Is Rabies disease a challenge

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Is Rabies disease a challenge to public health in Manipur?

By: Dr A.S.K. Felix *

Introduction :

The recent media coverage in the newspaper publications, Doordarshan presentation/interview, radio talk interview on rabies and the responses from various NGOs, clubs, societies, communities and other reflect a high degree of health awareness among the different sections of the people leaving aside the medical, veterinary personnel, and dog owners/lovers. We know correct knowledge with positive attitude and right practice is the key to the prevention, control, management of any disease. Such correct information awareness gives us the confident weapon in tackling any disease situations and health problems challenging the society.

Going through the media coverage and others, it seems the public had overstepped some medical and veterinary realities on the reported outbreak of rabies epidemic in Manipur.

What constitutes an outbreak of epidemic disease:

Oxford dictionary defines epidemic as 'disease spreading rapidly among many people in the same place for a time'. In other words it is the spread of disease out of proportion above normal expected occurrence of a population at a place at a time.

This varies from disease to disease depending upon the mode of spread e.g. air born (TB, respiratory tract infections), water borne disease, food borne disease through raw vegetables, fruits, milk, milk products etc) - Cholera, Typh-oid, diarrhoea disease, direct contacts AIDS, STDs, Leprosy etc. Fomide borne diseases through soil, to-wels, linens etc. vector bo-rne diseases - Malaria etc and unclean hands and fingers.

Epidemic disease and high prevalence:

Let us take few disease to know epidemic and high prevalence.

Drug addiction: Low prevalence- less than 1% of the population and high prevalence 1-5% and abo-ve. Manipur State has abo-ut 20000-40000 drug abusers.

HIV/AIDS - It is based on sentinel surveillance data, HIV prevalence in adult population under three groups (1) high prevalence States - Maha-rastra, Tamil, Nadu, Karna-taka, Andhra Pradesh, Manipur and Nagaland, where HIV infection has crossed 5% or more among high risk groups and 1% or mo-re in the anti-natal women. (2) 5% or more among high risk groups but less than 1% in anti-natal women. (3) less than 5% among high risk groups and less than 1% among anti-natal women.

Tuberculosis - National TV control Programme targets to the long term objectives (1) one case infects less than one new person (2) the prevalence of infection in age group 14 is brought down to less than 1% against about the present 30%.

Malaria: National Anti-Malaria Programme while fighting malaria set goals - Annual Parasite incidence 1.3 or less and Annual Blood Examination rate 10% with 25% reduction in morbidity and mortality due to malaria by 2007 and 50% by 2010 (NHP 2002).

Rabies disease in Manipur:

In the last 9 years from 1997 to 2005, 94 cases were found positive for rabies of which 87 were in dogs, 3 were in domestic cattle, 4 were in cats, 3 negative cases and 32 were unfit samples (Source Animal Diseases Awareness Bulletin 2004-05, Manipur). The number of rabies in man in the same period was not available. The reported death in human beings till 21st March 2006 from dog bite was 18 and that did not mean that all death persons were due to rabies disease.

The reported case of rabies in man till 20 April 2006 admitted at RIMS is 19 out of whom 7 already expired and the rest was sent home with no hope for recovery of the patie-nts. The reported improvement of 10 year old girl bitten by a rabid dog on March 15, 2006 and admitted at RIMS on 12 April 2006 is a good news.

The reported dog bite cases are mostly from Thoubal district and hence the figure for the reported rabies cases in Thoubal district with its population in the past few years will help us for a specific study of this disease for epidemic outbreak. The limited available information and data do not justify this rabies disease to be epidemic. However this does not mean that one should neglect the effort for preventing this disease.

It reminds me of 1994 suspected Plague epidemic at North Tusom village and its neighbouring villages in Ukhrul district when there was a mysterious incidence of unnatural death with biting and bleeding of a large number of brown rate more that 1000 coming from Myan-mar to the said village.

People started buying capsule Tetracycline suspecting the disease to be plag-ue spread from rats, mice to human beings and in no time this medicine ran out of stocks in Ukhrul district pharmacies and other drug centre. Of course the same happened in Delhi and Surat cities etc due to suspected reported outbreak of Plague epidemic.

We (C Moses, IAS the than ADM Ukhrul now Secretary IFAD, NEC Shillong, Ngairaipam Luikham, the than AI and the present DI and the writer Sr MO (Specialist Public Health) at District Hospital Ukhrul were deputed at Tusom.

The writer stayed their for one week to investigate the case and do the needful. Rat samples were sent to Imphal and Kolkata for pathological examination and Dr N Luithui, Veterinary Surgeon also went to the said villages and collected death rat samples which were sent to Imphal. One Professor from All India Institute of Public Health and Hygiene, Kolkata also visited Imphal and Ukhrul for the same. The suspected epidemic was nullified by the failure of isolation of Yersinia pestis organism.

