Rabies is deadly, but 99.9% vaccine-preventable. Children under 15 years in rural communities around the globe are at higher risk of being exposed to rabies. Controlling rabies widespread in endemic countries will largely depend on responsible dog owners, dog mass vaccination, awareness, and the appropriate administration of post-exposure prophylaxis (PEP) for bite victims. Garmie Voupawoe, a PhD student at Swiss TPH, talks about his research on rabies burden and control in Liberia.
Dogs are victims of rabies too
How did Charlie, once a friendly family pet, turn into a rabid dog that bit three family members? Charlie was a happy dog, and the children especially loved him. When they were not at school, they would spend the day playing around the house. Their bond was inseparable, but the rabies virus would soon break this bond. Like most dogs in resource-limited countries, Charlie roamed and interacted with stray dogs in the neighborhood. His interaction with stray dogs was dangerous and exposed him and the rest of the family to the disease. Currently, there are no treatment options available for infected individuals who show symptoms of rabies.
Facing the rabies in Charlie
Gradually, Charlie became rabid. He could no longer be a normal dog because he had fallen victim to the disease. One fateful Saturday morning, Charlie turned into a different animal, unrecognisable by his family. He became aggressive and bit the children he had played with for years. Before he bit the third person, the father, the neighborhood boys heard the screams of the children and came to the family’s rescue. The boys had no other choice but to kill the rabid dog with mortar pistils and rocks.
Getting and testing the sample
When the boys left to bury Charlie, they realised that they could sell his carcass at the dog meat market instead and make some money. This wasn’t going to be an easy task, as dog trade is usually done with live animals.
At the time, I was living in the neighborhood (about 200 meters away) where the incident occurred and was working as a laboratory technician on rabies diagnosis. I was on my way home when I met the group on their way to the market and overheard their plan. I knew the entire group because we had met at least once in the community. They explained to me what had happened and I was interested in the case. In Liberia, dog rabies is endemic and surveillance systems and disease control activities are still in the early phases.
However, rabies vaccination in humans has been documented since 1949, but following the civil-war and the devastating Ebola outbreak in 2014-2015, health care services and infrastructure were substantially weakened. A few studies have described rabies prevalence, the molecular characterisation of circulating rabies virus isolates and estimated post-exposure prophylaxis (PEP) demand based on dog bites. Based on this knowledge gap, we established rabies diagnosis in post-war Liberia to set the stage for improved and cost-minimized control programmes and prevention strategies.
I asked the boys if I could take the dog to run some tests. We needed to run these tests to find out if they were exposed to rabies or not. The incubation period for rabies is usually about 2-3 months, but may change from a week to a year, dependent on factors such as the bite location where the virus entered and the viral load. The first-aid measures include immediate and thorough washing of the wound with water and soap for a minimum of 15 minutes.
Depending on the severity of the contact with the suspected rabid animal, administration of a full PEP course is recommended. Based on their explanation, I suspected that it was a probable rabies case. I negotiated with the boys and bought the dog. After informing my boss, we raced to the laboratory in Fendall, Mount Barclay to run the tests.
The project “Multicentre and multinational assessment of the burden of rabies and vaccination impact in West and Central Africa” had established small-scale rabies control activities in Liberia in collaboration with the Central Veterinary Laboratory of Liberia where we could run the tests. Within 3 hours, the sample came back as positive for rabies (using both a RIDT and DFA tests).
The rapid immunochromatographic diagnostic tests (RIDTs) are based on the lateral flow principle, and the direct fluorescent antibody (DFA) test is an antibody-based protocol for detecting viral antigens.
We called the family and told them to seek medical treatment at the nearest health facility. But the man replied that he could not afford the cost of the vaccine for his family. This is always the case in resource-limited countries as the vaccine is often not available and when it was, the family could not afford the cost of PEP for four persons. So we contacted a colleague at the National Public Health Institute of Liberia responsible for PEP distribution to public hospitals. These vaccines were free of charge and meant for patients with probable rabies exposure.
Seeking treatment for the victims
We took the patients for treatment to the Redemption Hospital on Bushrod Island. When we arrived at the hospital, my boss and I instructed the patients to present the case to the nurses. As members of the rabies task force, we had received complaints of vaccine misappropriation at health facilities. We wanted to witness the situation first hand. But it was not long before the patients returned to us saying that there was no vaccine at the hospital. This is impossible. We hurriedly went to meet the nurses and presented the test result to them on the mobile phone.
In post-war Liberia, PEP administration to dog bite victims is based on the case history. So this was a unique case. It was an interesting moment for the nurses. One nurse called the other and they gathered to see the picture of the virus on the phone. After a little while, one of the nurses screamed from the back that there should be vaccines in the hospital's pharmacy! Give us a minute! Fast forward, thanks to the results, the patients received their first shots and were scheduled for the remaining treatment.
Was it the diagnostic result?
Until today, I still look back and appreciate the influence of the test result that saved those lives. Rabies is a public health burden on poor communities. Each year, an estimated 21,476 people die from rabies in Africa. Given that rural households are mostly affected, early diagnosis of the disease will prevent unnecessary death and the inappropriate use of PEP.
PhD student, Swiss TPH