Project created by Karan Daftary, intern at BSV summer associate class of 2013 with the purpose of increasing awareness about rabies and its immunization.

1. Rabies Control in India
Problems, Review and
Recommendations
Karan Daftary

2. The Genesis
In May 2010, I witnessed an extremely unfortunate incident wherein my friend was bitten
by a stray dog. Despite the requisite medical attention, he succumbed to his injuries. This
was my first encounter with Rabies –in which mortality is 100%.
In October 2010, there was a newspaper article titled “Rabies death despite vaccine” which
I came across – the title got my attention as it was contrary to my understanding that a
Rabies vaccine shot is all we need for protection against Rabies in case of dog bite. In fact
this was the general understanding that even my friends and acquaintances had. On going
through the article, it was a revelation for me to know that a vaccine takes almost 7 days
time to provide the protection to the human body. This got me going to delve a little bit
deeper into this to see what other steps can be taken by people in case of a dog bite. A
couple of hours and an internet connection was all I needed to come across the medicine by
the name “Rabies Immunoglobulin” which is supposed to provide an immediate protection
against Rabies.
During this quick search I was also overwhelmed by the enormity of the rabies problem in
my country – in fact I was stunned to find that the maximum number of deaths due to
rabies happened in India.
The question which came to my mind was why India suffered the dubious distinction of
largest number of deaths due to rabies and whether this is due to lack of general awareness
or availability of Rabies Immunoglobulin. A quick check also revealed that while there are
quite a few manufacturers of Rabies Vaccine in India, there were only two manufacturers of
Rabies Immunoglobulin.
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3. Reasons to undertake this Project & Plan
Reasons to Undertake this project:
To look at reasons why India has so many deaths due to rabies by
looking current practice of rabies control in India
Since there only 2 manufacturers of Rabies Immunoglobulin, one of
them being, Bharat Serums And Vaccines Limited (“BSV”), to interact
with BSV and understand whether there could be ways to increase
the usage of Rabies Immunolglobulin
Plan
Meet with the sales and marketing division of BSV
Visit select doctors in Mumbai
Visit the Rabies Immunoglobulin manufacturing site of BSV
Review literature relevant to the project at hand
3

4. Introduction on
Rabies

5. Rabies: A snapshot
Rabies is a viral infection spread by
the bite of an infected animal.
The rabies virus infects the Central
nervous system and travels to the
brain.
Globally, rabies is the tenth leading
cause of death due to infection in
humans.
Rabies is present on all continents
with the exception of Antartica, but
more than 95% of human deaths
occur in Asia and Africa
Rabies is 100% fatal if not treated immediately
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6. Incidence in India
A brief overview on the disease is provided below:
Indian Population
Estimated deaths due to rabies
Stray dog population
Estimated animal bites
Frequency of bite
Frequency of Human rabies deaths
approx.
:
:
:
:
:
:
1 billion plus
20,000 annually
25 million
17.4 million.
1 bite per 2 seconds.
1 per 30 minutes
India contributes to the highest number of human
deaths due to rabies in the world
Nearly 50% of total human deaths due to
rabies in the world is contributed by India
The post-bite treatment costs the Indian economy
over $25 million a year *
Children happen to be 40% of the cases most of
them below 15 yrs of age.
* India’s ongoing war against rabies.
Bull WHO 2009; 87(12): 885-964
National Journal of Community Medicine .
Volume 4, Issue 1, Jan – Mar 2013
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7. Lack of Awareness
Dr. B. J. Mahendra
Dr. G. Sampath
MandyaInstitute of Medical Sciences,
Mandya, Karnataka
IPM, Hyderabad
Dr.Ashwathnarayan
KIMS, Bangalore
Feedback from Discussions with Doctors and salient points:
Using only Rabies Vaccines as per Government recommendations
Rabies Immunoglobulin has to be funded by patients themselves
and hence reluctance to use
Children more susceptible to Rabies– more bites in the face and
neck area
Reported mortality of 5 to 15% in Category III bites despite active
immunisation
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8. WHO Guidelines on
Rabies

