Rabies still a health threat

Last summer, eight-year-old Raymond found a sick puppy lying in front of their yard seemingly needing some help. He decided to bring in the puppy inside the house so he could feed the animal. Unexpectedly, the puppy bit his fingers and right hand. The bites were not very severe but with some bleeding. He told his parents about the incident, but they did care at all. The puppy died the following day. The father dumped the dead body in garbage nearby.

They forgot all about it until two months later when Raymond developed fever, muscular aching all over his body and intense pain in his right arm. He was brought to the hospital but by this time he had trouble drinking water. In fact, he trembled just even seeing anything with water.

Five days after admission to the hospital, Raymond died. He was a victim of rabies, a viral infection of the brain to which all mammals, including human beings, are susceptible. While Hong Kong, Japan, Singapore, and Taiwan are considered rabies-free, the disease is still a serious health threat in the Philippines.

In 2015, some 783,879 cases of animal bites have been reported. This was 10% higher than in 2014, which recorded a total of 683,802 cases of animal bites. Records from the Department of Health (DOH) showed a total of 1,713 human deaths caused by rabies were recorded from 2010 to 2016. That’s an average of 245 deaths every year!

In Davao City, about five deaths caused by bites of rabid animals were recorded in 2013. “The city has the highest record in the region because it has also the highest population compared to other provinces in the region,” the rabies program manager of the regional office of the health department was quoted as saying.

Davao region is composed of Davao del Sur, Davao del Norte, Davao Oriental, Compostela Valley, and the newly-created Davao Occidental. It has 6 cities: Davao, Digos, Tagum, Panabo, Samal, and Mati.

Davao, however, is not included the among the areas with high incidence of rabies. Dr. Ernesto Villalon III, of the health department’s rabies prevention and control program, identified these provinces as having high number of rabies cases: Pangasinan, Nueva Ecija, Camarines Sur, Tarlac, Quezon, Isabela, Batangas and Bukidnon.

“Rabies is considered a neglected disease that is 100 percent fatal but 100 percent preventable,” said Health Secretary Jean B. Rosell-Ubial. “Usually, rabies is eventually fatal once the rabies virus reaches the spinal cord and brain,” says The Merck Manual of Medical Information.
The virus, however, takes at least 10 days – usually 30-50 days – to reach the brain (depending on where the bite is). “During that interval, measures can be taken to eradicate the virus and help prevent death,” the Merck manual claims.

Despite the enactment of Republic Act 9482, otherwise known as the Rabies Act of 2007 which seeks to eradicate rabies in the Philippines by 2020, the health department laments that rabies remains a public health problem in the country.

Bullet shape

The virus that causes rabies belongs to the group of viruses with a distinct “bullet” shape. It is usually introduced into humans through the bites of infected animals but other means of transmission are possible.

Aside from dogs, other animals which can transmit rabies are cats, bats, and foxes. Domesticated animals like cattle, carabao, pigs, goats, and horses also have rabies. Rabies rarely affects rodents (such as mice and rats), rabbits, or hares. Birds and reptiles do not develop rabies.

“The domestic dog is the most important reservoir of the virus,” says Dr. Mary Elizabeth Miranda, leader of the rabies research program of the Research Institute for Tropical Medicine. In fact, 98 percent of rabies cases are attributed to dog bites.

Contrary to common belief, puppies – upon birth – are not infected by rabies. Dr. Lester L. Quiano, a veterinarian who used to write a column for a national daily, explained: “Puppies could only acquire the disease as young as three months because at this stage, they start to lose their maternal immunity.

(At birth, the puppy sucks the first flow of milk containing colostrum, which gives protection to the puppy until three months of age. After this, the protection will start to dwindle).”

Saliva is the culprit

A dog can be infected with rabies if bitten by a rabid animal. “When a rabid animal bites a dog, it will take 10 to 80 days for the virus to multiply in the dog’s body, after which, it will show clinical signs of rabies infection,” Dr. Quijano wrote. “During this stage, the dog shows excitement and unusual restlessness, and will bite into any moving object.

It’s not the bite but the saliva. “The bite of any rabid animal is not the cause of the spread and infection of rabies,” corrects Dr. Silvius Jude B. Alon, a veterinarian who used to work with a Davao-based non-government organization. “It is the saliva of the affected animal. The bite is just an instrument so that the saliva with rabies virus can be transferred to any victim.”

Though bites are the usual form of transmission, rabies can also be contracted if open wounds or mucous membranes in the eyes, nose and mouth come into contact with saliva from a rabid animal, or if an infected person kisses a partner. In rare cases, victims contract it from inhaling the air-borne virus – in caves inhabited by rabid bats, for example – or by drinking unpasteurized milk from a rabid animal.

