We often talk about rabies in the context of high GDP countries, focusing on wildlife rabies and exposure during travel. However, in many parts of the world, exposure to canine rabies is an ever-present risk, and there can be substantial barriers to getting proper post-exposure prophylaxis (PEP) when needed. That’s part of the reason tens of thousands of people still die every year from canine rabies.
A recent paper in Clinical Case Reports (Audu et al. 2019) describes two cases of human rabies in Nigeria that highlight some of these challenges:
- The first person was a 40-year-old man who was bitten by a stray dog. The dog was killed by people in the community but not tested for rabies. He went to a local health clinic where he got a tetanus shot and antibiotics, but no rabies PEP because they didn’t have any. He was referred to another facility about 100 km away, but chose not to go. Rather, he tried a traditional treatment that involved eating the liver of the biting dog and putting hairs from the neck of the dog on the bite wounds. Two months later, he developed signs consistent with rabies and died.
- The second person owned a puppy that developed rabies. The puppy had bitten her and two neighbours and was confirmed as rabid after it died. Neither the puppy nor its dam had been vaccinated. The neighbours received PEP but the owner declined because of the cost. Five weeks later, she developed signs consistent with rabies and died.
These represent just two of the thousands of people who died of rabies in 2017, but their stories are not unique.
Getting people to go to a doctor after a dog bite is the first challenge, and education of the public is needed to make that happen. However, it doesn’t help if there is then no access to rabies PEP. Traditional treatments are sometimes used because there’s no alternative, but they are also sometimes used instead of available and highly effective conventional treatments. Vaccination of dogs is a useful rabies control tool but has limitations in areas where canine rabies is endemic and where feral dog populations are large. The target is vaccination of 70% of dogs, and groups such as Mission Rabies have done a lot to help hit that target. However, rabies will continue to circulate in many regions. Vaccinating pets, the animals that have the closest contact with people, is important but is not often done in some areas because of cost, failure to recognize the need and lack of access to vaccines.
Costs of seeking healthcare and rabies PEP can be a substantial barrier. In case 2, the cost was ~$68 USD (much less than the exorbitant $48000 that was recently charged to one woman in the US for rabies PEP), but even that was unaffordable to the victim.
The solution to the rabies epidemic isn’t straightforward. Education of the public, veterinarians and healthcare providers, improved healthcare access, reduced cost of treatment and more widespread vaccination of dogs are important but can be challenging. There’s no simple solution to the problem, but economic development (facilitating education, healthcare, transportation and drug access) is a big component. Barring that, education and vaccination efforts are critical.