RABIES: ALL FOR ONE, ONE HEALTH FOR ALL

RABIES: ALL FOR ONE, ONE HEALTH FOR ALL

Dr. Madhura Y, Dr. Malathi. V,  Dr. Anil Kumar. G.K and Pramood Doddamani

Veterinary College, Karnataka Veterinary and Fisheries Sciences University, Hebbal Bengaluru, Karnataka , India

Abstract

Rabies is a deadly viral disease that affects both animals and humans, posing a significant public health concern worldwide. The One Health approach, recognizing the interconnectedness of human, animal, and environmental health, provides a comprehensive framework for understanding and addressing rabies. This essay explores the multifaceted aspects of rabies, from its historical context to its contemporary global impact. It delves into the biology and transmission of the virus, the human and animal health implications, and the environmental factors contributing to its persistence. Moreover, it highlights the critical role of the One Health approach in preventing the spread of rabies and outlines strategies for its control and elimination.

Table of Contents

1. Introduction

1.1. Background and Historical Context

1.2. Objective and Scope

1. The Rabies Virus: Biology and Transmission

2.1. The Microscopic Culprit: The Rabies Virus

2.2. Modes of Transmission

2.3. Pathogenesis and Clinical Manifestations

1. The Global Impact of Rabies

3.1. Human Health Impact

3.2. Animal Health Impact

3.3. Socioeconomic Burden

1. The One Health Approach to Combat Rabies

4.1. Principles of One Health

4.2. The Role of One Health in Rabies Control

4.3. Interdisciplinary Collaboration

1. Rabies Control and Elimination Strategies

5.1. Mass Vaccination Campaigns

5.2. Public Awareness and Education

5.3. Surveillance and Monitoring

5.4. Environmental Considerations

1. The Global Strategic Plan to Eliminate Rabies

6.1. Overview of the Plan

6.2. Progress and Challenges

1. Case Studies in Rabies Control

7.1. Successful Rabies Elimination: The Case of Western Europe

7.2. Challenges in Rabies Control: Lessons from Asia and Africa

1. Future Prospects and Emerging Trends

8.1. Advancements in Rabies Vaccines and Treatments

8.2. Climate Change and the Impact on Rabies Transmission

8.3. The Role of Genomic Research

1. Conclusion

9.1. The Imperative of One Health

9.2. A Path Towards a Rabies-Free World

1. Introduction

1.1. Background and Historical Context

Rabies, a disease that has plagued humanity for millennia, remains a important public health issue today. Its origins can be traced back to ancient civilizations, with references to rabid animals found in texts dating as far back as 2300 BC in Mesopotamia. The term “rabies” itself is derived from the Latin word “rabere,” meaning “to rave” or “be mad,” reflecting the madness and suffering inflicted upon those afflicted by the disease.

Rabies, a neglected tropical disease (NTD), is the oldest known zoonotic disease and is responsible for over 60,000 human deaths globally per year, a statistic which is completely unacceptable considering that rabies is an entirely preventable disease. Although post exposure prophylaxis (PEP) is effective, it is expensive, in short supply, and doesn’t address the long-term maintenance of the disease in the dogs. Known as a disease of poverty, rabies affects low-income regions. Children, disproportionately, experience higher biting incidences, leading to 100 children dying per day across the globe. Additionally, little is known about the dog populations themselves in rabies endemic areas with dog ownership attitudes varying greatly region to region.

Throughout history, rabies has been the subject of fear and myth, often associated with supernatural beliefs and mysticism. It was not until the late 19th century that Louis Pasteur made groundbreaking advances in understanding and combating the disease, developing the first rabies vaccine, which paved the way for effective prevention.

Despite these historical milestones, rabies remains a global scourge, particularly in regions where resources for prevention and control are limited. The One Health approach, which emphasizes the interconnectedness of human, animal, and environmental health, offers a promising path toward eradicating this ancient menace.

1.2. Objective and Scope

This essay aims to provide a comprehensive overview of rabies, its impact on human and animal health, and the critical role of the One Health approach in combating the disease. It explores the biology and transmission of the rabies virus, examines the global implications of rabies, and analyzes strategies for its control and elimination. Case studies from different regions of the world illustrate both successful and challenging efforts in rabies control. Additionally, this essay discusses emerging trends and future prospects in rabies research and control.

