Record rabies outbreak kills 93 children

One of the most severe rabies epidemics to hit Angola has claimed the lives of at least 93 children within three months in the capital, Luanda.

"The 93 children were brought to our hospital and are the only ones we know of, so the number could be higher," said Luis Bernardino, head of the Hospital Pediátrico David Bernardino in Luanda, the country's biggest referral hospital. "The number of cases has, however, started declining now."

He said the hospital was unable to save any of the children, as it had run out of doses of rabies vaccine; in some instances the children were brought in too late. "It is a sad moment for us," said Bernardino.

Francois Meslin, the rabies expert at the World Health Organisation (WHO) headquarters in Geneva, said in the last severe rabies outbreak, from 1998 to 2003 in Indonesia's Flores Island, 100 people had died within a year. "The high number of deaths in Luanda within the short period of time is a cause for serious concern and calls for a thorough investigation."

Rabies is an incurable viral disease transmitted by close contact with saliva from infected animals, usually canines or rodents. It can be prevented by vaccination, either pre-exposure or as part of post-exposure treatment. However, once the symptoms of the disease develop it is fatal in both animals and humans.

The most common route of rabies transmission is the bite of rabid dogs, but the virus can also be transmitted by the saliva of an infected animal if it comes into contact with broken skin. Foxes, coyotes, wolves, jackals, cats, skunks, raccoons, mongooses, bats and other biting animals can also transmit the virus. The incubation period ranges from a few days to several years - most commonly three to eight weeks. Once exposed, WHO recommends Post-exposure prophylaxis (PEP), which could be a four- to five-dose regimen, and administration of rabies immunoglobulin in case of severe exposure, such as multiple bites in the head area. If an infected person does not receive medical attention before the symptoms develop, they will die within six days, usually because of respiratory paralysis. Rabies kills 55,000 people every year worldwide. According to WHO, due to the "complete absence of any successful medical treatment for clinical rabies and the horrific nature of the disease, most rabies victims die at home rather than being admitted to a hospital".

Post-exposure treatment comprises five doses of the vaccine and has to start "as soon as possible" to prevent the symptoms from developing, Meslin said.

The disease attacks the respiratory, gastrointestinal and or central nervous systems, leading to paralysis followed by coma and death in all cases, usually due to respiratory failure.

Slow reaction

Luanda's large stray dog population has been identified as causing the spread of the disease. "We have had some sporadic cases in other provincial capitals in the country; we think the virus was brought into Luanda and then spread through the dogs - Angolans love dogs," said Bernardino.

The capital was built to accommodate around 400,000 people but now has a population of more than 4.5 million, most of whom live in unhygienic conditions in "musseques" or slums.

The outbreak has raised concerns over the slow reaction of the Angolan authorities. "When the first 10 deaths were reported in December 2008 we alerted the authorities, but we do not have veterinary services in the city, no kennels [to keep and observe the animals] and vaccinate them," said Bernardino.

There were also not enough vaccines available. "I think it was probably that no one was prepared for such a high case load," he said. A vaccination campaign is underway.

"We now also have enough vaccines in stock. The cases have started dropping now - we have 12 cases in one week, it dropped to four cases, and this week it is down to three," Bernardino told IRIN.

Costs and shortages

Developing countries are often unable to afford rabies treatment, which is prohibitively expensive, said Melvin. "One dose costs about US$10 and five of those have to be administered, which makes the total cost of treatment $50, which is more than what a family can earn in a month in most developing countries."

Besides the vaccine, "in instances where the person has been heavily exposed - with multiple bites in the head," that person also has to be given rabies immunoglobulin to prevent death, which can cost another $50. "The treatment can be a huge drain on public health services, especially in countries where the vaccines are given free."

Melvin said there was a global shortage of the vaccines, "As there are few registered manufacturers who meet the WHO guidelines, the supply cannot keep up with the demand." At least 55,000 people die from rabies every year in Asia and Africa; most of the victims are children.

Polio outbreak

Besides the rabies outbreak, polio has also gripped densely populated Luanda and Benguela provinces. Sona Bari, a WHO spokeswoman, confirmed that 28 cases had been recorded in 2008 and another 1 so far this year.

Angola last experienced a polio outbreak in 1999, when more than 1,000 cases were recorded, but the number of cases had dropped to just 55 in 2000.

Bari noted that "If Angola were to fully implement the polio immunization campaign and pull out all stops, the disease can be eradicated in the country."

jk/he/oa