THE first World Rabies Day is being observed on Sept 8. At long last, rabies has come to be globally accepted as a serious, but neglected, disease of the poor. Ironically, it is the men in power who can control rabies which affects mainly the weaker sections of society which are most vulnerable.

One hopes that this occasion will create awareness of this lethal health problem in Pakistan at all levels of policymaking. The need is basically for a systematic and sustained control programme, sufficient resource mobilisation and allocation and inter-sectoral coordination.

Termed an “orphan” disease, despite its known existence for centuries, rabies has never been given the importance it should have as a serious, 100 per cent fatal infectious disease. Over the past two decades, four WHO regions covering Asia, Africa, the Americas and Eastern Europe have reported an estimated 50,000 to 55,000 rabies deaths annually, 20,000 of these being in India.

It is not generally realised that 40 per cent of rabies cases occur in children in the five to 15 years age group, mostly living in the rural areas. There they are taken to local traditional healers. Given the inevitability of death, most patients prefer to die at home rather than undertake a journey in futility to a distant hospital. Hence no accurate data is available of the incidence of rabies.Pakistan reports an estimated 2,500 rabies deaths per year which works out to 17 per million population. Compare this with 20 in India, four in Sri Lanka, 0.2 in Indonesia and 0.1 in Thailand (per million population). With the exception of India and Pakistan, most other countries have shown a decline in rabies deaths over a decade. This is attributed to improved quality and more widely available post-exposure prophylaxis along with better dog population control.

Mortality figures may not sound impressive to epidemiologists who compute deaths from tuberculosis, AIDS and malaria in the tens of thousands. It is the slow, painful, torturous form of death that evokes profound emotion from the family, community and healthcare givers. The psychological burden of dog-bite can be enormous, the trauma of the horrific death is devastating for the victim’s family.

The lethal virus lives in the saliva of a rabid animal, usually a dog though not all biting dogs carry the virus. A biting animal may not manifest external signs of rabies until a few days after biting the victim. Without testing the animal’s saliva it is impossible to guess the status of the rogue animal. A bite is analogous to playing Russian roulette where a six-chambered revolver with one bullet and five empty chambers is held to the head. When the trigger is pulled, one in six persons will surely die.

Hence the decision to give proper prophylaxis with quality vaccine to almost every dog-bite victim in order to prevent one case of rabies must be made urgently and expertly. Establishing a diagnostic reference laboratory in the public sector would go a long way in reducing unnecessary rabies vaccination.

With Pakistan’s health system as a whole riddled with problems of inadequate infrastructure and manpower, low accessibility and scarce resources, and the majority of people caught in the vicious cycle of poverty, ignorance and deprivations, rabies is unsurprisingly not considered a high priority problem. A case, therefore, needs to be built on the Disability Associated Life Years (DALYs) lost and economic losses of rabies.

The federal ministry of health’s response to this problem has been to mandate the National Institute of Health (NIH) in Islamabad to draw up policies to regulate all aspects of rabies. It has elegantly prepared plans but as is the wont here they have yet to be implemented. Time and again, pleas for replacing the poorly effective, harmful and obsolete sheep brain vaccine (SBV) with safe, effective and modern tissue culture vaccine (TCV) have fallen on deaf ears.

Pakistan, Myanmar, Bangladesh and Vietnam are the only rabies endemic countries in the world which still use SBV. All others have since long switched to the TCV, the proper use of which has greatly reduced the incidence of the disease. India is now one of the world’s largest vaccine exporters. Our plea to the ministry of health is to abandon SBV and import WHO-validated TCV at a competitive cost.

The vaccine can be produced in Pakistan, provided good manufacturing practices are adopted. NIH’s previous experiment in producing TCV ended in deaths of dog-bite victims who were injected with the vaccine. That is because the facilities and expertise were inadequate and these failures should be guarded against.

The thrust should, of course, be on prevention. By controlling the animal population that is responsible for the transmission of rabies, the disease in human beings can be eliminated. In rabies-free countries, the ministry of health coordinates closely with the livestock and agriculture authorities and the local governments. In Pakistan, this interaction and collaboration is either minimal or non-existent. As a result, resources are wasted.

The need is to institute a programme for animal birth control and for the vaccination of domestic, community and stray dogs, which is the only proven method of animal rabies control. Under the law, it is mandatory for pet owners to get their animals vaccinated but as is common here there is no enforcement of the law. Ad hoc immunisation of a limited number of dogs, and culling are unsustainable over a period of time and a waste of resources.

The first step in rabies control would be a situational analysis and reliable assessment of annual human and animal rabies deaths, animal bites, geographical distribution and other epidemiological information and data. This would allow us to focus resources on “hot” spots. Along with that, public awareness programmes must be an ongoing process in which the media’s participation must be enlisted.

Subspecialty training in indigenous infectious diseases at levels of undergraduate, postgraduate and continuing medical education should be mandatory while TCV should be made available in all district hospitals, and physicians trained in the use of the Thai Red Cross low dose intradermal method of giving vaccine, which reduces the cost of vaccination considerably.

The writer is a consultant in infectious diseases and member of WHO Rabies Expert Committee and President of Rabies in Asia (Pakistan Chapter) Foundation.