2. The Rabies Virus: Biology and Transmission

2.1. The Microscopic Culprit: The Rabies Virus

At the core of the challenge posed by rabies lies a minuscule agent—the rabies virus. This virus is a member of the Lyssavirus genus, characterized by its bullet-shaped structure. It primarily affects mammals and is particularly notorious for its ability to infect the central nervous system, leading to severe neurological symptoms and, ultimately, death.

The rabies virus belongs to the Rhabdoviridae family and is classified into various strains, each adapted to specific host species. Among these, the classic rabies virus, Rhabdovirus rabies, predominantly affects dogs, bats, and terrestrial mammals, with domestic dogs being the primary vector for human transmission.

2.2. Modes of Transmission

Rabies is typically transmitted through the saliva of an infected animal, most commonly via bites, scratches, or open wounds. However, the virus can also enter the body through mucous membranes, such as the eyes, nose, or mouth. Once the virus enters the body, it travels along peripheral nerves toward the central nervous system, leading to encephalitis.

2.3. Pathogenesis and Clinical Manifestations

Once the virus reaches the central nervous system, it causes encephalitis, which is characterized by a range of neurological symptoms. The progression of rabies can be divided into several stages:

• Incubation Stage: The incubation stage of rabies is a critical period during which the virus quietly establishes itself within the host’s body. This stage represents the time frame between the initial encounter with the virus, typically through a bite or scratch from an infected animal, and the emergence of noticeable symptoms.
• The duration of the incubation stage is highly variable and influenced by several factors. Firstly, the specific site of the exposure plays a role; bites or scratches closer to the central nervous system may result in shorter incubation periods. Additionally, the host’s immune response plays a significant role. Some individuals may mount a more rapid immune response that could potentially curtail the virus’s spread, leading to a shorter incubation period, while others may experience a delayed immune response, resulting in a longer incubation period.
• The variability in the incubation period, which can range from mere days to several years, underscores the complexity of rabies as a disease. This prolonged period without overt symptoms can pose a significant challenge for early diagnosis and intervention, as individuals may not be aware of their exposure until the disease progresses to a more advanced stage. It is during this latent period that timely administration of post-exposure prophylaxis (PEP), which includes rabies vaccination and immunoglobulin, can be most effective in preventing the virus from advancing to the acute neurological stage, where it becomes invariably fatal.
• Prodromal Stage: The prodromal stage of rabies represents a critical phase in the progression of the disease. During this stage, individuals who have been exposed to the rabies virus may start experiencing a range of non-specific symptoms that are often similar to those seen in common viral infections. These symptoms typically include fever, headache, and a general sense of malaise or discomfort.
• The prodromal stage presents a unique challenge because the early symptoms it manifests are not exclusive to rabies. Instead, they are quite similar to what one might experience with various everyday viral illnesses, such as the flu or a common cold. This similarity in symptoms can lead to confusion and misdiagnosis, as individuals may not immediately associate their discomfort with rabies exposure, especially if they are not aware of any prior contact with a potentially rabid animal.
• The non-specific nature of these symptoms further complicates early diagnosis. Physicians and healthcare providers may initially consider more common viral infections as the cause, potentially delaying the identification of rabies as the underlying issue. This delay in diagnosis can have significant consequences, as rabies rapidly progresses once neurological symptoms appear, and by that stage, it becomes virtually untreatable.
• Therefore, during the prodromal stage, there is a critical window of opportunity for early intervention through post-exposure prophylaxis (PEP), which includes rabies vaccination and immunoglobulin administration. Recognizing the possibility of rabies in individuals who have had potential exposure and presenting with non-specific symptoms is essential to ensure timely and potentially life-saving treatment. Education and awareness campaigns can also play a crucial role in informing communities about the importance of seeking medical attention promptly after any encounter with a potentially rabid animal, even if the symptoms appear mild and non-specific.

