The symptoms were evident: hypersalivation, hyperventilation and hydrophobia.

Four-year-old Mawusi* had been bitten by a neighbour’s dog. With fever, headache and general weakness, the little girl showed signs of difficulty in swallowing any food or water. Rushed to a hospital in the town of Kasoa, sadly she died almost 6 hours after admission. Autopsy confirmed her cause of death as rabies.

In a nearby town, a woman in her fifties presented almost the same symptoms, some 2 months after being bitten by her own dog. She died in hospital. Her cause of death was also rabies.

And then there was a third rabies death of a man who was bitten while trying to kill his dog after it started behaving abnormally. He did not seek medical care but instead was cared for by local “chemical sellers” in the community. About 40 days after the dog bite, he started showing symptoms including aggression and hydrophobia (fear of water due to difficulty in swallowing) and died.

Over the past year, the Awutu Senya East Municipality in Central Ghana of which Kasoa is the capital, had a significant increase in reported dog bites; the highest number of bites were recorded during the month of June. Among them were many children aged under 5 years.

It was time to take action.





Prompt investigation

The spike in the number of cases called for close collaboration with the community, multiple stakeholders and sectors, such as public health institutions, veterinary services and environmental health. It also involved the school system, teachers, the village elders, health care workers and volunteers.

A multidisciplinary, multisectoral committee, chaired by the Municipal Chief Executive, was set up to monitor and take appropriate measures to resolve this situation. The Committee meets and plans epidemic preparedness including the procurement of post-exposure human vaccines, promotion of free vaccination of all dogs in the municipal area and community awareness and education campaigns.

“We have met with community leaders and elders who have provided their full support for mobilization and to vaccinate dogs,” said Dr Paul Dsane-Aidoo, the acting Municipal Health Director of the Awutu Senya East Municipality. “We have also had a very good response from the community in contact tracing of pets.”

Contact tracing and surveillance

More than 140 people who were linked to the victims or who lived in the neighbourhood with suspected rabid dogs were investigated and interviewed; many of them were children aged under 15 years. Anyone considered to be at risk of rabies exposure was referred to receive post-exposure prophylaxis from a health facility.

When someone is bitten or scratched by an animal that could be carrying rabies, WHO recommends they should wash the wound thoroughly with soap and water. The person should receive a course of rabies vaccine, and possibly rabies immunoglobulin. While post-exposure prophylaxis should start as soon as possible after exposure, it can still be effective months later as the disease has an incubation period of up to 12 months.

The rabies committee in Awutu Senya East Municipality has launched a large-scale awareness campaign to inform people about responsible pet ownership and the importance of reporting any dog bite or abnormally behaving dog to the nearest health facility, and to encourage people to participate in mass dog vaccination campaigns.

Clinical and public health care workers are being provided with special training on animal bite protocols. The outbreak team of the locality is distributing printed copies of the management protocols as well as the case definition of rabies to the units of the major health facilities.

The multidisciplinary committee is working with the educational sector to inform school children about animal behaviour, rabies and how to prevent contact with and report any bite or scratch suspected from a dog or cat. At the municipal health management level, everything is being done to intensify surveillance.

Challenges

Although around 1000 dogs and cats have been vaccinated so far, the main obstacle is the shortage of animal vaccines. In some areas, cultural beliefs have prevented vaccination of dogs. Furthermore, human vaccines and immunoglobulins (for post-exposure prophylaxis) are not readily available.

To support these efforts, the community urgently needs an adequate supply of both dog and human vaccines.

Under the United Against Rabies collaboration, WHO is working with the Food and Agriculture Organization of the United Nations (FAO), the International Organisation for Animal Health (OIE) and the Global Alliance for Rabies Control (GARC) to support countries to achieve "Zero human rabies deaths by 2030". WHO is also working with partners to forecast the global need for human and dog vaccines and rabies immunoglobulin, to understand the global manufacturing capacity and to explore bulk purchasing options for countries in need.

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*not her real name