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Five shots and rabies-free

Jyotsna Singh | Updated on January 09, 2018 Published on December 08, 2017
Puppy love: An important component in the fight against rabies is the timely and periodic vaccination of dogs. Photo: S S Kumar

Puppy love: An important component in the fight against rabies is the timely and periodic vaccination of dogs. Photo: S S Kumar   -  The Hindu

Life savers: There has been no nationwide study on the stock-outs of rabies vaccine, but reports of shortages keep surfacing from across the country. Photo: C V Subrahmanyam

Life savers: There has been no nationwide study on the stock-outs of rabies vaccine, but reports of shortages keep surfacing from across the country. Photo: C V Subrahmanyam   -  The Hindu

On the jab: The first shot of anti-rabies vaccine must be administered within the first 24 hours of the animal bite or scratch. Photo: C V Subrahmanyam

On the jab: The first shot of anti-rabies vaccine must be administered within the first 24 hours of the animal bite or scratch. Photo: C V Subrahmanyam   -  The Hindu

Rabies is fatal, but entirely preventable... yet India accounts for one-third of all related deaths worldwide. The reasons range from lack of awareness to governmental apathy

In mid-November, seven-year-old Bhanuman Singh started to feel sick. He was unable to swallow water, could not bear the sight of the fan and hated any light falling on his eyes. In short, he remained confined in a dingy room without air, light and water at his home in Kurlipur, Uttarakhand. Clueless, his parents called a doctor a day later only to learn their son was suffering from a fatal disease — rabies. Singh had been bitten by a street dog a month ago. He was given all five shots of anti-rabies vaccine. But another crucial shot, the anti-rabies serum, or rabies immunoglobulin — which is a protection mechanism given even before the vaccine in case of severe bites — was not given to the child, which proved to be a deadly oversight.

“He was brought here at 10.30 pm on November 18. His vaccine schedule had ended only three days ago. His parents brought him in the hope that we will be able to help him. But we told them, as we tell the families of all rabies patients, that there is no chance of survival. His parents took him away after a few hours under LAMA (leave against medical advice). He must have died within a week,” says a nurse at the Maharishi Valmiki Infectious Disease Hospital (MVID) in north Delhi. It is the only government hospital in the National Capital Region that lists rabies among the treatment provided. Even though the disease is not treatable, the doctors at the rabies ward try to stabilise and counsel the patient and the family. A rabies patient survives for a week to a month after contracting the disease.

Hospital records show that it receives patients from as far as Nuh in Haryana and Farrukhabad in Uttar Pradesh.

“It is among the most painful diseases. The rabies virus attacks the nervous system. The brain is affected the last and, hence, the patients are conscious of everything that is happening to them. For example, they suffer from hydrophobia and cannot drink water. They remain aware of this fact, and the feeling of having a dry throat, till the end,” said Dr Sushil Kumar Gupta, director of MVID.

Rabies is caused due to a virus, which is transmitted when an infected animal bites or scratches a human being. Almost 95 per cent of the cases result from dog bites. If a person gets rabies, then death is almost certain. However, it can be prevented if the protocols recommended by the World Health Organization (WHO) are followed. The bite or scratch wound is to be washed properly, followed by the first shot of anti-rabies vaccine within the first 24 hours — the sooner the better. Severe cuts may require an added dose of anti-rabies serum, which works against the rabies virus before the vaccine’s effect kicks in. Though every bite does not lead to infection of rabies, this protocol must be applied every time there is a bite. Though simple, on the face of it, the protocols have a long way to go in terms of implementation.

According to a 2015 study published in the journal PLOS Neglected Tropical Diseases, 59,000 people die of rabies worldwide every year. India accounts for nearly 21,000, or more than one-third of those deaths. WHO has set a target of eliminating rabies from South-East Asia by 2020. Without active participation from India, the target will remain unachievable. The hurdles are too many.

No awareness, no vaccines

Among the major reasons for the high number of deaths is the lack of knowledge of the deadly nature of rabies. Manika Shahu, 35, was brought to Safdarjung Hospital in Delhi from Meerut, Uttar Pradesh. She had been bitten by a dog 10 days earlier when she went to the fields to defecate. As is the traditional practice in rural UP, her husband put red chillies on her wound. Four days later, when she started feeling paralysis in her legs, her family took her to a traditional healer nearby. After keeping her for a day in his ashram, the healer suggested taking her to Delhi.

“We did not know about the vaccine or medicines to be taken after a dog bite,” said Ramesh Shahu, Manika’s husband, as they waited to meet the doctor.

