Rabies – a viral disease transmitted by animal bite – has had a effective vaccine for more than a century. Yet people continue to die from it. Rage kills almost everyone known to show clinical signs of itmaking it arguably one of the deadliest infectious diseases in the world.
Africa represents 36.4% of the 59,000 human rabies deaths each year. Rabies is endemic in Kenya and is estimated to cause 2,000 deaths a year.
The country is implementing a strategy end human deaths from rabies by 2030, starting with selected pilot counties and gradually expanding to the rest of the country.
Kenya’s rabies elimination strategy, launched in 2014, combines mass vaccination of dogs, rapid provision of rabies vaccines, public education and enhanced disease surveillance in animal and human populations. But, as in many other developing countries, progress is slow. Obstacles include the low level of political commitment, in part due to the no data on the true impact of the disease on public health.
In recent years, many countries have stepped up their rabies control efforts by stepping up mass dog vaccination programs. They also provided pre-exposure and post-exposure vaccines and educated communities about rabies. Most industrialized countries have eliminated rabies in domestic dog populations.
In addition to these interventions, an important aspect of eliminating rabies deaths is ensuring that health workers are aware of the disease and know what to do. In our recent study we set out to determine the levels of awareness of rabies and its management among healthcare workers in south-eastern Kenya, an area with high number of rabies cases.
We found that many were ill-prepared to diagnose the disease in all its forms. Less than a quarter knew the World Health Organization (WHO) bite categorization. Few of them knew the international guidelines on the use of post-exposure vaccines.
We have also seen stock-outs of effective vaccines and immunoglobulins.
Our study highlights the possibilities of adapting health care training programs – pre-employment and then continuing – for rabies elimination. The emphasis should be on prevention and control.
Man’s best friend, the domestic dog, is the primary source of human cases of rabies. After a risky bite, two critical steps must be taken quickly to prevent illness and death.
First, the wound should be thoroughly washed with clean running water and soap for at least 15 minutes.
It must be followed by an injection of rabies vaccine on the day of the bite.
Multiple injections over the course of a month should follow. In the event of a severe bite, the patient would need immunoglobulins in addition to the vaccine.
Reducing the risk of exposure to rabies depends on the type of treatment received in a healthcare facility. A person bitten by a dog carrying rabies is more likely to develop the disease if the wound is not cared for properly and if they do not receive the rabies vaccine (and immunoglobulin in the event of severe exposure). This may be due to a lack of awareness of bite management by health workers, the unavailability of rabies vaccines and immunoglobulins, or the availability of poor quality vaccines.
We visited 42 health facilities and interviewed 73 health workers. These included doctors, nurses, clinicians, pharmacists, pharmacy and laboratory technologists, and public health workers.
Many healthcare workers were unaware that encephalitis – inflammation of the brain – is a differential diagnosis for rabies. They therefore did not suspect rabies in patients with encephalitis. Less than a quarter of healthcare workers knew the WHO bite categorization that guides the use of post-exposure prophylaxis. One person in 12 said they knew the indication for rabies immunoglobulin.
In addition, healthcare professionals were not fully aware of the latest WHO recommendations on the appropriate treatment of patients with dog bites.
A good example is the route of administration of the vaccine. The WHO has recommended injection into the layers of the skin rather than injecting the vaccine into the muscles. By taking this dose-saving route, the healthcare system could serve up to five times as many bitten patients for the same amount of vaccine that treats one patient.
Thorough washing of wounds is also essential. But only a third of healthcare workers we spoke to said they would for some time. category two bite – when the animal chews exposed skin or the patient has one or more minor bites or scratches without bleeding.
For category 3 bites, in which for example the animal licks the broken skin or the patient presents with one or more bites, 43% of respondents said they would clean the wound.
Vaccine storage was another major issue. In our study, rabies vaccines were only available in 12% of the health facilities we visited, with stock-out periods of up to 28 weeks.
We found that none of the health facilities had rabies immunoglobulin in stock at the time of the study.
Tackling the problem
Controlling and eliminating rabies requires a concerted effort by government, the private sector and the community. By making the rabies vaccine available to humans and animals and raising awareness among health professionals and the community, Kenya can achieve the goal of ending human rabies deaths by 2030.
But deliberate efforts must be made. Most importantly, healthcare workers need to be fully informed of the latest best practices. Integration of mass vaccination of dogs, provision of rabies vaccines for humans, adoption of the latest WHO recommendations, risk assessment through information sharing between health and veterinarian and the continuous training of health workers on the proper management of bitten patients and human rabies cases, including diagnosis, are all critical for the elimination of rabies in Kenya.
No one should die of rabies. Not when there is a 100-year-old effective vaccine.
Veronicah Mbaire ChuchuPhD student, Department of Medical Microbiology, University of Nairobi; Mutono NyamaiPhD student, University of Nairobi; Philippe KitalaLecturer, Epidemiology and Public Health, University of Nairobiand Thumbi MwangiAssociate Professor, Washington State University