Analysis of human rabies deaths reported at two hospitals in Karachi, Pakistan: a call to save lives by reforming rabies prevention facilities

BACKGROUND

Rabies is endemic in low- and middle-income countries. It is caused mainly by the bite of a rabid dog and is fatal if not treated effectively and in a timely manner with quality post-exposure prophylaxis. Despite a profusion of private and public healthcare centres in Sindh province, most are ill-equipped to treat dog bites.

METHODS

We analysed 129 human deaths from rabies who presented at the emergency departments of two tertiary care hospitals in Karachi over 10 y. Demographic data, time, location of the bite and distance travelled to report symptoms of rabies were recorded.

RESULTS

Most victims were male, and children were more often affected; almost none had received post-exposure prophylaxis. A total of 12% of bites were on the face, head or neck. The mean incubation period was 56 d. Most (60%) of the rabies victims travelled long distances, hoping to receive treatment.

CONCLUSIONS

Rabies deaths were either due to a lack of awareness or the non-availability of rabies immunobiologicals within easy reach. Public health services must raise awareness, conduct surveillance and provide appropriately spaced centres for free treatment of dog bites. This lethal disease must be prevented at all costs.

Rabies Vaccine and Rabies Immunoglobulin in Cambodia: Use and Obstacles to Use

BACKGROUND

Authorities have pledged to eliminate canine rabies by 2020 in Cambodia, a country with a very high rabies burden. Logistic and financial access to timely and adequate postexposure prophylaxis (PEP) is essential for preventing rabies in humans.

METHODS

We undertook a survey of the few identified sites where PEP rabies vaccination and rabies immunoglobulin (RIG) are available in Cambodia. We examined the Rabies Prevention Center at Institut Pasteur du Cambodge (rpc@ipc) database and rpc@ipc order forms for 2012 to assess vaccine and RIG use. We conducted a rapid internet survey of centers that provide rabies vaccine and RIG in Cambodia, other than rpc@ipc.

RESULTS

The cost of a full course of intramuscular or intradermal PEP in Cambodia, with and without RIG, was also estimated. Rabies vaccination is free of charge in one foundation hospital and is accessible for a fee at Institut Pasteur du Cambodge (IPC), some institutions, and some Cambodian private clinics. In 2012, 27,500 rabies vaccine doses (0.5 mL) and 591 equine RIG doses were used to provide intradermal PEP to 20,610 persons at rpc@ipc following animal bites. Outside of rpc@ipc, an estimated total of 53,400 vaccine doses and 200 RIG doses were used in Cambodia in 2012. The wholesale cost of full rabies PEP was estimated at 50% to 100% of a Cambodian farmer's monthly wage.

CONCLUSIONS

Local populations and travelers cannot be sure to locally access adequate and timely PEP due to high costs and low access to RIG. Travelers to high-endemic areas such as Cambodia are strongly encouraged to undergo pre-exposure vaccination or seek expert advice, as per World Health Organization (WHO) recommendations. State-subsidized, pre-positioned stocks of human vaccine and RIG in bite management centers would extend the rabies prevention centers network. Support from Institut Pasteur du Cambodge for staff training, cold chain, and quality control would contribute to reducing the risk of rabies deaths in Cambodia.