• The acute neurological stage of rabies marks a critical and often devastating phase in the progression of the disease. During this stage, the rabies virus has successfully invaded the central nervous system, which includes the brain and spinal cord, and begins to wreak havoc on the host’s neurological functions.This stage is characterized by a rapid escalation of symptoms, which can be severe and distressing for both the affected individual and those providing care. The hallmark symptoms of the acute neurological stage of rabies include:

 

• Hallucinations: Individuals with rabies may experience vivid and often terrifying hallucinations. These hallucinations can be auditory, visual, or both and are typically disorienting and distressing.
• Aggression: Rabies can trigger sudden and extreme changes in behavior, leading to unprovoked aggression. Infected individuals may become violent, lashing out at others in a frenzied manner. This aggression is a significant concern for caregivers and healthcare providers.
• Photophobia: Photophobia is an intense sensitivity to light. Individuals with rabies often experience extreme discomfort and pain when exposed to even minimal levels of light. This sensitivity can exacerbate their distress and contribute to the overall severity of the disease.
• Hydrophobia: Hydrophobia, or the fear of water, is a classic symptom of rabies. It arises from the difficulty and pain associated with swallowing due to muscle spasms in the throat and larynx. The mere sight or thought of water can trigger intense anxiety and discomfort.
• Paralysis: As the virus continues to spread and damage nerve cells, paralysis can set in. Initially, this paralysis may affect muscles near the site of the original exposure, such as the arms or legs, but it can progress to affect muscles throughout the body.
• Coma: In the later stages of the acute neurological phase, individuals with rabies often fall into a deep and irreversible coma. This coma results from the profound neurological damage caused by the virus and is a prelude to the final, fatal outcome of the disease.

 

It’s important to emphasize that once the symptoms of the acute neurological stage appear, rabies is virtually universally fatal. There is no cure for rabies once it reaches this stage, and the disease progresses rapidly, typically leading to death within a matter of days to weeks. Given the severity of the symptoms and the inevitability of a fatal outcome, early intervention is paramount. The most effective means of preventing rabies progression to this stage is to administer post-exposure prophylaxis (PEP) immediately upon suspicion of exposure to the virus, before the onset of symptoms. This underscores the critical importance of public awareness and education about rabies and the necessity of seeking medical attention promptly following any potential rabies exposure.

• Paralytic stage

As the disease advances into the paralytic stage, the most striking characteristic is the gradual and often profound muscle weakness and paralysis that ensues. This paralysis typically begins in the muscles close to the site of the original exposure, such as those in the arms or legs. However, it can progress rapidly to affect muscle groups throughout the body, including those involved in breathing and swallowing.

The progression of paralysis in the paralytic stage is insidious and relentless. Initially, individuals may notice weakness in their limbs, making it difficult to move or perform daily tasks. Over time, the paralysis intensifies, severely impairing mobility and function. Muscle spasms and twitches may also occur, adding to the physical and psychological distress.

One of the most critical and life-threatening consequences of the paralytic stage is the involvement of respiratory muscles. As paralysis spreads to the muscles responsible for breathing, individuals with rabies experience increasing difficulty in taking breaths. Respiratory function gradually deteriorates, leading to respiratory distress and, ultimately, respiratory failure.

Death in cases of rabies is almost inevitable once the disease reaches the paralytic stage. Respiratory failure is the primary cause of death in these cases, and it typically occurs within a few days to weeks after the onset of symptoms in the acute neurological stage.

The paralytic stage of rabies serves as a stark reminder of the urgency of early intervention, the importance of public awareness and education, and the critical role of the One Health approach in rabies control and prevention.

3. The Global Impact of Rabies

3.1. Human Health Impact

Rabies remains a significant threat to human health, particularly in regions where access to healthcare services and rabies vaccines is limited. Annually, tens of thousands of people worldwide succumb to this disease, with the majority of fatalities occurring in Africa and Asia. Alarmingly, children make up a significant proportion of rabies victims, often due to their increased likelihood of encountering rabid animals and their inability to seek timely medical attention.

The human suffering caused by rabies is immeasurable. Beyond the physical agony experienced by patients, the emotional toll on families and communities affected by rabies is profound. Moreover, the economic burden of rabies is substantial, encompassing healthcare costs, lost productivity, and the expenses associated with post-exposure prophylaxis.

3.2. Animal Health Impact

Rabies is not confined to humans; it affects a wide range of animal species, both domestic and wild. While domestic dogs are the primary vectors responsible for transmitting the virus to humans, other mammals such as cats, cattle, and wildlife can also contract and spread the disease. Rabies is zoonotic, meaning it can jump between species, making it challenging to control.

