At a bush hospital in Ghana I saw a little boy that was dying from rabies. A rabid dog bit their family’s herd of goats. Later, he was bitten by one of the goats, but didn’t tell his parents until 6 months afterwards when he started showing symptoms. Sadly, by then it was too late.

I was prompted to write this post when a patient in Lilongwe called for advice after the hedgehog her children were playing with died. At the lab they confirmed that the cute little critter had died from rabies. It was a good reminder that any mammal can carry rabies and we should discourage our children from touching wildlife.

Rabies is a virus that is spread from the saliva of infected mammals, most often through infected dog bites.  It can take anywhere from one week to one year to show symptoms. Unfortunately, once the patient shows symptoms, the disease is fatal. Most of deaths occur in Asia and Africa.  Children between the ages of 5-15 years of age are at highest risk since they are most often exposed to stray dogs and other animals.  According to the cdc American deaths are highest for bat exposure and dog bites among international travelers.

The good news is that rabies is preventable.  The World Health Organization has adopted two main strategies to prevent rabies:

  1. Immunize your dogs for rabies every year. Dogs account for 99% of all rabies transmission to humans.
  2. Immunize yourself if exposed. (See exposure categories and treatment below)

Rabies Exposure:

Categories of contact with suspect rabid animalPost-exposure prophylaxis measures
Category I – touching or feeding animals, animal licks on intact skin (no exposure) Washing of exposed skin surfaces, no PEP
Category II – nibbling of uncovered skin, minor scratches or abrasions without bleeding (exposure)Wound washing and immediate vaccination
Category III – single or multiple transdermal bites or scratches, contamination of mucous membrane or broken skin with saliva from animal licks, exposures due to direct contact with bats (severe exposure) Wound washing, immediate vaccination and administration of rabies immunoglobulin
Retrieved from: https://www.who.int/en/news-room/fact-sheets/detail/rabies on January 7,2020

Pre-exposure Prophylaxis:

If possible, children living in Africa should get a pre-exposure WHO pre-approved rabies immunization. Zain at PharmaGenNex in Lilongwe carries Rabivax-S, which is on the pre-approved list. The immunization is recommended for children one year and up, to be given at day 0, day 7, and day 21 or 28 in the arm or thigh muscle for babies.

If You Get an Animal Bite- Post-exposure Prophylaxis (PEP):

All exposures should be washed with soap or detergent, flushed with running water for 15 minutes, and cleaned with povidine-iodine solution.

If Category 2 or 3 exposure AND your child has been immunized then you need to receive a WHO pre-approved rabies vaccine (such as Rabivax-S) on days 0 and day 3.

+If Category 2 exposure AND your child has NOT been immunized then you need to receive a WHO pre-approved rabies vaccine (such as Rabivax-S) on days 0, 3, 7, 14, and 28*.

++If Category 3 AND your child has NOT been immunized then you need to vaccinate immediately with a WHO pre-approved rabies vaccine (such as Rabivax-S) on days 0, 3, 7, 14, and 28* and prepare to medically evacuate as the RABIES IMMUNOGLOBULIN IS NOT AVAILABLE IN MALAWI.


*According to the CDC the 5th dose is not given unless immunocompromised. (I’m continuing to follow the old WHO guidelines of 5 injections for my patients in Malawi, until I see new recommendations from WHO.)

+If unable to find a WHO pre-approved rabies vaccine such as Rabivax-S, then give what is available, but document the brand. Your doctor may choose to give a booster when returning to home country.

In government hospitals, Malawi requires a certificate from the vet before immunizing. This is to help monitor and control rabies in Malawi. The post-exposure vaccines are also effective at a lower dose administered just under the skin (intradermaly).

++There are times when a patient has a category 3 exposure, has not been immunized, and doesn’t have the ability to evacuate. In that case we do the best we can with the resources we have available. Be sure to flush the wound well. Clean with povidine-iodine and immunize with the 5-shot series as soon as possible. Ensuring pets are vaccinated yearly for rabies and supporting local animal control measures helps protect the entire community.

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