HEALTH: The lethal bite of horror

Nemesia V. Canoy used to wake up early in the morning to go to the rice field which her family owns. It was sort of a ritual for her but one morning, her daughter noticed that her mother wasn’t doing what she used to do.

Looking for her, she found her inside her room. She was having a high fever. But what alarmed her was the fact that her mother was afraid of light. Something is very wrong with her, the daughter thought.

The daughter contacted her mother’s sister, Emilia V. Sasam. Together, they brought her to the hospital. After Nemesia was examined thoroughly, the doctor said she had rabies.

The doctor advised that all family members should not go near her. But Emilia, being the sister, didn’t care at all. She tried to be with her.

It was found out that she was bitten by her 6-month-old puppy at home residence in barangay Pantaron in Santo Tomas, Davao del Norte. She thought that being a puppy, the dog had no rabies. But she was completely wrong.

Nemesia was already 74 years old when she died. “It was heartbreaking,” said J.B. Sasam, the son of Emilia. “My mother was with her throughout. She had to be quarantine as a result of what she did.”

“Without timely treatment, rabies infection is 100 percent fatal,” pointed out Dr. Nancy Nazaire-Bermal, head of the clinical research and development of the Novartis Vaccines and Diagnostics. “Rabies is the best example of an illness in which prevention is better than cure…”

Rabies may be a disease of the past (it is known since around 2000 B.C.) but still it continues to take a toll among Filipinos. Every year, an average of 245 people die of it. Despite the enactment of Republic Act 9482 – otherwise known as the Rabies Act of 2007 which seeks to eradicate rabies in the country by 2020 – the health department recognizes that rabies remains a public health problem in the country

In fact, the World Health Organization (WHO) ranked the Philippines fifth in the rabies list in terms of prevalence in a specific area. “We had gained notoriety among international communities as a nation with high or prevalence of rabies,” a doctor laments.

In 2001, a long-time resident of the United Kingdom contracted rabies after being bitten by a dog in the Philippines. He died in a London hospital. Five years later, two Japanese nationals were infected after being bitten by dogs in the country. United Kingdom and Japan have declared themselves rabies-free a long time ago. The last indigenous case of rabies infection in the United Kingdom occurred in 1902 while that of Japan was in 1954.

Oftentimes, most of the victims of rabies are children. This has been confirmed by the United Nations health agency, which said that that up to 60% of rabies cases occur in people less than 15 years of age.

Six-year-old Jonathan was playing in their front yard when a dog attacked him. His parents brought him immediately to the hospital since the little boy got three long scratches. But since they were not bites, the parents did not worry so much about it.

The scratches were completely healed. But two months later, Jonathan complained of a severe itch in the area where the dog made some scratches. Two days after the boy made a complaint, he died. The doctor’s finding of the boy’s death: rabies.

The parents never knew that rabies could be passed on not only through bites but also by a scratch from an infected dog or cat.

“Symptoms may appear in just a few days but in a lot of times, rabies virus works its way so slowly yet steadily to the brain, sometimes taking months before tell-tale signs would start to manifest,” explained Dr. Beatriz Quiambao, head of the clinical research division and rabies research group of Research Institute for Tropical Medicine.

“Rabies commonly begins with a short period of depression, restlessness, a general feeling of illness, and a fever,” notes The Merck Manual of Medical Information. “However, in 20 percent of people, rabies starts with paralysis in the lower legs that moves up through the body.”

Restless increases, leading to uncontrollable excitement, and saliva production greatly increases. “Spasms of the muscles in the throat and voice box occur because rabies affects the area in the brain that controls swallowing and breathing,” the Merck manual explains.

The spasms can be excruciatingly painful. “A slight breeze or an attempt to drink water can trigger spasms,” the Merck manual states. As such, a person infected with rabies cannot drink. For this reason, the disease is sometimes called hydrophobia (fear of water).

“As the disease spread through the brain, the person becomes more and more confused and very agitated,” the Merck manual notes. “Eventually, coma and death result. The cause of death can be blockage of airways, seizures, exhaustion, or widespread paralysis.”

Death is indeed inevitable once the symptoms appear. “Though a small number of people have survived rabies, the disease is usually fatal,” says the Minnesota-based Mayo Foundation for Medical Education and Research.

Anyone who thinks he has been exposed to rabies should receive a series of shots to prevent the infection from taking hold. “If the animal that bit you can’t be found, it may be safest to assume that the animal has rabies,” the Mayo Clinic suggests. “But this will depend on several factors, such as the type of animal and the situation in which the bite occurred.”

The Merck manual warns: “The closer the bite to the brain, the more quickly symptoms appear.”

Recently, the United Nations health agency issued new recommendations related to rabies exposure management or Post Exposure Prophylaxis (PEP). “Based on the available information, the guideline on animal bite management is revised in order to provide more cost-effective strategies for rabies prevention and control,” the Administrative Order No. 2014-0012 issued by the Department of Health (DOH) said.

According to the health department, the initiation of PEP “shall not be delayed for any reason regardless of interval between exposure and consultation as it increases the risk of rabies and it is associated with treatment failure.”

As much as possible the animal that has bitten must be located in order to know if it has rabies. “In case the animal is not available for observation or dies within the recommended 14-day observation period,” the AO said, “all rabies exposures shall receive at least the Day 0, 3 and 7 doses.”

Meanwhile, the decisions to give the Day 28 dose and D14 for IM regimen, shall depend on the result of the laboratory examination (FAT) on the biting animal and whether the biting animal manifested signs and symptoms of rabies.

It has been observed, however, that the most cost-effective strategy for rabies prevention in the Philippines is still elimination of rabies among dogs – where 99% of the cases were attributed to – through animal vaccinations.

Unfortunately, only very few families take good care of their dogs by having them vaccinated. As a matter of fact, some of them even allow their dogs to go astray. As such, the next best step of rabies elimination in the country is for family members to get the anti-rabies shot, especially if they are living in areas where incidence report is high.

Meanwhile, the local government unites are encouraged to enact and strictly enforce ordinance related to rabies. It urged LGUs to allocate funds for the procurement of syringes and anti-rabies vaccines for bite victims.