraine per 100,000 human population (2007–2019)
The number of such cases has decreased significantly over the past
7 years and from 2014 did not exceed 165.0 per 100,000 of the human
population. The features of geographical distribution were specific for
different species of animals. For our analysis, the most important task was
to study the spatial distribution of animals which were the main sources of
rabies for humans. Firstly we conducted a spatial analysis for dogs. During
the study period, a high number of dog attacks were observed in the East
of Ukraine, especially in Donetsk and Kirovograd oblasts (Fig. 8a).
When we compared distribution of attacks from rabid dogs we identi-
fied almost the same tendency, but in this case, the greatest number of dog
bites was identified on the territory of four eastern oblasts (Fig. 8b). Re-
garding cats, a high number of cat attacks were identified in the East of
Ukraine as well (especially in Donetsk, Kirovograd and Kharkiv oblasts),
in the South part of Ukraine (Odesa oblast) and also in the capital of
Ukraine, Kyiv city (Fig. 9a).
A high number of attacks from rabid cats was found also in the East
of Ukraine (especially on the territory of Kharkiv oblast) and also along
boundaries with Russian Federation as well as on the north part near the
Republic of Belarus (Fig. 9b). The most important reservoir of rabies
among wild animals was foxes. In comparison with dogs and cats, a high
number of attacks from foxes were identified in each oblast, but most
concentrated in some Western oblasts, such as Vinnytsia, Zhytomyr and
Volyn. The lowest number of bites from foxes was registered in the capi-
tal of Ukraine, Kyiv city (Fig. 10a).
The highest number of attacks from rabid foxes was observed in Vin-
nytsia oblast. At the same time almost in each oblast except 5 (among 24
overall) many attacks by rabid foxes were reported (Fig. 10b). Numerous
attacks were observed along borders with Moldova, Poland, the Republic
of Belarus and the Russian Federation. A minimal number of bites from
rabid foxes were observed in the central part of Ukraine. Since one animal
can contact a few humans, in general there were registered about 400 at-
tacks on humans per oblast by domestic carnivores and 100 by wild carni-
vores. The number of attacks by rabid animals was also high, accounting
for about 100 attacks from dogs and cats and 40 from foxes per oblast.
Discussion
This article includes for the first time long-term data on the causes of
human deaths from rabies, the most important problems and gaps in
knowledge on measures to prevent rabies and an assessment of the risk of
0
5
10
15
20
25
0
5000
10000
15000
20000
25000
The propor tio n of pati ent, who rec eived
combine course, %
Number of patient s, who rec eived PE P
0
500
1000
1500
2000
2500
3000
3500
1996
1997
1998
1999
2000
2001
2002
2003
2004
2005
2006
2007
2008
2009
2010
2011
2012
2013
2014
2015
2016
2017
2018
2019
2020
Number of animals cases
217.2
230.5
207.9207.5 209.4 216.6
185.3
153.6
164.0157.9163.1
158.4164.3
100
150
200
250
Number of attacs per 100,000 human
populat ion
255
Regul. Mech. Biosyst., 2021, 12(2)
animal attacks in view of their species and geographical distribution, ta-
king into account the epizootic and epidemic situation of rabies in Ukraine
in 1996–2020.
During 25 years, 63 people died of rabies, and unfortunately, this
trend is intensifying over the years. The situation is not quite defined, as
the possibility of incomplete accounting of cases due to underdiagnosis is
not excluded. Due to limited laboratory capabilities for diagnosing rabies
in humans, rabies could occur under other diagnoses. Quoting Chikanya
et al. (2020) the incidence of human rabies in Europe is very low, both for
cases contracted in Europe and imported from endemic countries.
