Rabies in Myanmar

Street dogs are part of the social fabric of Myanmar. The local street pooch and his gang are usually known to the humans who live there, and is typically fed by residents who love animals or are collecting religious merit. People seem to have varying opinions as to whether stray dogs are menacing and mean, or cute and loveable.

But the human-canine relationship becomes problematic when dogs bite. Dog bites cause pain, infection and scarring, and since rabies is endemic in Myanmar, bites pose an additional threat with serious outcomes. While I tell my patients that you could be bitten by a dog every day and probably not get infected with rabies, the problem is that contracting the disease is always fatal.

Myanmar is classified by the World Health Organization as a “high rabies endemic country”. Myanmar’s Ministry of Health has estimated – though I assume it is a rough estimate – that 600,000 dog bites lead to 1000 cases of rabies annually. That would make us by far the highest-risk country in Southeast Asia.

While I wouldn’t characterise the public health impact of rabies to be on the same scale as hypertension or obesity, it is one of the few infectious diseases that Western medicine is able to offer a vaccine against. Therefore, doctors and public health officials do risk-benefit analyses to determine if and when to recommend the rabies vaccine to individuals and populations.

So what does the existence of rabies and the availability of protection against it mean for the person living in Myanmar who can afford to be vaccinated? There are plenty of stray dogs in Myanmar – a 2014 YCDC survey found there to be 70,000 in Yangon alone. There is also plenty of biting going on – in only three months earlier, this year Insein General Hospital treated 500 people with dog bites, and we regularly treat patients who have been bitten at my international outpatient clinic in Yangon.

So the first step is obviously to avoid being bitten. We didn’t have any classes on this in medical school, so the best I can advise is common sense: Try not to walk into a pack of dogs; stop or stand still if you get chased by a dog while walking or riding a motorbike; don’t pet or play with street dogs.

The next step is to consider vaccination. There are a variety of practical things you should know to make this decision. If you’re bitten by a dog and have not been vaccinated, then you need an immediate injection into the wound of a medicine called immunoglobulin. Unfortunately immunoglobulin is expensive – up to several thousand dollars depending on your weight – and in the past has occasionally been unavailable, meaning a flight to Bangkok or Singapore if you’re lucky enough to be in a demographic that has the ability to do so. Additionally, you will need five additional doses of medicine over the course of the following month.

The reason we go to these lengths to treat people, even though the great majority of dogs don’t actually have rabies, is because if you get the disease there is no cure: 99.9 percent of patients die, making it the most fatal disease I’m aware of.

For people who have been vaccinated before they are bitten, the treatment regimen is reduced to only two doses of medicine over three days. As a treating physician I breathe a sigh of relief when the patient tells me they’ve been vaccinated.

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, except for occasional soreness or redness at the injection site and a short fever or headache. An informal survey of the 100 or so people I’ve vaccinated over the last few years indicates very few negative reactions to the vaccine.

I ask parents to strongly consider vaccinating their children. Globally 40pc of dog bites happen to children between 5-15 years old, probably because, as children explore the world around them, they might follow or scare dogs in an attempt to play. Rabies vaccination for children is on the same schedule as adults and is safe after one year of age.

Rabies vaccines should be available at most international clinics and private hospitals. In those settings the cost tends to be around US$100-$150 for the three-dose course. Unfortunately this 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 or township medical office.

For a dog bite, or any deep wound in general, the important thing is to thoroughly wash the area straight away to remove as much of the viral and bacterial content as possible. Vigorous pressure spray with soap and water can be done with a syringe, if available, or by puncturing a small hole in the top of a water bottle and squeezing it as firmly as possible.

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. Last week I visited one of the international schools in Yangon and we vaccinated 37 teachers against rabies. Their reasons for participating seemed to vary from knowing someone who had been bitten in the city previously to being afraid of the possibility of a future injection into a wound to just appreciating the availability of vaccines to guard against disease. As always, send me an email or get further information from your doctor if you have questions.