RABIES ELIMINATION IN INDIA BY 2030: Road Map Ahead
Compiled & Edited by-DR. RAJESH KUMAR SINGH, LIVESTOCK CONSULTANT
India held its first Rabies Awareness Summit on World Rabies Day on September 28 last year in 2020, to demand the government take drastic, persistent steps to eradicate rabies specifically by dog bites in India. In order to meet the World Health Organization’s target of eradicating rabies globally by 2030, experts at the summit advised the Indian government to make rabies a “notifiable disease” (required by law to be reported to government authorities to foster accurate record-keeping) like polio, to ensure the disease gets the attention and resources it has so far lacked, especially in rural areas stricken with poverty in the country.
Rabies is a vaccine-preventable disease. India accounts for 36% of all rabies deaths globally, reporting approximately 20,000 cases a year, according to the National Health Portal. These statistics have remained the same for more than a decade, the World Health Organization states, which signals a lack of dedicated resources assigned to fight the virus. This fight is especially important because it is close to impossible to recover from the disease once symptoms set in — rabies is the only disease that has a 100% fatality rate in India. Prevention, experts say, is everything.
One out of every three deaths in world due to rabies happens in India. With a 100 per cent mortality rate, and believed to be the world’s deadliest vaccine-preventable disease, rabies however is yet to make it to India’s priority list in the health sector. A coordinated and comprehensive national programme is non-existent in the country, even as the World Health Organisation (WHO) aims at “Zero Rabies Death by 2030”.
The disease is considered more deadly than the much talked about Encephalitis and H1N1 except in Andaman & Nicobar and Lakshadweep Islands. According to National Health Profile data, there were 4,370 rabies deaths in India in 2016, which accounted for one in three of the world’s 13,340 rabies deaths.
Only six persons have survived rabies infection in India since 2010, with the first case of partial recovery documented in 2002. Globally, there are only 15 known survivors of rabies. The WHO roughly attributed 36 per cent of the world’s rabies deaths to India.
Rabies is primarily a disease of warm blooded carnivorous animals like dogs, cats, jackals, monkey, bats and wolves and transmitted to human being by the bites or licks of rabid animals. It is caused by RNA virus belongs to Lyssa virus genus manifests as viral encephalitis in human beings and once symptoms develop, it is always fatal to human beings. There is no effective treatment for rabies; it can only be prevented by vaccination. According to World Health Organization (WHO), the annual cost of rabies worldwide estimated to be about 583.5 million US$, most of which is attributed by post-exposure prophylaxis (WHO, 2005). Even though a completely preventable disease, it is still a public health problem in India and other developing nations.
Rabies in livestock
Rabies in livestock is associated with bite of an infected animal of other species, usually of dogs and cats in cities and wild animals in near forest villages. Therefore, control of disease in livestock is entirely dependent upon either eradication of the disease in vector animals or immunization of livestock liable to be exposed Rabies is prevalent throughout India and South Asia, occurring primarily in dogs, domestic cats. Although rarely in serious proportions, it has been reported in wild foxes, wolf and other wild animals. At present times, rabies in dogs and other livestock is quite prevalent in all the states of India.
