Using Surveillance of Animal Bite Patients to Decipher Potential Risks of Rabies Exposure From Domestic Animals and Wildlife in Brazil

Direct contact with domestic animals and wildlife is linked to zoonotic spillover risk. Patients presenting with animal-bite injuries provide a potentially valuable source of surveillance data on rabies viruses that are transmitted primarily by animal bites. Here, we used passive surveillance data of bite patients to identify areas with high potential risk of rabies transmission to humans across Brazil, a highly diverse and populous country, where rabies circulates in a range of species. We analyzed one decade of bite patient data from the national health information system (SINAN) comprising over 500,000 patients attending public health facilities after being bitten by a domestic or wild animal. Our analyses show that, between 2008 and 2016, patients were mostly bitten by domestic dogs (average annual dog bite patients: 502,043 [436,391-544,564], annual incidence per state: 258 dog bites/100,000 persons) and cats (76,512 [56,588-97,580] cat bites, 41 cat bites/100,000/year), but bites from bats (4,172 [3,351-5,365] bat bites, 2.3/100,000/year), primates (3,320 [3,013-3,710] primate bites, 2.0/100,000/year), herbivores (1,908 [1,492-2,298] herbivore bites, 0.9/100,000/year) and foxes (883 [609-1,086] fox bites, 0.6/100,000/year) were also considerable. Incidence of bites due to dogs and herbivores remained relatively stable over the last decade. In contrast bites by cats and bats increased while bites by primates and foxes decreased. Bites by wild animals occurred in all states but were more frequent in the North and Northeast of Brazil, with over 3-fold differences in incidence between states across all animal groups. Most bites reported from domestic animals and wildlife occurred in urban settings (71%), except for bites from foxes, which were higher in rural settings (57%). Based upon the Ministry of Health guidelines, only half of patients received the correct Post-Exposure Prophylaxis following a bite by a suspect rabid animal. We identified areas and species of high-risk for potential zoonotic transmission of rabies in Brazil and reveal that, despite increasing human encroachment into natural ecosystems, only patients reporting bites by bats increased. Our study calls for future research to identity the socio-ecological factors underlying bites and the preventive measures needed to reduce their incidence and potential risk of rabies transmission.