Vaccination of Dog population in Manipur:

The State has 1.32 lakhs of dog population according to 2002 census and Uk-hrul district has 18 thousand dog population. According to Dr Th Doren Singh, Director V & AH, Manipur over 50,000 cani-nes were given free vaccination till 5th April 2006 with the cooperation of local bodies, NGOs, dog owners.

Visit of WHO team:

Dr Ashwath Narayan, core member of the WHO survey of rabbies arrived in Imphal on April 3 and immediately visited Thoubal district for investigation of Rabies cases as the focal point of study.

The investigation findings are not yet available. These findings will be a great help in tackling Rabies disease in the State.

Rabies also known as hydrophobia which literally means fears of water in drinking is one of the most important widespread virus zoonotic disease spread from animals like dog, cats, fox, cattle, mice etc. It is caused by a virus called Rhabido virus. Its incubation period in man is usually from 4 weeks to 8 weeks.

Geographic distribution:

Rabies is an enzootic and epizootic disease of world wide importance. Some countries have achieved rabies free status by vigorous campaigns of elimination. In some countries, the disease has never been introduced. According to WHO report rabies is spreading to a great extend in many countries inspite of great advances in research and field control methods.

Canine rabies continues to exist in 87 countries which account for 99% of all human rabies cases. The global death from rabies cases is about 60,000. 10 million people all over the world require post exposure treatment every year. In UK rabies was quite common in dogs and man until 1902 when it was finally eradicated. It is estimated that 35,000 to 40,000 human deaths occur due to rabies each year in the countries of South East Asia Region.

In India rabies occurs in all parts of the country except Lakshadweep and Andaman and Nicobar Island. Since rabies is not a notifiable disease, the 30,000 deaths reported by national authorities may not be a complete picture.

Identification, diagnosis of rabies dog:

1. Excited, aggressive appearance with bloodshot eyes.
2. Hypersensitivity to sounds and movements.
3. Attacking of any moving or any inanimate objects.
4. Drooling of saliva and refusal of its usual food.
5. Not responding to the call of it master.
6. Hydrophobia.
7. Wavering of gait and curtailing of tail.
8. Presence of Negri bodies in the pathological examination confirms rabies.

All dog bites are not rabies cases. Dog bite can occur in many circumstances/situations which are not related with rabies. Dog bites are common when the bitch has puppies, when man comes near the dog when he/she eats meal, bones, foods etc during mating season and to protect/guard the master and the acquainted family members, house, farm and its surrounding etc.

Observation of suspected rabies dog and confirmation:

When there is dog bite the said dog should be kept under observation for 10 day. Any dog suffering from rabies dies within 10 days. Presence of Negri bodies in dog's brain in the pathologic examination confirms this cases.

Clinical features of rabies in man:

At the onset, there may be fever, Paraesthesia at the site of the bite within 1-10 days. Patient is anxious, has hydrophobia. Although the patient is thirsty, attempts at drinking provoke violent contractions of diaphragm and inspiratory muscles. Delusion, hallucination may develop accompanied by spiting, mania, cranial nerve and lesions development (drooping of eyelids leading to open eyes). Death usually occurs in 1 week.

Investigation:

Rapid immuno-fioresnece technique can detect antigen in corneal impression smears or skin blopsies.

Management:

A few patients have survived. All received PEP and intensive care with facilities to control cardiac and respiratory failure. Only palliative treatment is possible once symptoms have appeared. Diazipam 10 mg 4-6 hourly supplemented by chlorpromazinc 50-100 mg is necessary.

Nursing care, anti-biotic, symptomatic treatment, nutrition and fluid through IV or through gastrotony etc are given. Injection T. Toxiod is to be administered in order to prevent tetanus disease as the rabies dog bites anything clean or dirty. Every year 1.1 million people receive post exposer treatment in India.

Prevention:

Human diploid cell strain vaccine 1 ml over glutal region on 0, 3, 7, 14, 30 and 90 day.

Vaccines:

Injection Rabipen, Rabivax, Verorab-R, Rabies vaccine (HDC) etc are available.

Control of spread:

Human disease is a rare disease even in epidemic areas. However because, it is usually fatal, major efforts are directed to limiting to its spread and preventing its import into uninfected countries such as Britain.

Prevention of Rabies/animals:

All dogs should be vaccinated against Rabies at Veterinary hospitals, centres, dog care centres etc. Vaccine are available at Bharat Medicos, Paona Bazar, Imphal, Jaipur Medical Hall, Thangal Bazar Imphal. Dog Clinc/Care centres Konung Mamang, Imphal and Veterinary hospitals, Centres, Dog care centres in other districts too.

In Manipur according to 2002 census the dog population is 1.32 lakh and in India the dog population is around 25 million, most of them are not vaccinated against rabies.

Dr A.S.K. Felix a Specialist (PH) from Ukhrul, Manipur wrote this for The Sangai Express
This article was webcasted on May 15th, 2006

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