CAMBODIA: Rural poor most at risk from rabies

KAMPOT, 1 April 2011 (IRIN) - Yinn Siet, 65, recalls in horror when a snarling dog bit her husband four years ago. Before he died, the farmer hallucinated and convulsed. “He barked like a dog,” she said. “We put a chain on him and locked him up.”

He had contracted rabies, a virus that kills nearly all victims who develop symptoms.

Yinn could not afford to bring her husband to the capital Phnom Penh, the only city in Cambodia that has a centre offering free treatment.

Even if she had, it would have been too late.

He left behind his family of seven, who are struggling to make ends meet through farming.

Cambodians in the countryside have little access to treatment for rabies, a preventable disease that disproportionately affects the rural young and poor.

If dog-bite victims do not seek immediate treatment, they are likely to die. The virus is untreatable after symptoms appear, which can be anything from 10 days to a year after being bitten.

“The loss of a family member to rabies has a profound psychological impact on the family,” said Deborah Briggs, head of the Global Alliance for Rabies Control, a US-based NGO. “The disease is frightening and it is devastating to watch a loved one die.” In 2007, the most recent year data are available, 810 human rabies deaths may have occurred in Cambodia, says a study in Neglected Tropical Diseases, a science journal.

The number is only an estimate. Hundreds of cases in the countryside go unreported, because patients are rarely hospitalized and tend to die at home.

The estimated rabies mortality for 2007 exceeded that of malaria (240 deaths) and dengue fever (400 deaths), the study said.

The report concluded that free post-exposure prophylaxis, an injection after a bite that prevents infection, is really only relevant for residents of Phnom Penh. Injections must be administered promptly, usually within 10 days of an infection.

The Pasteur Institute, a non-profit medical research and treatment centre in Phnom Penh, is the only institution in Cambodia offering free post-exposure treatments.

The rural poor often cannot afford lengthy and expensive visits to the capital and therefore miss out on the free treatment.

“We see maybe five patients per year who arrive with symptoms,” says Philippe Buchy, head of the virology unit at the Pasteur Institute, “and the only thing we can do is to send them to Calmette Hospital where they will die after few days.”

The fact that poor people are most susceptible to rabies means campaigns against the virus tend to be given lower priority, said François-Xavier Meslin, the Geneva-based team leader for neglected zoonotic diseases at the World Health Organization (WHO).

Epidemiology

Warm-blooded mammals, mostly dogs, spread the virus through bites, scratches, and licks on open wounds.
Typically between 10 days and a year after exposure, patients experience insomnia, headaches, a fever, and twitching around their wound.

Two to 10 days after those first signs appear, they hallucinate, have seizures, become fearful at the sight of water and experience paralysis. Most rabies patients die from respiratory failure.

Each year, about 55,000 people around the world die from rabies. More than 80 percent of cases are in Asia, according to WHO, which says half of all human rabies deaths occur in children under 15.

“Every one of those deaths could have been prevented as we have the vaccines… available to save their lives before clinical signs begin,” Briggs told IRIN.

In Bali, Indonesia, authorities culled 100,000 dogs to prevent the spread of rabies by shooting poison blow darts at them, but the authorities halted this policy last September in favour of a mass inoculation programme of 400,000 dogs (70 percent of the island’s dog population).

WHO’s Meslin does not advocate killing dogs because it is “inhumane,” he told IRIN.

In Cambodia, the Pasteur Institute recommends setting up a national rabies control programme to improve disease surveillance and access to treatment. It also recommends starting vaccination campaigns for dogs.