The onset of rabies in cattle is marked by prodromal symptoms which last from few hours to one to two days. In this period a clinical diagnosis of rabies is very difficult. There may be temperature rise of 1 to 3 oC, and general picture of malaise, anorexia, and abrupt cessation of lactation. Usually show marked depression which may be readily confused with some intestinal disturbance, such as impaction of rumen or rectum, or early stage of an infectious condition (FMD). Bellowing sound changes. At this stage, a good history and knowledge that rabies is prevalent in that area is invaluable and may save human exposure. The saliva may carry virus four to five days prior to the onset of symptoms. If in doubt, or if there is anything about the patient that arouses suspicion, it is advisable not to handle the mouth. Give only hypodermic medications and observe the patient in isolation. The vast majority of human exposure occurs during this early stage when one is groping for diagnosis. The transition from the prodromal to the furiousstage is usually rapid within few hours. There is a pronounced change of behaviour. The patient become nervous, often shows persistent tenesmus, has tendency to attack. It does not eat and although it may attempt to drink water but unable to drink water and dehydrate rapidly. The facial expression changes rapidly and becomes quite diagnostic, have a tense, alert appearance: the head is up, the eyes are wide open and follow any moving object. Bellowing is very common. The head is extended, the back arched, the flanks tucked in a hoarse, deep bellow is emitted. The tone of the bellow is quite characteristic. It is difficult describe but once heard, veterinarians can make tentative diagnosis of rabies. Due to paralysis of the throat and inability to swallow, saliva may drool from the mouth. Occasionally, animal lie down and refuse to get up, however, if a chicken or dog is tossed in front of them, they jump up and chase it. They will attack and butt a barrel, box or other loose object. They are particularly sensitive to movement and sound. Small amount of urine are voided at frequent intervals and many females will accept a male repeatedly. The excitement stage rarely lasts over two days. The animal weakens rapidly, becomes prostrate and dies within a few hours of cardiac or respiratory failure due to extensive braindamage. Clinical rabies in cattle may be diagnosed in the field without difficulty in many cases. However many rabid cattle show atypical symptoms and diagnosis may be difficult. Therefore, in areas where rabies exist sick animals should be handled as though they have rabies until one is sure they do not have this disease, livestock owner and veterinarians attribute salivation to the possible presence of a foreign body, such as stone or corncob or vegetableslodged between teeth or pharynx, with the bare hands, this may lead to scratches and abrasion on the hands from animal teeth, contamination of these wound with probable virus bearing saliva. Rabies is primarily an encephalomyelitic disease and may be confused with any other encephalitides or with the nervous type of acetonemia. A history of rabies or group of dog/ wild canines/ new dog in the immediate area two to three week before is very useful. To confirm the disease, better not to destroy the animal but allow it to die a natural death. And collect the brain sample from dead animal through foramen magnum method and submit the same for Laboratory diagnosis. We undertook Post Exposure Prophylaxis antirabies vaccination in the animals which were bitten from suspected or confirmed cases also. Pre exposure prophylactic vaccination undertaken in the owner dogs in the area of rabies report. There are scanty reports on post exposure prophylactic vaccination trials in livestock including cattle,7.8,9,10.Post exposure treatment in animalsisstill controversial despite the fact that it has been practiced on large scale in certain situations in developed countries11(Clark and Wilson,2001). The Post exposure prophylaxis treatment has been described for variety of species both experimentally and for field condition11, Furthermore, controlled challenge experiments are necessary to establish definitely the duration of immunity, the minimum age limit and the value of post exposure vaccination. We have no field or experimental data to indicate the efficacy of post exposure administration of rabies vaccine. Rabies is probably never transmitted from cattle to cattle. Control of the disease in livestock is therefore dependent entirely on control or complete eradication of the disease in the vector animals. The principal vectors are dogs and wild animals. Rabies control is essentially a program of reducing to a practical minimum the number ofsusceptible hosts within an infected area. The Control of the disease in wildlife is based entirely on maintaining a disease free dog population. We have made very little actual progressto date in eradication of rabies, therefore at present mass immunization of cattle in known infected area appearsto be the only available protective measures. The history of rabies eradication in this country has been and still is a masterpiece of lack of leadership confusion and in coordination. There is no uniform pattern of approach to the problem. The course of action pursued on the local level depends upon political expediency, enforcement officials are close to and responsive to local pressure groups. The result is that instead of being able to act immediately on the occurrence of one proved case of rabies to prevent its spread we must wait for an epidemic in order to have popular support, appropriation of funds or even demand. Rabies in livestock is almost entirely a problem in animal husbandry economics. Incidence of rabies in livestock is directly related to incidence of disease in dogs. National rabies control programme implemented by Dept. of Health and Family welfare have taken much of rabies control activities. We believe that joint action by the three responsive agencies (Health and Family welfare, Animal Husbandry and Municipal/Local govt) is imperative and that the presence of rabiesis disgrace. It could be eradicated without great difficulty but this would involve prompt coordination effort wherever the disease exists. We have more rabies than probably any other country in the world and the time is now past due for National programme of control and eradication.
Burden of the disease
It is a neglected tropical zoonotic disease, with 50,000- 55,000 deaths each year worldwide. Around 95% of human rabies occurs in Asia and African countries. It is estimated that there are about three billion people living in the region at risk for rabies in over 100 countries. India recorded more deaths from rabies than any other country in the world with 25,000-30,000 deaths annually (Wunner WH & Briggs DJ, 2010). Human rabies was reported throughout the country except Andaman, Nicobar and Lakshadweep islands. Since rabies deaths occur in a scattered manner, it doesn’t pose epidemic threat to claim immediate action (Chatterjee P, 2009).
