ABSTRACT
Context:
Rabies is a fatal zoonotic disease that is endemic in India. Both forms of rabies, namely, encephalitic and furious, invariably lead to coma and death. Lack of awareness is the most critical barrier in accessing timely post-exposure prophylaxis that can prevent the progression to clinical disease.
Aims:
To report the case series of fourteen clinically suspected rabies cases.
Settings and Design:
We followed a retrospective study design. Data were collected from the Anti Rabies Section of Government Medical College, Jammu, which is a tertiary care hospital of Jammu Division.
Methods and Material:
We collected data of all patients over a period of three years, from 2017 to 2020, who were diagnosed as cases of clinically suspected rabies on the basis of classic signs and symptoms and who finally succumbed to the disease.
Statistical Analysis Used:
Descriptive statistics was used to describe the results of the study
Results:
In the present description, the mean age of the patients was 31 ± 18.6 years. Out of 14 suspected cases, 9 had not received any post-exposure prophylaxis—neither vaccine nor serum—and instead visited spiritual faith healers. The remaining patients had history of either incomplete, unknown, or incorrect vaccination status. Median duration of presentation of symptoms after dog bite was 42 days, with a range of 15–180 days. Mean survival of patients after presentation of symptoms was around 1.8 days
Conclusions:
Low level of awareness resulted in non-seeking of health-care services after animal bites.
Keywords: Dog bites, hydrophobia, rabies, rabies immunoglobulin, rabies vaccine
Introduction
Rabies, a dreaded neglected tropical disease (NTD), is an acute viral disease that is almost invariably fatal but 100% preventable. Regions where there is high risk of human infection are South (Nepal, India) and South East Asia, but regions with increased risk also exist in Africa, South America, and eastern Europe. The virus claims an estimated 59,000 (95% confidence intervals (CI): 25–159,000) human lives annually, mostly among underserved populations in Africa and Asia.[1] Over 95% of rabies deaths in humans result from virus transmission through the bites of infected dogs.[2] In 2015, WHO member states and key partners set a global goal to achieve zero human deaths from dog-transmitted rabies by 2030.[3]
Although rabies is notifiable in many countries, surveillance is often weak and official reporting of disease incidence in humans and animals remains inadequate and incomplete.[4] It is increasingly accepted that the available data underestimate the disease’s true incidence[5] and that in many cases the true quantitative burden of rabies is best displayed using estimates.
In India, dogs are responsible for about 97% of human rabies cases, followed by cats (2%), jackals, mongoose and others (1%). The incubation period in humans is generally between three and eight weeks but is highly variable and has been reported to vary from a few days to up to several years in rare cases. In animals, signs of rabies develop within four to seven days. Death is usually secondary to respiratory and cardiac failure.[6] Survival from rabies is rarely seen, with fewer than 20 adequately documented cases reported worldwide.[7] Rabies encephalitis has the highest fatality rate among infectious diseases, with the average interval from clinical disease onset to death being reported to be 5.7 days in furious rabies and 11 days in paralytic rabies.[8] The present study reports a case series of 14 clinically suspected rabies cases.
Subjects and Methods
We describe the case series of 14 clinically suspected cases of rabies, the patients of which either presented themselves or their relatives gave information about them in the Anti Rabies Section of Government Medical College, Jammu, from July 2017 to September 2020. Due permission to conduct the study was taken from the Institutional Ethics Committee, Government Medical College, Jammu.
Case Definition of a Suspected Rabies Case: Death of a human with history of dog bite few weeks or months preceding death.[9] Diagnosis of rabies was antemortem as post-mortem diagnosis was not possible in all cases.
Results
In the present description, mean age of patients was 31 ± 18.6 years. All patients were men except one who was a woman. All patients had history of WHO category III stray-dog bites except one case of pet-dog bite.
Out of 14 suspected cases, 9 had not received any post-exposure prophylaxis–neither vaccine nor serum–and instead had visited spiritual faith healers; the remaining patients had history of either incomplete, unknown, or incorrect vaccination status. Median duration of presentation of symptoms after dog bite was 42 days with a range of 15–180 days. Mean survival of patients after presentation of symptoms was around 1.8 days [Table 1].
Table 1.