In wildlife, rabies can establish reservoirs, particularly in bat populations, which can then transmit the virus to other species. This creates a complex web of transmission dynamics that further complicates control efforts.

3.3. Socioeconomic Burden

The socioeconomic impact of rabies extends beyond healthcare costs and lost productivity. Communities heavily affected by rabies face economic challenges due to the costs associated with managing and preventing the disease. These costs include:

• Medical Expenses: The cost of providing post-exposure prophylaxis and medical treatment for rabies can be prohibitive for individuals and healthcare systems, especially in resource-limited areas.
• Animal Control and Vaccination: Controlling rabies in domestic dog populations through mass vaccination campaigns is expensive but essential for reducing human exposure.
• Productivity Loss: When individuals become infected or die from rabies, it results in productivity loss, particularly in agriculture-dependent communities where human health is closely linked to economic activity.
• Emotional and Psychological Costs: The emotional toll on families who lose loved ones to rabies is incalculable. Fear and anxiety surrounding rabies can also impact communities.

The socioeconomic burden of rabies underscores the urgent need for effective control and elimination strategies.

4. The One Health Approach to Combat Rabies

4.1. Principles of One Health

The success of rabies control hinges on interdisciplinary collaboration:

• Human Health Professionals: Physicians and healthcare workers play a critical role in diagnosing and providing post-exposure prophylaxis to individuals exposed to rabies. They also educate patients on wound care and the importance of seeking immediate medical attention.
• Veterinarians: Veterinarians are central to rabies control efforts. They are responsible for administering vaccines to domestic animals, conducting surveillance in animal populations, and participating in outbreak investigations.
• Environmental Scientists: Environmental scientists contribute to the understanding of rabies transmission dynamics by studying the ecology of reservoir species and their interactions with humans and domestic animals.
• Public Health Officials: Public health officials coordinate rabies surveillance, control, and prevention efforts. They work with healthcare providers and veterinarians to ensure timely reporting of cases and the administration of post-exposure prophylaxis.
• Wildlife Biologists: Wildlife biologists study wildlife species that can carry the virus, monitor populations, and implement management strategies when necessary.

4.2. The Role of One Health in Rabies Control

The One Health approach is particularly relevant in the context of rabies control and elimination for several reasons:

• Interconnected Health Systems: Rabies affects both humans and animals, with domestic dogs acting as a bridge between the two. Controlling the disease in one species can have a direct impact on its prevalence in the other.
• Environmental Factors: Environmental factors, such as the presence of rabies reservoirs in wildlife, can significantly impact the persistence of the disease. Understanding these factors is essential for effective control.
• Behavioral and Cultural Considerations: Human behaviors and cultural practices influence the risk of rabies transmission. One Health recognizes the need to work closely with communities to address these factors through education and awareness campaigns.

4.3. Interdisciplinary Collaboration

The success of the One Health approach in rabies control hinges on interdisciplinary collaboration:

• Human Health Professionals: Physicians and healthcare workers play a critical role in diagnosing and providing post-exposure prophylaxis to individuals exposed to rabies. They also educate patients on wound care and the importance of seeking immediate medical attention.
• Veterinarians: Veterinarians are central to rabies control efforts. They are responsible for administering vaccines to domestic animals, conducting surveillance in animal populations, and participating in outbreak investigations.
• Environmental Scientists: Environmental scientists contribute to the understanding of rabies transmission dynamics by studying the ecology of reservoir species and their interactions with humans and domestic animals.
• Public Health Officials: Public health officials coordinate rabies surveillance, control, and prevention efforts. They work with healthcare providers and veterinarians to ensure timely reporting of cases and the administration of post-exposure prophylaxis.
• Wildlife Biologists: Wildlife biologists study wildlife species that can carry the virus, monitor populations, and implement management strategies when necessary.

5. Rabies Control and Elimination Strategies

Effective rabies control and elimination strategies are multifaceted and align with the principles of the One Health approach:

5.1. Mass Vaccination Campaigns

Widespread vaccination of domestic dogs is a cornerstone of rabies control. Vaccinating dogs not only protects them from the virus but also reduces their role as reservoirs for rabies transmission to humans. Mass vaccination campaigns involve trained teams administering vaccines in communities and remote areas, with a particular focus on regions where rabies is endemic.

Vaccination programs are typically accompanied by efforts to raise awareness about the importance of vaccination and responsible pet ownership practices.

