Eliminating rabies

January 07, 2019

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The writer is an infectious diseases specialist and a member of the WHO Expert Panel for Rabies.
The writer is an infectious diseases specialist and a member of the WHO Expert Panel for Rabies.

OF all deaths among those affected by infectious diseases, none is more heart-wrenching than death caused by rabies. About six weeks after a bite from a rabid animal (usually a dog) the victim develops fever, headache, limb pain, and then a burning and choking sensation in the throat, and inability to swallow water. There is fear even at the sight of a glass of water (hydrophobia). Death is inevitable as breathing ceases, even as the victim remains awake. This horrific scenario happens to over 60,000 dog-bite victims in the world every year, and probably several thousand times a year in Pakistan.

Ironically, rabies is completely preventable if the wound is immediately and thoroughly washed with soap and flowing water, followed by an effective anti-rabies vaccine series and immunoglobulin. Unfortunately, in Pakistan, both these life-saving drugs are in chronic short supply. Also, in most government hospitals and clinics, doctors are not trained to administer these biologicals correctly. Consequently, dog-bite victims are neglected and face the consequences of what the WHO has appropriately classified as a neglected tropical disease (NTD).

In the sprawling metropolis of Karachi alone, over 120 dog-bite victims report daily to only three hospitals that have facilities to manage dog bites. Most other victims do not even report to hospitals, but apply unsafe home remedies. Children are scarred for life from deep lacerations to the face, head, neck or limbs, and the terror lives within them. Most such misfortunes occur in rural or mountainous areas, where even basic medical care is usually unavailable.

Over 120 dog-bite victims are reported daily in Karachi alone.

People who travel in closed vehicles are not exposed to stray dogs and often have little or no empathy for those who suffer from their attacks. Unfortunately, local, provincial and federal governments, doctors and veterinarians are also unconcerned. The Drug Regulatory Authority of Pakistan (Drap) has other priorities. Consequently, dog bites and rabies remain abjectly neglected. The general public, out of exasperation, demands that street dogs be killed, and the municipalities periodically order the mass culling of dogs. Not only is this barbaric, it is also futile in the long run, because other dogs will fill the void and continue to procreate and transmit the virus.

Acknowledging difficulties in eliminating rabies, WHO strongly advocates the One Health Initiative: that rabies be eliminated by scientifically and consistently run campaigns of mass dog vaccination, which would eliminate dog-dog or dog-man transmissions of the virus, in tandem with animal birth control, which will reduce dog population over time. Coupled with these measures, increased public awareness and timely wound management have markedly reduced — even eliminated — rabies in Thailand, Sri Lanka, Malaysia, and Brazil. Pakistan has not even gotten off the ground, and continues to distrust the scientific approach for eliminating this deadly problem.

In response to growing concerns of dog-bite incidents in Karachi, a pilot project, in which this writer participated, was formed under the aegis of Indus Hospital Research Centre from January to December 2018. The project was implemented in Ibrahim Hyderi, selected because of its proximity to the hospital, and recorded outbreaks of rabies from within the village. The mission was in collaboration with Karachi’s leading veterinarians, animal-right activists, community engagement experts, doctors and researchers. At the start, the community was engaged and a baseline of dog count established. Dog-catchers were trained by an international expert, and veterinarians were trained for animal birth control. Animal vaccines were provided by the WHO, and funding was partially provided by the KMC, along with donations from members of civil society.

At the conclusion of the project, it was observed that there were no outbreaks of dog bites, no incident of rabies, a visibly reduced number of newborn puppies, and a highly satisfied community. The full impact of the project is being compiled and will be published in a scientific journal. Replicating the project in other parts of Karachi requires funds and strong public support.

Meanwhile, the WHO’s NTD division aims to eliminate rabies globally by 2030, and all assistance to countries is channelled through national rabies programmes.

For Pakistan, this is a tall order. There is no national-scale programme. Drap is apathetic about quality life-saving vaccines and immunoglobulin. Municipal authorities are in denial of this problem that affects the marginalised. Veterinary colleges neither teach nor practise rabies or stray dog control. Mounds of garbage are killing fields for hapless citizens, but inviting pastures for strays. As ever, caring NGOs, charity hospitals and worried individuals attempt to fend for the poor. Civil society must raise its voice to demand a rabies-free country.

The writer is an infectious diseases specialist and a member of the WHO Expert Panel for Rabies.

Published in Dawn, January 7th, 2019