Description of rabies cases
| Case No. | Age (years) | Sex | History of dog bite (days) | Survival after presentation of symptoms (days) |
|---|---|---|---|---|
| 1 | 6 | F | 37 | 1 |
| 2 | 55 | M | 26 | 2 |
| 3 | 14 | M | 75 | 3 |
| 4 | 13 | M | 30 | 2 |
| 5 | 35 | M | 39 | 1 |
| 6 | 35 | M | 15 | 3 |
| 7 | 32 | M | 45 | 3 |
| 8 | 49 | M | 150 | 1 |
| 9 | 13 | M | 90 | 2 |
| 10 | 12 | M | 60 | 2 |
| 11 | 55 | M | 30 | 2 |
| 12 | 52 | M | 90 | 2 |
| 13 | 50 | M | 24 | 1 |
| 14 | 14 | M | 180 | 1 |
Case series is described as follows.
Case no. 1
A six-year-old girl presented to the Anti Rabies Clinic on July 7, 2017, with history of WHO category III stray-dog bite on the right hand 37 days back. After the bite, the patient had not sought any medical help and instead had been taken to quacks in the local area where some religious rituals were performed. She had not received any anti-rabies vaccine or rabies immunoglobulin. At the time of presentation, the attendants reported that the patient had history of hydrophobia and aerophobia since few days. We also elicited the same signs. When she was offered a glass of water, she became aggressive and cried. Vitals were stable. She was admitted to the pediatric intensive care unit for critical care, where diazepam infusion and IV fluids were started for correction of fluids and electrolyte imbalance. However, the patient did not improve and died on the day of admission.
Case no. 2
The case came to our knowledge when we received a call from an associated hospital on August 21, 2017, to examine a male patient, aged 55 years, who had been admitted with history of stray-dog bite 26 days back. As post-exposure prophylaxis, he had received two doses of intramuscular vaccine from a nearby district hospital. However, other details of vaccine administration were not known. He presented with loss of consciousness and fever and grade II/III encephalopathy and aspiration pneumonitis. Hydrophobia and aerophobia were not present, as per attendants history. The patient did not respond to standard line of management in the intensive care unit and died two days after admission.
Case no. 3
Family members of a 14-year-old boy reported on September 22, 2017, for post-exposure prophylaxis in the Anti Rabies Section, Government Medical College, Jammu (GMC). They reported that the boy had a history of dog bite two-and-half months back on the chest. After the bite, he had neither received the rabies vaccine nor the rabies immunoglobulin. He also had a history of fever and signs of aerophobia and hydrophobia since a few days. He had succumbed on September 9, 2017. Since he had distributed sweets on Teachers’ Day, all of his friends and classmates had come to our hospital for post-exposure prophylaxis in apprehension.
Case no. 4
A 13-year-old boy reported on June 20, 2018 (Day 30) to the Anti Rabies Clinic with history of stray-dog bite on the left forearm. Category of the bite was III. The patient had received rabies vaccination from a private clinic, but the injections had been given in the gluteal region. Rabies immunoglobulin had not been not given. The patient had been showing signs of hydrophobia and aerophobia since two days. His vitals were stable. However, he was lethargic and drowsy. He was administered both the rabies vaccine and the serum here and was referred to pediatric emergency for symptomatic management. He died the next day. Later on,the family reported to the Anti Rabies Clinic for seeking post-exposure prophylaxis as they were in close contact with the patient.
Case no. 5
A 35-year-old man presented on Day 39 to the Anti Rabies Clinic with history of category III stray-dog bite on the forehead and bilateral thigh. He had received only four doses of intramuscular rabies vaccine from a government hospital. However, the site of injections was not known. He had not received any serum. He also consulted local spiritual faith healers. At the time of presentation, he was febrile (temperature of 100°F) and had altered sensorium. His vitals were stable. We elicited signs of hydrophobia and aerophobia. His attendants reported that he had a history of similar symptoms since five days. The patient was immediately referred to the intensive care unit for further management. He died on the day of admission.
Case no. 6
A 35-year-old man presented with apparent signs and symptoms of aerophobia, hydrophobia, fever, and fatigue since two to three days. He had visited a spiritual faith healer at a place famously known as Balley Bagh in Jammu city and had not received any post-exposure prophylaxis after stray-dog bite 15 days back. We started him on diazepam infusion and IV fluids and kept him in isolation in the intensive care unit. But the patient died the next day.
Case no. 7
A woman reported to the Anti Rabies Section after the death of her husband on July 21, 2018. According to the patient, her husband had been bitten by a stray dog one-and-half months back (from the date of death, that is, July, 10, 2018). She stated that her husband had gone to Balley Bagh for some spiritual treatment from faith healers and had not reported to any hospital nor had he received any post-exposure prophylaxis. Five days before death, he developed altered mental status, fever, and lethargy. Classic symptoms of rabies, like aerophobia and hydrophobia, developed three days before death.