5.2. Public Awareness and Education

Community engagement and education are essential components of rabies control. These efforts aim to:

• Raise awareness about the risks of rabies and its modes of transmission.
• Promote responsible pet ownership, including spaying/neutering, leash laws, and confinement of animals.
• Encourage prompt reporting of animal bites or scratches to healthcare providers and local authorities.
• Emphasize the importance of seeking immediate medical attention and post-exposure prophylaxis following potential rabies exposure.

Public awareness campaigns often employ various communication channels, including radio, television, community meetings, and printed materials.

5.3. Surveillance and Monitoring

Robust surveillance systems are vital for tracking the prevalence of rabies in both animal and human populations. Surveillance efforts include:

• Monitoring animal populations for signs of rabies.
• Diagnostic testing of animals suspected of being rabid.
• Reporting and investigating human rabies cases.
• Collaborating with neighboring regions to detect and respond to outbreaks promptly.

Effective surveillance systems enable timely intervention and help prevent the spread of the virus.

5.4. Environmental Considerations

Understanding the ecological factors that contribute to rabies transmission is crucial for implementing effective control measures. Key aspects of environmental considerations include:

• Wildlife Reservoirs: Identifying wildlife species that serve as reservoirs for rabies and monitoring their populations is essential. When necessary, wildlife management strategies can be employed to reduce the risk of transmission.
• Human-Wildlife Conflicts: Mitigating conflicts between humans and wildlife can minimize the risk of rabies transmission. This may involve developing strategies to protect livestock or implementing measures to reduce interactions between humans and wildlife.
• Climate and Habitat: Environmental factors, such as climate change and habitat fragmentation, can influence the distribution of rabies. Understanding these factors helps predict and respond to changes in rabies epidemiology.

6. The Global Strategic Plan to Eliminate Rabies

6.1. Overview of the Plan

Recognizing the urgency of addressing rabies, several international organizations, including the World Health Organization (WHO), the World Organization for Animal Health (OIE), the Food and Agriculture Organization of the United Nations (FAO), and the Global Alliance for Rabies Control (GARC), have collaboratively developed the “Global Strategic Plan to Eliminate Dog-Mediated Human Rabies by 2030.”

This ambitious plan outlines a roadmap for the elimination of rabies as a public health threat and builds on the principles of the One Health approach. Key components of the plan include:

• Mass Vaccination: The plan advocates for the widespread vaccination of domestic dogs, particularly in regions where rabies is endemic. By vaccinating dogs, the virus’s reservoir is diminished, reducing the risk of transmission to humans.
• Public Awareness and Education: The plan emphasizes the need to educate communities about rabies transmission, prevention, and responsible pet ownership. This includes promoting spaying/neutering, leash laws, and proper wound care following potential rabies exposure.
• Surveillance and Monitoring: The plan calls for robust surveillance systems to track and respond to rabies outbreaks. This includes monitoring both animal and human cases, enhancing diagnostic capacity, and reporting cases in a timely manner.
• Interdisciplinary Collaboration: Collaboration among governments, healthcare providers, veterinarians, and communities is central to the plan’s success. It also encourages international cooperation to address rabies in cross-border regions.

6.2. Progress and Challenges

While the Global Strategic Plan represents a significant step toward rabies elimination, it faces several challenges:

• Resource Constraints: Implementing mass vaccination campaigns and comprehensive surveillance systems requires substantial resources, which may be limited in some regions.
• Human-Wildlife Interface: Rabies in wildlife, particularly in bat populations, presents challenges for control efforts. Identifying and managing wildlife reservoirs is complex.
• Cultural and Behavioral Factors: Cultural practices and behaviors that increase the risk of rabies transmission, such as dog meat consumption, can be deeply ingrained in some communities.
• Access to Healthcare: In remote or underserved areas, access to healthcare and post-exposure prophylaxis may be limited, hindering efforts to prevent human rabies cases.
• Climate Change: Changes in climate and habitat can alter the distribution of rabies vectors and reservoirs, affecting the epidemiology of the disease.

Despite these challenges, the commitment of governments, organizations, and communities to the goal of rabies elimination by 2030 demonstrates the potential for success through a coordinated, One Health approach.

