As its rabies plan lags, Cambodia feels the bite
Despite killing some 800 people in the Kingdom each year, rabies has been largely off the public health radar. Plans are in the works for a nationwide response, but can funding catch up?
When her 15-year-old daughter Thai Sopheak was bitten by a dog last month, Kat Soklim took no chances. She had known a man from a nearby village who died following a dog bite the year before, and she wasn’t going to let her daughter suffer the same fate.
Sopheak is one of the lucky ones; for the past month, she has been leaving her village in Kampong Cham’s Prey Chhor district every few days at 6 in the morning to head to Phnom Penh. Her destination is the Pasteur Institute’s vaccination centre, where she can get postexposure rabies treatment against the otherwise incurable virus.
Rabies, which is known as chkae chkuot or “mad dog” disease in Khmer, has a 100 percent fatality rate if a patient isn’t vaccinated before the disease takes hold, and it is estimated to kill as many as 800 people – disproportionately children – each year in the Kingdom. Nonetheless, there is currently no national programme to address the disease, and a lack of resources persists when it comes to vaccinating both people and animals.
“It’s years late,” Dr Ly Sowath, who is in charge of the rabies vaccination centre at the Pasteur Institute, said of a nationwide rabies strategy.
“The progress is rather slow in putting together a national programme compared to programs for dengue or malaria or tuberculosis.”
In part because of this, access to the vaccine – which if administered in time is completely safe and effective – is extremely limited. People are often forced to take hours-long journeys to the only trusted vaccination centres, which are in Phnom Penh or Siem Reap – a precaution they will only take if they are aware of the disease and can afford the travel.
From the day her bitten neighbour died, Soklim said, “people in the villages knew about it by word of mouth”.
“So whenever there is a dog-biting case, we hurry to the hospital,” she continued, adding that while she was offered a vaccination at her local district health centre, she did not trust it, nor did she want to pay for it. At the Pasteur Institute, vaccinations are heavily subsidised.
Sowath said that about 22,000 patients – or more than 60 each day – come to the clinic every year, mostly with dog bites. “More than 50 percent are children aged under 15,” he said. “They are more at risk of dog bites.”
The patient data collected by Pasteur highlight the disparity of coverage in the country, with a vast majority of patients coming from provinces within 100 kilometres of Phnom Penh. Sowath attributes this to access, not to the relative scarcity of bites in farther-flung parts of the country, meaning that most incidents likely go untreated and unreported.
Any patient arriving at the clinic is first interviewed. Knowing whether or not the biting animal is still alive by the time the patient receives their third shot helps to discern if the animal was rabid, as it would have died within seven to 10 days. A quicker way to find this out, however, is to test the animal itself, which is why the clinic receives an average of 20 to 30 dog heads each month.
“We do the test for free at the lab so we can know within 24 hours whether the head was [rabies] positive,” Sowath said. “Fifty percent of dog heads brought to the institute test positive.”
To assess the scope of rabies among the dog population, the Pasteur Institute is currently tracking dogs in 10 villages in Kandal province over a year-long period to see how many die or disappear and how many are born.
“This will inform the plan of a vaccination of dogs – if there is ever a plan of vaccination,” Sowath said.
For now, the priority is saving human lives through post-bite vaccinations, which need to be administered as soon as possible.
Most reach the Pasteur clinic within two days of being bitten, which means they are being treated very early in the one-to-three-week incubation period of the virus. Once the virus begins exhibiting symptoms – fear of water, light sensitivity, difficulty breathing, sensitivity to stimulation and ultimately convulsions – it’s a death sentence.
“There’s nothing we can do for them except ease the suffering,” Sowath said.
Worldwide, rabies fails to capture the same attention as other deadly diseases. It is largely ignored by global health organisations and in Cambodia, the government has failed to set up a plan to combat it.
While commitments exist on paper, and the relevant ministries are working together, a lack of financial commitment is stalling progress.
