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When a dog bites what you should do

by Edward Arambewala

A dog being vaccinated against rabies.

Prof. David A. Warrell (Head of the Nuffield Department of Clinical Medicine, Oxford University, UK) who was here in Colombo last week explains.

All bite wounds should be cleaned vigorously, as soon as possible, whatever the perceived risk of rabies. Public education should promote immediate vigorous scrubbing of he bitten area with soap and copious amounts of water. Effective virucidal solutions include iodine and 40% alcohol. Mammal (including human) bites carry the risk of bacterial infections, but routine prophylactic antibiotics are not recommended. A tetanus toxoid booster is usually appropriate.

If there is a risk of rabies, PET should be instigated as a matter of urgency with rabies immunoglobulin (RIG) infiltrated around the bite wounds and anti-rabies vaccination. In 1985, when production of MRI's Semple-type nervous tissue rabies vaccine was being phased out, to be replaced by expensive imported Pasteur-Merieux human diploid cell strain vaccine, I reported studies of economical mutli-site intradermal regimens of tissue culture vaccines carried out at Queen Saovabha Memorial Institute in Thailand.

In 1997, these regiments were recommended by WHO and subsequently adopted in Sri Lanka. Despite the shortage of RIG in Sri Lanka and an increasing crisis in RIG production worldwide, the 2-site regimen was selected by the Sri Lankan authorities rather than the more robust, rapidly immunogenic and economical 8-site regimen which is generally recommended if RIG is not available. It might now be timely to review this decision.

Pre-exposure immunization is increasingly recommended especially for children, who are at higher risk of exposure. Rabies vaccine could be included in the EPI. Vaccines, who are subsequently exposed, need urgent vaccine boosting (2 doses on days 0 and 3) but do not require RIG. No failures of pre-exposure prophylaxis with post-exposure boosting and only 2 failures of prompt full PET have been reported among the more than 1 million people treated with tissue culture vaccines.

The number of human deaths from rabies in Sri Lanka has been slow to fall from 377 in 1973 (29 per million population) to 109 in 2000 (6 per million). Currently, some 80,000 people receive post-exposure treatment (PET) each year at a cost of over US $ 1 million. More than 50% of rabies victims are children.

In Sri Lanka, rabies is enzootic in domestic dogs and cats and in wild mammals such as monkeys, mongooses ("hothambuwa") and jackals. The island supports a massive dog population, variously estimated as 1-1.5 million and, in some areas, numbering one for every 8 or even one for every 4 humans. Recently, new rabies-related viruses have been discovered in frugivorous and insectivorous bats in Australia, Philippines and Europe.

However, in Sri Lanka, only classical genotype I rabies virus has been found which is of minimally-divergent lineage, distantly related to other rabies virus lineages in India and elsewhere in Asia, implying ecological isolation.

The most economical and effective means of preventing human rabies is by controlling the infection in dogs by mass vaccination. This has been applied successfully in the great conurbations of Latin America but the necessary 75% saturation, including stray dogs, has not been achieved in Asia. Like the United Kingdom, which eliminated rabies in 1992, Sri Lanka has the great advantage of being an island. The National Rabies Elimination Programme, initiated in 2000, has the opportunity to create the first rabies-free country in Asia in more than 30 years.

World Animal Day theme Rabies control through sterilisation

The Animal Welfare and Protection Association (Sri Lanka) has informed us that this year's emphasis on World Animal Day which falls on October 4th would be sterilization of stray dogs to control rabies.

The Association is organising a walk round Viharamaha Devi Park of animal lovers, and schoolchildren taking this message across to the public.

The Society for the Protection of Animal Rights (Sri Lanka) headed by the Mr. Penny Jayewardena will also be joining this walk, taking the message that animal rights should also be honoured by the society as they are also part of the living society with man though in a lower category.

Prof. David Worrell of UK who was in Colombo last week said that Sri Lanka has been able to lower its incidents of rabies from 29 per million in 1973 to 9 per million in 2002, a creditable achievement through sterilization and other methods.

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Neck pain therapy ineffective

A new study in this week's BMJ shows that two types of physiotherapy commonly prescribed to treat female office workers with neck pain do little to alleviate their pain.

Researchers examined the progress of 393 female office workers with chronic neck pain. These women were divided into three groups who were prescribed either dynamic muscle therapy or relaxation therapy, with a third group continuing with everyday activities. The patient's level of neck pain was assessed after twelve weeks of treatment with follow-up assessments made after three, six and twelve months.

The results showed that the levels of neck pain experienced by women treated with dynamic muscle therapy or relaxation therapy were no different to active women receiving no treatment. Furthermore, there was no difference in the intensity of the pain experienced by the groups of women receiving the different treatments in any of the follow-up assessments.

The authors conclude that the prescription of these therapies to treat neck pain is not based on clinical evidence calling into question whether these types of physiotherapy should be prescribed to treat neck pain.

Contact: Dr. Matti Viljanen, Tampere Regional Institute of Occupational Health, Tampere, Finland

Email: matti.viljanen@ttl.fi

Better treatment needed for constipation

Doctors need to consider new therapies to treat constipation that go beyond the use of laxatives says a leading gastroenterologist in this week's BMJ.

