# Human rabies in Avignon, France, following exposure in Morocco, 2025

Maria Law Wun, David Grandbesançon, Philippe Cano, Hichem Gassoumi, Perrine Parize, Philippe Poujol, Hervé Bourhy, Philippe Gautret

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## To cite this version:

Maria Law Wun, David Grandbesançon, Philippe Cano, Hichem Gassoumi, Perrine Parize, et al. Human rabies in Avignon, France, following exposure in Morocco, 2025. International Journal of Infectious Diseases, 2026, 163, pp.108285. 10.1016/j.ijid.2025.108285. hal-05474257

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Short Communication

Human rabies in Avignon, France, following exposure in Morocco,
2025

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Maria Law Wun<fnref n="1" />, David Grandbesançon<fnref n="1" />, Philippe Cano<fnref n="2" />, Hichem Gassoumi<fnref n="2" />, Perrine Parize<fnref n="3" />, Philippe Poujol<fnref n="4" />, Hervé Bourhy<fnref n="3" />, Philippe Gautret<fnref n="5" />,<fnref n="6" />,*

ARTICLE INFO

Article history:

Received 13 October 2025

Revised 29 November 2025

Accepted 2 December 2025

Keywords:

Rabies

Travel

Visiting friends and relatives

Human-to-human transmission

Post-exposure prophylaxis

A B S T R A C T

**Objectives:** In early 2025, a patient died in the South of France with confirmed rabies following a dog bite while traveling in Morocco to visit relatives. This report summarizes the patient's clinical course and the subsequent public health investigation.

**Methods:** Demographics, epidemiological, and medical data from the infected patient and from contacts at risk of exposure were retrospectively retrieved from medical files.

**Results:** The patient presented with fever, cardiac and neurological symptoms. Initial clinical presentation mimicking psychiatric disorders and suggesting a myocarditis led to multiple exposures of family members and health care workers (HCWs). Rabies virus was retrieved from saliva, skin biopsy, and post-mortem brain biopsy. A total of 44 potentially exposed persons were identified among family and community contacts and among HCWs who cared for the patient, and received rabies post-exposure prophylaxis (RPEP). Most family members shared food and drinks with the patient, notably during a large family meal with potential mucosal exposure to infected saliva. Several HCWs had a contact with the patient's body fluids without application of standard of isolation precautions.

**Conclusions:** Recommendations for RPEP in contacts with a human rabies case differ between countries, and practices differ between teams. The dramatic nature of the disease often leads to irrational fear that may compromise the strict application of recommendations. Travelers to North African countries, including those visiting friends and relatives should be informed about the risk for rabies when injured by dogs or cats and about the need to receive an adequate RPEP.

© 2025 The Authors. Published by Elsevier Ltd on behalf of International Society for Infectious Diseases.

This is an open access article under the CC BY license ([http://creativecommons.org/licenses/by/4.0/](http://creativecommons.org/licenses/by/4.0/))

Introduction

Many European nationals travel to North Africa every year as tourists or to visit family and may be exposed to rabies, such as canine rabies, that remains enzootic in North Africa. The proportion of people seeking rabies post-exposure prophylaxis (RPEP) in France after being exposed to an animal in North Africa has increased over the last 10 years, reaching 35% of all individuals seeking RPEP after an exposure outside France in 2023 [1]), compared to <7% before 2017. In early 2025, a patient died in south

France, with suspected rabies following a dog bite sustained while traveling in Morocco. This report summarizes the patient's clinical course and the subsequent public health investigation.

Materials and methods

A first inquiry was conducted by local public health authorities to identify individuals at potential risk of exposure who were invited to consult for further evaluation and RPEP in specialized structures. All family and community members who had physical contact with the patient during the 15 days before the onset of the patient's symptoms were considered exposed. Health care workers (HCWs) were considered exposed if they had a contact with the patient's body fluids without application of standard of isolation.