In contrast to the animal data, the global trend of reported human data over
time suggests relative stability in the number of cases reported. Indigenous
cases were mostly reported from Eastern Europe, corresponding to pa-
tients bitten by stray or aggressive domestic dogs or foxes.
a b
Fig. 8. Geographical distribution of attacks from dogs on the territory of Ukraine (2007–2019): a – from all dogs, b – from rabid dogs
a b
Fig. 9. Geographical distribution of attacks from cats on the territory of Ukraine (2007–2019): a – from all cats, b – from rabid cats
a b
Fig. 10. Geographical distribution of attacks from foxes on the territory of Ukraine (2007–2019): a – from all foxes, b – from rabid foxes
The current definition in Ukraine of confirmed cases according to di-
agnostic criteria, when there are clinical manifestations and laboratory
confirmation of rabies, includes 50 cases.The remaining 13 cases were
probable, without laboratory research, but with an epidemiological link
and met the clinical criteria for the diagnosis of rabies (acute encephalitis,
and at least two of the following symptoms: change in sensitivity at the
site of the bite, paresis or paralysis, muscle spasms, fear of water, delirium,
convulsions, anxiety). The highest number of human rabies cases was
observed in 2007 (n = 7). This could be explained by the peak of rabies
cases in animals in 2007 (Fig. 6). Due to an increase of over 100% in the
number of cases of animal rabies in 2006–2007 compared to 2005, the
frequency of requests for medical assistance also increased – 4,732 hu-
mans were affected by rabid animals in 2007. After that, the number of
such attacks and their victims slowly decreased by 2019 to 1,161. Accor-
ding to Yoder et al. (2019), the increase in rabies in dogs by 10.0% is
associated with an increase in human morbidity by 6.3%. In our study, the
number of rabies cases among attacking dogs increased by 2007 to 1,121
and then decreased by 2019 to 337 (by 33.0%). But during all this time,
40 people died from rabies and the source of the rabies virus for 24 of
them was dogs. In the 12 years preceding 2007, 23 people died and only
2 after dog attacks. Regarding geographical distribution, the largest num-
ber of human rabies cases was confirmed in the east of Ukraine (Donetsk
256
Regul. Mech. Biosyst., 2021, 12(2)
– 10, Kharkiv – 7) in more populated, urban areas, dominated by the high
density of the human population and domestic animals respectively,
which had a major role as sources of the rabies virus for humans. Sporadic
cases occurred in almost every administrative territory, except for the
Crimean peninsula and five small western regions.
During 13 years, the proportion of the risk of attacks by rabid dogs as
compared of a general number of dogs attacks on humans was 1:124,
which is significantly less than the risk of rabies from cats (1:25), wild
animals (1:7) and farm animals (1:2). But it is important to note that dogs
are in constant contact with people, the number of their attacks is more
than three times higher than the number of attacks by other animals.
In addition, attacks are more often reported from domestic dogs, which is
confirmed by the fact that owners are irresponsible with their animals and
by the lack of conducting vaccination measures, so the risk of transmission
of rabies from dogs remains the most anticipated.
Geographical features of animal attacks also have certain patterns.
For instance, in the territories of eastern Ukraine, where there is a large
human population with a high density of domestic carnivores, there are
more attacks by dogs and cats (Makovska, 2020a). Also in places of the
higher human population there is a higher number of stray domestic car-
nivores. As noted by Warembourg et al. (2021) the higher density of stray
dogs was associated with closeness to potential food sources such as
commercial food places and a university restaurant. Besides this, due to
the rabies transboundary disease, the permanent endemic situation of
eastern oblasts can be linked with sick animals which can move from
neighbouring countries with endemic rabies, such as the Russian Federa-
tion and the Belarus Republic (Mogilevsky, 1997; Makovska et al., 2018).
Quoting Baker et al. (2020), incursions from other regions account for less
than 1.0% of cases but allow for re-emergence of the disease. The afore-
mentioned also was submitted by Polupan et al. (2021) during their study,
the genetic sequences of the studied samples from Ukraine are characteris-
tic of isolates isolated in the Russian Federation, South-Eastern Europe,
Western Siberia, and Kazakhstan. Similar results were received by Picard-
Meyer et al. (2012) when they investigated samples from Ukraine. In the
central and western oblasts, where population density is lower and there
are more fields and forests, there was a large number of fox attacks, as was
evidenced previously by another author (Freuling, et al., 2013; Makovska,
2020b).
