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Not Just a Dog Bite: Rabies Alert

Stray Dogs

Rabies is endemic in India and accounts for approximately 36% of world’s rabies deaths. Although the true burden of rabies in India is not fully known, around 20,000 human deaths occur from rabies each year and 99% of animal-to-human transmission of rabies occur from dog bites. Mostly the poor people and children between the ages of 5 and 15 years often playing and sharing food with the stray dogs are frequent victims of dog bites. Why higher incidence of dog-mediated rabies? Because of the growing dog population or increasing incidents of dog bites.

India has about 30 million stray dogs and the annual incidence of a dog bite is around 1.75 million. But who are the ones to be blamed? The garbage generated every day in Indian households is dumped in the open, there is overflowing of garbage bins and the meat shops also dump waste in the drains. The more the garbage, the greater the number of strays are attracted. The larger the number of dogs roaming freely, the further their population will increase, and controlling their population becomes harder. On the other hand, animal lovers usually feed dogs, but no one is responsible for vaccinating them or their birth control. Then, why do dogs bite? Man-animal conflict is on rising. Any hostility of the human aggressors will render the dogs aggressive following which they may resort to biting in self-defense. While the Prevention of Cruelty to Animals Act (PCA), 1960, talks about culling street dogs, the Animal Birth Control (Dogs) Rules of 2000 (ABC) allows the stray dogs population.

Rabies is a serious disease of humans and animals caused by the rabies virus. The virus is present in the saliva of infected animals and most often spread through bites of infected dogs, bats, and raccoons. Interestingly, rabies can also be transmitted in the absence of bite, if the saliva gets directly into a person’s eyes, nose, mouth, or an open wound via scratches. An unvaccinated dog, if bitten by a rabid dog can contract rabies. A bite breaks the integrity of the skin which results in the entry of the virus. The virus enters the body, travels through nerves to the central nervous system. The rabies symptoms appear when the virus reaches the brain. The closer the bite to the brain, the more quickly symptoms appear. The well-known signs of rabies infection in humans include flu-like symptoms initially, and as the disease progresses the person may develop anxiety, confusion or agitation.

Muscle spasms occur in the throat and larynx. The person feels pain in the throat and produces a lot of saliva causing the foaming of the mouth effect. An attempt to drink water can trigger the spasms. Swallowing becomes difficult and the person cannot drink water. This leads to what seems like a fear of water or hydrophobia. For this reason, rabies is sometimes called hydrophobia. Eventually, paralysis develops and results in death. Although rabies is a deadly disease, there is a 100% chance of survival if the person gets treatment before symptoms appear. There are effective human vaccines and immunoglobulins for rabies. Rabies is a vaccine-preventable disease.

These are some of the reasons human rabies is neglected and treated as just a dog bite.Most dog bite cases get unnoticed due to lack of awareness. Even if they are aware of this, due to unavailability or non-accessibility to vaccines in rural areas, the poor populations are more vulnerable. There is a 20-80 percentage shortage in anti-rabies vaccines an all states, except Gujarat and Kerala. Moreover, the rabies-prevention strategies are not implemented successfully by the Indian Government. This is something that can make the French Scientist, Louis Pasteur turn in his grave who developed the earliest effectivevaccine against rabies that was first used to treat a human bite victim on 6 July, 1885.

Dog bites can be prevented. Don’t panic, stay calm. Think prevention! When a dog bites, it is important to assess the wound to determine its severity. Some dog bites and scratches may be minor while some need to be treated as an emergency.

The WHO categorized rabies exposure as:

Category I: Touching or feeding animals, licks on intact skin (no exposure);

Category II: Nibbling of uncovered skin, minor scratches or abrasions without bleeding (exposure);

Category III: Single or multiple transdermal bites or scratches, contamination of mucous membrane or broken skin with saliva from animal licks, exposures due to direct contact with bats (severe exposure).

The only way to fight and prevent rabies is through vaccination either before exposure or immediately after exposure. All bite wounds and scratches should be attended to as soon as possible after the exposure. The bitten area should be washed immediately with soap or detergent and running water for approximately 15 minutes. If soap is not available, wash thoroughly with water alone. Remember, wound washing is the first-aid treatment against rabies. If the bite area is bleeding, put on pressure using a sterile cloth and apply iodine-containing or similar antiseptic on the wound and seek medical attention immediately. The wound shouldn’t be covered with any dressings or bandages. Avoid applying any local traditional cures such as jhhad-phoonk, gobar, castor oil, turmeric, or irritants such as chili powder, plant juices, acids, and alkalis on the wound. The biting animal should be confined safely, where possible, and collect information about the kind of animal that bit if it was a wild or stray animal or a pet, whether its vaccination was up-to-date if the animal was acting strangely or any unusual behavior, and the bite circumstances. This information should be provided to the health care professional for further assessment and treatment. The biting animal should be kept confined and under observation for 10 days. If the animal is rabid, it will usually show clinical signs, or die, within the 10-days observation period. Though it is not advisable to simply observe the biting animal for 10 days without starting post-exposure prophylaxis (PEP).

The PEP can be converted into a PrEP (pre-exposure prophylaxis) regimen if the animal remains healthy during the observation period.  There is currently no effective treatment for rabies after clinical signs appear.

PEP:It is the administration of rabies vaccine, with or without rabies immunoglobulin (RIG) after exposure to rabies.  The rabies PEP regimen involves the administration of four doses of rabies vaccine given intramuscularly on days 0, 3, 7, and 14. For immunocompromised persons, a fifth dose can be given on day 28. RIG should be administered for severe category III exposures and infiltrated in wounds that require suturing. RIG and the first dose of rabies vaccine are given on the first day of treatment (day 0). RIG can be given up to day 7 after the first rabies vaccine. Doctors will provide antibiotics, analgesics, and tetanus vaccines depending on the characteristic of the wound.

PrEP: It is the administration of several doses of vaccines as prevention before exposure to rabies. The rabies PrEP regimen involves the administration of two doses of rabies vaccine given intramuscularly on days 0 and 7. A dog bitten person who has previously received either pre-or post-exposure rabies prophylaxis does not require administration of RIG. They should be given only two rabies vaccine boosters on days 0 and 3, following an exposure.

Dog vaccination and bite prevention are the keys to preventing rabies virus transmission between dogs and from dogs to humans.The primary vaccination against rabies should be given at 3 months of age and the booster should be given annually. The World Health Organisation (WHO) mandates that at least 80% of dogs need to be vaccinated annually to break the rabies transmission cycle. There is a need of government programmes to set up free sterilisation centres to bring down the canine population, campaigns to improve public awareness, mass vaccinations covering the entire dog population and to provide free medicines and/or vaccines to all rabies victims to prevent and eliminate rabies. A multi-pronged approach incorporating a “one health programme” in a coordinated manner at all levels would be a holistic solution to this menace. Among the Indian states, Sikkim, in northeast India, is an outlier, it is declared rabies-free after all its strays have been neutered. To raise global awareness about rabies prevention, 28 September is celebrated as World Rabies Day. Recently, India launched its new National Action Plan for dog mediated rabies elimination (NAPRE) by 2030 with rabies now also declared as a notifiable disease.

Adopt One Health, Stop Rabies.

Reference: Rabies website (https://www.who.int/india/health-topics/rabies)

Authors

Sangeeta Das1*, Anu Malik1, Pankaj Deka2

1PhD Scholar, Department of Microbiology, LUVAS, Hisar, Haryana-125001

2Assistant Professor, Department of Microbiology, CVSc, AAU, Khanapara, Guwahati-781022

Email: sangitakashyap9864@gmail.com; Ph No. +91 9706590513

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