Constipation affects a quarter of the population at some time, and has a variety of different causes including dietary factors, disease and psychological problems. The treatment of constipation is often limited to the prescription of laxative or in the most serious cases, surgery. Dr. Michael Kamm believes the treatment of constipation needs to improve and suggests that behavioural treatment and new drugs that aid bowel movement should be considered.

Kamm explains that laxatives do not always provide relief from constipation and increasing dietary fibre intake can cause increased bloating with little improvement in bowel function creating a need for new innovative approaches to treating constipation.

Behavioural therapy aims to improve the control patients have over their own bodies, and when used in conjunction with exercises focused on the gut, reduced use of laxatives and psychological support can be a very effective treatment for constipation.

New drugs are also being developed that focus on a process known as peristalsis that is critical to bowel movements. These drugs are not yet widely available in Europe, but they may soon offer new hope to those who suffer from constipation.

The author concludes that it is time stop dismissing constipation as a trivial complaint, when it has a major impact of the quality of life of sufferers and requires substantial investment in healthcare resources.

- (Sent for Health Page by Dr. Dennis J. Aloysius)

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New Intellectual Property Rights 

Oust third world from effective diabetic medicine

So claims the Diabetes Voice in an article on - Developing countries need access to cheap treatment for Diabetes, carried in its June issue.

The article written by Dr. Mohga Kamal Smith states "Although most of the diabetes drugs which are currently available will not be affected under the new rules, it will no longer be possible for generic companies to produce less expensive versions of new drugs using process patents.

The much needed next generation of improved anti-diabetic medicines will not be manufactured at an affordable price. Treatment with these more effective products will therefore remain beyond the means of people in developing countries'.

Medical Advisory Panel picked this article to be used in this Page today as it raises an important issue very relevant to Sri Lanka too. The majority of our diabetic patients are from the hardpressed upper and lower middle classes who can hardly afford the high cost branded drugs.

The Medical Advisory Panel fully endorses the stand taken by the writer, Oxfam Health Policy Advisor Dr. Mohga that as a matter of priority World Trade Organisation should be fair and flexible in applying the (TRIPS) with regard to the Third World countries.

Here are some extracts from the article:
Why is the incidence of diabetes rising?

Socio-economic changes in developing countries play a major role in the rising incidence of chronic progressive diseases, including diabetes. Ageing populations and rising levels of obesity associated with changes in diet and decreased physical activity, are contributing factors.

Poverty is driving people of all ages, including children, to work longer hours, especially in cities where low-paid hourly work is often all that can be found. Such workers depend on take-away food from street stalls where the traditional nutritious diet is being replaced by poor quality Western-style cooking that uses more fat, salt, sugar, and meat. The consumption of high-sugar, high-fat snacks by both rich and poor children is also increasing. Food advertising, especially on television, is contributing to the changes in diet in both urban and rural areas.

Policy makers must approach prevention through education programmes.

TV and obesity

Watching television has become a popular social activity in developing countries. Even in poor and remote areas, it may be the only recreational activity for children and adults. Children's time in front of television is at the expense of their normal play. In urban areas, children's physical activity is also constrained by the need to work, the lack of play space in urban slums, and the lack of facilities and attention to physical exercise in schools. Such changes to the diet and culture are contributing to increasing levels of obesity among adults and children.

Obesity is now a public health problem in urban and some rural areas in middle-income countries such as India and China, as well as in poor countries such as Tanzania. The incidence is increasing. For example, between 1978 and 1995, obesity in children under five years almost quadrupled in Egypt (a middle-income country) and increased 3.5 times in Haiti (a least-developed country).

The increasing risk of developing diabetes and other chronic diseases is clearly linked to these factors.

Policy makers must approach prevention through education programmes. Those affected are now at risk of developing the disabling complications of diabetes, and require treatment.

Access to medicines

Anti-diabetic products are essential life-saving medicines which can improve the quality of life and the productivity of people living with diabetes, and can decrease the risk of developing complications. The World Health Organisation (WHO) estimates that 40% of people with diabetes need oral medicines and 40% need insulin injections.

However, it is estimated that only 3% of people with diabetes in developing countries are being treated. This is partly because the majority of these people have to pay for their drugs out of their own pockets. In addition, health services are overburdened by the high cost of treatment. (To be continued)

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Boosting flagging potency

Q: I suffered an inferior myocardial infarction at age 29. I am now 60 years old. My recent echo reveals a dilated left ventricle with good left ventricular function and inferior to apical ischaemia plus. L.V.E.D.P. is 60. My E.C.G. reveals Q waves in L11, L111, AVF and T inversion in L1, L11, L111, AVL, AVF, V4, V6.

I now take Atenolol 50 mg mane, Losarten 25 mg nocte and Metformin 500mg b.d. I married at 35 and fathered four children.

On the current evidence of the Echo and E.C.G. can I venture to take a low course of Sildenafil Citrate to boost my flagging potency.

C. Francke

Moratuwa

Sildenafil for loss of Libido in patients with I.H.D.

A: As you are suffering from ischaemic heart disease and diabetes and as your 2 D Echo had revealed a dilated left ventricle (main pumping chamber of the heart) it is not advisable for you to take sildenafil without consulting your family physician or cardiologist. Loss of libido and interference with sexual function can be due to your long standing diabetes mellitus or due to atenolol. You may discuss your problems with your family physician or cardiologist and request him or her to substitute atenolol with a calcium antagonist such as diltiazem, which as far as I am aware, does not interfere with sexual function.

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