PRIMER

Rabies
Anthony R. Fooks1–3, Florence Cliquet4, Stefan Finke5, Conrad Freuling5,
Thiravat Hemachudha6,7, Reeta S. Mani8, Thomas Müller5, Susan Nadin-Davis9,
Evelyne Picard-Meyer4, Henry Wilde6 and Ashley C. Banyard1
Abstract | Rabies is a life-threatening neglected tropical disease: tens of thousands of cases are
reported annually in endemic countries (mainly in Africa and Asia), although the actual numbers are
most likely underestimated. Rabies is a zoonotic disease that is caused by infection with viruses of the
Lyssavirus genus, which are transmitted via the saliva of an infected animal. Dogs are the most
important reservoir for rabies viruses, and dog bites account for >99% of human cases. The virus first
infects peripheral motor neurons, and symptoms occur after the virus reaches the central nervous
system. Once clinical disease develops, it is almost certainly fatal. Primary prevention involves dog
vaccination campaigns to reduce the virus reservoir. If exposure occurs, timely post-exposure
prophylaxis can prevent the progression to clinical disease and involves appropriate wound care,
the administration of rabies immunoglobulin and vaccination. A multifaceted approach for human
rabies eradication that involves government support, disease awareness, vaccination of at‑risk human
populations and, most importantly, dog rabies control is necessary to achieve the WHO goal of
reducing the number of cases of dog-mediated human rabies to zero by 2030.

Rabies is a zoonotic disease caused by viruses of the dogs in North America, Europe and some countries of
Lyssavirus genus (in the family Rhabdoviridae of Latin America as well as in wildlife species in Europe and
the order Mononegavirales) that was first described Canada10. The subsequent substantial reduction in cases
in the 4th century BC1. Rabies virus (RABV), the proto­ of human rabies in such regions advocates for the ‘One
type virus of the Lyssavirus genus (TABLE 1), is by far the Health’ approach to rabies control (that is, a collaborative
most common causative agent of rabies2 and is most and transdisciplinary approach at the local, national and
readily transmitted by the bite of an infected mammal global level that aims to achieve optimal health outcomes
(FIG. 1). Dog-transmitted rabies causes >99% of the human by recognizing that the health of people is connected to
cases reported. Both animal and human rabies are entirely the health of animals and the environment)11. With this
preventable through vaccination, and the first efficacious in mind, the WHO, World Organisation for Animal
Correspondence to A.R.F. rabies vaccines for human use were developed in the Health (OIE) and Food and Agriculture Organization of
Animal and Plant Health
19th century. However, in the 21st century, the virus is still the United Nations (FAO) have set the target to eliminate
Agency (APHA), Wildlife
Zoonoses and Vector Borne enzootic (that is, endemic in animals) in many regions of dog-transmitted human rabies in endemic countries by
Diseases Research Group, the world, and human rabies remains one of the most 2030 (REF. 12). This Primer summarizes the epidemiology
(WHO Collaborating Centre serious and distressing diseases and an important threat of RABV; global efforts to diagnose, control and elimin­
for the Characterisation of to public health3. Indeed, when an individual with rabies ate the transmission of RABV by terrestrial animals; and
Rabies and Rabies-Related
Viruses, World Organisation
develops symptoms, the disease is nearly always fatal4. the mechanisms and pathophysiology of RABV infec­
for Animal Health (OIE) Rabies is often considered a disease of poverty, ignorance tion. Conundrums regarding treatment options and
Reference Laboratory and, in some circumstances, misinformation5. both existing and potential future prophylactic tools to
for Rabies), Weybridge, RABV enters peripheral nerves at the synapse level at combat infection of the CNS are discussed, along with
New Haw, Addlestone,
the site of the bite and is transported to neurons in the initiatives aimed at the global elimination of this deadly
Surrey KT15 3NB, UK.
[email protected] central nervous system (CNS); the virus then replicates zoonotic virus.
and causes cerebral damage. Rabies can manifest in two
Article number: 17091
doi:10.1038/nrdp.2017.91 classical forms (furious and paralytic) with a range of Epidemiology
Published online 30 Nov 2017 symptoms, but ultimately leads to coma and death. The Lyssaviruses and their hosts
© The Author(s) 2017, under priority for reducing the burden of human rabies is con­ Since the 1970s, methods of viral characterization have
exclusive licence to Macmillan
Publishers Limited, part of trolling dog rabies, especially in free-roaming commu­ revealed the extensive diversity of the Lyssavirus genus13
Springer Nature nity dogs6–9. Rabies elimination was achieved in domestic (TABLE 1), and the taxonomy of this genus continues to

NATURE REVIEWS | DISEASE PRIMERS VOLUME 3 | ARTICLE NUMBER 17091 | 1

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PRIMER

Author addresses RABV probably evolved from a bat-associated pro­

geni­tor 18, and several host-switching events yielded a
1
Animal and Plant Health Agency (APHA), Wildlife Zoonoses and Vector Borne Diseases complex pattern of RABV variants. Worldwide, seven
Research Group, (WHO Collaborating Centre for the Characterisation of Rabies main lineages of RABV are recognized13,19; within each
and Rabies-Related Viruses, World Organisation for Animal Health (OIE) Reference lineage, multiple variants, each associated with a particu­
Laboratory for Rabies), Weybridge, New Haw, Addlestone, Surrey KT15 3NB, UK.
lar mammalian host and geographical range, have
2
Institute of Infection & Global Health, University of Liverpool, Liverpool, UK.
3
Institute for Infection and Immunity, St. George’s Hospital Medical School, University emerged. The most widespread lineage is found in several
of London, London, UK. continents (Europe, the Americas, Africa and Asia), and
4
French Agency for Food, Environmental and Occupational Health & Safety it is maintained by dog populations in many ­countries
(ANSES)-Nancy Laboratory for Rabies and Wildlife (European Union Reference Laboratory and by several wildlife species (for example, foxes,
for Rabies, WHO Collaborating Centre for Research and Management in Zoonoses raccoon dogs, skunks and jackals)20. Throughout the
Control, OIE Reference Laboratory for Rabies, European Union Reference Institute for Americas, many bat-associated RABV variants persist 21,
Rabies Serology), Technopôle Agricole et Vétérinaire de Pixérécourt, Malzéville, France. including one harboured by the vampire bat, which is an
5
Institute of Molecular Virology and Cell Biology (WHO Collaborating Centre for Rabies important source of disease for humans and ­domestic
Surveillance and Research, OIE Reference Laboratory for Rabies), Friedrich-Loeffler- livestock in Latin America.
Institut, Federal Research Institute for Animal Health, Greifswald-Insel Riems, Germany.
6
Department of Medicine (Neurology) and (WHO Collaborating Centre for Research
and Training on Viral Zoonoses), Faculty of Medicine, Chulalongkorn University, Bangkok, Disease
Thailand. Large-scale control programmes have eliminated dog
7
Thai Red Cross Emerging Infectious Disease-Health Science Centre, Thai Red Cross rabies in Europe, the United States and Canada and
Society, Bangkok, Thailand. substantially reduced its prevalence in Latin America,
8
Department of Neurovirology (WHO Collaborating Centre for Reference and Research in with a concomitant decrease in cases of human rabies22.
Rabies), National Institute of Mental Health and Neurosciences (NIMHANS), Bangalore, India. However, as dog rabies is controlled, the existence of
9
Ottawa Laboratory Fallowfield, Canadian Food Inspection Agency (WHO Collaborating sympatric (occurring in the same area) wildlife rabies
Centre for Control, Pathogenesis and Epidemiology of Rabies in Carnivores), Ottawa, reservoirs often becomes more-evident, and sylvatic
Ontario, Canada. rabies (affecting wildlife) has been identified in ­countries
that were historically considered free of rabies 23.
evolve, owing to enhanced surveillance and sequencing In Europe, oral vaccination campaigns have demon­
technologies. Most Lyssavirus spp. are maintained by strated the feasibility of eliminating rabies from wildlife
chirop­teran hosts (the only mammals capable of true reservoirs, but the continued circulation of Lyssavirus
flight; that is, bats). The reservoir hosts and geographi­ spp. in bat hosts with an aerial lifestyle will challenge
cal range of some of these viruses, such as the European future global rabies eradication efforts, owing to difficul­
bat lyssaviruses (EBLVs) in Europe, are quite well docu­ ties in the development and administration of vaccines
mented, but similar information for many others is to these highly mobile, poorly accessible species3.
lacking, owing to the recovery of only small numbers of Globally, human rabies is considered a neglected
isolates14. By contrast, RABV is maintained in most parts zoonosis, especially in resource-limited countries in
of the world by mesocarnivores (animals whose diet con­ Africa and Asia where the disease burden falls dis­
sists of 50–70% meat), including dogs, foxes, raccoon proportionately and mortality is substantial24 (FIG. 2).
dogs, raccoons, mongooses and skunks3. Exceptions It has been estimated that someone dies from rabies in
include the maintenance of RABV in multiple bat species a rabies-endemic country every 10–20 minutes and that
(only in the Americas) and the reported role of a herbi­ 40–50% of fatalities are in children <15 years of age3.
vore, the kudu, as an RABV reservoir in Namibia15. For Owing to their small size and frequent interactions with
all Lyssavirus spp., other mammals, including humans, domestic or free-roaming dogs, children are at a higher
cattle and equids, represent cases of cross-species trans­ risk of being bitten, not only on their extremities but also
mission (or spillover; that is, the ability of a virus to infect on the head, which leads to shorter incubation times.
a member of a new host species)3. Although such spill­ Thus, in endemic countries, rabies should be considered
over infections normally result in ‘dead-end’ infections a neglected paediatric disease25.
with no further spread to other hosts, n ­ euroinvasion The estimated 60,000 human deaths annually world­
leading to clinical disease can still occur. wide3,26 do not capture the true burden of this disease.
RABV is estimated to be responsible for hundreds Predictions suggest that as many as 20,000 lives are
of thousands of cases of animal rabies annually, and lost annually in India alone26. Lack of surveillance27
the application of sequencing methods to this exten­ due to limited health-care services, such as labora­
sive pool of data has enabled the investigation of the tory capabilities, qualified personnel and medical and
epidemio­logy and evolution of RABV and has provided veter­inary infrastructures, results in under-reporting
insights into the detailed phylogeography of disease of human cases, which is further compounded by
outbreaks16. Such studies identify natural landscape cultural, religious and social taboos28. Furthermore,
features such as mountain ranges and waterways as fre­ in humans, rabies can present with symptoms that are
quent ­barriers to epizootic spread, whereas man-made common to other clinically indistinguishable condi­
roads and human-mediated movement of animals, often tions (for example, Guillain–Barré syndrome and cere­
accompany­ing large-scale human migrations, can facili­ bral malaria)29; consequently, without confirmation of
tate disease dispersion; such information is valuable to the diagnosis using established laboratory protocols30,
control programmes17. rabies might be misdiagnosed. These inaccuracies in

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 PRIMER

collating empirical data of disease incidence can dis­ entry, the virus is contained in endosomal transport
courage policymakers from considering rabies as a vesicles41,42 and retrogradely transported along axons
high-priority disease26,31. via microtubules43–47. In the neuronal soma, the ribo­
nucleoproteins (RNPs), which are complexes formed
Mechanisms/pathophysiology by the viral RNA, nucleoproteins and phospho­proteins,
Host infection are released into the cytoplasm from the ­vesicles48 and
The main mode of RABV transmission is through expo­ primary transcription occurs, leading to the production
sure of broken skin to the saliva of an infected animal. of viral proteins. With the accumulation of viral pro­
Exposures that can lead to infection can vary from teins, cytoplasmic inclusion bodies are formed, which
severe bites, most often by a dog, to superficial skin are sites of viral RNA synthesis (secondary transcrip­
lesions. These lesions are often described as cryptic tion)49. From replication sites in inclusion bodies, newly
infection because the exposure goes unrecognized and generated RNPs are transported to postsynaptic mem­
­unreported32, and most frequently result from contact branes, where the new ­virions are assembled and trans-­
with bats. Other potential transmission routes include synaptically transmitted50 to next-order neurons in a viral
organ transplantation from donors with undiagnosed or glycoprotein-­dependent manner 51. This process includes
misdiagnosed rabies, which caused several cases of rabies budding in the synaptic cleft and subsequent receptor-­
in transplant recipients33–36. Infection via the aero­sol route mediated entry at pre­synaptic membranes (FIG. 3). The
has also been rarely reported37–39 and probably depends virus eventu­ally reaches the brain; what brain area is
on efficient viral excretion in the saliva and exposed infected is determined by what motor neurons innervate
­ocular or nasal mucosa37,40. the site of entry. From the brain, the virus spreads to the
In vitro, lyssaviruses can infect most cell types, ­salivary glands and is intermittently excreted in the saliva,
although the underlying molecular interactions are not ready to be transmitted to another host. Local symptoms
completely understood. In the host, lyssaviruses generally start once the virus, after dissemin­ating in the CNS,
infect peripheral nerves (sometimes also muscle cells) centri­fugally spreads and reaches the dorsal root ­ganglia
at the motor endplate of neuro­muscular junctions or at corresponding to the nerves at the site of entry; in the
other innervated tissues (FIG. 3). After receptor-mediated dorsal root ganglia, viral replication causes inflam­mation,

Table 1 | The Lyssavirus genus

Species Virus Countries of virus isolation* Most common
reservoir based
on virus detection
Phylogroup I
Rabies lyssavirus Rabies virus (RABV)‡ Global All mammals
Aravan lyssavirus Aravan virus (ARAV) Kyrgyzstan Bats
Australian bat lyssavirus Australian bat lyssavirus (ABLV) ‡
Australia Bats
Bokeloh bat lyssavirus Bokeloh bat lyssavirus (BBLV) France and Germany Bats
Duvenhage lyssavirus Duvenhage virus (DUVV)‡ Kenya and South Africa Bats
European bat 1 lyssavirus European bat lyssavirus 1 (EBLV‑1) ‡
Belgium, Denmark, France, Germany, the Netherlands, Bats
Poland, Russia, Slovakia, Spain and Ukraine
European bat 2 lyssavirus European bat lyssavirus 2 (EBLV‑2)‡ Denmark, Finland, France, Germany, the Netherlands, Bats
Norway, Switzerland and the United Kingdom
Gannoruwa bat lyssavirus Gannoruwa bat lyssavirus (GBLV) Sri Lanka Bats
Irkut lyssavirus Irkut virus (IRKV) ‡
China and Russia Bats
Khujand lyssavirus Khujand virus (KHUV) Tajikistan Bats
Phylogroup II
Lagos bat lyssavirus Lagos bat virus (LBV) Central African Republic, Ethiopia, France§, Ghana, Bats
Nigeria, Senegal, South Africa and Zimbabwe
Mokola lyssavirus Mokola virus (MOKV)‡ Cameroon, Central African Republic, Ethiopia, Nigeria, Rodents and
South Africa and Zimbabwe domestic animals
Shimoni bat lyssavirus Shimoni bat virus (SHIBV) Kenya Bats
Phylogroup III
Ikoma lyssavirus Ikoma lyssavirus (IKOV)|| Tanzania African civet
Lleida bat lyssavirus Lleida bat lyssavirus (LLEBV)|| Spain Bats
West Caucasian bat lyssavirus West Caucasian bat virus (WCBV) Russia Bats
Based on the International Committee on Taxonomy of Viruses classification194. *Countries where the virus was isolated. ‡Associated with human fatality. §It is unknown
whether the infected animals arrived in France from Egypt or Togo. ||Could be single member of new phylogroup.

