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29th November 1998
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The Kandy Society of Medicine

The Rabies virus enters the human body only if salivary contact is associated with a break in the skin

When that dog bites

By Vasanthie Thevanesam 
Rabies is a fatal disease for humans. In 1994 and 1995, 105 and 151 deaths were recorded in Sri Lanka respectively. It is caused by the rabies virus - a member of the Rahabdovirus family.

Rabies is a zoonosit disease (ie. a disease of animals where human infection can occur if conditions are right) with risk of human disease only when there is exposure to saliva of a rabid animal. Entry of virus is possible only if salivary contact is associated with a break in the skin surface (eg. bite, lick on abraded skin or scratch) or intact mucousa.

Not all patients exposed to the virus develop the disease. However, as the disease is invariably fatal, it is necessary to view all encounters with rabid or suspect rabid animals where the necessary salivary contact has occurred as risk exposures. In addition, the incubation period after a risk exposure is very variable, the majority of patients with human disease presenting within 3-6 months although later presentation has been documented.

Animal rabies is endemic in Sri Lanka. As in the rest of the world, the majority of risk exposure are to dogs (90%). 

Sri Lanka has a very high dog population, estimated at a dog/human ratio of 8:1. Many of these dogs roam these streets, either as stray animals or semi-domestic animals. Attempts at controlling these dog populations have been largely unsuccessful for a variety of reasons. Risk encounters with other animals, both domestic and wild, may result in rabies, although the proportion, remains very small in comparison with dogs. The mongoose is believed to be an important host to the virus in Sri Lanka. Cats, cattle (bitten by rabid dogs), monkeys, bears and wild canines may also develop rabies and therefore be a risk to a human being if salivary contact as described above occurs.

The eradication of animal rabies will result in the disappearance of human rabies. Both animal and human rabies are eradicable, given the necessary resources.

Eradication programmes are based on:

* post exposure management of patients following risk exposure 
* immunization of domestic animals - dogs and cats
* eradication, immunization or sterilization of stray dogs
* pre-exposure immunization of high risk groups.

All risk exposures should be assessed for post exposure immunization. However washing of the bite or salivary contact site with copious amounts of water and soap or antiseptic as soon as possible after the bite is essential. This reduces the virus load at the site and substantially reduces the risk of disease. Where the patient has been extensively bitten or in children where facial and upper extremity bites are not uncommon, washing after anaesthesia should be considered.

All patients with risk exposures should be given ARV. Currently available Anti- Rabies Vaccines ARV are produced in cell cultures and are safe. 2 regimes are in use in Sri Lanka. One consists of 5 doses of vaccine given on days 0 (day of first vaccine dose), 3.7.14 and 28. The vaccine is given by intra muscular injection. All 5 doses should be given to be sure of the protective effect of the vaccine. Immunity lasts for at least one year, although if further exposure occurs during this period, it is safer to ask for an expert opinion on the need for booster doses. ARV is given intradermally (into the skin) in the second recently introduced regime. 4 injections are given on the first visit and a further four at a second visit one week later.

If the virus load is high or virus is innoculated at a site with a high density of nerves (finger and toe tips, face, genitalia) the incubation period may be too short for the vaccine to be effective. Already prepared antibody in the form anti-rabies serum (ARS - prepared in horses) or Human Rabies Immunoglobin (HRIG) needs to be given urgently in these situations. It is important to give as much of the antibody as possible around the bite/s, and the antibody preparations should be injected around all bite wounds. In children and patients with extensive bites, this too may be best done under anasthesia. ARS and ARV should be given as early as possible after a bite from a risk animal. However, they should still be given even if delays have occurred.

Immunization of domestic animals - dogs and cats - is both the responsibility of owners and of the State. Anti-rabies vaccine is available free from the state veterinary service. Animals should be immuized annually and immunization records kept. The eradication, immunization or sterilization of stray dogs is perhaps the single most important factor in the prevention of human rabies.

Prevention of human rabies therefore in the foreseeable future will depend on immunization with anti rabies vaccine (ARV). Persons in occupations which put them at risk (eg. veterinarians, quarantine officers, etc.) are offered the vaccine prior to starting their work and immunity maintained by regular boosters (annually or every 2 years). The majority of those requiring vaccine however are offered vaccine after a risk exposure - defined as contact with rabies virus which could result in human rabies (post exposure immunization). Such risk exposures are assessed on 3 criteria: animal concerned, type of contact and site and extent of bite.

All exposures to wild animals (carnivores including stray dogs and cats, foxes, bear etc., mongoose, monkeys large squirrels etc.) and to domestic animals ( cat, dog, cattle) which are not immunized within the past year and/or with altered behavior are considered risk exposures. It is important to remember that salivary contact through a bite or of broken skin or intact mucosa (conjunctiva) is needed for the virus to enter the body.

