Moaning in pain with tears trickling down his eyes, 13-year old Mohammad Afzal was firmly held down by two attendants; a nurse administered an anti-rabies vaccine (ARV) directly into the dog-bite wound near his right-hand ankle. Before that, he was given a shot of rabies immunoglobulin (RIG) — a fast-acting drug which is given in severe bite cases for immediate protection against rabies — on his arm.

Accompanied by his older brother's friend to The Indus Hospital (TIH) in Karachi a week after he was bitten by a dog, this was the first time his wound was being treated by a healthcare professional.

Afzal had been nursing his wound for a week, with his mother putting chillies on it. "My sister had been bitten five months ago and she did the same and had become well," explained the young boy from Shah Abdul Latif Colony.

He was passing through an alley on a bicycle when the dog pounced on him and bit him on his ankle.

"My wound worsened after I took a bath a few days later. So we went to the local clinic and the doctor there advised us to come to this hospital," he told Muhammad Aftab Goher, manager at the TIH's rabies programme, where the vaccine is given free of charge.

In the last six months, six cases of rabies were reported from two hospitals in Karachi — TIH and the Jinnah Post Graduate Medical Institute.

Infectious disease specialists say steps need to be taken to curb the trend.

Symptoms include a 'choking sensation'

A string of dog-bite victims continue walking into the rabies prevention clinic (RPC) at the TIH. Others wait patiently outside in the corridor. Some are follow-up patients, some come with fresh wounds and some come nursing a few days old ones, mostly because the ARV was not available in their area clinics.

Editorial: Rabies on the rise

The ones who have been freshly bitten are immediately made to sit near a washing area inside the small clinic where the wound is washed with soap and water for up to 20 minutes before they are attended to.

Immediate, thorough wound washing with soap and water after contact with a suspected rabid animal is crucial and can save lives.

"The symptoms appear nearly six weeks after a bite from a rabid animal (usually a dog) when the victim develops fever, headache, limb pain, and then a burning and choking sensation in the throat," explains Dr Naseem Salahuddin, who heads the infectious disease department at TIH, and also founded the rabies prevention clinic there back in 2008.

This eventually leads to an inability to swallow water.

The RPC attends to nearly 30 new patients in a day. "If you include the follow-up patient, the number can go up to 80 patients on a given day," says Goher, who is also a WHO-certified expert for rabies surveillance and control.

According to the World Health Organisation (WHO), rabies is a 100 percent vaccine-preventable viral disease, which is spread to people through bites or scratches of animals, usually infected dogs.

Once the clinical symptoms appear, it almost always causes death.

Dr Salahuddin says the last few moments of a rabies patient, which include "gasping and trying to swallow their spit but choking instead", are the most horrifying.

Treating more than a hundred dog-bites a day

Three other facilities in Karachi also cater to dog-bite cases —the Civil Hospital Karachi (CHK), National Institute of Child Health (NICH) and the Jinnah Postgraduate Medical Institute (JPMC).

"Indus and the JPMC are two big centres in Karachi so mostly the CHK and NICH refer rabies patients to us," says Goher, adding, "clearly these are not enough given the huge number of people bitten by dogs every day."

At the JPMC rabies prevention clinic, they treat anywhere from 100 to 140 bite cases a day.

In the last six months, the clinic has treated 5,004 dog-bite victims. In 2018, the number was 7,900 and they administered the anti-rabies vaccine to all. The same year the hospital received nine patients with full-blown rabies who had not been given the vaccine.

And at the Indus Hospital, informs Goher, they vaccinated a little over 3,500 dog-bite cases in the first six months of this year. Many of the patients had been referred to them by CHK.

"With the number of stray dogs roaming about the city and the huge mounds of garbage, the number is definitely going to increase," pointed out Jamali, who heads the dog bite clinic and rabies prevention centre based inside JPMC's emergency.

Jamali tells Dawn.com, "The nine dog-bites cases that came to us with rabies in 2018, all died within 24 hours. None of them had been administered the vaccine prior to coming to us. All we can do at that point is to provide them comfort. We just sedate them to make their last moments easier for them and their relatives."

"It is a poor man's disease," Dr Salahuddin points out. Internationally, too, it remains on the list of WHO's neglected tropical diseases.

Despite being preventable and its end being so horrific, rabies remains under the radar of the government.

Karachi's mayor, Wasim Akhtar, lamented that since the past 12 years, with the local government stripped of its powers by the provincial government who held the purse strings, the civic situation in Karachi had worsened.

Vaccine in short supply

Experts at both TIH and JPMC complained of a vaccine shortage. "We survive month to month," acknowledged Jamali, adding it was not easy to procure this imported drug.

"Earlier last month, a father from Shikarpur brought his 11-year old son to our clinic who had been bitten a few weeks back. The father had been going around various clinics in Shikarpur and Larkana, in search of the vaccine and by the time he reached Karachi and our clinic, it was too late," says Goher, adding, "If the person is able to get the vaccine administered before the onset of clinical symptoms, his chances of survival are high, otherwise this infectious viral disease can almost always prove fatal."

"Vaccines from France and Germany are reliable but logistics make it very expensive. So we get the ones produced in India which is more economical," he explained.

Since the last one year, importing these biologicals has become very difficult from the neighbouring country," said Goher, but was not sure of the reasons behind the shortage.

Soon the shortage will be a thing of the past if the Islamabad based National Institute of Health (NIH) gets it act together. Set up in 1960, NIH is an autonomous organization under the Ministry of Health (MoH), which has been conducting research and producing various life-saving vaccines for over 40 years.

