Khatri, Ismail A.

Salahuddin, Naseem

Wasay, Mohammad

eCommons@AKU

eCommons@AKUDepartment of Medicine Department of MedicineApril 2008Tetanus and rabies eradication in Pakistan; amission not impossibleMohammad WasayAga Khan UniversityIsmail A. KhatriShifa College of MedicineNaseem SalahuddinAga Khan UniversityFollow this and additional works at: http://ecommons.aku.edu/pakistan_fhs_mc_med_medPart of the Public Health Commons, Veterinary Infectious Diseases Commons, Virus DiseasesCommons, and the Viruses CommonsRecommended CitationWasay, M., Khatri, I. A., Salahuddin, N. (2008). Tetanus and rabies eradication in Pakistan; a mission not impossible. Journal ofPakistan Medical Association, 58(4), 158-159.Available at: http://ecommons.aku.edu/pakistan_fhs_mc_med_med/135References1. Ruggeri ZM, Ware J. von Willebrand factor. FASEB J 1993; 7:308-16. 2. Sadler JE. A revised classification of von Willebrand disease. For theSubcommittee on von Willebrand Factor of the Scientific and StandardizationCommittee of the International Society of Thrombosis and Haemostasis.Thromb Haemost 1994; 71: 520-5.3. Rodeghiero F, Castaman G, Dini E. Epidemiological investigation of theprevalence of von Willebrand disease. Blood 1987; 69: 454-9. 4. Sadler JE, Granick HR. Commentary: a new classification for von Willebranddisease. Blood 1994; 84: 676-9.5. Saeedi I, Razziq F, Ur Rehman M, Ahmad H. Von Willebrand disease. JPostgrad Med Inst 2001; 15: 202-7.6. Khalid S, Bilwani F, Adil SN, Khurshid M. Frequency and clinical spectrumof inherited bleeding disorders other than Hemophila A and B 2008. (acceptedfor publication- JPMA)7. Rick ME. Diagnosis and management of von Willebrand's syndrome. MedClin North Am 1994; 78:609-23.8. Rick ME, Walsh CE, Key NS. Congenital Bleeding Disorders. HematologyAm Soc Hematol Educ Program 2003; 559-74.9. No authors listed. Spectrum of von Willebrand disease: A study of 100 cases.Italian working group: Br J Haematol 1977; 35: 101-12.10. Sadler JE, Blinder M. von Willebrand Disease: Diagnosis, Classification andtreatment. In: Colman RW, Hirsh J, Marder VJ, Clowes AW, George JN, eds.Haemostasis and Thrombosis - Basic principles and clinical practice. 4th ed.Philadelphia, PA:Lippincott, William and Wilkins 2001; pp 825-37.11. Gill JC, Endres-Brooks J, Bauer PJ, Marks WJ Jr, Montgomery RR. The effectof ABO blood group on the diagnosis of von Willebrand disease. Blood. 1987;69:1691-5.12. Rick ME. Von Willebrand Disease: Clinical presentation and diagnosis of vonWillebrand disease. In: Rose BD, ed. UpToDate (Online textbook ofmedicine). Wellesley, MA, USA 2007. Available from: URL: http://www.uptodateonline.com/utd/content/topic.do?topicKey=coagulat/10924&selectedTitle=1~150&source=search_result (accessed on10-11-2007). 158 J Pak Med AssocEditorialTetanus and rabies eradication in Pakistan; a mission not impossibleMohammad Wasay1, Ismail A. Khatri2, Naseem Salahuddin3Department of Medicine1,3, The Aga Khan University, Karachi, Section of Neurology2, Shifa College of Medicine & Shifa International Hospital, Islamabad.Tetanus and rabies are two potentially preventablediseases that have been eradicated from many countries ofthe world.  They still take a heavy toll of human life in thedeveloping world.  According to World Health Organization(WHO) reports, rabies causes at least 55,000 annual deathsworldwide, of which 56% occur in Asia and 44% in Africa1;and the estimated worldwide deaths from tetanus were213,000 in 2002 including 198,000 in children under 5 yearsof age including neonatal tetanus.2 A total of 610 cases oftetanus were reported from Pakistan in 2006.3 Tetanus andRabies are both non reportable diseases in Pakistan andincidence is grossly under reported. There is no specifictreatment for rabies and once established it remains auniversally fatal disease, whereas mortality from tetanusapproaches close to fifty percent in developing countrieslike Pakistan.4One of the most important aspects in success of anyprevention program is the correct understanding of theprogram.  