A local initiative to save lives of rabid dog bite patients amid acute shortage of costly rabies immunoglobulin (RIG) in a government hospital in Shimla a few years back has turned out to be a big leap in rabies research globally.
The modified low cost treatment protocol for post-exposure rabies prophylaxis (prevention) adopted at Deen Dayal Upadhyaya hospital, Shimla, has recently been endorsed by the World Health Organisation (WHO) in its latest position on Rabies Vaccines and Immunoglobulins.
The WHO position, a summary of which was released earlier this month, is based on recommendations of its Strategic Advisory Group of Experts (SAGE) Committee, which referenced research papers by Dr Omesh Kumar Bharti (field epidemiologist in DDU) with the late Dr SN Madhusudana, head of WHO Collaborating Centre on Rabies Research in National Institute of Mental Health and Neurosciences (NIMHANS), Bengaluru, and Dr Henry Wilde, WHO consultant in Thailand for RIG use.
As per earlier WHO guidelines, any dog/monkey bite patient was administered vaccine intradermally and along with this, the RIG was injected in the wound and the remaining intramuscularly (IM). The RIG was calculated on body weight (of victim), which was a costly option.
While the vaccine part almost remains the same, the recent WHO update involves injecting RIG only in wound/s in dog/monkey bite victims. The RIG neutralises the rabies virus in the wound within hours.
The omission of RIG injection intramuscularly reduces the dose of RIG more than ten times and cost of rabies prophylaxis (vaccination and RIG) from Rs 35000 to Rs 350 per patient.
The research work was done by Dr Bharti with technical clearance of WHO Collaborating Centre on Rabies Research, NIMHANS, after a go-ahead by health authorities in HP, including the then Medical Superintendent of DDU, Dr PL Gaunta, in 2014.
Dr Gaunta’s successors in DDU and other doctors supported it as Dr Bharti, who is a master trainer for intradermal anti-rabies vaccination in Himachal, has been working in the rabies field for over two decades.
“I was working on the concept for several years. What troubled me were repeated reports that people died of rabies for want of RIG. They would get vaccine but not RIG. I reviewed available literature and discussed with top rabies experts in the country and abroad. It wasn’t just unaffordability, but the scarcity of RIG as well that made many people go without it, risking their lives,” said Dr Bharti.
With the new protocol, however, every patient started getting life-saving RIG. The entire testing of blood samples was done at NIMHANS. So far, more than 20,000 dog/monkey bite victims have been treated across the state with the new technique, half of them in DDU alone, including some patients bitten by lab-confirmed rabid dogs.
The DDU hospital, which used to get very few patients of dog and monkey bites, now receives 15-20 cases of animal bite every day and rabies prophylaxis is given virtually free here.
Since health department officials in rural Himachal Pradesh, where over 70 per cent people are dependent on government health care services, are generally sensitive about low cost solutions to increase access of patients, it helped Dr Bharti continue with the work with ease. So much so that on the lines of DDU, even Indira Gandhi Medical College (IGMC) hospital started following the modified protocol, helping patients get medicine free.
“Earlier it was very difficult for the government to provide RIG to patients as it was too costly. The dog/monkey bite patients either skipped getting injected or had to rush to Central Research Institute, Kasauli, in Solan on their own to get it. But with the low cost technique, complete rabies prophylaxis is free in IGMC and there is no hassle in dealing with such patients now,” said Dr Ramesh Chand, Senior Medical Superintendent at IGMC. As per estimates, around 59000 deaths are caused globally by rabies every year, out of which around 20,000 are reported in India.