Living Well in Myanmar

Should My Family and I Get the Rabies Vaccine?

Recently a friend of mine was walking in Lashio when he noticed a sudden tugging on his leg.  He looked down to find a dog attached to his extremity, inflicting a bite that went through his trousers and pierced his skin.  Of course he immediately began worrying about rabies, and since he hadn’t been vaccinated, started calling doctors to find out what to do.  Apparently the advice ranged from ‘do nothing’, to ‘go to Yangon for some shots’, to ‘go to Bangkok because the medicine we have here is not enough’.  He wound up flying to Thailand because the immunoglobulin injection that is the safest course of action for a dog bite (along with 5 doses of vaccine) was not immediately available in Lashio. 

Contrast that story to a 5-year old patient I had last week who was bitten by a street dog in front of his house.  He came into clinic with a fairly nasty set of wounds in his lower leg that we were able to wash out and dress.  Luckily his parents had planned ahead and he had been vaccinated against rabies.  All he needed was a dose of vaccine that day and then another 3 days later, and that medicine is typically available in Yangon. 

Despite some recent controversial efforts to reduce the street dog population in preparation for the SEA Games, their numbers are likely to remain strong across the country.  Exploring the city or country will involve exposure to street dogs for the foreseeable future.  And the dogs do bite.  In fact the doorman at my friend’s office claims a certain dog residing nearby has bitten over 40 people. 

Myanmar is classified by the World Health Organization as a ‘high rabies endemic country’.  The Myanmar Ministry of Health has made what I assume is a very rough estimate of 600,000 dog bites leading to 1000 cases of rabies annually.  That would make us by far the highest risk country in SE Asia.

The trouble with rabies is that the disease itself is always fatal – there is no cure.  Therefore we go to great lengths to prevent its onset.  This means recommending vaccination for anyone at risk, which is anyone living in Myanmar.  It also means giving injections to everyone with a dog bite even though the majority of dogs aren’t infected with rabies.

Getting vaccinated against rabies is straightforward and requires 3 shots into the upper arm over the course of a month.  The side effects are mild:  typically none, sometimes a soreness or redness at the injection site, and very occasionally a short fever or headache. 

It is difficult to know whether a street dog has rabies or not, so we avoid death by taking medicine immediately after the bite.  If the unfortunate recipient of the bite is lucky enough to have received the vaccine, she needs only 2 dose of medicine over 3 days.  If unvaccinated she needs 5+ doses over the course of a month, as well as an immediate injection of a second medicine called immunoglobulin directly into the wound.  Not only is the immunoglobulin expensive (US$150 to US$1000 depending on type), its availability in Yangon is sporadic, so may necessitate a trip to Singapore or Bangkok.

Children are considered to be higher risk of rabies because they have a greater chance of being bitten by dogs.  The global estimate is that 40% of dog bites happen in kids between 5-15 years old.  Presumably this is because as children explore the outside world they might chase or scare dogs in an attempt to play.  Rabies vaccination for children is on the same schedule as adults. 

At the moment in my Yangon clinic a full course of vaccine costs around US$120 (the vaccine seems to cost between $0-$100 in Europe depending on the country and upwards of $200 in USA/Canada).  In Yangon, rabies vaccination should be available at most international clinics and private hospitals.  Unfortunately the price point puts proper rabies prevention out of reach for the majority of the country.  The WHO has a protocol for a smaller dose of the same medicine to be injected under the skin rather than into a muscle, which can reduce the cost substantially.  Therefore anyone interested in rabies vaccination should discuss medication access with his or her local General Practitioner.

If you are unlucky enough to get bitten and have difficulty getting to a clinic quickly, the key thing to do at home is aggressively wash out the bite.  The goal is to mechanically clean rabies virus out of the wound.  You should do this vigorously with water or soap and water.  Sterile water that you shoot through a syringe is best, which is how we do it in clinic.  If possible, follow-up the irrigation with application of ethanol or iodine.  In rural areas I’ve made a small hole in the top of a water bottle so that when squeezed it shoots a high powered fast stream of water directly into a wound.

Making the decision to vaccinate against rabies ultimately depends on the individual’s appetite for risk and comfort level with the steps that would be necessary after a dog bite.   Because of the higher risk for kids, I recommend thinking three times before deciding not to vaccinate your children.  Always best to further consult with your doctor

gelsdorfMD@gmail.com  © Christoph Gelsdorf 2013