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Task Force to eradicate rabies

The College of General Practitioners Sri Lanka in its Expert Committee Report on Rabies released last week recommends the establishment of a National Task Force to eradicate rabies in Sri Lanka.

The thirty one member expert committee, which was headed by Prof. Tissa Vitharana took 4 years to complete its work.

The committee secretary Dr. Dennis J. Aloysius said, "It was a uphill task that we undertook as we had to find time to meet for discussions and make other visits, conduct inquiries and investigations amidst our other professional work."

Among the other recommendations made by the committee are: promoting responsible dog ownership, through educational programmes and by legal action.

Recommendations

The National Rabies Control Programme is now decentralised. Each province should implement a comprehensive rabies control programme. This should include the appointment of a public health veterinarian to lead and coordinate each provincial programme.

Rabies diagnostic laboratories should be established in each province.

Provincial Councils should give priority to rabies control and allocate adequate resources.

As strategies for the elimination of rabies are available at national level, each province should prepare for complete eradication of rabies through capacity-building in all aspects.

Low-cost intradermal vaccination regimen for humans should be made available in all health institutions where 6-8 patients seek post exposure prophylaxis per day.

Sri Lanka, being an island, should be able to eliminate rabies. We recommend the establishment of a Task Force with adequate human and financial resources and the necessary authority to achieve this within a given frame of time.

A comprehensive rabies information network should be established involving hospitals, public health officers, veterinary surgeons, family physicians, rabies diagnostic units, local authorities and researchers.

In their report the committee states:

Rabies is endemic in Sri Lanka and has been a major health problem for a long time. Recorded incidence of human rabies dropped steadily from 377 in 1977 to 78 (the lowest) in 1998. The incidence for the year 2000 was 109. The dog is the major reservoir of rabies in Sri Lanka. In recent years about 97 per cent of human rabies has been following rabid dog bites. Cat bites and scratches were responsible for about 2 per cent. Between 30-50 per cent of infecting dogs were domestic while 50-70 percent strays, in the different years up to 1999. In the year 2000 about 80 per cent were stray dogs and 20 per cent were domestic.

Only at MRI

In Sri Lanka, tests for the detection and confirmation of rabies virus infections are carried out only at the Medical Research Institute (MRI) in Colombo.

Vaccines expensive

At present, tissue culture vaccines (TC ARV) are imported for post-exposure prophylaxis of rabies. They are safe and effective, but expensive. In 2001, 450,000 vials were imported at a cost exceeding Rs. 126 million. These were available in most government hospitals.

Over use of vaccines

Specific rabies immunoglobulin (RIG) has to be used in combination with rabies vaccine, in some patients. Here, too, the consumption has increased in the recent past. In 2001, 89,000 vials of equine rabies immunoglobulin (ERIG) were imported at a cost exceeding Rs. 45 million. There is mounting evidence of the overuse of TC ARV and RIG when they are really not necessary.

For these reasons, the College of General Practitioners took the initiative to establish an Expert Committee on The Prevention and Control of Rabies, with co-sponsoring and collaboration by the College of Microbiologists, Ceylon College of Physicians, Sri Lanka College of Paediatricians, College of Medical Administrators, College of Community Physicians and Sri Lanka Medical Association.

Main issues examined

The main issues examined by the expert committee were: * reducing the incidence of human rabies, * reducing the incidence of rabies in the animal reservoir, * improvement of the service provided to the public, and * reducing the excessive cost of post-exposure therapy.

Risk category

A. High risk - If one or more of the following are present: * Wild animal bite, * Animal cannot be identified or observed (eg. stray dog), * Non-immune animal, * Animal showing a change in its behaviour pattern within the previous two weeks, * Several people bitten without provocation, * Animal dies or appears unwell within 14 days following the bite and the brain is not available for examination.

Note: Wild animals those of importance in Sri Lanka are jackals, bandicoots, mongoose, polecats, monkeys, rock squirrels and civet cats.

