Fatal Bite

Immediate post-exposure treatment is crucial to preventing full-blown rabies infection

Worldwide, rabies posts a major health problem. More than 2.5 billion people live in areas where rabies is endemic. Globally, at least 50,000 cases per year are reported, a figure that is underestimated because many cases are unreported in some countries due to poor surveillance. Nearly all (99 percent) of rabies cases occur in Asia, Africa, and South America. Children five to 15 years old are considered the high-risk group. Each year, more than 10 million people receive treatment after being exposed to the virus or bitten, scratched, or licked by suspected rabies-infected animals (Weekly Epidemiological Record No. 14, 05 April 2002).

    Rabies persists in almost all islands in the Philippine. Dogs, the most common vector, cause more than 98 percent of rabies cases. Cats account for the rest. The latest WHO report ranked the Philippines fifth in the number of cases with 321 to 591 deaths per year (1992-2000 DoH data). In 2000, the Department of Health reported 353 deaths from 115,133 documented bite victims. Many more cases go unreported, especially in rural areas where people resort to "traditional medicinal practices" like "tandok," in which a horn is used to suck out the virus. Such practices have resulted in higher morbidity and mortality, as they only serve to delay proper medical treatment. Many rabid patients seek treatment when signs and symptoms of rabies have already set in to a point beyond medical intervention.

    There are two major animal bite centers where patients may seek treatment or get much-needed post-exposure treatment: the San Lazaro Hospital and the Research Institute for Tropical Medicine. Although DoH data show that Region III has the highest fatality rate from the infection with 86 deaths from 8,606 animal bite incidences, the National Capital Region reports the highest number of cases (20,042 with 14 progressing to rabies).

    Being a tertiary hospital and disease referral center, Philippine General Hospital catches a lot of animal bite victims. In the past, PGH could only provide first aid treatment (wound management) and refer the patients to either SLH or RITM for PET. Despite the evident demand, the country's largest government hospital for years had neither the facilities nor the training to handle animal-bite-cases. Data gathered from eight private hospitals near PGH showed that at least three cases weekly have been recorded for treatment.

    Aware of this shortcoming and the persistence of rabies, PGH a few years back decided to create its own Anti-Rabies Unit (ARU). "Imagine the premier hospital in the Philippines, where everybody sends their patients and the doctors don't even treat dog bite cases," exclaims Dr. Cecilia Sta. Cruz-Montalban of the Infectious Disease Section.

    The PGH Anti-Rabies Unit (ARU) is a product of almost three years of planning, objectives-setting, and intensive training for the unit's medical and nursing staff at the RITM. Housed at the second floor of the outpatient department, it was formally inaugurated last May 6. On its first day alone, Dr. Montalban relates that the unit was immediately besieged by 20 patients, attesting to the need for an additional animal bite center in Metro Manila.

    Prior to the opening, the hospital acquired purified vero cell rabies vaccine manufactured by Aventis Pasteur. The staff underwent training in cold chain storage to ensure the potency of the vaccine.

    Pointing out that "prevention is more important for there is no cure when the patient starts to have clinical manifestations of rabies," Dr. Montalban says one of the unit's objectives is to provide knowledge to the patient on how to apply first aid treatment for animal bite.

    In addition, the unit will serve as a training center for medical students and residents on the proper management of dog bites. Although ARU is open from 8:00 a.m. to 3:30 p.m. daily, the PGH emergency room is also equipped to handle dog bite cases.