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PRIMER

which triggers pain, paraesthesia (a tingling sensation) involved, to a greater or lesser degree, in RABV cell
and/or pruritus (itch)52. The virus could also reach entry 53–55 and, therefore, are considered as RABV recep­
peripheral nerves; inflammation in these nerves (caused tors (FIG. 3). However, there is conflicting evidence on
by viral replication) could result in weakness in paralytic the role of p75NTR56, and other potential receptors have
rabies. The mechanisms underlying the symptoms that also been suggested57. p75NTR co‑internalization and
manifest during the acute neurological phase are not subsequent retrograde axonal co‑transport with RABV
completely understood. have been directly shown by live-cell imaging in sensory
dorsal root ganglion neurons42. Nevertheless, how RABV
Receptors and neuroinvasion enters neurons at peripheral inoculation sites has yet to
The nicotinic acetylcholine receptor (nAChR), neuronal be completely defined. Within neuro­muscular junctions,
cell adhesion molecule (NCAM) and tumour necrosis the presence of nAChR at, or close to, the postsynaptic
factor receptor superfamily member 16 (TNFRSF16; membranes of muscle cells might support the infection
also known as p75NTR) have been proposed to be of muscle cells before neuronal infection. Virus amplifi­
cation (due to replication) in muscle cells and the sub­
sequent budding of progeny virions in the synaptic cleft
a Glycoprotein
b could increase the efficiency of neuro­invasion through
Matrix protein receptors at presynaptic axonal membranes. However,
nAChR could also act as an attachment receptor that
Phosphoprotein could concentrate extra­cellular virus in the synap­
Large RNA tic cleft for presentation to receptors such as NCAM
polymerase
protein and p75NTR on the presynaptic membranes of motor
neurons57 (FIG. 3). Finally, RABV could directly bind to
Nucleoprotein
neuro­nal receptors and infect the neuron independ­
Lipid bilayer ent of nAChR binding or muscle cell infection. In fact,
whether one or more of these receptor-mediated path­
ways occur and whether infection of non-neuronal
cells at peripheral sites contributes to the efficiency of
neuroinvasion and disease development remains con­
troversial. In addition to neuromuscular junctions,
3′ N P M G L 5′ sensory neurons could also serve as entry routes,
50 μm
as RABV has been detected in sensory nerves58. Both
c d retro­grade and anterograde axonal transport have been
Cell observed in culti­vated dorsal root ganglion neurons44,59
(Supplementary information S1 (video)), and in vivo
anterograde trans-synaptic ­transfer in sensory neuronal
circuits has been demonstrated60.

Virion Immune response and host manipulation

* RABV virulence resides in its ability to escape the
host’s immune response while retaining the viabil­
ity of infected neurons. The concept of the CNS as an
immune-­privileged cellular environment has been chal­
50 nm 100 nm lenged by the discovery that peripheral immune cells can
cross the intact blood–brain barrier and that CNS neu­
rons and glia can regulate macrophage and lymphocyte
Figure 1 | Structure of the rabies virus. a | The rabies virus (RABV)
Nature virion is| Disease
Reviews bullet-shaped,
Primers
responses. Thus, it must be assumed that RABV repli­
with a plasma membrane covered in homotrimers of type 1 transmembrane glycoprotein
with peplomers (glycoprotein spikes). The ~12 kb negative-sense RNA genome of cation in the CNS occurs in a fully immunocompetent
lyssaviruses encodes five viral proteins: the nucleoprotein (N), phosphoprotein (P), matrix cellular environ­ment. However, in experimental models,
protein (M), glycoprotein (G) and large RNA polymerase protein (L). Within the virion, attenuated and pathogenic RABV strains induce differ­
the genomic RNA is tightly encapsidated with N and P to form a ribonucleoprotein (RNP), ent inflammatory markers and other host parameters61,62,
which is closely associated with a viral RNA polymerase complex consisting of P and L. and virus clearance from the brain, which correlates
The RNP forms a helix that is encapsidated with M, which in turn connects the RNP and the with the level of B cell infiltration and antibody produc­
lipid bilayer membrane envelope. b | Hippocampal neurons of a laboratory mouse infected tion in the CNS63,64, is reduced in models infected with
with street RABV (that is, obtained from a naturally infected dog) that were isolated during pathogenic RABV strains. These findings support the
the clinical phase of the disease. Despite clear neuronal infection (shown by the presence hypothesis that adaptive immune responses are impaired
of N, labelled in red), the structural integrity of the neurons seems to be preserved.
in natural RABV infections.
Green labelling denotes the neuronal marker tubulin β3 chain; blue labelling indicates
cell nuclei. c | A cross section of the virion demonstrates the distinct G peplomers (arrow), Enhancing the permeability of the blood–brain
plasma membrane (arrowhead) and RNP core (yellow arrow). d | Longitudinal view of the ­barrier to the infiltration of immune cells is considered
virion, highlighting the bullet shape. Here a virion is being engulfed by a cell, presumably necessary for successful virus clearance, and enhan­
through endocytic mechanisms. *Indicates the cell from which the virion is budding. ced permeability increased the clearance of attenu­
Parts c and d are reproduced with permission from Kati Franzke. ated RABV from the CNS in experimental models65.

4 | ARTICLE NUMBER 17091 | VOLUME 3 www.nature.com/nrdp

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Presence of
dog-transmitted
human rabies
Absent
Suspected
Confirmed
Unknown
Nature Reviews | Disease Primers
Figure 2 | The global distribution of dog-transmitted human rabies. Dog-transmitted human rabies caused by the
rabies virus (RABV) is responsible for most human fatalities. The map does not reflect very low numbers of cases of
human rabies resulting from exposure to RABV via wildlife reservoirs in areas where dog rabies has been eliminated
(for example, North America). Figure reprinted from World Health Organization. Rabies: epidemiology and burden
of disease. http://www.who.int/rabies/epidemiology/en/ (date accessed: 17/10/2017) (REF. 174).

Consistent with the findings in the canine model that Several mechanisms could enable RABV to escape
infected animals develop limited immune responses66, or manipulate adaptive immune surveillance in the
wild-type RABV infection does not increase the perme­ nervous system. Upregulation of FASLG expression73
ability of the blood–brain barrier 67. The permeability and subsequent activation of Fas ligand could induce
of the blood–brain barrier remains unaltered in dogs apoptosis of antigen-activated T cells and contrib­
and patients in both furious and paralytic rabies68 dur­ ute to the termination of the immune response. The
ing early-stage clinical disease, as demonstrated by expression of HLA class I histocompatibility antigen,
MRI (in humans and dogs)52,69 and diffusion ­tensor α chain G (HLA‑G), a nonclassical, immunosup­
imaging (in dogs). However, the permeability of the pressive HLA 74,75, and upregulation of the expres­
blood–brain barrier is considered one of the main sion of programmed cell death 1 ligand 1 (PDL1; also
reasons for the rare survival of patients with clinical known as B7H1) could inhibit T cell proliferation
rabies and might be a potential target for future treat­ and apoptosis73,74,76.
ments70. Nevertheless, whether the diminished immune
response in the brain of patients infected by wild-type Neuronal survival. Although the clinical manifesta­
lyssaviruses is the result of a reduced permeability of the tions of RABV infection can be severe, both macro­
blood–brain barrier or the virus-dependent inhibition scopic and histopathological changes are often quite
of immune cell infiltration to the CNS remains to be mild. RABV replication is self-limited by suboptimal
investigated. In any case, virus-neutralizing antibodies transcription signals and large RNA polymerase protein
(VNAs), which might be detected in the acute neuro­ expression to avert cytopathogenic effects77, thereby
logical phase of naturally acquired RABV infection in supporting the maintenance of vital CNS functions
humans, are considered to be unable to prevent a fatal and intraneuronal transport machineries. The viral
outcome of the infection. load in the brain is greater in dogs that develop furious
rabies than in dogs with paralytic rabies, and in dogs
Immune evasion. Numerous mechanisms have been with paralytic rabies the viral intracellular spread is
proposed to explain how RABV can evade or counteract reduced69,78. In para­lytic dog rabies, axonal integrity
the host’s defence strategies71,72, and RABV replication is also disrupted at the level of the brainstem, impairing
in the CNS seems to be characterized by limited patho­ the viral spread to each hemisphere78,79. Similar data for
gen recognition and immune reactions (FIG. 4). Type I human infection are lacking.
interferon is the main mediator of antiviral innate Viral infections cause cellular stress responses that
immune responses, but RABVs seem to be poor indu­ modulate the host’s gene expression by affecting the
cers of type I interferon62, and such dampened type I regu­lation of mRNA translation, localization and
interferon initial responses at the virus peripheral entry degrad­ation while promoting viral transcription, repli­
sites might only partially eliminate replication. cation and translation. One stress response induced

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by RABV infection is the assembly of both viral and host whether the formation of stress granules is directly
mRNA complexes into dynamic cytoplasmic structures stimu­lated by RABV as a means to control the number
known as stress granules80. Although an antiviral role of viral transcripts and limit cytopathogenic effects and
for stress granules has been suggested81, it is not clear ­consequently cellular damage80.

Entry

Replication
1 Axonal transport
2 Neuron

Soma
Axon

Trans-synaptic
Muscle spread

Microtubule Nucleus
Axon ER
Dynein 3 RNP

mRNA
5 Translation
4 Transcription
Axon AAA 5'
N P M G L

–
6 Replication +
Golgi
–
RABV
Neuron
p75NTR
NCAM

Entry into
neuron G Synaptic
M cleft

Amplification 7
nAChR

Muscle

Figure 3 | Spread of rabies virus within the nervous system. At the motor assembled with the nucleoprotein (N) to form new RNPs while the
Nature Reviews | Disease Primers
endplate, after receptor-mediated endocytosis at the presynaptic replication process is ongoing and can either be used as templates for
membrane (step 1), the virion travels by retrograde axonal transport further RNA synthesis (full-length genome replication and mRNA
towards the neuron soma (step 2), probably in a dynein-dependent manner, transcription) or encapsidated into progeny virions. Assembly and budding
as suggested by transport directionality43, measured transport velocities59 of virions is essentially mediated by M177, but how M is recruited to budding
and co‑transport with the dynein-motor transported tumour necrosis sites is unknown. M is located in the cytoplasm, inclusion bodies (not shown)
factor receptor superfamily member 16 (p75NTR) 42. In the soma, the and the nucleus and accumulates at cellular membranes178. Oligomerization
ribo­nucleoprotein (RNP) is released from the endocytic vesicle (step 3), and of M at membranes could increase the binding affinity of M for the lipid
primary transcription produces 5ʹ‑capped and polyadenylated (AAA) viral bilayer and could play a major part in membrane curvature, envelopment
mRNAs, a process driven by the virion-associated large RNA polymerase of RNPs and virus egress (step 7). A late domain (a protein interaction motif
protein (L) and the phosphoprotein (P) (step 4). Viral proteins are translated that has a role in the budding process) in M increases the efficiency of the
on free ribosomes in the cytoplasm with the exception of the G protein, virus egress179. The glycoprotein (G) on the surface of virions is required for
which is translated through the endoplasmic reticulum (ER) Golgi network receptor binding and subsequent pH‑dependent membrane fusion of the
(step 5). In later phases, the matrix protein (M) shifts the activity of the RNA endocytic vesicle180. G is transported to budding sites through the secretory
polymerase complex (enzymatic subunit L and cofactor P) from pathway, which includes translation at the rough ER and transport through
transcriptase to replicase175,176 and replication of full-length RNA genomes the Golgi apparatus. During surface transport, G is glycosylated181 and
(step 6) occurs. The negative-sense RNA genome is first transcribed in forms homotrimers that are incorporated into budding virions182. nAChR,
full-length, positive-sense RNA strands, which are subsequently transcribed nicotinic acetylcholine receptor; NCAM, neural cell adhesion molecule;
into full-length, negative-sense RNA strands. Both replication products, RABV, rabies virus. Figure adapted with permission from REF. 182, Macmillan
full-length positive-sense and negative-sense RNA genomes, start to be Publishers Limited.