<footnote n="1">¹Emergency Ward, Centre Hospitalier d'Avignon, Avignon, France</footnote>

<footnote n="2">2 Agence Régionale de Santé, Provence-Alpes-Côte d'Azur, Marseille, France</footnote>

<footnote n="3">³ Institut Pasteur, Université Paris Cité, Unité Lyssavirus, Epidémiologie et Neuropathologie, National Reference Centre for Rabies, WHO Collaborating Centre for Reference and Research on Rabies, Paris, France</footnote>

<footnote n="4">⁴Institut Pasteur, Centre Médical, Centre Antirabique, Paris, France</footnote>

<footnote n="5">⁵Aix Marseille Univ, AP-HM, SSA, RITMES, Marseille, France</footnote>

<footnote n="6">⁶IHU-Méditerranée Infection, Marseille, France</footnote>

<footnote>* Corresponding author. Tel.: + 33 (0) 4 13 73 24 01; fax: + 33 (0) 4 13 73 24 02.</footnote>

<footnote>E-mail address: philippe.gautret@ap-hm.fr (P. Gautret).</footnote>
tion precautions. Demographics, epidemiological, and medical data from the infected patient and from contacts were retrospectively retrieved from medical files.

## Results

### Case report

In early January, a young adult patient presented to the Emergency Department at the Avignon Hospital with a “sense of imminent death”, associated with psychomotor agitation, aggressiveness, hypersalivation, diffuse pain, total anorexia for a week and an aversion to any contact with water. There was no reported substance abuse, and the medical history only included a surgically repaired ventricular septal defect 10 years ago, without ongoing medications.

The initial physical exam only revealed well-tolerated tachycardia (170 bpm) with diffuse ST-segment depression on the admission electrocardiogram (Supplementary Figure 1). Attempts to reduce tachycardia using vagal maneuvers and medications were unsuccessful. Blood examinations were normal, except elevated cardiac markers (NT-proBNP 7501 pg/ml; troponin level 317 ng/l).

The patient then developed a fever of 39.7°C, profuse sweating, increasing confusion, neck extensor muscle spasms, glottic spasms, and hydrophobia. Cerebral angiogram was normal.

Rabies encephalitis was suspected and upon re-interviewing the family, it was revealed that the patient sustained a dog bite, resulting in an open leg wound, while visiting family in Taza, Morocco, 6 months prior. The patient received one dose of rabies vaccine at a local hospital, but the vaccination protocol was abandoned upon returning to France. The dog was found dead 2 days after the incident. The cerebrospinal fluid analysis revealed clear fluid with <4 nucleated cells/mm³, normal protein and glucose levels, and a hyperlactatemia (3.6 mmol/l). Polymerase chain reaction was negative for common pathogens (QIAstat-Dx Meningitis/Encephalitis Panel, Qiagen, Hilden, Germany).

The patient's clinical condition deteriorated rapidly leading to emergency intubation. The patient died despite resuscitation efforts.

Viral RNA was detected by reverse transcription-polymerase chain reaction in pre-mortem saliva and skin biopsy (FastStart Essential DNA Green Master kit, Roche Diagnostic). Post-mortem rabies testing of brain biopsy by direct fluorescent antibody and rabies tissue culture infection tests further confirmed the diagnosis [2]. Sequencing data indicate that the isolate belongs to the Africa 1 clade and to a cluster of dog-related virus circulating within a triangle in the north-western coastal strip of Morocco (between towns of Bensliman, Sidi Kacem, and Tanger) [3].

