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Coverpage
September 2019
Volume 63 | Issue 5 (Supplement)
Page Nos. 1-53

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EDITORIAL  

Providing evidence for effective prevention and control of rabies in India Highly accessed article p. 1
Mysore Kalappa Sudarshan, Doddabele Hanumanthaiah Ashwath Narayana
DOI:10.4103/ijph.IJPH_410_19  
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GUEST EDITORIAL Top

Time for India to move towards rabies elimination by 2030! p. 2
Gyanendra Gongal
DOI:10.4103/ijph.IJPH_393_19  
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ORIGINAL ARTICLES Top

Appraisal of surveillance of human rabies and animal bites in seven states of India p. 3
Mysore Kalappa Sudarshan, Doddabele Hanumanthaiah Ashwath Narayana
DOI:10.4103/ijph.IJPH_377_19  
Background: The key to understanding the burden of animal bites and rabies lies in accurate and timely data with the help of proper surveillance system across the country. Such a surveillance system needs to be evaluated also for a programmatic purpose. Objectives: The present study was conducted to appraise the surveillance system of human rabies and animal bites in seven states of India and also to describe the characteristics of human rabies cases in the states. Methods: The record-based study was conducted from July to December 2017. The survey team collected information about the surveillance status of human rabies from the infectious diseases hospitals and animal bites from integrated disease surveillance programme (IDSP) offices of the respective states for 2012–2016. At the national level, also number of animal exposures and the human rabies cases were collected from the Central Bureau of Health Intelligence and IDSP and compared for concordance. Results: There was a gross underreporting of human rabies from the states to Government of India, and there was no concordance in the reports of animal bites between the IDSP offices of the states and NCDC, New Delhi, India. There was a gradual decline in the reported cases of human rabies from the states during the 5-year period of 2012–2016, attributable to improvement in the overall rabies postexposure prophylaxis services. The documentation of information of the human rabies cases was poor in the infectious disease hospitals. Conclusion: The surveillance system on human rabies and animal bites in India has to be improved under the national rabies control program to eliminate rabies by the year 2030.
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A multicentric community survey on animal exposures among humans in India p. 9
NR Ramesh Masthi, BS Pradeep, Gangaboraiah Bilagumba
DOI:10.4103/ijph.IJPH_374_19  
Background: Rabies is a 100% fatal disease. There are inadequate data on animal exposures and rabies postexposure prophylaxis (PEP) from community-based field surveys in India. Objectives: The main objective of the study is to estimate the incidence of animal exposures (bite, scratch, or lick) in the study population and to describe the rabies PEP among the cases. Methods: A descriptive survey was conducted in seven states of India between July and November, 2017. In each state, multistage sampling methodology was followed for selection of district, taluka/tehsil, block, and clusters within the block. The primary sampling unit was a household (HH). A case was a patient with animal exposure (bite, scratch, or lick) in the last 1 year from the date of survey. The animal exposure was categorized based on the WHO guidelines (Category-I, Category-II, and Category-III). The patients with the history of multiple animal exposures any time during the survey period was considered as a single case. Results: A total of 1012 HHs were surveyed covering a population of 4294. 3016 (70.2%) participants were from rural settings and 1278 (29.8%) were living in urban settings. 2181 (50.8%) participants were male and 2113 (49.2%) were female. The annual incidence of animal exposure was 1.26% (confidence interval [CI]: 0.93%–1.59%). The annual incidence in urban setting was 1.33% (0.70 - 1.96) and rural settings were 1.23% (CI: 0.84 - 1.62). Majority (68.5%) of the cases were from rural settings, 61.2% of the cases were in the age group of 15–60 years. Among the 43 cases who had received PEP, 21 had Category-II exposures, of whom 66.7% had completed vaccination with either five doses intramuscular or four doses intradermal route. Similarly, 22 had Category-III exposures and only 4 (18.2%) cases had received rabies immunoglobulin and completed rabies vaccination. Six ( 11.1%) cases did not receive PEP. There was no report of human rabies case. Conclusion: The incidence of animal exposure was 1.26%. Rabies PEP in the cases was not satisfactory.