6 | ARTICLE NUMBER 17091 | VOLUME 3 www.nature.com/nrdp

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 PRIMER

complex. In addition, a high affinity of glycoprotein to the

PDZ-binding domain of tyrosine-protein phosphatase
Type I non-receptor type 4 (PTPN4) correlated with virulence
Plasma interferon attenuation83,84. Accordingly, a model has been proposed
membrane IFNAR1 IFNAR2
in which the binding of viral proteins to the PDZ-binding
domains of host proteins could represent a decisive viru­
Cytoplasm P TYK2 JAK1 P
5′-triphosphate lence marker 82. This model is supported by the following
P P P
ssRNA
STAT1 STAT2
observations: the strong binding of glyco­protein from an
N P M G L attenuated RABV to the PDZ-binding domain of PTPN4
increased cell death; pathogenicity and apoptosis induc­
P
STAT1 tion by RABV inversely correlate85; and, in histopatho­
P
RIG-1 STAT2 logical findings, neuronal apoptosis does not have an
P P P important role in human rabies-­associated encephalitis86.
IRF9
IRF3 Evidence of an autophagic response has been observed
P
STAT1 in wild-type RABV infection and this response might be

IRF9
P
IRF3 STAT2 influenced by matrix protein expression87,88. Indications
P
p43 p50 p65 IRF3 P of an autophagic response include minimal pathology
with minimal or no inflammation89; signs (in immuno­
histochemistry tests) of mitochondrial outer membrane
P
Nucleus STAT1 permeabilization (but not of apoptosis) in post-mortem

IRF9
P
IRF3 P3 STAT2 brain examination90; and preserved brain and spinal
P
p50 p65 Antiviral NF-κB IRF3 P IFN ISGs cord function despite abundant viral particles, as in
cytokines
both furious and paralytic rabies coma occurs only at
the pre-terminal phase of the disease, and in paralytic
Figure 4 | Mechanisms of immune evasion of the rabies Nature
virus.Reviews | Disease
Viral infection Primers
triggers rabies electrophysiological and pathological measure­
numerous signalling cascades, including the induction of the genes encoding type I
ments of peripheral nerves show either axonopathy or
interferons and chemoattractive and inflammatory responses, resulting in an antiviral
myelinopathy 91. Apoptosis seems to be more-prevalent in
environment and efficient innate immune responses182,183. However, the rabies virus
(RABV) has developed several different mechanisms to counteract these innate signalling infections with attenuated or fixed viruses (a fixed virus
cascades184–188. Expression of antiviral cytokines is activated by the transcription factor is a cultured strain in which the incubation period and
nuclear factor-κB (NF‑κB). NF‑κB is a homodimeric or heterodimeric complex of various virulence have been stabilized)92.
proteins, of which the heterodimeric complex composed of transcription factor p65 (p65)
and NF‑κB p50 subunit (p50) seems to be the most abundant. A variant of p65, p43, Diagnosis, screening and prevention
which stabilizes p50‑containing dimers and promotes their activation, is inhibited by Clinical disease
RABV matrix protein (M)189,190. The innate immune system recognizes intracellular RABV Clinical descriptions have reported many manifesta­
replication through internal receptors such as probable ATP-dependent RNA helicase tions of rabies93. It has been demonstrated that symp­
DDX58 (also known as retinoic acid-inducible gene 1 protein (RIG‑1))186,191,192, which
toms do not correlate with the site of viral replication in
promotes type I interferon regulator factor 3 (IRF3) phosphorylation and IFN
the brain69,89. Two classical forms of rabies are gener­ally
transcription. RABV nucleoprotein (N) interferes with RIG‑1 activation186, whereas RABV
phosphoprotein (P) inhibits IFN induction by blocking IRF3 phosphorylation. The binding recognized: furious (also called encephalitic) and para­
of interferon to its receptors triggers the dimerization, phosphorylation, association with lytic. The factors that determine the development of
interferon regulatory factor 9 (IRF9) and nuclear import of signal transducer and activator either form remain ill-defined69,94, but each form may
of transcription 1 (STAT1) and STAT2 heterodimers, which promote the transcription of be character­ized by specific symptoms, although case
interferon stimulated genes (ISGs). The nuclear import of STAT1‑STAT2 is prevented definition can typically be established with certainty
by P193, and, within the nucleus, an N‑terminal truncated phosphoprotein form of P (P3) only when the disease reaches the acute neurological
interferes with STAT1- STAT2‑dependent transcription193. P also inhibits type II phase (FIG. 5). Incubation periods can vary considerably,
IFN-γ-dependent signalling through STAT1 homodimers (not shown)193. IFNAR, IFN-α although most patients develop symptoms 20–90 days
and IFN-β receptor; JAK1, tyrosine-protein kinase JAK1; ssRNA, single-stranded RNA;
after exposure3. The cause of this variation is probably
TYK2, nonreceptor tyrosine-protein kinase TYK2. Figure adapted with permission from
multifactorial and can include the site of virus entry
REF. 182, Macmillan Publishers Limited.
and the viral load, the species and strain of the infecting
virus and the immunological competence of the host.
Furthermore, RABV could also directly modulate Initial symptoms are triggered by the viral replication
neuronal cell death, as it has been hypothesized that a in the dorsal root ganglia and include pain, paraesthe­
PDZ-binding domain in the cytoplasmic tail of glyco­ sia and/or pruritus52. After a short prodromal phase, the
protein could be involved in the regulation of neuro­ patient enters the acute neurological phase of the dis­
nal survival by binding to microtubule-associated ease, which is characterized by clinical manifestations.
serine/threonine protein kinase 2 (MAST2)82. The Furious rabies typically presents during this phase with
complex formed by MAST2 and phosphatidylinositol intermittent agitation, hypersalivation and hydrophobia
3,4,5‑­trisphosphate 3‑phosphatase and dual-­specificity (a flight response to fluids) (FIG. 5). By contrast, the para­
phosphatase and tensin homologue (PTEN) can prevent lytic form presents with muscle weakness and, eventu­
or reduce neurotrophin-dependent apoptosis inhib­ition. ally, paralysis and generally a longer acute neurological
Thus, the binding of glycoprotein to MAST2 could phase than furious rabies94. Both forms of rabies lead to
impair the pro-apoptotic function of the MAST2–PTEN coma and death.

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PRIMER

Hyperactivity, confusion and agitation

Fever, pruritus and paraesthesia Hypersalivation, piloerection,

Furious rabies periodic dilation of the pupils, hydrophobia,
aerophobia, dysphagia, inspiratory spasms,
Exposure First symptom Clinical expression hyperventilation and haematemesis Coma

20–90 days Prodrome (1–2 days) Acute neurological phase (1–4 days) Death (1–7 days)

Paralytic rabies
Fever, pruritus and paraesthesia Quadriplegia, dysarthria, dysphagia, hypersalivation,
inspiratory spasms, respiratory failure and hydrophobia
or aerophobia (in ~50% of cases)

Behaviour
Clinical symptom Drowsiness

Figure 5 | The spectrum of clinical rabies. The clinical presentation of rabies can vary substantially
Nature Reviews
between| Disease Primers
patients,
which makes diagnosis on the basis of observed symptoms problematic. In individuals with furious rabies, hyperactivity
manifests during the prodromal phase and can alternate with confusion or agitation once the patient enters the acute
neurological phase. In patients with paralytic rabies, during the prodromal phase the patient is fully alert, but confusion or
drowsiness can intermittently occur during the acute neurological phase, although not as prominently as seen in the furious
form of the disease. The course of clinical disease and some clinical manifestations can be observed in both paralytic and
furious rabies; thus, it is generally not possible to differentiate between the two forms until the acute neurological phase.
The average time from the onset of symptoms to death is 7.8 days in furious rabies and 11 days in paralytic rabies94.

Diagnostic evaluation a number of RT‑PCR-based and quantitative RT‑PCR

The specific clinical symptoms of hydrophobia or aero­ (RT‑qPCR)-based assays have been proved rapid,
phobia (fear of drafts or fresh air) provide a strong indi­ highly sensitive and specific and are increasingly used
cation of RABV infection. However, only the results for ante-mortem RABV testing 98–101. Other biological
of laboratory tests can provide a definitive diagnosis of ­samples that could be used for RT‑PCR testing include
rabies30, as other differential diagnoses are possible urine and extracted hair follicles102; as detecting the
(FIG. 6). In fact, the absence of pathognomonic symp­ virus, especially in the early stages of disease, is chal­
toms means that fluctuating consciousness, phobic or lenging, increasing the number of tested samples can
inspiratory spasms and autonomic stimulation can indi­ improve the probability of identifying the virus, if pres­
cate infection with RABV. Some presentations can ent. Ante-mortem testing of corneal impressions is of
commonly occur in paralytic rabies or other atypical limited value and is no longer recommended30, and
forms, caused by infection with dog or bat variants of other diagnostic methods such as viral culture are not
RABV90. Although early diagnosis is important, the lack sufficiently sensitive or timely for diagnostic applica­
of tools to enable survival once the patient develops tion and require tissue culture facilities that are often
clinical disease means that, regardless of the timeliness unavail­able. Although saliva can be obtained quite
of the diagnosis, the prognosis is extremely poor and ­easily, because of the intermittent secretion of the virus
will almost certainly result in death if RABV infection into this fluid the diagnostic findings should be inter­
is confirmed29. preted with caution, and multiple samples collected
daily might be required to confirm virus presence30,97,102.
Ante-mortem diagnostic testing. In endemic settings, However, it must be stressed that laboratory tests can
ante-mortem diagnostic tests are not routinely con­ only confirm infection: a neg­ative ante-mortem test
ducted, as facilities often lack the necessary resources. result does not necessarily rule out infection.
This situation is unfortunate, as ante-mortem confir­ Humoral immune responses to RABV usually
mation of infection enables appropriate patient care arise in the serum or the cerebral spinal fluid (CSF)
and alerts caregivers to potential risks of RABV trans­ at late stages of infection103. Nevertheless, although it
mission. The most useful samples for ante-mortem is not directly considered a diagnostic test, the detec­
diagnosis are obtained from nuchal (nape) skin biop­ tion of virus-specific antibodies against viral antigens
sies and saliva (TABLE 2). Live virus has been occasion­ in the serum of unvaccinated individuals, or in the
ally isolated from human saliva93,95; in dog models, high CSF of both vaccinated and unvaccinated individ­
viral titres can be intermittently detected in secretions uals, can be of diagnostic value. VNAs in the CSF were
(saliva) up to 10 days before the onset of clinical dis­ detected in 20 (22.4%) of 89 clinically suspected cases
ease96. Skin specimens can be tested for the presence of rabies in India104. By contrast, antibodies in the CSF
of virus antigen (that is, the nucleoprotein) in neurons were not detected in 31 Thai patients with rabies and
in close proximity to hair follicles, and both skin and 43 unvaccin­ated patients who were infected with dog
saliva samples can be tested for the presence of viral RABV variants from Cambodia, Madagascar and
RNA by reverse transcription PCR (RT‑PCR)97. Indeed, Senegal52. Individuals who develop VNAs in the serum

8 | ARTICLE NUMBER 17091 | VOLUME 3 www.nature.com/nrdp

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 PRIMER

or CSF early during the disease course are consid­ with other molecular-based methods, has been com­
ered potentially favourable candidates for aggressive pleted, and this procedure, or variations thereof 109,
manage­ment 105. Of note, most documented survivors is expected to increase the availability of antigen detec­
of rabies were diagnosed solely by the presence of VNAs tion methods to endemic regions and could enable
in the CSF or serum, and no viral RNA or ­antigens were reliable primary diagnosis in resource-limited areas27.
detected in biological samples (TABLE 3). Further antigen detection tests, including lateral flow
devices (LFDs), have been developed (TABLE 2) but lack
Post-mortem diagnostic testing. Brain tissue is the validation. Depending on the sensitivity and specifi­
speci­m en of choice for post-mortem diagnosis 29. city of routine diagnostic tests (such as the FAT and
Historically, the presence of Negri bodies (intracellular RT‑PCR), a confirmation of results could be required
accumulations of RABV particles), first described in by a validated secondary method, such as the rabies
1903, was considered indicative of rabies, but this test ­tissue culture isolation test (RTCIT) for virus isolation
has now been replaced by more-sensitive and speci­fic or the mouse inoculation test (MIT), in which brain
methods98,106. However, the detection of Negri bodies ­s amples are inoculated intracranially in laboratory
upon autopsy can warrant further testing for RABV mice, in areas where tissue culture facilities for RTCIT
infection. The fluorescent antibody test (FAT) to detect are unavailable107 (TABLE 2).
virus antigen in brain impressions is the diagnostic test Molecular diagnostic assays that can detect the RNA
recommended by both the WHO and the OIE, and it of many lyssaviruses are available110,111 (TABLE 2) and
yields reliable results in fresh specimens in <4 hours107 will replace the cumbersome existing secondary tests
(TABLE 2). The sensitivity of the FAT depends on the for rabies diagnosis in animals. Compared with the
quality of the specimen and the degree of autoly­sis of FAT, molecular methods are less prone to subjective
the brain tissue. However, the FAT requires expensive interpretation and have the added benefit that they
equipment; thus, it is often unavailable in resource-­ can identify the virus species, a useful tool in cases
limited settings. To overcome this limitation, a direct with undefined history of potential exposure to RABV.
immunohistochemical test (dRIT) that uses a mix­ Molecular assays are now recognized by the OIE; how­
ture of biotinylated antibodies and light microscopy ever, these tests need to be performed in well-controlled
has been generated; dRIT is cost-effective and can environments to avoid false-positive results and, as a
rapidly detect virus antigen in fresh brain material108 consequence, the standardization of the assays and
(TABLE 2). Extensive validation of dRIT, through evalu­ use of appropriate controls are required before these
ation against the gold-standard FAT and comparison tools can be used for routine post-­mortem diagno­
sis of rabies in animals in resource-limited settings30.
Most post-­mortem diagnoses are currently based on
Rabies-like symptoms the previously recommended techniques (the FAT,
RTCIT and MIT): adoption of new reliable and valid­
ated tools (dRIT and RT‑PCR) will improve diagnostic
Consider rabies in case of... Differential diagnoses options for rabies in endemic areas where empiri­cal
data are lacking and the burden of the disease is
• Autoimmune
disproportionately high.
Animal contact Tissue or organ encephalopathy
transplant • Toxicity-induced Prevention
encephalopathy Primary prevention is the best defence against rabies.
• Metabolic or electrolyte It includes: elimination of animal rabies through dog
disturbances
• Illicit drug use vaccination campaigns; promoting awareness of the
• Bacterial infections disease and available prevention; and encouraging
Dogs Wild animals (such as fox, Bats (fruit,
or jackal, raccoon, raccoon dog, insectivorous • Other viral infections responsible dog ownership and vaccination, particu­
cats skunk and wolf) or vampire bats) • Parasitic infections larly in endemic areas, where existing cultural practices
Figure 6 | Algorithm for the evaluation of differentialNaturediagnoses. The|diagnosis
Reviews of
Disease Primers might need to be adapted to integrate these interven­
rabies cannot be made solely on the basis of clinical presentation, as several other tions27. Where possible, rabies pre-exposure prophylaxis
infectious or noninfectious aetiologies are possible. The geographical context can (PrEP) via immunization is recommended for travel­
provide valuable information during the evaluation of a patient presenting with lers to endemic regions, although such advice might
rabies-like symptoms. It is also important to establish whether the patient had contact not always be followed112. However, in the absence of
with potentially infected animals and, if this is the case, what kind. Rarely, rabies can infrastructure to support such initiatives, secondary
occur after interaction with less commonly reported animal hosts, such as rodents. prevention attempts to prevent the onset of clinical
The circumstance of the bite can provide information on the category of exposure that disease through post-exposure prophylaxis (PEP).
occurred. Several autoimmune encephalitides are thought to be quite common in Assessing the ­category of exposure as defined by the
rabies-endemic areas and, therefore, should be considered alongside other potential
WHO (BOX 1) determines the course of action required.
aetiologies, such as bacterial infections (for example, Mycobacterium tuberculosis,
Clostridium tetani or Rickettsia spp.), other viral infections (for example, herpes simplex The combin­ation of PrEP and PEP can successfully pre­
or enteroviruses) and Guillain–Barré syndrome. Parasitic infections (for example, vent infection in virtually 100% of cases and, regardless
Plasmodium spp.) are another possibility, as rabies could be misdiagnosed as cerebral of whether or not PrEP has been administered, appro­
malaria in the absence of laboratory evaluation. Importantly, the exclusion of other rabies priate wound care and application of PEP are almost
mimics and confirmation of diagnosis can cause delay in management planning. invariably effective in preventing deaths30.

