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Published Date: 2013-05-21 17:02:52
Subject: PRO/AH/EDR> Rabies - Pakistan: (Islamabad) canine, human exposure
Archive Number: 20130521.1728601

RABIES - PAKISTAN: (ISLAMABAD) CANINE, HUMAN EXPOSURE
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International Society for Infectious Diseases
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Date: Tue 21 May 2013
From: Naseem Salahuddin <naseemsal@hotmail.com> [edited]


Lost battle
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Dr Abdus Salam Khan, FACP, Director of the Emergency Department. Shifa International Hospital, Islamabad in Pakistan shares his perspective:

"As emergency room physicians we come across patients who are faced with death and need our help to fight this battle. Most of them are success stories, but when I see a patient with rabies, I know that we have lost the battle without even trying anything.

I recently had sleepless nights over one particular case. A 28 year old lady with a 2 year old child was chased by a stray dog and ultimately the dog bit the child on the face. She was taken to a local doctor in her remote city, and the doctor instructed them to go to the big city hospital for vaccination and immunoglobulins. She [the mother] came to the city hospital with her family and she was vaccinated, but without immunoglobulins. Fast forward 18 days and she presented at our emergency department with signs of rabies. Now it is irreversible. Nothing can be done. How do you tell a 2 year old? Can we comfort them that it is OK?. How do we tell the mother to see her child for the last moments, and then it will be over for her? This case is especially tragic in that the patient and the family came to the hospital on time and the medical community failed them. I am speechless and ashamed.

Although rabies and its devastation have been known for a long time, we are still not able to lessen its impact in my part of the world. We see patients showing the signs of rabies, and we cannot offer them anything. They eventually die in their home or other places.

We have failed as a medical community to address this disease in a meaningful way. Although we run educational campaigns and celebrate World Rabies Day, using print media and electronic media [such as, ER Medicine http://www.emergencymedicineforum.org]. I, we, have not yet been able to put a significant dent in the incidence of rabies. Our emergency responder physicians sometimes don't know the latest guidelines and treat based upon their own understanding, which may result in a bad outcome.

Efforts are needed to educate the public regarding vaccination of their pets and the treatment of bite wounds. Government-run facilities see the majority of dog bite cases, but because of the lack of policy, resources, and most important of all, lack of emergency medicine training, this results in a less than optimal level of care. Private institutions also serve these roles and do a relatively better job, but their care is mostly out of the reach of common people due to the costs.

Being a member of the emergency medicine community and also involved in training of physicians, I am sure that persistent effort will ultimately improve care. I am working on forming a group to offer educational support along with logistic help to people with dog bites. We can start a rabies registry and update it on the net so that we can calculate the burden of disease in a more accurate way. I would also like to start a 24-hour active hotline to generate information and create awareness to act in the responsible way against dog bites and rabies.

Rabies control is a team effort and requires input from all stakeholders, but in the case of Pakistan, unfortunately it has been neglected by too many."

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Communicated by:
Dr Abdus Salam Khan, FACP
Director of the Emergency Department
Shifa International Hospital
Islamabad
Pakistan

[In the treatment of bites by rabid animals WHO recommendations state that:
- wounds should be washed/flushed and disinfected immediately. Vaccine and immunoglobulin therapy should instituted as soon as possible,
- If rabies immunoglobulin is not available on 1st visit its use can be delayed by a maximum of 7 days from date of 1st vaccine injection,
- initiation of PEP (post-exposure prophylaxis) should not await the results of laboratory diagnosis or be delayed by dog observation when rabies is suspected,
- pregnancy and infancy are never contraindications to PEP,
- persons who present for evaluation and rabies post-exposure prophylaxis even months after having been bitten should be dealt with in the same manner as if the contact occurred recently.

Rabies immunoglobulin (RIG) should be given for all category III exposures [single or multiple transdermal bites, scratches, or contamination of mucous membrane with saliva (that is, licks)], irrespective of the interval between exposure and beginning of treatment. 2 kinds of rabies antibody preparations may be used: human rabies immunoglobulin (HRIG) and equine rabies immunoglobulin (ERIG). A skin test must be performed prior to the administration of ERIG. As much as possible of the recommended dose (20 IU/kg of body weight of HRIG or 40 IU/kg of body weight of ERIG) should be infiltrated around the wounds if anatomically feasible. The remainder should be administered intramuscularly (into the gluteal region) in a single dose and followed by a complete course of vaccine.

Rabies immunoglobulin of human origin (HRIG) is available in some countries; however, it is expensive and only limited amounts are available. Rabies immunoglobulin of equine origin (ERIG) is available in many countries and is considerably cheaper than HRIG. Most of the currently available preparations of ERIG are highly purified and quite safe.

Dr Khan's tragic account above is both a plea for increased efforts in control of animal rabies in Pakistan and for better provision of treatment in Pakistan hospitals. ProMED-mail welcomes the opportunity to further publicise these messages. - Mod.CP

A HealthMap/ProMED-mail map can be accessed at: http://healthmap.org/r/6dG6.]

See Also

2011
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Rabies - Pakistan 20110729.2285
2001
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Rabies, human - Pakistan (05) 20010417.0764
Rabies, human - Pakistan (04) 20010415.0749
Rabies, human - Pakistan (03) 20010413.0739
Rabies, human - Pakistan (02) 20010411.0718
Rabies, human - Pakistan 20010227.0390
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