Strategies for prevention of rabies
Due to the complex nature of rabies control, it needs multiple levels of interventions with respect to humans and animals. Prevention of infection at human level by pre-exposure prophylaxis for high risk group and postexposure prophylaxis for exposed persons. Animal interventions includes registration and licensing of dogs, immunization of dogs, restraint of dogs in public places, control of stray dog population by birth control, destruction of dogs bitten by rabid animals, quarantine of imported dogs for 6 months and better solid waste management (WHO, 2007).
WHO’s strategy for endemic South-East Asian countries
World Health Organization’s regional office for South East Asia, after an expert consultation provided a regional strategic framework in 2011 for eliminating human rabies transmitted by dogs. The target is to eliminate the disease by 2020 in endemic South-East Asian countries. The initial strategy is to reduce by half the current number of human rabies death by 2016 which covered a period of 5 years from 2012-2016 (WHO, 2012).
India’s action towards rabies
Government of India as per WHO’s recommendation, had replaced nerve tissue vaccine with cell culture vaccine since 2004. Planning commission had identified rabies as priority zoonotic disease in its 11th five year plan. Government of India has introduced pilot project on rabies control programme from 2008 to 2011 with the objectives of prevention of human deaths due to rabies and reduction of transmission of disease in animals. It has set a target to reduce the human rabies deaths by at least 50 per cent by the end of the 11th Plan period which covered Delhi, Ahmedabad, Madurai, Pune, and Bangalore (Planning Commission of India, 2011). In 12th five year plan, Government of India has planned to extend this comprehensive programme which has both human and animal component. This programme focuses on training health professionals about management of animal bites, providing post exposure prophylaxis, creation of awareness and reduction of animal bites, vaccination and sterilization of dogs (Dhar A, 2012). Government of India, National Center for Disease Control, New Delhi, WHO collaborating center for Rabies Epidemiology has released Revised National guidelines on Rabies Prophylaxis in 2013 for bringing out uniformity in post exposure prophylaxis. It gave guidelines for indications of anti-rabies vaccine and rabies immunoglobulin. It recommends the use of cell culture vaccine given either intramuscularly or intradermally for pre/post exposure prophylaxis. It also stresses on using rabies immunoglobulin for category II immune compromised patients and for all category III animal bites (Government of India, 2013). Government of Tamil Nadu, Rabies control initiative is a first large scale comprehensive programme on rabies started in the year 2008, with universal coverage targeting both human and animal population (Abbas SS et al., 2014). In collaboration with local non-governmental organization, the health departments of Chennai, Jaipur and Kalimpong have achieved zero rabies incidence followed by sustained Animal Birth Control-Anti Rabies Program (ABC-AR Program) (Krishna, S.C, 2010). Sikkim is about to be certified free of rabies followed by statewide campaigning for vaccination of dogs (Chatterjee S & Riaz H, 2013).
Epidemiological situation of animal bite
Every year, about 1.7% of Indian population gets bitten by animals of which only 46.9% took anti rabies vaccine (Rahman AS, 2011). Around 97% of human rabies are transmitted by dogs of which 62.9% were stray dogs, followed by cats 2% and others 1% (Jackals, Mongoose) (Government of India, 2013). The vulnerable groups for rabies are males, children below 15 years, poor and
uneducated people, and those who are living in rural area (Chatterjee P, 2009; Rahman AS, 2011; Suraweera W et al., 2012). Among those vaccinated, compliance to full course of vaccine was found to be 40.5% and was not satisfactory. It has been shown that adequate local wound treatment can reduce the chances of developing rabies by up to 80%. Among the animal bite victims, only 39.5% washed their wounds with water and soap (Sudarshan MK, 2004). The use of rabies immunoglobulin was very low at 2.1% (Kole AK et al., 2014). Vaccination of 70% of total dog population in an area for a period of six months is needed to achieve herd immunity. But only few cities are conducting sustained anti rabies vaccination for stray dogs (Chatterjee P, 2009).