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Table 2 | Diagnostic tests

Test Target Turnaround Advantages Disadvantages
time
Ante-mortem
Conventional Viral nucleic 3–4 hours • Rapid • Requires specialist equipment
RT‑PCR*‡§ acid • High sensitivity and specificity • Potential for contamination
• One-tube systems reduce
contamination risks
• Amplicons can be used for
genetic characterization
Real-time RT‑PCR*‡§ Viral nucleic 2–3 hours • Rapid • Requires specialist equipment
acid • High sensitivity and specificity • Potential for contamination
• One-tube systems reduce • Amplicon not useful for genetic characterization
contamination risks
Fluorescent antibody Virus- 5–8 days • Useful for assessment after • Long turnaround time
virus neutralization neutralizing vaccination • Incompatible with ante-mortem confirmation of
(FAVN) and rapid antibodies diagnosis, as antibodies are usually detected after
fluorescent focus the onset of clinical signs
inhibition test (RFFIT) • Requires specialist containment and operator expertise
Post-mortem
Fluorescent antibody Virus 2–3 hours • Rapid • Expensive conjugate
test (FAT)*‡ antigen • High sensitivity and specificity • Requires an ultraviolet light microscope
• Can be difficult to interpret results
Direct Virus 2–3 hours • Rapid • Can be difficult to interpret results
immunohistochemical antigen • Requires only a light
test (dRIT)*‡ microscope
Lateral flow devices Virus 30–60 • Simple point‑of‑care test • Requires validation
(LFDs)‡ antigen or minutes • Safety risk associated with • Batch-to-batch variation reported
antibody sample preparation in the field
Rabies tissue culture Live virus 4–6 days • Enables propagation of virus • Requires specialist facilities and operator expertise
isolation test (RTCIT)*|| for characterization • Long turnaround time
Mouse inoculation test Live virus Up to • Enables propagation of virus • Requires specialist facilities and operator expertise
(MIT)*|| 28 days for characterization • Very long turnaround time
• Ethical issues owing to the use of in vivo models
RT-PCR, reverse transcription PCR. *Awaiting validation by the World Organisation for Animal Health (OIE). ‡Low relative cost per test. §Can also be used
post-mortem. ||High relative cost per test.

Rabies vaccines. Several inactivated preparations of Although the use of refrigerated reconstituted vaccines
RABV are available as vaccines to immunize humans has not been sanctioned by any major organization or
and domestic animals. For wildlife vaccination, both vaccine manufacturer, studies have demonstrated that it is
live-­attenuated and subunit vaccines are available. safe, and such vaccine preparations can retain immuno­
Human rabies vaccines are administered intra­muscularly genicity for weeks to months, as long as uninterrupted
or intradermally, and the same vaccines that are used local electrical supply can support storage115,116. Vaccines
for PrEP can also be given as part of PEP. The goal of are now locally manufactured in India, Thailand and
vaccin­ation is to induce VNAs against glycoprotein that China, and the WHO is developing methods to ensure
provide protection against RABV infection113, although the uniformity, safety and efficacy of these new products,
the precise location and mechanisms by which VNAs in line with existing recommendations114–119. Research has
inhibit viral replication are unknown. The availability focused on the develop­ment of new vaccines that could
of inactivated, lyophilized, cell culture-based vaccines reduce the number of clinic visits required through over­
with increased antigenicity has led to a reduction in expression of the virus glycoprotein. Live-attenuated
the ­number of doses needed to elicit a sufficient VNA RABV variants in which glycoprotein expression is two­
response and, hence, a reduction in the number of clinic fold to threefold the physiological levels have proven to
visits required, which in turn has improved patient be effective as PrEP in murine and canine models120–122.
participation, in both PrEP and PEP113. The WHO has An attenuated virus vaccine with three copies of the gene
issued recommendations for inactivated rabies vac­ encoding glyco­protein induced RABV VNAs in the CSF
cines for human use114 and pre-qualified three vaccines of mice following intrathecal administration123 and could
(TABLE 4). All licenced vaccines have good safety records, be of value as a human therapeutic.
and severe adverse events after vaccination are very rare.
However, clinicians should be aware that, as with virtu­ Primary prevention: pre-exposure immunization. The
ally all vaccines, minor adverse effects, such as mild fever near‑100% case fatality rate and high case incidence of
and localized reactions to i­ noculations, are common. RABV infection in children <15 years of age have led

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 PRIMER

to the proposal that PrEP should be considered as part rabies vaccines as part of the Expanded Programme
of a recommended paediatric vaccination strategy in on Immunization initiative for children would increase
high-risk regions25,30,124. PrEP regimens currently con­ the probability of preventing the development of clin­
sist of the administration of 4 vaccine doses, on days 0, ical disease in exposed individuals in the absence of
7, 14, and 21 or 28 (REF. 30). Where PrEP is implemented, rabies immunoglobulin (RIG) treatment 125. However,
the assessment of serological positivity is important to in endemic areas economic difficulties limit the avail­
ensure adequate protection and longevity of the anti­ ability of vaccines; thus, widespread PrEP coverage is
body response. Furthermore, the administration of unattainable and, as a result, PEP is the primary barrier

Table 3 | Human rabies survivors reported worldwide

Country Sex and age Mode and site of PEP Incubation Antibodies in Type of Viral material Refs
and (years) of the exposure type and period CSF and serum antibody detected (sample
year of patient and doses; (highest titres or and tested)
disease disease outcome type concentrations method
onset of RIG recorded) of testing
India, Male, 6, severe Dog bite; neck PCECV, 4; ~22 days CSF (8,192); RVNA; None (saliva, nuchal 195
2014 sequelae*‡ and back ERIG serum (>200,000) RFFIT skin and CSF)
India, Male, 13, severe Dog bite; right hand PCECV, 3; ~2 weeks CSF (>64,000); RVNA; Antigen (nuchal skin) 196,
2014 sequelae none serum (>64,000) RFFIT 197
South Male, 4, severe Dog bite on left Type NA, ~3–7 weeks CSF (>13,975 RVNA; None (saliva, nuchal 198
Africa, sequelae ankle and scratch 3; none (multiple IU/ml); serum RFFIT skin and CSF)
2012 on forehead exposures (>13,975 IU/ml)
to dogs)
USA, Female, 8, Scratches from None; Unknown CSF (8); IgM None (saliva and 199
2011 complete free-roaming, none serum (160) antibody; nuchal skin)
recovery§ unvaccinated cats IFA
(probable source);
site NA
India, Male, 17, severe Dog bite; left calf PCECV, 4; ~2 weeks CSF (>8,000); RVNA; None (corneal smear 146
2011 sequelae|| HRIG serum (>16,000) RFFIT and nuchal skin)
India, Male, 4, severe Dog bite; face PCECV, 4; 25 days CSF (512); RVNA; Antigen (nuchal skin) 200
2010 sequelae¶ HRIG serum (16,384) RFFIT and RNA (nuchal skin
and CSF)
Turkey, Male, 17, complete Dog bites; left VCV, 1; ~3 weeks CSF (NA); RVNA; Antigen (corneal 201
2008 recovery# forearm and right none serum (3,788) RFFIT smear) and RNA (CSF
shoulder and saliva)
Brazil, Male, 15, moderate Vampire bat bite; Type NA, ~29 days CSF (>100 IU/ml); RVNA; RNA (nuchal skin 202
2008 sequelae site NA 4; none serum (>100 IU/ml) RFFIT hair follicles)
USA, Female, 15, mild Bat bite; left index None; 1 month CSF (1,300); RVNA; None (saliva and 148
2004 sequelae**‡‡ finger none serum (1,604) RFFIT nuchal skin)
India, Female, 6, severe Dog bites; face and PCECV, 3; 20 days CSF (312,000); RVNA; None (CSF, nuchal skin 203
2000 sequelae hands none serum (182,000) MNT and corneal smear)
Mexico, Male, 9, severe Dog bite; face VCV, 3 and 18 days CSF (78,125); RVNA; None (saliva, nuchal 204
1992 sequelae HDCV, 1; serum (134,800) RFFIT skin and corneal smear)
none
USA, Male, 32, severe Laboratory exposure None¶¶; ~2 weeks CSF (16,225); RVNA; None (nuchal skin 205,
1977 sequelae§§ to virus (aerosol) none (probable) serum (175,000) RFFIT and corneal smear) 206
Argentina, Female, 45, nearly Dog bite; left arm SMBV, 21 days CSF (160,000); RVNA; None (saliva, nuchal 207
1972 complete recovery 14 and 2 serum (640,000) MNT skin and corneal smear)
boosters;
none
USA, Male, 6, complete Bat bite; left thumb DEV, 14; 20 days CSF (3,200); RVNA; None (saliva, CSF, brain 208
1970 recovery|||| none serum (63,000) MNT biopsy, corneal smear)
Only published and adequately documented cases are included. CSF, cerebral spinal fluid; DEV, duck embryo vaccine; ERIG, equine rabies immunoglobulin; HDCV,
human diploid cell vaccine; HRIG, human rabies immunoglobulin; IFA, indirect immunofluorescence assay; IgM, immunoglobulin M; MNT, mouse neutralization
test; NA, not available; PCECV, purified chick embryo cell vaccine; PEP, post-exposure prophylaxis; RFFIT, rapid fluorescent focus inhibition test; RIG, rabies
immunoglobulin; RVNA, rabies virus-neutralizing antibodies; SMBV, suckling mouse brain vaccine; VCV, purified vero cell vaccine. *Sequelae generally include
neurological problems and can vary depending on cases. Examples include convulsions, poor swallowing reflex and paralysis. ‡Deviations in PEP protocol used.
§
Rabies-neutralizing antibodies not detected in CSF or serum. Diagnosis based on virus-specific antibodies in CSF and serum detected by IFA. ||Delay in initiating
PEP. ¶Nuchal skin biopsy sample positive for viral RNA even 4 years after onset of illness. #ERIG administered after onset of symptoms. **The US case definition for
human rabies is “a clinically compatible case that is laboratory confirmed by testing at a state or federal public health laboratory” (https://wwwn.cdc.gov/nndss/
conditions/rabies-human/case-definition/2011/). The patient met these criteria, and at the time of publication, the state of California has not withdrawn this case
notification. ‡‡The first reported rabies survivor who had never received prior vaccination. §§The first reported case of rabies in a pre-immunized individual. ||||Virus
isolated from bat. ¶¶Pre-exposure immunization with DEV.

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to preventing deaths30. Population groups who are at (true PEP failures) are rare129 and can be attributed to
increased risk of exposure to lyssaviruses, including short incubation periods that result from multiple bites,
veterinarians, scientists and bat workers, should also especially on highly innervated areas such as the face,
receive PrEP100,126. Travellers to endemic areas might be neck or hands.
unaware of the need for vaccination, and even if they are,
misperception of vaccine-associated risks might prevent Rabies immunoglobulin and vaccination. PEP can
them from seeking PrEP112. include both the administration of RIG and vaccin­
ation, although individuals who received adequate PrEP
Secondary prevention: wound care. Appropriate wound should receive a booster vaccination, but not RIG. The
care (in combination with PEP regimens) can save lives; application of RIG directly to the wound aims to neutral­
in the absence of wound care, the probability of success­ ize any live virus in the immediate wound area and pre­
ful PEP decreases127. Wounds should be irrigated with vent the spread of the virus in the time that it takes to
soapy water and scrubbed to remove foreign bodies, and develop sufficient immunity in response to vaccination
the use of iodine-based antiseptics is recommended. (up to 14 days103). Human RIG (HRIG) or, if not avail­
Unless absolutely necessary, suturing the wounds should able, chromatography-purified, pepsin-digested equine
be avoided or delayed, certainly until after the adminis­ RIG (ERIG) can be used. The WHO recommends a
tration of RIG, as neuronal trauma could allow direct weight-based total dose calculation: 20 IU/kg for HRIG
viral access to nerve endings. The local treatment of the and 40 IU/kg for ERIG. If possible, all of the calculated
wound as well as PEP should be sought immediately dose of RIG should be infiltrated into wounds, and any
after exposure. residual RIG should be injected intramuscularly at a dis­
tant site30. However, owing to high manufacturing costs
Secondary prevention: post-exposure prophylaxis. and difficulties in large-scale production, RIG is often
If exposure is suspected, the WHO guidelines for risk scarce in endemic countries26. Although ERIG is safe,
assessment should be followed30 (BOX 1) and medical easier to prod­uce than HRIG, effective and increasingly
advice should be sought to evaluate the need for PEP. available in rabies-endemic countries, the development
PEP should be administered as soon as possible after of new alternatives is warranted130. Studies have assessed
a potential exposure to increase the probability of pre­ the application of RIG to wounds alone, omitting the
venting clinical disease; of note, rare cases of very long injection of the usually large residual volume of RIG to
incubation times in humans suggest that PEP could be distant sites, in an effort to save RIG supplies for future
of value even if the administration is delayed and should, patients131. This approach could enable resource-limited,
therefore, always be provided in suspected cases if con­ rabies-­endemic countries to provide PEP to all patients
cerns are raised. Although the development of clinical with category III exposure131. Nevertheless, a lack of
disease is almost 100% preventable with prompt PEP, knowledge regarding the potential tools available for
failures do occur, most often because of deviations in PEP means that, even where RIG is available, it might
recommended PEP protocols101. Such deviations include not be used.
delay in seeking PEP, improper wound care, lack of or In addition to RIG administration, vaccination
incorrect RIG administration and inadequate vaccine is advised at a distant site. For previously vaccinated
doses. Very rarely, failures can result from the use of patients, an intradermal or intramuscular booster regi­
substandard black-market products128. Cases of patients men has been recommended by the WHO30,132 (TABLE 4).
who develop fatal rabies despite receiving adequate PEP For unvaccinated individuals, several vaccine regimens
are approved for PEP; as all vaccines are considered
equally effective, the choice of the regimen is deter­
Box 1 | Exposure risk (WHO categories) and appropriate treatment mined by the available vaccine and the local medical
Category I exposure: touches or licks on intact skin centre experience30 (TABLE 4). Immunocompromised
Contact with intact skin is not considered exposure; thus, post-exposure prophylaxis is patients and those with low CD4+ T cell counts might
not required. However, exposure assessment based on only the information provided by respond poorly or not at all to vaccination133. Such
the individual involved might not be sufficient if the person is a minor, as contact with patients require intense PEP, including wound care with
mucous membranes cannot be excluded. In such cases, it is indicated to test for the RIG infiltration and vaccination, to elicit an adequate
presence of broken skin with the application of an alcohol swab over the scratches immune response. Patients receiving haemodialysis
(pain indicates broken skin). If the individual reports pain, the exposure risk is category II. could also have impaired immunological responsive­
Category II exposure: nibbling over uncovered skin, minor scratches with ness to vaccines, although rabies vaccination is safe
broken skin and effective if applied before the onset of symptoms134.
Rabies vaccination is required, but rabies immunoglobulin (RIG) is not. The exposed Vaccination for PEP can be time consuming and costly,
area should be vigorously cleansed and irrigated with detergent, alcohol or iodine. owing to a need for multiple separate clinic visits. Studies
Category III exposure: single or multiple transdermal bites or scratches have attempted to shorten PEP vaccination regimens to
or contamination by saliva from rabid animals on broken skin or mucous 1 week135 to make PEP more-affordable and a­ ccessible136.
membranes Although the use of intradermal rabies vaccination
The exposed area should be vigorously cleansed and irrigated with detergent, alcohol schedules is expanding worldwide 137,138, the WHO
or iodine. Human or equine RIG should be administered and infiltrated as much as requirement to use reconstituted vaccine within 6 hours
possible into the wounds; if the calculated RIG dose is inadequate to infiltrate all limits this practice to large clinics, which encounter
wounds, RIG should be diluted with saline to infiltrate all wounds.
­several patients who need PEP each day.

