Rabies and the Philippines - A Guide and Rant

Rabies is scary.  I kid you not.  I can't walk down the street in the neighborhood without thinking every dog and cat I encounter has it.  Dogs and cats are running around everywhere unchecked and unleashed and until pet owners take the responsibility for their pets this disease will continue to proliferate in the Philippines.  Not to mention the huge amount of poo that I have to watch out for daily!  But that's a whole separate blog.

If you're not familiar with rabies it is a viral disease that causes acute inflammation of the brain in humans and other warm-blooded animals.  It's not a pretty disease.  So if you get bit, get the shots.  No buts about it just get the shots.  Also, if you get scratched get the shots.  You might think it would be a long shot but it is better to be safe than sorry.  Filipino's have this tendency to just shrug it off or "mahiya" and they don't get the shot.  But I implore you, get the shots.

Now that I have mentioned that, what is the procedure here in the Philippines?  Well, it depends on the area you live in.  In Taguig, the standard shots are free of charge.  But in other areas you have to pay for everything.  The first thing you need to do after getting bit is to clean the wound with soap and clean water.  Dress the wound and make sure the animal is secured.  Go to the local barangay health office and tell them what happened.

They will give you an anti-tetanus shot and give you some instructions.  Most likely they will tell you to observe the animal for about a week and if it shows rabies symptoms to kill the dog/animal and take its head to San Lazaro.  The local health office will also give you a recommendation letter that you will need to show to the hospital staff when you get your shots.

NOTE:  If you get bitten or scratched on your upper extremities such as your hands, arms or head, do not stop at go.  Go directly to the hospital as this is considered an emergency.  The shorter the travel to your brain is the faster you can get the symptoms.  And once you get the symptoms it is pretty much over.

UPDATE:  DO NOT TAKE THE ANIMAL HEAD TO SAN LAZARO!  That information is incorrect.  The hospital hasn't taken animal heads in years.  Not sure why the local health workers still give out that old information.  But well, they still do and most likely because they haven't trained or gotten updated training in years.  Food for thought.  Anyways, the animal head has to be brought to the Bureau of Animal Industry, which is located in Quezon City near the Department of Agrarian Reform.

To transport the head you have to put the head in a plastic bag and secure it.  Make sure you don't get cut and get infected.  Then to preserve the head for the voyage you have to fill a container with ice and put the plastic bag with the animals head in it.  The ice is to make sure the head stays fresh until you can get it to QC.

Once you get to the gate the guards will ask you to fill out a form with your information and the history of the incident.  The head will be taken to the lab.  After about 2-4 days you will receive a text message stating the status and results of the lab test.  You will also receive an email with a PDF copy of the test results.  See below.

After you receive the confirmation that the animal died or did not die of rabies there is NO follow up.  They just tell you to consult a physician.  Which makes this whole bringing the animal head to QC a pretty fruitless endeavor unless you want to make sure you know if there was rabies involved or not.  I for one personally believe that you should still take the animal head in for testing, but it's a pretty expensive trip since you have to take the effort and time to go there.  But that's the procedure so lets follow it since the bureau most likely takes note of the areas where the dogs came from for survey purposes.  But I do understand that most of our fellow citizens don't have the luxury, time, and money to go there.

So since you still have to get the anti-rabies shots they will also ask you to go to San Lazaro in Manila or at the RITM aka Research Institute for Tropical Medicine.  These are the two government operated hospitals in the Philippines that serve rabies cases locally.  I am not sure if private hospitals have anti-rabies vaccines so you would need to check with them.

If you go to San Lazaro please go early.  Be there around 5-6am unless you're planning on staying there the whole day.  Most cases of rabies bites/scratches go to this hospital.  Expect it to be jam packed and hospital staff to be rude.  And when I mean rude I mean rude.

The procedure at San Lazaro is chaotic to say the least.  Like pretty much any other government run institution that I have encountered in the country.  To make it less stressful I have listed the procedure below.

1.  Get a number.  And get it early.  The hospital staff will start calling numbers around 8am or 7am if they feel like it.  You will need to give them the recommendation letter/form that you got from the barangay health office.
2.  Once you have a number just wait and relax until they call you.  you can grab some breakfast at the canteen that is nearby.

