Friday, June 12, 2015

Rabies 101 Sri Lanka - Bitten or scratched by an animal, what should I do?

Until a couple of weeks ago, I hadn't had a brush with this fatal infectious disease other than responding to a recent email from a traveler seeking some information regarding treatment for rabies in Sri Lanka. So it was a bit of a shock to find myself sat in the emergency room at the hospital late one evening after my friend was attacked by a stray cat. And then the next day, to have accompanied my friend to the Anti-Rabies Vaccination Unit at Kalubowila Teaching Hospital ("KTH")  while he discussed the attack, the possibility of cutting off the cat's head and bringing it to the hospital (if it died), and then administered the injections for anti-rabies post exposure treatment eek

According to the World Health Organization ("WHO"), around 60,000 people die from rabies each year, and around 95% of those cases occur in African and Asian countries. Sri Lanka is still classed as high risk although it has reportedly cut rabies deaths by more than 90% in the past 40 years through an intensive anti-rabies campaign and increased awareness program. Some countries still advise their citizens to get the anti-rabies vaccination before departing for Sri Lanka for a long stint, or planning to work with animals while visiting the country, or if they are planning adventure travels that increase the risk of exposure to animals.

Did you know that still  around 20 to 30 deaths occur in Sri Lanka annually due to rabies? And these deaths in Sri Lanka are mainly caused by exposure to infected dogs. A recent estimate of the total dog population in Sri Lanka is something like three million dogs with the roaming or stray population accounting for 30% of this total (though I think this estimate of roaming dogs is actually higher!). For those of us living or traveling in Sri Lanka my question is, are we situated within a literal death trap given the numbers of roaming or stray dogs (and cats) throughout the island? Notwithstanding, there's also owned dogs and cats that may not have been vaccinated against rabies. However, I hasten to add the chances of a stray dog or cat biting or scratching you is low unless you actually engage or pester the animals.

What you need to know about Rabies


The rabies virus enters the body if you are bitten, scratched or an open wound is licked by an infected animal (i.e. mammals such as dogs, cats, rodents, bats etc). Note - the rabies virus is transmitted through saliva (during the final stage of the disease in the infected animal), and not via blood, urine or feces of an infected animal. It can only infect via broken skin. It travels through the nervous system to the brain and then to other organs.

The incubation period is usually one to three months, though this can vary from less than one week to more than one year. The closer the infected area is to your brain, the shorter the incubation period i.e. near your neck, face or head.

The initial symptoms of rabies last for two to ten days in humans include fever, tiredness, insomnia, lack of appetite, headaches, sore throat and sometimes vomiting. In addition, there may be pain or a tingling sensation around the wounded or infected area.

After this, the more serious symptoms start to develop leading to advanced rabies. There are two types - furious rabies and dumb or paralytic rabies. Two-thirds of cases are the former, but I'm not sure if this is also the case in Sri Lanka. A few days following the onset of advanced symptoms, the patient will go into a coma. And then, heart or lung failure usually cause death.

Also worth mentioning is how to detect signs in animals. In the furious type of rabies, infected animals may drool excessively, appear agitated, and bite or snap at imaginary and real objects. In the dumb or paralytic type of rabies, infected animals may appear tame and fearless of humans and may appear to be choking before paralysis of jaw, mouth and throat muscles.  Other general signs may take the form of infected animals appearing excessively wobbly, circling, seeming partially paralyzed, acting disorientated, or mutilating itself. If you observe any of these signs in animals, it is wise to steer clear to avoid coming in contact.


Checklist


If you are are bitten or scratched by an animal in Sri Lanka, it is advisable to follow the following checklist:
  1. If the animal that bit, scratched or licked your open wound is wild, stray or roaming, then take note of its appearance and behavior so you can advise any medical staff (if necessary). Pay the most attention if the animal is behaving in an abnormal manner. Refer to the description in the previous section of signs of rabies in animals
  2. Do not approach or handle the animal
  3. Immediately wash the area where you have been bitten with soap and water, or with a disinfectant such as dettol and water for  five to ten minutes
  4. If the animal has an owner, speak to the owner to ascertain if their pet has been vaccinated against rabies and details of these vaccinations, such as dates (so you can advise a doctor if necessary)
  5. Seek medical advice regarding the bite. If the bite has broken skin and drawn blood it is highly advisable to visit a doctor or hospital so they can examine the wound and undertake further treatment of the wound. Anything more severe, head straight to the hospital
  6. Anti-rabies post exposure treatment is administered (minor or major), which is available free of charge at public hospitals


What is the Anti-Rabies Post Exposure Treatment ("PET")?


There is usually a protocol in place for Anti-Rabies PET. In Sri Lanka this involves:
  • the management of the patient following an animal bite (i.e. cleaning wound, tetanus shot and prescription for antimicrobial medicine); 
  • screening of the patient to classify whether it is a major or minor case; and 
  • screening the animal (as required).

If you are diagnosed in the minor category, patients are given a course of anti-rabies vaccine. Major category patients are given rabies immunoglobulin followed by a course of anti-rabies vaccine. There is a set treatment schedule and dosages for the anti-rabies vaccine.

To give you an idea of this, I'll use the example of my friend who recently had treatment for minor exposure category. On the evening of the animal attack, he washed the wound with dettol and water before I accompanied him to the hospital. As it was late at night, so we went to the emergency room. After seeing a doctor he was given a tetanus shot and asked to take some oral medicine immediately.

The next day, when we attended the Anti-Rabies Vaccination Clinic (Room 23) at the Kalubowila Teaching Hospital, he was examined and questioned by the doctor regarding the incident with the animal. After a minor category diagnosis he started on a course of the anti-rabies vaccine. This entailed immediately injections - one dose in each shoulder. He was then asked to return on day 3 and day 7 and then a month after the last injection for further two doses each time.

As an interesting aside, while we were at the Anti-Rabies Vaccination Clinic, I noted that most of the patients receiving treatment were mainly small children with all kinds of bites and wounds. I guess they're are more prone to approaching an animal than adults as well as more vulnerable due to their size and lack of awareness of the risks (especially with stray or roaming animals).


Further reading


Since having this experience and in doing some research on rabies in Sri Lanka, it seems to be quite topical at the moment in local media. I have found some of the articles most informative about the history of the disease in Sri Lanka and how it's been tackled.

The Public Health Veterinary Services is the main body in Sri Lanka responsible for the prevention of human and animal rabies. Their website has a wealth of information on the history of rabies on the island, policies for rabies control, projects and initiatives to combat the infectious disease, guidelines for treatment, and reports and statistics.




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