Vaccine conundrum

01 Sep 2019

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The writer is a member of the WHO Expert Committee for Rabies.
The writer is a member of the WHO Expert Committee for Rabies.

RABIES is an ancient and much feared disease, manifesting with horrendous symptoms in which the victim is unable to swallow and suffocates while still alert, ultimately ending in coma and death. The psychological trauma of a dog attack can be enormous, and the horrific death devastating for the victim’s family.

Most Pakistanis still associate rabies vaccine with ‘14 injections into the abdomen’. This was the killed-virus vaccine inoculated on nerve tissue developed in 1911. It was often ineffective, painful and unsafe. With the advent of new effective and safe cell culture vaccines, WHO recommended discontinuing nerve tissue vaccines in 1984. Pakistan was almost the last country to discontinue this ‘poor man’s vaccine’ in 2015, and now depends upon imported anti rabies vaccine (ARV) and rabies immunoglobulin (RIG).

The modern cell culture ARVs and RIG are produced in several European countries, as well as in China, Philippines and India. At least five pharmaceuticals in India export to most Asian and African rabies- endemic countries. Unfortunately, several Chinese and Philippine products were withdrawn because of poor efficacy. European products are prohibitively expensive and unlikely to reach the poor who most need it, which leaves Indian products as the only option.

How can we prevent a rabies outbreak without vaccines?

In April this year, the Indian government announced that, due to rising demand of these products within India, they would discontinue export to all countries. This is a big blow to all the importing countries, as hundreds of thousands of dog-bite victims will be deprived of these life-saving products. In Pakistan, we can expect havoc from rabies, compounding our encounters with many new and emerging infectious diseases. We receive rabies patients almost weekly from inner Sindh, though few deaths occur in Karachi through appropriate management at The Indus Hospital and JPMC. With absent supplies, we will be seeing many weeping families.

The National Institute of Health is primarily responsible for rabies data collection and vaccine production. It estimates 2.5 million stray dogs in Pakistan, 100,0000 to 150,0000 dog bites, and 800,000 doses of ARV required annually. It is highly unlikely that NIH will be able to rapidly produce efficacious ARV and RIG to fill the gap for the entire country.

The reservoir of this dangerous virus is the saliva of unvaccinated dogs. WHO, OIE and FAO have targeted 2030 for universal elimination of rabies through mass dog vaccination (MDV) and animal birth control (ABC) by surgical sterilisation. Vaccinating at least 70 per cent of dogs within an area could eliminate rabies by producing herd immunity. Bangladesh, Turkey and others are already following this timeline.

For Pakistan, this is a tall order unless we too endorse scientific methods. Those who propound mass dog killing or exporting them to dog meat-eating countries are venting barbaric and illogical ideas. A female dog breeds 10-20 pups a year and can continue breeding for five to seven years. Even if some die, the remaining will continue to procreate, and the stray dog population will increase exponentially.

The Indus Hospital Research Centre initiated a pilot programme called ‘Rabies Free Karachi’ with MDV and ABC in January 2018 in Ibrahim Hyderi, and extended to Mehran Town and Korangi. Stray dogs are caught humanely in nets, vaccinated and spray-painted for identification. Surgical sterilisation is performed in a purpose built container. Teams of dogcatchers, vaccinators and veterinarians are trained and salaried by IHRC. WHO supported RFK through donation of animal vaccine and deputed an experienced trai­ner from South Africa.

To date, RFK successfully vaccinated over 20,000 dogs and sterilised 2,200 male and female dogs, and even donated 8,000 vaccine doses to other organisations, and engaged the local population. It is possible to scale up the programme throughout Karachi so that, within three to five years, the stray dog population is perceptibly reduced and stays free of rabies, while male dogs will be less likely to be aggressive after neutering. What is needed from the administration and civil society is the encouragement, financial support and space to perform MDV and ABC. The team is also ready and willing to train other agencies in order to speed up the effort to make Karachi rabies-free in two to three years.

Given that the requirements for human ARV and RIG will likely remain unfulfilled for all of Pakistan, we reiterate our expert advice: do not provoke dogs, rather, show kindness to all God’s creatures; in case of bite, do not apply home remedies, but immediately flush and wash the wound with soap and water, and apply antiseptic; defer suturing for at least a few days; and keep neighbourhoods free of garbage.

We leave our fate in the hands of the local administration, NIH and Drap, and the ministries of health and animal husbandry.

The writer is a member of the WHO Expert Committee for Rabies.

Published in Dawn, September 1st, 2019