The incubation period is short if inoculation (by bite) occurs in highly innervated areas as the face, tips of fingers and toes and genitalia. These bites are considered high risk bites and preventive action should be taken as rapidly as possible. Small rodents such as mice, rats and small squirrels are not recorded as carrying the rabies virus. Bites by these animals are therefore not considered risk exposures. Although patients with rabies also have virus in their saliva, human to human transmission of this disease has not been reported. However, bites by these patients or heavy salivary contamination of eczematous or otherwise damaged skin may also be treated as risk exposures.

The writer is attached to the Department of Microbiology, Faculty of Medicine, Peradeniya. 

Medical Diary

* December 3, 1998, (Thursday) - A Course in Practical Dermatology for doctors at the Sri Lanka Medical Association, Wijerama Mawatha, Colombo 7.

* December 5 and 6, 1998, (Saturday and Sunday) - Sri Lanka Medical Association and Ruhunu Clinical Society conduct a joint clinical meeting at the Weligama Beach Hotel and the Matara YMBA.

* December 16 to18, 1998 (Wednesday to Friday) - Symposium on "Technology for health care beyond the year 2000" conducted by the Peradeniya Medical School Alumni Association at the Plant Genetic Research Centre, Gannoruwa.

* December 19, 1998 ( Saturday) - 7.00 p.m. - Annual General Meeting of the Sri Lanka Medical Association at Wijerama House, Colombo 7.

Watch out for the Kandy Society of Medicine confab

The Kandy Society of Medicine (K.S.M.) will hold its 21st Annual Scientific Conference from February 11-13 in Kandy.

Shaun E. Donnelley, the Ambassador of the United States of America will be the Chief Guest.

The Programme highlights are: 

The Bibile Memorial Oration, The Kandy Society of Medicine Oration, The Kandy Society of Medicine Research Prize Lecture, Guest Lectures, Symposia, Short papers, Poster Presentation and Meet the Expert-sunrise sessions.

A pre-congress workshop, which is a new feature added this year has been organised on "Stoma Care". Several renowned scientists from Sri Lanka and abroad are due to participate, according to Dr. Sarath Wettegama, President, Kandy Society of Medicine.

How much do you know about AIDS?

December 1 is World AIDS Day. There has been a gradual public awareness of this deadly disease in Sri Lanka and you could test your knowledge about it by trying your hand at these questions. See whether the statements given below are true or false:

1. The majority of HIV infected persons are homosexuals.
2. Deep kissing can transmit the AIDS virus.
3. Sri Lanka has about 10,000 people carrying the AIDS virus.
4. Medical accidents are a major method of transmitting the AIDS virus.
5. A pregnant mother carrying the AIDS virus has only a small chance of passing the disease to the baby.
6. AIDS can be transmitted through coughing, sneezing or the sharing of food utensils.
7. A blood test taken two weeks after sexual activity with an infected partner, if negative, will exclude the disease. 
8. The age group which is most at risk of developing AIDS are those in the thirties.
9. The proper use of condoms slightly reduces the chance of contracting the AIDS virus.
10. AIDS is curable with advanced treatment in developed countries

Answers: all are false!

1. Not any more; Now most cases acquire the disease through heterosexual contact.
2. No such cases have been demonstrated, but it must be remembered that saliva carries the AIDS virus, so it remains theoretically possible.
3. At present only about 300 cases have been identified but the actual number of people infected with HIV may exceed 25,000.
4. Medical accidents account for less than 0.05% (one in 2000) cases
5. The risk is high. About 30% of infected pregnant women pass the virus on to the child.
6. No. These contacts are absolutely safe.
7. Some tests may take over six months to become positive after a sexual or any other type of exposure. This is called the "window period"
8. The age group with the highest incidence of AIDS is the 15 to 25 age group. More than half of all HIV positive cases occur within this group.
9. The use of condoms reduces the chance of contracting the disease by over 90%.
10. No drug has yet been discovered to satisfactorily combat the disease, though some may after it's progression.

HRT: What women should know 

* Hormone Replacement Therapy 

* What is Hormone Replacement Therapy? (HRT)

Hormone Replacement Therapy (HRT) is the replacement of female hormones around the time of menopause. Now widely practised in western countries, it is gradually gaining acceptance in Sri Lanka too. The hormones replaced are aestrogen and progesterone.

*Why is HRT undertaken?

HRT is prescribed when menopausal symptoms cause discomfort to a woman. However it has the added benefits of reducing osteoporosis (a condition caused by weakening of bones) and also the risk of heart disease.

