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Rabies update pedicon 2020
- 1. RABIES UPDATES Dr. Neeti Agarwal Professor and head A.B.V. medical college Vidisha
- 2. Fact trekking ⢠Rabies : dreaded zoonotic disease ⢠Lyssa virus ⢠100% fatal yet preventable ⢠Safe and effective vaccine available yet no place in routine immunization schedule ⢠higher incidence of rabies deaths among children (40-50%) ⢠Highly variable incubation period
- 3. Facts trekking ⢠In India-rabies occurs 97% through dogs , 2% cat ,1 % others ⢠17.4 million dog bites every year, yet we face up to 80% shortage of anti-rabies vaccines and immunoglobulin (2015 PLOS âneglected tropical disease )
- 4. INDIA 59,000 death globally 20,800 death in India 65 % of total Asian death 36% of global death in India 59,000 death 20,800 death
- 6. GOA Targets Human rabies-free 2020 ⢠Zero deaths in 2018-2019 in Goa ⢠1 lakh dog vaccinated annually ⢠106 positive sample dog eliminated in 2017 ⢠23,000 school teachers and 5.2 lakh school children educated
- 7. Case 1 ⢠Raju 6 year old boy was playing with friends in the colony .he saw 2 days old puppy and tried to pick up the puppy, suddenly mother dog came and inflicted injury shown in picture . how you will manage Raju ?
- 8. RISK ASSESSMENT ⢠PROVOKED /UNPROVOKED ⢠Street/pet ⢠Category of exposure ⢠Site of exposure ⢠Vaccinated /unvaccinated dog ⢠Past history of documented completion of pre and post exposure prophylaxis with good potency DGCI approved vaccine (2.5 IU/ dose ) ⢠Immuno-competent or suppressed host
- 9. Case 2 ⢠Rishita 8 year old Girl playing with friends suddenly a dog came and bite on leg ,she fell down and had bite wound over the face. ⢠How you will manage Rishita ?
- 10. CASE 3 ⢠Harsh 5 year old boy was pelting stone on stray dog ,suddenly dog attacked on boy and inflicted injury . He had similar episode in past and received documented and completed post exposure prophylaxis last year . ⢠How you will manage Harsh?
- 11. CASE 4 ⢠Kavya 9 year old girl went to neighbor house having small puppy who is 1 month old,she got bite wound over hand .owner assured her parents that dog is vaccinated but they came for consultation . ⢠How you will handle the case?
- 12. WHO rabies exposure categories Category I touching or feeding animals, animal licks on intact skin (no exposure); Wash exposed skin surfaces. No PEP Category II nibbling of uncovered skin, minor scratches or abrasions without bleeding (exposure) Wound management + Vaccination (ID/IM) Category III single or multiple transdermal bites or scratches, contamination of mucous membrane or broken skin with saliva from animal licks, exposures due to direct contact with bats (severe Wound management + immediate vaccination +RIG
- 13. Wound management
- 14. Rabies immunoglobulin ⢠Category III bite ⢠Immuno compromised patient in both CAT II and CAT III ⢠only once, on day 0 along with first ARV ⢠can be administered till 7th day but not beyond that ⢠In re- exposure cases RIGs are not indicated. ⢠Full dose of RIG infiltrated in wound
- 15. RIG Equine 40 IU/Kg ⢠40 I.U / kg Human 20 IU/Kg Brand Product Pharmace utical 1 . Anti- Rabies Serum (ARS) 5 ml vial (300 IU/ml Central institute kasoli 2 . Equirab 5ml vial (300 IU/ml, Bharat Serums Mumbai 3 . Vinrig 5ml vial (300 IU/ml 4 . Abhayr ig 5 ml vial (300 IU/ml)
- 16. RIG infiltration
- 17. Rabies human monoclonal antibody human IgG1 monoclonal antibody that binds to the ectodomain of G glycoprotein . Produced by recombinant technology ,quality standard is assured Equivalent to HRIG in efficacy Easy availability no requirement of animals in its production Thus proven cost effective alternative to RIG
- 18. ACVIP ENDORSES RHMAB AS AN ALTERNATIVE TO RIG HUMAN OR EQUINE RHMAB is licensed in India (as Rabisheild, Serum Institute of India; 40 IU/mL) since 2017. The recommended dose is 3.33 IU/kg SCHDULE : Same as RIG
- 19. Vaccines approved in India GOOD BYE TO NERVOUS TISSUE VACCINE APPROVED FOR INTRA DERMAL ⢠PVRV â Verorab, Aventis Pasteur (Sanofi Pasteur) India ⢠⢠PCECV â Rabipur, Chiron Behring Vaccines Pvt. Ltd. ⢠⢠PCECV â Vaxirab N, Zydus Cadila ⢠⢠PVRV â Pasteur Institute of India, Coonoor ⢠⢠PVRV â Abhayrab, Human Biologicals Institute ⢠⢠PVRV- Indirab, Bharat biotech ⢠⢠Only the anti-rabies vaccines approved by DCGI for ID administration should be used for ID route.
