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EDITORIALS: Derrick Pounder Avoiding rabies BMJ 2005; 331: 469-470 [Full text]

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Rapid Responses published:

throw some light

Naveed S Aziez   (2 September 2005)

Does Rabies Spread from Infected Human Being to Another Human Being?

ChidambaranGanapathy Ganapathy   (4 September 2005)

warning

dr mohan devegowda   (5 September 2005)

Rabies schedule

Charlie Easmon   (5 September 2005)

Old axiom:New way to live

Matiram Pun   (7 September 2005)

Lost opportunity to get the correct advice on rabies prevention to clinicians

Natasha S Crowcroft, Jill Morris, Jane Jones, Bill Reilly and David Brown   (7 September 2005)

Avoiding rabies: room for collaboration

Darryn Knobel, Sarah Cleaveland, Eric Févre, Kate Hamilton   (16 September 2005)

throw some light 2 September 2005
Naveed S Aziez, ER supervisor Aga Khan University Hospital,Karachi Send response to journal: Re: throw some light	Excellent and very informative. But sitting in the ER of a third world country one is exposed to this million dollar question every day, where to offer vaccination to every one is easier said then done,because of the prohibitive cost of the vaccine.On an average for a 60kg male the cost of vaccination would be around Rs.40,000 (USD 650) imagine this in a country with average earning of Rs.4000. (USD 70).In the end most of the patients I come across say that they would rather take their chance with the disease (which we all know is none) then have the vaccination. It would have been nice if the article would also have covered cat bites,which is also quite common. Of course I have also had to make decisions in cases of donkey's,camel,monkey and horse bites. Recently all the Karachi hospitals got together to formulate a common policy to agree to vaccinate or not to vaccinate in certain bites. Is there an internationally acceptable standard? Could someone comment on that. Competing interests: None declared
Does Rabies Spread from Infected Human Being to Another Human Being? 4 September 2005
ChidambaranGanapathy Ganapathy, Hon.Medical Officer,VHS,Chennai 600020 Send response to journal: Re: Does Rabies Spread from Infected Human Being to Another Human Being?	Sir, I wiil be gratefiul to the author if he can clear this doubt of whther there is man to man spread in Rabies? Thank You. DrChidambaran/03/09/05 Competing interests: None declared
warning 5 September 2005
dr mohan devegowda, GP 613 2nd main first stage indiranagar Bangalore 560038 Send response to journal: Re: warning	dear sir, We have a lot of stray dogs which were killed by the city civic body. But animal lovers really fought against this and have made a mess of rabies control in our city. In my General Practice I see 3 to 5 dogbite cases a month. Fortunately our government is providing the best vaccine in all the Government run hospitals. But I see many tourists particularly from the west playing with the street dogs -like fondling, feeding and contacting with saliva. They should be made aware of rabies in our country. And if possible they should have pre-exposure prophylaxis. And told if bitten they will recieve the best vaccine [including the immunoglobulin]. Vaccination should be made compulsory for all who visit our country. Competing interests: None declared
Rabies schedule 5 September 2005
Charlie Easmon, Doctor The Number ONe Health Group, 1 Harley Street, London W1G 9QD Send response to journal: Re: Rabies schedule	A good article but it should refer to the UK Green book guidelines on Rabies. A schedule of 0, 7 and 21-28 is recommended with boosters at 2-3 years. Competing interests: I run a travel health clinic
Old axiom:New way to live 7 September 2005
Matiram Pun, Medical Student Institute of Medicine, Kathmandu, Nepal Send response to journal: Re: Old axiom:New way to live	Nice coverage on Rabies; this is something very regularly seen in the Indian subcontinent, especially in summer and the rainy season more than in winter. Stray dogs, cats, monkeys, jackals and foxes are the main animals that bite human beings here in this region. The old axiom- Prevention is better than cure-is definitely better but it is only practiced by Western travellers and veterinarians. Since, the disease is dead-end in human being it is mandatory to take postexposure prophylaxis vaccine after the bite of the rabid animal. To leave wound open and let it bleed as well as washing in running water if possible with soap is the standard one after being bitten. Then the tetanus vaccine and postexposure prophylaxis vaccine immediately given. In Nepal, we still use sheep brain vaccine. For Westerners, vaccination before coming in these vulnerable region is highly recommended. For permanent residents, keep yourself away from these animals, take vaccine if you can afford it, have knowledge to recognize rabid dogs, cats and monkeys (especially pet ones) and last but not least go to hospital as soon as you are bitten even if animals are not suspected or do not show the symptoms of rabies. Competing interests: I have been bitten by a stray dog and took post-exposure prophylaxis vaccine five years ago.
Lost opportunity to get the correct advice on rabies prevention to clinicians 7 September 2005