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Community awareness and risk of rabies associated with exposure to animals in India p. 15
NR Ramesh Masthi, TV Sanjay, SB Pradeep, HS Anwith
DOI:10.4103/ijph.IJPH_373_19  
Background: Rabies is a fatal but preventable disease. Around the world, awareness studies about rabies have been widely used to understand the disease and in its preventive measures. Objectives: The present study was conducted to assess the awareness of rabies as a disease, its transmission, and prevention among the general population and also to assess the perceived health risks associated with exposure to animals. Methods: A cross-sectional study was undertaken across seven representative states in India between July and November 2017. Multistage sampling methodology was followed to select 1012 households as the primary sampling unit, and one adult responsible respondent from each household was interviewed as study participants. Results: Six hundred and eleven (60.4%) participants had heard of rabies. Only 0.2% had extensive knowledge of rabies. Majority (440, 72.0%) of the participants considered rabies as a fatal disease; 77.3% opined that risk of rabies from dogs was high compared to 41.6% who believed that there was little or no risk of rabies from cats. Only 37 (3.7%) participants were aware about preexposure prophylaxis. Conclusion: The awareness on rabies and its prevention in the study population was not satisfactory.
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Health-seeking behavior and compliance to post exposure prophylaxis among animal bite victims in India p. 20
Ravish Shankaraiah Haradanhalli, Hulawadi Shivalingaiah Anwith, Banandur S Pradeep, Shrikrishna Isloor, Gangaboraiah Bilagumba
DOI:10.4103/ijph.IJPH_364_19  
Background: In rabies endemic countries, where every animal bite is potentially a suspected rabid exposure, the exposed individuals should seek early and proper health care. It is also essential to complete the full course of postexposure vaccination to protect against rabies. Objectives: The study aimed at determining the health-seeking behavior of animal bite victims; assessing the perceived risk of rabies transmission from different animals and knowledge on its prevention and finding out the compliance to complete course of rabies vaccination and associated factors. Methods: A multi-centric, health facility-based survey was conducted during May 2017 to January 2018 in six regional-representative states involving 18 health facilities. Study participants were animal bite victims attending the health facilities. The data from all the study participants across the country were compiled and analyzed using descriptive statistics and Chi-square test to find out the association of factors influencing compliance. Results: Among a total of 529 animal bite victims, 83.6% sought postexposure prophylaxis coming directly to health facility; others visited nonallopathic/traditional healers/veterinarians/Auxiliary Nursing Midwifery before coming to health facility. The perceived risk of disease transmission and knowledge on the prevention of rabies was insufficient among the exposed victims. All participants were started with anti-rabies vaccination; the compliance rate for the full course of intramuscular rabies vaccination was 65.9% and for intra-dermal rabies vaccination, it was 85.1%. Among Category III exposures, only 46.2% received rabies immunoglobulin. Conclusions: Health-seeking behavior and compliance to complete course of anti-rabies vaccination is unsatisfactory, which has to be improved to prevent rabies.