High mortality of rabies in India
It was attributed by huge stray dog population which accounts for 25 million throughout India that poses great risk to the people. Moreover, there was lack of awareness about rabies and lack of understanding of the need for immediate action against rabies together with poverty, unavailability of anti-rabies vaccine and immunoglobulin (Sudarshan MK, 2004). Ichhpujani et al study reported that only 30% knew how to clean the wound after any animal bite and majority of the study population were not compliant with the treatment guideline (Ichhpujani RL et al.,2006). Interventions against rabies were mainly concentrated in urban areas leaving behind the vulnerable rural area (Abbas SS et al., 2014).
Poor disease surveillance system on rabies
Better estimation of rabies incidence is not available because of lack of systematic rabies disease surveillance system and moreover it is not a notifiable disease in India (Maroof K, 2013). And many cases were not reported and some other cases were missed because of atypical presentation (Rahman AS, 2011). It has been found that there was a gap between rabies research done in India and existing rabies policy interventions. Even though, India contributes to more number of rabies cases globally, Indian research output represents only 4.4% of the global research on rabies (Abbas SS & Kakkar M, 2013). Multicentric studies should be undertaken to reveal the true status of the disease, thereby it will provide a proper input for policymakers to develop strategies against rabies.
Key challenges in rabies control
Current challenges are lack of intersectoral coordination between multiple disciplines involved in rabies control like public health department, animal husbandry department, government and non-government agencies; limited information on dog population, poor surveillance data on human and animal rabies, lack of adequate dog bite epidemiology for predicting vaccine requirement, delay in scaling up of successful pilot interventions from local setting to national level, poor diagnostic capacity, limited evidence of effectiveness and efficacy of interventions in different ecological settings, lack of thrust on environmental management which contribute to uncontrolled dog population (Kakkar M et al., 2012). To conclude, breaking the rabies cycle in a sustained manner is necessary to eliminate rabies from this part of the world. For elimination of rabies by 2020, strong political commitment along with intersectoral coordination between government and non-government health agencies are essential for promoting the use of intervention tools at human and animal level throughout the nation.
National Rabies Control Programme (NRCP)
Rabies is responsible for extensive morbidity and mortality in India. The disease is endemic throughout the country. With the exception of Andaman & Nicobar and Lakshadweep Islands, human cases of rabies are reported from all over the country. The cases occur throughout the year. About 96% of the mortality and morbidity is associated with dog bites. Cats, wolf, jackal, mongoose and monkeys are other important reservoirs of rabies in India. Bat rabies has not been conclusively reported from the country.
To address the issue of rabies in the country, National Rabies Control Programme was approved during 12th FYP by Standing Finance Committee meeting held on 03.10.2013 as Central Sector Scheme to be implemented under the Umbrella of NHM .The Programme had two components – Human and Animal Components in 12th FYP. Human Component for roll out in the all States and UTs through nodal agency NCDC with total budget of Rs 20 Crores and Animal Health Component for pilot testing in Haryana and Chennai through nodal agency Animal Welfare Board of India(AWBI)under the aegis of MoEF&CC, GOI with total budget of Rs 30 Crores for the Plan period. The Human Health Component has been rolled out in 26 States and UTs (Pilot Project for Animal Health Component by AWBI has been ended with closure of last FY of 12th FYP i.e. with effect from 31.3.2017)
Objectives:
- Training of Health Care professionals on appropriate Animal bite management and Rabies Post Exposure Prophylaxis.
- Advocacy for states to adopt and implement Interdermal route of Post exposure prophylaxis for Animal bite Victims and Pre exposure prophylaxis for high risk categories.
- Strengthen Human Rabies Surveillance System.
- Strengthening of Regional Laboratories under NRCP for Rabies Diagnosis.
- Creating awareness in the community through Advocacy & Communication and Social Mobilization.
Activities undertaken in last one year ( 2018-19 ) under NRCP –
- Training and capacity building – Under the programme to review the activites undertaken by the states review Meeting of State Nodal Offciers ( SNOs ) and Training of Master Trainers & under National Rabies Control Programme (NRCP) was held on 11th October and 12th October 2018. States were advocated in the meeting to put emphasis on rabies surveillance and ensuring the availability of ARV and ARS for animal bit victims. State level Training plans on Animal Bite management and Rabies prophylaxes, Surveillance received from 6 States and training of medical officers and health workers are being conducted across the states. All states and UTs have designated Nodal Officers for NRCP& District Nodal Offices is being appointed in 7 states. To standardize the trainings under NRCP, Technical Committee of experts has been formed for developing Modules and following training modules are being prepared-Training module for the Medical Officers,Training module for the Health workers, Manual for Rabies diagnostics.
