Raiva no estado do Ceará: caracterização epidemiológica, ações de vigilância e o conhecimento da população sobre a doença (1970-2020)

Abstract

Although canine rabies is under control in Ceará, major problems related to the sylvatic cycle of the disease are still faced. The study aimed to characterize the dynamics of rabies virus transmission and the operational effectiveness of surveillance actions in the state of Ceará between 1970 and 2020 and describe the knowledge, attitudes, and practices of the population about the disease. Descriptive type studies were conducted, using data from the Health Secretariat of the State of Ceará (Sesa), the São José Hospital for Infectious Diseases (HSJDI) and questionnaires applied in 27 municipalities, with division into five substudies: 1 – Characterization of rabies surveillance actions in bats in Ceará state (Northeast Brazil) after the implementation of the passive surveillance program; 2 – Description of the epidemiology of human rabies in Ceará state from 1970 to 2019; 3 – Characterization of human rabies cases in Ceará state, Brazil, in a period of 44 years, from 1976 to 2019; 4 – Description of the integration of human rabies surveillance and preventive measures in the state of Ceará, Northeast Brazil; 5 – Description of the knowledge, attitudes and practices of people in contact with wild mammals with potential transmission risk for rabies in the state of Ceará. In sub-study 1: a total of 8.4% of the 1,180 bat samples sent for laboratory diagnosis were confirmed positive for rabies virus. Of these, 96.2% were non-hematophagous species and 75% belonged to the Molossidae family. There was an increase in sample submission and positivity after the implementation of passive surveillance. Sub-study 2: Of the 171 RH cases, 75.7% were male, 60% were up to 19 years old, and 56% resided in urban areas. The dog was a transmitter in 74% of cases. Between 1970 and 1978, there was an increase in cases of 13.7 - 95% CI 4.6; 41.5); and between 1978 and 2019, a decrease of - 6.7 - 95% CI -8.8; -5.9), with a reduction in transmission by dogs and an increase by wild ones starting in 2005. Sub-study 3: of the 171 cases (76.2%) were per dog. Only 30% had initial diagnosis for rabies. Hand bite was the most frequent exposure (96.6%). Only 22% of patients sought care after aggression. The most prevalent symptoms were aggression/irritability (79.4%) and fever (66.7%). Sub-study 4: The last six cases of RH occurred in the period from 2005 to 2016 in rural areas where there were few resources. Actions and training were carried out in an integrated manner. Patients and their families were unaware of the risk of rabies mediated by wild animals and raised marmosets. Only one patient sought care but did not receive treatment. In none of the cases was the initial diagnosis rabies. In four cases, the transmission was by marmosets. Bats should be considered targets for rabies surveillance with an emphasis on studying AgV to provide additional evidence for planning and implementing effective control measures. Sub-study 5: Most respondents (92%) had heard of rabies and cited at least one species that transmitted the disease (79.6%). The most commonly mentioned species were monkeys (69%) and dogs (67.2%). However, 16% of those listed an incorrect species. In general, knowledge about the symptomatology and prevention measures was poor. Most raised dogs and cats (93.8%) and reported vaccinating them against rabies (85.7%). A total of 67.3% reported the appearance of free-living wild animals around their homes, mostly marmosets and wild canids, and 18.3% stated attacks on animals or humans. Seventy-three percent had raised or were still raising wild animals as pets, mostly nail monkeys (79.5%) and marmosets (24.1%). It is concluded that passive surveillance of bats in urban and rural areas and the strengthening of assistance, are fundamental to avoid new human cases in Ceará and throughout the national territory. There was a change in the dynamics of RH transmission in Ceará, with a reduction of cases per dog and an increase in wild cases. Most human deaths were due to not seeking care and failures in the health system. It is necessary to carry out educational campaigns on the wild cycle and prevention measures in a continuous and integrated way, strengthening surveillance and professional training. Rabies, in Ceará is a wildlife-mediated disease that affects the most vulnerable rural populations. An integrated health approach is inevitable for the elimination of human rabies. Important knowledge gaps exist within a high-risk population with contact with wild mammals, with inadequate practices regarding the keeping of wild animals, and with measures taken after animal aggression.