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Table 4 | Rabies vaccine regimens for post-exposure prophylaxis determined on a case-by-case basis. However, in most
cases palliative care is the only option, as there is, as yet,
Regimen Route of Days of visits Regimen details no therapy of proven efficacy for human rabies30, and the
administration
decision to provide aggressive intensive care is fraught
Pre-immunized individuals with several medical, ethical, legal, social and economic
Booster i.d. or i.m. 0 and 3 One dose each day challenges for physicians as well as care­givers of patients
Unvaccinated individuals with rabies141,142. The data on in vitro efficacy of anti­
viral drugs have rarely translated to in vivo successes
Essen i.m. 0, 3, 7, 14 and 28 One dose each day in experi­mental models and, therefore, these research
Modified Essen i.m. 0, 3, 7 and 14 One dose each day findings have not translated to clinical settings143,144.
Zagreb (2‑1‑1) i.m. 0, 7 and 21 Two doses administered Intravenous sedatives (for example, diazepam, midazo­
at different sites on day 0; lam or barbiturates) and analge­sics (for example, mor­
one dose on days 7 and 21 phine or ketamine) might be required to relieve agitation,
Thai Red Cross i.d. 0, 3, 7 and 28 Two doses at different phobic spasms, anxiety and other neuro­logical symp­
Intradermal (TRC‑ID) sites on each visit toms in patients with furious rabies30,141. Antipsychotics
i.d., intradermal; i.m., intramuscular. Data from REF. 30. (for example, haloperidol) can be benefi­cial; however,
patients with rabies tend to require higher and more
Management numerous doses than generally prescribed, which could
The management of furious and paralytic rabies does increase the risk of developing neuro­leptic malignant
not substantially differ. Treatment approaches are syndrome. In furious rabies, all of these symptomatic
mainly symptomatic and might differ on a case-by- or palliative treatments aim to alleviate limbic manifes­
case basis owing to the variety of rabies manifestations. tations caused by functional selective impairment via
Furthermore, the availability of therapies varies greatly neuro­transmitter dysregulation52. New approaches (such
across countries. Once the clinical signs and symptoms as experimental drugs or protocols) might be consid­
of rabies are evident, the prognosis is uniformly dis­ ered to treat a critically ill patient if the potential benefits
mal, generally culminating in death within 5–11 days52, ­outweigh the risks.
although survival can be prolonged by 1–3 months in Palliative care is imperative even if critical care is not
some patients receiving critical care104. feasible because of medical, logistical or financial reasons.
Unfortunately, few studies have addressed palliation in
Exposure assessment rabies141,145, and standard national guidelines for palli­
In patients who present with encephalitis with undefined ative care remain absent in endemic regions. Patients
origin, the initial assessment should involve a thorough continue to be isolated, often physically restrained, for
evaluation that should focus on looking for minor bites fear of aggression and transmission of infection to others.
that might have been missed and the examin­ation of
existing wounds. Anamnesis (medical history of the Surviving rabies. Fewer than 20 adequately documented
patient) should include any complicating factors, such survivors of rabies have been reported worldwide105
as underlying illnesses or (allergic) reactions to previous (TABLE 3). Most reports are dated after 2000, which could
vaccinations or drugs. If exposure to RABV is suspected reflect an increased awareness of the disease and greater
and domestic animals are implicated, the a­ nimal should access to better critical care facilities in rabies-endemic
be observed for clinical signs for 10 days30 and PEP countries142. Although almost all described patients
should be initiated. Further treatment can be stopped had poor functional outcomes that required lengthy
if the suspect animal remains healthy after quarantine. rehabilitation and care, with long-term emotional and
If the animal shows clinical disease and is available financial repercussions for family members, complete
for testing, rabies can be excluded only by a negative or good functional recovery is possible. This possibil­
FAT result that is confirmed by another reference test ity should compel physicians to consider and m ­ anage
(RTCIT or MIT), as recommended by the OIE. In areas rabies as a curable disease, which is not ­usually ­possible
where terrestrial rabies has been eliminated, bat rabies in under-resourced rabies-endemic countries 146.
constitutes a small but not negligible human health Incremental triage of potential candidates for an inten­
threat and, therefore, this possibility should be consid­ sive therapeutic approach should be implemented,
ered139,140. If possible, a veterinary examination of the and favourable factors that could indicate a potential
implicated a­ nimal should be arranged with necropsy candi­date include young age and immunocompetence,
when necessary. prior vaccination, early appearance of VNAs in the CSF
and serum, rabies due to a bat RABV variant and mild
Management of overt rabies. The hospitalization ­neurological illness at i­ nitiation of therapy 144,147.
of patients with rabies-like clinical manifestations The difficulty in treating clinical rabies is clear.
is required to confirm the diagnosis and prevent One therapeutic modality that was developed in the
contamin­ation or exposure of others to virus-­containing United States that seemed to show early promise of
bio­logical fluids (FIG. 7). Regardless of whether the diag­ success was the ‘Milwaukee protocol’ (REF. 148), which
nosis of rabies has been confirmed, these patients should enabled the survival of an unvaccinated 15‑year-old
receive intensive care, if available, as recovery is possible girl who was infected with a US bat RABV variant. The
(albeit very rarely); the duration of treatment should be Milwaukee protocol focused on supportive critical care

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PRIMER

Rabies suspected

Diagnosis: confirmed Diagnosis: equivocal

Patients with Alert patients or
severely depressed those with mildly Cardiopulmonary support
sensorium depressed sensorium

Palliative care Aggressive Mimics excluded or rabies Unclear

(analgesia and Where possible ICU care with diagnosis confirmed diagnosis
anaesthesia) therapeutics

Intrathecal Bio-manipulation Use of small interfering New broad- Empirical treatment

administration of the RNA or microRNA spectrum and broad-
of genetically blood–brain with appropriate delivery RNA virus spectrum RNA virus
manipulated vaccines barrier and targeting systems inhibitors inhibitors

Temporary disruption measures enabling

Current treatment
influx of therapeutics or neutralizing
antibodies administered systemically Future treatment

Figure 7 | Management of clinical rabies. The treatment of patients with suspected or laboratory-confirmed rabies
Nature Reviews | Disease Primers
at present is purely symptomatic; sedation therapy should alleviate neurological symptoms but avoid compromising
cardiopulmonary function. Future therapies should aim to eliminate the virus completely and be applied to alert patients
whose nervous system functions are still not corrupted. However, before such therapies can be included in intensive care
regimens, it is necessary to ensure that they do not to pose any harmful complications. The proposed therapeutics shown
remain to be proven effective in experimental animal models. ICU, intensive care unit.

with the aim to evade fatal dysautonomia (dysfunc­ bites from rabid animals can potentially contribute
tion of the autonomic nervous system) during the first substantially (>10%) to the estimated DALYs26, and is
week of hospitalization and to presumably slow the often augmented by uncertainty about the availability
normal metabolic processes, thereby enabling natur­ and affordability of PEP in many dog rabies-endemic
ally developed immune responses to confer a sterilizing countries30. Livestock losses due to dog-mediated rabies
immunity until RABV was cleared from the brain. This account for a small proportion of the global economic
goal was achieved by induction of a therapeutic coma burden (6%); however, they disproportionately affect
(by administering GABA receptor agonists and NMDA communities that rely on livestock for subsistence
(N‑methyl-d‑aspartic acid) receptor antagonists) and and livelihoods26.
concurrent administration of antiviral drugs. The
original protocol has since undergone several modifi­ Outlook
cations, and induction of coma is no longer recom­ In the 21st century, it is anticipated that human rabies
mended. However, despite an intial success, the protocol will be confined to history: the goal is to eliminate the
remains controversial, owing to the associated risks and disease by preventing the transmission of the virus
­uncertain benefit 149. between terrestrial animals (principally dogs) and
humans. For this vision to be realized, a combination of
Quality of life improved diagnostic tools and veterinary and medical
Globally, dog-mediated rabies is estimated to cause infrastructures — to enable access to more-inexpensive
>3.7 million (95% CI 1.6–10.4 million) disability-­ and efficacious biologics (vaccines, new antivirals and
adjusted life years (DALYs), resulting, for example, from HRIG) — as well as increased education and awareness
adverse events of vaccination with nerve tissue vaccines of rabies in endemic countries is urgently required27.
(which are derived from animal brain tissue, for exam­
ple, sheep, goat or mouse) or mortality due to rabies26. Diagnosis
The annual global economic burden of dog-mediated One of the first steps towards human rabies elimin­ation
rabies is US$8.6 billion (95% CI $2.9–21.5 billion); lost is to ensure that all regions have the capability to accur­
productivity due to premature deaths is a major compo­ ately diagnose the infection using a network of dedi­
nent (55%), whereas direct costs of PEP (depending on cated laboratories with validated diagnostic tools. The
the biologics used and their regimens) and indirect costs development of molecular diagnostic techniques and
of seeking PEP (such as travel, accommodation, multiple next-generation sequencing has revolutionized high-
clinic ­visits, lost income and so on) account for 20% and throughput diagnostic testing and genetic character­
15% of the economic burden, respectively 26. Although ization of microorganisms. However, these techniques
difficult to quantify because of the lack of valid­ated are not available in all diagnostic laboratories and remain
methods, anxiety associated with life-threatening largely a research tool for pathogen discovery rather

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than pathogen diagnosis per se27. The future challenge Although the actual burden of human rabies remains
is to combine molecular assays that can genetically difficult to quantify, it is evident that rabies can be
character­ize the RABV variant with point‑of‑care test­ managed at a community level by increasing disease
ing 98. The ‘laboratory in a box’ concept, which consists awareness in addition to the control of dog populations.
of a toolbox of basic laboratory equipment that can be Increasing disease awareness in children, and especially
used for preliminary field diagnosis, will enable the rapid what actions to take if an exposure is suspected, could
assessment of cases of suspected RABV infection and, contribute to reducing deaths and could be achieved
as a result, to provide initial care early 150, while awaiting through the adoption of a few straightforward messages
confirmation of diagnosis from reference laboratories27. as part of an educational curriculum147,159. Nevertheless,
Studies are underway to assess such new technologies. cultural approaches to dog ownership and the multi­
The WHO and OIE have clarified that both human factorial challenges associated with dog licensing and
and animal rabies should be considered notifiable dis­ vaccination mean that any elimination campaign will
eases. However, in areas without the appropriate labora­ require long-term investment 7. The number of animal
tory infrastructures, the timeliness of case reports is bites is often high in regions where rabies is endemic,
often inadequate. Thus, national governments should and every bite should be considered a potential expo­
consider it a high priority to follow a step-wise approach sure160. It is estimated that PEP is given to >15 million
towards dog rabies elimination151. Such approaches link individuals each year to prevent the establishment of dis­
achievable goals on a structured pathway to eliminate the ease161. However, owing to lack of awareness, the simplest
disease152. The FAO in collaboration with the OIE and actions required as part of PEP, including washing the
the WHO has proposed a Progressive Control Pathway wound and avoiding suturing it, are rarely implemented.
towards rabies elimination, in which the final stage is Moreover, the biologics required for PEP present chal­
maintaining both humans and animals free of rabies. lenges, and alternative products are needed. Vaccines
require multiple inoculations and are often unavailable
Vector control and disease awareness because of the lack of a sustained supply across endemic
The elimination of RABV from dogs (the principal regions. The use of a paediatric rabies vaccine as part
reser­voir) and, as a result, the prevention of human of an Expanded Programme on Immunization ­initiative
disease rely on pragmatic actions that can be adopted would increase the probability of exposed c­ hildren
where the veterinary structures are adequate to support not to develop rabies if they do not receive PEP125.
a sustained approach153. The costs required to eliminate Optimization of current vaccines to reduce production
dog-­mediated rabies in all endemic countries have been costs and the number of doses required and to develop
estimated at $6.3 billion, whereas current spending is non-injectable formulations could enable the inclusion
only $2.4 billion7. Most cases of human rabies would of rabies vaccines into existing childhood immunization
be prevented if dog populations in endemic regions schemes. New approaches to overcome the scarcity of
were controlled (principally by immunization but also RIG, the high production costs and the problems associ­
by reducing their numbers by sterilization or culling of ated with blood products include the development of
sick animals) and dogs were licensed and vaccinated. murine monoclonal antibody cocktails162, camelid nano­
Numerous studies have demonstrated that 70% vac­ bodies (single-domain antibodies)163 and the generation
cine coverage is required to stop rabies transmission in of antibodies in planta164. However, all of these research
free-roaming dog communities154–156, and responsible efforts require substantial economic investments to
dog ownership and vaccination are pivotal in prevent­ reach commercial viability.
ing human rabies11. Targeted campaigns for vaccination
of domestic dogs that were supported by adequate sup­ Management of clinical disease
plies and awareness campaigns have demonstrated that The outlook for treating clinical rabies remains poor.
dog vaccination can be achieved to a level that prevents Despite promising in vitro proof‑of‑principle data,
virus circulation. However, to be effective, vaccinations none of the antivirals tested have demonstrated suffi­
require follow‑up visits for booster vaccinations; dog cient in vivo efficacy in experimental models to warrant
owners’ compliance with this requirement is scarce and, further investigation. The development of antivirals
therefore, these campaigns need to be supported by a for rabies remains an urgent priority, but it is a major
global emphasis on eliminating rabies. Oral vaccination challenge because of numerous viral factors (including
of free-roaming dog populations has been proposed as a replication in the CNS and multiple species) and host
complementary measure to parenteral vaccination, but factors, such as various stages of presentation, exposure
assessment of vaccine coverage using oral formulations is history and immune response. An effective antiviral that
challenging 157. The lessons learned from the oral vaccin­ could be used therapeutically in symptomatic patients
ation of wildlife species have demonstrated difficulties with rabies would have to cross the blood–brain ­barrier,
in achieving adequate seroconversion with this formula­ interfere with RABV replication (without affecting the
tion and, therefore, oral vaccination for dog populations life cycle of the host’s cells) and inhibit detrimental
might also be challenging 158. Additionally, the develop­ host responses to RABV infection. Strategies already
ment of vaccines against Lyssavirus spp. that are more-­ attempted include mechanisms to cause temporary dis­
divergent from RABV has been proposed but is unlikely ruption of the blood–brain ­barrier, such as ultrasound
to gain support unless the burden of these viruses to and microbubbles, which could facilitate the entry
human or animal populations is demonstrated126,153. of therapeutics to the optimal site for their action165.