Besides this, we determined that for a long time, cats were the main
source of rabies for people in Ukraine. But, over the past 20 years, the role
of dog transmission of the rabies virus to humans has increased signifi-
cantly to 66.7% (Fig. 4). The beginning of the increase was observed in
2003. It can be explained by the reduction in efforts for vaccination of
domestic carnivores and reduction in attention paid to pets due to the start
of the ORV campaign in 2001 (Makovska et al., 2020). In addition, the
risks of human infection with the rabies pathogen transmitted by dogs are
increasing due to their owners’ failure to comply with the rules of animal
keeping, a lower level of vaccination of pets, low-level of public aware-
ness and absence of expert appraisal and increasing of the dog population.
As reported by Kornienlko et al. (2019) according to various estimates,
there are between 6–8 million dogs kept in Ukraine and the number of
homeless animals of this species can be 10–20 thousand per city (oblast
centre). As asserted by Roebling (2014), responsible pet ownership, uni-
versal rabies vaccination of pets and removal of strays remain integral
components to control rabies and other diseases.
In general, control of rabies in domestic carnivorous remains relevant.
Among the human victims of rabies, 24 had dangerous contact with dogs
and 22 with cats. Among these animals, 19 were homeless and 25 had
owners. No animal was vaccinated against rabies. Twelve patients out of
63 who died of rabies died following attacks by wild animals, including
1 from a bat and 11 from foxes. It is known that the incubation period for
victims of fox attacks in one case lasted 3 years. The sources of rabies in
5 patients out of the 63 cases studied are unknown. In one case, rabies was
diagnosed in the laboratory after the death of the patient, in another – the
diagnosis occurred during life, but the history is unknown. Three did not
remember contact with the animals. A total of 12 children aged 3 to 17
died of rabies. Young children tend to be attacked by animals due to neg-
lect, and older children are afraid to confess to their parents about an at-
tack. But in all cases, the precondition was the ignorance of both adults
and children about the dangers of contact with animals. The behaviour of
the majority of victims in relation to medical treatment was rather poor,
more than 60.0% (27 adults and 11 children) did not apply for post-
exposure prophylaxis, almost 25.0% suffered from their own pets. Ob-
viously, the people were not sufficiently informed about rabies – clearly,
there is a need to implement educational prevention campaigns. The fact
that 12 victims of rabies were children and that among their parents there
were medical and veterinary professionals suggests that children should be
included in the target audience, and the training of professionals should be
improved. Ignorance can also be seen in the fact that only 7 animals that
attacked rabies victims were examined in the laboratory. In other cases,
when animals were killed or killed after the attacks on people, these events
were not reported anywhere, visits to medical facilities did not take place.
As a result, in 38 cases, people died due to ignorance, irresponsible owner-
ship of animals, neglect of their own health and people’s neglect of the
health of other people and animals. They lost their chance to survive be-
cause they did not seek help to obtain a post-exposure prophylaxis.
The remaining 25 patients out of 63 sought help after animal attacks.
Because rabies can be prevented in a person who has had dangerous con-
tact with a sick animal with the help of post-exposure prophylaxis, this
should be done as soon as possible after dangerous contact with the ani-
mal, and the amount of PEP should correspond to the category of damage.
But the vaccine was not always available during the study period.
Since 2003 rabies vaccines for human immunization have not been
produced in Ukraine. From the same year, deliveries of rabies immuno-
globulin to medical institutions were suspended and deliveries of rabies
vaccine financed from the state budget were significantly reduced.
The function of providing immunoglobulin was entrusted to local bud-
gets. In recent years, the volume of vaccine supplies from the state budget
has increased. But not all local budgets are ready to spend on rabies im-
munoglobulin (Antonova et al., 2021). As noticed by Grigoryan & Metlin
(2016) in countries where there is no local production of anti-rabies vac-
cines, governments and other donors are likely to subsidize a limited
number of doses of rabies vaccine, which will reduce their availability.
This situation can be exacerbated by two factors: 1) the lack of rabies
immunoglobulin for treatment; 2) the fact that pharmaceuticals must be
imported, which leads to a lack of access due to the high price.