* Is there an age limit for HRT?

In general, menopause occurs in women between the age of 45 and 55 years. HRT can be prescribed whenever a women feels that her menopausal symptoms are causing her distress. There is no upper age limit to prescribing HRT. Also, it has been noted that women who reach menopause early in life (earlier than 40 years) have a greater risk of osteoporosis or heart disease. 

They are good candidates for HRT.

* Are there any other benefits of HRT?

There are recent studies showing evidence that HRT may also protect or delay the onset of Alzheimer's Disease, a disease of the brain causing progressive loss of memory.

*What are the side effects of HRT?

The commonest complaints from women taking HRT are breast tenderness, leg cramps at night, nausea and irritability. In addition there may be bleeding similar to that experienced during periods. Some women find this very discomforting in which case, special "no period" HRT preparations may be be prescribed.

*Does HRT cause breast cancer?

Since oestrogens are thought to promote breast cancer, many women believe the use of HRT could increase the risk of breast cancer. However, this has not been proved despite extensive research. In fact some doctors go to the extent of prescribing HRT for women who have been completely and successfully treated for breast cancer. However HRT is not used on those with untreated breast cancer.

* When should HRT not be used?

If a women has unexplained vaginal bleeding, active breast cancer or cancer of the uterus or has active liver disease, HRT should not be used. A past history of breast cancer or cancer of the uterus, fibroid or heart disease are other conditions where HRT is used with extreme caution if at all.

*Does HRT also act as a contraceptive method?

HRT is not a reliable form of contraception. So if a sexually active woman is prescribed HRT, other methods of contraception should be used, because an un-planned pregnancy in the late forties would be a significant burden on a woman. However, it is recognised that HRT significantly reduces fertility.

More problems than solutions

Second Opinion

Sections of the media re ported last week that a privately funded medical college was to begin accepting students in 1999. This college would function as a BOI company, these reports said.

This country has had previous experience of one private medical college and that experience has been a bitter one. That college was taken over by the government after becoming the rallying cry of the 1989 youth uprising and is today the medical faculty of the University of Kelaniya.

In the light of these events but more importantly, given the circumstances 10 years later the prudence of setting up a privately- run medical college affiliated to an overseas university will naturally be questioned.

Certainly, Sri Lanka needs more doctors: in fact, as much as it can produce. At present the state is training about 1000 doctors a year in the six state medical faculties. Supplementing them are the so-called "foreign" graduates; Sri Lankans graduating from overseas medical schools.

But, despite a definite shortage of doctors in the state sector, the government is faced with a dilemma. In a few years, it will not be able to offer employment to even doctors graduating from our universities because the health infrastructure has not kept pace with the development of more medical faculties producing more doctors. Already this situation is creating unnecessary friction between doctors, where foreign qualified graduates are perceived by local graduates as "those who take away our jobs". Already disputes between these factions have gone to courts. And, what's more, the number of foreign qualified graduates has been steadily increasing, compelling more stringent qualifying examinations (the famous 'Act 16' examination) and more fears among local graduates about future job security.

In such circumstances, what would be the plight of doctors from a privately funded medical school affiliated to an overseas university? Are they to be treated as "foreign qualified" graduates? What would their status be with regard to state sector employment? Will they, for instance, be asked to sit the 'Act 16' examination?

These questions must be comprehensively answered by the administrators of this college before they begin. Some respected names in the medical profession are being mentioned as being behind this medical school, but even they should consider these issues before they begin.

We are sure they would agree that parents now sending children overseas for medical education spend several millions of rupees. This could be drastically reduced if a private medical school were to be opened in Sri Lanka. As simple as this may seem, this must be considered against the fact that five years from now, there will be many many unemployed doctors in the country.

Hindsight tells us that private medical education in Sri Lanka is subject to many social and political pressures. The previous private medical school has produced doctors who excelled even in post-graduate examinations. But the turbulence it caused forced other students in that school to abandon studies or spend even more money and enlist again in foreign universities. Altogether, the experience was a traumatic one.

If one is to learn from this little bit of recent history the lesson is that histry should not be allowed to repeat itself. So, it is the duty of the administrators of this new medical school as well as the government, the Medical Council and the medical profession to ensure that innocent students - even if they are "rich" - will not suffer again as a result of embarking on a medical career in a private medical school.

Now there's a new book on PIH

"Pregnancy Induced Hypertension" (PIH) edited by Professor Harshalal R Seneviratne and Dr. (Mrs.) Chandrika N Wijeyaratne, the latest book in the series"Obstetrics and Gynecology in Perspective" will be launched at 11.30 am on Monday, November 30 1998 at the Faculty of Medicine, Colombo. The lauch is sponsored by Vijitha Yapa Bookshop.