- 20. Intra muscular (0.5 ml/1 ml) intradermal ( 0.1 ml) 5 vials 5 visits One dose into deltoid on each of days: day 0 3 7 14 28 Rabies immunoglobulin
- 21. WHO position paper April 2018 ⢠Replaces 2010 paper ⢠Focusing on shorter, simpler and cost-effective vaccination schedule ⢠Evidence shows that modern rabies vaccines (>2.5 IU/IM dose), when administered ID for either PEP or PrEP, have immunogenicity and effectiveness equivalent to or higher than IM administration (The WHO position on rabies immunization â 2018 updates). Vaccine 2018
- 22. Overview of key changes in the WHO 2018 update TOPIC 2010 PAPER 2018 PAPER PEP regimen 3-4 Weeks 1-2 Weeks Duration 4-5 visit 3-4 visit PrEP regimen 3-4 Weeks 1 week Duration 3 visit 2 visit Vaccine dose (PEP) ID: 0.8 ml IM: 5 ml ID: 0.6 ml I.M:4 ml RIG infiltration mode RIG allocation Full calculated volume in and around wound. Residual volume IM, at distant site. In and around wound only, up to maximum calculated volume. No I.M administration RIG allocation All category III exposures High risk category III exposures
- 23. rabies post-exposure IM regimens. PRIMARY PEP REGIMN NUMBER OF SITE INJECTED VISIT VIAL Days of vaccination 0 3 7 14 21 28 1 site schedule Essen 1 1 1 ___1___ 4 4 2 site schedule Zagreb 2 0 1 ____1___ 3 4
- 24. Post exposure I.D Schedule PRIMARY PEP ID REGIMN NUMBER OF SITE INJECTED ( 0.1 ml) VISIT VIAL Days of vaccination 0 3 7 14 28 2 site schedule Updated Thai regimen 2 2 2 0 2 4 2 other WHO recommended schedule I.D 4 site 1 week 4 4 4 0 0 3 1.5 -3 vial I.D 2 site 1 week 2 2 2 0 0 3 1.5 -2 vial I.D 4 site 1 month 4 2 0 0 1 3 2 vial
- 25. ACVIP 2018-2019 endorses the new schedule suggested by WHO in 2018
- 26. Pre âexposure vaccination schdule PRIMARY PrEP REGIMN NUMBER OF SITE INJECTED VISIT VIAL Days of vaccination 0 3 7 14 28 1 site schedule 1 0 1 0 0 2 2 RE EXPOSURE SCHDULE NO RIG 1 Site schedule 1 1 0 0 0 2 2
- 27. RABIES PREVENTION LICENSING & VACCINATION OF PET DOG CONTROL OF STRAY DOGS POPULATION THROUGH ABC PUBLIC HEALTH EDUCATION DOG MASS VACCINATION PRE EXPOSURE VACCINE TO ALL SCHOOL CHILDREN MAKE RABIES NOTIFIABLE Global goal is to achieve zero dog transmitted human deaths by 2030
Hinweis der Redaktion
- Rabies is a dreaded zoonotic disease ,though ancient still holds public health importance in india in 2020.
- A 2015 study, published in peer-reviewed PLOS Neglected Tropical Diseases corroborates his observation. The study that estimates the global burden of endemic canine rabies says India witnesses about 20,800 rabies deaths every yearâthe highest in the world
- Every 30 min one person dying of rabies in india.