- Guidelines and techncial support to states- To review the recent WHO recomondation on Rabies post exposure propohylaxis ( 2017 ) expert group meeting on Revision of National Guidelines for Rabies Prophylaxis held at NCDC on 8th January, 2019 & minutes were circulated to stakeholders Review of Rabies control in the state of Goa under the Mission Rabies was underken in oct. 2018.
- Rabies and animal bite surveillance– The standard cases definition on suspected, probable and confirmed cases has been finalized in the expert group meeting held at NCDC. The probable case definition for suspected human rabies has been included under IDSP. Apart from this programm is also mapping and networking of tertiary care hospital (Infectious disease hospitals/Medical College, District Hospital etc.) in the States and Districts. Reporting formats on Animal bite, rabies, laboratory surveillance are being finalised to standardize the reporting Process for Rabies as a notifiable disease initiated.
- Laboratory strengthening for rabies diagnosis– Four regional laboratories has been supported under the programme to Strengthening Rabies Diagnostics( National Institute of Mental Health and Neurosciences (NIMHANS), Disease Investigation Unit Lab, Directorate of Animal Husbandry and Veterinary Services,Government of Goa, Panaji, Goa, AIIMS Jodhpur, National Center for Disease Control (NCDC), Delhi ) Review meeting of above labs conducted on 12 thOct 2018. For further labs. Strengthening in the country regional workshops are planned for Medical & Vet. Microbiologists.NIMHANS banglore organised the workshop in March 2019 and more 30 microbiologist were trained during the workshop from 4-5 states.
- IEC activites – Under the Programme Prototype IEC material was developed and disseminated to the States. World Rabies Day is observed on 28th September each year at NCDC and States were advocated to observe it at State/District level as per the theme of Audio and video spots were created and maass media comapign was conduected for 10 days for generating community awrnesss on rabies from 25 sept to 4 oct 2018.
- Interectoral coordination for Rabies control– To institutionalize the “ONE HEALTH”approach at National level – Collaboration with DADF, Ministry of Agriculture and Farmer Welfare (MoA&FW) for development of technical guidelines for animal component of rabies control has been done. MoU is proposed to be signed between DADF, MoA&FW, MoH&FW, Wild life institute of India for prevention and control of Zoonotic Disease in India including rabies. 14 States constituted State Level Zoonosis Committee (SLZC) for intersectoral coordination for prevention and control for zoonosis including Rabies. SOPs for institutionalizing One Health approach for Rabies is under process.
- Operationl research – Preliminary meeting on study on assessment of Rabies burden in the country held with stakeholders ( NIE Chennai, APCRI ) at ICMR on 28th December, 2018.
Post-exposure prophylaxis (PEP)
The following World Health Organization (WHO) classification is used for grading the exposure to rabies and guide to provide rabies prophylaxis (Table-2). Table-2: WHO classification of rabies exposures Note: In HP, human rabies has been reported even following category II exposures of scratches (without bleeding) by dogs5 . Hence, in such cases after wound wash, both vaccine and RIG are indicated. The RIG is used only to infiltrate the affected area/scratch of the skin.
The PEP has broadly four components i.e.
i. Wound management
ii. Vaccination
iii. RIG infiltration
iv. Counselling
1. Wound management.
Following a rabid animal bite, as saliva containing the lethal rabies virus is inoculated into the wound, it is very imperative the virus is removed from the wound and thus prevent rabies infection. This greatly eliminates the risk of rabies death, is life saving and many times this simple procedure (of wound wash) is not done by the patients due to ignorance. Hence, it is important that wound washing facilities comprising of running tap water and liquid soap are provided at the antirabies clinics (ARCs) for animal bite victims to wash their wounds. All animal bite victims are advised to thoroughly flush the wound/s with running tap water, when appropriate for 15 minutes to remove the traces of saliva from the wound. Then wash the wound/s with soap so that the virus, if still present is inactivated. In case of young children, they need to be closely examined for any unnoticed wound/s in the covered part of their body, and if these are missed may prove fatal later on. Then all the wounds are applied with povidone iodine or any other antiseptics available to neutralize the virus. In case of large bleeding wounds, after wound wash with copious amount of water and application of antiseptics, a simple covered dressing shall be done. If the wounds are covered with local applicants like turmeric powder, plant juices, chillies, etc. they need to be removed by flushing with running tap water and then gently cleaned with a clean dressing material. If the wound is infected, still it is washed and an antiseptic applied. If the wound/s is gaping then (after careful infiltration of RIG ) the edges are brought together and a pressure bandage is applied and delayed (after 72 hours) suturing is done. If the wounds are severe and profusely bleeding, then these are immediately infiltrated with RIG as anatomically feasible and loose occlusive minimal sutures are done to stop bleeding. In case of wounds on the face thorough wound care is done and after careful infiltration of RIG, wound is sutured to the minimum to avoid scarring. Thus, proper and timely wound management is very important and life saving, more so in severe exposures. It is important to propagate this message in the families and community. All closures of wound/s should only be done after careful infiltration of RIG.
