Tackling rising incidence of rabies - the messenger of death

A couple of months ago, a young and sprightly Chetana lapsed into coma, never to wake up again.

She was not a victim of medical negligence, as initially alleged by her family, but of the deadly bug rabies that she fell prey to, as evident from the diagnosis confirmed at NIMHANS, Bangalore.

 Alan Samuel, another young student and a committed dog lover from Chennai, succumbed to rabies which he acquired through a seemingly innocuous nip from a rabid pup on campus, last November. Two deaths due to rabies were reported in the Tibetan settlement at Bylakuppe, near Mysore last year. 

These are just a few of the several thousand precious human lives that rabies, the lethal viral disease, extinguished. With 20,000 human deaths every year, India accounts for more than a third of the global toll due to rabies. Rabies has plagued mankind for ages and true to its reputation of being the most fatal virus, the rabies virus is aptly bullet shaped as seen under the electron microscope! Rabies cuts across all barriers; men and women, rich and poor, young or elderly - all can be victims alike of this vicious disease.All mammals (pet, stray or wild) can potentially transmit rabies to humans.

In India, most of the human rabies cases are acquired through the bite or scratch of a rabid dog; cats, mongooses, monkeys, foxes, wolves and jackals occasionally transmit the disease to humans. Bats are known to transmit rabies in the US and some other countries, but not in India. The duration between exposure to an infection and the appearance of the first symptoms is usually one to three months, but can vary from as less as one week to more than a year. 

Unlike most other viruses which travel inside the human body through the bloodstream, this wily bug creeps up the nerves to reach the brain, thus evading the immune sentinels in the blood! The disease may manifest initially with flu-like symptoms- fever, headache, and as discomfort and itching at the site of bite. This is followed by anxiety, uncontrolled excitement, aggression, and fear of water-hydrophobia-a classical symptom of furious rabies. Some patients may develop paralytic rabies with inability to move body parts, loss of consciousness and coma. Both these forms of disease will invariably result in an agonising death, most often within one week.

 No specific treatment or cure exists for this disease anywhere in the world. Once a person manifests with the symptoms of rabies, death is almost certain. However, the good news is that this fatal disease is almost 100 per cent preventable if treatment (prophylaxis) is offered immediately following the animal bite.

Any animal bites, scratches, or licks on damaged skin warrant immediate attention! Wash or flush the exposed area thoroughly with soap and running water for 10-15 minutes. This helps wash away the virus deposited at the site of bite. Antiseptics like Dettol and Savlon can be used; however, local application of turmeric, lime, chilli powder and coffee powder should be avoided. Consult a doctor as soon as possible- he/she will decide further management and the post-exposure prophylaxis you need depending on the severity of the bite/exposure.

Post-exposure prophylaxis is a preventive treatment given to an individual immediately after an exposure (bite/scratch/licks on damaged skin) from a suspected rabid animal, so that he does not acquire the disease. This is done by boosting the immune system before the virus reaches the nerves and travels to the brain!  It consists of five doses of rabies vaccine administered on days 0,3,7,14 and 28 (where day 0 is the day of first injection).

The vaccine should be given intramuscularly on the deltoid region (upper arm) in adults or the outer aspect of thigh in children, but never in the gluteal region (buttocks). All rabies vaccines presently available in India have a proven track record of being safe for use, with almost no side effects. Vaccines derived from sheep brain which needed 14 or more painful shots in the abdomen are no longer used in India and have mercifully been relegated to medical history books!

Don’t delay 

In addition to the vaccine, individuals who have severe bite wounds also require rabies immunoglobulin (RIG) which is injected directly into all the wounds sustained. Post-exposure prophylaxis is offered free at public hospitals and it is prudent not to delay it when indicated. One need not wait for an untoward event (animal bite) to happen to get vaccinated for this deadly disease.

It is a matter of shame and concern that even in the 21st century, people continue to die of rabies, a vaccine preventable disease. Since human rabies is indelibly linked with canine rabies in India, interventions in both animal and human sectors are required for rabies control. Animal interventions include strict licensing and vaccination of pet dogs, vaccination of stray dogs and measures to decrease their number-a long-term yet definitive strategy to eliminate rabies. 

Canine rabies elimination in India remains a distant prospect; every effort should be made to prevent human rabies deaths. Prompt prophylaxis following animal exposures, pre-exposure vaccination of vulnerable groups like schoolchildren, and use of cost-effective strategies like intradermal vaccination, can help reduce the disease burden.

A national programme for rabies control envisaged in the 12th five year plan has been initiated recently, which will garner attention for this neglected disease. Most importantly, rabies must be declared a notifiable disease by the Central government which will increase awareness, help estimate the true disease burden and facilitate preventive measures for this fatal disease. 

(The writers are with the Department of Neurovirology, WHO Collaborating Centre for Reference & Research on Rabies, National Institute of Mental Health and Neurosciences, Bangalore)