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Small interfering RNA (siRNA) or multiple artificial As part of the Millennium Development Goals to
microRNAs (miRNAs) targeting multiple RABV genome reduce poverty and preventable childhood deaths from
sequences have been shown to suppress viral replication infectious diseases, especially in resource-limited regions
in vitro166. Broad-spectrum antiviral molecules such as of the world, dog-mediated rabies has been targeted for
favipiravir (6‑fluoro‑3‑hydroxy‑2‑pyrazinecarboxamide) global eradication by 2030 within all endemic regions12.
have demonstrated an in vitro effect, and favipiravir was Rabies in wildlife will also need to be controlled to pre­
also effective as a PrEP in mice167,168. Appropriate drug vent repeated host-switching of the virus from wildlife
delivery and targeting systems that have been devel­ reservoirs into domestic dogs16,171. Successful elimination
oped for neurodegenerative diseases could be applied of dog rabies from some regions across Latin America
to rabies therapeutic tools. Transvascular delivery of has demonstrated once again how targeted initiatives
therapeutic siRNA molecules to neuronal cells using can be successful in clearing the virus3,172. However, the
short peptides derived from the RABV glycoprotein has number of rabies cases across endemic regions and
been reported169. Other delivery methods that have been the knowledge gained from targeted initiatives suggest
tested include stable nucleic acid lipid particles or nano­ that the 2030 eradication target will require additional
engineered particles with siRNAs or mi­RNAs170. If such financial support to be achieved7,173, and the acknow­
therapeutics are demonstrated to be beneficial in vivo, ledgement of rabies as a neglected tropical disease by the
then their administration to patients with confirmed WHO will encourage investments172. Despite all of the
or even suspected rabies with alert or mildly depressed challenges, the eradication goal should promote global
sensorium could be an option. Certainly, it is only with a initiatives to encourage pharmaceutical companies,
better understanding of the host factors and patho­genetic international organizations, governments, charities and
mechanisms of RABV that a safe, effective ­antiviral non-governmental bodies to work together to achieve
­therapeutic protocol can be developed in the future. human rabies elimination worldwide.

1. Neville, J. in Historical Perspective of Rabies in Europe 15. Scott, T. et al. Complete Genome and molecular 29. Mallewa, M. et al. Rabies encephalitis in malaria-
and the Mediterranean Basin (eds King, A. A., epidemiological data infer the maintenance of rabies endemic area, Malawi, Africa. Emerg. Infect. Dis. 13,
Fooks, A. R., Aubert, M. & Wandeler, A. I.) 1–12 among kudu (Tragelaphus strepsiceros) in Namibia. 136–139 (2007).
(OIE, 2004). PLoS ONE 8, e58739 (2013). This is a case study report from Malawi showing
2. Afonso, C. L. et al. Taxonomy of the order 16. Brunker, K. et al. Elucidating the phylodynamics of that rabies is regularly misdiagnosed if a clinical
Mononegavirales: update 2016. Arch. Virol. 161, endemic rabies virus in eastern Africa using whole- diagnosis is undertaken without laboratory
2351–2360 (2016). genome sequencing. Virus Evol. 1, 1–11 (2015). confirmation of rabies.
3. Fooks, A. R. et al. Current status of rabies and prospects 17. Horton, D. et al. Complex epidemiology of a zoonotic 30. World Health Organization. WHO Expert Consultation
for elimination. Lancet 384, 1389–1399 (2014). disease in a culturally diverse region: phylogeography on Rabies, Second Report. WHO Technical Report
4. Jackson, A. C. Rabies pathogenesis. J. Neurovirol. 8, of rabies virus in the Middle East. PLoS Negl. Trop. Series, no. 982 (WHO, 2013).
267–269 (2002). Dis. 9, e0003569 (2015). 31. Lembo, T. et al. The feasibility of canine rabies
5. Warrell, M. J. The dilemma of managing human rabies 18. Badrane, H. & Tordo, N. Host switching in Lyssavirus elimination in Africa: dispelling doubts with data.
encephalitis. Trop. Med. Int. Health 21, 456–457 history from the Chiroptera to the Carnivora orders. PLoS Negl. Trop. Dis. 4, e626 (2010).
(2016). J. Virol. 75, 8096–8104 (2001). 32. Messenger, S. L., Smith, J. S. & Rupprecht, C. E.
6. Meslin, F. X. & Briggs, D. J. Eliminating canine rabies, This is a pivotal manuscript showing that Emerging epidemiology of bat-associated cryptic
the principal source of human infection: What will it host-switching occurred in the history of cases of rabies in humans in the United States.
take? Antiviral Res. 98, 291–296 (2013). lyssaviruses and that lyssaviruses evolved in Clin. Infect. Dis. 35, 738–747 (2002).
7. Wallace, R. M., Undurraga, E. A., Blanton, J. D., chiropters long before the emergence of carnivoran 33. Srinivasan, A. et al. Transmission of rabies virus from
Cleaton, J. & Franka, R. Elimination of dog-mediated rabies, very likely following spillovers from bats. an organ donor to four transplant recipients. N. Engl.
human rabies deaths by 2030: Needs assessment 19. Bourhy, H. et al. The origin and phylogeography of J. Med. 352, 1103–1111 (2005).
and alternatives for progress based on dog dog rabies virus. J. Gen. Virol. 89, 2673–2681 34. Chen, S. et al. Rabies virus transmission in solid organ
vaccination. Front. Vet. Sci. 4, 9 (2017). (2008). transplantation, China, 2015–2016. Emerg. Infect.
This article highlights the resources needed to 20. Bernardi, F. et al. Antigenic and genetic Dis. 23, 1600–1602 (2017).
achieve elimination of dog-mediated human rabies characterization of rabies viruses isolated from 35. Maier, T. et al. Management and outcomes after
deaths by 2030, which will result in a concomitant domestic and wild animals of Brazil identifies the multiple corneal and solid organ transplantations from
reduction in human cases of rabies. hoary fox as a rabies reservoir. J. Gen. Virol. 86, a donor infected with rabies virus. Clin. Infect. Dis. 50,
8. [No authors listed.] Aiming for elimination of 3153–3162 (2005). 1112–1119 (2010).
dog‑mediated human rabies cases by 2030. 21. Banyard, A. C. et al. in Rabies: Scientific Basis of 36. Vora, N. M. et al. Clinical management and humoral
Vet. Rec. 178, 86–87 (2016). the Disease and its Management (ed. Jackson, A. C.) immune responses to rabies post-exposure
9. Reece, J. F. Rabies in India: an ABC approach to 215–267 (Academic Press, 2013). prophylaxis among three patients who received solid
combating the disease in street dogs. Vet. Rec. 161, 22. Vigilato, M. A. N. et al. Progress towards eliminating organs from a donor with rabies. Transplant Infect.
292–293 (2007). canine rabies: policies and perspectives from Latin Dis. 17, 389–395 (2015).
10. Lankester, F. et al. Implementing Pasteur’s vision for America and the Caribbean. Philos. Trans R. Soc. 37. Johnson, N., Phillpotts, R. & Fooks, A. R. Airborne
rabies elimination. Sci. Justice 345, 1562–1564 Lond. B Biol Sci.368, 20120143 (2013). transmission of lyssaviruses. J. Med. Microbiol. 55,
(2014). 23. Chiou, H.‑Y. et al. Molecular characteridation of 785–790 (2006).
11. Lavan, R. P., King, A., Sutton, D. J. & Tunceli, K. cryptically circulating rabies virus from ferret badgers, 38. Winkler, W. G., Baker, E. F. Jr & Hopkins, C. C.
Rationale and support for a One Health program Taiwan. Emerg. Infect. Dis. 20, 790–798 (2014). An outbreak of non-bite transmitted rabies in a
for canine vaccination as the most cost-effective 24. Baxter, J. M. One in a million, or one in thousand: laboratory animal colony. Am. J. Epidemiol. 95,
means of controlling zoonotic rabies in endemic What is the morbidity of rabies in India? J. Glob. Health 267–277 (1972).
settings. Vaccine 35, 1668–1674 (2017). 2, 10303 (2012). 39. Winkler, W. G. Airborne rabies virus isolation.
This article contains case studies from endemic, 25. Fooks, A. R., Koraka, P., de Swart, R. L., Wildl. Dis. 4, 37–40 (1968).
resource-poor regions illustrating how mass canine Rupprecht, C. E. & Osterhaus, A. D. Development of a 40. Davis, A. D., Rudd, R. J. & Bowen, R. A. Effects of
vaccination programmes that achieve a minimum multivalent paediatric human vaccine for rabies virus aerosolized rabies virus exposure on bats and mice.
70% coverage are cost-effective in controlling in combination with Measles-Mumps-Rubella (MMR). J. Infect. Dis. 195, 1144–1150 (2007).
zoonotic rabies and decrease the economic burden Vaccine 32, 2020–2021 (2014). 41. Klingen, Y., Conzelmann, K. K. & Finke, S. Double-
of rabies by reducing expenditures on 26. Hampson, K. et al. Estimating the global burden labeled rabies virus: live tracking of enveloped virus
post-exposure prophylaxis. of endemic canine rabies. PLoS Negl. Trop. Dis. 9, transport. J. Virol. 82, 237–245 (2008).
12. Abela-Ridder, B. et al. The beginning of the end of e0003709 (2015). 42. Gluska, S. et al. Rabies Virus Hijacks and accelerates
rabies? Lancet Glob. Health 4, e780–e781 (2016). 27. Banyard, A. C., Horton, D. L., Freuling, C., Muller, T. the p75NTR retrograde axonal transport machinery.
13. Nadin-Davis, S. A. in Rabies: Scientific Basis of the & Fooks, A. R. Control and prevention of canine rabies: PLoS Pathog. 10, e1004348 (2014).
Disease and its Management (ed. Jackson, A. C.) the need for building laboratory-based surveillance 43. Tsiang, H. Evidence for an intraaxonal transport of
123–177 (Academic Press, 2013). capacity. Antiviral Res. 98, 357–364 (2013). fixed and street rabies virus. J. Neuropathol. Exp.
14. Banyard, A. C. & Fooks, A. R. The impact of novel 28. Dodet, B., Korejwo, J. & Briggs, D. J. Eliminating the Neurol. 38, 286–299 (1979).
lyssavirus discovery. Microbiol. Australia 38, 18–21 scourge of dog-transmitted rabies. Vaccine 31, 1359 44. Lycke, E. & Tsiang, H. Rabies virus infection of cultured
(2017). (2013). rat sensory neurons. J. Virol. 61, 2733–2741 (1987).

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A
l
l
r
i
g
h
t
s
r
e
s
e
r
v
e
d
.
 PRIMER