But this may soon change as the government is in the process of finalising national guidelines on rabies surveillance, prevention and control, with support from the United Nations Food and Agriculture Organization, the World Health Organization and the Pasteur Institute.
Dr Ly Sovann, the director of the Communicable Disease Control Department at the Ministry of Health, acknowledged this week that the government has its work cut out for it.
While the last comprehensive study 10 years ago estimated 810 rabies deaths each year, the government confirms, on average, fewer than 20 deaths yearly. The vast majority of cases fly under the radar, he says, because local health officials may not report all the way back to Phnom Penh.
“I think it’s still our culture that when the doctor diagnoses [a case] as rabies, they usually refer the patient to go back home, so that is why there is not much reported,” Sovann said. “We may miss the people who die and don’t report.”
When a case is reported, an “animal health doctor” from the Ministry of Agriculture is dispatched to visit the house and inspect for other dogs. When asked about rabies reduction and elimination, Sovann simply raised his hands and pointed to a lack of funds.
“It’s still very limited,” he said. According to Sovann, the Health Ministry’s meagre rabies budget is supplemented in part by the World Health Organization and the United States Centers for Disease Control, among other partners. Nonetheless, total funding is less than $100,000 per year, much of which goes towards responding to cases.
What’s needed for elimination is millions of dollars, Sovann said, for a concerted public education campaign to get people to vaccinate their dogs, as well as to buy and administer the animal vaccines.
The guidelines for a national plan, Sovann said, will focus education first and then on a national animal vaccination campaign.
“We need to vaccinate at least 70 percent of the dogs,” he said.
According to Etienne Careme, a spokesman for the FAO in Cambodia, the government does have a stock of several thousand animal vaccines, which it deploys in several provinces. Nonetheless, none of the provinces meet the 70 percent targeted vaccine coverage.
In 2016, Asean governments agreed to aim for the elimination of rabies by 2020, but it is doubtful that Cambodia or its neighbours will reach that goal, as no concerted effort to fund the plan at a regional level was ever set in motion, according to Sovann.
Given that rabid animals can freely cross borders, regional cooperation to actually eliminate the disease is required, he added.
“We have planned together in the Asean countries – every government – but the commitment for the funding . . . to work together to eliminate [rabies] is not there yet.”
According to Careme at the FAO, the costs and lack of a years-long commitment to a countrywide dog vaccination campaign are the greatest obstacles to eliminating rabies.
The lack of resources to fight rabies is a global concern not limited to Cambodia, said Pasteur Institute Director Dr Didier Fontenille.
“There are no big companies or big foundations interested in putting money in rabies,” he said, noting that the institute is involved in global lobbying efforts to that end.
When it comes to Cambodia, the data being collected on the dog population are showing a mix of good and bad news.
“What is not good news . . . is that the dogs are making a lot of babies. The turnover of dogs is high,” he said, noting that 25 to 30 percent of the dog population is replaced each year.
“That means that if you vaccinate dogs only every three years, you miss 80 percent.” On the other hand, nearly all of the country’s dogs have owners – even many of those that roam freely – which means that responsibility for vaccination can be pinned on owners, Fontenille said.
In a pilot trial in a village earlier this year, done with the Ministry of Agriculture, Fontenille said that they found owners to be happy to vaccinate their dogs – probably because the service was free.
“It is very complicated, but for me it is very possible,” he said.
But while a full prevention effort to eliminate rabies may be out of reach for now, at least preventing human deaths through post-exposure treatment is an attainable aim.
To that end, the Pasteur Institute is aiming to raise $1.2 million to operate two more rabies vaccination clinics over five years – one in Battambang to cover the northwest of the country, and one in Kampong Cham, chosen because many national roads intersect there.
According to Fontenille’s estimates, these two clinics alone would save as many as 400 lives per year. They could also serve as pilots for the Ministry of Health to then scale up with their own resources, placing a clinic every province. Saving these lives, he said, is a must.
“One hundred and thirty years after Louis Pasteur discovered the rabies vaccine and we still have 800 deaths per year in Cambodia,” he said. “It is not acceptable.”