RECENTLY, I saw an eight-year-old boy from Dadu, who had been mauled by a pack of dogs. His scalp was torn off, his ear lobe was hanging and his armpits were chewed up. In fact, his entire body was mutilated. The distraught father, a simple peasant, carried him to small and large hospitals in Sindh, but none had the wherewithal to treat the child. Twenty-four hours later he reached the Indus Hospital where he was attended to. Under anaesthesia his wounds were washed and debrided; each wound was injected with Rabies Immunoglobulin (RIG), and the anti-rabies vaccine series initiated. Extensive plastic surgery procedures are still in process, and we hope the child will survive, although he will remain physically and mentally scarred for life.
Pakistan’s population is over 186 million and growing. The literacy rate is one of the lowest in the world. Tuberculosis, malaria, hepatitis, dengue, typhoid, polio and a host of infectious diseases account for the majority of disease, disability and deaths. Among these myriad problems, animal bites and rabies are nowhere on the radar of health authorities. The population of stray dogs is growing, as is the incidence of dog bites and rabies deaths.
Infected animals, mostly dogs, harbour the virus in their saliva. Several weeks after a bite from an infected dog, the victim develops headache, fever and becomes intermittently confused. Gradually, the muscles of swallowing and breathing go into spasm, and he has difficulty swallowing food or water (hydrophobia) and breathing (aerophobia). A few days pass without food or water. He is fatigued and dehydrated. The dying person feels a sense of impending doom. Death is inevitable. The family he leaves behind will remain with the indelible memory of his tortured death. Sixty-thousand deaths from rabies occur globally each year, of which 20,000 take place in India, and around 2,000 to 5,000 in Pakistan. Rabies is 100pc preventable if treated correctly at the time of the bite. Delayed or no treatment ends in sure death.
Rabies is totally preventable if treated correctly at the time of the bite.
In a WHO-sponsored Rabies Surveillance Project we studied nearly 10,000 cases of dog-bite victims from nine emergency departments across Pakistan. Nearly 80pc were male, and one-third between five to 14 years. Few victims washed their wounds with soap and water as recommended; instead, they applied unsafe household remedies: salt, turmeric or red chillies. Interviews of healthcare workers revealed that modern, lifesaving modalities of treatment were virtually unknown to them, since most emergency departments are not even equipped with modern vaccine and RIG. Stray dog bites occur frequently in rural areas. Often villagers must travel for hours, even days, to reach an equipped hospital; frequently, they do not complete the full vaccination course. If and when symptoms of rabies develop and death seems certain, the despairing family consults a mystic in a shrine for mumbo-jumbo treatment.
As evident at a recent Saarc workshop in Sri Lanka, the entire focus of human rabies elimination has shifted to dog rabies elimination. A ‘one health’ approach was recommended for all member countries to establish national and sub-national multi-sectoral steering committees for elimination of both animal and human rabies.
This is entirely logical. The difficulty is the logistics. Dog culling has totally failed in the long run wherever attempted. Developed, and now some developing countries, have demonstrated that vaccinating at least 70pc of feral dogs in a given area will create herd immunity. Immunised dogs are less aggressive, and even if provoked to bite, they will not transmit the virus. Sri Lanka, Bhutan and Thailand are well on their way to eliminating dog rabies by mass dog vaccination through organised campaigns. Many other countries are practising Capture, Neuter and Vaccination of stray dogs. Their population will eventually reduce, while maintaining the ecological balance. This is the only sure way to eliminate rabies in dogs and thus in humans.
In Pakistan, there is no such consideration. Most graduates of veterinary colleges specialise in lucrative practices of livestock and animal husbandry; municipal authorities either ignore the issue, or organise sporadic but ineffective dog-killing campaigns; hospital directors choose not to provide lifesaving medicines, assuming they are too expensive; medics remain unaware of treatment modalities; the uneducated continue in the time warp of unsafe antidotes. The result is heartrending cases of rabies deaths on the rise.
The Indus Hospital, Rabies in Asia and Medical Microbiology and Infectious Diseases Society of Pakistan jointly launched an intensive month-long awareness campaign in underprivileged districts of Karachi to wake up the slumbering authorities, and advise dog-bite victims on the proper course for rabies prevention. World Rabies Day was observed yesterday, and we should say as loudly as we can: ‘nobody in Pakistan should die of rabies’.
The writer is a member the WHO Expert Panel for Rabies and president Rabies in Asia, Pakistan chapter.
Published in Dawn September 29th, 2015