- âPrevalent in all states except Lakshadweep and the Andaman & Nicobar Islands. Karnataka 22 death in 2016,15 death in 2017 Karnataka sees second highest rabies deaths in the country(national health profile 2018). The true burden of rabies in India is not known. The reported incidence is probably an underestimation because in India rabies is still not a notifiable disease,â In India rabies is present throughout the country, except in the islands of Lakshadweep, Andaman and Nicobar. It is estimated that India continues to report every year 25,000 to 30,000 human rabies deaths, with incidence of 1.7 per 100,000 population which accounts to 60% of the global report of 55,000 deaths. But actual number of deaths due to rabies may be 10 times more than those reported. The annual animal bite load is estimated to about 17.4 million (1.7%) and 46.9% takes anti-rabies vaccination.4 Main biting animal is dog (91.5%). The dog population in India is estimated to be around 25 million, and most of them are not protected against rabies.3 Awareness about rabies is very poor. Cite this article as: Mohammad K, Gupta P. A study of human rabies cases admitted in infectious disease hospital KGMU, Lucknow, North India. Int J Community Med Public Health 2018;5:4795-8.
- Goa is the first state that did not report a single human death due to rabies last year. No rabies cases were reported in the state in 2018. The progress came on the heels of Mission Rabies, a statewide drive in place since 2014 which saw almost one lakh dogs given the anti-rabies vaccine yearly and an awareness campaign which educated 5.2 lakh schoolchildren and 23,000 teachers about the virus. This included 50,316 vaccinations administered and 78,437 students reached until August 31st this year alone. As such, rabies deaths in the state dropped from seventeen in 2014 to five in 2015 to one death each in 2016 and 2017 â to zero deaths in 2018. No cases of rabies transmitted from dogs to humans have been reported so far this year. With this progress in mind, a rabies-free Goa is decidedly on the cards according to Mission Rabies education director Dr Murugan Appupillai. âGoa is going to be the first state in India to go rabies-free,â he said. Having anticipated that humans would be rabies-free by 2020 and animals by 2023, Appupillai asserts that âwe are however well ahead of the schedule. Dog-mediated human rabies has come down to zero from 2018 onwards, but rabies was still prevalent in animals until the beginning of 2019. However, there havenât been any cases detected in the past six months.â âThe volunteers are still working very hard to continue the vaccinations each year while a continuous watch is being kept to ensure there is no disease outbreak. data-driven rabies transmission model fit to human rabies autopsy data and human rabies surveillance data from Tamil Nadu. Integrating local estimates for canine demography and costs, we predicted the impact of canine vaccination and sterilization on human health outcomes and evaluated cost-effectiveness according to the WHO criteria for India, which correspond to thresholds of $1,582 and $4,746 per disability-adjusted life-years (DALYs) for very cost-effective and cost-effective strategies, respectively. We found that highly feasible strategies focused on stray dogs, vaccinating as few as 7% of dogs annually, could very cost-effectively reduce human rabies deaths by 70% within 5 y, and a modest expansion to vaccinating 13% of stray dogs could cost-effectively reduce human rabies by almost 90%.
- Provoked bite , category II exposure , Street dog ,unvaccinated ,no past history of dog bite or pre exposure and post exposure prophylaxis. So raju should receive thorough skin wash And post exposure vaccination .
- Unprovoked bite ,street dog , category III wound ,no past history of prep and PEP . Wound washing ,RIG ,and vaccination , Tetanus prophylaxis .
- Provoked bite , street dog ,category III wound ,immunocompetent ,past history of documented complete post exposure prophylaxis with good potency vaccine . Wound management .vaccination .no RIG
- Not certain about provoked or unprovoked bite ,pet vaccinated dog .no past history of prep/pep ,immunocompetent.wound management ,RIG and vaccination
- RIG is most effective when administered locally and early. The RIG should be brought to room temperature (25°C to 30°C) before administration to the patient. Inject RIG into all wounds (anatomically feasible). Infiltrate as much as possible in the depth and around the wound(s). Remaining quantity, if any, to be given by deep intramuscular injection at a site distant from the vaccine injection site. RIG must never be given intravenously. RIG is most effective when administered locally and early. The RIG should be brought to room temperature (25°C to 30°C) before administration to the patient. Inject RIG into all wounds (anatomically feasible). Infiltrate as much as possible in the depth and around the wound(s). Remaining quantity, if any, to be given by deep intramuscular injection at a site distant from the vaccine injection site. RIG must never be given intravenously. Animal bite wounds can be severe and multiple, especially in small children. In such cases, the calculated dose of the rabies immunoglobulin may not be sufficient to infiltrate all wounds. Dilute the calculated volume of RIG in sterile normal saline to a volume sufficient to infiltrate all the wounds. The total recommended dose of RIG may not preferably be exceeded as it may suppress the antibody production stimulated by the anti-rabies vaccine.  Skin Test Not Required  There is no rationale of performing a skin test before RIG administration.  Skin Test does not reliably predict reaction.  Presently available ERIGs are highly purified and the occurrence of adverse events has been significantly reduced. So anaphylactic reactions are extremely rare.