Even though extensive efforts are made to spreadthe message of prevention programs, the overall knowledge,attitude, and practices are dismal.  In one survey fromKarachi, only 25% of general practitioners had correctknowledge about pre-exposure and 13% had correctknowledge about both pre- and post-exposure tetanusimmunization.5 The same study suggested that only 2%practitioners were practicing the post-exposureimmunization correctly.5 In a more recent survey ofreproductive age women about tetanus toxoid vaccine,81.3% participants had inadequate knowledge; 12.5% hadincorrect knowledge, and 6.3% had no knowledge.6 Thesame survey revealed that 28 out of 54 participants (52%)were not concerned about tetanus toxoid vaccination [6].This study further revealed that of those who werevaccinated, only 40.6% were properly vaccinated.  Anotherstudy published from Peshawar showed 65% vaccinationrate among the women of reproductive age, however, thestudy did not comment on proper or improper vaccination.7Currently global DTP3 coverage is estimated at 79% byWHO.Neonatal tetanus remains a high contributor to infantmortality in Pakistan.  Refusal to feed and poor sucking,convulsions, locked jaw, and opisthotonus are the majorclinical features.  Multitude of factors have been associatedwith the risk for developing neonatal tetanus.  One casecontrol study found application of substances on theumbilical cord, home delivery, and illiterate mother asindependent risk factors for neonatal tetanus.8 A very recentstudy from a large tertiary care hospital in Lahore reported100% mortality among premature neonates with tetanus,and 44% mortality in full term neonates.9 In this study, 80%of the neonates were home delivered with 88% mothers notbeing vaccinated against tetanus.  The umbilical cord wascut with a blade in 60% and desi ghee (butter) applied to20% umbilical stumps.The scenario for rabies is even more disappointing.Even though no population based studies are available fromPakistan, rabies incidence was estimated at 7 to 9.8 casesper million population annually in Karachi.10 Two studiespublished from Karachi.10,11 showed that none of thevictims received rabies immunoglobulin which is a WHOrecommendation after severe exposure to rabies1, and is theonly hope for survival if administered immediately alongwith efficacious vaccine.   Most of the affected victims weregiven nerve tissue vaccine and in the larger study of 40patients, 23% did not receive any vaccination.10,11In the above scenario, it becomes imperative thatcurrent practices should be re-evaluated and measures betaken to eradicate these preventable deaths.  Even thoughdifficult this is not impossible as many other developingcountries have been able to achieve this goal. There is aneed for a better surveillance system for early identificationof all patients with suspected tetanus and rabies.  Exclusivetetanus and rabies centers at the district or divisional levelshould be established where not only the suspected patientsare managed by properly trained staff, but these centers alsoact as epicenters for education of masses about thesediseases, assurance of appropriate preventive coverage withEPI vaccines in the whole district population, andsurveillance and reporting of these diseases.  These centersshould be equipped to make appropriate diagnosticevaluation including antibody testing.In the current infrastructure, union council nazimsshould also take the responsibility of health education, andmass vaccination.  The WHO goals of immunization canonly be achieved by contribution both from government andpublic. Periodic visits by appropriately trained staff toschools and colleges can make significant contribution tohealth education not only for vaccine preventable diseases,but also for other health related issues.  At the time of schooland college admissions and job interviews, it should bemade mandatory that appropriate vaccination is proven.Medical colleges and teaching hospitals should takethe responsibility of proper education of physicians, inparticular general practitioners and other health careprofessionals about knowledge, attitude, and practices(KAP) of vaccine preventable diseases. The availableliterature suggests that we fall way behind the targets as faras the KAP of our general practitioners are concerned.Public awareness and physician awareness programs shouldbe run on regular basis.  