Nepal | May 27, 2019

Fatal rabies virus: Unknowingly emerging disease

Dr Sher Bahadur Pun

An increasing number of dogs are being adopted as pets in Nepal. Many pet owners are not well aware of zoonotic diseases that can be transmitted from dogs to humans. But they don’t know about the post-vaccination immunity of their dogs

Illustration: Ratna Sagar Shrestha/THT

Over the one-and-a-half months from January through February 15, Sukraraj Tropical and Infectious Disease Hospital (STIDH) saw six rabies patients, who later died of its complications. Some colleagues, who are working in different hospitals, have also expressed concern over the rise in rabies cases in Nepal. Moreover, veterinarians and those who are working for sick animals have increasingly encountered rabies – confirmed animals, mainly stray dogs, in recent years. It shows that rabies, a well-known virus, is unknowingly emerging in Nepal.

Rabies is a viral disease and is usually transmitted to humans by the bite of an infected animal through the saliva. Once the symptoms appear, it is always fatal. However, it is 100% preventable if an anti-rabies vaccine is administered at the earliest possible. Tingling, prickling or a burning sensation at the site of the bite are some of the early symptoms. It, however, goes unnoticed in many patients. They usually seek medical care only after they begin to exhibit signs, such as aerophobia (fear of fresh air), hydrophobia (fear of water), unusual behaviours, such as confusion, anxiety and agitation. These are considered to be late signs of rabies.

In Nepal, many rabies patients stated that they first experienced a sudden onset of low back pain followed by hydrophobia and aerophobia. Moreover, majority of the patients were found to be calm, cooperative and well-oriented instead of being in anxiety, agitation and confusion as explained in the medical textbooks. Signs and symptoms of rabies usually develop 2-3 months after the infection. In Nepal, however, majority of the rabies cases displayed signs and symptoms 6-8 months after the bite or infection.

Animal bite victims, who reside in urban areas, usually visit a nearby hospital or doctor and receive appropriate counseling or get vaccinated against rabies. Those living in the remote rural areas go first to a local pharmacy or even a spiritual healer, where they get inappropriate counseling. This corroborates that healthcare providers in the rural areas require continuing medical education on rabies.

WHO recommends a vaccine be given on days 0, 3, 7, 14 and 28 via the intramuscular route (IM) into the deltoid muscle. Recently, Nepal has introduced the intradermal (ID) route that requires only four doses (no need for a vaccine on the 14th day).

A new guideline for rabies management being introduced in Nepal in the near future will require only four doses via the IM route while three doses for the ID route are sufficient.

In addition to this, if the bite occurs in highly innervated areas, such as the head, neck, genitals, hands (fingers), and multiple deep bites, then rabies immunoglobulin should be administered.

Such bites are considered as “category III” bites, which are at high risk of rabies transmission. It is, however, unfortunate that rabies immunoglobulin use is not widespread and is not administered except at the STIDH. Rabies immunoglobulin is a life saving vaccine and should be given as early as possible.

At present, all animal bite victims with category III exposure are being referred to the STIDH from across the country. This is, however, a major financial burden on the victims. Therefore, this life saving vaccine should be made easily available and be administered at the local healthcare centres across the country.

In recent years, an increasing number of dogs are being adopted as pets in Nepal. However, many pet owners are not well aware of zoonotic diseases that can be transmitted from dogs to humans, including the rabies virus. They do vaccinate their dogs but don’t know about post- vaccination immunity (or quality of vaccine) of their dogs. If a dog leaves the home compound, it can potentially carry the rabies virus after being bitten by a rabid dog. Very recently, a young adult victim developed rabies symptoms, although his dog was vaccinated. Thus, it is clear that if a person is bitten by his own pet dog that frequently goes outside, then he must seek medical advice as soon as possible.

Many people think that minor scratches, no bleeding after the animal bites and bites from small puppies do not pose a rabies risk. So, they do not go to a hospital or even attempt to get counseling from qualified healthcare providers. It is unfortunate that a vast number of rabies cases in recent years are of this nature. Victims even refuse to visit a hospital despite the repeated requests from their own family members. Moreover, it is a matter of regret that the victims know very well where a rabies vaccine is readily available.

In summary, it is important to know that minor scratches (with or without bleeding) from a dog regardless of the size or a bite from one’s own pet irrespective of the vaccination status can lead to symptoms of rabies, and thus there is immediate need for medical attention or advice. Continuing medical education on rabies is a must for medicine sellers, healthcare providers and spiritual healers, particularly in the remote rural areas of Nepal. Changing the people’s mindset, or attitude, towards the rabies virus is crucial to eliminating human rabies from Nepal.

Dr Pun is Chief, Clinical Research Unit, Sukraraj Tropical & Infectious Disease Hospital

A version of this article appears in print on March 06, 2019 of The Himalayan Times.

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