Natasha S Crowcroft, Consultant in Public Health Medicine HPA Centre for Infections, 61 Colindale Avenue London NW9 5EQ, Jill Morris, Jane Jones, Bill Reilly and David Brown Send response to journal: Re: Lost opportunity to get the correct advice on rabies prevention to clinicians	Professor Pounder’s recent editorial (1) is a timely reminder of the potentially devastating consequences of exposure to rabies. However clinicians in the UK, who are key readers of the BMJ, will search his article in vain for the most authoritative sources of advice on rabies prevention, which are missing despite being readily available. These including the Department of Health’s Green Book (2) and Yellow Book (3), various websites (4,5,6,7) and through the public health departments at national and local level in the various countries of the UK which provide emergency advice for returning travellers who may have been exposed to rabies abroad. While post exposure regimes do vary throughout the world it is of concern that the editorial is at variance with advice in the UK, US and similar countries on post exposure prophylaxis. A 5-dose post-exposure vaccination course for the previously unvaccinated, not 4 doses, is recommended. The effectiveness of current recommendations is shown by the fact that there have been no cases of rabies in UK travellers who have received post-exposure prophylaxis. None of the very few cases of rabies that have occurred in UK travellers to rabies endemic countries in recent years received appropriate immediate post-exposure treatment, as illustrated by this recent case (8). UK clinicians who are trying to respond to the “medical urgency” of a patient with a potential rabies exposure need to know that they can obtain advice, vaccine and immunoglobulin from the Health Protection Agency Centre for Infections (020 8200 4400) or (020 8200 6868); Health Protection Scotland (0141 300 1100); and the Public Health Laboratory, Belfast City Hospital (028 9032 9241) in Northern Ireland. Similarly travel health advice for health professionals is available from various sources which are not mentioned in the Editorial, including Travax (6) and the National Travel Health Network and Centre (7). It is easy for those who are not involved in writing and implementing effective public health policy to make statements such as “get vaccinated prior to travel”. In the real world, rabies vaccines are expensive and unnecessary for most travellers. The most important measures are discussions about the risks of travel prior to departure and the measures that should be taken in case of possible exposure, and clinicians should follow authoritative guidance to determine when vaccination is recommended. It is also easy for those who are not involved in delivering a 24 hour public health service which supplies urgent vaccine and human rabies immunoglobulin for patients in the NHS to fail to appreciate the practicalities of delivering such a service and the importance of giving clinicians correct information and referring them to the correct sources for further advice (1,8). 1. Pounder D. Avoiding rabies. BMJ 2005;331:469-470 2. http://www.dh.gov.uk/assetRoot/04/11/09/70/04110970.pdf 3. http://www.archive.official-documents.co.uk/document/doh/hinfo/ 4. http://www.hpa.org.uk/infections/topics_az/rabies/menu.htm 5. http://www.hps.scot.nhs.uk/ 6. http://www.travax.scot.nhs.uk/ 7. http://www.nathnac.org/ 8. Solomon T, Marston D, Macpherson M, Felton T, Shaw S, McElhinney LM. Paralytic rabies after a two week holiday in India BMJ 2005;331:501-503 Competing interests: None declared
Avoiding rabies: room for collaboration 16 September 2005
Darryn Knobel, Research Fellow Alliance for Rabies Control, c/o Centre for Tropical Veterinary Medicine, University of Edinburgh, Sarah Cleaveland, Eric Févre, Kate Hamilton Send response to journal: Re: Avoiding rabies: room for collaboration	The responses posted to Professor Pounder’s succinct editorial highlight an insidious yet pervasive rift within public health bodies charged with the control of zoonotic diseases, a gap in the system into which rabies all too often falls. Rabies is a disease of significant human health concern in endemic countries, but it is on the principal reservoir host species, domestic dogs, that vaccination efforts must be focused if we are to achieve sustainable and, importantly, economically effective control of this pathogen. As Dr Aziez points out in his response ‘throw some light’, many patients in developing countries cannot afford effective post-exposure vaccination. Even where such vaccination is provided free of charge by the government (which in itself creates a substantial societal burden) out-of-pocket patient expenses such as transport and lodging can also be costly, particularly in those bite victims from remote rural areas. Subsidised post-exposure vaccination often extends only to the provision of cheaper but more dangerous nerve tissue vaccines (as in Nepal) or to the application of truncated vaccination regimens (as in Tanzania). Reduction of canine rabies incidence through the mass vaccination of dogs decreases the incidence of human bite injuries from suspect rabid dogs and results in a reduced demand for post-exposure vaccination (Cleaveland et al., 2003). It must be stressed that attempting to reduce dog populations through lethal control has never been shown to have an impact on the incidence of dog or human rabies cases (WHO 1992) or to halt the spread of epidemics (Windiyaningsih et al., 2004). The tools for canine rabies control through the mass vaccination of domestic dogs are well developed and effective where they have been deployed appropriately. But it will only be through the strengthening of partnerships between the medical and veterinary fields, both in the public and private sectors, that lasting control of this appalling disease will be achieved. References: Cleaveland, S., Kaare, M., Tiringa, P., Mlengeya, T. & Barrat, J. (2003). A dog rabies vaccination campaign in rural Africa: impact on the incidence of dog rabies and human dog-bite injuries. Vaccine 21: 1965- 1973. WHO (1992a). WHO Expert Committee on Rabies, 8th report. Technical Report Series no. 824, WHO, Geneva. Windiyaningsih, C., Wilde, H., Meslin, F.-X., Suroso, T., & Widarso, H.S. (2004). The rabies epidemic on Flores island, Indonesia (1998-2003). Journal of The Medical Association of Thailand 87: 1389-1393. Competing interests: The Alliance for Rabies Control (ARC) aims to alleviate the burden of rabies in developing countries, particularly those in Africa and Asia. www.rabiescontrol.org