Due to limited budgets, disruptions in the manufacture of rabies im-
munoglobulin in Ukraine, hospitals have not always provided a perma-
nent supply of rabies vaccines and immunoglobulin, thus patients have not
always been able to buy drugs in the pharmaceutical network due to their
high cost. This situation has caused the unwillingness of adequate (timely
and in full) provision of medical care by medical staff; loss of access and
unequal access to patient care, as a result we have experienced non-
vaccination, refusal, or incomplete vaccination without the use of rabies
immunoglobulin (n = 8). Due to incorrect requirements in the instructions
(Table 2), the observation of animals was mistakenly conducted on other
animals than the ones which were the source of the biting attack, and in
the other 3 cases, the animals concerned were killed or their death within
10 days of the attack on a person was not reported (Table 1). Thus, the
main reason for post-exposure prophylaxis failures is not the quality of
vaccines, but the violation of vaccination schemes, non-use of immuno-
globulin. This statement is confirmed in our study. The greater number of
people did not receive immunoglobulin, although they suffered from
attacks by foxes and stray animals and suffered an injury to dangerous
locations. Only one case of PEP failure was related to the ineffectiveness
of the Cocav vaccine, but the evidence was not convincing. An important
element of rabies surveillance is the diagnosis of the disease in both hu-
mans and animals. In 2 cases, the reasons for rabies developing in humans
were a delay in the verification of animal rabies in combination with de-
laying the onset of PEP and waiting for laboratory results. In such a situa-
tion, medical prophylaxis of rabies is the last chance, when the salvation of
people’s lives depends on the organization and quality of practical imple-
mentation.
The role of animals is found for each case, which is ensured by the
close interaction of two sectors of health care: humans and animals. Every
year more than 80,000 victims of animal attacks occur, about 20,000
people are vaccinated. In addition, 71.5% of victims of the attack suffer
from dogs and cats that had owners. Thus, irresponsible possession of
257
Regul. Mech. Biosyst., 2021, 12(2)
animals occurs due to imperfect legislation in this area. The share of at-
tacks from stray cats and dogs was 27.4%, but it was due to attacks from
homeless animals that about 17,000 people a year had to be vaccinated as
a high-risk group, because of the impossibility of observing homeless
animals and also of conducting post-mortem laboratory tests on them in
order to exclude rabies. Such a difficult situation regarding stray animals
described in the literature (Cliquet et al., 2014; Roebling et al., 2014).
According to the investigation of Chikanya (2021), in some countries of
southeastern Europe, homeless dog populations also very high and their
supervision difficult. This carries a high risk of threatening human health
and animal welfare.
The highest number of attacks was in 2008, which can be explained
by the highest peak among animals in 2007. This contributed to the wider
spread of the disease among animals, which increased the incidence of
rabies, animal aggression and, consequently, the number of attacks on
humans. A similar statement is confirmed in the works of Yoder et al.
(2019). The results show a positive relationship between current reported
contacts and rabies cases in dogs and humans in the previous year. This
suggests that past cases of rabies in humans and dogs are important events
for assessing the risk of current exposure, which showed that the disease
resonates over the next year. The smaller number of attacks in 2014 is
explained by the beginning of political conflicts on the territory of
Ukraine, which affected the quality of monitoring, both among animals
and among people. Besides this as suggest by Antonova et al. (2021)
given that as a result of hostilities some territories of the eastern regions of
Ukraine, as well as the Crimean Peninsula were separated from Ukraine to
Russia, the total number of attacks and requests for medical aid has de-
creased accordingly. Due to the difficult political situation between
Ukraine and the Russian Federation, which previously provided us with
its vaccines, an absence of a vaccine was observed, also cases of redistri-
bution of vaccine residues between institutions, and a search for drugs in
other areas and even abroad. Thus, in 2016, out of 9 administrative areas,
786 cases were reported when patients did not receive PEP or PEP was
not prescribed.
Previously for collaborating in the eradicatation of rabies in Ukraine,
there were programmes aimed at preventing animal rabies. In 2008 the
state programme of rehabilitation of the territory of Ukraine from rabies
for 2008–2015 was adopted. The crucial task of the Programme was a
comprehensive solution to the protection of humans and animals (wild,
domestic, farm) from rabies and finally to eradicate this disease in our
country. According to Kornienko et al. (2019) despite the conducting of
campaigns of oral and parenteral vaccination among wild and domestic
animals in Ukraine, they did not achieve great success. In addition, the
lack of registration of domesticated companion animals and the ability to
control their immune status prevents proper planning and evaluation of the
effectiveness of immune prevention of rabies. The last comprehensive
programme, which provided for intersectoral cooperation at the state level,
was completed in 2010. Since then, the same rabies prevention programs
have been developed and implemented at the oblast and rayon levels.
