It happened in June this year: 45 year old Hameed was returning home from work at dusk. He had just got off the bus and turned into a dusty lane towards his house when he felt a gnaw in the calf of his right leg. As he turned round to look, he was face to face with a menacing dog that leapt at him. Hameed punched the dog which fell, got up and with bared teeth, dug its claws into his victim’s face. Hameed bled copiously from a cut lip, dabbed it with the end of his shirt and headed home. The dog disappeared into a side lane. At home his wife applied powdered red chillies into the leg and lip wounds and took him to a city hospital an hour away where the face and leg were washed. He was given an injection of rabies vaccine, tetanus and a prescription for an antibiotic. Next morning he had a swollen lip which improved over the next few days. He promptly forgot to get the remaining injections and continued on his daily work.
Six weeks to the day the man ran a fever, headache and began sweating. His throat hurt on swallowing. A local doctor recorded his blood pressure as “extremely high”, and sent him to a hospital. He was given pills to swallow, at which point he said he could not. He avoided the sight of water. His old aunt, watching him, cackled “you know, in my days we were told that a person who was bitten by a mad dog avoided drinking water.” And that is when Hameed realized the gravity of her ominous words.
That afternoon I got called to the ER at Indus Hospital to see this man with “suspected rabies”. The man had unmistakable hydrophobia and aerophobia and he was sweating profusely from every pore in his body into his soaked clothes. He told me himself in between spasms of his throat his misadventure with the vicious dog. The bite wounds were no more visible. Hameed was doomed to die, as indeed he did 4 hours later in an isolation room in our hospital.
Had his bite wounds been washed with soap and water immediately to remove the dog saliva, had he received rabies immune globulin (RIG) into the bite wounds and the vaccine series of 5 injections into the arm, Hameed would have been alive, taking care of his wife and five children.
Witnessing yet another horrific rabies death has only reaffirmed my determination that the message for rabies prevention will reach far and wide on World Rabies Day
Dr Naseem Salahuddin
Prof and Head, Dept of Infectious Diseases
The Indus Hospital, Karachi, Pakistan
President Rabies Asia (Pakistan Chapter)
She had boarded a bus in her village to journey 50 kilometers into the city, and hobbled another two to reach the Emergency Room at the Indus Hospital in Karachi where treatment is free. She was exhausted, her tongue was dry, her skin shriveled and the furrows on her forehead and cheeks were lined with sweat and dust. She held out her frail, trembling hand and in a hoarse whisper cried out to the nurse: “Son, I am tired. Please help me”. She held out her withered hand wrapped in a dirty piece of cloth. The nurse unraveled it and exposed a piece of flesh. Five days back a wild looking mangy dog had lunged at her and chewed up a piece of her forearm, leaving a gaping window into the bone.
The nurse washed the wound thoroughly with soap and water, injected Rabies immune globulin into it, and vaccine into the skin of her wasted arm and loosely covered the wound with a bandage. He advised her to return on subsequent days for the vaccine series. “Son, I must go back to my village. It is too far and I cannot come back. My girl is alone and I must feed her. May Allah bless you.” She shuffled away and disappeared into the crowd of waiting patients.
Several weeks later a young girl led the same woman into the ER. A dirty bandage hung over the wound. “My mother has a headache and she is confused. She wants to drink water but she can’t swallow. Doctor, you know a dog bit her arm last month”. The girl’s eyes held fear. I turned away from her to hide my repulsion at the death sentence. Inaccessible care near her home was the reason for her cruel fate.
This and other similar tales have taken decades of advocacy to reach the attention of Pakistan’s health authorities. At World Rabies Day 2012 it was announced that the government is opening ten rabies PEP centers in rural and urban locations in each province. The center for Master Trainers for the province of Sindh will be at the Indus Hospital in Karachi. Hopefully the centers should materialize by the end of the year so that dog bite victims will receive complete care in their own district and not have to travel distances. There is a dim light at the end of the tunnel
Dr Naseem Salahuddin
Prof and Head, Dept of Infectious Diseases
The Indus Hospital, Karachi, Pakistan
President Rabies Asia (Pakistan Chapter)
