Human Rabies in India
During the Second Commonwealth Veterinary Conference which was held in Bangalore, India (February 1998), Professor M K Sudarshan from the Rabies Epidemiology Unit, Kempegowa Institute of Medical Sciences, Bangalore, India gave a lecture on the human rabies in control in India. Some of his observations are summarized and we thank him for this contribution.
Human rabies is not a notifiable disease. It is endemic throughout the year in India, in all states, except in the island of Lakshwadweep, Andaman and Nicobar. About 30,000 people die of rabies annually which accounts to 80% of 36,000 deaths reported officially to the World Health Organisation. In India, nearly 96% of rabies is due to bites from dogs which are mostly stray and ownerless. Annually about one million people receive post exposure anti-rabies vaccination. Children constitute about 35-40% of those who receive post exposure treatment. Half a million receive, free of cost, through government Health Institutions the Semple (Sheep Brain BPL inactivated) vaccine which is indigenously produced in 12 centres. Another half a million receive through private outlets the cell culture vaccines (Purified Chick Embryo Cell (PCEC), Purified Verocell Rabies Vaccine (P~VRV) and Human Diploid Cell Vaccine (HDCV). The PCEC vaccine (Rabipur) is indigenously manufactured and distributed in India by Hoechst Marion Roussel Ltd. The PVRV (Verorab) is imported from Pasteur Merieux Connaught, Lyon, France.
Anti-rabies serum (ARS) of equine origin is indigenously produced only at Central Research Institute, Kasauli, Himachal Pradesh with an annual production of 120 litres. However, this is short of an estimated need of 1,500 litres. This gap is now being bridged with the import of Equine ARS from Pasteur Merieux, Connaught, Lyon, France which is available privately. Small quantities of Human Rabies Immune Globulin (HRIG) are imported from Germany (Berirab - P) and Frances (Imogamrab) and are expensive. The HRIG is available mostly in the metropolitan and bigger cities. However, the majority of the severe exposures do not receive ARS. Unfortunately this can be attributed to lack of awareness amongst medical profession of the availability and need of using ARS in high risk exposure bites.
Facilities for management of rabies in man (hydrophobia) are available at specially identified Government isolation hospitals and at some district hospitals. The diagnosis of hydrophobia is made mostly on the basis of clinical signs and symptoms and the corroborative history of animal bite. The facilities for laboratory confirmation (antemortem/postmortem) by Fluorescent Antibody Test (FAT) are available only at few select centres in the country. Consequently many cases of typical rabies are missed or diagnosed very late by attenting physicians. Cases diagnosed by private physicians usually referred to isolation hospitals for fear of contagion. The treatment at isolation hospitals is mostly symptomatic and facilities at isolation hospitals need lots of improvement and modernization. Regular training courses in laboratory techniques and workshops on surveillance and control are held with financial assistance from the World Health Organisation and other agencies. Publicity campaigns are carried out through education material and mass media by organisations such as the Pasteur Institute of India, Coonoor, Tamilnadu.
The immediate requirements in India are:
- to increase the indigenous production of CCVs so as to replace Semple's vaccine.
- to increase the annual production of ARS.
- to intensify education programmes for doctors regarding post exposure treatment and proper use of vaccines and sera.
- to improve the facilities better for better management of hydrophobia.
- to initiate surveillance on the control of rabies and trials of the newer anti-rabies vaccines.
Professor M K Sudarshan,
Bangalore, India