7. Case Studies in Rabies Control

7.1. Successful Rabies Elimination: The Case of Western Europe

Western Europe provides an example of successful rabies elimination through a combination of mass vaccination, public awareness campaigns, and rigorous surveillance. Countries like France, Germany, and the United Kingdom, which once faced rabies epidemics, have effectively controlled the disease.

Key factors contributing to their success include:

• High Vaccine Coverage: Mass vaccination campaigns achieved high coverage rates among domestic dog populations, reducing the reservoir of the virus.
• Strict Pet Regulations: Stringent pet regulations, including mandatory vaccination and pet identification, helped control rabies in domestic animals.
• Early Detection: Robust surveillance systems enabled the early detection of rabies cases, allowing for rapid intervention.
• Effective Communication: Public awareness campaigns educated communities about rabies prevention and responsible pet ownership.
• Cross-Border Cooperation: Collaboration between neighboring countries prevented the reintroduction of rabies from endemic regions.

7.2. Challenges in Rabies Control: Lessons from Asia and Africa

While Western Europe has made significant strides in rabies control, parts of Asia and Africa continue to grapple with the disease’s burden. The challenges faced in these regions provide valuable lessons for the global rabies elimination effort:

• Resource Limitations: Resource constraints in many Asian and African countries hinder mass vaccination campaigns and access to post-exposure prophylaxis.
• Cultural Practices: Some communities have cultural practices that involve close contact with dogs, increasing the risk of rabies transmission.
• Wildlife Reservoirs: Wildlife reservoirs, such as bats, play a significant role in maintaining the virus, making rabies control more challenging.
• Limited Healthcare Access: Remote and underserved areas often lack access to healthcare facilities and vaccines, leading to delayed or inadequate treatment.
• Intersectoral Coordination: Coordination between human and animal health sectors and local communities is crucial for effective rabies control but can be challenging to establish.

These challenges underscore the importance of tailoring rabies control strategies to the specific context of each region and the need for international collaboration and support.

8. Future Prospects and Emerging Trends

As we look to the future, several emerging trends and developments hold promise for advancing rabies control and elimination:

8.1. Advancements in Rabies Vaccines and Treatments

Research in the field of rabies vaccines and treatments continues to evolve. Advancements in vaccine technology, including oral vaccines for wildlife and improved formulations, can enhance rabies control efforts. Additionally, research into antiviral therapies and immune-based treatments may offer new options for managing rabies in exposed individuals.

8.2. Climate Change and the Impact on Rabies Transmission

Climate change is expected to influence the distribution of rabies vectors and reservoirs. As temperatures and habitats shift, understanding these changes is vital for predicting shifts in rabies epidemiology and adapting control strategies accordingly.

8.3. The Role of Genomic Research

Genomic research has the potential to shed light on the genetic diversity of rabies viruses, providing insights into transmission dynamics and aiding in the development of more effective control measures. Genetic sequencing can help trace the origin and spread of specific virus strains.

9. Conclusion

9.1. The Imperative of One Health

Rabies, a disease deeply ingrained in human history, continues to exact a toll on human and animal populations worldwide. The One Health approach, emphasizing the interconnectedness of human, animal, and environmental health, offers a comprehensive framework for addressing the complex challenge of rabies.

By recognizing the shared responsibility for rabies control and adopting a collaborative, interdisciplinary approach, we can make significant strides toward eliminating this ancient scourge. One Health underscores the idea that the health and well-being of all species are interdependent, requiring collective efforts to tackle global health challenges.

9.2. A Path Towards a Rabies-Free World

The Global Strategic Plan to Eliminate Dog-Mediated Human Rabies by 2030 represents a beacon of hope in the fight against rabies. It outlines a clear roadmap for rabies control, emphasizing mass vaccination, public awareness, surveillance, and interdisciplinary collaboration.

As we look to the future, emerging trends in research, vaccine development, and climate change adaptation provide opportunities for further progress. With unwavering commitment, resource allocation, and international cooperation, a rabies-free world is within reach.

The battle against rabies is a testament to the power of the One Health approach—a reminder that when humans, animals, and the environment unite, we can overcome even the most ancient and deadly of foes. In the spirit of “One Health for All,” we must continue to work together to ensure a safer, healthier future for all species on our shared planet.

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ONE HEALTH APPROACH: THE NEED OF THE HOUR