B. Low risk - If one or more of the following are present: * Domestic healthy non-immune animal that could be observed, * bite due to provocation of a healthy animal, * Known fierce animal, * Animal immunised within the preceding year but appears unwell at the time of bite.

Measures to reduce costs

Where ARV is indicated, promote its intradermal application. Since there is an active and successful programme to administer BCG by the intradermal route throughout the island, there is no reason by why the administration of ARV by the ID route should not be widely practised. However, considering that failure in the technique can have fatal results there should be a supervised training programme for all nurses involved in ARV administration. Such a programme has been started. It should be progressively extended to all hospitals where 6-8 patients seek post-exposure rabies prophylaxis per day.

Avoid use of anti-rabies post-exposure therapy when not indicated according to instructions in Section 4.

When ARV is required, follow treatment guidelines as stated in Section 6.

Avoid unnecessary use of rabies immunoglobulin. Please see Section 6.

Discontinue the ARV if the animal remains healthy 14 days following the exposure. Measures to expand and improve laboratory diagnosis

There is a need to set up regional laboratories to improve rabies diagnostic facilities, initially in Galle, Ragama, Kandy and Kurunegala. The Expert Committee recommends that a virologist, microbiologist or a trained veterinary investigation officer, supported by a trained laboratory technician and a labourer should be available in these units.

Necessary equipment, such as an immunofluorescene microscope, an incinerator, and the necessary consumable items, should be provided. Utilisation of university facilities and personnel for this purpose should be explored.

Measures to reduce rabies

Minimising rabies exposure by reducing the animal reservoir The most effective course of action is to eliminate all stray dogs and ensure regular immunisation of all domestic dogs that are licensed periodically. However, because of our cultural, religious and social milieu, killing of stray dogs is not acceptable to many people. Therefore, this should be done only according to the rabies legislation.

The following are also recommended: * Making towns clean by clearing garbage to discourage stray animals, * Making parenteral immunisation widely available to domestic and stray dogs, * Promoting oral live vaccination, which has been proved safe and effective, * Making sterilisation facilities for domestic and stray dogs widely available.

Improvement for rabies surveillance

Rabies is an infection primarily of wild and domestic carnivorous mammals, where man is accidentally exposed. In Sri Lanka, rabies has been confirmed in dogs, cats, cattle, goats, deer, horses, squirrels, mongooses, bandicoots, jackals, polecats, civet cats, monkeys and, recently, in two elephants, but not all of them contribute to the chain of transmission.

In Sri Lanka, human rabies has largely been due to dogs, with strays as the main reservoir.

Human rabies has been unevenly distributed over the country and the highest incidence was observed in 4 of 9 provinces, namely Western, North Western, Central and Sabaragamuwa.

Although the number of human deaths from rabies reported annually is about 100, it is very likely that this may be an underestimation as many may not be reported because they are treated by Ayurvedic physicians, traditional healers and quacks. There is currently no proper recording system to provide information about rabid animals or to identify the species in the different districts of the country.

Lack of effective communication and collaboration between the relevant institutions (government and private), public health officers and veterinary surgeons, and insufficient rabies diagnostic centres are current problems affecting the efficiency of the rabies surveillance system.

In order to assess the efficacy of the present and future control programmes and to better understand the situation in Sri Lanka, a comprehensive surveillance system should be established. Valid epidemiological data should be obtained and analysed and information should be transferred to the control programme to plan, implement and monitor its activities.

Need for reliable data

Data should be obtained on the following: * The total number of human deaths due to rabies and its distribution both in time and space, should be accurately recorded. Relevant details such as the nature of rabies exposure, species of rabid animal involved and type of management should be noted with each case. * The number of animals suspected of having rabies and the number positive by laboratory confirmation should be recorded. *

The number of rabid animals and their species identification should be recorded in every part of the country.

Collection of data: * More rabies diagnostic units should be established in order to ensure quick and proper diagnosis of the maximum number of cases of animal and human rabies.

