Rabies, a neglected viral disease, is one of Nepal's silent public health problems. Almost all the patients who died of rabies in the past in Nepal were bitten by dogs (stray). In fact, according to the World Health Organisation, dogs are the primary source of human rabies deaths, contributing up to 99 percent of all rabies transmission to humans. Hence, the world, including Nepal, has aimed to eliminate dog-mediated human rabies deaths by 2030. However, over the past five months, Sukraraj Tropical and Infectious Disease Hospital (STIDH) has recorded at least 12 dog-mediated rabies cases, indicating an epidemic of rabies in Nepal. This triggers doubt about achieving the goal.

Rabies is a preventable viral disease transmitted by the bite of an infected animal through saliva. It causes inflammation of the brain and spinal cord. The symptoms of rabies usually develop within 20-60 days but vary from a week to years. In the majority of patients, I, however, have been observing rabies symptoms in an interval of more than three months (on average 6-8 months) after animal bites. Classic symptoms of rabies include aerophobia (fear of the movement of air), hydrophobia (fear of water), and aggression or irritability.

Nevertheless, more than 80 percent of rabies patients have become non-aggressive since the last decade, suggesting a change in rabies symptoms, perhaps due to virus mutations. Early symptoms are non-specific and similar to flu-like illnesses, such as fever, pain, and headache, as well as unexplained tingling, pricking, or burning sensations at the bite site. Interestingly, I frequently observed severe lower back pain in patients a few days before aerophobia and hydrophobia developed.

Besides dog bites, I had observed two rabies cases after cat bites, while the remaining cases were due to jackal/fox bites. No cases have been reported owing to rat bites, one of Nepal's most common animal bite problems. In fact, “rat bite fever” is increasingly seen after rat/mouse bites. Each month, nearly 8-12 thousand animal bite victims visit STIDH, and among them, almost all are victims of dog bites. Unfortunately, no information is available about the possibility of transmission of other infections through animal bites (especially dogs or cats) in Nepal.

In the past decade, as per STIDH data, on average, 12-16 rabies deaths due to animal bites yearly. At that time, this may have been due to a lack of easy access to anti-rabies vaccines. Nevertheless, vaccines are now easily accessible in all government health centres and private hospitals, clinics and pharmacies. However, despite the availability of vaccines, the number of deaths attributed to the rabies virus is increasing. Several reasons for the increasing number of rabies cases in Nepal have emerged, and these are specific and yet to be addressed.

Many people believe that small puppies do not possess and transmit rabies virus. Veterinarians also suggest an anti-rabies vaccine for puppies only after three months. The majority of the rabies patients, however, have been found to be bitten by puppies (especially stray puppies). A few days ago, a 32-year-old male visited the outpatient department (OPD) with a history of aerophobia and hydrophobia. He was bitten on the right hand by a stray puppy eight months back. He ignored his relatives’ suggestion to get vaccinated immediately. According to his relatives, he thought that puppies do not harbour the rabies virus, so he developed rabies symptoms.

Similarly, a 38-year-old male visited the hospital with a 7-day history of sudden onset of chest pain, fever, headache, aerophobia and hydrophobia. He had a history of dog bite on his hand. This patient also refused to get vaccinated for the same reason. These are some examples of people not believing that puppy bites can transmit rabies virus to humans.

People, especially those living in rural areas, initially visit local pharmacies for medicines, treatment, and suggestions. Unfortunately, there have been observations of incorrect suggestions from pharmacists or medical hall shopkeepers to animal bite victims—another major cause of rising rabies cases in Nepal. For example, a few months ago, a 34-year-old male visited a nearby local pharmacy after being bitten by a dog. However, the medical hall shopkeeper did not recommend vaccination due to a minor bite wound. Later, the victim developed rabies symptoms.

It is interesting to note here that the majority of pharmacies usually offer tetanus toxoid vaccine (T.T.) instead of rabies vaccine after animal bite incidents. Regrettably, many victims also believed that the T.T. vaccine protected them from the rabies virus. This clearly shows a knowledge gap in the community regarding rabies. Thus, training pharmacists/medicine sellers, particularly in rural areas, is worthwhile in mitigating rabies cases in the coming years. Rabies should be included as an emerging disease (non-neglected disease) and given a high priority by the government to reduce and stop this silent-killer virus.