Rural Rabies Prevention Project - A ‘One Health’ Experiment in India: An Overview.

Aim: To assess the feasibility of implementing "one health approach" to prevent human rabies and control animal rabies in a rural community. Study Design: Health services research in a rural setting. Place and Duration of Study: A medical college and a veterinary college along with an animal welfare organization delivered a wide array of "integrated services" in three villages' i.e. Kumbalagodu, Thagachikuppe and Gerupalya near Bangalore, India comprising a population of 10,220 persons for a period of two years from December, 2009 to November, 2011. The nearby three villages of Ramohally, Vinayakanagara and Bhimanakuppe with a population of 6,023 persons formed the control group, with no project inputs. Methodology: This consisted of household surveys at the beginning and end of two years ; rabies awareness campaigns; clinical and laboratory surveillance of rabies in dogs; rabies post-exposure prophylaxis (PEP) in humans; pre-exposure rabies prophylaxis (PrEP) by intradermal route in school children, pet dog owners and veterinarians ; mass dog vaccination and deworming; and sero-surveillance in both dogs and humans. Results: The ratio of veterinary and medical manpower in study villages was 1: 11 and dog to human ratio was 1: 23.The information, education and communication materials developed and used were domestic outdoor wall writings (11), domestic indoor annual wall calendar (2000), school book labels (1000); game charts (16); wall posters (65); flip chart (15); rabies educational DVD (1). There were 102 local cable television transmissions on rabies prevention. 69 persons received rabies PEP. PrEP was given to 368 school children, pet dog owners and veterinarians. Sixty one human serum samples were analyzed by rapid fluorescent focus inhibition test for rabies antibody detection. Sixteen veterinarians were trained to use direct rapid immunohistochemical test (dRIT) for rabies diagnosis. Six ruminants were confirmed rabid by dRIT. There were no cases of human rabies. The cost of entire project was US $ 85,958. Conclusion: A blend of medical, veterinary and animal welfare services were successfully delivered through a "one health" approach. Based on this success a "conceptual model" was evolved to propagate its replication in other rural communities across India.

Is the skin sensitivity test required for administering equine rabies immunoglobulin.

Background. Rabies immunoglobulins are life-saving in patients with severe exposure to rabies. Despite the high degree of purification of equine rabies immunoglobulin (ERIG), the product inserts still recommend a skin sensitivity test before administration of this heterologous serum. A recent WHO recommendation states that there are no scientific grounds for performing a skin test before administering ERIG because testing does not predict reactions and it should be given irrespective of the result of the test. In this conflicting situation, we assessed the use of the skin sensitivity test in predicting adverse events to ERIG. Methods. The data analysed were from the Antirabies Clinic of the Kempegowda Institute of Medical Sciences Hospital, Bengaluru, India. The period of study was 26 months (June 2008–July 2010). The skin sensitivity test was validated by evaluating its sensitivity, specificity, predictability, falsepositive and false-negative results. Results. A total of 51 (2.6%) adverse events were reported in 31 (1.5%) subjects. Most of these were mild to moderate in nature and subsided without medication. There was no serious adverse event. The sensitivity and specificity of the skin sensitivity test to predict an adverse event was 41.9% and 73.9%, respectively. Conclusion. Our experience with the skin sensitivity test suggests that it may not be required before administering ERIGs, as recommended by WHO.

A survey of hospitals managing human rabies cases in India.

A survey of 23 infectious diseases (ID) hospitals/ID wards of general hospitals was done during 2008-09 to assess the facilities for and management of rabies patients. All were Government hospitals and 0.5% of total beds was earmarked for rabies cases. The hospitals were mostly run by medical colleges (47.8%) and ID hospitals (30.4%) and located outside city limits (52.2%). The patients were admitted to 'rooms (39.1%)' and 'wards (43.5%)'. The general conditions of rabies sections i.e. sanitation and linen (65%), space and toilet (52% and 56%) and bed (47.8%) require improvements. There is a need to improve staff availability, use of personal protective wears, preventive vaccination of care providers and medicinal supplies. It is recommended to encourage hospitalization of human rabies cases to ensure a 'painless and dignified death' and this must be considered as a 'human rights' issue.

Boosting effect of purified chick embryo cell rabies vaccine using the intradermal route in persons previously immunized by the intramuscular route or vice versa.

BACKGROUND: At present, in the event of re-exposure to rabies, 2 booster doses are recommended for people who have been previously vaccinated with cell culture rabies vaccines by the conventional intramuscular route. As the intradermal route of vaccination is likely to be introduced in the future, we investigated the immune response to a cell culture rabies vaccine after crossing over from the intramuscular to the intradermal route and vice versa. METHODS: Twenty healthy adult volunteers who had received a primary course of rabies vaccination with purified chick embryo cell rabies vaccine by either the intramuscular (n = 10) or intradermal (n = 10) route received booster vaccination with the same vaccine by the alternative route. The regimen used was 0.1 ml of vaccine by the intradermal route at two sites (deltoid area) for the intramuscular group, or 1 ml of vaccine by the intramuscular route (deltoid muscle) to the intradermal group on days 0 and 3. RESULTS: There was a 15-fold rise in the rabies virus neutralizing antibody response both by the intradermal and intramuscular routes of booster vaccination (p < 0.0001). Thus, the change of route of purified chick embryo cell booster vaccination did not alter the anamnestic immune response to the vaccine. No side-effects were observed after vaccination with either of the routes. CONCLUSION: Purified chick embryo cell vaccine was found to be safe and immunologically efficacious following booster vaccination after cross-over from the intradermal to the intramuscular route and vice versa.