### Post-exposure prophylaxis in at risk contacts

Thirty-two family members and one traditional healer were evaluated (Table 1). Most family members shared food and drinks with the patient, during a large family meal, where guests traditionally eat with their hand in a single shared large plate. Some family members reported that the patient fed children with hand. In addition, two family members were living in the same home and reported finishing the patient's dishes. Three family members reported wiping off saliva without specific precautions and one reported repeated kissing of the patient's face immediately following his death. All contacts, despite reporting frequent trips to North Africa, never received pre-exposure prophylaxis against rabies. Given the high level of anxiety among contacts, notably regarding children, RPEP was provided to all of them (Zagreb regimen). Three contacts also received rabies immunoglobulin (RIG) because of repeated contacts with saliva in two cases, and because

<table><caption>**Table 1**

General characteristics of 33 family members and community contacts.</caption><tr><td>Gender (Male/Female)</td><td>19/14</td></tr><tr><td>Mean age (min-max)</td><td>31 (2-77 years)</td></tr><tr><td>&lt;5 years</td><td>3 (9%)</td></tr><tr><td>5-15 years</td><td>10 (30%)</td></tr><tr><td>&gt;15 years</td><td>20 (61%)</td></tr><tr><td>Type of exposure<sup>a</sup></td><td></td></tr><tr><td>Living in same home</td><td>2 (6%)</td></tr><tr><td>Sharing food (eating with hands in same plate) and drink</td><td>30 (91%)</td></tr><tr><td>Contacts with saliva, intact skin</td><td>2 (6%)</td></tr><tr><td>Contact with saliva, broken skin</td><td>-</td></tr><tr><td>Repeated contacts with saliva, broken skin</td><td>3 (9%)</td></tr><tr><td>Contact with saliva, mucous membrane</td><td>30 (91%)</td></tr><tr><td>Repeated contacts with saliva, mucous membrane</td><td>1 (3%)</td></tr><tr><td>Type of rabies post-exposure prophylaxis</td><td></td></tr><tr><td>Vaccine only</td><td>30 (91%)</td></tr><tr><td>Vaccine and immune globulin<sup>b</sup></td><td>3 (9%)</td></tr></table>

<table><caption>**Table 2**

General characteristics of 11 medical staff (hospital) contacts.</caption><tr><td>Gender (Male/Female)</td><td>4/7</td></tr><tr><td>Mean age (min-max)</td><td>29 (22-40 years)</td></tr><tr><td>&lt;5 years</td><td>-</td></tr><tr><td>5-15 years</td><td>-</td></tr><tr><td>&gt;15 years</td><td>11 (100%)</td></tr><tr><td>Professional category (medical)</td><td></td></tr><tr><td>Doctor</td><td>2 (18%)</td></tr><tr><td>Nurse</td><td>5 (19%)</td></tr><tr><td>Nurse aid</td><td>2 (18%)</td></tr><tr><td>Medical student</td><td>2 (18%)</td></tr><tr><td>Type of exposure<sup>a</sup></td><td></td></tr><tr><td>Contacts with saliva, intact skin</td><td>4 (36%)</td></tr><tr><td>Contact with saliva, broken skin</td><td>4 (36%)</td></tr><tr><td>Contact with saliva, mucous membrane</td><td>4 (36%)</td></tr><tr><td>Close and prolonged contacts with saliva and bronchial secretion (intubation)</td><td>2 (18%)</td></tr><tr><td>Type of rabies post-exposure prophylaxis</td><td></td></tr><tr><td>Vaccine only</td><td>9 (82%)</td></tr><tr><td>Vaccine and immune globulin</td><td>2 (18%)</td></tr></table>

of an exposure to a potentially rabid cat in Turkey, in one case. Fifteen HCWs were evaluated (Table 2). None was previously vaccinated against rabies. Four were considered not at risk because they used standard precautions and had little contact with the patient. Two medical doctors who practiced intubation without medical goggles and who were unsure if they kept their face-mask on during the whole process, received RPEP, including injection of RIG. Two residents, five nurses, and two assistant nurses who participated to resuscitation procedures received RPEP with vaccine only. Of note, the two assistant nurses were scratched by the patient without bleeding, and all HCWs at some point had close contact with the patient without wearing gloves and/or face-mask. All reported high levels of personal concern about possible exposure to rabies.