9. Rabies Treatment regimes
Definition of categories of exposure and use of rabies biologicals
Category III – single or multiple transdermal bites or
scratches, licks on broken skin; contamination of mucous
membrane with saliva from licks, contacts with bats.
- Use immunoglobulin plus vaccine
Category II – nibbling of uncovered skin, minor scratches or
abrasions without bleeding
- Use vaccine alone
Category I – touching or feeding animals, licks on intact skin
- No exposure therefore no prophylaxis
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10. Rabies Immunoglobulin – method of Action
Administration of Rabies Vaccine stimulates
production of neutralizing antibodies by the
patient's immune system.
Protective levels of antibodies are seen 7 to
14 days after the initial dose of vaccine.
Moreover when the bites are on the
head, neck, face & hands, the incubation
period will be shorter
The patients are vulnerable to develop
rabies during this window period of 7 to14
days.
Hence, administration of Rabies
Immunoglobulin, after thorough cleansing of
wounds, is life saving as their timely and
proper administration neutralizes the virus
in the wound and aborts the risk of
developing rabies.
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11. Observations

12. Observations
On meeting with BSV’s sales & marketing division, the following were the
broad findings:
BSV’s current product offering is only Rabies Immunoglobulin
The cost of treatment of this has to be borne entirely by the patient as this is
not part of the Government programs
This increases the economic burden to the patient
Currently, the most common treatment regimen followed in India is the
intra-muscular administration of anti-rabies vaccine
As this is in the Government program
Though economical and safe to use, the use of Rabies Immunoglobulin in
India has been limited because of:
Challenges in the administration of the product as this had to be
administered into the affected area.
Non-inclusion in government programs
Economic burden on the lower strata of patients
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13. Observations
Inclusion of Rabies Immunoglobulin in Government programs as a
treatment regimen along with anti-rabies vaccines has its own hurdles:
Inclusion of Rabies Immunoglobulin will increase the treatment cost per
patient and will result in more expenditure for the government; and
May not be viable within the current budget allocated by the government
The WHO Expert Committee on Rabies recommended Intradermal
route of rabies vaccination (“IDRV”) (1/5th dose as compared to IM) in
1992.
This regimen led to considerable savings in terms of the amount of vaccine
needed, thereby reducing the cost of vaccination.
This also helped to bridge the gap of short supply of vaccine and increased
the availability of the same.
However, the response to implementation of this regimen has been poor
Insufficient support from the Government
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14. Findings

15. Comparison of Current & New cost of treatment using WHO
recommendation of active and passive immunization:
2350
Cost of Treatment (Rs)
2500
2000
Vaccine
ARS
1750
1500
950
1000
500
350
0
IM
ID
IM+RIG
Regimen
ID+RIG
Cost of treatment per patient using WHO
recommended
approach
of
active
immunization and passive immunization
IM: Intramuscular; ID: Intradermal; RIG: Rabies Immunoglobulin
Introduction of the new
vaccine method would
mean that within the same
budget, 5 more patients
can be treated
Cost savings due to
implementation of the
above would mean that the
Rabies
Immunoglobulin
can now be included in
government
funded
program within the same
budget
Introduction
of
the
combined
treatment
regimen
would
mean
within
the
same
budget, approximately 2
patients can be treated
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16. Requirement of Rabies Ig in India
4
Vials (Mn)
3
Deficit: ~0.9Mn doses
2
3.4
0
Requirement
Availability
~17.0Mn
~1.7Mn
No. of vials of Rabies
Immunoglobulin per patient
2 vials
Total vials required
1
Total No. of Dog bites
Category III bites (10%)
2.5
~3.4Mn vials
Conclusion:
Currently, there is deficit of around 30% for the availability of
Rabies Immunoglobulin
By adding about 120-150 horses, BSV can cater to the eventual
capacity requirement of Rabies Immunoglobulin for the country

17. Recommendations

18. Recommendations
Work with the government to include Rabies Immunoglobulin in
government funded programs as this would go a long way in meeting
WHO’s goal of eliminating rabies
To first include the IDRV regimen as a standard therapy for rabies vaccination – this
would free lot of financial resources of the Government to allow them to include ARS
also
BSV should consider launching a Rabies Vaccine so as to make its product
offering more comprehensive
This will make BSV the first company in India to offer the TOTAL SOLUTION
for Prevention of Rabies
The education and training of hospital doctors and staff on the New
vaccination regimen will increase the treatment of patients who have
come with bites
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19. Food for Thought
Should BSV consider
efficient means of
waste management
such as conversion to
Biogas as an effective
means of reducing
costs?
400 horses can produce
approx. 11.6MWh of
electricity
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20. Acknowledgements
Within BSV
Dr. Aldon Fernandes
Mr. Adeet Ghosh
Mr. Rahul Srivastava
Mr. Gaurav Gurnaney
Outside BSV
Dr. B. J. Mahendra
Dr. G. Sampath
Dr. Ashish Kundu
Dr. Ranjit Mankeshwar
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21. Appendix
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