Dog bites man is still news in Nepal

Last year this time, the Infectious and Tropical Disease Hospital in Teku would be filled with patients suffering from mosquito or dog bites. But for the past week, entire families are sleeping in the open overnight at the hospital gate waiting for their turn to get Covid-19 PCR tests in the morning.

The novel coronavirus has overshadowed many prevalent diseases and their treatment in Nepal, and one of the deadliest among them is rabies.

Last month, on a day that saw six Covid-19 fatalities nationwide, at least three people died of rabies in Dolakha district after a dog bit 10 people. The three, aged 32, 14 and 8, died despite receiving anti-rabies vaccines.

Their families filed police complaints against a local clinic for using faulty vaccine, but ward chair Raj Kusum Lama later said the three died because they did not go for the full treatment of three injections.

In Kathmandu, the Teku hospital is the only one which administers free anti-rabies vaccines. It used to get as many as 150 dog bite cases a day, but the number dwindled to only about 30 daily cases in the past months – even though there is anecdotal evidence of hungry street dogs getting more aggressive during the lockdown.

Surya Ghimire was recently walking from his home in Dhapakhel to a school in Patan where he is a security guard, when he was suddenly attacked by a canine pack.

"There were no cars on Sat Dobato, and the dogs ruled the intersection. It was so dangerous, I started carrying a stick to protect myself,” he recalled. “The dogs were chasing people on motorcycles. They never did this before.”

The lockdown also meant that without transport, people could not travel to health facilities to access the vaccine on time. Even after travel restrictions were lifted, many dog bite victims are afraid to visit Teku because it is also where Covid-19 patients are tested and treated.

“Rabies is a under-diagnosed and under-rated in Nepal,” explained Buddha Basnyat of Patan Academy of Health Sciences. “Rabies doesn’t take any prisoners, it kills. Good thing we have a set of highly effective preventive measures.”

A post-exposure prophylaxis, commonly known as anti-rabies vaccine, must be administered immediately after a dog bite, even if the dog may not be rabid. No one wants to take the chance. The vaccine takes about a week for the body to develop antibodies to fight the virus.

While completely preventable, rabies is a disease with the highest documented case-fatality rate -- close to 100%. Globally, it is responsible for 59,000 deaths every year, and 40% of all human rabies deaths are of children under 15.

While rabies occurs in more than 150 countries, it is endemic in South Asia and Africa. India alone accounts for 40% of all annual rabies deaths in the world.

Nepal has an average of 125 cases a year, but experts say most of the cases in remote rural areas go unreported. In fact, given the uncontrolled and growing population of stray dogs in urban areas, rabies and its preventive measures deserve more attention.

“Teku hospital is synonymous with dog bite treatment, but the anti-rabies vaccine should be made available across the country and not just in few government hospitals,” says Prativa Pandey of CIWEC Travel Medicine Centre in Kathmandu. “Widespread access to the vaccine also means cutting down on travel cost for patients seeking treatment.”

Indeed, if all major hospitals, health facilities and clinics had a stock of vaccines, many more lives would have been saved during the lockdown. Free anti-rabies vaccines are available only in Teku and limited district hospitals. Private hospitals stock the vaccine, but there is a hefty charge. Even then, most facilities are not equipped with immunoglobulin, which together with post-exposure prophylaxis is considered a complete treatment against rabies.

An immunoglobulin shot is crucial in severe bite wounds, but both equine and human immunoglobulin can be found only in a select few clinics.

“South India has made much progress in equine serum and we should invest on making it more widely available in Nepal,” says Basnyat. “It’s much cheaper than human immunoglobulin and doesn’t need a lot of maintenance, and the side effects are reduced.”

Knowledge about immediate and thorough bite wound washing with soap and water is also crucial, and can save lives. But prevention by controlling the street dog population and canine vaccination are equally important. Although bats and monkeys also carry the rabies virus, dog bites make up 99% of all transmission in Nepal.

Animal welfare organisations such as Kathmandu Animal Treatment (KAT) Centre and Sneha’s Care have been immunising community dogs in the Valley. Along with individual initiatives, they have also been busy feeding and caring for stray animals during the lockdown so they are not as aggressive.

On Monday, 28 September, the Global Alliance for Rabies Control is marking the 14th World Rabies Day with the slogan ‘End Rabies: Collaborate, Vaccinate’. Nepal and other endemic countries should renew their commitment to end rabies by prioritising and investing on preventive measures and meet the World Health Organisation (WHO) target of bringing down human deaths from dog-mediated rabies to zero by 2030.

Elsewhere in the world, pre-exposure vaccines are readily available and most travellers to Nepal use one so that even in case of a dog bite, they can survive with only one booster dose of the anti-rabies vaccine.

Says Prativa Pandey: “Ideally, immunisation against rabies like we have for polio is recommended for this part of the world even though it is expensive. Even so, we must make the vaccine available and invest on preventive measures to save lives.”