Probable rabies in a child in a Bhutanese town bordering India, 2020

Human rabies encephalomyelitis in the background of rabies outbreak in animals in Gelephu, Bhutan, 2023: a case report

BACKGROUND

Rabies continues to pose significant public health challenges in many developing countries including Bhutan. A probable case of rabies was admitted to our hospital and its reporting led to the uncovering of an outbreak in domestic and wild animals. We discuss the challenges in the diagnosis and management of rabies in a resource-limited setting.

CASE PRESENTATION

A 35-year-old male presented with intermittent fever, bilateral lower limb weakness that was rapidly progressive, urinary incontinence with episodes of palpitations and sweating. He had sustained a Category III bite on the right lower thigh with four bite marks, inflicted by a stray dog. He had received post-exposure prophylaxis with intra-dermal anti-rabies vaccine. On initial examination, the patient was in distress but cooperative for the interview. He had pulse rate ranging from 60 to 100/min with episodes of diaphoresis and palpitations, but with normal capillary blood glucose. In the lower limb, the muscle power was zero with absent tendon reflexes in the lower limb and impaired abdominal reflex below T10 level. He had hyperaesthesia below T8, hydrophobia, aerophobia and photophobia. He had multiple spontaneous fasciculations in both the thighs and right deltoid and these later involved the intercostal muscles, neck and face muscles. He had altered sensorium and desaturation for which he required mechanical ventilation. Polymerase chain reaction for rabies virus was negative in cerebrospinal fluid and saliva. Rabies virus neutralizing antibody was negative in cerebrospinal fluid but had high titres in the serum. He received Human Rabies Immunoglobulin after admission. He was managed in the intensive care unit and died 23 days later. After this case was notified, a rapid response team was deployed in the field, and uncovered rabies outbreak in animals in the locality.

CONCLUSIONS

This case called for a serious evaluation of the country's efforts in achieving zero rabies deaths by 2030. The management of this case identified several critical areas of context-specific interventions in Bhutan. There is also an urgent need to improve diagnostic capabilities at the national reference laboratory and enhance the technical competencies of healthcare workers in the management of dog bite cases.

Rabies in a postpandemic world: resilient reservoirs, redoubtable riposte, recurrent roadblocks, and resolute recidivism

Rabies is an ancient disease. Two centuries since Pasteur, fundamental progress occurred in virology, vaccinology, and diagnostics-and an understanding of pathobiology and epizootiology of rabies in testament to One Health-before common terminological coinage. Prevention, control, selective elimination, and even the unthinkable-occasional treatment-of this zoonosis dawned by the twenty-first century. However, in contrast to smallpox and rinderpest, eradication is a wishful misnomer applied to rabies, particularly post-COVID-19 pandemic. Reasons are minion. Polyhostality encompasses bats and mesocarnivores, but other mammals represent a diverse spectrum of potential hosts. While rabies virus is the classical member of the genus, other species of lyssaviruses also cause the disease. Some reservoirs remain cryptic. Although global, this viral encephalitis is untreatable and often ignored. As with other neglected diseases, laboratory-based surveillance falls short of the notifiable ideal, especially in lower- and middle-income countries. Calculation of actual burden defaults to a flux within broad health economic models. Competing priorities, lack of defined, long-term international donors, and shrinking local champions challenge human prophylaxis and mass dog vaccination toward targets of 2030 for even canine rabies impacts. For prevention, all licensed vaccines are delivered to the individual, whether parenteral or oral-essentially 'one and done'. Exploiting mammalian social behaviors, future 'spreadable vaccines' might increase the proportion of immunized hosts per unit effort. However, the release of replication-competent, genetically modified organisms selectively engineered to spread intentionally throughout a population raises significant biological, ethical, and regulatory issues in need of broader, transdisciplinary discourse. How this rather curious idea will evolve toward actual unconventional prevention, control, or elimination in the near term remains debatable. In the interim, more precise terminology and realistic expectations serve as the norm for diverse, collective constituents to maintain progress in the field.