- Gogtay NJ, Munshi R, Ashwath Narayana DH, Mahendra BJ, Kshirsagar V, Gunale B, et al. Comparison of a novel human rabies monoclonal antibody to human rabies immunoglobulin for postexposure prophylaxis: A phase 2/ 3, randomized, single-blind, noninferiority, controlled study. Clin Infect Dis. 2018;66:387-95. In view of the irregular availability and high cost of Rabies immunoglobin (RIG), ACVIP endorses the use of RHMAB as an alternative to RIG â human equine â along with rabies vaccines in all category-III bites. RHMAB is licensed in India (as Rabisheild, Serum Institute of India; 40 IU/mL) since 2017. The recommended dose is 3.33 IU/kg body weight, preferably at the time of the first vaccine dose. However, this may also be administered up to the 7th day after the first dose of vaccine is given. If the calculated dose is insufficient (to infiltrate all the wounds), it should be diluted in sterile normal saline to get a volume th
- Points to remember   Day 0 (D0) - Day of 1st dose of vaccine given, not the day of bite.  All modern Tissue Culture Vaccines (TCVs) are equally effective and safe. Never inject the vaccines into the gluteal region.  Interchange of vaccines acceptable in special circumstances but not to be done routinely. Reconstituted vaccine to be used immediately.  Vaccine dosage is same for all age groups. Stated potency of > 2.5 IU per IM dose, irrespective of the re-constituted volume. The same vaccine is used for ID administration as per stated schedule 0.1 ml of vaccine, irrespective of reconstituted volume is administered per ID
- . Single dose (0.5ml or 1ml) of anti-rabies vaccine when given by IM route gets deposited in the muscle. There after the antigen is absorbed by the blood vessels and is presented to antigen presenting cells which triggers the immune response. Whereas, while using ID route, small amount (0.1ml) of anti-rabies vaccine is deposited in the layers(dermis) of the skin at one or more than one site, the antigen is carried by antigen presenting cells via the lymphatics to the regional lymph nodes and reticulo-endothelial system eliciting a prompt and protective antibody response. Immunity is dependent mainly upon the CD 4 + T-cell dependent neutralizing antibody response to the G protein. The cell-mediated immunity is also an important part of the defense against rabies. Cells presenting the fragments of G protein are the targets of cytotoxic T- cells and the N protein induced T helper cells. The immune response induced by ID administration of anti-rabies vaccine is adequate and protective against rabies. Use of intradermal route of administration of anti-rabies vaccine allows wider Use of intradermal route of administration of anti-rabies vaccine allows wider coverage of PEP in available quantity of vaccines and hence makes it cost effective. WHO recommended use of ID route for administration of anti-rabies vaccines in 1992.Based on WHO recommendation and results of various safety, efficacy studies and feasibility trial conducted by ICMR, Drug Controller General of India (DCGI) approved the use of intra-dermal vaccination regimen Use aseptic technique to withdraw the dose Store in a refrigerator at 20C to 80C Reconstituted vaccines should be used as soon as possible or within 6 to 8 hours if kept at 20C to 80C. All unused reconstituted vaccine should be discarded at the end of immunization session.
- 1.Dog vaccination to interrupt virus transmission to human
- There is wide gap in demand and supply .in india only 46.8 % of dog bite cases receive vaccination . Less than 1% dog bite cases received immunoglobulin
- The April 2018 position paper replaces the 2010 WHO position on rabies vaccines. It presents new evidence in the field of rabies and the use of rabies vaccines, focusing on programmatic feasibility, simplification of vaccination schedules and improved cost- effectiveness.
