Rabies as a Major Zoonotic Disease in Nepal - How to Address the Problem

1. Introduction

• Large numbers of stray, unvaccinated dogs
• Poor awareness among rural communities
• Limited access to post-exposure prophylaxis (PEP) in remote areas
• Inadequate surveillance and reporting

2. Addressing the Problem of Rabies - A Comprehensive Approach

A. Animal Reservoir Control (Source Control)

1. Mass dog vaccination - The cornerstone of control. At least 70% coverage of the dog population is needed to interrupt transmission. Annual drives should be conducted.
2. Dog population management - Reducing the stray dog population through humane methods (e.g., Animal Birth Control - ABC programs) rather than culling, which is ineffective.
3. Registration and licensing of dogs to ensure accountability.
4. Oral rabies vaccination (ORV) - Bait vaccines placed in wildlife habitats to control sylvatic (wildlife) rabies where relevant.

B. Post-Exposure Prophylaxis (PEP) - Managing Exposed Humans

• Wash the wound immediately and thoroughly with soap and water for 15 minutes, or with a virucidal agent (povidone-iodine, alcohol).
• This alone significantly reduces viral load at the entry site.
• Do NOT suture the wound immediately.

• Rabies Immunoglobulin (RIG) - Human Rabies Immunoglobulin (HRIG) or Equine Anti-Rabies Serum (EARS/ERIG):
  • Injected into and around the wound site.
  • Provides immediate passive antibody protection while the vaccine generates active immunity.
  • Dose: HRIG 20 IU/kg body weight; ERIG 40 IU/kg body weight.

• Modern tissue culture vaccines are used: Human Diploid Cell Vaccine (HDCV) or Purified Vero Cell Rabies Vaccine (PVRV).
• Essen regimen: 5 doses on Days 0, 3, 7, 14, and 28 (IM).
• Zagreb regimen: 2-1-1 schedule (2 doses on Day 0, then 1 dose on Day 7 and Day 21).
• The slow incubation period of rabies (typically 20-90 days from bite) allows active immunity to develop in time to protect.

C. Pre-Exposure Prophylaxis (PrEP)

• 3 doses of HDCV or PVRV on Days 0, 7, and 21/28 (IM).
• Provides 2 years of protection; booster doses as needed based on serum neutralizing antibody titers.

D. Public Health and Awareness Measures

1. Health education - Educate communities, especially in rural Nepal, on:
   • First-aid wound management after bites
   • The importance of immediate medical attention
   • Not to abandon treatment partway through
2. Training of health workers - Paramedics, health assistants, and village health workers must know how to administer PEP and recognize rabies.
3. Strengthening surveillance - Establish a reliable reporting system for animal bites and human rabies cases.
4. School-based programs - Teach children how to safely interact with animals and what to do if bitten.

E. National Policy Level Measures (Nepal Context)

1. Strengthen response and capacity of health care providers for prevention and control of zoonoses.
2. Improve coordination among/between key stakeholders at different levels.
3. Reduce judicious use of tissue culture ARV/ASVS in hospitals/PHC/HP.
4. Provide tissue culture ARV as post-exposure treatment to all victims bitten by suspicious/rabid animals.
5. Reduce burden of zoonotic diseases through public awareness programs.

• Reduce the death rate due to rabies per annum
• Reduce the number of suspicious animal bites
• Ensure ARV is available at the primary health care level
• Train medical officers and paramedics on bite management

F. Vaccination of At-Risk Persons (Preemptive)

• Persons working with animals, in laboratories, or in endemic areas should receive pre-exposure prophylaxis.
• Monitoring of antibody titers every 2 years and booster doses when needed.

3. Summary Table

4. Prognosis

Key point for exams: The slow progression of rabies (incubation 20-90 days) is what makes post-exposure vaccination uniquely effective - there is enough time to mount active immunity before the virus reaches the brain.