Case no. 8
A 49-year-old male patient reported to us. He was referred from a nearby district hospital as a suspected case of rabies on September 27, 2018. According to the attendants of the patient, he had been bitten by a stray dog five months back. The patient had started developing symptoms three to four days ago before reporting to that district hospital. At presentation, the symptoms and signs were irrelevant talking, pain in the abdomen, vomiting, diarrhea, uncontrolled body movements, aerophobia, and hydrophobia.
The patient’s attendants did not give proper treatment history of the patient. No further information could be elicited from the patient as he was talking irrelevant. He was admitted to the intensive care unit for further management and died the same day.
Case no. 9
The mother of a deceased visited the Anti Rabies Section of GMC, Jammu, for post-exposure prophylaxis as her 13-year-old son had been bitten by a stray dog on the face about three months from the date of his death, which was October 22, 2018. After being bitten by the dog the patient had visited Balley Bagh for spiritual treatment but had not visited a hospital for treatment. He had not received any post-exposure prophylaxis from any health facility. According to his mother, he had been disoriented to time and person, and had a history of fever, lethargy, and fear of water and air around two days before his death. All the family members came for post-exposure prophylaxis in apprehension.
Case no. 10
Family members reported to the Anti Rabies Section of GMC, Jammu, for post-exposure prophylaxis after coming in contact with a rabies patient (son) who had been bitten by a suspected rabid stray dog while coming back from school. The patient had not received any treatment from any hospital but had instead gone to Balley Bagh for spiritual treatment. He was admitted at Paediatric Hospital Tertiary care hospital Jammu. As per hospital records, he had fever, headache, stomach pain, weakness in both legs, hydrophobia, and aerophobia for two days before his death. He had been given IV fluids and the disease had been managed as per protocol. He died on the day of admission.
Case no. 11
A 55-year-old man reported to the emergency wing of GMC, Jammu, on March 11, 2019, with a history of suspected stray rabid dog bite on the right hand one month back. He had received all doses of the rabies vaccine in the gluteal region. However, he had not received rabies immunoglobulin. The patient visited our hospital with chief complaints of shortness of breath, fever, lethargy, aerophobia, and hydrophobia since a few days. On examination, we found that he had left upper limb monoparesis. He was diagnosed as a suspected case of rabies with acute encephalitis. He went LAMA the next day, and the day after that, he died, as per the information received from attendants.
Case no. 12
A 52-year-old man reported to us on February, 5, 2019, with complaints of weakness, lethargy, aerophobia, and hydrophobia since two days. He had been bitten on the nose and neck area by a stray dog while walking on a road about three months back. At that time, he had visited the Anti Rabies Section of GMC, Jammu, for vaccination where he received rabies immunoglobulin and first dose of the rabies vaccine. But he did not turn up for subsequent doses. He was admitted to the intensive care unit for further management. No further information is available about the patient’s condition as the patient left the hospital the next day.
Case no. 13
A 50-year-old male patient reported to the Anti Rabies Section on May 29, 2019, on Day 24 of category III pet-dog bite on the right leg, right parietal region, and right thumb. The dog had killed by attendants. There was history of decreased appetite the day before. At the time of presentation, he was conscious and well alert but breathless. Symptoms of hydrophobia and aerophobia were also present. There was no history of fever, irritability, confusion, convulsion, and weakness. He had not received any rabies vaccine or rabies serum. Rather, he had visited some spiritual faith healers in Balley Bagh.
The patient was given appropriate post-exposure prophylaxis and was admitted to the intensive care unit of our hospital for further management. He died the next day, that is, on May 30, 2019.
Case no. 14
A 14-year-old boy presented to the Anti Rabies Section on May 29, 2019, with history of stray dog bite six months back on the left foot. Category of wound was III and the status of the dog was unknown. There was no history of previous animal bite/exposure, no history of previous rabies vaccine and rabies immunoglobulin administration. On examination, we found that the patient was conscious but disoriented and irritable. Signs of pallor, aerophobia, and hydrophobia were present. There was no history of convulsions and weakness. The patient was given appropriate post-exposure prophylaxis and admitted to the intensive care unit for further management. However, the patient died the same day.
