As the clock struck five in the evening, Umar was at his usual haunt: The neighbourhood park. The 12-year-old from Hyderabad was playing with his friends when a stray dog appeared out of nowhere. It was unusual to see a dog enter the gated premises, but the creature’s behaviour was even stranger.
When Umar first caught sight of it, the dog was circling around the park’s fence. An instant later, it turned and streaked straight for the playground, where the children were gathered. It took mere seconds for matters take a turn for the worst as the dog attacked Umar.
He screamed and tried to run, but it was too late. The animal was already on top of him. It clung to the boy’s arms, teeth sunk deep into flesh. A bystander broke its grip, and gave it a kick for good measure. But before it suddenly dropped dead, the dog had already bitten many other children in the park.
Umar was frightened and hurt. He had ugly wounds on his hands, upper arms, thighs, chest and back. His uncle arrived at the scene of the attack, and carried the boy to the hospital. The doctors washed Umar’s wounds with soap and water, injected a vaccine in his arms and covered it with gauze dressing. That – for the moment, at least – appeared to be sufficient. It was not, however, the end of the story.
Six weeks later, Umar was rushed to The Indus Hospital (TIH) in Karachi with symptoms indicative of a virus invasion of major proportions. He was burning with fever, his face flushed, and his breathing in fits and starts. He continued to have epileptic seizures, unable to speak or swallow.
Umar’s uncle began narrating the incident to the doctors with rising dread. He wanted to have the boy examined; it was his understanding that stray dogs were the main carriers of rabies. Somewhere deep inside, however, he maintained a glimmer of hope and wanted to hear an alternative diagnosis.
When Dr Naseem Salahuddin, Head of the Infectious Disease Department at TIH, saw the boy lying on the stretcher, she asked the only question that mattered: “Did they inject a medicine into the wound?”
Umar looked perplexed and answered in brief sentences, as his breathing steadied. “No, but I went back to the hospital in Hyderabad three more times to get the shots. They said I would be safe.”
The writing was on the wall: It was too late to administer any preventive measures. Umar attempted to drink water to quench his thirst, but choked immediately. “Please, doctor, help me get better,” he begged.
Some nurses present lowered their moist eyes, while others simply walked away to hide their tears. Dr Salahuddin composed herself and spoke to the boy’s family about the futility of further care. “We can only give him terminal care with heavy sedation to ease his suffering,” she said somberly. The doctor stroked the boy’s forehead and said all would be well. That night, Umar sank into a coma, and died.
The boy’s excruciating end served as the catalyst which would fuel Dr Salahuddin’s will to ensure that more people did not succumb to this deadly virus. The journey ahead for Dr Salahuddin and her handful of peers would prove to be an arduous one, but their efforts might finally begin to bear fruit.
Rabies is one of many diseases that is known to be of viral origin and is almost invariably fatal. It has taken its name from the Greek goddess of frenzy and rage; while its root word (rabere) means ‘to be mad’ in Latin.
The appearance of the first case of rabies is still undefined, but the virus was recorded as far back as 335 BCE by Aristotle in Historia Animalium. “We don’t know when and where any virus originated from,” Dr Salahuddin explains. “Back then, rabies was simply known as ‘Mad Dog Disease’. It was present in wild animals, mainly wolves and foxes. Dogs evolved from the same wild animals. So if a wolf or a fox bit another one, it would perpetuate its spread. It could even affect the entire wildlife population.”
Like encephalitis, which causes inflammation of the brain, it has a special affinity for the cells of the central nervous system. Unlike other viruses, the disease has a wide range of habitat and is able to exist and grow rapidly in any warm-blooded animal. Its causative agent is the rabies virus (RV), a member of the most mysterious form of life in the rhabdovirus family. The viruses are exceptionally small, infinitely abundant, and unable to grow or reproduce outside a living host — its means of transmission is its own.
The rabies virus infiltrates the host by way of a bite contaminated with the saliva of one of its carriers. Its bullet-like proteins hook onto a nearby nerve cell and treat the nervous system as a kind of freeway, jumping from cell to cell.
Rabies poses a threat to nearly three billion people worldwide, and kills more than 55,000 each year. There are almost 2,000-5,000 annual deaths in Pakistan alone. However, these are unverified and vaguely estimated numbers, provided over a decade ago by the National Institute of Health (NIH).
The incubation period (the interval between the exposure to an infection and its establishment in the brain) is primarily dependent on the depth of the wound, burden of virus, and its proximity to the brain. The period is typically one to three months, but can vary depending on the circumstances. Whether it spreads to the brain in one day or one year, the result is almost always the same: Rabies is a fatal disease, and recoveries are seldom heard of.