- If a limited amount of RIG is available, its allocation should be prioritized for patients with high risk, category III exposures: multiple bites; those with deep wounds, or bites to highly innervated parts of the body, such as the head, neck and hands; patients with severe immunodeficiency; and cases where the biting animal is a confirmed or probable rabies case, or where bites, scratches or exposure of a mucous membrane were caused by a bat. RIG should be infiltrated into and around the wound up to
- RABIES VACCINE Recent data indicate that duration and number of doses for post-exposure prophylaxis (PEP) and pre-exposure prophylaxis (PrEP) regimens can be shortened. ACVIP endorses the new schedule suggested by WHO in 2018 [48]. Pre-exposure prophylaxis (Pre-EP) is recommended in the following two situations. ⢠Children exposed to pets in home. ⢠Children identified to have a higher risk of being bitten by dogs. WHO recommends a â1-site vaccine administration on days 0 and 7 for intramuscular administrationâ [48]. For post-exposure prophylaxis, recently the WHO
- Re exposure after a full course (Pre/Post-exposure) I/M or I/D irrespective of Category of exposure or Time since previous vaccination 2 boosters (Day 0 & Day 3) No RIG Â Â All incomplete/partial vaccinations - Treat as fresh case Re-exposure following PEP with NTV As fresh case
- Previous studies have suggested that the existing rabies vaccine -- which is costly and complicated to administer -- works by activating the immune system's B cells. However it can take time for the vaccine, which contains inactivated virus particles, to interact with the B cells. In the new work, James McGettigan of Thomas Jefferson University, USA, and colleagues turned to a signaling protein known as B cell activating factor (BAFF), which binds directly to B cells. They designed a rabies vaccine which included an attenuated rabies virus and BAFF on the same particle, hoping to target the vaccine directly to B cells for activation. Then they tested the new vaccine in mice. Mice immunized with the new BAFF-enhanced rabies vaccine showed a faster and stronger response of the immune system compared to animals that received the typical vaccine. Levels of virus neutralizing antibodies increased more quickly and to higher levels, however the duration of the response was not affected. Additional studies on the safety of the vaccine are needed before testing it in humans. "This new vaccine strategy significantly enhanced the speed and magnitude of the anti-rabies antibody responses and has the potential to improve the efficacy of currently used inactivated RABV-based vaccines, No rabies cases were reported in the state in 2018. The progress came on the heels of Mission Rabies, a statewide drive in place since 2014 which saw almost one lakh dogs given the anti-rabies vaccine yearly and an awareness campaign which educated 5.2 lakh schoolchildren and 23,000 teachers about the virus. This included 50,316 vaccinations administered and 78,437 students reached until August 31st this year alone. As such, rabies deaths in the state dropped from seventeen in 2014 to five in 2015 to one death each in 2016 and 2017 â to zero deaths in 2018. No cases of rabies transmitted from dogs to humans have been reported so far this year. With this progress in mind, a rabies-free Goa is decidedly on the cards according to Mission Rabies education director Dr Murugan Appupillai. âGoa is going to be the first state in India to go rabies-free,â he said. Having anticipated that humans would be rabies-free by 2020 and animals by 2023, Appupillai asserts that âwe are however well ahead of the schedule. Dog-mediated human rabies has come down to zero from 2018 onwards, but rabies was still prevalent in animals until the beginning of 2019. However, there havenât been any cases detected in the past six months.â âThe volunteers are still working very hard to continue the vaccinations each year while a continuous watch is being kept to ensure there is no disease outbreak,â Appupillai added. â Vaccines hidden in dog food could help curb the spread of rabies more effectively than injections, say UK scientists who conducted a study on street dogs in India. There are an estimated 100 million stray dogs in India. Experts say that the combination of an injectable and oral vaccination approach could help them reach the minimum 70 per cent vaccine threshold needed to minimise risk of rabies being passed to people. According to researchers from University of Edinburgh in the UK, three times as many dogs could be vaccinated each day when the new process is combined with existing injectable techniques. The team worked with experts from Mission Rabies, and the Worldwide Veterinary Service to assess the feasibility of the approach in Goa. The oral rabies vaccine is not yet licensed for use in India so the team embedded empty capsules in dog food to test the concept. Working with the Government of Goa Animal Husbandry Department, teams on mopeds searched for free-roaming dogs, delivering capsules in an attractive bait. Each member of the team reached 35 dogs each day, compared with just nine using current vaccination methods. They accessed 80 per cent of the dogs they spotted, compared with 63 per cent when only using the catch-vaccinate-release method. The study, published in Vaccine X, shows that combined vaccination approach could be cheaper, helping to further maximise limited resources. "Rabies has a massive impact on societies, not only from the disease, but also from the fear that results," said Luke Gamble, a Founder of Mission R