The Ugent Gap Between Prevention and Treatment for Rabies


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Promoting rabies control in dogs as a key strategy to control rabies in humans was endorsed by multiple partners, including governments and other stakeholders in rabies control. Rabies is widely distributed across the globe, with only a few countries (mainly islands and peninsulas) that are free of the disease.

Rabies is a neglected disease of poor and vulnerable communities. The major reason why it persists today is that rabies is a disease which often affects people whose deaths are not heard about or recorded. This tragic silence keeps decision-makers from understanding that resources aimed at eliminating human and dog rabies can and should be mobilized from the international community.

As a result, measures to avert human disease through the proper management of suspect rabid animal bites are not set up and activities for the control and ultimate elimination of dog rabies are not conducted. Canine rabies predominates in most of the developing world where the greater burden of human rabies also falls. It is estimated that approximately 50 000 people die from dog mediated rabies annually, mostly in Asia and Africa (WHO, 2005; Knobel et al., 2005). Human rabies deaths following contact with wildlife species, including bats, are rare compared with those caused by dog-transmitted rabies.

Generally, rabies is transmitted by saliva from infected animal bites but may also be transmitted by scratches, secretions that contaminate mucus membranes, aerosolized virus that enters the respiratory tract, and corneal transplants. Since 1980, most human cases in the United States have not involved obvious bite wounds, but rather, less direct mechanisms of transmission. Guidelines from the Centers for Disease Control and Prevention (CDC) for postexposure rabies prophylaxis for humans who have had contact with a bat (see “Prevention” section) have changed dramatically in the past few years, after it became obvious that rabies could be transmitted from bats to humans by relatively casual contact.

The rabies virus has a predilection for nerve tissue and spreads along peripheral nerves and possibly muscle fibers7 from the contact site to the central nervous system (CNS), causing encephalomyelitis. Initial symptoms are typical of a nonspecific viral syndrome, with fever, malaise, and headache, which progress to anxiety, agitation, and delirium. One clue for the clinician is tingling at the site of the bite during the first few days after contact, a consistent symptom of a rabid bite. The virus then spreads from the CNS throughout the peripheral nervous system, especially to highly innervated areas such as salivary glands. This causes hypersalivation—“frothing at the mouth”—and spasm of the pharyngeal muscles at the sound, sight, or taste of water leading to hydrophobia. The disease progresses inexorably to generalized nervous system failure and death.

Rabies is a uniformly fatal disease once clinical symptoms manifest. Only 6 documented cases exist of survival after onset of clinical rabies; all these patients had received either preexposure prophylaxis or expeditious postexposure prophylaxis after the rabid contact and before the patients had established clinical disease. Obviously, to consider the possibility of rabies at this stage requires a high index of suspicion and a thorough patient history. The remarkable bat-associated cases reported by the CDC during the past few years have shown that often a bat contact was missed because it was considered inconsequential by family or friends.

Rabies presents with 1 of 2 clinical features. Encephalitic (furious) rabies (80%-85% of cases) has the classic presentation with hydrophobia, pharyngeal spasms, and hyperactivity leading to paralysis, coma, and death. The paralytic form is much less common. Rabies progresses through 5 clinical stages with much variability, depending on extent of bites, amount of secretion encountered, and proximity to the CNS, ie, disease transmitted through bites close to the brain will progress faster than disease transmitted through bites on the lower extremities.

Incubation—ranges from 10 days to 1 year (average, 20-60 days).

Prodrome—occurs 2 to 10 days postexposure and lasts 1 day to 2 weeks. This stage is characterized by nonspecific flulike symptoms, including malaise, anorexia, irritability, low-grade fever, headache, nausea, vomiting; paresthesia, pain, or numbness may be present at the bite site.

Acute neurologic syndrome—occurs 2 to 7 days after onset of prodrome. This syndrome includes dysarthria, dysphagia, excessive salivation, diplopia, vertigo, nystagmus, restlessness, agitation, visual or auditory hallucinations, manic behavior alternating with lethargy, hydrophobia secondary to painful contractions of pharyngeal muscles, polyneuritis; hyperactive deep tendon reflexes with positive Babinski signs and nuchal rigidity often are present.

