• Most victims travelled to Karachi after failing to get proper care in other parts of Sindh
• Govt urged to improve infrastructure, supply chains for procuring vaccines

KARACHI: As many as 129 patients have lost their lives to rabies in over a decade at two major tertiary care hospitals of the city. Most of the victims travelled by road to Karachi after failing to receive treatment at health facilities in the interior parts of Sindh, says a research study.

Recently published in the journal Transactions of the Royal Society of Public Health and Hygiene, the research is authored by Dr Naseem Salahuddin and co-workers at the Indus Hospital and Health Network (IHNN).

The study analysed 129 cases of the fatal disease reported at the emergency departments of the IHNN, Karachi, and the Jinnah Postgraduate Medical Centre (JPMC) between January 2009 and December 2019.

There was a complete lack of information on the number of rabies deaths in Pakistan as it was not a ‘notifiable ailment’, she added.

It revealed that there is very poor awareness of rabies prevention among laypersons, and home remedies such as application of salt, chillies, etc., are often employed, which preclude correct post-exposure prophylaxis (PEP) and may actually be harmful.

“Most people do not wash the wound immediately with soap and water, as recommended, as this simple process would remove saliva and dirt, and reduce chances of rabies by 30 per cent. The challenge is that most deaths occur in rural areas where the victim is taken to a shrine for dum-dua,” Dr Salahuddin shared.

Neglected disease

According to the study, rabies is a grossly neglected disease in Pakistan. The 129 cases of the fatal disease were either the result of a lack of awareness or the non-availability of anti-rabies vaccine and rabies immunoglobulin (RIG) at the healthcare facilities where the victim initially reported after the bite.

“The disease is 100 per cent fatal if not treated effectively soon after a bite from a rabid animal, whose saliva contains the rabies virus. Once inoculated into the skin or mucous membranes, the virus travels gradually toward the central nervous system and results in acute, progressive encephalitis (inflammation of brain tissues),” it says.

Rabies can be completely prevented if the wound is immediately and thoroughly flushed and washed with soap and flowing water, followed by an effective anti-rabies vaccine series and rabies RIG injection into each bite wound.

Failure to get complete vaccination

Under the study, one rabies case was attributed to a cat while another to a jackal, while all other attacks were reported from stray dogs and had occurred one to two months prior to their presentation with rabies’ symptoms.

Majority of the health facilities, experts say, do not follow rabies prevention protocols, and most doctors and paramedics in emergency departments are neither trained nor equipped to give the PEP to dog-bite victims in an updated protocol. There is not even a place to wash the wounds properly.

The symptoms described were fever, headache, and restlessness; family members became suspicious of rabies when the victim was unable to swallow food or liquids. In some cases, the experts say, paralysis of the limbs and coma slowly develop and eventually death occurs.

The average time interval between the bite and appearance of rabies symptoms (incubation period) in the study was 30-84 days. No case of rabies had been treated by the PEP with vaccine or RIG.

Ninety-seven per cent of the patients did not receive complete vaccination, and only three were given some ‘injection into the wound’, but had no record of the dose and timing of the injection. None could verify if the wounds were adequately washed with soap and water.

According to the study, children and young adults with rabies accounted for 38.5pc of the patients since they are likely to provoke street animals and cannot defend themselves after an assault.

By the time the patients presented with rabies, wounds were self-healed, but when asked about the severity, 94.6pc of the wounds were described as being ‘deep’ or ‘multiple’. Bites on the face, head, neck, and fingers are most lethal as these areas have more nerve endings. However, any untreated bite from a rabid animal may result in rabies.

The most glaring observation was that 60pc of the patients had to travel by road from outside Karachi to reach the IHNN or JPMC. The furthest a patient had to travel was 548.3km (from Jacobabad to Karachi) because there are no functional PEP centres in these areas.

The study highlights a gap in clinical and public health practices where rabies treatment following dog bites is grossly inadequate.

It urges the government to improve infrastructure and supply chains for procuring vaccines and sustaining their availability, and to train staff in dog-bite treatment and adopt the one-health approach by vaccinating dogs and reducing their population by humane means.

Published in Dawn, March 25th, 2023