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Facilities and services of postexposure prophylaxis in anti-rabies clinics: A national assessment in India p. 26
Mysore Kalappa Sudarshan, Ravish Shankaraiah Haradanhalli
DOI:10.4103/ijph.IJPH_367_19  
Background: The rabies postexposure prophylaxis (PEP) is provided through anti-rabies clinics in the country. It was considered important to assess their facilities under a nationwide multi-centric survey. Objectives: The objective of this study is to assess the facilities available for PEP at the anti-rabies clinics and to ascertain the PEP provided at the anti-rabies clinics. Methods: The cross-sectional assessment was made from May 2017 to January 2018 in selected seven states of India. Thirty-five anti-rabies clinics from both Government and private; urban and rural areas from the states were assessed by an expert team using a pretested checklist for facilities and services available for PEP. Results: On an average, 10 new animal bite cases were attended at each anti-rabies clinic per day. The cold chain facilities for rabies biologicals were satisfactory. The facilities for wound washing (54.3%) and the use of antiseptics to animal bite wounds were not adequate. Rabies vaccines were administered by intramuscular in 54.3% and by intradermal route in 45.7% of the cases. The vaccine stock-outs were reported only in the government sector (18.5%). The type of rabies immunoglobulin (RIG) used was equine (63.2%) and human (36.8%); given free of cost in 40% of Anti rabies clinics. The local wound infiltration of RIG was in practice at 58.6% of anti-rabies clinics. The stock-out of RIG was more in private (50%) hospitals than in Government (40.7%) hospitals. Conclusion: The facilities available for PEP at the anti-rabies clinics were inadequate and have to be improved across the country.
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Assessment of procurement, distribution, availability, and utilization of rabies biologicals for postexposure prophylaxis in seven states of India p. 31
Ashwath Narayana D Hanumanthaiah, Ravish Shankaraiah Haradanhalli
DOI:10.4103/ijph.IJPH_365_19  
Background: To achieve the elimination of dog-mediated human rabies by 2030, all bite victims shall have access to life-saving rabies biologicals across the country. The information on procurement, distribution, availability, and utilization of rabies biologicals for postexposure prophylaxis is insufficient. Objectives: The objective of the study is to assess the demand, procurement, distribution, availability, storage, and utilization of rabies biologicals and to appraise the monitoring and reporting of rabies biologicals at all the levels. Methods: A multicentric survey was conducted from July to December 2017 in seven regional representative states across the country. The survey team visited the offices in-charge for logistics of rabies biologicals at the survey states and districts; information was collected using structured pro formas and perusing relevant records. District vaccine stores and health institutions in urban and rural areas were visited to assess the availability and stock-outs of rabies biologicals. Results: Procurement, distribution, and availability of rabies biologicals grossly vary between states, since it is the state subject. In Gujarat, both vaccines and immunoglobulins were available even at the Primary Health Centre level; paradoxically, there was a scarcity of both at the district level in Manipur. Immunoglobulins were used only in nine of the surveyed 27 government health-care facilities (33.3%) and two of the eight private facilities (25%). The cold chain facility for storage of rabies biologicals was satisfactory; however, the monitoring and reporting of rabies biologicals were not complete. Conclusion: The procurement, distribution, availability, and utilization of rabies biologicals were not universal across the states. Frequent shortages of supply have to be improved to attain universal coverage.
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Market mapping and landscape analysis of human rabies biologicals in India p. 37
Mysore Kalappa Sudarshan, Doddabele Hanumanthaiah Ashwath Narayana, Mahendra Bangalore Jayakrishnappa
DOI:10.4103/ijph.IJPH_379_19  
Background: Rabies vaccines and immunoglobulins are lifesaving in humans following animal exposures. These biologicals should continuously be available throughout the year to prevent and eliminate human rabies by 2030. Objectives: The present study aimed at assessing availability of different kinds of human rabies biologicals in the country and undertaking market mapping and landscape analysis of human rabies biologicals in India. Methods: The study comprising both quantitative and qualitative approach was conducted from May to November 2017 as a part of the Indian multicentric rabies survey by Association for Prevention and Control of Rabies in India. All stakeholders (agencies/personnel) associated with rabies biologicals were the study units/participants. Required data were generated through brainstorming sessions with key stakeholders; reviewing of databases/existing literature; conducting in-depth surveys; interviewing; focused group discussions, etc. Results: Two types of cell culture rabies vaccines are available in the country manufactured by different pharmaceutical companies; most of the vaccines are indigenously produced and the market size of the rabies vaccines is about INR 125 crores with highest sales in the northern region followed by South. Likewise, there are 2 types of immunoglobulin available, i.e., equine rabies immunoglobulins (RIGs), which are indigenously produced and human RIGs, which are imported. The market value of RIGs is about INR 83 crores. A novel rabies monoclonal antibody is also been marketed in the country from November 2017. Conclusions: There are many lacunas in the market availability of rabies biologicals in different parts of the country; therefore, a significant expansion/shift in focus must be considered, through rigorous strategic planning process.