Continuing education is the onlyway to assure that practices meet the standards. Professionalsocieties especially for family physicians and generalpractitioners could play an important role in physician'sawareness.The policy makers should ensure that these ailmentsget high priority on their list and appropriate budgetsallocated to ensure the availability of vaccines andimmunoglobulins.  In two studies, none of the rabies victimreceived immunoglobulins.10,11 Approximately 3/4th ofpatients at dedicated tetanus unit do not receive humanimmunoglobulins only because of cost issues.12It is time that national tetanus and rabies eradicationprograms are established. General practitioners are usuallythe first contact of the affected patient.  They should be fullyaware of the symptoms, signs, initial management, andappropriate referral points for tetanus and rabies. The use ofelectronic media especially television and radio channelsand news paper advertisement by health care authorities arethe most important means of mass awareness. Thedistrict/divisional level dedicated centers should be fullyequipped with appropriately trained personnel, vaccines,immunoglobulins, and supportive care needs.Immunization coverage for tetanus should be assured at alllevels.  The recently suggested WISE approach with a focuson wound washing (W), injecting immunogenic vaccinesand immune globulins (I), and stray dog euthanization (SE)is implemented to prevent the painful deaths from rabies.13This is a difficult mission but is not impossible.Sincere efforts, appropriate policies, and acting inanticipation can eradicate these painful and life threateningdiseases from Pakistan. References1. http://www.who.int/rabies/epidemiology/Rabiessurveillance.pdf   Accessedon November 1, 2007 2. http://www.who.int/immunization_monitoring/diseases/GS_TT.pdf  Accessedon November 1, 2007 3. http://www.who.int/immunization_monitoring/en/globalsummary/timeseries/tsincidencette.htm  Accessed on November 1, 2007.4. Khichi GQ.  Tetanus neonatorum in Bahawalpur.  Pak Paed J 1997; 21:31-6.5. Ahmed SI, Baig L, Thaver IH, Siddqui MI, Jafery SI, Javed A.  Knowledge,attitudes and practices of general practitioners in Karachi District Centralabout tetanus immunization in adults.  J Pak Med Assoc 2001; 51: 367-9.6. Zeb A, Zaidi SA, Jehan I.  Knowledge, attitude and practices of reproductiveage females about tetanus toxoid vaccine: a pilot study.  J Coll PhysiciansSurg Pak  2006; 16: 791-3.7. Afridi NK, Hatcher J, Mahmud S, Nanan D.  Coverage and factors associatedwith Tetanus Toxoid vaccination status among females of reproductive age inPeshawar.  J Coll Physicians Surg Pak 2005; 15:391-5.8. Raza SA, Akhtar S, Avan BI, Hamza H, Rahbar MH.  A matched case-controlstudy of risk factors for neonatal tetanus in Karachi, Pakistan.  J PostgradMed. 2004; 50: 247-51.9. Shah AA, Ali AS, Hussain RR, Hussain A, Saeed A, Butt TK.  Complicationsand outcome of neonatal tetanus.  Pak Paed J 2007; 13: 126-31.10. Parviz S, Chotani R, McCormick J, Fisher-Hoch S, Luby S.  Rabies deaths inPakistan: results of ineffective post-exposure treatment.  Int J Infect Dis 2004;8: 346-52.11. Salahuddin N, Jawad M.  Human Rabies: experience of eight cases at LiaquatNational Hospital, Karachi.  Infect Dis J 2000; 9: 23-4.12. Raza MA, Abbas MH.  Tetanus disease patterns observed in a specialized unit.J Coll Physicians Surg Pak 2000; 10: 249-54.13. Aftab O, Jawaid A.  Rabies control in Pakistan - the WISE strategy.  J CollPhysicians Surg Pak 2005; 15: 748.Vol. 58, No. 4, April 2008 159

Tetanus and rabies eradication in Pakistan; a mission not impossible

http://ecommons.aku.edu/cgi/viewcontent.cgi?article=1134&context=pakistan_fhs_mc_med_med

Tetanus and rabies eradication in Pakistan; a mission not impossible

Abstract

Similar works

Full text

Available Versions

eCommons@AKU