Death of children due to rabies points to need for pre-exposure prophylaxis vaccination

The recent deaths of three young girls following rabies, in separate incidents in Pathanamthitta, Malappuram and Kollam, in spite of post-exposure prophylaxis with anti-rabies vaccine as well as rabies immunoglobulin, have yet again brought attention to the need to protect children with pre-exposure prophylaxis vaccination.

Pre-exposure prophylaxis for children in a highly rabies-endemic State like Kerala, where the number of human rabies deaths have been increasing, was a strategy recommended as a short-term priority—to be achieved in 1.5 years—by the B. Ekbal committee that framed the State Vaccine Policy in November 2022.

The detailed field investigation into the recent rabies deaths of children by the Health department, in association with the National Centre for Disease Control, Central Drugs Standards Control Organisation, the State Public Health Lab and the district surveillance units, had looked into all aspects of the case, including the nature of animal bite, the timeliness of interventions, adherence to standard protocols, vaccine cold chain, techniques of vaccine administration, training for staff and public awareness of prophylaxis .

Submitted to child rights panel

The report, which was submitted by the Director of Health Services to the Kerala State Commission for Protection of Child Rights last week following a petition filed by advocate Kulathoor Jaising points out that all three children had sustained severe, deep Category 3 dog bites in highly innervated areas as the head, neck and upper limb, resulting in direct inoculation of the virus into the nerves, thus rendering the administered immunoglobulin and vaccine ineffective

In one case, the child had been bitten by the neighbour’s pet dog and despite taking vaccine and immunoglobulin, she had developed rabies symptoms three months later. In two other cases, there were delays in care seeking, but which was likely due to the distance to the health facility, non-availability of rabies immunoglobulin at the taluk hospital or public health centre and lack of awareness about the importance of wound washing.

Category 3 bites

“Because of their small size, children fall down when a rabid dog attacks them, making them vulnerable to repeated bites, which are invariably Category 3 bites (face, head, neck or hand where there is a concentration of nerve fibres). When the wounds are deep, more nerve fibres are exposed and the virus enters the nervous system directly,” public health experts point out.

There could be unanticipated delays in getting proper treatment. But if a child has been given pre-exposure prophylaxis, rabies antibodies are already there in the body to fight the virus, if he/she sustains an animal bite later. A child who has been given pre-exposure prophylaxis will not need rabies immunoglobulin after an animal bite and even the post-exposure vaccination can be contained to two doses.

The report submitted by the DHS makes it clear that people dying despite taking post-exposure anti-rabies vaccination is a regular occurrence in the State.