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BRIEF RESEARCH ARTICLES Top

Cost of rabies post exposure prophylaxis in different healthcare settings in six states of India p. 44
Ravish Shankaraiah Haradanhalli, Ashwath Narayana D. Hanumanthaiah, Sanjay T Varadappa
DOI:10.4103/ijph.IJPH_366_19  
The expenditure for rabies postexposure prophylaxis (PEP) is substantial, especially for the poor who are affected the most. The present study was conducted to determine the cost incurred to a patient and the healthcare facility for providing PEP in different healthcare settings. A multicentric, health facility-based study was conducted from May 2017 to January 2018 in the six states involving 18 healthcare facilities. The study included 529 animal bite cases; most of them belonged to either category III (54.4%) or category II (43.1%) exposures and all of them received complete PEP. The total median cost incurred to the patients for complete PEP in the government health facility was INR 1400 (USD 22) and in private hospitals was INR 3685 (USD 58). The cost of PEP for the bite victims is considerable; therefore, it has to be provided free of charge at all healthcare facilities.
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Assessing rabies-free status of Andaman, Nicobar, and Lakshadweep Islands, India p. 48
Shrikrishna Isloor, Reeta S Mani, Mahendra Bangalore Jayakrishnappa
DOI:10.4103/ijph.IJPH_412_19  
The Indian Islands of Andaman, Nicobar, and Lakshadweep have been historically rabies-free. However, reliable laboratory evidence to substantiate rabies-free status was lacking. In this background, the study was conducted as a component of the World Health Organization-Association for Prevention and Control of Rabies in India, Indian Multi-Centric Rabies Survey; to assess the rabies-free status of the two Islands and to examine the feasibility of initiating laboratory surveillance for rabies in dogs in Andaman, Nicobar, and Cats in Lakshadweep Islands. A team of medical and veterinary investigators visited these Islands in 2017. A review of 10 years records (2007–2017) in medical and veterinary institutes and interviews with different stakeholders were conducted. Based on the review of records, there was no evidence of human/animal rabies in the Islands. Eight dog brain samples from Andaman, Nicobar Islands, and ten cat brain samples from Lakshadweep Islands were tested negative for rabies by fluorescent antibody test at two rabies diagnostic laboratories at Bengaluru.
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COMMENTARY Top

Background paper for developing a policy for the use of rabies biologicals and vaccination of humans in India p. 51
Mysore Kalappa Sudarshan, Doddabele Hanumanthaiah Ashwath Narayana
DOI:10.4103/ijph.IJPH_378_19  
National Rabies Control Programme, India, is in operation since 2012–2013 without much impact due to poor funding and no set policy for the rabies prevention and control. An effort was made to develop a draft policy paper which can help the Government of India to develop a national rabies vaccination policy for humans and for achieving the goal of zero dog-mediated human rabies deaths by the year 2030. A technical stakeholders meeting was held under the chairmanship of the Drug Controller General of India at New Delhi in December 2017 to discuss the problems and solutions for providing essential rabies postexposure prophylaxis (PEP). The following problems and dilemmas were identified: frequent shortages of life-saving rabies vaccines and rabies immunoglobulin for PEP; as rabies vaccines are mostly procured by the state governments that often face resource crunch and hurdles in logistics within the states; production levels of rabies biologicals in the public sector are low; and the export of rabies biologicals from the private sector needs to be critically evaluated in the context of frequent stock-outs in the domestic market and also the national vaccine security.
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