Since rabies cannot be cured, our emphasis should be on prevention and control-David Warrell


 Dr. David Warrell’ presentations at IMC Lahore

Since rabies cannot be cured, our emphasis
should be on prevention and control-David Warrell

Over 70% of Snake bite deaths in rural areas
in Asia are never recorded

LAHORE: Dr. David A. Warrell from University of Oxford was one of the distinguished speaker’s member of the Royal College of Physicians London delegation which visited Pakistan to participate in the International Medical Conference organized by RCP London in collaboration with Azra Naheed Medical College at Lahore from February 26-28th 2016. He made significant contributions to the scientific programme and two of his important presentations which were much more relevant to the situation in Asia were on Rabies and Snake Bite in South Asia.

Speaking about the epidemiology of Rabies Dr. David Warrell said that this virus comes from domestic dogs and other domestic animals. There are six rabies genotypes which are capable of infecting the humans.  Classic rabies virus is wide spread and lot of deaths due to rabies are reported from countries like Australia, India and Bangladesh. India recorded seventeen million cases of dog bites during 2015, eight million had post exposure courses and about thirteen thousand deaths were recorded due to rabies in one year. Its incubation period is from twenty to ninety days. He also talked about identifiable furious course of rabies deaths. It has lot of morbidity and mortality. Since it cannot be cured, our emphasis should be on prevention and control.

Photographed during the International Medial Conference organized by RCP London in collaboration with
AZNMC Lahore from (L to R) are Dr.Zahid, Peter Trewby, David A. Warrell,Prof. M.Akbar Chaudhry,
Dr. Masood Jawaid, Dr. Tanzeem Haider Raza, Dr. Fraz Mir and Mr. Shaukat Ali Jawaid.

Continuing Dr. David Warrell pointed out that recipients of corneal and solid organ grafts died due to rabies. Even doctors died due to miss-diagnosed neurological illnesses.  He discussed the pathogenesis of rabies in detail. He then showed slides of furiousrabies with hydrophobic spasm and paralytic rabies. Diagnosis is with rtPCR saliva and CSF. Virus isolation is from saliva and brain and cerebrospinal fluid during first week of illness. He also mentioned about immunofluorescence antigen (skin punch biopsy) and antibody response. Referring to a study he said that there were ten reported survivors of confirmed rabies encephalomyelitis. Seven had severe neurological sequelae, three had complete recovery.

Talking about primary post-exposureprophylaxis he suggested urgent thorough wound cleaning with soap, water, iodine and alcohol. Passive immunization rabies immunoglobulin’s RIG, infiltrate around wound except in most trivial exposures besides active immunization using tissue culture vaccine. It was suggested that rabies vaccine should be included in EPI programme in high endemic areas.  He also talked about reducing the cost of new generation rabies vaccines while maintaining full immunogenicity, induce rapid immunity especially when RIG is not available. Multi-site intra-dermal immunization has proved effective.In Pakistan, Indus Hospital at Karachi, he said uses the four dose regimen and it results in 80% cost reduction. Four intra dermal sites is less expensive. Give one ampoule on Day-1. Hospitalize and start looking after the rabies patients.  Immunize all dogs to control rabies in domestic animals particularly dogs.

He also referred to lack of awareness about rabies among doctors and public in Pakistan. People have limited access to modern cell culture and rabies vaccines. There is also lack of surveillance. There are very few diagnostic facilities besides inadequate resources and political support. In addition there is poor coordination between different government departments and local government. Quoting another study of rabies from Pakistan from Aga Khan University Hospital, he said that of the forty patients admitted with rabies encephalomyelitis, thirteen had received no vaccine. Sixteen patientshad received full course of sheep brain vaccine. Another eleven patientshad received anincomplete course of SBV and none had received RIG. In the Year 2010 ninety seven thousand cases of dog bites werereported by basic health units including thirty thousand in the city of Karachi alone. Vaccination of dogs is not yet implemented fully though some pilot project was planned some time ago. It is estimated that between two to five thousand people die every year due to rabies. In December 2015 NIH Islamabad stopped producing simpletype sheep brain vaccine. Now NIH imports this vaccine from China. Most non-governmentinstitutions are importing rabies vaccine from India. RIG is rarely available. Indus Hospital in Karachi provides full PEPusing intra-dermal regimen free of cost and during 2015 it treated four thousand cases of animal bites without rabies death. Under the supervision of Dr. Naseem Salahuddin an infectious disease specialist Indus Hospital has also trained seventy Emergency Room doctors, nurses and technicians. Control of Canine rabies, Dr. David Warrell opined was the most economical method for preventing human rabies.

