Perspectives

The One Health approach for the management of an

imported case of rabies in mainland Spain in 2013
A C Prez de Diego (anacristina@[Link])1, M Vigo2, J Monsalve2, A Escudero2
1. Livestock Department (Epidemiology), Environmental Management of Castilla-La Mancha (GEACAM), Department of
Agriculture, Government of Castilla-La Mancha, Toledo, Spain
2. General Directorate of Agricultural and Livestock, Department of Agriculture, Government of Castilla-La Mancha, Toledo,
Spain
Citation style for this article:
Prez de Diego AC, Vigo M, Monsalve J, Escudero A. The One Health approach for the management of an imported case of rabies in mainland Spain in 2013. Euro
Surveill. 2015;20(6):pii=21033. Available online: [Link]
Article submitted on 19 May 2014 / published on 12 February 2015

After more than 30 years without any reported cases

of rabies in terrestrial carnivores in mainland Spain,
an imported case was detected in June 2013 in Toledo.
Although the infected dog was moved across different
locations and had contact with humans and dogs, the
incident was controlled within a few days. An epidemiological investigation was performed and rabiesfree status in terrestrial carnivores in mainland Spain
was restored six months after the incident. Key to the
successful management of this case were the previous vaccination of susceptible animals in the affected
area before the case was detected, the collaboration
of different authorities in decision making, and the
application of control measures according to national
and international regulations and to the One Health
concept.

Background

In the 20th century, mainland Spain suffered continuous outbreaks of rabies until 1966, when the country
was declared free of rabies for the first time. In 1975,
a new outbreak occurred in Malaga in southern Spain
which was started by an infected dog owned by a tourist. The disease spread to 81 confirmed animal cases
(dogs and cats), leading to the destruction of more than
10,000 dogs within one year. Rabies also caused three
human deaths between 1975 and 1978 [1]. Since 1978,
mainland Spain has been considered free of rabies in
terrestrial carnivores; however, every year, the autonomous cities of Ceuta and Melilla report rabies cases,
most imported from Morocco. In 2012, five cases were
reported in these cities [2]. Some sporadic cases in
bats have been reported since 1987 [3]. The eradication programme in Spain succeeded thanks to the
elimination of suspicious animals and vaccination of
susceptible animals.
Taking into account the distribution of rabies across the
world according to data from the World Organization
for Animal Health (OIE), summarised in Figure 1, it was
essential for Spain and the European Union (EU) to use
risk analysis for the potential introduction of domestic
[Link]

rabies. Several studies were conducted for this purpose

[4-6]. This research concluded that the most vulnerable
entry route would be the introduction of domestic dogs
from Morocco [6]. When border surveillance is working
correctly, the probability of importation of the disease
decreases considerably, but the possibility of illegal
entry of people and animals from Morocco should be
taken into account. This is not surprising seeing as
sporadic imported cases have been reported in other
EU countries, for example recently in France and the
Netherlands [7,8].
Since there is no clinical treatment for this zoonotic
disease, and only prevention by vaccination is possible
public and animal health authorities such as the OIE,
recommend the vaccination of domestic animals to
avoid the spread of rabies. However, in Spain, mandatory legislation about animal vaccination against rabies
is the responsibility of the regional administration, not
the national government. Some regions require mandatory vaccination of dogs, and in some places cats are
also vaccinated. In some cases mandatory vaccination
is annual, in others biennial, and in some autonomous
communities it is not mandatory (Figure 2).

Chronology of the event

In Castilla-La Mancha, a region in mainland Spain, the

vaccination programme has changed over time. Since
2002, when there were no rabies cases, vaccination
has been voluntary, but in June 2012, the regional government introduced mandatory biennial vaccination
[10]. In 2013 an imported case was detected in a dog
in Args, Toledo. The epidemiological investigation
established the following sequence of events:
On 1 December 2012, the four year-old Spanish dog
was vaccinated, for first time, against rabies with one
dose of a polyvalent vaccine. On 12 December 2012, the
dog travelled from Spain to an endemic area (Morocco).
The time since vaccination was too short for immune
protection to develop (the manufacturers instructions
describe the beginning of the immunity three weeks
1

Figure 1
Rabies presence by country, 2012

Rabies status
ABSENCE
NO DATA
PRESENCE

4
The information includes only the data reported to the World Organization for Animal Health [9], therefore information was not available for all
countries in 2012.

