orld Rabies Day, observed annually on September 28, highlights the urgent need to control this deadly yet preventable viral infection. In Pakistan, according to government data, 2, 000 to 5, 000 rabies-associated deaths occur annually, mostly due to dog bites and lack of timely medical intervention. The actual number is believed to be higher. Street dogs contribute to this public health challenge. Pakistan has a large population of stray dogs roaming in both urban and rural areas. Compounding this challenge is the fact that rabies vaccines and immunoglobulinslife-saving injections given immediately after exposure are not always easily available in public hospitals. So, people have to turn to private labs and hospitals for costly healthcare facilities. In rural areas, where dog bites are more common than in cities, the nearest medical centre may be several hours away, making victims vulnerable. Poverty, lack of awareness and basic education further worsen the problem, as many families are unable to afford the full course of vaccination or are unaware of its importance. Some dog-bite cases go unreported due to the social stigma attached to animal bites. Rabies is a viral disease transmitted from animals to humans, primarily through bites or scratches. Around the world, dogs, bats, foxes and badgers are common reservoirs of rabies in different ecosystems. A single bite from a rabid animal can be fatal. Even without a bite, scratches contaminated with saliva can transmit infection. Once symptoms appear, rabies is almost always fatal. Early signs (whether in humans or animals) include fever, nausea, vomiting, diarrhea, runny nose, light sensitivity, muscle cramps and loss of appetite. Aggression, restlessness and fear of water (hydrophobia a classic sign) are also present. Patients bitten by a dog must be instructed that if bitten or scratched by a suspect animal, they should wash and flush the affected area immediately with soap and water for 15 minutes. If available, use 70 per cent alcohol/ethanol or povidone-iodine. Healthcare providers must examine and properly categorise the wound. Category I constitutes licking of intact skin. In this condition, no vaccination is required. Category II includes nibbling and minor scratch wounds without bleeding; it will require vaccine. Category III wounds include transdermal bites/ scratches and mucous membrane exposure. These require both vaccine and immunoglobulin. The wound must be kept open and tight bandaging must be avoided. However, for large wounds, loose stitches may be applied on days 3-4. Patients must be instructed with emphasis that they should not use home remedies such as chili powder, acids or plant juices or turn to traditional healers, which have no role in preventing or curing rabies. Its important to observe the dog that has bitten the patient for 10 days after a bite to ensure it isnt infected with rabies. If the animal remains healthy and alive, it was not infectious with rabies at the time of the bite. If the animal dies, becomes sick, or is lost to follow-up during the 10-day period, continue/ complete the patients PEP as per protocol. Rabies is 100 per cent fatal with no cure, once symptoms appear, but it is also 100 per cent vaccine-preventable. Public health education about seeking immediate medical care after bites/ exposures to saliva, rather than engaging in unsafe practices, is the need of the hour. Moreover, schools and colleges should implement public awareness programmes that encourage humane strategies instead of dog abuse, which increases bite risks. It must be emphasised that stray dogs may appear harmless but pose a deadly risk as carriers of rabies; therefore, avoid contact with stray or wild animals. Every union council in major cities must have effective, sustainable control measures such as stray dog birth control and vaccination strategies. Moreover, the UCs must encourage the general public to report any sightings of rabid animals to local authorities as soon as possible. Pet owners, especially dogs, must be fully vaccinated before the owners contact. In villages, dairy product handlers must be taught that although milk or meat of a rabid cow is not harmful, they should still stay away from the cow since its foaming saliva coming out of the mouth may penetrate any wound the handlers might have on their body. Furthermore, pre-exposure prophylaxis (PrEP meaning prevention of rabies before a dog bite) is recommended for travelers visiting rabies-prone areas and for professionals handling animals. The WHO recommends pre-exposure prophylaxis as two 1 mL doses of rabies vaccine, given intramuscularly, one injection per day, on days 0 and 7, in the deltoid area of adults or in the anterolateral thigh of young children. Pre-exposure prophylaxis (PrEP) does not eliminate the need for post-exposure prophylaxis (PEP meaning prevention of rabies after a dog bite); any individual exposed to a suspected rabid animal must still receive appropriate post-exposure care. Independent data, in Pakistan, show that more than 100, 000 people are treated every year with rabies post-exposure prophylaxis. The obsolete vaccination schedule involved 14 injections. Nowadays, the rabies vaccine is available in two categories: intramuscular and intradermal. The intramuscular vaccine is administered as 1 ml at a single site on days 0, 3, 7 and 14. Care must be taken not to administer in the gluteal area. In immunocompromised patients, such as diabetics, HIV, cancer patients etc, will also receive an injection at day 28. The second type of vaccine, i. e., intradermal vaccine 0. 1 ml in each injection at 2 sites on days 0, 03, 07, and 28. Its to be noted that the intramuscular or intradermal vaccine will be applied in children under two years, on the anterolateral thigh. Administer Human Rabies Immunoglobulin (HRIG) for all Category III exposures. Infiltrate as much as possible into and around the wound; the remainder of the vaccine must be given intramuscular at a different site from the vaccine or used in another patient. Immunoglobulins are either Human Rabies Immunoglobulin (HRIG), administered 20 IU/kg, or Equine Rabies Immunoglobulin (ERIG), which is a 40 IU/kg injection. The ERIG immunoglobulin is much cheaper than HRIG and equally effective. It can therefore be preferred in underdeveloped countries. Infiltrate thoroughly into/ around the wound with an insulin syringe (and taking care not to use the insulin syringe in case of large wound); remaining dose given IM at a different and preferably opposite site from the vaccine. Dilute immunoglobulin in saline if there are multiple wounds. If the patient gets a dog bite wound after getting fully immunised, then booster doses must be given at day 0 and say 3 (whether its intramuscular or intradermal vaccine, and at one site). However, patients who have previously received incomplete vaccination, whether pre-exposure prophylaxis or post-exposure prophylaxis, must receive full post-exposure prophylaxis. Dow University of Health Sciences has imported a molecule from China and developed a rabies vaccine from it, at the local level this year, but it still has to be approved by the Drug Regulatory Authority of Pakistan for commercial use. Rabies is 100 per cent fatal with no cure, once symptoms appear, but it is also 100 per cent vaccine-preventable. By ensuring timely wound care, vaccination, immunoglobulin administration and responsible interaction with animals, needless loss of life can be prevented. Priority must be prevention and early intervention to protect from rabies.
https://www.thenews.com.pk/tns/detail/1346841-protecting-communities-preventing-deaths
Protecting communities, preventing deaths
