1. RABIES AND ITS PREVENTION AND
CONTROL IN ONE HEALTH CONTEXT
Md Mostaque Ahmed
PGT
Department of Community Medicine
Gauhati Medical College & Hospital
Guwahati, Assam
2. • The prevention of human rabies is dependent upon the effective and
verifiable control of the disease within the domestic dog population,
being the most common reservoir of the virus and cause of more
than 95% of human cases.
• Dog-mediated human rabies is completely preventable using
biological tools and vaccination.
• Public awareness, health education, dog vaccination, and the
availability and accessibility of PEP are key for rabies prevention and
control.
3. Rabies Prevention and Control
It has two components:
1. Animal Rabies Control
2. Human Rabies Prevention
4. Elements of Animal Rabies Control
Rabies control strategies include:
- Mass vaccination of dogs
- Movement restriction/Confinement
- Control of ‘stray’ dogs
5. Mass vaccination of dogs
• Animal Pre-Exposure
Vaccination
• For effective control at
least 75-80% of the
population should be
vaccinated
• Should be done on a
regular basis
6. Movement
restriction/Confinement
• Isolation and Observation
Periods( 10 days for Dogs
and cats):- Suspected Rabid
Animal
• Animal Quarantine(Six
months):- Animal Exposes
but previously vaccinated.
• Euthanasia of unvaccinated
animals:- if found exposed
(In some countries)
7. Control of ‘stray’ dogs
The objective is to decrease
the stray dog population to a
certain level or to keep and
management with the
population at a certain level.
A ‘Stray’ dog is a dog that is
not under the direct control of
the owner or is not being
stopped in roam (including
lost and abandoned dogs).
8. Measures for ‘stray’ dog control
• Create responsible dog ownership in the community.
• Dog registration and Identification:- mandatory rabies vaccination
and traceability.
• Environmental Control:-excluding dogs from sources of food (e.g.
rubbish dumps and abattoirs, and installing animal-proof rubbish
containers).
• Human-dog population management:- Animal Birth control
• Control of dog movements:- (e.g. leash laws, roaming restrictions)
9. Elements of Human Rabies Prevention
• Avoiding exposure:-
-Avoiding contact with unknown animals
-Nursing rabid Humans/animals with care
• Pre-Exposure Prophylaxis (PrEP):-
- is recommended for anyone who is at continual, frequent, or
increased risk for exposure to the rabies virus such as laboratory
workers, veterinarians, and animal handlers.
• Post-Exposure Prophylaxis (PEP)
- anti-rabies prophylaxis(Vaccine/RIG)administered after an exposure
10. Top 10 General Considerations in Rabies PEP
1. Wounds must be immediately washed/flushed for 15 minutes and
disinfected
2. Rabies PEP should be instituted immediately. PEP consists of a course of
potent, effective rabies vaccine that meets WHO recommendations and the
administration of rabies immunoglobulin.
3. PEP must be applied using vaccine regimens and administration routes
that have been proven to be safe and effective.
4. PEP does not have contraindications if purified rabies immunoglobulin and
vaccine are used. Pregnancy and infancy are not contraindications to PEP.
11. 5. If rabies immunoglobulin is not available on the first visit, use can be
delayed by up to 7 days from the date of the first vaccine dose.
6. Initiation of PEP should not await the results of laboratory diagnosis
or be delayed by dog observation when rabies is suspected
7. When suspected rabid animal contacts (excluding bats) occur in
areas free of carnivore-mediated rabies and where there is adequate
surveillance in place, PEP may not be required. The decision must be
based on expert risk assessment
8. Patients presenting for rabies PEP even months after having been
bitten should be treated as if the contract had recently occurred.
12. 9. PEP should be administered even if the suspect animal is not available
for testing or observation. However, vaccine and immunoglobulin
administration may be discontinued if the animal involved: is a
vaccinated dog (cat or ferret) that following observation for 10 days,
remains healthy OR is humanely killed and declared negative for rabies
by a WHO-prescribed laboratory test.
10. In areas enzootic for (canine and wildlife) rabies, PEP should be
instituted immediately unless adequate laboratory surveillance and data
indicate that the species involved is not a vector of rabies.
13. Rabies Post-Exposure Prophylaxis Modalities
Wound treatment:
• Should be immediate
• Is essential even if the person presents long after exposure
• it consists of:
• Immediate washing and flushing wound for 15 minutes with soap and
water, or water alone, Disinfection with detergent, ethanol (700ml/l),
iodine (tincture or aqueous solution), or other substances with
virucidal activity, Bleeding at any wound site indicates potential severe
exposure and must be infiltrated with either human or equine rabies
immunoglobulin
• Other treatments include- the administration of antibiotics and
tetanus prophylaxis
14.