3. Once they call you, go to the desk that they have set up and an initial interview will be done by a nurse.
4.  Once that is over with you will have to wait another few minutes until they usher you into another office where a doctor will conduct another interview with you.  There the doctor will explain what will happen next and what you should do.  They will ask the patient to get either one of two types of anti-rabies shots.  One is called HRIG and the other is ERIG.  The patient will also get a few shots of PCEC.

What is the difference?  The main difference is how the vaccine was created.  I have listed it below.  All of these vaccines are given through an IM injection.  Meaning they will stick a huge needle into your thigh muscle and deltoid.

PCEC - Pure chick embryo cell
HRIG - Human rabies-specific immunoglobulin
ERIG - Equine antirabies immunoglobulin

5. The patient will get a skin test to test for allergies for the HRIG or the ERIG.  If you're on a tight budget hope that you are not allergic to ERIG.  Because the HRIG is EXPENSIVE!  It costs about P4300 per shot and a small 5 foot teenager would probably need about 4-5 of these (depends on weight of patient).  That's a whopping P20,000!  Luckily that is only given once.  The ERIG isa bout P2300.  The sad part about this is San Lazaro doesn't have the HRIG in stock.  It is subsidized so would cost a whole lot less if you buy it there.

HRIG and ERIG is available at surrounding stores but San Lazaro will not allow you to buy them unless they don't have them in stock.  Apparently they want you to buy it from them.  If you buy the vaccine outside and they have it in stock, they will absolutely refuse to serve you.

NOTE:  The vaccines are kept in cold storage and so should be used right away.

PCEC is the most affordable of the 3 at P1200 and is in stock at the hospital.  I wonder why.

6.  After a 30 minute wait you will need to go back to the doctor and have the skin test checked.  Depending on allergies the doctor will now ask you to buy the vaccines.  At some time during the interviews the doctor will give you a small form showing the vaccines you need to buy. Don't lose them.

7.  Buy vaccines.  Note that for PCEC they will ask you to find 2 other patients (or was it 3?) to share the vaccine with.  The staff will not allow you to buy the vaccine unless you have other patients to share the vaccine with.  They yet again will absolutely refuse to help you if you do not buy the vaccine with other patients.  Since the PCEC is available at their pharmacy you will need to get in line and pay for it at the hospital cashier along with the needles.  It's a long line so be patient and kind.

8.  Further into the doctors area there are nurse's stations that do nothing but give injections.  So you have nurses there that work 8 hours a day...giving injections.  This is where you need to go next.

Give the nurse your forms and vaccines and wait for your turn.  The PCEC is injected into your shoulder muscle while the other vaccines are injected into your thigh muscles.  Since the amount of vaccine needed depends on your weight you will be in for several injections.  So what they do there is take the vaccine ERIG/HRIG and accumulate it into one giant syringe with a giant needle.  Most likely the 4 injections will now be only 2 injections.  One injection in each thigh.

After that you're pretty much free to go home and get some rest.  Because the injections will make you feel like you did a 10 hour trek.  Your thigh muscles will feel sore and it'll hurt for a day or two.

You will need another two PCEC shots a few weeks afterwards.  The doctor will give you a timetable on when to go back.  You can either go to your local barangay health center or go back to San Lazaro.

Now that we got that done, I now have to do a little rant.  I wish we could spend more money on prevention instead of being reactive about rabies.  We're spending so much money on reactive measures that would be better spent on proactive measures such as education, pet neutering, anti-rabies vaccine for pets, etc.  Filipino's should take better care of their pets and in the long run rabies could be virtually eliminated from our islands.

And if you're poor and get bit, best to just pray and hope that the animal didn't have rabies.  How can a poor person afford P20,000 for the vaccines plus all the transpo cost and food cost of going to San Lazaro?  The hospital staff isn't going to entertain you if you don't have the vaccines.  The hospital DOESN'T give out free vaccines.  So where does that leave the poor?  Pretty much out on the doorsteps.  Rant done.

If you have any comments or would like to point out any mistakes please let me know.  I love to hear from my readers.  Thanks!