On 22 March 2020, two weeks after SARS-CoV-2 had reached Bhutan, the King of this small Himalayan country addressed the nation saying that "As a small country with a small population, we can overcome any challenge we are faced with, if the people and the government work together." In the following days, Bhutan sealed its international borders and, given the increasing number of COVID-19 infections in neighboring India, it strengthened surveillance at all formal and informal border crossing points in its southern districts. In August, the first nationwide lockdown was imposed. These precautions helped keep the COVID-19 transmission, and especially its case fatality rate, pretty low in the country, with the first death occurring only in January 2021. In the meantime, while the coronavirus was struggling to enter Bhutan’s borders, the rabies virus easily found its way in, carried around by some of the free-roaming dogs that live across the Bhutanese-Indian border of Samtse district, one of the south-western districts bordering India. In September 2020, a 3-year-old girl was attacked by an unknown, rabid dog while playing by her house located in this rabies endemic area. Her parents washed the wound appropriately (with water and soap for at least 15 minutes). Despite a clinic being available within an hour’s drive, they did not seek post-exposure prophylaxis (PEP) as they assumed the child’s wound was minor and unable to cause rabies. Unfortunately, the girl died two months later. A few weeks before this tragic incident – the first human rabies death since 2016 in Bhutan – in the same area, a pet dog and a calf were also lethally infected by some unknown dogs. In pre-pandemic times, these dogs would most likely have been intercepted by the mass dog vaccination (MDV) programs that Bhutanese and Indian veterinary officers routinely run along the border. Coupled with the high levels of anti-rabies vaccination in the Bhutanese dog population, this measure is implemented to further reduce chances of cross-border transmission. Because of the lockdown both in Bhutan and India, the closure of the border, and the strict movement restrictions imposed in the Samtse district – which was a high-risk area not only for rabies but also for COVID-19 – no annual MDV could happen in 2020 in rabies high-risk areas (Chhukha and Samtse districts), as well as no cross-border activity. This interruption was enough to reduce the herd immunity in the local dog population, which should be at least 70% to stop dog-to-dog and dog-to-human rabies transmission. “Because of COVID-19”, observed a field veterinary officer working in the area, “human movements on the border are now strictly controlled, but for dogs, it's very easy to cross. I hope that now [global] policymakers will realize that rabies should be included in border management activities”. Parallel to MDV, appropriate access to and delivery of PEP is also crucial, especially in rural, remote areas where the access to and provision of adequate health care can be particularly challenging. To achieve the global goal of reaching human rabies deaths by 2030, it is fundamental to have people know that even minor scratches or abrasions without bleeding require prompt medical attention. With regards to PEP provision, the pandemic has shown once more – not only in the case of rabies but of many other health issues – how critical is proximity of emergency health care centers to the communities they serve. The distance from health care centers, and the time and money required to reach them, may easily discourage people from seeking PEP when they are not sure about the severity of the bite. Bhutanese veterinarians have played a key role in the design and implementation of the country’s response strategy to COVID-19 along with officers from the Ministry of Health, demonstrating that a truly operational One Health approach can effectively reduce the impact of health challenges. The same multidisciplinary, cross-sectoral collaboration – where MDV and PEP, and awareness activities too, go hand in hand – is key to achieve zero dog-mediated human rabies by 2030. Despite the sad loss of its young citizen recently, Bhutan is on the right track to achieve this goal. Story by Chendu Dorji (Regional Livestock Development Centre, Chhukha, Bhutan) and Deborah Nadal (University of Glasgow) Story source: World Health Organization
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