15. Rabies Post-Exposure Prophylaxis Modalities
In countries or areas enzootic for rabies, exposure to suspected or
confirmed rabid animals are categorized by WHO as follows:
17. Anti Rabies Immunization
Active Immunization (by Anti-Rabies Vaccine)
• Nerve Tissue Vaccine
• Duck Embryo Vaccine
• Tissue Cultured Vaccine(HDCVs or PCEC-V)
Passive Immunization (by Rabies Ig)
• Equine Rabies Ig (ARS)
• Human Rabies Ig (hRIG)
18. Intramuscular regimens for rabies
Post-Exposure Prophylaxis
There are 2 intramuscular schedules
for categories II and III
exposures:
• The 5-dose regimen
• The 2-1-1 regimen
1. Vaccine should be injected into
the deltoid muscle for adults and
children aged 2 years and more.
2. The anterolateral thigh is
recommended for younger
children.
3. Vaccines should not be injected
into the gluteal region.
19. • Intramuscular regimens for rabies
Post-Exposure Prophylaxis
• The 5 dose intramuscular
• Essen regimen: (1-1-1-1-1)
• One dose of the vaccine should be
administered on days 0, 3, 7, 14
and 28
• Given in the deltoid region or, for
young children, into the
anterolateral area of the thigh
muscle.
20. Intramuscular regimens for
rabies Post-Exposure
Prophylaxis
The 2-1-1 Zagreb Regimen:
• 2-0-1-0-1
• Two doses are given on day 0
in the deltoid muscle, right
and left arm
• An additional dose is
administered in the deltoid
muscle on day 7 and day 21
21. Intradermal regimen for rabies
Post-Exposure-Prophylaxis:
• The intradermal (ID) regimen
requires a reduced volume of
vaccine to be utilized than any
of the intramuscular regimens,
therefore, reducing vaccine
cost by 60-80%
• This method is appropriate
where vaccines or/and money
are in short supply, particularly
in rural areas with high-flow
clinics
22. Intradermal regimen for rabies Post-Exposure-Prophylaxis
- The volume per intradermal (ID) site is 0.1 mL
- Using the ID route of administration, PVRV (Verorab™) and PCECV
(RabipurTM) have been proven to be safe and efficacious.
- 0.1 mL per ID site is used, according to WHO’s recommended ID
regimen
- Vaccine-administered ID must raise a visible and palpable “bleb” in
the skin. If a dose of vaccine is inadvertently given subcutaneously or
intramuscularly, a new dose should be administered intradermally.
23. Intradermal PEP regimen for Category
II and III Exposures
- The 2-site intradermal method: (2-2-2-0-2)
- One dose of vaccine, of 0.1 ml is given intradermally at two
different lymphatic drainage sites
- Usually administered in the deltoid muscle on the left and right
upper arm and supra-scapular area
- given on days 0, 3, 7, and 28, the day 14 dose is missed.
24. Administration of Rabies Immunoglobulin (RIG)
It is to provide neutralizing antibodies at the site of
exposure before patients can begin producing their
antibodies physiologically after vaccination.
- Administration of rabies immunoglobulin (RIG) to
wounds classified as category III exposure, is of
utmost importance in wound management.
- Bites to the head, neck, face hand, and genitals
are category III exposures
- Infiltrate RIG into the depth of the wound and
around the wound.
- RIG should be infiltrated around the wound as
much as anatomically feasible
- Remaining RIG should be injected at an
intramuscular site distant from that of vaccine
inoculation (e.g. into the anterior thigh)
25. Administration of Rabies Immunoglobulin (RIG)
Quantities/volume of RIG:
- 20 IU/kg for Human RIG (HRIG) or 40 IU/kg of
Equine RIG (ERIG)
- Total recommended dose should not be
exceeded
- If RIG is unavailable on the first visit, its
administration can be delayed by a maximum of
7 days from the date of the first vaccine dose
- If the calculated dose of RIG is insufficient to
infiltrate all wounds, sterile saline may be used
to dilute it 2 to 3 fold to permit thorough
infiltration.
- Human rabies immunoglobulin:
201U/dose(max=1500IU)
- Equine rabies immunoglobulin:
401U/dose(max=3000IU)
26. Short rabies PEP of previously vaccinated persons
• Local treatment of wound(s) should be ensured
• Two active immunization schedules are available
- No RIG should be applied
- However full PEP should be given to persons:
a) who have received pre-or post-exposure prophylaxis with
vaccines of unproven potency
b) where immunological memory is no longer assured as a result of
HIV/AIDS or other immunosuppressive causes.