## Discussion

Of the 800 people injured in North Africa and seeking RPEP in France in 2023, 59% were exposed in Morocco [1]. The last two travelers who died of rabies in France had been exposed in Morocco, in 2023 and 2025 [1]. Furthermore, since France was declared free of rabies in non-flying terrestrial mammals in 2001, 14 illegally imported domestic animals tested positive for rabies, including 10 dogs and one cat from Morocco, one dog from Algeria, one from Gambia, and one found on a car park in Spain, infected with a virus harboring a very strong homology with viruses iden-

<footnote><sup>a</sup> Some individuals had more than one type of exposure.</footnote>

<footnote><sup>b</sup> One family member also suffered a trans-dermal cat scratch during a trip to Turkey.</footnote>

<footnote><sup>a</sup> Some individuals had more than one type of exposure.</footnote>
tified in Morocco [4]. In 87 rabies cases in international travelers reported from the literature worldwide, since 1990, the top countries of exposure were India, The Philippines, and Morocco [5-9].

No documented laboratory-diagnosed human-to-human rabies transmission cases have been published from a bite or non-bite exposure other than the transplant cases. However, human-to-human transmission of rabies is considered to possibly occur in the same way as animal-to-human transmission [10]. During 2015-2019 an average of 177 United States (US) HCWs underwent an exposure risk assessment for every hospitalized human rabies patient [11]. The type of exposure that led to RPEP in contacts with confirmed human rabies, were exposure to infected saliva through mucous membranes or small open hand wounds, prolonged contact with a patient's fluids with ungloved hands and non-intact skin, potential contacts with saliva through kissing or sharing food and drink, contact of intact skin with patient's fluids, bite, sexual intercourse, common usage of personal equipment, and indirect contact with environmental surfaces (Supplementary Table 1).

According to the US Advisory Committee on Immunization Practices (ACIP), RPEP is only indicated for health care providers who have mucous membrane or open skin contact with saliva, tears, or nervous tissue during the infectious period [10]. The US ACIP recommends using standard precautions when providing care to persons suspected of having clinical rabies, including wearing gowns, goggles, masks, and gloves, particularly during procedures that might result in splashes or sprays from body fluids [10]. According to French recommendations [12], RPEP is recommended to HCWs participating in resuscitation procedures, notably with exposure to respiratory secretion when standard precautions, including wearing medical goggles, masks, and gloves are not used properly. RPEP is recommended to individuals living in the same home as the patient and to any other person in direct contact with saliva and other body fluids during the period of contagion.

In conclusion, the dramatic nature of the disease often leads to irrational fear that may compromise the strict application of recommendations. Travelers to North Africa, including those visiting family should be informed about the risk for rabies when injured by dogs or cats and about the need to receive an adequate RPEP.

## Funding

This research did not receive any specific grant from funding agencies in the public, commercial, or not-for-profit sectors.

## Ethical approval

The study was approved by the Ethic and Scientific Committee of the AP-HM (n°CSE25-323) and declared to the General Data Protection Regulation registry (n° PADS25-335). Because it was not possible to obtain a signed informed consent of the deceased patient for publication of the case report, any information allowing identifying the patient was removed from the publication.

## Author contributions

**Maria Law Wun:** investigation, writing first draft, reviewing, and editing final draft. **David Grandbesançon:** investigation, reviewing and editing final draft. **Philippe Cano:** investigation, reviewing and editing final draft. **Hichem Gassoumi:** investigation, reviewing and editing final draft. **Perrine Parize:** investigation, reviewing and editing final draft. **Philippe Poujol:** investigation, reviewing and editing final draft. **Hervé Bourhy:** investigation, reviewing and editing final draft. **Philippe Gautret:** investigation, writing first draft, reviewing, and editing final draft, coordination.

## Declaration of competing interest

The authors have no competing interests to declare.

## Supplementary materials

Supplementary material associated with this article can be found, in the online version, at doi:10.1016/j.ijid.2025.108285.

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