The need for coordination at the central level is palpable. Nowadays the
deficiencies in the fight against rabies, as well as other zoonoses, are the
lack of agreed coordination of inter-sectoral interactions on the central
level, the attitude towards zoonoses as non-priority problems, the lack of
funding for prophylaxis programs, and the use of old methods of interven-
tions. As noticed by Fahrion et al. (2017) for any public health program,
permanent funding resources are essential for continuing a rabies control
programme, and the lack of those resources is one of the primary barriers
to eradicating the fatal disease.
As we compare Ukraine’s experience with that of other countries that
have succeeded in overcoming rabies, it is clear that this work takes consi-
derable time. This happens even when the activities are carried out under a
comprehensive programme and have financial support (Taylor et al.,
2021). The concept of the frame of “One Health” approach has highlights
the integral division of responsibilities between institutions focused on
animal health and human health (Wallace et al., 2017; Acharya et al.,
2020). We recommend strengthening health applications against rabies by
health workers, using a “One Health” approach by multiple stakeholders
in Ukraine, and stepping up and monitoring the effectiveness of regular
pet vaccination campaigns by the Veterinary Departments in each oblast
and conducting further assessments of pets bites and controlling all rabies
measures.
Conclusions
Overall, during 25 years (1996–2020) about 37,338 cases of rabies
among animals and 63 cases among humans were registered. The leading
source of rabies for human cases was dogs (24) and cats (22). The main
causes of death were absence of seeking medical assistance after animal
attacks (60.3%), error and underestimation of risk during referral for medi-
cal assistance after animal attacks (39.7%), errors during animal quaran-
tine (9.5%), errors in diagnosis of rabies in animals (3.2%), refusal of PEP
by the patients (6.3%), failure to prescribe PEP (4.8%), failure of PEP
(15.9%).
During the last 13 years (2007–2019) on average, about 84,148 peo-
ple (187.4 per 100,000 population) suffered from animals attacks every
year, among which 2,155 people (4.8 per 100,000 population) were af-
fected by rabid animals. PEP was prescribed annually, on average, for
21,435 patients, from which by the end of each year, 14,619 (68.0%)
patients had completed the course and were immunized. The frequency of
the proportion of the risk of attack by rabid dogs compared to the total
number of dog attacks on humans was (1:12) from cats (1:25), wild ani-
mals (1:70) and farm animals (1:20), but the largest general proportion of
animal attacks on people was from dogs – 838,635 attacks (77.7%). Geo-
graphically, the highest frequency of attacks by domestic carnivores was
observed in the east of Ukraine, that of attacks by foxes in the central and
western oblasts. The majority (71.5%) of victims of attack by dogs and
cats were victims of animals that had owners, the share of attacks from
stray cats and dogs was 27.4%.
The risks to humans of infection with the rabies virus transmitted by
pets are increasing due to their owners’ failure to comply with the rules of
keeping animals, increase in the population of stray domestic carnivores,
the low level of vaccination of pets, low-level of public awareness and the
absence of comprehensive expert assessment. Ensuring the prevention of
rabies in humans requires the availability of PEP for the population, the
availability of vaccines against rabies and RIG, the readiness of medical
staff, high efficacy of rabies drugs, and the need to closely link the two
sectors of human and animal health based on a “One Health” approach.
In conclusion, our results confirm he high risk of infection by the ra-
bies virus from wild animals and also from domestic animals, which is a
matter of concern to European countries due to the distribution of unvac-
cinated domestic carnivores and the possibility of transmission of rabies to
humans in cases of tourism because most EU countries eliminated rabies
in humans many years ago.
The authors would like to acknowledge the United States Defense Threat Reduction
Agency, SAFOSO AG, Switzerland and Ukraine Biological Threat Reduction
Program for their assistanc e and financial support in the preparation of this p aper.
The authors declare no competing interests.
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