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Rabies Control in India
Problems, Review and
Recommendations

Karan Daftary
The Genesis
In May 2010, I witnessed an extremely unfortunate incident wherein my friend was bitten
by a stray dog. Despit...
Reasons to undertake this Project & Plan
Reasons to Undertake this project:
To look at reasons why India has so many death...
Introduction on
Rabies
Rabies: A snapshot
Rabies is a viral infection spread by
the bite of an infected animal.
The rabies virus infects the Cent...
Incidence in India
A brief overview on the disease is provided below:
Indian Population
Estimated deaths due to rabies
Str...
Lack of Awareness

Dr. B. J. Mahendra

Dr. G. Sampath

MandyaInstitute of Medical Sciences,
Mandya, Karnataka

IPM, Hydera...
WHO Guidelines on
Rabies
Rabies Treatment regimes
Definition of categories of exposure and use of rabies biologicals
Category III – single or multi...
Rabies Immunoglobulin – method of Action
Administration of Rabies Vaccine stimulates
production of neutralizing antibodies...
Observations
Observations
On meeting with BSV’s sales & marketing division, the following were the
broad findings:
BSV’s current produc...
Observations
Inclusion of Rabies Immunoglobulin in Government programs as a
treatment regimen along with anti-rabies vacci...
Findings
Comparison of Current & New cost of treatment using WHO
recommendation of active and passive immunization:
2350

Cost of T...
Requirement of Rabies Ig in India
4

Vials (Mn)

3

Deficit: ~0.9Mn doses

2
3.4

0
Requirement

Availability

~17.0Mn
~1....
Recommendations
Recommendations
Work with the government to include Rabies Immunoglobulin in
government funded programs as this would go a...
Food for Thought
Should BSV consider
efficient means of
waste management
such as conversion to
Biogas as an effective
mean...
Acknowledgements
Within BSV
Dr. Aldon Fernandes
Mr. Adeet Ghosh
Mr. Rahul Srivastava
Mr. Gaurav Gurnaney

Outside BSV
Dr. ...
Appendix

21
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Rabies Project_Bharat Serums and Vaccines Limited_Karan Daftary

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Project created by Karan Daftary, intern at BSV summer associate class of 2013 with the purpose of increasing awareness about rabies and its immunization.

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Transcript of "Rabies Project_Bharat Serums and Vaccines Limited_Karan Daftary"