2. Intradermal rabies vaccination (IDRV).
In the government institutions as a policy, only IDRV is provided free of cost to treat animal bite victims. The vaccine supplied shall be reconstituted only with the diluent provided with it. Disposable Insulin syringe with fixed needle or a suitable alternative 1 mL syringe provided shall be used for ID vaccination. The recommended regimen consists of injecting one dose of 0.1mL of the reconstituted vaccine at two sites on days 0, 3,7 and 28 ( 2-2-2-0-2) . This is known as the updated “Thai Red Cross (TRC)” regimen. The opened vials having reconstituted vaccine shall not be exposed to sunlight, used in 6-8 hours and any leftover vaccine shall be discarded at the end of the day. Day 0 is the day of first dose of vaccination and not necessarily the day of bite/exposure. The commonly recommended site/s of ID vaccination is the deltoids. The alternate sites are suprascapular and rarely lateral thighs only if necessary and with the consent of the patient; in case of women strictly in the presence of a female attendant. A successful ID injection is evident by the appearance of a bleb (3-4 mm) and peau de orange (orange peel) effect. If ID injection fails (no appearance of a bleb) at one site, than at an adjacent area the ID dose shall be injected. The patient shall be informed not to rub or apply any applicant to the injection sites. The common side effects of IDRV are soreness, redness, itching, occasionally slight pain, etc. and these are self limiting and no medication is ordinarily needed. Spirit swab shall not be used before ID vaccination. The vaccination series may be discontinued if the biting dog or cat (not other animals) is alive after ten days of observation. In the process, if the patient has received at least two doses of rabies vaccine then he/she is considered to have received pre-exposure rabies vaccination/prophylaxis (PrEP) and in future in the event of a re-exposure to rabies than such patients require wound management, one dose (0.1mL) of rabies vaccine at one site on day 0 & 3 and no RIG. In the private sector, PEP is provided for a fee by IM route, using the five dose Essen regimen given on days 0, 3,7,14 and 28. The doses are given in alternate deltoids; in case of children below 2 years of age, it is given in the antero-lateral thigh.
3. Rabies immunoglobulin (RIG).
The role of RIG in passive immunization is to provide readymade rabies neutralizing antibodies at the site of exposure before patients start producing their own antibodies as a result of vaccination. RIG administration is recommended after category III exposures of individuals who have not been previously vaccinated against rabies. RIG is administered only once, preferably at or as soon as possible after initiation of post–exposure vaccination. It is not indicated beyond the seventh day after the first dose of rabies vaccine, regardless of whether the doses were received on day 3 and 7, because an active antibody response to the rabies vaccine has already started, and this would represent a waste of RIG. There are two types of RIG. Equine RIG (eRIG) and Human RIG (hRIG). Equine RIG is supplied to government institutions and is provided free of cost to the patients. The hRIG that is imported and expensive is available in the private sector. Both the RIGs are considered to have similar clinical effectiveness. ERIG that is supplied to government hospitals is procured from Central Research Institute, Kasauli, HP or from other sources. It comes as 5 mL vial with a potency of 300 IU per mL and thus having 1500 IU/ vial. The maximum dosage is 40 IU per KG body weight. Skin testing before eRIG administration is not necessary because of its unreliable prediction of adverse effects. However, it is important to keep emergency drugs like injection adrenaline, cortisone, antihistamine, oxygen, etc. to manage any anaphylaxis that is remote. However, from the calculated volume of eRIG, the quantity that is sufficient to adequately infiltrate all wounds shall be used. Injecting remaining volume of eRIG intramuscularly at a distance from the wound provides no or little additional protection against rabies as compared with infiltration of wound alone. Hence, the left over eRIG may be stored at 2 to 8 degree centigrade in a refrigerator. Following strict aseptic conditions and using a separate syringe/needle this saved eRIG can be used in other patients. However, this constitutes “off label” use. In case the calculated volume of eRIG is not enough to infiltrate all wounds in a patient (when there are multiple/extensive wounds, more so in children or those mauled by wild animals) then the calculated volume of eRIG is diluted with sterile normal saline to a volume sufficient to infiltrate all wounds and the infiltration done carefully covering the surface of each wound till its depth.