Coma—occurs 7 to 10 days after onset of acute neurologic syndrome. This stage is characterized by hydrophobia, prolonged apnea, and generalized flaccid paralysis that can intensify as in Guillain-Barré syndrome, seizures, and coma with ultimate respiratory and vascular collapse.

Death—may follow 2 to 3 days after onset of paralysis but may be delayed by life-support equipment. Recovery is rare.

Rabies can be diagnosed in humans before death by observation of virus-specific fluorescent material in skin biopsy specimens, isolation of the virus from patient saliva, or by the presence of antirabies antibodies in the serum or cerebrospinal fluid of patients who have not been immunized. Unfortunately, once the patient is symptomatic, use of antirabies vaccine or rabies immune globulin (RIG) does not improve prognosis, and treatment consists entirely of supportive care.

Rabies cannot be treated; therefore, efforts must be focused on preventing the disease. Disease-prevention measures are aimed at the animals that can transmit rabies or can include postexposure treatment of a person. The gap widely happened when people is not aware of prevention but they are more focusing on the treatment.

Meanwhile prevention is really important to treating and get rid away of rabies as soon as possible. The incidence of rabies in humans in the United States has decreased dramatically with the introduction of communitywide rabies immunization for domestic animals. Although most domestic animals in urban areas are immunized repeatedly, this is not always the case for all farm animals or for feral animals living on the fringes of domestic society.

Rabies-prevention measures are the responsibility of animal owners. Maintaining immunizations for domestic pets not only protects the pet but also provides some protection for pet owners and wild animals. Pets should be supervised so that they do not come into contact with wild animals. Communities maintain animal-control agencies to remove stray or wild animals to decrease the risk of disease. It is really important to make the pets get vaccinated to make the risk rabies lower than not doing anything at all.

How about if we travel and there is a lot of wild animals? Try to get the pre-exposure prophylaxis. Preexposure prophylactic immunization is recommended for people who are likely to be exposed to rabid animals. Veterinarians, animal handlers, and laboratory personnel should consider routine immunization. Also, people traveling to areas where dog rabies is endemic and who will not have easy access to medical care should consider immunization before traveling. We always forget to protect ourselves when we will go to travel.

It is creating the urgent gap between prevention and treatment because we always seeking for treatment rather than prevention. Sometimes, treatment can be too late and it is lead to fatal condition.

A person who was previously immunized and who has had a potential rabies exposure should receive 2 intramuscular doses of vaccine, the first dose as soon as possible after exposure and the other 3 days later. “Previously immunized” persons include those who received 1 of the vaccines according to recommended US schedules or those who had a documented adequate rabies antibody titer after other vaccination administration. RIG is unnecessary because of the anamnestic response in previously vaccinated persons. Routine serologic testing after booster vaccination is not recommended because of the uniformity of an antibody response.

We should really be aware of prevention and treatment when we are talking about rabies. We should make the gap closer by making both of things balance. Seeking for treatment is really important but don’t forget that doing prevention make everything going better in the end. For post exposure treatment we can do wound care. After an animal has bitten a person, the bite should be cleaned extensively with soap and water to help reduce the risk of bacterial infection. Povidone solutions or 70% alcohol may reduce viral transmission from a bite. Cosmetic repair of a bite wound should be assessed; however, closing a wound may increase the risk of bacterial infection.

In developing countries, immunization of domestic animals may not be current. Therefore, all bites should be considered potentially rabid, and treatment should be started immediately after any dog bite, whether the animal is domestic or wild. This also can be a reason why prevention of rabies is really necessary to do. It is really important to reach the balance between the prevention and treatment of rabies. Unfortunately, rabies virus is present in the wild animal population, and human exposure to this fatal disease cannot be eradicated. Current methods for preventing rabies both before and after potential rabies virus exposure are safe and readily available. Public health officials maintain up-to-date information about exposure risks and appropriate therapeutic measures.

If you still want to learn more about Rabies Vaccine and HRIG during your visit in Bali, you can go and contact Hydro Medical Bali. They will provide you the information that you needed for Rabies Vaccine and HRIG. Also, they will provide you the vaccine when you needed it with the handling of their professional health care. Hydro medical team will explain to you all of the things you need to know about rabies either it prevention, treatment or both things.