Discussion
Rabies is one of the deadliest endemic zoonoses. The present case series describes dreadful deaths in patients of suspected rabies presented to us in the Anti Rabies Section of Government Medical College, Jammu. We reporte approximately 10,000 cases of animal bites annually under the National Rabies Control Programme. Identification of predisposing factors that lead to rabies can pave a way toward reduction of rabies deaths. In our study, the reason behind the higher number of male deaths could be their increased involvement in outdoor occupations and, hence, increased exposure. There has been an increase in man–animal contact, mainly due to outdoor occupations, especially among the rural poor. Children, especially small children, are also another vulnerable group as they have a habit of playing outdoors. They often play near them and share their food, which results in frequent bites. Our study paints a disappointing picture of a very low level of awareness among the public regarding severity of rabies, which lead them to approach spiritual faith healers rather than reporting to health facilities for immediate management. A similar picture was observed in another study.[10] Finally reporting late to the health-care facility after presentation of signs and symptoms of rabies. Mean survival of patients after presentation of symptoms was around 1.8 days. Clinical presentation of rabies is often variable and may actually represent a spectrum of signs and symptoms in different patients, as observed in our case series as well. In a study conducted by Fooks et al.,[7] the average time from the onset of symptoms to death was found to be 7.8 days in furious rabies and 11 days in paralytic rabies. We could not confirm the diagnosis of rabies by laboratory diagnosis as the mean survival of almost all admitted patients was only a day or two. The most probable reason for this could be their presentation to us at an advanced stage of the disease. Hydrophobia was the most characteristic symptom present in rabies patients and that was unlikely to be present in any other disease. Families of the deceased refused post-mortem diagnosis because of prevailing sociocultural customs. Two cases went LAMA and information about the remaining three patients came from attendants of the deceased.
Out of 14 suspected cases, 9 had not received any post-exposure prophylaxis—neither the vaccine nor the serum—and instead they had visited spiritual faith healers; the remaining had a history of either incomplete, unknown, or incorrect vaccination status. This finding corroborates with a study done in Bangladesh.[12] In our case series, no case had received a full course of post-exposure prophylaxis. This fact strongly emphasizes the need for increasing awareness among the public and among health professionals.
A strong surveillance and notification system needs to be put in place. As per the WHO, interrupting transmission of rabies is feasible through vaccination of dogs and prevention of dog bites. Failure to vaccinate dogs against rabies could constitute a considerable public health threat to both humans and animals. Maintaining vaccination rates of at least 80% in dogs is critical not only to protect pets but also to protect pet owners as well.[13] We also recommend strengthening health infrastructure, especially in rural areas, in terms of training and equipping health personnel with the rabies vaccine and serum to timely manage animal bite cases. Awareness of rabies prevention and control in communities, which includes education and information on responsible pet ownership, how to prevent dog bites, and immediate care measures after a bite. People, especially those living in remote areas, generally ignore dog bites and simply treat the wound by applying indigenous products such as hot peppers or turmeric. A multipronged, one health strategy involving all stakeholders, like the Department of Animal Husbandry, Wildlife, the municipal corporation, and state health and veterinary representatives, to share joint responsibility is the need of the hour to achieve the WHO goal of reducing the number of cases of dog-mediated human rabies to zero by 2030.
The findings of our study can provide valuable inputs to primary care physicians on how timely administration of post-exposure prophylaxis and appropriate wound management can be very crucial in the prevention of rabies deaths. Additionally, patients should be thoroughly counselled on the importance of completing the full course of post/pre-exposure prophylaxis, the risks of missing doses, and the importance of rabies immunoglobulin and appropriate wound management.
New Message from Manuscript: Although a completely preventable disease, rabies deaths still continue to occur, and all of them have been associated with preventable risk factors like lack of awareness in receiving timely post-exposure prophylaxis, inappropriate wound management, and visits to traditional faith healers. A big difference could be made through regular IEC (Information, Communication, and Education) activities to sensitize the community and health care professionals.
Key messages
Delay in seeking post-exposure prophylaxis is observed as a major factor responsible for morbidity and mortality
There is an urgent need to increase awareness regarding rabies prevention and control among masses through multi sectoral involvement.
Declaration of patient consent
The authors certify that they have obtained all appropriate patient consent forms. In the form the patient(s) has/have given his/her/their consent for his/her/their images and other clinical information to be reported in the journal. The patients understand that their names and initials will not be published and due efforts will be made to conceal their identity, but anonymity cannot be guaranteed.
Financial support and sponsorship
Nil.
Conflicts of interest
There are no conflicts of interest.
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