For the purpose of infiltration, insulin syringe or 2 ml syringe with 24 G needles or 5 mL syringe with 24 G needles shall be used depending on the site, size, type and number of wounds. The needle shall puncture from the edge of the wound and following slow, gentle push of the plunger while withdrawing the needle backwards and resultant oozing of eRIG on the raw surface of the wound is an indication of successful infiltration. In superficial wounds besides from the edge/s, even the base of the wound as anatomically feasible shall be infiltrated. As far as possible minimal punctures shall be made to infiltrate the wound(s)/ scratch/s. While infiltrating care must be taken not to damage any blood vessel or nerve or to cause any compartment syndrome while injecting finger tips/toes/ear lobes/nasal area/external genitalia. An infected wound is not a contraindication to injection of eRIG.
After the administration of PEP/ eRIG, the patients shall be kept under medical supervision for 20-30 minutes and monitored for any immediate adverse events expected to occur rarely like syncope, urticaria, anaphylaxis, etc. These shall be managed by the medical officer using the emergency drugs available. In State Intra-dermal Anti-rabies Clinic & Research centre (SIARCRC), D.D.U. Zonal Hospital, Shimla, Himachal Pradesh, with only local wound infiltration of eRIG and IDRV adverse reaction rate was 0.41% (8 of 1923 patients) in 2016 and 0.2% (4143 of 2020 patients) in 2017. There was no anaphylaxis.
4. Counselling:
Animal bite, more so when severe and in children is distressing. A word of advice and comforting the patient by the doctor, informing the patient to comply with the series of vaccination & not to default; no dietary restrictions; no alcohol & no strenuous physical exercises during the course of vaccination are to be given.
5. PEP in individuals re-exposed.
If an individual has a repeat exposure less than three months after a previous exposure, and has already received a complete PEP or pre-exposure vaccination (PrEP), then only wound treatment is required; neither vaccine nor RIG is needed. For repeat exposures occurring more than three months after the last PEP or PrEP , the PEP consists of only one dose of vaccine (0.1mL by ID route) given on day 0 and 3 would suffice. RIG is not needed.
Pre-exposure Prophylaxis ( PrEP)
Pre-exposure vaccination may be offered to at risk groups like laboratory staff handling the rabies virus and infective material, clinicians and persons attending to human rabies cases, veterinarians, animal handlers and catchers, wild life wardens, quarantine officers and travellers from rabies free areas to rabies endemic areas. The regimen is one dose of 0.1mL vaccine given by ID route on days 0, 7 and 21 or 28. The recent WHO, 2018, recommendation is giving 0.1mL vaccine on both deltoids by ID route on days 0 & 7 only. But using this new regimen will constitute an “off label “practice. PrEP induces circulating memory cells for life time and further booster doses are indicated in high risk groups based on expert advice and monitoring their periodic anti-rabies antibody titre levels. However, PrEP shall be offered only with prior approval of the authorities as the rabies vaccine is supplied in the government institutions to provide life saving PEP in rabies exposed individuals.
HURDLES IN THE WAY
Lack of proper awareness, education, training about dog behaviour, the importance of vaccination and sterilization, immediate care and prophylaxis etc. paves the main hurdle in reaching the goal. Dog owners must be sensitized to get their pets immunized and keeping an eye on their pets’ interaction with the stray dogs. Proper record maintenance on the number of stray dogs, their vaccination status, birth control measures, etc., in a community is the responsibility of every official concerned. Proper infrastructure in the rabies hot-spot areas like primary health centres; transport facilities; availability of required medicines, vaccines, immunoglobulins in case of emergency; recruitment of the staff concerned etc., are far ahead in achieving. Lack of financial aid encouraging incomplete treatment course is another major concern. Increasing demand for the stockpile of vaccines is always an unheard concept. Targeting on increasing the number of studies, research laboratories, technology improvement, instruments, health care facilities, etc. are left out each time. In a country like India where rabies is still not considered as a notifiable disease, extra efforts are the only way out.