Pregnancy induced hypertension is high blood pressure occurring in pregnancy. It has the potential to affect the life of the mother and her unborn child. Approximately 10 percent of pregnant mothers can be afflicted with this problem. Recent data has revealed that severe forms of this disorder have contributed to maternal deaths in Sri Lanka.

This book has been compiled with contributions from many Sri Lankan specialists in this field of medicine, as well as experts from the South Asian region. 

It addresses the difficulties of managing critically ill mothers and their unborn babies in the setting of a developing country with limitations in health care facilities.

This book could assist medical undergraduates, postgraduate trainees in obstetrics and medicine as well as trainers and health care workers in related fields to obtain comprehensive knowledge in this important field of obstetric medicine.

Harshalal R Seneviratne is the Professor and Head of Department of Obstetrics and Gynaecology at the Faculty of Medicine, University of Colombo and Dr.( Mrs.) Chandrika N. Wijeyaratne is a senior lecturer in Reproductive Medicine at the Faculty of Medicine, University of Colombo.

December 1 is World AIDS Day

A 'nest' for the sick

Caring for AIDS patients is a priority for this group 

By Eric Samuel
Part of the work of Nest is caring for people with HIV and AIDS. We were often asked how we set about it. Well, this was one way. 

We met a man who was HIV positive. He was very weak when we met him. He could barely sit up, in fact, he did not want to. He had young children. His wife had no idea of the condition of the husband. We started visiting him regularly. Chatting with him about how he was feeling, what he had gone through, his fears and his hopes. 

Gradually he begun to sit up to talk of the future of planning for his family. Meanwhile, we took him nourishing food, fresh linen, and magazines. He became stronger and was able to walk again.

We continued to visit him at his home and talked to his family and encouraged them to talk to each other. We taught them how to care for him. It was marvellous to see his neighbours begin to help us as well.

As he had lost his job (he was fired when his employers found out that he had AIDS), we provided his family with a monthly cash allowance to buy essentials.

One day, he and his wife came to Kare House, our main base in Hendala. He had acute diarrhoea and was in intense pain. We took him in a three-wheeler to hospital. We visited him there daily, sometimes twice a day. Often, we took food and essential medicines. We realised he was dying and he knew it. Well, our friend died in hospital.

We supported the family with a monthly cash allowance for some time and visited regularly. But I am happy to say the family is on its own now, but know they can contact us at any time.

That was an example of the type of care that Nest gives people.

We began in 1986, with the objective of helping people who were stigmatised. And therefore isolated or institutionalised.

At the beginning, we visited women who were institutionalised because they had been diagnosed as mentally ill. Gradually our work evolved to other areas in community health and to HIV and AIDS. Today our staff consisting of 34 paid and qualified community health workers are in eight districts of Sri Lanka. In each district Nest rents a house where they live. They visit people in homes and institutions daily.

We also organise training programmes and workshops for different groups and for our own staff at Kare House in Palieyewatte, our main home.

The aims and objectives of Nest are:

* To promote coping within communities;
* To promote understanding in the areas of mental health;
* to lift the yoke of labelling and stigmatization;
* to promote justice and freedom;
* To see happiness

What emerges from the objectives of Nest, is the strengthening of people and communities to cope with their lives. An important aspect is challenging attitudes which discriminate and stigmatise people for being different to others.

For instance, do you meet people who are not conforming to a particular standard or norm in society? We feel, that the biggest threat to health and well-being, is lack of acceptance and support in our communities.

We regularly conduct workshops aimed at changing people's attitudes, and we recently conducted a series of pavement stalls where our community health workers met the people of Colombo and gave out free literature. We have also produced two short films showing how a person living with AIDS can live a full and happy life with good home care.

The challenge today is one of spreading the word that the need for care and support of people living with HIV and AIDS is of utmost importance and the need of the hour. The emphasis now is on prevention. 

Those programmes should be designed remembering that people with HIV and AIDS exist. The attention given to stigma, care and support needs to be more pronounced and obvious - not superficial.

Nest has always shown that the divide between prevention and care cannot be artificial and that a continuum between these two has to exist. This is our path. Our challenge to our fellow citizens.

Every person we work with is different and special, Nest's reason for helping them is not due to the fact that they are diagnosed as HIV positive. We felt that the way they are being treated needs to change.

At Nest, we feel it is our responsibility to help each person to live as happy and full a life as possible, for as long as possible.

The writer is Associate Director and Community Health Worker at Nest

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