Figure2
Rabies vaccination strategy for dogs in different autonomous communities, Spain, 2012
P. de Asturias

Cantabria

P. Vasco

Galicia

C. F. Navarra

La Rio
ja
Catalua

Castilla y Len

drid

C. V
alen
cian
a

C. M a

Aragn

Castilla-La Mancha
Extremadura

R. M

I. Baleares

urcia

Andaluca

Voluntary

Ceuta y Melilla

Mandatory annual
Mandatory biennial

I. Canarias

Frequency as specified by vaccine manufacturer

[Link]

after vaccination and the European regulation requires

a period of thirty days between vaccination and seroneutralisation test [11]). On 12 April 2013, the dog
returned to Spain. The entry route is unknown, but it
is suspected that it was an illegal entry across the border at Ceuta [12]. Earlier, in February, the dogs owners
had tried to cross the border legally, but were denied
entry because the seroneutralisation assay according
to EU regulation [11] had not been done before the trip
to Morocco [13].
The dogs owners remained in Catalonia (Barcelona
and Piera) until 5 May 2013, then continued to Huesca
(Monzn), and returned to Catalonia (Banyoles y
Porqueres) on May 18. From 20 to 22 May, they stayed
in Barcelona and thereafter in Args in Toledo province [14]. On 1 June, the dog escaped and attacked
four children and one adult in different parts of Toledo.
After several attempts to capture the dog and because
of its aggressiveness, the police decided to shoot it.
The body was retained and according to the protocol
for suspicion of rabies, public health authorities sent
the head to the national reference laboratory at the
National Centre of Microbiology for diagnosis on 3 June
2013. On 5 June, rabies was confirmed by direct immunofluorescence and PCR. The laboratory further identified the genetic profile of the rabies virus as one of the
strains circulating in in Morocco.
On 6 June, according to the Spanish contingency plan
for rabies [5], a crisis committee was convened to evaluate and establish control measures which included
mandatory vaccination of all susceptible domestic animals (dogs, cats and ferrets) in restriction areas; these
were areas where the affected dog had been present
during the virus excretion period and that were therefore defined as at risk of disease occurrence. Further
control measures included restricted movement of
susceptible animals, improved control of stray dogs,

active surveillance of dogs and their correct vaccination and identification status, and rabies vaccination
for people exposed to the infected dog and people who
could have otherwise been exposed to the virus [5]. The
virus excretion period was assumed to be from 8 May
to 1 June, but to ensure the detection of all potential
contacts, the period was extended back to 1 May. The
four children and the adult that were attacked by the
rabies-positive dog on 1 June received post-exposure
treatment with human rabies immunoglobulin (HRIG)
and rabies vaccine.
The case data, alert status, and adopted measures
were reported to all veterinarians who might know
about possible dog contacts. In Castilla-La Mancha,
all dogs that were potential contacts were placed in an
animal health authority facility on 8 June 2013, (nine
dogs). All dogs that could have had contact with the
infected animal were serologically examined to ensure
their vaccination status. One immunosuppressed dog
with insufficient protection against rabies was identified as a high risk for transmission. According to the
contingency plan, the immunosuppressed dog was
sacrificed on 21 June to prevent rabies dissemination
[15].
After six months without new cases, rabies-free status for terrestrial carnivores was restored in Spain in
December 2013 [16,17]. Many authorities and institutions were involved in this crisis management. Some
of them, such as the veterinary association, the Melilla
Government or the Spanish Agency for Medicines and
Health Products (AEMPS), were not initially included in
the contingency plan (Table 1), but were crucial for the
resolution of the incident.
In terms of risk perception, it is important to note that
at the beginning of this rabies episode, the population
reported many stray dogs, dog attacks, and suspicions

Table 1
Institutions and agents involved in rabies crisis management, Spain, 201213
Type of institution
National Administration
Spanish Medical Agency
Regional Administration
(Castilla-La Mancha, Aragn,
Catalua and Madrid)
Security agents

Professionals and experts

Name

Foreseen in
contingency plan

Field of work

MAGRAMA

Yes

Animal health

MSSSI

Yes

Public health

National Reference Laboratory-ISCIII

Yes

Laboratory assays

AEMPS

No

To ensure sufficient vaccine

Department of Agriculture

Yes

Animal health

Department of Health

Yes

Public health

Melilla government

No

Advisor to authorities

SEPRONA

Yes

Local police department

Yes

Veterinary association

No

To report new data to veterinarians

Private veterinarians

No

To detect potential contact

VISAVET, other scientific experts

Yes

Advisor to authorities

Animal and proprietary identification

AEMPS: Spanish Agency for Medicines and Health Products; ISCIII: Institute of Health Carlos III; MAGRAMA: Ministry of Agriculture, Food
and Environment; MSSSI: Ministry of Health; SEPRONA: Nature Protection Service of the Civil Guard; VISAVET: Health Surveillance Centre.