The symptoms of rabies are the same in all affected mammals, with only a few differences in humans and animals. Its earliest manifestations in humans begin with fever, followed by a tingling pain at the site of the wound — the first diagnostically significant indication of rabies.
From then on, the virus tightens its grip beyond release. It travels up to the brain and causes inflammation. This causes the muscles to stiffen, the nerves to become tense and rigid, and the mind to fray with tension and apprehension. The patient experiences a sense of approaching doom and worries endlessly for the time to come. The anxiety hastens into fear, before the patient experiences homicidal fury.
When the virus infiltrates the salivary glands, the patient collects saliva in the mouth and begins frothing. Cerebral irritation causes convulsions and epileptiform seizures. The anxious moments are followed by periods of calm, in which the patient attempts to drink water, but experiences an immediate contraction of muscles and chokes. After several repeated attempts to drink, the pain is so severe that despite intense thirst, even the sight of water brings on another attack. This is why rabies is also called “hydrophobia”. As a rule, death occurs within a few days due to respiratory failures.
According to Dr Salahuddin, there are only a handful of people who have recovered after developing the earliest symptoms of rabies in medical literature — and all of those were a result of bat bites. However, the first human to survive rabies without vaccination was a Wisconsin teenager who was bitten by a bat at a church service in September 2004. Weeks later, the critically-ill girl was admitted to a hospital with symptoms of full-blown rabies. She was sedated for weeks and given antiviral drugs after which she made a surprising recovery.
“Yes, the girl survived bat rabies in an isolated freak incident. But has anyone recovered from dog rabies without vaccination? No. Never,” Dr Salahuddin states.
When it comes to patients infected by rabies, the World Health Organisation (WHO) recommends treating them humanely, providing comfort, care and letting them pass in peace. “We receive patients who have acquired rabies, and perhaps, the most difficult part is communicating with the family,” Dr Salahuddin adds. “It is akin to passing a death sentence. Oftentimes, the families beg anxiously to save the patient. Nothing is more heartbreaking than that. There is no cure for rabies. There is only prevention.”
The key difference in the manifestation of rabies in humans and animals is that the latter bites in rage and fury. Dr Isma Gheewala, a senior veterinarian at Animal Care Center, breaks the virus down into two types: ‘Furious’ and ‘dumb’ rabies.
“A furious rabid animal will try to bite a rock, wire or literally anything it sees in its immediate surroundings.” Dr Gheewala has come across instances, mostly in Lahore, where the caged animals twisted and bent the rods of the cage in fits of rage. “The only way to prevent further harm to the animals – and the humans surrounding them – is to euthanise the animal.”
Animals with dumb rabies usually have a certain level of immunity against the virus, but still become a target due to a lapse in their vaccination cycle. In those cases, Dr Isma explains, the animal is unresponsive and numb. They are unable to swallow and their jaw is perpetually open. “A lot of times, owners panic and think something is lodged in the animal’s throat. They try to open the mouth to see what is stuck inside. The animal then bites them, and the virus is transmitted to the human.”
However, in early 2017, a woman from Punjab brought a small, fluffy dog to Dr Gheewala’s clinic. The dog had suddenly started displaying character imbalances. It looked quite normal from the outside, but would try to bite the owner every so often. Oddly enough, the dog was eating and drinking, which made the doctors think it was not rabies. Even stranger was the fact that on the third day of observation, the dog went round and round in circles, before it dropped dead. According to Dr Gheewala, this was an odd case of dumb rabies.
Although all animals are equally susceptive to its mysterious embrace, the rabies virus has its favoured circle of hosts. The virus is more commonly found in warm-blooded carnivores such as the fox, wolf, coyote, jackal, skunk, mongoose, cat and dog. Of these, the last – for reasons still unknown – has always been its preferred victim.
When Dr Salahuddin was touring Punjab in 2004, she came across a case in which a rabid dog bit a goat, the goat then bit a cow, and the cow went ‘mad’. It was eventually slaughtered to stop the further spread of the disease. She came across another case in which a rabid dog bit a sheep, which then bit the herdsman. “It can happen in cattle as well. It’s unusual as you won’t see it in the cities, but [these cases] can be found in rural areas, and loss of livestock affects their livelihood.”
Even though the absolute lethality of the disease is universally accepted, Umar’s story became the starting point in the development of a strategy of prevention in Pakistan. Something about the manner of his death and its unsettling implications prompted Dr Salahuddin to shift her gaze away from outdated methods and look squarely at the world around her.
She proceeded to challenge the first misconception, which was to get rid of stray dogs by mass culling. “A lot of people have turned up in anger, suggesting we shoot them all,” she says. “Well, our country has a rapidly rising population. Can you solve the problem by killing people?”
