Rabies: Still a silent killer targeting the poor

Rabies: Still a silent killer targeting the poor

Vaccine xxx (2017) xxx–xxx Contents lists available at ScienceDirect Vaccine journal homepage: www.elsevier.com/locate/vaccine Commentary Rabies: ...

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Vaccine xxx (2017) xxx–xxx

Contents lists available at ScienceDirect

Vaccine journal homepage: www.elsevier.com/locate/vaccine

Commentary

Rabies: Still a silent killer targeting the poor Henry Wilde, Siriporn Ghai ⇑, Thiravat Hemachudha WHO Collaborating Centre for Research and Training on Viral Zoonoses, Faculty of Medicine, Chulalongkorn University, Bangkok, Thailand

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Article history: Received 8 September 2016 Received in revised form 28 February 2017 Accepted 1 March 2017 Available online xxxx Keywords: Human rabies deaths Access to rabies post exposure prophylaxis in developing countries Post exposure prophylaxis

The total number of reported human rabies deaths by WHO have been mostly estimates, varying between 40,000 to 60,000 human deaths annually over the past 3–4 decades. This is despite successes in virtually eliminating canine rabies from most developed countries [1–3], accomplished by dog population control, restricting movements of canines across borders, promotion of responsible pet ownership and sustained canine vaccination with potent rabies vaccines [2]. Post-exposure prophylaxis (PEP) for rabies exposed subjects, is also readily available in some more prosperous countries, and is often free or affordable [4]. We now have all the knowledge and tools to virtually eradicate this disease worldwide. Unfortunately, the majority of deaths are from unvaccinated dogs, and often in poor and remote regions, where PEP is not readily available nor affordable [1,5]. Rabies is not even a reportable disease in many less fortunate, endemic regions. This is particularly true for countries with unstable governments, or those harbouring civil strife [1–3]. Unvaccinated owned, stray, or community dogs are the major reservoirs and vectors of rabies worldwide. Vaccination of over 70% of dogs is required to control endemic canine rabies and, if successful, can result in virtual elimination of it in humans. Only undefined risks from wildlife, which often includes migrating bats, will remain [2]. However, rabies in wildlife reservoirs, especially terrestrial canids, contributes as continuous sources of spillover into free-roaming, unvaccinated dogs. Thus vaccination of wildlife ⇑ Corresponding author at: WHO Collaborating Centre for Research and Training on Viral Zoonoses, Faculty of Medicine, Chulalongkorn University, 1873 Rama IV Road, Pathumwan, Bangkok 10330, Thailand. E-mail addresses: [email protected] (H. Wilde), siriporn.ghai@gmail. com (S. Ghai), [email protected] (T. Hemachudha).

Ó 2017 Elsevier Ltd. All rights reserved.

should be considered, especially in some rabies-endemic countries. On the other hand, the number of human rabies cases caused by bats remains unknown, although lower than dog-mediated rabies, accurate data is not available. Most resource-limited countries do not have the facilities or funding to characterise the strain of virus to determine whether they are dog- or wildlife-derived. WHO has long advocated sustained canine rabies vaccination programs, and they have virtually eliminated this disease from many prosperous countries. But they have not reached most of the remote, poor, canine rabies endemic parts of the world. Lacks of motivation and funding have been major barriers. WHO has now delegated a badly needed worldwide dog vaccination effort to OIE (World Organisation for Animal Health) and FAO (Food and Agricultural Organization of the United Nations). During the WHO Rabies Global Conference in Geneva of 2015, the strategic vision was to achieve zero human deaths from dog-mediated rabies by 2030 in participating countries [3]. This is something we all hope for however, whether this can be achieved by that time is far from certain. Rabies is often not even diagnosed or reported in the less fortunate countries. It does not always present as the ‘‘furious” classical form known since antiquity. This is true for both humans and dogs, as approximately 20–30% have the paralytic form and atypical symptoms. Many forms of encephalitis and meningitis, including those common in the tropics and transmitted by mosquitoes and ticks, can present in dogs and man with similar symptoms as paralytic and atypical rabies [6]. Therefore, rabies can be difficult to diagnose using only observational and clinical data [2,4]. Traditional treatments with application of curry paste, or other local potions by a ‘‘healer”, is widely sought in many poor canine rabies

http://dx.doi.org/10.1016/j.vaccine.2017.03.001 0264-410X/Ó 2017 Elsevier Ltd. All rights reserved.