[Link]

of rabies after a dogs deaths. All these cases were

analysed and no rabies was detected. The social alarm
gradually decreased within a few weeks to a residual
level similar to the one that exists when no case has
been reported in years.

played an essential role in making information available to the general population and veterinarians, which
underlines the importance of establishing an efficient
collaboration system between public and private veterinarians and public health authorities.

As a preventive measure, people at risk were vaccinated; in Castilla-La Mancha, about 300 people were
considered at risk during the event surveillance period
until the end of December 2013. Although only 12 people in Castilla-La Mancha could be considered at risk
according to the World Health Organization (WHO) category III, 118 people received the complete post-exposure treatment of HRIG and vaccination in this region
(Table 2).

One of the crucial points in the management of this

imported case and its control was the mandatory vaccination ordered in 2012 in the most affected region
Castilla-La Mancha, which led to most dogs in this
region being vaccinated against rabies. All nine contact dogs in Castilla-La Mancha had been vaccinated
in the twelve months previous to the rabies incident.
Since vaccination is essential in the prevention of
rabies [19,20], it is crucial to establish national legislation for this. It would be useful to require vaccination
across the EU not only for movement purposes. Also,
it is important to control the movements of pets and
comply with the existing regulation, including rabies
vaccination of all carnivores entering the EU, especially
in areas that have been declared rabies free [4,21].

Evaluation of management and

recommendations

Although more than 15 different institutions, agents

and authorities were involved, communication was
immediate and complete from the moment disease
was suspected. The effective communication allowed
to prevent the potential spread of rabies in Spain,
when consequences could have been as severe as in
the outbreak of 1975 [1]. The successful collaboration
underlines the importance of the One Health concept
in preventing emerging disease and the spread of
infectious animal disease that could have a significant
impact on public health, animal health and national
economics [18].
It is important to take into account that the animals
involved in this rabies incident were pets. When working in animal health, one of the first measures is to
restrict movement of susceptible animals and trade,
and to review the most recent movements of the animal involved. When the disease affects pets, all these
measures become far more complicated because in
contrast to livestock, there is no registration system
for the movement of pets. The Veterinary Association

Table 2
Exposure category of human contacts, and post-exposure
protocol adopted in Castilla-La Mancha, Spain, 201213
(n=378)
Number of people
WHO category
Type I

321

Type I/II

37

Type II

Type III

12

Post-exposure treatment
Vaccination

64

HRIGand vaccination

118

No treatment administered

188

No data available

This case demonstrates how the One Health concept

must enlist collaboration from different scientific disciplines [22]. Educating the general population about the
importance of pet vaccination could prevent a mortal
disease not only of animals but also of humans, and
make them participants and collaborators in providing
epidemiological data when an outbreak of an emerging disease happens. It is also crucial to educate the
population about the risks related to the illegal introduction of pets to the EU and about the appropriate
measures to take when travelling to endemic countries. Considering that the infected dog in this report
was in fact vaccinated but travelled to Morocco before
the immune protection was established, it is important
that veterinarians emphasise the necessity to observe
correct timing between vaccination and travel to
endemic areas. Globalisation comes with the continuous movement of people, animals, products and, consequently, diseases. It is essential to stay alert for the
potential risk of disease entry at all times. In the EU,
border controls have become more important because
a European citizen, once returned from a third country into the EU, could travel across the Schengen area
without restriction.
Finally, it is relevant to note the importance of having
reference laboratories with updated diagnostic assays
and trained personnel who can respond to an alert
within hours and provide relevant results.
Acknowledgments
The authors would like to thank the collaboration of the different authorities involved in the management of the case,
especially the Consejera de Sanidad, the emergency service, and the veterinarians from GEACAM. The authors would
also like to thank everyone that helped in compiling the data
for this study.

HRIG: human rabies immunoglobulin; WHO: World Health

Organization.

[Link]

Conflict of interest
None declared.

Authors contributions
ACPD: wrote the outbreak report and collaborated in the
field actions for management. MV, JM, AE: managed the outbreak, worked in decision making and collaborated to collect
data for publication.

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