1/8 Revista da Sociedade Brasileira de Medicina Tropical Journal of the Brazilian Society of Tropical Medicine Vol.:54 | (e0104-2021) | 2021 https://doi.org/10.1590/0037-8682-0104-2021 Corresponding author: Prof. Jorg Heukelbach. e-mail: heukelbach@ufc.br  https://orcid.org/0000-0002-7845-5510 Received 6 April 2021 Accepted 14 June 2021 www.scielo.br/rsbmt I www.rsbmt.org.br Major Article Clinical aspects of human rabies in the state of Ceará, Brazil: an overview of 63 cases Naylê Francelino Holanda Duarte [1] , Roberto da Justa Pires Neto [1] , Victoria Forte Viana [2] , Levi Ximenes Feijão [3] , Carlos Henrique Alencar [1] and Jorg Heukelbach [1] [1]. Universidade Federal do Ceará, Faculdade de Medicina, Programa de Pós-Graduação em Saúde Pública, Fortaleza, CE, Brasil. [2]. Universidade de Fortaleza, Centro de Ciências da Saúde, Fortaleza, CE, Brasil. [3]. Secretaria da Saúde do Estado do Ceará, Fortaleza, CE, Brasil. Abstract Introduction: Rabies is considered one of the most relevant public health problems owing to its high fatality rate and the high number of deaths worldwide. Methods: We included patients with human rabies who attended a reference hospital in the state of Ceará during 1976-2019. Results: Data were available for 63 out of 171 (36.8%) patients. Of these patients, 48 (76.2%) were attacked by dogs. In recent years, wild animals have been the most common aggressor species (marmosets and bats). Only 39 (70%) patients were initially correctly suspected with rabies. Bites were the most frequent exposure (56; 96%), most commonly on the hands (21; 42%) and the head (9; 18.4%). Only 14 (22%) patients had sought medical assistance before the onset of symptoms, and only one completed post-exposure prophylaxis. The most prevalent signs and symptoms included aggressiveness/irritability (50; 79.4%), fever (42; 66.7%), sore throat/ dysphagia (40; 63.5%), and myalgia (28; 44.4%). Hydrophobia was present in 17 patients (22.0%). Conclusions: Most cases of human rabies in Ceará occurred due to the failure to seek medical assistance and/or the failure of the health system in initiating early post- exposure prophylaxis. There is a need for specifc information and education campaigns focusing on the cycle of sylvatic rabies as well as prevention measures. Health professionals should undergo refresher training courses on the signs and symptoms of rabies and on the specifc epidemiological features of the disease in Brazil. Keywords: Rabies. Zoonosis. Epidemiology. Public Health. INTRODUCTION Human rabies (HR) is a zoonotic viral disease that afects the nervous system. It is a vaccine-preventable disease; however, its course is practically irreversible after the onset of signs and symptoms 1 . The disease causes approximately 60,000 human deaths per year worldwide, with the highest number of cases recorded in rural areas in Africa and Asia 2,3 . The main transmitter is the domestic dog (Canis familiaris), which accounts for approximately 99% of cases worldwide 1 . In Brazil, a signifcant reduction in mortality rates due to HR has been achieved in the last 30 years after the implementation of canine vaccination campaigns and the intensifcation of the provision of post-exposure prophylaxis. Currently, there are only sporadic cases of HR transmitted by dogs 4 . In the last decade, 9 (23.7%) of the 38 HR cases registered in Brazil were transmitted by dogs. The other cases were primarily transmitted by hematophagous bats (52.6%), followed by non-human primates (10.5%) and felines (10.5%) 4 . In fact, the hematophagous bat (Desmodus rotundus) is the main transmitter of rabies virus to humans in Brazil, and the variant maintained and transmitted by this species is commonly found in human cases where other species, mainly dogs and cats, are aggressors 5,6 . In the state of Ceará in Northeast Brazil, dogs, hematophagous bats (Desmodus rotundus), and other wild species are responsible for maintaining and transmitting variants of the rabies virus to humans 5-7 . Of the 46 HR cases registered during 1990-2016 in the state, 52% occurred in Fortaleza, and dogs were the most common transmitters of the virus. The other cases were distributed throughout the state's municipalities, and the virus was transmitted