Snake Bite in South Asia

Dr. David Warrell’s second presentation was on Snake Bite in South Asia. He pointed out that it was a neglected tropical disease. Reported deaths from snake bite are 75,000 in Asia, 20,000 in Africa, 4,000 in America and about fifty deaths in Europe annually. The tragedy was that almost 70% of the victims in rural area die and deaths outside hospitals are never recorded. Bangladesh has reported over six thousand deaths due to snake bite every year. National data about deaths due to snake bite in Pakistanis not available. However, various studies have reported estimated snake bites between 13,000-18,000 annually and estimate snake bite deaths could be about twenty thousand, hence it is a major public health problem. Incidence of snake bites increase in rainy seasons. Those who sleep on ground, work in the fields have highest risk and they can have early morning paralysis.  Bleeding, local swelling and necrosis, shock and coagulopathy were mentioned as some of the clinical features of snake bite.

Speaking about the recommended First Aid for snake bite victims he mentioned  reassurance of the patient, immobilization of whole body particularly the bitten limb, remove rings, bracelets and anklets from  limb, use pressure pads plus immobilization, rapid evacuation and refer to healthcare facilities. Prevent early death due to shock and respiratory problems besides avoiding harmful treatments.

As regards medical treatment, he suggested clinical assessment plus twenty minute whole blood clotting test, antivenom, and support for failing systems like circulatory, respiratory and renal. Treat bitten limb and rehabilitation restoring to normal functions. NIH in Islamabad produces antivenom vaccines while some is also imported form India. Sindh province had started antivenom project some time ago. Community educaiotn, Dr. David Warrell said was extremely important. It is essential to identify most dangerous areas, environment and times in the year. Other measures include promoting safe walking, working, using footwear, gloves, protect lower legs, carry light and stick after darkness. Do not sleep on the ground and use mosquito nets.

Dengue Fever

In the same session Prof. Javed Akram Vice chancellor of SZBMU from Islamabad who was also Convener of the conference spoke about Dengue a public health challenge. Dengue is now seen in over one hundred thirty counties of the world. Pakistan, he said, had an epidemic of dengue in 2011. It is estimated that there are about fifty million infections due to dengue and twenty two thousand deaths are due to dengue every year globally.  Most patients present with fever and rash. In Pakistan we had seen very complex cases of dengue, he remarked. For the first time the new guidelines on dengue has highlighted the importance of measuring fluids that we give.  Blood pressure goes down, intake remains the same and urine output increases. He laid emphasis on fluid management in dengue patients and said that efforts should be made that patients being managed should walk out of the ward after complete recovery rather than dying. How to confirm dengue in critical phase is a dilemma. Avoid shock and do not give platelets. Dengue patients usually die of complications and prolonged shock.

Dr. Somia Iqtidar’s presentation was also on Dengue Fever. Tracing the history she said that it was first reported in Philippines in 1953.  We had the biggest epidemic in Lahore in Punjab in 2011 with 22,000 confirmed cases and 375 deaths in seventy two days. Dengue was reported from six cities in Punjab and thirty six districts were affected. She then discussed in detail the diagnosis, management of dengue and its prevention. Almost 90% of these patients are asymptomatic, they complain of abdominal pain, fever and rash. She also spoke about clinical criteria for probable, suspected cases of dengue fever which had to be reported in the province of Punjab. Dengue Fever patients usually goes into shock. Treatment is symptomatic and fluids management. It is important to tell the patients of warning signs like persistent vomiting, bleeding, severe abdominal pain, giddiness. A strict fluid regimen is needed for these patients. One must avoid shock and overload of fluids. A dengue vaccine developed by Sanofi has now been approved, she added.

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