45. Gillet, J. P., Derer, P. & Tsiang, H. Axonal transport of in human rabies. AJNR Am. J. Neuroradiol. 24, 94. Hemachudha, T. et al. Pathophysiology of human
rabies virus in the central nervous system of the rat. 1102–1109 (2003). paralytic rabies. J. Neurovirol. 11, 93–100 (2005).
J. Neuropathol. Exp. Neurol. 45, 619–634 (1986). 69. Laothamatas, J. et al. Furious and paralytic rabies 95. Hunter, M. et al. Immunovirological correlates in
46. Kucera, P., Dolivo, M., Coulon, P. & Flamand, A. of canine origin: neuroimaging with virological and human rabies treated with therapeutic coma. J. Med.
Pathways of the early propagation of virulent and cytokine studies. J. Neurovirol. 14, 119–129 (2008). Virol. 82, 1255–1265 (2010).
avirulent rabies strains from the eye to the brain. 70. Hooper, D. C., Roy, A., Kean, R. B., Phares, T. W. 96. Fekadu, M., Shaddock, J. H. & Baer, G. M. Excretion
J. Virol. 55, 158–162 (1985). & Barkhouse, D. A. Therapeutic immune clearance of of rabies virus in the saliva of dogs. J. Infect. Dis. 145,
47. Ceccaldi, P. E., Gillet, J. P. & Tsiang, H. Inhibition of rabies virus from the CNS. Future Virol. 6, 387–397 715–719 (1982).
the transport of rabies virus in the central nervous (2011). 97. Dacheux, L. et al. A reliable diagnosis of human
system. J. Neuropathol. Exp. Neurol. 48, 620–630 71. Johnson, N., Cunningham, A. F. & Fooks, A. R. rabies based on analysis of skin biopsy specimens.
(1989). The immune response to rabies virus infection Clin. Infect. Dis. 47, 1410–1417 (2008).
48. Piccinotti, S. & Whelan, S. P. Rabies internalizes into and vaccination. Vaccine 28, 3896–3901 (2010). 98. Fooks, A. R. et al. Emerging technologies for the
primary peripheral neurons via clathrin coated pits 72. Lafon, M. Evasive strategies in rabies virus infection. detection of rabies virus: challenges and hopes in the
and requires fusion at the cell body. PLoS Pathog. 12, Adv. Virus Res. 79, 33–53 (2011). 21st century. PLoS Negl. Trop. Dis. 3, e530 (2009).
e1005753 (2016). 73. Baloul, L., Camelo, S. & Lafon, M. Up‑regulation 99. Nadin-Davis, S. A., Sheen, M. & Wandeler, A. I.
49. Lahaye, X. et al. Functional characterization of Negri of Fas ligand (FasL) in the central nervous system: Development of real-time reverse transcriptase
bodies (NBs) in rabies virus-infected cells: Evidence a mechanism of immune evasion by rabies virus. polymerase chain reaction methods for human rabies
that NBs are sites of viral transcription and J. Neurovirol. 10, 372–382 (2004). diagnosis. J. Med. Virol. 81, 1484–1497 (2009).
replication. J. Virol. 83, 7948–7958 (2009). 74. Kojima, D. et al. Pathology of the spinal cord of 100. Fooks, A. R. Rabies - the need for a ‘one medicine’
50. Charlton, K. M. & Casey, G. A. Experimental rabies C57BL/6J mice infected with rabies virus (CVS‑11 approach. Vet. Rec. 161, 289–290 (2007).
in skunks: immunofluorescence light and electron strain). J. Vet. Med. Sci. 71, 319–324 (2009). 101. Wilde, H. et al. Failure of postexposure treatment
microscopic studies. Lab. Invest. 41, 36–44 (1979). 75. Kojima, D. et al. Lesions of the central nervous system of rabies in children. Clin. Infect. Dis. 22, 228–232
51. Etessami, R. et al. Spread and pathogenic induced by intracerebral inoculation of BALB/c mice (1996).
characteristics of a G‑deficient rabies virus with rabies virus (CVS‑11). J. Vet. Med. Sci. 72, 102. Wacharapluesadee, S. & Hemachudha, T. Ante-
recombinant: an in vitro and in vivo study. J. Gen. 1011–1016 (2010). and post-mortem diagnosis of rabies using nucleic
Virol. 81, 2147–2153 (2000). 76. Lafon, M. et al. Detrimental contribution of the acid-amplification tests. Expert Rev. Mol. Diagn. 10,
52. Hemachudha, T. et al. Human rabies: immuno-inhibitor B7‑H1 to rabies virus encephalitis. 207–218 (2010).
neuropathogenesis, diagnosis, and management. J. Immunol. 180, 7506–7515 (2008). 103. Rupprecht, C. E. & Plotkin, S. in Vaccines
Lancet Neurol. 12, 498–513 (2013). 77. Finke, S., Cox, J. H. & Conzelmann, K. K. Differential (eds Plotkin, S., Orenstein, W. & Offit, P.) 646–668
53. Thoulouze, M. I. et al. The neural cell adhesion transcription attenuation of rabies virus genes by (Elsevier, 2013).
molecule is a receptor for rabies virus. J. Virol. 72, intergenic regions: generation of recombinant viruses 104. Mani, R. S. & Anand, A. M. & Madhusudana, S. N.
7181–7190 (1998). overexpressing the polymerase gene. J. Virol. 74, Human rabies in India: an audit from a rabies
54. Tuffereau, C., Benejean, J., Blondel, D., Kieffer, B. 7261–7269 (2000). diagnostic laboratory. Trop. Med. Int. Health 21,
& Flamand, A. Low-affinity nerve-growth factor 78. Shuangshoti, S. et al. Intracellular spread of rabies 556–563 (2016).
receptor (P75NTR) can serve as a receptor for rabies virus is reduced in the paralytic form of canine rabies 105. Jackson, A. C. Human rabies: a 2016 update.
virus. EMBO J. 17, 7250–7259 (1998). compared to the furious form. PLoS Negl. Trop. Dis. Curr. Infect. Dis. Rep. 18, 38 (2016).
55. Lentz, T. L., Burrage, T. G., Smith, A. L., Crick, J. 10, e0004748 (2016). 106. Meslin, F., Kaplan, M. & Koprowski, H. Laboratory
& Tignor, G. H. Is the acetylcholine receptor a rabies 79. Shuangshoti, S. et al. Reduced viral burden in Techniques in Rabies (World Health Organization,
virus receptor? Science 215, 182–184 (1982). paralytic compared to furious canine rabies is 1996).
The data in this paper indicate that acetylcholine associated with prominent inflammation at the 107. Office International des Epizooties. Manual of
receptors serve as receptors for the rabies virus. brainstem level. BMC Vet. Res. 9, 31 (2013). Diagnostic Tests and Vaccines for Terrestrial Animals
56. Tuffereau, C. et al. The rabies virus glycoprotein 80. Nikolic, J., Civas, A., Lama, Z., Lagaudriere- (OIE, 2013).
receptor p75NTR is not essential for rabies virus Gesbert, C. & Blondel, D. Rabies virus infection 108. Lembo, T. et al. Evaluation of a direct, rapid
infection. J. Virol. 81, 13622–13630 (2007). induces the formation of stress granules closely immunohistochemical test for rabies diagnosis.
57. Lafon, M. Rabies virus receptors. J. Neurovirol. 11, connected to the viral factories. PLoS Pathog. 12, Emerg. Infect. Dis. 12, 310–313 (2006).
82–87 (2005). e1005942 (2016). 109. Coetzer, A., Sabeta, C., Markotter, W.,
58. Velandia-Romero, M. L., Castellanos, J. E. 81. Onomoto, K., Yoneyama, M., Fung, G., Kato, H. Rupprecht, C. E. & Nel, L. H. Comparison of
& Martínez‑Gutiérrez, M. In vivo differential & Fujita, T. Antiviral innate immunity and stress biotinylated monoclonal and polyclonal antibodies in
susceptibility of sensory neurons to rabies virus granule responses. Trends Immunol. 35, 420–428 an evaluation of a direct rapid immunohistochemcial
infection. J. Neurovirol. 19, 367–375 (2013). (2014). test for the routine diagnosis of rabies in southern
59. Bauer, A. et al. Anterograde glycoprotein-dependent 82. Caillet-Saguy, C. et al. Strategies to interfere with Africa. PLoS Negl. Trop. Diseases 8, e3189 (2014).
transport of newly generated rabies virus in dorsal PDZ‑mediated interactions in neurons: What we can 110. Freuling, C. M. et al. in Current Laboratory Techniques
root ganglion neurons. J. Virol. 88, 14172–14183 learn from the rabies virus. Prog. Biophys. Mol. Biol. in Rabies diagnosis, Research and prevention Vol. 1
(2014). 119, 53–59 (2015). Ch. 7 (eds Rupprecht, C. & Nagarajan, T.) 63–84
60. Zampieri, N., Jessell, T. M. & Murray, A. J. Mapping 83. Prehaud, C. et al. Attenuation of rabies virulence: (Academic Press, 2015)
sensory circuits by anterograde transsynaptic transfer takeover by the cytoplasmic domain of its envelope 111. Wadhwa, A. et al. A pan-Lyssavirus Taqman real-time
of recombinant rabies virus. Neuron 81, 766–778 protein. Sci. Signal. 3, ra5 (2010). RT‑PCR assay for the detection of highly variable
(2014). 84. Babault, N. et al. Peptides targeting the PDZ domain rabies virus and other lyssaviruses. PLoS Negl.
61. Zhang, D. et al. Genome-wide transcriptional profiling of PTPN4 are efficient inducers of glioblastoma cell Trop. Dis. 11, e0005258 (2017).
reveals two distinct outcomes in central nervous death. Structure 19, 1518–1524 (2011). 112. Fooks, A. R., Johnson, N., Brookes, S. M., Parsons, G.
system infections of rabies virus. Front. Microbiol. 7, 85. Prehaud, C., Lay, S., Dietzschold, B. & Lafon, M. & McElhinney, L. M. Risk factors associated with travel
751 (2016). Glycoprotein of nonpathogenic rabies viruses is a key to rabies endemic countries. J. Appl. Microbiol. 94
62. Wang, Z. W. et al. Attenuated rabies virus activates, determinant of human cell apoptosis. J. Virol. 77, (Suppl.), 31S–36S (2003).
while pathogenic rabies virus evades, the host innate 10537–10547 (2003). 113. Rupprecht, C. E., Nagarajan, T. & Ertl, H. Current
immune responses in the central nervous system. 86. Jackson, A. C., Randle, E., Lawrance, G. status and development of vaccines and other
J. Virol. 79, 12554–12565 (2005). & Rossiter, J. P. Neuronal apoptosis does not play biologics for human rabies prevention. Expert Rev.
63. Hooper, D. C., Roy, A., Barkhouse, D. A., Li, J. an important role in human rabies encephalitis. Vaccines, 15, 731–749 (2016).
& Kean, R. B. Rabies virus clearance from the central J. Neurovirol. 14, 368–375 (2008). 114. World Health Organization. Oral Vaccination of Dogs
nervous system. Adv. Virus Res. 79, 55–71 (2011). 87. Peng, J. et al. Wild-type rabies virus induces Against Rabies. Guidance for Research on Oral
64. Hooper, D. C., Phares, T. W., Fabis, M. J. & Roy, A. autophagy in human and mouse neuroblastoma cell Rabies Vaccines and Field Application of Oral
The production of antibody by invading B cells is lines. Autophagy 12, 1704–1720 (2016). Vaccination of Dogs Against Rabies (ed. Meslin, F.)
required for the clearance of rabies virus from the 88. Li, L. et al. Autophagy is highly targeted among host (WHO, 2007).
central nervous system. PLoS Negl. Trop. Dis. 3, e535 comparative proteomes during infection with different 115. Khawplod, P. et al. Use of rabies vaccines after
(2009). virulent RABV strains. Oncotarget 8, 21336–21350 reconstitution and storage. Clin. Infect. Dis. 34,
The data in this paper show that the production (2017). 404–406 (2002).
of rabies-virus-specific antibodies by infiltrating 89. Tirawatnpong, S. et al. Regional distribution of rabies 116. Lodmell, D. L. & Ewalt, L. C. Rabies cell culture
B cells across the blood–brain barrier is crucial viral antigen in central nervous system of human vaccines reconstituted and stored at 4 degrees C for
for the elimination of rabies virus. encephalitic and paralytic rabies. J. Neurol. Sci. 92, 1 year prior to use protect mice against rabies virus.
65. Gnanadurai, C. W. & Fu, Z. F. CXCL10 and blood-brain 91–99 (1989). Vaccine 22, 3237–3239 (2004).
barrier modulation in rabies virus infection. 90. Hemachudha, T., Laothamatas, J. & Rupprecht, C. E. 117. Khawplod, P. et al. Potency, sterility and
Oncotarget 7, 10694–10695 (2016). Human rabies: a disease of complex immunogenicity of rabies tissue culture vaccine after
66. Wang, L., Cao, Y., Tang, Q. & Liang, G. Role of the neuropathogenetic mechanisms and diagnostic reconstitution and refrigerated storage for 1 week.
blood-brain barrier in rabies virus infection and challenges. Lancet Neurol. 1, 101–109 (2002). Vaccine 20, 2240–2242 (2002).
protection. Protein Cell 4, 901–903 (2013). 91. Mitrabhakdi, E. et al. Difference in neuropathogenetic 118. Kamoltham, T., Khawplod, P. & Wilde, H. Rabies
67. Roy, A., Phares, T. W., Koprowski, H. & Hooper, D. C. mechanisms in human furious and paralytic rabies. intradermal post-exposure vaccination of humans
Failure to open the blood-brain barrier and deliver J. Neurol. Sci. 238, 3–10 (2005). using reconstituted and stored vaccine. Vaccine 20,
immune effectors to central nervous system tissues 92. Jackson, A. C. & Park, H. Apoptotic cell death 3272–3276 (2002).
leads to the lethal outcome of silver-haired bat rabies in experimental rabies in suckling mice. 119. Hu, R. L., Fooks, A. R., Zhang, S. F., Liu, Y. & Zhang, F.
virus infection. J. Virol. 81, 1110–1118 (2007). Acta Neuropathol. 95, 159–164 (1998). Inferior rabies vaccine quality and low immunization
68. Laothamatas, J., Hemachudha, T., Mitrabhakdi, E., 93. Warrell, M. J. & Warrell, D. A. Rabies and other coverage in dogs (Canis familiaris) in China.
Wannakrairot, P. & Tulayadaechanont, S. MR imaging lyssavirus diseases. Lancet 363, 959–969 (2004). Epidemiol. Infect. 136, 1556–1563 (2008).

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©
2
0
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i
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a
r
t
o
f
S
p
r
i
n
g
e
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a
t
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.
A
l
l
r
i
g
h
t
s
r
e
s
e
r
v
e
d
.
PRIMER