The expert committee comprised: Prof. Tissa Vitarana - Chairman, Dr. Dennis J. Aloysius - Secretary/Convenor, D. Lucien Jayasuriya - Rapporteur, Dr. Ariyarani Ariyaratnam - Rapporteur, Prof. Colvin Goonaratna - Editor.

Members: Prof. H. A. Aponso, Prof. P. L. Ariyananda, Dr. B. G. D. Bujawansa, Prof. Harendra de Silva, Prof. Janaka de Silva, Prof. Nandani de Silva, Prof. W. A. S. de Silva, Dr. W. A. Ferdinand, Dr. Desmond Fernando, Prof. Devaka Fernando, Prof. Ravindra Fernando, Prof. Saman Gunatilleke, Dr. P. A. L. Harishchandra, Dr. G. M. Heennilame, Dr. L. D. Jayawardene, Dr. Prasad Kumarasinghe, Prof. Lalitha Mendis, Prof. Shanthi Mendis, Dr. Sarath Paranavitane, Dr. J. B. Peiris, Dr. K. P. Piyasena, Dr. S. Ramachandran, Dr. Lakshman Ranasinghe, Dr. Seneth Samaranayake, Dr. A. Sathasivam, Dr. Kolitha Sellahewa, Prof. Nimal Senanayake, Prof. Rezvi Sheriff, Prof. N. P. Sunil Chandra, Dr. Vasanthi Thevanesan, Dr. C. G. Uragoda, Dr. Nalini Vithana, Prof. David Warrell, Dr. Preethi Wijegoonewardene, Dr. Anula Wijesundera, Dr. Omala Wimalaratne.

 

Question Box

Dr. Atukorale will reply

Mr. R. Chandrasena of Dematagoda and Mr. Rustom Jalaldeen of Church Street, Colombo 1, your questions on serum cholesterol and what foods will help to lower LDL in the blood have been sent to D.r. D.P. Atukorala Consultant Cardiologist. Please await his reply next week in this column.

Amino Tissue

M. Kamil from Kawdana, Dehiwala inquired from us last week, as to what amino tissues are which are prescribed by some doctors for dressings of diabetic ulcers He state "I am inquiring about this as I have been told it is kind of a human tissue. I just want to vetyfy this from an authoritative source."

It is The Water Bag

Mr. Hemaka de Mel, Manager Human Tissue Bank at Vidya Mawatha Colombo 7 on Amino Tissue state. Amino is the baloon like tissue that covers the baby at birth, which is also referred to commonly as the water bag. This is a good skin substitute, and a waste product thrown away with the placenta.

This tissue can be preserved after process and in the irradiated state could be kept for long periods.

This tissue helps in normalising heat exchange process in the body and as a result when used for dressings of ulcers, burns, the healing becomes faster, than other dressings. The patient also feels the minimum of pain.

In this bank we have this tissue sterilized by Gamma radiation. Blood from placenta donors are tested for HIV 1 and 2 Hepatitis B and VDRL.

SLMA to SLMC Fundamental Rights Issue

The SLMA in the Health Watch column of the 5th April issue requests the SLMC to change its decision regarding the conducting of lectures for categories of medical practitioners not eligible for registration with the SLMC. The SLMA states that it is deeply perturbed about this decision of the SLMC as it violates the fundamental rights guaranteed in Section 14 of the constitution.

On that, the SLMA is perhaps right. Indeed the fundamental rights of any individual should be considered sacrosanct.

This is precisely the reason why the SLMA should view this matter from another perspective also. The categories that the SLMA refers to are mainly the practitioners of what is referred to as native medicine. These are the Ayurveda, Siddha and the Unani systems of medicine.

Sometime back at an indigenous institution students were lectured on selected aspects of allopathic medicine by doctors registered in the SLMC. Even elsewhere in the sub-continent, students at indigenous medicine colleges are lectured on allopathic medicine. This is a common practice and is in keeping with the current views of the world medical community referred to by the SLMA.