A nurse at the hospital said Manika’s symptoms were clearly those of rabies and no doctor can help. “We need to create awareness about the disease and its prevention. People come to Delhi in the hope of a treatment when none exists. The patient has to be vaccinated at the place of their stay. It is one of the vaccines that should be mandatorily available at the primary health centres,” the nurse said, declining to be named. The vaccine is in short supply and not found in remote areas, she added.

“We had a patient yesterday who had received three shots of the vaccine instead of five at a PHC. The doctor told him the stock had run out and he must wait for a month for the new stock to arrive. The patient had caught rabies meanwhile,” the nurse shared.

While there has been no nationwide study on the stock-outs of rabies vaccine, reports of shortage keep surfacing at the local level. For example, in September this year, the district hospital in Amritsar reported a stock-out for more than a fortnight. Similarly, there was no immunoglobulin for almost a month in Panaji in March 2015.

The vaccine must be stored at 2-8° Celsius, so every PHC and district-level hospital must have a working fridge. If electricity supply is irregular or non-existent, then the health facility cannot store the vaccine.

Pharmaceutical company Pfizer uses temperature-controlled thermocol boxes to transport its vaccines. “Our boxes can hold the vaccines for up to two days at the required temperature. We transport them to far-off places in India,” said Rajesh Parmar, Delhi field officer of Zoetis, a Pfizer entity. Once it arrives at its destination, the vaccine must be kept at low temperatures, otherwise it will lose its potency. “We need to understand that rabies can be controlled at the local level, not in big hospitals,” said Dr Gupta.

Cost factor

The vaccine should be available free of cost at government facilities. In private clinics and hospitals, each dose costs ₹350-400, so five doses cost ₹1,700-2,000. Besides five doses of vaccine, if a patient also requires immunoglobulin, then it entails an additional cost of ₹2,400. Only a few government set-ups provide the immunoglobulin for free. The cost of the treatment forces poor patients to opt instead for home remedies or traditional healers.

Dr Harshal Salve, assistant professor, community medicine, All India Institute of Medical Sciences, Delhi says that nearly 50 per cent of those bitten by a dog do not receive the vaccine, and unless this is changed, we cannot eliminate rabies.

Working extensively on the issue at a PHC in Chhainsa, Haryana, he has created a low-cost model to treat animal-bite patients. Until now the vaccine has been administered in the muscles (intra-muscular), but new guidelines from WHO suggest that intra-dermal vaccines — namely, administered on the skin — are equally effective and require only one-fifth the dosage otherwise used. Thus, one vial is enough for five patients if used within eight hours of opening it.

The cost per patient for five doses has come down to ₹350. The footfall of animal-bite patients at the PHC increased by 38 per cent within a year (2011-12).

Caring for dogs

An important component in the fight against rabies is the anti-rabies vaccination of the dogs themselves. Delhi’s example shows this is an area that needs a lot of improvement. Stray dogs are given anti-rabies vaccine when the Municipal Corporation of Delhi (MCD) catches them for sterilisation with the help of non-governmental organisations. But a one-time vaccination is not enough.

“In developed countries, it is enough to vaccinate a dog once in five years. But in a country like India with so many dogs, most of them not vaccinated, the immunity lasts only for a year or so,” said Dr Vijay Kumar Yadav, veterinarian with Sonadi Charitable Trust, an NGO that is helping MCD in its anti-rabies campaign.

The resources allocated for follow-up vaccinations are way below what is needed. “We have to hire a vehicle to catch the dogs, use two skilled people in sterilising them, use consumables like anaesthesia, medicines and so on, inject anti-rabies vaccine, and drop them back to their locality. All this costs ₹1,200-1,500 per dog. But the MCD provides ₹750 per dog,” said Dr Yadav. A yearly follow-up of the vaccinated dogs is impossible.

Severity of the problem

According to the National Health Profile 2017 of the health ministry, there were 86 rabies cases in the country and no survivors, so the fatality rate is 100 per cent. In comparison, the next most fatal communicable disease, Japanese encephalitis, has a fatality rate of 17 per cent.

Additionally, there is gross underestimation in the data. According to data from MVID, in January this year, of the nine patients admitted, seven were categorised under LAMA and the other two were reported dead. The situation was identical every month. This implies that the LAMA patients too would have died for sure, but were not categorised as such.

As Dr Salve summed it, “It is among the most neglected diseases. It is ironical that even though every case of animal bite can be saved with vaccine, we have such high mortality. We should look for better management and awareness among people.”

Jyotsna Singh is a Delhi-based journalist currently on a WHO media fellowship researching India’s national health policy

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Published on December 08, 2017
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