Q&A | NICD on South Africa's rabies outbreak: Who is to blame?

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  • There has been a recent spike in rabies infections in South Africa, especially in the Eastern Cape. 
  • This has raised questions about whether a lack of vaccinations by the South African government is to blame. 
  • News24 spoke to the National Institute for Communicable Diseases about the situation currently in South Africa and who is to blame.

Questions have been raised whether a lack of rabies vaccinations has led to a recent spike in cases, specifically in the Eastern Cape.

The Eastern Cape provincial government have launched a mass rabies vaccination rollout targeting dogs in a bid to curb the spread of this vaccine-preventable disease. 

News24 spoke to National Institute for Communicable Diseases's (NICD) Sinenhlanhla Jimoh, Nileen Gale and Dr Jacqueline Weyer about what rabies is, and what the situation currently in South Africa is: 

What is rabies?  

The World Health Organisation (WHO) reports that up to 59 000 deaths of human rabies occur annually in more than 150 countries. Most of these cases occur in Africa and Asia, primarily as a result of poor rabies prevention and control measures in communities beset by dog rabies. 

Rabies is a fatal infection, both in humans and animals. However, the disease may be effectively controlled through mass vaccination in dogs, with a herd immunity achieved when 70% or more dogs in a population are fully vaccinated.  

Humans mostly contract the disease through contact with rabid dogs - therefore, if the disease is controlled in dogs, the risk of human rabies is largely removed. 

In countries where dog-transmitted rabies remain, rabies post-exposure prophylaxis is required to prevent infection in the exposed. 

What is the current situation in South Africa?

In South Africa, approximately 10 cases of human rabies are reported annually, largely as a result of exposure to rabid dogs. Eight cases of human rabies have been confirmed in South Africa to date. 

In addition, a further three probable cases have been reported. The heartbreaking stories of human rabies cases are very similar. The first recorded human rabies death for 2021 was a two-year old child from eNgonyameni in KwaZulu-Natal. He contracted the virus from a dog in January, was hospitalised in February and succumbed to the disease shortly thereafter. 

During the same period, a second human rabies case was reported from Thohoyandou in Limpopo, this time involving a nine-year old child who was bitten by a dog in December 2020, and died two months later (recorded as a 2020 rabies death). 

In June 2021, a seven-year old boy was bitten by a stray dog, and was admitted to hospital after the presentation of symptoms. He died shortly thereafter. Most of the cases reported in 2021 have been in children below the age of nine. 

Increases in the number of dog rabies cases in different locations of South Africa have been reported in 2021. Districts of the Eastern Cape and KwaZulu-Natal are hardest hit. 

More than 150 dog rabies cases have been confirmed in the Eastern Cape, with at least 70 of those cases of rabies from Nelson Mandela Bay. In KwaZulu-Natal, more than 200 cases of dog rabies have been reported for 2021 to date. 

In August 2021, the Western Cape Department of Agriculture Veterinary Services reported two confirmed cases of dog rabies from Khayelitsha in the City of Cape Town. This was the first report of rabies in dogs from the province in decades.   

What is to blame for the spike in infections? 

The Covid-19 epidemic in South Africa has affected everyday life. And as the disease spread, not a single community was spared from its devastating aftermath.  

Safeguarding lives and livelihoods became the top priority, which likely resulted in domestic pet owners and communities, in general, being less involved and less able to ensure the vaccination of their pets.  

It is also anticipated that the lockdown regulations have impacted the ability of veterinary services to deliver routine rabies vaccination campaigns and support surveillance efforts as per usual.  

The full extent of the impact on the delivery of healthcare services for conditions other than Covid-19 will still be learnt. It is generally believed that the healthcare-seeking behaviour of the South African public was greatly affected during lockdown, and as such also those who would have been required to seek rabies post-exposure prophylaxis [PEP].

How can rabies control efforts get back on track?

Rabies is not transmitted from human-to-human, and each case is associated with a sick animal. It is clear that the vaccination of dogs (and to some extent, domestic cats) is the most important intervention to support rabies prevention and control efforts. Globally, the link between dog rabies and human rabies are appreciated. 

Also, in South Africa, the majority of human rabies cases are linked to exposure to rabid dogs. The WHO and other global stakeholders have also taken hands in a pledge towards eliminating dog-mediated human rabies by 2030, a collaboration that seeks to strengthen healthcare systems, give equal access to care and contribute towards sustainable development. 

This is a worldwide goal. Disadvantaged communities are disproportionately impacted, with the majority of deaths recorded in children. In order to achieve zero rabies deaths, bite prevention education and awareness of rabies are needed. For the effective delivery of PEP, good public awareness of rabies and access to treatment is critical. Timely prophylaxis, including wound cleaning, vaccines and occasionally rabies immunoglobulin, are required for people exposed to rabies.

In South Africa's state healthcare facilities, human rabies vaccines and immunoglobulin are provided free of charge. A thorough risk assessment and adequate delivery according to the WHO and national guidelines will minimise the overuse or misuse of PEP and guarantee the availability of PEP for individuals requiring rabies post-exposure prophylaxis. 

As infections are acquired in most cases from dog bites, the importance of dog vaccination awareness and increased vaccination rates is essential to minimise human exposure.

A future free from human rabies deaths will not transpire on its own.

Increasing community awareness of the disease and its prevention is vital, and initiatives, for instance, World Rabies Day on 28 September, aims to achieve exactly that.

Vaccination is key.

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