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Introduction The WHO Expert consultation on rabies which met in Geneva from 5 to 8 October, 2004 pointed out that more than 99% of all human rabies deaths occur in the developing world and the disease has not been brought under control. Although effective and economic control measures are available, their application in developing countries is hampered by a wide range of economic, social and political factors. The number of deaths officially reported in most developing countries greatly underestimates the true incidence of the disease. Disparities in the affordability and accessibility of post exposure prophylaxis, levels of rabies awareness and risks of exposure to rabid dogs result in a skewed distribution of the disease burden across society. Under reporting leads to lack of attention by national authorities in much of African an.d Asian countries and by the international organizations concerned. Human mortality from endemic canine rabies was estimated to be 55,000 deaths per year (90% CI: 24,500-90,800) with 56% of deaths estimated to occur in Asia and 44% in Africa. (1) Rabies is endemic in India. It has been estimated that more than 30,000 people die of rabies in India every year. (2) More than 7,00,000 people receive anti rabies vaccine in India yearly. Dog population in India is estimated as over 16 million. The problem is very much immense. The majority (84%) of the deaths occur in rural areas. Deaths caused by rabies are responsible for 1.74(90% CI: 0.25-4.57) million DALYS lost each year. The psychological burden of the disease amounts to 32,385 DALYS in Africa and 139,893 DALYS lost in Asia. The estimated annual cost of rabies in Asia and Africa are US $563(90%: CI 520-605.8) million and US $ 20.5 (90% CI: 19.3-21.8) million respectively. The majority of all post exposure prophylaxis expenditures are borne by patients who can least afford to pay. In India patients pay for nearly half of the financial burden attributed to rabies (Data from APCRI). Case Profile A 60 year old female from low socio-economic class of district of Ganjam, Orissa sustained an unprovoked lacerated bite from a stray dog on 25 April, 2007 over left leg and reported to ARC of MKCG Medical College, Berhampur on 10 May, 2007.The dog with abnormal behaviour had been killed. The bite was a Category III exposure, as per WHO classification. The patient did not move to ARC instead she was taken for witch-craft to another village. After 3 days of bite she was taken to a quack. The quack administered 3 doses of modern tissue culture vaccine over gluteal area on Day 0, 3 and 7. The patient developed fever after 13 days of dog bite. She presented at ARC of MKCG Medical College Hospital with complaints of fever, pain and tingling sensation over site of bite for last 2 days. Her other complaints included pain over left lower limb for 2 days, inability to stand for 1 day and difficulty in swallowing solid foods and fluids for 1 day. On general examination the patient was conscious, febrile and apprehensive. Her vital parameters were as follows: (i) Pulse Rate-108 beats per minute (ii) BP-132/88 mm of Hg (iii) Respiration Rate-22 per minute. The patient did not show any features of aerophobia or hydrophobia. But there was marked paraesthesia and cellulitis around the site of bite. Of course she was administered 3 doses of tissue culture vaccine on DO (28 April), 03 (1 May), 07 (5 May) by the village quack but over the gluteal region. Neither rabies immunoglobulin was administered nor advised to the patient. The patient was diagnosed as a case of "Category III exposure following a Dog bite, and she was in the prodromal stage of clinical rabies". The patient was advised to do Rabies Antibody Estimation Assay but she could not afford it. She was advised to get admitted to the Infectious Disease Ward of MKCG Medical College Hospital but her attendants refused and took her back to home. On 11 May 2007 she was brought with features of both aerophobia and hydrophobia. The case succumbed to rabies in the early hours of 12 May 2007. Discussion In last 6 years (From 1st April 2001 to 31st March 2007) a total of 28,969 new cases of animal bites have been reported to ARC of MKCG Medical College Hospital with an average of 4828 cases yearly. Among them, 37 cases of clinical rabies have been registered. In last 6 years, on an average, 14 new cases of patients bitten by animals and seeking postexposure prophylaxis(PEP) against rabies, are registered daily. Out of the 37 cases of rabies, 30 cases (81 %) were due to bites from stray dogs. It is also observed that only 12.6% of the new cases seeking PEP against rabies have reported within 24 hours of exposure. Majority of the new cases (61.2%) have reported within 24 to 48 hours of exposure. Nearly two-third of the new cases (70%) took ERIG after due counseling to patients and their attendants. Low level of awareness, undue faith on traditional healers, late reporting, and unwillingness to come to ARC, allows these patients to get exposed to Rabies. In the above case in spite of potential exposure to a suspect rabid dog the relatives of the patient could not bring her to the nearest ARC at MKCG Medical College Hospital which is only 15 kilometres away from her village due to low level of awareness. Conclusion The case presented reveals the importance of creating an awareness among people about recognition of a potential fatal exposure and judicious administration of rabies biologicals. In developing countries the prevention of rabies is hindered not only by economic conditions but also because of inadequate access to health facilities, recent knowledge and the availability of modern biologicals. To reduce the cost of post-exposure treatment with cell culture vaccines WHO has recommended intra-dermal regimen with CCVs. ID regimens has been evaluated by WHO and recommended for use. Many trials have been done in India with satisfactory outcome of ID regimen and Drug Controller General of India has approved the use of ID regimen. Eradication of rabies from a country like India with abundant wild life may not be practicable. But prevention and control of rabies is feasible through awareness generation of public and health care personnels. ARV by Essen Regime should be injected over deltoid or antero-lateral aspect of thigh and not over gluteal area is an important point which should be disseminated among health care professionals. The other aspect is the advice and use of RIG. Low cost and effective ERIG which is now available in the pharmaceutical markets must be made more acceptable by the health care providers. The role of the manufacturing units of these products in creating awareness among health professionals needs to be highlighted. References
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