The problem in Sri Lanka is that a sizeable number of those passing out from these indigenous institutions very often end up practising allopathic medicine only.

The SLMA has only to go around Colombo to see the number of qualified native doctors practising only allopathic medicine. If the SLMA has the time and inclination, it can also visit and see a similar state in the rest of the country.

When sometime ago authorised medical officers of the health department checked these errant native practioners, the powers that be at the health department issued a circular that this checking should be stopped forthwith as the Ayurveda Medical Council would be responsible for that in future. Of course, as is clearly seen, nothing has come of it and the qualified quacks continue merrily.

The SLMA's concern for the fundamental rights of the categories not eligible for registration with the SLMC is understandable and ought to be appreciated.

But what then of the fundamental rights of the hundreds of thousands of patients who are exposed to these quacks? Are not the fundamental rights of these innocent patients guaranteed in the constitution?

It is in this context that the SLMA should view the decision of the SLMC. Can the SLMA assure that the categories they refer to, who if imparted a limited knowledge of allopathic medicine, will not end up using this insufficient knowledge to indulge in fulltime allopathic practice? If that can be assured, then without reservation, the SLMC will no doubt reverse its decision.

Undoubtedly, the SLMC is violating the fundamental rights of a small category of individuals, but the SLMA will be violating the fundamental rights of a much larger number of hundreds of thousands of individuals by permitting the imparting of limited knowledge to these categories, only to let them loose on innocent patients.

Sharing of knowledge is indeed commendable and necessary, provided, that this knowledge is not abused as is being done by considerable number of the medical practitioners from ayurveda, siddha and unani system of medicines.

Perhaps, both the SLMA and the SLMC should work this matter out together.

M. Nilofer, , Colombo 13.

Mrs. Pillai on Sore Nipples

We had a fax on "Sore Nipples" (on which we had an article last week) from reader Mrs. S. Ponnampalam Pillai.

She writes: "I had Sore Nipples few years ago. The expensive treatment my gynaecologist prescribed did not work, and I had to stop breast feeding after 5 days.

"When I had the second baby the same thing started again. This time the chief nurse advised me to apply a little liquid from Aroma codliver oil capsule.

Would you believe by the next feeding time the cracks got healed.

After every feed wash the breast with warm water, dry well, and apply the oil on the nipples.

Wipe the nipples with a clean cloth before feeding. Health watch: Thank you Mrs. Pillai for sharing your tried out simple remedy for Sore Nipples with our readers.


Research on sleep

Mr. D. P. Goonasekera from Botupana, Ratmalana wants to know from any doctor who has done research on sleep, or who has read on the subject widely on the sleep requirements of a person at the various stages of life infant, child, adult, middle age and the old.

He writes, "We have heard various people telling us that they are so busy and burdened with responsibilities that they don't get three to four hours of sleep a day. Can we believe this? Is it possible for a person to go on with inadequate sleep, without getting into some mental state? Noise pollution is so much in the cities that even if we try to sleep, we just can't fall asleep owing to the noise.

Will you please publish this request so that somebody will reply.

Health Watch - Mr. Goonasekera here we have obliged you. You have touched on noise pollution also which is an interesting topic. We also look forward to hear from some doctor or researcher on this topic. Thank you for writing.

Address of National Diabetes Centre

Two of our readers Mrs. E. Gunasekera of Jayanthi Road, Dehiwala and Mr. V. R. Jayaratne of Power Management Technology, Union Place want to know the address of the National Diabetes Centre as they want to get some reading material from them. We oblige. Here's the address - National Diabetes Centre, No. 50, Sarana Mawatha, Cotta Road, Rajagiriya, Fax: 872952, Tel. 789930.

Next issues of Health Watch will be devoted to the following health issues:

New causes for new diseases

By Prof. John M. Last

We invite you to send your health problems on the above to:

Health Watch Coordinator Edward Arambewala
Daily News 
Lake House Colombo 10-Fax: 429210, 
Email: editor@dailynews.lk

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