The latest incident of mass stray dog culling in Karachi occurred on May 3, 2017. The campaign to either shoot or poison stray dogs with impunity was backed by municipal authorities, but was condemned by animal rights activists for being cruel and inhumane.
But Dr Salahuddin had a plan. It was possible, she suggested, to adopt a humane approach and cover all aspects of eliminating the disease without causing an uproar among concerned groups. She offered a valid solution to eliminate the spread of the disease in animals through her pilot project – Rabies Free Karachi (RFK) – aimed at vaccinating dogs, controlling dog populations and creating public awareness on dog behaviour and rabies.
Launched at TIH on January 12, 2018, the project is a collaboration between WHO and the Karachi Metropolitan Corporation (KMC). Speaking on the urgency of the situation, Dr Salahuddin presented data on the number of dog bites and the feasibility of the project.
“Vaccinating 70 per cent of the dogs will eradicate rabies in an endemic area,” she addressed the audience. “In 2016, there were at least seven incidents in different parts of the city in which a single dog bit several people. The highest number of cases was reported from Korangi and Landhi (23), whereas 82 such cases were reported altogether in the city.” However, the large number of free roaming dogs can only be reduced by birth control.
Dr Sara Salman, head of WHO in Sindh, extended her support on behalf of her organisation, while Mayor Wasim Akhtar offered funds to set the project in motion. The session was brought to a close by Dr Naila Baig Ansari, chairperson of TIH’s research centre, followed by a visit to the site in Ibrahim Hyderi – the town worst hit by cases of rabies – where the RFK facility is located.
The place reeks of a smell that serves as a constant reminder of the fisheries nearby. On the extreme right is a 20-foot-long container, built solely for the purpose of neutering or spaying dogs. Inside the container are two operating tables with lamps and an IV drip stand. A cursory glance of the interior reveals the presence of medical supplies and instruments, vaccines, water supply line, autoclave, refrigerator, and a generator. Towards the extreme left of the facility, cages are lined up in an orderly fashion, where the dogs will be kept for a short period of time. After being labelled, they will be released into the community.
Following the inhumane methods of controlling the dog population, animal rights activist Zain Mustafa stepped in to work with RFK on a socially acceptable solution that was ethical in its approach. Mustafa was also the driving force behind the introduction of Sindh Welfare and Prevention of Cruelty to Animals Act 2017 — a law that aims to free animals from all kinds of abuse.
“We started this discussion last summer,” he says. “The previous law – Prevention of Cruelty to Animal Act, 1890 – still exists on paper, but has been lying dormant for years. There is no implementation whatsoever. The new law hopes to change that.”
Along with government officials and the Society for the Protection of Animal Rights (SPAR), Mustafa pushed for change and successfully revamped the law that now makes it illegal to kill, ill-treat, torture or abuse any animal.
By the same token, Mustafa adds, the relationship between the animal and human plays a significant role in the rising number of dog bites. Bites are not always triggered by rabid dogs. They are often provoked by dogs who are either defending themselves from potential aggressors or displaying territorial ownership of space. “It is extremely rare for a dog, of any nature, to attack humans without reason. Children throw stones at animals, and adults make loud, unpleasant noises to incite a reaction instead of minding their own business,” says Mustafa. “When this happens, the animal reacts, whether its rabid or not.”
Mustafa’s concession that animals need not be killed to eradicate rabies was finally taken seriously when SPAR proposed the Trap-Neuter-Return (TNR) programme as a core programme of their agenda which coincided perfectly with the RFK TIH programme. “Dogs will be picked up by trained dog catchers, spayed or neutered by trained veterinarians, and released to the communities where they belong.”
However, stray dogs are not socialised around humans, and catching them unawares might cause a certain degree of stress. “There are two aspects to the TNR programme: Vaccination and sterilisation,” explains Daniel Stewart, a senior animal behaviourist from South Africa. “When we catch the dogs, we vaccinate and release them in the shortest time span, which reduces the stress period in the dog’s life.” According to him, training the personnel is also of paramount importance, as the method involves risk to humans too.
The second leg of Dr Salahuddin’s journey was to propose a preventive technique and, less acutely, an antidote and course of treatment. Originally, the vaccine invented to treat rabies was derived from animal nerve or brain tissue: The so-called nerve tissue vaccine (NTV). The first reported case of recovery with an NTV was in 1885 when French biologist Louis Pasteur successfully treated a young boy severely bitten by a rabid dog with a series of vaccinations derived from the brain of rabid sheep and goats.
“The vaccine relied, at first, on the growth of rabies in the brain of sheep or goats,” explains Dr Salahuddin. “When the animal developed symptoms of the disease, they would kill it, take out the brain, elute it, and run a standard process. They would then put it in 10 milliliter vials.”
