ONE DOG AND TWO VICTIMS – A sad African tale

The Travel Doctor

Friday, 28 September was World Rabies Day.

The theme this year is: “Share the Message, Save a Life” and it is in the spirit of this message that we at Travel Doctor want to share the story of two of our clients.

A few weeks ago, we received a phone call from a remote game reserve in Zambia where a handful of people are doing amazing things for wildlife conservation. Each and every one of them are there because they care for the dwindling numbers of Africa’s biggest treasure and at the same time create work opportunities for the people who have the privilege and responsibility of their custody.

Late on a Friday afternoon we had a call on a very bad line: Two of the employees had been attacked by a stray dog from the adjoining village:

Lyssa relates: “At midday I drove back to our compound. On reaching the closed gate I noticed a stray dog from the village. There are always village dogs around so I thought nothing of it when I got out of the car to open the gate. I drove in only to find the dog had followed me in. That is when it attacked…”

The dog bit her on her leg, straight through her trousers. It then continued into the house of a colleague, running straight into the lounge where Iris, her young children and their ridgeback were home schooling. The dog attacked the ridgeback and in trying to separate the dogs, Iris sustained a bad bite to one hand and her leg. The dogs left the house fighting and then the stray ran away.

Lyssa: “Immediately afterwards, when Iris showed me her hand, my mind went to rabies and when she told me she hadn’t been vaccinated I realised we needed to get her to a hospital to start treatment as quickly as possible.  …It was only later that night that I realised that I too had been bitten badly as the dog had drawn blood, when I got into the shower.”

Unlike Iris, Lyssa had received rabies pre-exposure vaccination from a travel clinic. However, both of them needed post exposure treatment: Immediate, effective washing of the wounds with soap and running water and the application of a disinfectant with anti-viral properties, e.g. 60% alcohol or iodine; post exposure rabies vaccine and in the case of Iris, Human Rabies Immunoglobulin.

The women faced several immediate challenges, foremost, poor telephone communication and in addition, Iris continues: “The paperwork trail in Zambia to be issued with the drug – if it is available – is ridiculously long winded. We first went to a private clinic in the nearest town, who told us to the go to the district veterinarians office, who then told us to go to the district health office to get a form which we then had to take to the police to open a case – to get a case number, to then go back to the veterinarian to stamp and fill out the form. After the paperwork was completed the vet then referred us to a local clinic, but when we arrived the nurses told us that they didn’t have stock of the anti-rabies drug and referred us to the pharmacy in town. The pharmacy also didn’t have stock, so we went to the state hospital to be told they also didn’t have stock. In short there was not a single vial of the drug available in town. Our project financial accountant, in the meantime had been phoning around in the next town, several kilometres away, looking for the drug there. Somehow he managed to track the drug down there.”

It was only after receiving the first post-exposure vaccine that the women were alerted to the fact that the vaccine was from an unknown manufacturer, not registered in South Africa or any other developed country.  An even bigger concern was maintenance of the cold chain.

Lyssa recalls: “ The region has regular, erratic and extended power outages and the local clinic – where we found the drug – doesn’t have a generator….”

Rabies is universally deadly if not treated effectively within 48 hours of exposure to the virus, irrespective whether it is a bite (as they both had), a scratch or exposure of a mucous membrane.  (Eye or mouth)

The virus literally burrows into the victims nerve endings –  it does not spread in the blood circulation as other infective agents do –  and once the virus had migrated to the brain, the person becomes symptomatic and dies within  7 –  10 days. A slow, terrifying death, never losing consciousness until the end.

This process can be as short as a week if the bites occurred on the head or take several months if the bite occurred on an arm or leg.

Lyssa and Iris share their message: “ Prevention is better than cure and that you should always heed the advice of your travel doctor. Educating yourself on the risks associated with various diseases is very important, especially if you intend to live in a remote area for extended periods of time.”

In the absence of reliable vaccine and any Rabies Immunoglobulin, the women were flown back to Johannesburg the next day where both received rabies vaccine and Iris also received HRIG around the wounds on her hand and leg – a very painful and unpleasant process.

There was no need for HRIG for Lyssa as she had received a full course of pre-exposure rabies vaccine and only needed proper wound cleaning and post exposure rabies vaccine on Day 0 and 3. Iris has to receive a series of four post exposure vaccines on Day 0, 3, 7 and 28. This poses another logistical challenge as she is under pressure to return to Zambia for work and to take care of her family.

Their experience is in no way unique.  Travel Doctor deals with several similar cases a year.

Rabies kills ± 60 000 people a year, mostly in Africa, India, China and South East Asia. Although any warm blooded animal can carry and transmit rabies, by far the majority of rabies deaths in humans is due to exposure to domestic animals – mainly stray dogs. This is also true for rabies deaths in South Africa, of which we see a dozen or so a year –  12 too many and the majority in children.

There is good and bad news  –  as always in life:

The bad news is that rabies vaccine is in short supply globally  – also in South Africa.  It is an expensive vaccine and in addition, the only manufacturer of Human Rabies Immunoglobulin in (South) Africa is facing severe challenges in terms of the supply of antibodies from donors who had been vaccinated, support from the blood supply industry and political will to prioritise the production of HRIG and the vaccination of all domestic animals and strays. If there are no stray dogs and all dogs are vaccinated against rabies (is yours?)  then humans cannot get infected.

The good news is that the World Health Organisation (WHO) have approved a new pre-exposure vaccination regime, following great research done, amongst other places, on troops in the Belgian Armed Forces. Instead of three pre-exposure vaccines on Day 0, 7 and 28 one now only needs two vaccines, on Day 0 and 7.  In addition they could prove that a full intramuscular dose is not necessary  –  one fifth of the dose can be given in two places intradermal in one go, providing an equal or better immune response.

This new regime makes it more practical for “last minute adventurers” (Think upcoming year end 4*4 safari to Botswana, Zambia or further afield) to receive the vaccine timeously and cuts the cost of the vaccine by almost two thirds.

Who should NOT be vaccinated?

• Persons who live in glass houses or solitary confinement and who will NEVER have any contact with any animals (Including bats…)
• Any person who would not mind the fear, inconvenience and cost suffered by Lyssa and Iris
• Any person who is sure they will be able to source reliable, affordable rabies vaccine AND HRIG whenever they want it in an emergency

For the rest, have you been vaccinated yet?

Oh, and the dog? Like MILLIONS of other dogs in the world he lost his life –  millions to rabies and millions killed as suspect of carrying the devil in their saliva.  This dog was shot and killed shortly after the incident  –  and we will never know whether he was actually rabid….

For more information please visit the dedicated Rabies page.