Escaping Rabies’ Death Crawl: PH’s combat against the deadly disease

Posted on September 1, 2014 by Information Technology Department

Published in RITM Update Volume 1 Issue 2 (July to September 2014)

“Why am I tied down? Untie me. Before I die,” begs Rolando*.

Strapped to a steel hospital bed with his hands shaking, Rolando pleads as he forcefully tries to free himself from the thick white band tied around his waist.

He is confused. He doesn’t understand why he’s locked in a room behind bars, with his own son Marco* just watching him suffer.

On the other side of the bars, Marco holds back his tears. “I don’t know what to do with him anymore”, he silently utters.

Marco knows that this is the safest situation for his father to prevent him from harming himself and others around him. A few weeks earlier, Rolando was bitten by a dog. He did not seek treatment then, and a few days earlier, he started having fever, and his behavior changed.

Although extensive research has been done on rabies, scientists have not yet developed a cure once the virus reaches the human nervous system.

Rabies-free PH by 2020

Rabies continues to be a prevalent public health threat in the Philippines. The Philippines ranks among the highest in the world in terms of rabies prevalence. The Department of Health accounts that around 200 to 300 Filipinos die of rabies every year. The Philippine government aims to bring these figures down to zero. In 2007, the government passed the Anti-Rabies Act (RA 9482), a law that calls for the control and elimination of human and animal rabies. It mandated the creation of the National Rabies Prevention and Control Program (NRPCP), a multi-agency/multi-sector initiative that targets to eliminate human rabies by 2016, and declare a rabies-free Philippines by 2020.

The main component activities of this program are: (1) mass vaccination of dogs; (2) establishment of a central database system for registered and vaccinated dogs; (3) impounding field control and disposition of unregistered, stray and unvaccinated dogs; (4) information and education campaign on the prevention and control of rabies; (5) provision of pre-exposure treatment to high-risk personnel and Post Exposure Treatment to animal bite victims; (6) provision of free immunization or Pre-Exposure Prophylaxis of schoolchildren aged five to fourteen in areas where there is high incidence of rabies as well as the (7) encouragement of the practice of responsible pet ownership. The program also provides support services in the form of capacity-building.

Since the launch of the NRPCP, the number of deaths due to rabies has slowly dropped. From 257 deaths in 2010, it went down to 187 last year. The number of human rabies cases has also dropped by 27 percent from 2010 to 2013.

The rabies virus already reached Rolando’s brain. The doctors told Marco that they are 100% sure that his father will die.

‘Deadliest disease on Earth’

Rabies claims a person’s life every 10 minutes, according to the United States Centers for Disease Control and Prevention (CDC). Most of these death incidents happen in Asia and Africa with children aged below 15 years old comprising more than half of the deaths.

Rabies is a viral disease that attacks the central nervous system. It is transmitted to a person through a bite of an infected animal. All warmblooded mammals may carry the rabies virus, but dogs account for the most number of reported rabies cases. Other animals such as cats also contribute to the virus transmission.

Once a person is bitten by a rabid animal and the victim was not vaccinated, the rabies virus will travel from the site of the bite to the victim’s brain. As it reaches the human nervous system, it becomes 100% fatal.

As the rabies virus goes on a death crawl to the brain, the victim will feel the initial symptoms such as a high temperature of 38ºC, chills, fatigue, irritability, anxiety, and vomiting. After two to 10 days, more severe symptoms will start to manifest including aggressive behavior such as biting, excessive salivation, hallucination, hydrophobia, aerophobia, and muscles spasm.

When these symptoms start, death is fast approaching. Rabies is tagged by the Global Alliance for Rabies Control as the ‘deadliest disease on Earth’. Although extensive research has been done on rabies, scientists have not yet developed a cure once the virus reaches the human nervous system.

Rabies-free PH by 2020

The Philippine government aims to bring these figures down to zero. In 2007, the government passed the Anti-Rabies Act (RA 9482), a law that calls for the control and elimination of human and animal rabies. It mandated the creation of the National Rabies Prevention and Control Program (NRPCP), a multi-agency/multi-sector initiative that targets to eliminate human rabies by 2016, and declare a rabies-free Philippines by 2020.

RITM’s Role in Rabies Control and Elimination

The Research Institute for Tropical Medicine serves as a referral center for human rabies and animal bite management. Around 12,000 to 13,000 new animal bite patients are treated in the Institute annually, and it manages two to three severe human rabies cases every month.

Also, as the principal research arm of the Department of Health, RITM conducts research on rabies and provides results which can help improve NRPCP’s strategies for rabies control and elimination.

Laboratory confirmation of rabies is essential for a country desiring to eliminate rabies. It identifies current epidemiologic patterns of rabies and helps in the planning and monitoring of control programs. A study in RITM headed by Dr. Daria Manalo of RITM’s Veterinary Research Department, in partnership with the Japan National Institute of Infections Disease (NIID), aims to produce a local reagent for the Direct Rapid Immunohistochemical Test (DRIT), an alternative diagnostic test developed by the Center for Disease Control. The test is more rapid, simpler, and more cost-efficient than the direct fluorescent antibody test (dFAT), the gold standard and most frequently used diagnostic test for rabies.

According to Dr. Manalo, this alternative test is more applicable to developing countries like the Philippines. “There are only 19 laboratories in the Philippines that are capable of conducting laboratory confirmation of rabies in animals. Most local laboratories are not financially capable in conducting dFAT. As a result, animal rabies is underdiagnosed and underestimated in the country,” added Manalo.

Another study by Manalo and NIID seeks to provide an alternative specimen for rabies diagnosis (i.e. salivary gland) in cases that the brain sample is autolyzed, or if invasive procedure of getting a brain sample is not possible.

Meanwhile, another collaborative study by the the RITM-Tohoku University Research Center for Emerging and Re-emerging Infections aims to describe how rabies viruses circulate in the country through molecular epidemiology. Molecular epidemiology traces viral spread as documented in the viral genome; such study provides insights on the improvement of the mass dog vaccination strategies of NRPCP.

This molecular epidemiological study of rabies used samples from all over the Philippines to identify major clusters. The findings of the study suggest that a geographically targeted dog vaccination campaign may effectively control rabies in the country.

The Institute also conducts clinical researches that are directed towards evaluating new rabies biologicals and new vaccination regimens.

Ongoing clinical trials by Dr. Beatriz Quiambao, Dr. Rose Delos Reyes, Dr. Ma Cecilia Ama, and Dr. Cristina Ambas, in collaboration with different pharmaceutical institutions, aim to evaluate the safety, efficacy and immunogenicity of a new four-sites intradermal vaccine regimen for post-exposure prophylaxis (PEP) that can be completed within one week. PEP is required to ensure that an animal bite patient does not succumb to rabies.

The currently used intradermal regimen for PEP takes a month to complete and requires four visits to the clinic. RITM also provides laboratory diagnosis services. It is the only laboratory in the country that is capable of performing human rabies diagnosis and antibody analysis. It also assists in quality assurance of animal rabies diagnosis in Regional Animal Disease Diagnostic laboratory (RADDL).

Furthermore, RITM contributes to the capacity-building of the staff involved in rabies control and prevention. The Institute conducts quarterly trainings on rabies and animal bite management. It also conducts training on laboratory diagnosis of rabies for RADDLs and other local rabies laboratories.

A Continuing Combat

The combat with rabies is still far from over. But with these combined efforts from the government, private institutions, and the community, there is still hope that one day, rabies will be eliminated in the country – and that steel hospital bed that was once occupied by Rolando in the room behind bars, will be empty forever.