Among Filipinos, rabies remains a highly-misunderstood disease. Many, especially those in rural areas, still believe that garlic and a few drops of vinegar can cure rabies. Others believe that a quack doctor have the power to eliminate the virus from the body with the use of a stone or by sucking with the use of a carabao horn.

Signs and symptoms

Dr. Rubina O. Cresencio, a veterinarian with the Bureau of Animal Industry, said that there are some signs to know whether an animal is rabid or not? A dog, for instance, is rabid when when it shows any of the following clinical signs: sudden behavioral change (sudden anorexia, signs of apprehension or nervousness, irritability, hypersensitivity), hydrophobia (fear of water), muscle paralysis, and nervous signs.

“The early stage of rabies usually lasts 2-3 days or sometimes only a few hours,” says Dr. Cresencio. This includes changes in attitude and behavior or temperament, dilated pupils and slight rise in body temperature.

In humans, rabies symptoms can take weeks or months to appear. This presents a real problem when treating the disease because by the time symptoms have developed it may be too late to prevent death. When an infected animal bites a person, the virus travels along the nerves to the central nervous system where it incubates for up to three months. In this period the victim shows no signs of illness.

At the end of the incubation period, the virus multiplies rapidly, spreading to the brain and throughout the body, even to the eyes and extremities like hair follicles. Initial symptoms, in what doctors refer to as the “prodromal stage” of the disease, may be mild. They last from two to ten days and include a slight fever, headache, nausea and persistent loose cough. There may be pain, itching, tingling or a sensation of cold at the bite site.

Then, in the “acute neurological stage,” symptoms become more and more frightening. For the next two to seven days, the patient becomes nervous, agitated, restless and irritable, and may salivate excessively. As the virus replicates in the brain, the victim experiences eye problems (like enlargement of the pupils), weakness of the facial muscles and hoarseness.

In one out of six cases, there’s hydrophobia. “In this stage, there is forceful, painful muscle spasms of the throat, which expel liquids administered orally,” says Dr. S.N. Madhusudana, associate professor of the Department of Neurovirology at the National Institute of Mental Health and Neuroscience in Bangalore, India.

Finally, the virus overwhelms the brain and central nervous system. The patient falls into a coma, becomes paralyzed and dies. Actually, a person dies of rabies because of the overwhelming viral infection of the brain or central nervous system.

Vaccinations

Don’t ever wait for symptoms to appear or that’s already too late. So, if you think you are bitten by a rabid animal, “you must get a series of shots to prevent the infection from taking hold,” suggests Minnesota-based Mayo Foundation for Medical Education and Research.

But before doing, you must know if the animal really has rabies. But if you can’t find the animal, “it may be safest to assume that the animal has rabies.” However, some factors should be considered like the type of animal and the situation in which the bite occurred.

Generally, rabies vaccine – which is made from killed rabies virus – as a pre-exposure treatment is given to people who are at high risk of exposure which include veterinarians, animal handlers, rabies laboratory workers, spelunkers, and travelers who are going to areas where rabies is common.

The US Center for Disease Control and Prevention (CDC) says pre-exposure for rabies vaccination is three doses given at the following times: dose 1, as appropriate; dose 2, 2-7 days after dose 1; and dose, 21 days or 28 days after dose 1.

“Anyone who has been bitten by an animal, or who otherwise may have been exposed to rabies, should clean the wound and see a doctor immediately,” CDC points out. “The doctor will determine if they need to be vaccinated.”

A person who is exposed and has never been vaccinated against rabies should get 4 doses of rabies vaccine: one dose right away, and additional doses on the third, seventh and fourteenth days. “They should also get another shot called rabies immune globulin at the same time as the first dose,” CDC says.

But like any medicine, a vaccine is capable of causing serious problems, such as severe allergic reactions. “The risk of a vaccine causing serious harm, or death, is extremely small,” the CDC claims. “Serious problems from rabies vaccine are very rare.”

Among the mild problems are: soreness, redness, and swelling or itching where the shot was given (30%-74%) and headache, nausea, abdominal pain, muscle aches, and dizziness (5%-40%).

Moderate problems include hives, pain in the joints and fever (about 6% of booster doses).

Among the severe allergic reactions may include hives, swelling of the face and throat, difficulty breathing, a fast heartbeat, dizziness and weakness. These would start a few minutes to a few hours after the vaccination. If this happens, bring the person to the nearest hospital. Otherwise, call your doctor.

It is high time to end rabies in the Philippines. “Prevention of human rabies must be a community effort involving both veterinary and public health officials,” said the United Nations health agency. “Rabies elimination programs focused mainly on mass vaccination of dogs are largely justified by the future savings of discontinuing prevention programs. However, until canine (dog) rabies is eliminated or at least well controlled, safer and more economical post-exposure treatments for humans are a desirable alternative to the use of nerve tissue vaccines.”

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