Rabies is a fatal illness caused by a virus, the Rabies virus. The virus is transmitted through several means, the commonest ones being the bite or scratches from an infected domestic pet usually dogs. Cases of Rabies from cat bites have also been reported. Other modes of transmission of the disease include bites from infected vampire bats, wild canines such as foxes and other similar wildlife. Rabies can also be transmitted from an infected person to an uninfected person through contact with saliva and other secretions from the nostrils. The evidence supporting person-to-person spread is not well documented. People most at risk of Rabies include veterinary workers, children exposed to stray animals as well as owners of domestic unvaccinated pets. Following exposure (from bite, scratch, or other forms of contact with infected secretions) to the virus, a person may develop symptoms between a few weeks or even up to a year. Several factors influence the rapidity of the development of symptoms. These include the proximity of the bite to the nervous system (the brain, spinal cord and nerves), the depth of the bite, the immediate actions taken following the exposure to the virus, immunity (from vaccination) and the amount of virus introduced during exposure. The onset of symptoms is usually gradual but progression of the disease thereon is rapid and fatality is inevitable. Common symptoms include sense of apprehension, fever, malaise and changes in sensation at the bite site. Hydrophobia (fear of water) associated with spasms of the muscles for swallowing often occurs. Coma and death usually occur within 2 weeks of the onset of symptoms.

Epidemiology

The World Health Organisation (WHO) estimates that over 55,000 deaths from Rabies occur worldwide. The majority of deaths occur in Asia (about 31,000) with Africa accounting for about 24,000 of the estimated deaths. This figure is presented as an underestimate largely due to misdiagnosis of cases. Cases of rabies rarely occur in developed countries and where they do, these have largely been associated with wildlife. In some developed countries however, Rabies has been eliminated even among wildlife due to continuous process of vaccination of wildlife through the distribution of vaccine-laden baits to wildlife.

Why is Rabies dangerous?

Rabies has an absolute case fatality rate (All persons who get Rabies die!). Rabies has virtually no peers when  it comes to claiming the lives of its victims. The much trumpeted Ebola Virus Disease in the recent outbreak killed only less than 50% of its victims overall. Although an outbreak on the scale of Ebola or other similar diseases is unlikely in the case of Rabies, the high case fatality rate is a source for concern. Even more worrying is the fact that most of the deaths can be averted if the necessary measures are taken.

So why we are not concerned?

A few years ago, I teamed up with one time Journalist of the Year, Mr Seth Kwame Boateng to produce a documentary on Rabies. Following the airing of his documentary, Mr Boateng spoke of the numerous calls he received some from people in powerful positions. Sadly, the documentary has not caused any significant change in our attitude towards the disease. So I ask, why are we not concerned? I have some schools of thought:

  1. Rabies kills fewer people than a lot of diseases. So why should we be concerned? Diseases like Malaria, Pneumonia and Diarrhoea kill people by the minute while Rabies doesn’t. So people are more likely to be concerned about such diseases instead of Rabies. Rabies kills a few tens maybe low hundreds in a year so in terms of numbers, it may be considered insignificant.
  2. Rabies does not feature on the National Public Health Agenda- Rabies is lumped together with a list of diseases categorised ‘Neglected Tropical Diseases’. As the name suggests, it is a neglected disease and while the objective for the categorisation of Rabies as one of such NTDs was to bring it to the fore, which is hardly the case.
  3. Lack of an integrated approach to Rabies control and prevention in Ghana. Rabies control in Ghana is expected to be a multi-sectoral activity with the key players being the Ghana Health Service, Local Government Service and the Veterinary Services Department. Currently, there is no clear integration of activities by these agencies in the area of Rabies control.

Can Rabies be prevented?

The answer is a VERY BIG YES! Rabies has been eliminated in most developed countries. These did not happen by chance. Proactive efforts were instituted and conscientiously pursued to achieve the set objective. The activities that can lead to preventing Rabies include the Vaccination of domestic pets (Cats and Dogs); the enforcement of legislation on stray animals; Provision of effective post-exposure prophylaxis (Medicines or vaccines given to people who have been potentially exposed to an organism that can cause disease- in this case animal bites or contact with saliva from an infected person); Public Education on the need to vaccinate domestic animals, Enforcement of Legislation on stray animals especially dogs.

Public Education on and Vaccination of Domestic Animals

As a young boy in growing up in the 1980s, I remember massive public education and vaccination drives for domestic pets especially dogs. Indeed, there was a tag around the neck of dogs and I remember older persons refer to such dogs as having the ‘license to bite’ by virtue of their vaccination. Such public education drives have been missing recently and there is the need for these to be re-introduced to ensure that most if not all dogs, are vaccinated against Rabies and pet owners adhere to the vaccination schedule as provided by the Veterinary officers. Rabies is largely transmitted by dogs although cats and other animals including humans with the disease can also transit the disease. Vaccination of dogs in particular has the potential to reduce the occurrence of the disease. There is the need to intensify the campaigns to get pets vaccinated against rabies.

Provision of Vaccines for Human Use

One of the real challenges I have encountered in my practice as a Public Health Physician is the non-availability of Rabies vaccines in our health facilities. The sad reality is that some victims of Rabies actually visited health facilities when they were exposed to the virus- through a dog or cat bite. However because of the non-availability of these vaccines and Immunoglobulins, they do not receive the recommended treatment (Post-exposure Prophylaxis) and they all died subsequently. Some commercially available vaccines are beyond the pockets of the average Ghanaian.

Enforcement of Legislation on Stray Animals

Ghana is reputed as having a lot of laws and other subsidiary legislation but the enforcement has largely been the challenge. The Public Health Act and other local government regulations are clear on stray animals and the actions to be taken. It is commonplace to find cattle, dogs, sheep and goats roaming rural and urban areas. Although ruminants may not pose clear health hazards to humans, the same cannot be said of stray dogs. There is empirical evidence from health facilities of stray dogs being common sources of infections reported. Ridding our streets and communities of these stray animals can be a useful step in reducing the incidence of Rabies in Ghana.

Way Forward

RABIES KILLS ALL ITS VICTIMS. This must inform all actions aimed at preventing the occurrence of the disease. The Ghana Health Service, the District Assemblies and the Veterinary Services must integrate their activities to ensure a well-coordinated programme of Rabies control in Ghana. This must include improved vaccine availability, enforcement of legislation on stray animals especially dogs, surveillance on animal vaccination, provision of prompt and efficacious treatment for victims of dog bites, training of healthcare workers at all levels on the management of animal bites especially those from dogs and cats and strengthened surveillance for human and animal rabies.

Non-governmental organisations ought to be involved in the campaigns to get dogs vaccinated against Rabies. Such actions must be guided by the

There is the need to include animal bites in our disease surveillance system. A surveillance system for animal bites means people who are victims of animal bites will be followed up by Public Health staff and such follow-ups will among other things ensure that patients have received the recommended treatment for animal bites. 

 

Dennis Odai Laryea

Head Public Health Unit of the Komfo Anokye Teaching Hospital, Kumasi Ghana

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