27. Short rabies PEP of previously vaccinated persons
Schedule 1:
- One dose to be injected intramuscularly or intradermally on days 0
and 3
- The dose is either 1 single immunizing intramuscular (IM) dose (1 ml
or 0.5 ml, depending on vaccine type) or one intradermal (ID) dose of
0.1 ml per site
Schedule 2:
A “4-site” intradermal (ID) PEP can be used
- Consists of 4 injections of 0.1 ml equally distributed over left and right
deltoids, thigh, or suprascapular areas during a single visit.
(Decision to use schedule 1 or 2 is left with the health care provider in
consultation with the patient)
28. PEP for immunosuppressed individuals
Thorough wound treatment should be
further stressed for immunosuppressed
individuals.
- RIG should be administered deeply into
the wound for both category II and III
exposures.
- Vaccines should always be administered
and no modification of the recommended
number of doses is advisable.
- When possible, the rabies virus
neutralizing antibody response should be
determined 2-4 weeks after vaccination to
assess whether an additional dose of
vaccine is required!
29. Pre-exposure rabies prophylaxis (PrEP)
PrEP is recommended for anyone who is
at continual, frequent or increased risk
for exposure to the rabies virus, as a
result of their occupation or residence
such as:
- Groups of persons at high risk of
exposure to live rabies virus (laboratory
staff, veterinarians, animal handlers
and wildlife officers)
- Dog handlers, Municipal sweepers pet
owners postman etc.
- Children living in or visiting rabies
affected areas.
- Travelers to rabies-affected areas
- according to the level of risk in that
area.
30. Pre-exposure rabies prophylaxis regimens (PrEP) with vaccines fulfilling
WHO requirements
Intramuscular:
• One intramuscular dose is given on each of days 0, 7, and 21 or 28
• Site of injection: deltoid area of the arm for adults; anterolateral area
of the thigh is recommended for children aged less than 2 years.
Intradermal:
• One intradermal injection of 0.1 ml is given on each of days 0, 7, and 21
or 28
• If anti-malarial chemoprophylaxis is applied concurrently, intramuscular
injections must be used.
31. Booster vaccination and monitoring of previously immunized persons
a) Persons working with live rabies virus in diagnostic laboratories, research
laboratories, and vaccine production laboratories at permanent risk of exposure to
rabies should have:
- One serum sample is taken every six months.
- A booster dose when the titer falls below 0.5 IU/ml
b) Other professions (veterinarians, animal handlers, wildlife officers, etc.) working
in rabies endemic areas should have:
- One serum sample is taken every two years.
- A booster dose when the titer falls below 0.5 IU/ml
c) Routine booster vaccine doses after primary rabies vaccination are not required
for the general public living in areas of risk.
32. National Rabies Control Programme
(NRCP)
Background:
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 are associated with dog bites. Cats, wolves, jackals,
mongoose, and monkeys are other important reservoirs of rabies
in India. Bat rabies has not been conclusively reported in the
country.
34. To address the issue of rabies in the country, National Rabies Control
Programme was approved during the 12th FYP by the 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 the 12th FYP
- Human Component for roll out in all States and UTs through nodal
agency NCDC with a total budget of Rs 20 Crores
- 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 a total budget of Rs 30 Crores for the
Plan period. The Human Health Component has been rolled out in 26
States and UTs.
35. Human Component- which is being implemented in all the states &
UTS. National Centre for Diseases control is the nodal agency for the
Human Component of the program. The strategies for the human
component are:
-Training of health professionals
-Implementing the use of an intra-dermal route of inoculation of cell
culture vaccines
-Strengthening surveillance of human rabies
-Information Education & Communication Laboratory strengthening
36. Animal Component-
which is being pilot-tested in Haryana & Chennai. The Animal
Welfare Board of India, Ministry of Environment & Forests is the
Nodal agency for the Animal Component of the program. The
strategies for the animal component are:
-Population survey of dogs
-Mass vaccination of dogs
-Dog population management
37. Objectives:
1. Training of Health Care professionals on appropriate Animal bite
management and Rabies Post Exposure Prophylaxis.
2. Advocacy for states to adopt and implement the Interdermal route of Post-
exposure prophylaxis for Animal bite Victims and Pre-exposure prophylaxis for
high-risk categories.
3. Strengthen Human Rabies Surveillance System.
4. Strengthening of Regional Laboratories under NRCP for Rabies Diagnosis,
5. Creating awareness in the community through Advocacy &
Communication and Social Mobilization.
38. State level components
-Capacity Building
-Promote utilization of cost-effective Intra-dermal rabies vaccines
for rabies Post Exposure Prophylaxis.
-Strengthen rabies diagnostics
-Strengthening Surveillance of animal bites and rabies cases
-Information, Education & Communication
-Intersectional coordination
39.
40. The Need for a One-Health Approach
In the fight against rabies, the priority is to safeguard human
welfare but it should not be at the unnecessary expense of
dogs.