"We are already producing the anti-rabies serum (immunoglobulin) and also producing a limited quantity of top of the line cell culture ARV," informs NIH's executive director, Dr. Aamer Ikram, over the phone from Islamabad.

"We produce the serum and now the vaccine as well on order only for public hospitals, not for the market," he clarified.

Read: Rabies vaccine short world over, says minister

This year the NIH labs produced 200,000 doses of the serum. "Our target is to be able to produce 400,000 by end of this year, although if all goes smoothly on the funding front, we may be able to produce up to 600,000 ARVs," he said, estimating the requirement to be 10,000,000.

Evaluating an endemic problem

Annually, nearly 60,000 such deaths have been reported the world over. There is no central registry in Pakistan to get an accurate data of reported dog bite cases or even of deaths caused by rabies, but Dr Salahuddin estimates the number of dog bites to be in "several thousand".

While the government may not be interested in counting the country's dog population, between 2008 to 2010, a national dog-bite and rabies surveillance was carried out by TIH in partnership with Interactive Research and Development. The nine tertiary health centres that were part of the study reported 367 deaths by rabies.

The research found 76.8% cases were reported from urban centres compared to 23.2% from rural, more men (83%) than women (17%) were reportedly bitten, and males aged between 10 and 14 were bitten the most.

"Our policymakers remain unconcerned as they never know what it is to walk or bicycle in narrow alleys where stray dogs are lurking and ready to pounce," said Akhtar, who is concerned about the large number of dog bite cases the hospitals receive every day.

Yet, Jamali equally holds the people responsible for their lackadaisical attitude. She says there is a complete lack of awareness about the dangers of contracting rabies.

"They do not take dog bites seriously. In rural areas especially, the kids often do not tell parents if they have been bitten unless it's really bad. Then when they do find out, mothers usually try some home remedies. If that does not work, they take them to pir/faqir (faith healers) who puts a herbal medicine on the wound," explains Jamali.

"When the extreme symptoms of fits appear, they think he or she is under the influence of some djinn and continue seeking the help of a faith healer until the person succumbs to death."

In her 30 years of practice, Jamali has seen as many as 60 deaths from rabies at JPMC — many of them kids under 15.

Making Karachi rabies-free

The WHO wants to eliminate human deaths caused by rabies by 2030 globally, but Dr Salahuddin does not think Pakistan will be on the list of countries that can proudly claim this feat.

"No way! We are probably on our way upwards!" was her first reaction, but added more cautiously: "Since we don't have surveillance we don't know the incidence."

And although deaths by rabies fill her with "sadness, deep dissatisfaction and frustration at Pakistan's dysfunctional healthcare," Dr Salahuddin rebounds and says, that after every death she has witnessed in herself a "renewed resolve" to prevent this horrible tragedy from ever happening again.

For now, TIH is concentrating on tackling the disease one locality at a time in making Karachi rabies-free; the Karachi Municipal Corporation partnered with Dr Salahuddin in the Rabies Free Karachi (RFK) campaign, initiated last year.

It all started with a pilot to control dog-bites and transmission of rabies. The fishing village of Ebrahim Hyderi, historically known to have had outbreaks of dog-transmitted rabies, was selected.

"The aim was to eradicate the problem from the root, and killing dogs was not only inhuman but least effective," says Goher.

They planned to vaccinate all the dogs, catch the stray ones and neuter them to control the dog population and to engage with the community and sensitize them about treating animals with compassion (not unnecessarily teasing or attacking them).

Goher explains, "We knew if we succeeded in vaccinating even 70% of the dogs, we would have developed herd immunity and the disease would not spread," adding, that they vaccinated 3,500 dogs and 1,500 were neutered.

According to him, this has successfully been carried out in Sri Lanka, Bhutan and even the Philippines.

Goher says Karachi's leading veterinarians, animal-rights activists, doctors and researchers were all involved in this project. But before that, a dog count was carried out. An international expert trained the team of vaccinators, dog catchers, and vets.

Fifty thousand vaccines were provided by the WHO, and although the city government pledged Rs20 million, the project received only 25% of that amount. Irrespective, TIH managed to collect the rest from philanthropists and civil society.

Acknowledging he was unable to provide the pledged amount to TIH, in his defence Mayor Akhtar said that extricating funds for such campaigns from the Sindh government as well as the federal government "was a gargantuan task" when he cannot even get enough to pay salaries to the municipal staff.

He continues, "It's a huge city and it needs resources. Without funds, our hands are tied."

Akhtar also points out that to really make Karachi rabies free, the project has to be scaled up to cover the entire city and everyone must have a stake in it, "It will succeed only if all the landowning agencies work together simultaneously."

Related: Eliminating rabies

After the resounding success in Ebrahim Hyderi village where no outbreak has been reported since last year, the project has been replicated in Korangi, Landhi and Lyari simultaneously. In all, eight TIH teams have vaccinated 15,000 dogs in these four areas.

However, to have Karachi free of rabies, they need to spread the same plan across the city, not do it in pockets.

Zofeen T. Ebrahim is a Karachi based independent journalist. She has written extensively on development issues including climate change, water, energy, renewables, sanitation, health, gender, child rights, women’s rights and health, diseases etc., and how these impact our lives every day.

She is currently the Pakistan editor for The Third Pole, dedicated to promoting discussion about the Himalayan watershed and the rivers that originate there.