World Rabies Day: evidence of rise in paediatric rabies cases in Malawi

Sept 28 marks World Rabies Day, launched in 2007 to increase public health awareness and reduce the incidence of this fatal but preventable disease. 5 years on, our experience in Malawi suggests that rabies incidence is rising and control measures are inadequate. We have seen ten cases of rabies in children at the Queen Elizabeth Central Hospital in Blantyre, Malawi, over a 9-month period (June, 2011, to February, 2012). This is the largest number of paediatric rabies cases described from a single institution in Africa and a threefold increase in the number of cases reported between 2002 and 2005 at the same hospital. All the patients had clear evidence of rabies encephalitis and all died. In the eight patients for whom history of exposure was obtained, all were secondary to a dog bite. A third of the patients did not report the exposure to their guardian; another third sought medical attention but there was unavailable or inadequate vaccine; one patient was denied treatment because they did not have a vet’s certifi cate. These cases presented to a tertiary referral hospital and the true incidence will be much higher. Current reporting systems in Africa have been shown to underestimate true numbers of rabies cases by up to 100-fold. Of the 14 rabies cases previously reported from Queen Elizabeth Central Hospital, four were misdiagnosed as cerebral malaria or meningitis. Anti-rabies vaccine in Malawi is often limited or unavailable. This is despite investment in its provision having been shown to be highly cost eff ective even if only 1% of those receiving anti-rabies vaccine were at actual risk of developing rabies. Additionally, the adoption of intradermal regimens can signifi cantly reduce the volume and thereby the cost of delivering antirabies vaccines. Our experience is that medical practitioners continue to use intramuscular regimens. Mass dog immunisation programmes are essential to control rabies spread, but often perceived as too expensive and logistically diffi cult to implement. Nevertheless, it has been shown than these barriers are surmountable and elimination of canine rabies in Africa is feasible, with initiatives such as the Rabies Blueprint website off ering practical support and guidance. Our recent experience highlights the ongoing burden from this terrible disease. Greater advocacy of intradermal regimens, better education and training of ground-level healthcare professionals, and governmental commitment to dog vaccination programmes are needed urgently if we are to stop these needless deaths from continuing to occur.