Please cite this article in press as: Wilde H et al. Rabies: Still a silent killer targeting the poor. Vaccine (2017), http://dx.doi.org/10.1016/j. vaccine.2017.03.001

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endemic countries. Human rabies deaths thus remains undiagnosed and are grossly underreported in poverty stricken countries with large canine rabies reservoirs [1,2]. Unknown number and distribution of human rabies deaths is caused by lack of education and inadequate numbers of locally accessible healthcare facilities that can provide PEP. Rapid cleansing and disinfecting of bite wounds, as well as rabies vaccination are the essentials of PEP administration. It can be locally provided, by training community healthcare staff and by supplying the needed biologicals (vaccines and immunoglobulin). Even when a biting dog is suspected of being rabid, PEP by wound cleansing and disinfection, followed by vaccination with modern rabies biologicals, may not be locally available in many, if not most, poverty stricken regions. Most human rabies deaths today are thought to occur in regions where PEP facilities are not locally available. Victims are often subsistence farmers, fishermen, and day labourers who cannot afford vaccines or the repeated travel costs to a distant animal bite centre where PEP can be provided. A recent publication from the Philippines of the 1839 reported human rabies deaths between 1987 and 2006, showed that none of them had received any PEP [5]. Similar data could likely be collected in many other poor canine rabies endemic regions of the world. Thailand, as a rabies endemic country, has managed to reduce annual human rabies deaths dramatically to less than 10 during the last decade [7]. This was accomplished by educating the public and healthcare staff, and making sure PEP was readily available, and free, throughout the entire country. This was achieved even though extensive sustained dog vaccination had not nearly reached the required 70%, and dogs still remain the major vector for this dreaded disease [8]. Provision of readily available and affordable PEP must be our priority. Expansion of PEP services to rural, highly endemic regions represents a difficult task, but must no longer be neglected. Current human rabies deaths are mostly occurring in communities with no facilities for PEP [1,5]. Regions that act as reservoirs of canine rabies are often the very ones which lack good governance, and extreme poverty. Worldwide eradication of canine rabies will therefore be a difficult task, not likely to be accomplished by the year 2030. We can no longer neglect provision of expansion of PEP facilities to where most current human rabies deaths come from. Further, in those areas, government and public sectors need to take the One Health approach, and collaboratively promote alertness and awareness of rabies and provide free pre- and postexposure prophylaxis. This has to go hand-in-hand with accelerated efforts of sustained dog vaccination.

Many countries are already expanding basic healthcare services to community nurses or trained sub-professional staff at the village level. Such services include primary care and stabilization of many common ailments, wound care, prenatal care, routine deliveries, infant vaccinations, treatment of uncomplicated communityacquired pneumonia, and many other services that are more complex than cleansing and disinfecting a dog bite, and providing rabies vaccination. Developing new rural facilities for PEP would require energetic encouragement by WHO, participation by local governments and, hopefully, an international non-governmental organization. It is time to focus rabies eradication efforts in remote regions, using a One Health approach, where all concerned parties, organisations, governments and funding bodies collaborate to eliminate human rabies deaths. Funding source disclosure This work received support from Chairman’s grant from the National Science and Technology Development Agency, Thailand, as well as Chulalongkorn University’s Faculty of Medicine and the Thai Red Cross Society. Conflict of interest The authors have no conflicts of interest to declare. References [1] Wilde H, Lumlertdacha B, Meslin FX, Ghai S, Hemachudha T. Worldwide rabies deaths prevention. Focus on the current inadequacies in postexposure prophylaxis of animal bite victims. Vaccine 2016;34(2):187–9. [2] WHO. Expert Consultation on Rabies. Technical Report Series 982. Geneva; 2012. [3] WHO. Global elimination of dog-mediated human rabies. WHO/HTM/NTD/NZD/ 2016.02. Geneva; 10–11 Dec 2015. [4] Hemachudha T, Ugolini G, Wacharapluesadee S, Sungkarat W, Shuangshoti S, Laothamatas J. Human rabies: neuropathogenesis, diagnosis, and management. Lancet Neurol 2013;12(5):498–513. http://dx.doi.org/10.1016/S1474. [5] Dimaano EM, Scholand SJ, Alera MT, Belandres DB. Clinical and epidemiological features of human rabies cases in the Philippines: a review from 1987 to 2006. Int J Infect Dis 2011;15(7):e495–9. [6] Mallewa M, Fooks AR, Banda D, Chikungwa P, Mankhambo L, Molyneux E, et al. Rabies encephalitis in malaria-endemic area, Malawi, Africa. Emerg Infect Dis 2007;13(1):136–9. [7] Department of Disease Control. Rabies situation in Thailand. Ministry of Public Health; 2014. [8] Wilde H, Hemachudha T, Wacharapluesadee S, Lumlertdacha B, Tepsumethanon V. Rabies in Asia: the classical zoonosis. Curr Top Microbiol Immunol 2013;365:185–203.

Please cite this article in press as: Wilde H et al. Rabies: Still a silent killer targeting the poor. Vaccine (2017), http://dx.doi.org/10.1016/j. vaccine.2017.03.001