ROAD MAP FOR MITIGATION
It is not the Covid-19 that has been recognized as the national emergency by many countries of the world including India, however it is the neglected tropical disease “DOG-MEDIATED RABIES” that has been endemic since decades, the most rueful. Let us not allow this pandemic to come in the way for attaining the Sustainable Development Goal 3 (to end the epidemics of neglected tropical diseases and combat other communicable diseases) by 2030. Rabies can become a role model for one health collaboration by:
Eliminate by awareness and Education:
The greatest barrier that India will have to tackle is Illiteracy, lack of awareness, prevailing myths, and taboos. According to a survey conducted, 54% of people in urban slums didn’t know about the disease Rabies and many didn’t know how to proceed if ever encountered with a rabid dog. This indicates that steps have to be taken by the Government as well as Non- governmental organizations to organize, educate & aware the people about this dreaded yet preventable disease through proper vaccination.
Proper and timely treatment:
Post-exposure vaccinations need to be timely available in clinics, the cold chain of vaccines has to be effectively maintained to maintain the efficacy of treatment, knowledge of animal bite management and necessary trained personnel have to be made available.
Vaccination:
The stray dog population in India is around 25 million. So, it needs to maintain a vaccination status of around 70%of dogs to create herd immunity by routine vaccinations, breaking the transmission chain. It is vital on the part of veterinarians to see to the vaccination of pregnant bitches so that the immunoglobulins are transferred to the puppies through colostrum or by placental transfer.
Strengthening Surveillance:
Routine monitoring and Surveillance of slums and prone areas to decrease the number of cases and treat the affected cases within the golden tie frame. All the personnel who are susceptible to this virus knowingly or unknowingly and are in contact with rabid animals with or without choice such as veterinarians, forest officials, animal welfare workers, pet owners, people working in slaughterhouses, etc. have to get vaccinated at regular intervals to maintain the prophylactic immunity level in the body against the rabies virus.
Strengthening diagnostic techniques:
The labs have to be equipped with state of art diagnostic tools to diagnose the positive cases timely. The diagnostic tools should have proper specificity and sensitivity. The Gold standard test for detection of rabies in animals and human is Fluorescent antibody test (FAT), Lateral flow devices (LFDs), have been devised for rapid detection of rabies under field condition, Fluorescent antibody neutralization test (FAVN), Rapid fluorescent focus inhibition test (RFFIT) & ELISA are some of the serological diagnostic tests used widely.
Efforts by the Veterinary sector:
The department of Animal Husbandry, Dairying, and Fisheries develop schemes, assists the state regarding animal diseases, training of manpower, strengthening lab facilities, production of biological products, and immunologicals. Not just dogs but all livestock are susceptible to rabies, timely detection & isolation of rabid animals is necessary to prevent the economic loss of the marginal farmers of our country.
Various Municipal Corporations:
In Urban areas, they have taken the role of stray dog management under ABC Rules, 2001-which includes neutering and spaying of dogs, vaccinating them, and releasing them back into their respective localities.
NGOs and Private organizations:
Organizations such as Blue cross India, World Veterinary Services, Mission Rabies, APCRI, and consortium against rabies are some of the many private undertakings providing a helping hand to the Government to fight the viral enemy.
- This is a really interesting time for India as Indian Immunologicals has been acting as a pioneer in making available anti-rabies vaccines at ease. IIL is one of the world’s largest producers of vaccines and consistent supplier of “Abhayrab” vaccines (for human use); “Raksharab’ vaccines (for animal use).
- The introduction of the intradermal vaccine for rabies by Padmashree Dr. Bharti made the vaccine accessible country-wide reducing the burden caused by cell culture vaccine by 60-80%.
CONCLUSION
India has always been a role model to the world by eliminating smallpox, polio and now its role in preventing COVID-19 is commendable that the world is praising. Though the idea of eliminating rabies is imminent, it is a stepwise strategic process that involves a multifaceted approach to deal with.Unveiling the strength of unity in teamwork and collaboration is the platform where we all stand in this journey. As the pristine generation of this era let us embark our role to make ours the last generation to fight dog-mediated rabies.
Reference-on request
