KATHMANDU, March 29: One and a half months ago, Shyam Gautam (name changed), 33, of Makwanpur was bitten by a dog while he was walking on the road outside his house. Relatives advised him to get vaccinated against rabies but he did not care. After about six weeks, he began exhibiting symptoms of rabies. He experienced difficulty in swallowing water, developed a fear of the wind from a fan, complained of stomach pain, and started to feel anxious. His family then took him to Sukraraj Tropical and Infectious Disease Hospital in Teku. The doctor diagnosed rabies and admitted him to the ICU. He died less than three days later.

A four-year-old boy from Makwanpur, Shravan Shrestha (name changed), was bitten by a dog in his house in November. Parents took him to the nearest medical center. The doctor said that he should be vaccinated against rabies. In the mid of February, he was taken to Teku Hospital after showing symptoms of rabies. The hospital confirmed that it was rabies. He died within two days.

In the mid of March, Rajan KC (name changed), 38, of Lalitpur also died due to rabies. He was bitten by a stray dog a few months ago. He did not tell anyone about it nor did he take the rabies vaccine. He went to Teku Hospital only after having visible symptoms of rabies.

Nine people have died of rabies while undergoing treatment at the Teku hospital within one month (from the mid- February to mid- March) and 11 people have died in a period of six months since mid-October. According to the hospital, five of them died in the third week of March alone.

ICU in-charge Usha Devkota said that they do not have the exact data of death caused by rabies because some patients go to other hospitals or return home after visiting the specialized hospital in Teku. The zoonotic branch of the National Epidemiology and Disease Control Division reported 18 rabies-related deaths in the last fiscal year. However, this branch does not have comprehensive data from all regions of the country. International statistics indicate that approximately 100 individuals succumb to rabies annually in Nepal.

What is rabies?

Rabies infection is caused by the bite of animals such as dogs, foxes, monkeys, cats, and rats that have rabies. Rabies infection occurs when the rabies virus reaches the brain through the bloodstream.

A person infected with rabies initially has fever, a sensation of burning and tingling in the affected area. Gradually, the patient becomes agitated, afraid of water and air, breathing and circulatory system are obstructed, and subsequently dies. According to doctors, 100% of people infected with rabies die if vaccination is not taken on time. Treatment against rabies in Nepal started in 1987. Its vaccine was first administered in the stomach and later in the arm.

Control in developed countries, challenge in Nepal

Rabies, which was controlled two decades ago in some developed countries, is still a challenge in Nepal. Experts point out that many people die every year due to rabies in Nepal. Former head of the animal health branch Dr Sujan Rana said, “Rabies was brought under control in American and European countries two decades ago.”

He said that many countries have controlled rabies, which is usually transmitted from dogs to humans, but the situation is the same as before in Nepal, India, Pakistan and Africa. "Bhutan has also made significant progress by vaccinating all dogs against rabies," he said.

Sukraraj Tropical and Infectious Disease Hospital’s Research Branch Coordinator Dr Sher Bahadur Pun said that rabies, which has already been brought under control in developed countries, is causing hundreds of deaths in Nepal every year. "It is ironic that people die without getting vaccinated against rabies even when the Government of Nepal provides it free of charge," he said.

Nepal has set a goal of controlling rabies by 2030. If rabies occurs at the current rate, controlling it will be challenging, Dr Pun said.

Growing number of stray dogs, lack of public awareness about rabies

Doctors and health workers involved in treating rabies in Nepal say that cases of rabies are not thunder control due to the belief that 'rabies does not occur if a pet dog bites', 'rabies does not occur if there is a small wound'. 

"There is still a belief that rabies does not occur if bitten by a puppy," said Devkota, ICU in-charge of Teku Hospital. “It is seen that people do not come to get the rabies vaccine thinking that there is a small wound, and will heal on its own,” said Dr Pun.

Veterinarian Dr Rosika Shrestha said that recently, even cows and buffaloes get infected with rabies after being bitten by wild animals. According to Dr Pun, the people of remote areas are not aware that 'rabies is caused by a dog bite and death is inevitable’, hence, they do not seek medical help. 

Even when children hide the information about dog bites from their parents, they get rabies. In the experience of Devkota, the ICU in-charge of Teku Hospital, this infection occurs due to lack of correct information about rabies even among medical staff.

Veterinarian Dr Rana said that the main cause of rabies in Nepal is the growth of dogs and their lack of proper management. According to Rana, last year, the World Bank calculated the number of dogs per human population according to which it is estimated that there are 2.9 million dogs in Nepal. Fewer of these dogs are vaccinated against rabies. According to statistics, 200,000 rabies vaccines are produced in Nepal and 300,000 are imported from abroad. In this way, only 500,000 dogs in Nepal receive the rabies vaccine.

According to the zoonotic branch, 40,000 people are vaccinated against rabies every year in Nepal. According to this calculation, at least 40,000 people are bitten by dogs in Nepal every year. According to the treatment records at Teku, a total of 39,206 individuals have been bitten by dogs since mid-July. All of these individuals received vaccination as part of their treatment.

“Out of the total animal bites in Nepal, 75 percent of rabies is caused by dogs,” Dr Shrestha said, “The remaining 25 percent of rabies is caused by the bites of foxes, cats and other wild animals.” Veterinarians say that 70 percent of vaccinated dogs develop autoimmunity.

The first reason for the lack of rabies control in Nepal is the lack of proper management of community dogs, said Dr Rana. According to him, the number of stray dogs is increasing day by day due to garbage in the city. The practice of feeding dogs without managing meat waste has also increased the number of dogs around meat shops. The custom of giving leftovers to dogs in the villages has also caused dogs to gather in large numbers. He said that the number of dogs will decrease naturally if attention is paid to waste management.

Similarly, due to the lack of human resources, a sufficient number of rabies vaccines could not be administered, Dr Rana said. According to him, litter plays a major role in the growth of dogs. According to Rana, the main reason for the increase in dogs in Nepal is the lack of proper waste management.

“Due to the lack of neutering of dogs, the number of dogs in Nepal has increased,” Dr Rana said, “About 5,000 dogs are sterilized in Nepal every year. The rest is left as it is. In developed countries, dogs are managed only in homes, shelters and systematic dog breeding centers. Due to this policy, it seems possible to control rabies from dogs.”

In Nepal, policies and programs related to these three aspects are weak, Dr Rana said. According to medical professionals, there is a significant population of stray dogs that have not been taken in by the community or provided with proper housing. Furthermore, the community often neglects its responsibility towards community dogs, and some individuals fail to vaccinate their domestic dogs against rabies. Consequently, the prevalence of rabies infections has not decreased as expected. 

Dr Rana said, “While these dogs are referred to as community dogs, there is a lack of accountability regarding their vaccination and sterilization.”

 
• Rabies