A 32-year-old male recently visited Sukraraj Tropical and Infectious Disease Hospital (STIDH) to get an anti-rabies vaccination after caring for a puppy with a skin disease two weeks earlier. The visitor’s team had rescued the puppy, along with its mother and sibling, from Hanumankhola, Bhaktapur municipality. Initially, the puppy appeared fearful and avoided close contact with humans. Subsequently, it became aggressive and bit several other dogs in the same dog shelter and even attempted to bite humans. The puppy died the following day.

Laboratory testing conducted at the Central Veterinary Laboratory confirmed rabies virus infection. Although the source of the rabies virus infection in the puppy could not be identified, the visitor reported hearing that a stray dog in the area from which the puppies were rescued had bitten multiple people; however, it remains unclear whether that dog was captured or euthanised. Likewise, a few months ago, a suspected rabid dog bit nearly 50 people in the Sanepa area of Lalitpur. In fact, several veterinary professionals have shared their experiences, noting that a significant number of rescued street dogs were found to be infected with the rabies virus, indicating that rabies infection among street dogs may be more widespread than previously assumed. This highlights the risk of a rabies outbreak in Kathmandu, a ticking time bomb that threatens the government’s commitment to eliminate dog-mediated rabies in Nepal by 2030.

Nearly a month ago, a 12-year-old boy died of rabies at a Kathmandu-based hospital. He had been bitten by a stray dog in Lalitpur. Following the bite, he was taken to a local pharmacy, where he did not receive a rabies vaccine; instead, he was given tetanus toxoid and wound medication only. In Nepal, many local pharmacies prioritise tetanus toxoid over rabies vaccination after animal bites. Similarly, nearly three years ago, a female student in grade 11 visited Sanga, Banepa municipality, where she offered biscuits to a stray dog. Unfortunately, the dog caused a minor injury to her hand, which she ignored and did not seek medical attention. According to her uncle, approximately two and a half months later, she developed classical features of rabies, i.e., hydrophobia (fear of water) and aerophobia (fear of air), and was admitted to a Kathmandu-based hospital, where she was diagnosed with rabies. Likewise, about two years ago, a 28-year-old man from Kirtipur municipality, Kathmandu, was admitted to the intensive care unit (ICU) after developing hydrophobia and aerophobia four months following a dog bite. He had adopted a street puppy, but when it bit him, he abandoned it. He did not seek vaccination, assuming that a small puppy posed no risk. In Nepal, rabies caused by puppy bites is a serious public health problem, as many people mistakenly believe that small puppies cannot transmit the virus. These cases illustrate the increasing presence of rabies-infected dogs in the Kathmandu Valley.

A critical question remains regarding responsibility for rabies vaccination of stray dogs. Many dog-bite victims frequently ask which government authority is responsible for addressing this issue. There is, however, still no clear framework for the management and vaccination of stray dogs. Moreover, a significant increase in cat bites and scratches has been observed in recent years, also raising concern about a potential rise in rabies in Kathmandu.

Rabies is a fatal viral disease transmitted through infected mammals, predominantly dogs. However, death can be prevented if post-exposure rabies vaccination is administered as early as possible. Clinical symptoms typically appear one to three months after the bite but may develop years later, depending on factors such as the bite location and the severity of injury. Aggression, hydrophobia and aerophobia are considered classical manifestations of rabies.

Interestingly, in recent years, the majority of rabies patients have not exhibited aggression after the onset of symptoms. The reasons for this apparent shift in classical presentation require further investigation. Viral evolution or mutation over time, which are possible contributing factors, warrant genetic and molecular studies. Early symptoms are often non-specific, including flu-like illness and tingling sensations, and are therefore frequently overlooked by patients. Notably, based on my observations, many patients complain of severe lower back pain before the development of hydrophobia and aerophobia. This recurring observation suggests that severe lower back pain may deserve consideration as an additional clinical feature in medical textbooks.

The trend of domesticating dogs has significantly increased in Nepal. However, many people do not consider getting vaccinated after being bitten by domestic dogs. While a vaccinated dog is expected to be protected against the rabies virus, there have been several instances in Kathmandu where domestic dogs were confirmed rabies-positive through laboratory testing despite being vaccinated. This may be due to the quality of the vaccines administered, which could be substandard and fail to provide adequate protection against the rabies virus, particularly when domestic dogs are exposed through fights or bites involving stray dogs.

The reporting of dozens of human rabies cases at STIDH and the frequent detection of the virus in stray dogs suggest that the virus is circulating in the Valley more widely than previously thought. So far, most individuals bitten by dogs typically first visit local pharmacies for an initial shot, from where they are advised to visit a hospital (mainly STIDH) for the remaining doses or further guidance, which may explain why a larger number of rabies cases have not yet been detected in Kathmandu. Despite the widespread availability of rabies vaccines at government and private hospitals, as well as private hospitals and clinics, rabies cases continue to rise due to insufficient rabies control measures and limited public awareness, making rabies a ticking time bomb in Kathmandu.