120. Faber, M. et al. Overexpression of the rabies virus 144. Jackson, A. C. Current and future approaches to the 169. Kumar, P. et al. Transvascular delivery of small
glycoprotein results in enhancement of apoptosis and therapy of human rabies Antiviral Res. 99, 61–67 interfering RNA to the central nervous system.
antiviral immune response. J. Virol. 76, 3374–3381 (2013). Nature 448, 39–43 (2007).
(2002). 145. Marsden, S. C. & Cabanban, C. R. Rabies: a significant 170. Schnee, M. et al. An mRNA vaccine encoding rabies
121. Faber, M. et al. Effective preexposure and palliative care issue. Prog. Palliative Care 14, 62–67 virus glycoprotein induces protection against lethal
postexposure prophylaxis of rabies with a highly (2006). infection in mice and correlates of protection in
attenuated recombinant rabies virus. Proc. Natl Acad. 146. de Souza, A. & Madhusudana, S. N. Survival from adult and newborn pigs. PLoS Negl. Trop. Dis. 10,
Sci. USA 106, 11300–11305 (2009). rabies encephalitis. J. Neurol. Sci. 339, 8–14 (2014). e0004746 (2016).
122. Gnanadurai, C. W. et al. Differential host immune 147. Sambo, M. et al. Knowledge, attitudes and practices 171. Elmore, S. A. et al. Management and modeling
responses after infection with wild-type or lab- (KAP) about rabies prevention and control: a approaches for controlling raccoon rabies: the road
attenuated rabies viruses in dogs. PLoS Negl. Trop. community survey in Tanzania. PLoS Negl. Trop. Dis. 8, to elimination. PLoS Negl. Trop. Dis. 11, e0005579
Dis. 9, e0004023 (2015). e3310 (2014). (2017).
123. Li, J. et al. Postexposure treatment with the live- 148. Willoughby, R. E. Jr et al. Survival after treatment of 172. Abela-Ridder, B. Rabies: 100 per cent fatal, 100 per
attenuated rabies virus (RV) vaccine TriGAS triggers rabies with induction of coma. N. Engl. J. Med. 352, cent preventable. Vet. Rec. 177, 148–149 (2015).
the clearance of wild-type RV from the Central Nervous 2508–2514 (2005). 173. Shwiff, S., Anderson, A. & Hampson, K. Potential
System (CNS) through the rapid induction of genes 149. Zeiler, F. A. & Jackson, A. C. Critical appraisal of the economic benefits of eliminating canine rabies.
relevant to adaptive immunity in CNS tissues. J. Virol. Milwaukee protocol for rabies: this failed approach Antiviral Res. 98, 352–356 (2013).
86, 3200–3210 (2012). should be abandoned. Can. J. Neurol. Sci. 43, 44–51 174. World Health Organization. Rabies: epidemiology and
124. Kessels, J. A. et al. Pre-exposure rabies prophylaxis: (2016). burden of disease. WHO http://www.who.int/rabies/
a systematic review. Bull. World Health Organ. 95, 150. Duong, V. et al. Laboratory diagnostics in dog- epidemiology/en/ (2017).
210–219C (2017). mediated rabies: an overview of performance and a 175. Finke, S., Mueller-Waldeck, R. & Conzelmann, K. K.
125. World Health Organization. Rabies vaccines: proposed strategy for various settings. Int. J. Infect. Rabies virus matrix protein regulates the balance
WHO position paper-recommendations. Vaccine 28, Dis. 46, 107–114 (2016). of virus transcription and replication. J. Gen. Virol.
7140–7142 (2010). 151. Coetzer, A. et al. The SARE tool for rabies control: 84, 1613–1621 (2003).
126. Evans, J. S., Horton, D. L., Easton, A. J., Fooks, A. R. current experience in Ethiopia. Antiviral Res. 135, 176. Finke, S. & Conzelmann, K. K. Dissociation of rabies
& Banyard, A. C. Rabies virus vaccines: is there a need 74–80 (2016). virus matrix protein functions in regulation of viral
for a pan-lyssavirus vaccine? Vaccine 30, 7447–7454 152. Fahrion, A. S. et al. The road to dog rabies control RNA synthesis and virus assembly. J. Virol. 77,
(2012). and elimination — what keeps us from moving faster? 12074–12082 (2003).
127. Hanlon, C. A., Niezgoda, M., Morrill, P. A. Front. Public Health 5, 103 (2017). 177. Mebatsion, T., Weiland, F. & Conzelmann, K. K. Matrix
& Rupprecht, C. E. The incurable wound revisited: 153. Rupprecht, C., Kuzmin, I. & Meslin, F. Lyssaviruses and protein of rabies virus is responsible for the assembly
progress in human rabies prevention? Vaccine 19, rabies: current conundrums, concerns, contradictions and budding of bullet-shaped particles and interacts
2273–2279 (2001). and controversies. F1000Res 6, 184 (2017). with the transmembrane spike glycoprotein G. J. Virol.
128. McLaughlin, K. Scandal clouds China’s global vaccine This is a fundamental review of rabies, providing a 73, 242–250 (1999).
ambitions. Science 352, 506 (2016). realistic plan to achieve success in eliminating this 178. Pollin, R., Granzow, H., Kollner, B., Conzelmann, K. K.
129. Shantavasinkul, P. et al. Failure of rabies postexposure disease. & Finke, S. Membrane and inclusion body targeting
prophylaxis in patients presenting with unusual 154. Coleman, P. G. & Dye, C. Immunization coverage of lyssavirus matrix proteins. Cell. Microbiol. 15,
manifestations. Clin. Infect. Dis. 50, 77–79 (2010). required to prevent outbreaks of dog rabies. Vaccine 200–212 (2013).
130. Both, L. et al. Passive immunity in the prevention 14, 185–186 (1996). 179. Wirblich, C. et al. PPEY motif within the rabies virus
of rabies. Lancet Infect. Dis. 12, 397–407 (2012). 155. Hampson, K. et al. Transmission dynamics and (RV) matrix protein is essential for efficient virion
131. Bharti, O. K. et al. Success story of a low cost intra- prospects for the elimination of canine rabies. release and RV pathogenicity. J. Virol. 82,
dermal rabies vaccination (IDRV) clinic-lessons learnt PLoS Biol. 7, e1000053 (2009). 9730–9738 (2008).
over five years of 12,000 patient vaccinations “without 156. Leung, T. & Davis, S. A. Rabies vaccination targets for 180. Roche, S. & Gaudin, Y. Evidence that rabies virus forms
failure” at DDU Hospital Shimla, Himachal Pradesh, stray dog populations. Front. Vet. Sci. 4, 52 (2017). different kinds of fusion machines with different pH
India — “Saving a drop of rabies vaccine and 157. World Health Organization. Oral Vaccination of Dogs thresholds for fusion. J. Virol. 78, 8746–8752 (2004).
immunoglobulins” 12 innovations to make Himachal Against Rabies (ed Meslin, F.) (World Health 181. Anilionis, A., Wunner, W. H. & Curtis, P. J. Structure of
Pradesh rabies free state by 2020. World J. Vaccines Organization, 2007). the glycoprotein gene in rabies virus. Nature 294,
5, 129–139 (2015). 158. Muller, T. et al. Analysis of vaccine-virus-associated 275–278 (1981).
132. Shantavasinkul, p. et al. A 4‑site, single-visit intradermal rabies cases in red foxes (Vulpes vulpes) after oral 182. Schnell, M. J., McGettigan, J. P., Wirblich, C.
postexposure prophylaxis regimen for previously rabies vaccination campaigns in Germany and Austria. & Papaneri, A. The cell biology of rabies virus: using
vaccinated patients: experiences with >5000 patients. Arch. Virol. 154, 1081–1091 (2009). stealth to reach the brain. Nat. Rev. Microbiol. 8,
Clin. Infect. Dis. 51, 1070–1072 (2010). 159. Lapiz, S. M. et al. Implementation of an intersectoral 51–61 (2010).
133. Wilde, H., Khawplod, P. & Hemachudha, T. program to eliminate human and canine rabies: the 183. Scott, T. P. & Nel, L. H. Subversion of the immune
Post‑exposure rabies prophylaxis in patients Bohol Rabies Prevention and Elimination Project. response by rabies virus. Viruses 231, 1–26 (2016).
with AIDS. Vaccine 27, 5726–5727 (2009). PLoS Negl. Trop. Dis. 6, e1891 (2012). 184. Blondel, D., Maarifi, G., Nisole, S. & Chelbi-Alix, M. K.
134. Tanisaro, T. et al. Neutralizing antibody response 160. Cleaveland, S., Fevre, E. M., Kaare, M. Resistance to Rhabdoviridae infection and subversion
after intradermal rabies vaccination in hemodialysis & Coleman, P. G. Estimating human rabies mortality in of antiviral responses. Viruses 7, 3675–3702 (2015).
patients. Vaccine 28, 2385–2387 (2010). the United Republic of Tanzania from dog bite injuries. 185. Brzozka, K., Finke, S. & Conzelmann, K. K. Inhibition
135. Shantavasinkul, P. et al. Postexposure rabies Bull. World Health Organ. 80, 304–310 (2002). of interferon signaling by rabies virus phosphoprotein
prophylaxis completed in 1 week: preliminary study. 161. World Health Organization. WHO Expert Consultation P: activation-dependent binding of STAT1 and STAT2.
Clin. Infect. Dis. 50, 56–60 (2010). on Rabies, First Report. WHO Technical Report Series, J. Virol. 80, 2675–2683 (2006).
136. Wilde, H., Lumlertdacha, B., Meslin, F. X., Ghai, S. no. 931 (WHO, 2005). This report shows that the rabies virus
& Hemachudha, T. Worldwide rabies deaths 162. Muller, T. et al. Development of a mouse monoclonal phosphoprotein is responsible for preventing
prevention‑A focus on the current inadequacies in antibody cocktail for post-exposure rabies prophylaxis IFN-α/β-stimulated and IFN-γ-stimulated JAK-STAT
postexposure prophylaxis of animal bite victims. in humans. PLoS Negl. Trop. Dis. 3, e542 (2009). signalling in rabies-virus-infected cells by the
Vaccine 34, 187–189 (2016). This paper presents results from an in vivo study retention of activated STATs (signal transducer
137. Warrell, M. J. et al. A simplified 4‑site economical in mice, proving that mouse monoclonal and activator of transcription) in the cytoplasm.
intradermal post-exposure rabies vaccine regimen: antibodies conferred protection against rabies 186. Masatani, T. et al. Rabies virus nucleoprotein functions
a randomised controlled comparison with standard that was comparable with that of human rabies to evade activation of the RIG‑I‑mediated antiviral
methods. PLoS Negl. Trop. Dis. 2, e224 (2008). immunoglobulin. response. J. Virol. 84, 4002–4012 (2010).
138. Brown, D. et al. Intradermal pre-exposure rabies 163. Terryn, S. et al. Protective effect of different anti-rabies 187. Vidy, A., Chelbi-Alix, M. & Blondel, D. Rabies virus P
vaccine elicits long lasting immunity. Vaccine 26, virus VHH constructs against rabies disease in mice. protein interacts with STAT1 and inhibits interferon
3909–3912 (2008). PLoS ONE 9, e109367 (2014). signal transduction pathways. J. Virol. 79,
139. Simani, S. et al. Six fatal cases of classical rabies virus 164. Both, L. et al. Production, characterization, and antigen 14411–14420 (2005).
without biting incidents, Iran 1990–2010. J. Clin. specificity of recombinant 62‑71‑3, a candidate 188. Brzozka, K., Finke, S. & Conzelmann, K. K.
Virol. 54, 251–254 (2012). monoclonal antibody for rabies prophylaxis in humans. Identification of the rabies virus alpha/beta interferon
140. Dato, V. M., Campagnolo, E. R., Long, J. FASEB J. 27, 2055–2065 (2013). antagonist: phosphoprotein P interferes with
& Rupprecht, C. E. A. Systematic review of human bat 165. Gabathuler, R. Approaches to transport therapeutic phosphorylation of interferon regulatory factor 3.
rabies virus variant cases: evaluating unprotected drugs across the blood-brain barrier to treat brain J. Virol. 79, 7673–7681 (2005).
physical contact with claws and teeth in support of diseases. Neurobiol. Dis. 37, 48–57 (2010). The data in this paper show that the rabies virus
accurate risk assessments. PLoS ONE 11, e0159443 166. Israsena, N., Supavonwong, P., Ratanasetyuth, N., phosphoprotein is an interferon antagonist
(2016). Khawplod, P. & Hemachudha, T. Inhibition of rabies counteracting transcriptional activation of type I
141. Tarantola, A. et al. Caring for patients with rabies in virus replication by multiple artificial microRNAs. interferon.
developing countries — the neglected importance of Antiviral Res. 84, 76–83 (2009). 189. Luco, S. et al. RelAp43, a member of the NF‑κB family
palliative care. Trop. Med. Int. Health 21, 564–567 167. Yamada, K., Noguchi, K., Komeno, T., Furuta, Y. involved in innate immune response against Lyssavirus
(2016). & Nishizono, A. Efficacy of favipiravir (T-705) in infection. PLoS Pathog. 8, e1003060 (2012).
142. Mani, R. S. Human rabies survivors in India: an rabies postexposure prophylaxis. J. Infect. Dis. 213, 190. Ben Khalifa, Y. et al. The matrix protein of rabies virus
emerging paradox? PLoS Negl. Trop. Dis. 10, 1253–1261 (2016). binds to RelAp43 to modulate NF‑κB-dependent gene
e0004774 (2016). 168. Virojanapirom, P., Lumlertdacha, B., expression related to innate immunity. Sci. Rep. 6,
143. Jackson, A. C. Why does the prognosis remain so poor Wipattanakitchareon, A. & Hemachudha, T. 39420 (2016).
in human rabies? Expert Rev. Anti Infect. Ther. 8, T-705 as a potential therapeutic agent for rabies. 191. Hornung, V. et al. 5ʹ‑triphosphate RNA is the ligand
623–625 (2010). J. Infect. Dis. 213, 1253–1261 (2016). for RIG‑I. Science 314, 994–997 (2006).

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192. Faul, E. J. et al. Rabies virus infection induces type I 201. Karahocagil, M. K. et al. Complete recovery from Author contributions
interferon production in an IPS‑1 dependent manner clinical rabies: case report. Turkiye Klinikleri J. Med. Introduction (A.R.F. and A.C.B.); Epidemiology (S.N.-D.);
while dendritic cell activation relies on IFNAR Sci. 33, 547–552 (2013). Mechanisms/pathophysiology (A.C.B., C.F., S.F., T.M. and
signaling. PLoS Pathog. 6, e1001016 (2010). 202. PromedMail. Rabies - Brazil (04): Pernambuco), T.H.); Diagnosis, screening and prevention (A.C.B., F.C. and
193. Vidy, A., El Bougrini, J., Chelbi-Alix, M. K. Recovery. (PromedMail, 2008). E.P.-M.); Management (A.C.B., T.H., R.S.M. and H.W.);
& Blondel, D. The nucleocytoplasmic rabies virus P 203. Madhusudana, S. N., Nagaraj, D., Uday, M., Quality of life (R.S.M.); Outlook (A.C.B. and A.R.F.); Overview
protein counteracts interferon signaling by inhibiting Ratnavalli, E. & Kumar, M. V. Partial recovery from of Primer (A.R.F.).
both nuclear accumulation and DNA binding of STAT1. rabies in a six-year-old girl. Int. J. Infect. Dis. 6,
J. Virol. 81, 4255–4263 (2007). 85–86 (2002). Competing interests
194. Amarasinghe, G. K. et al. Taxonomy of the order 204. Alvarez, L. et al. Partial recovery from rabies T.M., C.F. and S.F. have a research cooperation and project
Mononegavirales: update 2017. Arch. Virol. 162, in a nine-year-old boy. Pediatr. Infect. Dis. J. 13, (2014–2019) with a German vaccine company on
2493–2504 (2017). 1154–1155 (1994). oral vaccination of wildlife (for example, mechanisms of oral
195. Karande, S. et al. Atypical rabies encephalitis in a 205. Tillotson, J. R., Axelrod, D. & Lyman, D. O. Rabies in a vaccination and immunity and development of a novel
six‑year-old boy: clinical, radiological, and laboratory laboratory worker — New York. MMWR Morb. Mortal. oral rabies virus vaccine). All other authors declare no
findings. Int. J. Infect. Dis. 36, 1–3 (2015). Wkly Rep. 26, 183–184 (1977). competing interests.
196. Manoj, S., Mukherjee, A., Johri, S. & Kumar, K. V. 206. Tillotson, J. R., Axelrod, D. & Lyman, D. O. Follow‑up
Recovery from rabies, a universally fatal disease. on rabies — New York. MMWR Morb. Mortal. Wkly Publisher’s note
Mil. Med. Res. 3, 21 (2016). Rep. 26, 249–250 (1977). Springer Nature remains neutral with regard to jurisdictional
197. Kumar, K. V., Ahmad, F. M. & Dutta, V. Pituitary 207. Porras, C. et al. Recovery from rabies in man. claims in published maps and institutional affiliations.
cachexia after rabies encephalitis. Neurol. India 63, Ann. Intern. Med. 85, 44–48 (1976).
255–256 (2015). 208. Hattwick, M. A., Weis, T. T., Stechschulte, C. J., How to cite this Primer
198. Weyer, J. et al. A case of human survival of rabies, Baer, G. M. & Gregg, M. B. Recovery from rabies. Fooks, A. R. et al. Rabies. Nat. Rev. Dis. Primers 3, 17091
South Africa. South Afr. J. Infect. Dis. 31, 66–68 (2016). A case report. Ann. Intern. Med. 76, 931–942 (1972). (2017).
199. Wiedeman, J. et al. Recovery of a patient from clinical
rabies — California, 2011. MMWR Morb. Mortal. Acknowledgements
Wkly Rep. 61, 61–65 (2012). A.R.F. and A.C.B. were financially supported by the UK SUPPLEMENTARY INFORMATION
200. Netravathi, M. et al. Unique clinical and imaging findings Department for Environment, Food and Rural Affairs (Defra), See online article: S1 (video)
in a first ever documented PCR positive rabies survival the Scottish Government and the Welsh Government (grant ALL LINKS ARE ACTIVE IN THE ONLINE PDF
patient: a case report. J. Clin. Virol. 70, 83–88 (2015). number SV3500).

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