• One health approach will provide good animal welfare which
will have a direct benefit to human health
• To ensure sustainability, dog vaccination programmes will
need political support and will need to integrate public health,
veterinary, livestock, and animal welfare agencies
41. Rabies is a classic 'One Health' challenge:
• More than 96% of human Rabies deaths arise from exposure to a rabid
dog.
• Standard animal vaccines for providing pre-exposure prophylaxis to
dogs and human vaccines for providing optimum post-exposure
prophylaxis to dog bite victims are available.
• However, imperfect awareness compounded by variable accessibility
of PEP has resulted in the persistence of human Rabies fatalities.
• Rabies is a typical example of a zoonotic infection that does not fit into
the domain of any one single department having the responsibility of
controlling Rabies. Although there is an animal reservoir involved,
mortality and morbidity mainly affect human beings.
• Therefore, for prevention, control, and elimination of Rabies an
effective and concerted effort from the Animal Husbandry sector,
Human Health sector, Local governing bodies, communities, and
other stakeholders, is the need of the hour
42. In 2015, The WHO/FAO/OIE declared a vision for the elimination of dog-
mediated Rabies in 2030 and called for action by setting a global goal of
zero human dog-mediated Rabies deaths by 2030, worldwide and thereby
contributing as part of SDG 2.
• As Rabies disproportionately affects poor and rural communities,
eliminating human deaths from Rabies is also consistent with SDG 1 to
"end poverty in all its forms and the commitment of Member States to
"leave no one behind".
The One Health approach is the most successful model which has
been adopted by many countries for Rabies elimination. The target for
Rabies elimination can only be achieved by sustained and synergistic
political commitment and administrative support of all stakeholders
from the highest level up to the village level.
43. The Rabies prevention and control by "One Health Approach" is also challenging in the
Indian Context due to varied administrative structures and priorities across sectors
involved at the National and sub-national levels. The key challenges for realizing One
Health in the context of Rabies are as under:
1. Lack of understanding about One Health Concept among the concerned stakeholders.
2. The priorities are different for different sectors and accordingly poor and inadequate
resource allocation for undertaking activities and achieving the target.
3. Fragmented activities of animal health components such as dog population management
and mass dog vaccination across the sectors.
4. Poor surveillance, reporting of human and animal rabies cases, and lack of structured
mechanism of data sharing across human and veterinary sectors.
5. Large Stray dog population both in urban, peri-urban, and rural areas.
6. Biodiversity and challenging wildlife sector at urban, peri-urban, and rural interface
resulting in spillover.
44. 7. Limited logistics and poor supply chain management for undertaking the activities of Human and
animal health components.
8. Lack of awareness among professionals as well as general communities about the legal framework.
9. Lack of administrative and political will.
45.
46.
47. Challenges faced in
Surveillance and Intersectoral
coordination
• No single administrative unit thus
collection and collation of data from all
the agencies involved in animal bite
management is a challenge
• Involvement of Intra-city multiple
stakeholders
• Continues to remain a disease of low
priority with Dept of Animal Husbandry
48. Challenges for Rabies Control
in India
• Generating political
awareness and will for large-
scale control programme -
Ownership for dog rabies
control
• Development and
implementation of a national
rabies control strategy
• Devolving responsibility to
local government authorities
• Legislation:
Registration/Licensing and
vaccination of dogs.
49. Future Plans To Control Rabies At Source In India Through One Health Approach
General Considerations
• Prevention: Introduce cost-effective public health intervention techniques to improve
accessibility, affordability, and availability of post-exposure prophylaxis
• Promotion: Improve understanding of rabies through advocacy, awareness, education, and
operational research
• Partnership: Provide coordinated support for the anti-rabies drive with the involvement of the
community, civil society, government and non-government sectors, and international partners
• Establish surveillance on human as well as animal side and identify Rabies as a Notifiable disease
• Strengthen State-level coordination committees
• Identify and fill gaps in current implementation programmes e.g. Rural and peri-urban areas pose
a major threat to the success of rabies control efforts
• Document Rabies intervention as a model for replication
• Draft a blueprint that can guide the national disease control programme to combat rabies and
other zoonoses in the country
50. Specific Considerations
• Human rabies prevention is possible through the promotion of responsible
dog ownership, mass dog vaccination, and animal birth control programme with a
partnership approach
• Mass vaccination campaigns targeting dogs: of all age groups to develop herd
immunity.
• Mass dog vaccination alone is effective but providing additional dog population
management interventions can help overcome the challenges
Conclusion
• A Rabies Control programme focused on mass vaccination of dogs and animal
birth control is largely justified by the future savings in human rabies prevention.
• This is where dog owners, civic societies, animal welfare, and non-government
organizations need to play a proactive role.
• A concerted effort between the human and animal health sectors can achieve the
goals of rabies elimination.