  1. 1. Rabies Control in India Problems, Review and Recommendations Karan Daftary
  2. 2. The Genesis In May 2010, I witnessed an extremely unfortunate incident wherein my friend was bitten by a stray dog. Despite the requisite medical attention, he succumbed to his injuries. This was my first encounter with Rabies –in which mortality is 100%. In October 2010, there was a newspaper article titled “Rabies death despite vaccine” which I came across – the title got my attention as it was contrary to my understanding that a Rabies vaccine shot is all we need for protection against Rabies in case of dog bite. In fact this was the general understanding that even my friends and acquaintances had. On going through the article, it was a revelation for me to know that a vaccine takes almost 7 days time to provide the protection to the human body. This got me going to delve a little bit deeper into this to see what other steps can be taken by people in case of a dog bite. A couple of hours and an internet connection was all I needed to come across the medicine by the name “Rabies Immunoglobulin” which is supposed to provide an immediate protection against Rabies. During this quick search I was also overwhelmed by the enormity of the rabies problem in my country – in fact I was stunned to find that the maximum number of deaths due to rabies happened in India. The question which came to my mind was why India suffered the dubious distinction of largest number of deaths due to rabies and whether this is due to lack of general awareness or availability of Rabies Immunoglobulin. A quick check also revealed that while there are quite a few manufacturers of Rabies Vaccine in India, there were only two manufacturers of Rabies Immunoglobulin. 2
  3. 3. Reasons to undertake this Project & Plan Reasons to Undertake this project: To look at reasons why India has so many deaths due to rabies by looking current practice of rabies control in India Since there only 2 manufacturers of Rabies Immunoglobulin, one of them being, Bharat Serums And Vaccines Limited (“BSV”), to interact with BSV and understand whether there could be ways to increase the usage of Rabies Immunolglobulin Plan Meet with the sales and marketing division of BSV Visit select doctors in Mumbai Visit the Rabies Immunoglobulin manufacturing site of BSV Review literature relevant to the project at hand 3
  4. 4. Introduction on Rabies
  5. 5. Rabies: A snapshot Rabies is a viral infection spread by the bite of an infected animal. The rabies virus infects the Central nervous system and travels to the brain. Globally, rabies is the tenth leading cause of death due to infection in humans. Rabies is present on all continents with the exception of Antartica, but more than 95% of human deaths occur in Asia and Africa Rabies is 100% fatal if not treated immediately 5
  6. 6. Incidence in India A brief overview on the disease is provided below: Indian Population Estimated deaths due to rabies Stray dog population Estimated animal bites Frequency of bite Frequency of Human rabies deaths approx. : : : : : : 1 billion plus 20,000 annually 25 million 17.4 million. 1 bite per 2 seconds. 1 per 30 minutes India contributes to the highest number of human deaths due to rabies in the world Nearly 50% of total human deaths due to rabies in the world is contributed by India The post-bite treatment costs the Indian economy over $25 million a year * Children happen to be 40% of the cases most of them below 15 yrs of age. * India’s ongoing war against rabies. Bull WHO 2009; 87(12): 885-964 National Journal of Community Medicine . Volume 4, Issue 1, Jan – Mar 2013 6
  7. 7. Lack of Awareness Dr. B. J. Mahendra Dr. G. Sampath MandyaInstitute of Medical Sciences, Mandya, Karnataka IPM, Hyderabad Dr.Ashwathnarayan KIMS, Bangalore Feedback from Discussions with Doctors and salient points: Using only Rabies Vaccines as per Government recommendations Rabies Immunoglobulin has to be funded by patients themselves and hence reluctance to use Children more susceptible to Rabies– more bites in the face and neck area Reported mortality of 5 to 15% in Category III bites despite active immunisation 7
  8. 8. WHO Guidelines on Rabies
  9. 9. Rabies Treatment regimes Definition of categories of exposure and use of rabies biologicals Category III – single or multiple transdermal bites or scratches, licks on broken skin; contamination of mucous membrane with saliva from licks, contacts with bats. - Use immunoglobulin plus vaccine Category II – nibbling of uncovered skin, minor scratches or abrasions without bleeding - Use vaccine alone Category I – touching or feeding animals, licks on intact skin - No exposure therefore no prophylaxis 9
  10. 10. Rabies Immunoglobulin – method of Action Administration of Rabies Vaccine stimulates production of neutralizing antibodies by the patient's immune system. Protective levels of antibodies are seen 7 to 14 days after the initial dose of vaccine. Moreover when the bites are on the head, neck, face & hands, the incubation period will be shorter The patients are vulnerable to develop rabies during this window period of 7 to14 days. Hence, administration of Rabies Immunoglobulin, after thorough cleansing of wounds, is life saving as their timely and proper administration neutralizes the virus in the wound and aborts the risk of developing rabies. 10
  11. 11. Observations
  12. 12. Observations On meeting with BSV’s sales & marketing division, the following were the broad findings: BSV’s current product offering is only Rabies Immunoglobulin The cost of treatment of this has to be borne entirely by the patient as this is not part of the Government programs This increases the economic burden to the patient Currently, the most common treatment regimen followed in India is the intra-muscular administration of anti-rabies vaccine As this is in the Government program Though economical and safe to use, the use of Rabies Immunoglobulin in India has been limited because of: Challenges in the administration of the product as this had to be administered into the affected area. Non-inclusion in government programs Economic burden on the lower strata of patients 12
  13. 13. Observations Inclusion of Rabies Immunoglobulin in Government programs as a treatment regimen along with anti-rabies vaccines has its own hurdles: Inclusion of Rabies Immunoglobulin will increase the treatment cost per patient and will result in more expenditure for the government; and May not be viable within the current budget allocated by the government The WHO Expert Committee on Rabies recommended Intradermal route of rabies vaccination (“IDRV”) (1/5th dose as compared to IM) in 1992. This regimen led to considerable savings in terms of the amount of vaccine needed, thereby reducing the cost of vaccination. This also helped to bridge the gap of short supply of vaccine and increased the availability of the same. However, the response to implementation of this regimen has been poor Insufficient support from the Government 13
  14. 14. Findings
  15. 15. Comparison of Current & New cost of treatment using WHO recommendation of active and passive immunization: 2350 Cost of Treatment (Rs) 2500 2000 Vaccine ARS 1750 1500 950 1000 500 350 0 IM ID IM+RIG Regimen ID+RIG Cost of treatment per patient using WHO recommended approach of active immunization and passive immunization IM: Intramuscular; ID: Intradermal; RIG: Rabies Immunoglobulin Introduction of the new vaccine method would mean that within the same budget, 5 more patients can be treated Cost savings due to implementation of the above would mean that the Rabies Immunoglobulin can now be included in government funded program within the same budget Introduction of the combined treatment regimen would mean within the same budget, approximately 2 patients can be treated 15
  16. 16. Requirement of Rabies Ig in India 4 Vials (Mn) 3 Deficit: ~0.9Mn doses 2 3.4 0 Requirement Availability ~17.0Mn ~1.7Mn No. of vials of Rabies Immunoglobulin per patient 2 vials Total vials required 1 Total No. of Dog bites Category III bites (10%) 2.5 ~3.4Mn vials Conclusion: Currently, there is deficit of around 30% for the availability of Rabies Immunoglobulin By adding about 120-150 horses, BSV can cater to the eventual capacity requirement of Rabies Immunoglobulin for the country
  17. 17. Recommendations
  18. 18. Recommendations Work with the government to include Rabies Immunoglobulin in government funded programs as this would go a long way in meeting WHO’s goal of eliminating rabies To first include the IDRV regimen as a standard therapy for rabies vaccination – this would free lot of financial resources of the Government to allow them to include ARS also BSV should consider launching a Rabies Vaccine so as to make its product offering more comprehensive This will make BSV the first company in India to offer the TOTAL SOLUTION for Prevention of Rabies The education and training of hospital doctors and staff on the New vaccination regimen will increase the treatment of patients who have come with bites 18
  19. 19. Food for Thought Should BSV consider efficient means of waste management such as conversion to Biogas as an effective means of reducing costs? 400 horses can produce approx. 11.6MWh of electricity 19
  20. 20. Acknowledgements Within BSV Dr. Aldon Fernandes Mr. Adeet Ghosh Mr. Rahul Srivastava Mr. Gaurav Gurnaney Outside BSV Dr. B. J. Mahendra Dr. G. Sampath Dr. Ashish Kundu Dr. Ranjit Mankeshwar 20
  21. 21. Appendix 21
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