Controlling rabies

Prasanna Deshpande

Rabies causes an estimated 21,000 deaths in India each year, despite being completely vaccine preventable. However, gaps in the supply chain create obstacles to accessing anti-rabies vaccine (ARV). As reported in various media, in the past few months several States have reported shortages of ARV, due to a combination of factors including growing demand, imperfect demand signal, and supply disruptions.

ARV is sold in the retail market as well as procured by State governments, some Central government agencies and public sector units (PSUs). In the past five years, the overall demand for anti-rabies vaccine has shot up. In 2015-16, the estimated use of ARV in all States and PSUs combined was 10-11 million doses. In 2018-19, the supply of ARV was estimated at 10-11 million doses in the government segment alone, while the demand grew to 18-20 million doses.

The estimated demand for ARV in the retail market alone is eight million doses, implying that the nation-wide demand for ARV is about 26-28 million doses. Some reports have even pegged the demand at as high as 44 million doses, possibly capturing the demand not reported in formal channels.

There are only limited manufacturers of anti-rabies vaccine in India, which include Human Biologicals Institute (a division of Indian Immunologicals Ltd), Zydus Cadila, Serum Institute of India and Bharat Biotech. The combined manufacturing capacity of ARV in the country is around 50 million doses, which is more than the required quantities.

Demand forecast

However, to avoid recurrence of shortages and supply imbalances of this life-saving vaccine, governments, policymakers, regulatory agencies and vaccine manufacturers all have to play a part. Firstly, an accurate and steady demand signal is important. State-wise assessment of the actual requirement of the rabies vaccine can give a clearer picture to manufacturers on planning their capacities. The current mechanism of ‘rate-contracts’ with the State governments certainly needs improvement. These contracts fix the purchase price of the vaccine but do not specify the required quantities or the time period of the contracts. This makes it difficult for manufacturers to plan the capacities properly. The contracts also have ‘ever-greening’ clauses which extend the contracts, adding further uncertainty.

It may be helpful to have a nodal centre to track the stock situation in government hospitals across all the States in real time and to generate a centralised order once the stock status dips below the optimum level. Hospitals should be empowered for local (intermittent) procurement or wherever the tender process is getting delayed. Further, intradermal route of administration can significantly reduce the demand-supply gap.

The government and manufacturers need to identify the epicentres of animal bites and ensure adequate stocks are maintained in these areas. Sterilisation of dogs should be prioritised, to bring down the disease burden. The cost of a rabies vaccine for canines is less than one-tenth the cost of a human rabies vaccine. Thus, it will be prudent to adopt this strategy throughout the country. Real-time stock data can also be used to direct patients to the nearest hospitals where ARV is available.

With continued upgradation of medical infrastructure, focussed efforts by State governments, and increased public awareness, the disease burden of rabies can be reduced significantly.

The writer is Deputy Managing Director, Indian Immunologicals Ltd

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