While generally considered effective in the past, NTV is now seen as risky. It causes several side effects, including allergic reactions and paralysis, is unpleasantly long, and – above all – dangerous. It has, in an uncomfortably high number of cases, proven to be fatal. It is for this reason that WHO does not recommend the use and production of NTV for rabies. However, the vaccine is still used in a few countries in Africa and Asia. Until 2016, it was still in use in Pakistan.
“I spoke to the then NIH director and asked when Pakistan was going to move ahead,” says Dr Salahuddin. “The gentleman said that that this is what we can afford for the poor, since the modern vaccine was too expensive for them. His answer didn’t sit well with me.”
She conceived the idea of propagating the modern cell culture vaccine in Pakistan at a time when even India and Bangladesh had adopted newer methods. The modified vaccines – embryonated duck egg-based vaccine (DEV), purified chick embryo cell culture vaccine (PCEC), and purified vero cell vaccine (PVRV) – had better safety profiles, reduced dosing schedules and minimal side effects. “The only problem was that it was expensive, but at least it was saving a person’s life,” she adds.
For nearly 20 years, she kept writing and protesting against SBV and promoting modern cell culture vaccines. After a lot of haranguing, NIH finally put an end to NTVs in January 2016. At a South Asian Association for Regional Cooperation conference in September 2017, it was announced that Pakistan was the last country to discontinue NTVs. There was a loud cheer in response.
The final, and most important, part of Dr Salahuddin’s journey was to push forward the implementation of WHO-recommended Post-Exposure Prophylaxis (PEP) — a method of neutralising and destroying the virus immediately following exposure. It was possible, she suggested, to immunise a human against rabies – not only before – but after exposure to the disease, if the step was undertaken promptly.
One afternoon in June 2008, a man in his 50s was admitted to TIH. He was taking a stroll on the sidewalks of Club Road in Karachi when a dog suddenly jumped on his feet and bit his finger without warning or provocation. The wound did not appear to be particularly nasty, but it was obvious that he needed medical attention. The staff at Jinnah Postgraduate Medical Centre (JPMC) gave him the vaccine and thought it was enough to merely clean, close and properly dress the wound. But what was missing was the all-important immunoglobulin medicine — antibodies which enable the immune system to neutralise bacteria and viruses.
“Immunoglobulin must be given at the same time as the vaccine,” explains Dr Salahuddin. “If you give the vaccine and wait a week to administer the immunoglobulin, it’s going to deform the formation of antibodies. There’s a lot of negligence in this regard.” Unfortunately, the vaccine and RIG have to be imported, and there are many roadblocks which cause shortfalls in obtaining these life-saving medicines. “The government must enable these imports” she says.
The dreaded disease against which all therapeutic measures have nearly failed has only one remedy: Timely immunisation through PEP. “It takes almost two weeks for the body to build up a certain level of antibodies to protect itself. Doctors should learn to immediately administer RIG to kill the virus at site,” says Dr Salahuddin. Unfortunately, most centres in Pakistan do not administer RIG.
The risk of human exposure to rabies in developed countries is small because of mandatory vaccination of household pets. In England, except for a handful of cases, there have been no cases of rabies outbreak among animals since the First World War. The United States, by similar exertions, is wholly free of the disease. Developing countries, however, face a higher risk of the disease due to the unavailability of the vaccines.
Last year, around 20,000 people were treated for bites inflicted by animals in Karachi alone. Of these, 5,500 were treated at TIH; roughly 10,000 at JPMC; and 4,500 in Civil Hospital. According to a study by TIH, the incidence of dog bite cases recorded by tertiary care centers in Pakistan is 16.8 per 100,000 each year. “It’s only people walking on roads that get bitten by dogs, not the privileged who drive in cars,” says Dr Salahuddin.
The persistence of rabies in man and animal throughout the country has been differently explained, but two factors remain constant. One of these is the presence of garbage in various localities. “Although municipal authorities pick up trash in most areas, most households still make it a habit of throwing their waste,” says Mustafa. “Garbage is the main source of food for stray dogs. They develop an allegiance and loyalty to the neighbourhood because of the garbage that is thrown outside.”
The other factor is a dearth of rabies prevention clinics in Sindh. The only clinics that are up and running are located in TIH, JPMC and the National Institute of Child Health. The others are in rural areas. “Except for the one at TIH and JPMC, the rest are always running short on supplies” says Dr Salahuddin. “I keep getting calls from Hyderabad. Sometimes, the personnel is missing. Other times, the faucets used to wash the wounds are missing. It’s always a filthy mess out there — it’s a sad situation.”
Despite all these obstacles, Dr Salahuddin is committed to a rabies-free Pakistan. “It is my firm belief that rabies will become a disease of the past. We have taken the first step, and we hope it will develop into a movement.”