Knowledge, Attitude and Practices of rabies during an outbreak in Samtse Municipality, Bhutan: A cross-sectional study

Background

A rabies outbreak in dogs occurred on February 22, 2021, in the Samtse Municipality, Bhutan. A rapid response team (RRT) was activated comprising of human and animal health teams to investigate and contain this outbreak. An assessment of the knowledge, attitude, and practice (KAP) on rabies was elicited during this period to develop evidence-based education material.

Methods

A face-to-face KAP questionnaire was administered to a volunteer member of 55 households in two communities (Norbuling and Xing Workshop areas) following the rabies outbreak in the Samtse Municipality from March 15 to 22, 2021. Descriptive statistics were used to describe the demographic characteristics. The associations between the KAP scores were assessed using the Pearson correlation coefficient.

Results

Of the 55 respondents, 63.6% (35) had poor knowledge, 90.9% (50) and 63.6% (35) reported good attitude and practice toward rabies. Three (5.5%) participants had not heard about rabies. The other misconceptions were that rabies can be prevented with antibiotics (67.3%, 37), dressing the bite wounds (20.0%, 11), and seeking treatment from the local healer (5.5%, 3). Correct knowledge was reported on excessive salivation as the sign of the rabid animal (58.2% 32), rabies prevention through vaccination (81.8%, 45), and seeking medical care on the same day (94.5%, 52). Eighty-nine percent (49) vaccinated their dogs and domestic animals annually, 100% received post-exposure prophylaxis (PEP) after an animal bite, 78.2% (43) washed the animal bite wounds with soap and water, and 9.1% (5) would consult the local healer for animal bites. A majority (78.2%, 43) of them agreed that rabies is a serious public health problem in the Samtse Municipality and 49.1% (27) agreed that the public was adequately informed about rabies. A positive correlation was observed between the knowledge-practice scores (r = 0.3983, P value = 0.0026), and attitude-practice scores (r = 0.4684, P value < 0.001).

Conclusion

The poor knowledge of rabies in this study needs to be addressed urgently. The main misconceptions included were that rabies is not fatal, dressing animal bite wounds, and seeking dog and animal bite care from local healers. Health education should focus on these misconceptions.

The Impact of the First Year of the COVID-19 Pandemic on Canine Rabies Control Efforts: A Mixed-Methods Study of Observations About the Present and Lessons for the Future

Achieving zero human deaths from dog-mediated rabies has been set as a global target for 2030. However, the COVID-19 pandemic has disrupted essential health services across the world, with disproportionate impacts on Neglected Tropical Diseases. Through a mixed-method study using stakeholder questionnaires and in-depth interviews, we examined the scale and nature of disruption from the first year of the pandemic to rabies control programs, and reflected on lessons for the future. Study participants included practitioners and policymakers working in government, academia, international organizations, and the pharmaceutical industry across 48 countries, mainly in Africa and Asia. Mass dog vaccination, essential to rabies control, was most heavily impacted and in 2020, was carried out as planned in just 5% of surveyed countries. Access to post-exposure prophylaxis (PEP) also decreased due to fear of COVID-19 infection and difficulties in reaching health care centers. Dog vaccination and PEP delivery suffered from disruptions to the importation and distribution of vaccines. School closures affected rabies awareness activities and, when public events moved online, they could not reach the most disadvantaged groups. Surveillance, already weak, was severely disrupted by movement restrictions which, together with reduced demand for PEP, exacerbated under-reporting. Participants reported growing complaints around free-roaming dogs, with numbers likely to have increased in some settings. In some countries, dog rabies outbreaks and human rabies cases were already ascribed to the pandemic, but further impacts are likely still to be realized. Meanwhile, decreased demand for PEP from COVID-19 constraints could lead to reduced procurement in future. In the wake of post-COVID-19 demands on health services, there is an opportunity for veterinary services to show leadership in progressing the Zero by 30 agenda, particularly in scaling up mass dog vaccination within and across countries, as well as potential to make better use of community-based vaccinators. Countries must further secure stable procurement of dog and human vaccines, classifying them as essential goods prioritized for import and where needed, through sharing of stocks. Dedicated telemedicine services also show promise, for example through fostering participatory disease surveillance, including Integrated Bite Case Management, and delivering up-to-date instructions on the closest sources of PEP.