Human rabies cases in Northwestern Iran: Lessons on prevention, diagnosis, and public health response

Rabies is a nearly universally fatal disease, yet it is preventable with timely post-exposure prophylaxis (PEP). In Iran, despite a comprehensive network of free rabies clinics, human fatalities continue to occur. This retrospective case series describes all laboratory‑confirmed human rabies deaths from Northwestern Iran in 2023 and analyzes the factors contributing to failures in post-exposure prevention. Each case involved high-risk animal exposure (fox bite, dog saliva to the face, severe dog bite) and a failure to seek immediate medical attention. Although vaccination was initiated after symptom onset and rabies immunoglobulin (RIG) was administered in two cases, these did not constitute effective PEP; consequently, all three individuals died from rabies. Rapid RT‑PCR confirmation by the Pasteur Institute of Iran and prompt vaccination of identified contacts demonstrated the system's capacity for effective response once a case is identified. These fatalities reveal that the main barrier to rabies elimination in Iran is not the availability of prophylaxis but its proper utilization. Fatalities arise mainly from delays in seeking care and underestimating exposure-related risk, emphasizing the urgent need for community-level interventions.