Rabies and other neglected envenomings

[Guest guest]

Hi,-

Most of the political representatives are from rural areas as the

population based representation exists in India. But once they reach

the corridors of power, they forget the problems of rural

population. It is irony that these politicians live on public money,

get handsome perks and yet are not interested in solving public

problems. But finally it is public who is responsible for electing

such impotent duffers, non-efficacious representatives who can not

influence the bureaucracy for solving the problems of marginalised

population. The " right to recall " these non-performing liabilites

does not exist and hence once elected it is cozy stint of full term

whether they work or not. Hence the inefficiency in politics

continues.

Nonavailability of snake venom is a serious issue and pointer to the

(mis)management of health services. It is the poor living in rural

areas who are often bitten by snakes, dogs and scorpions. It is

this " orphan population " which suffers from the venomic bites and

yet does not get the right treatment in time. Private industry has

already shut the production of vaccines because it is no more

profitable business for them. Public sector continues to produce the

vaccines but is pushed against the wall. Shortage of funds restricts

them from upgrading the production facilities, which finally counts

for GMP.

The pressures from animal rights activists has further aggreviated

the problem.It is indeed mockery of freedom that animal rights

activists are more worried about the health of animals then the

health of fellow humanbeings. They enjoy the limelight and media

attention which they get for being pro-animals(anti-human. Science

has taught us that higher animals survive better by ensuring proper

exploitation of lower in the order. Those who are more worried about

bleeding of horses and killing of rabid stray dogs etc need to be

sent back to schools for re-education.

I have serious objection to the top animal activist of india having

foreign breeds of dogs as pets. Why she did not get Indian breeds

from the roads that she often tries to speak for on television.If

such are the hypocrites in activism, the result is shortage of

vaccines. And we discuss the topic " Rabies and other neglected

envenomings " .

Vijay

[Guest guest]

Hi,-

I will be thankful if the moderator can reveal the names, designations

and e-mail Ids of the Indian representatives who attended this meeting

which was called by WHO. I would like to extend invitation to them to

attend this E-discussion.

Vijay

[Guest guest]

Dear Madam, Other problems could be: -Distance to travel to nearest health centre -Transport problem -Non-availability of medical staff at rural hospital all the 24 hours. -No refrigeration facilities for the antisera or no/minimum electric supply -corruption by medical staff in selling the medicines meant for poor. -Ignorance of the patients about seriousness of their problem Anupama. kunda gharpure <gharpurekunda@...> wrote: Hello all, lets take the topic further by discussing the importance of why this topic needs attention. Last year a meeting was held on rabies and envenomings, which was convened to discuss the means to ensure production of effective and safe antisera. It was noted that there is a growing crisis in the production, accessibility and the proper use of therapeutic antisera in areas where they are needed the most. People affected the most by rabies and other envenomations are those who live in- rural areas and are mostly poor unorganized . Their voices are not strong enough to reach the politicians, who live in capital cities and are unaware of the problems in rural areas. However the affected population is mostly the agricultural workers and they are, many a times, left with life long disabilities affecting their production capabilities. Considering this fact, the economic impact of these debilitating envenomings is sure to raise an alarm. Can you think of some other reasons of why this area is neglected and why a concerted effort to deal with these envenomings must be

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[Guest guest]

hello Anupama,

you have surely pointed out the reasons why we need to discuss these neglected envenomings. And surely these problems are to be tackled at the national /state level.

As Vijay has pointed very vociferously, that one of the hurdles in production closures is the animal activists.Here is one area where politicians can interfere and lay down regulations in favour of the human beings.

I however request Vijay to exercise restraint while voicing his opinions.

in reply to Vijay's querry here are the addresses of Indian participants.

Dr. S.S. Jadhav,Quality Assurance and Regulatory Affairs,Serum Institute of India Ltd., Hadapsar, Pune and

Dr. K.R. Mani,central drugs Laboratory,Kasauli, Solan

WILL GET BACK IN THE NEXT POST. KUNDA

Hello all,

lets take the topic further by discussing the importance of why this topic needs attention.

Last year a meeting was held on rabies and envenomings, which was convened to discuss the means to ensure production of effective and safe antisera. It was noted that there is a growing crisis in the production, accessibility and the proper use of therapeutic antisera in areas where they are needed the most.

People affected the most by rabies and other envenomations are those who live in-

rural areas

and are mostly poor

unorganized .

Their voices are not strong enough to reach the politicians, who live in capital cities and are unaware of the problems in rural areas.

However the affected population is mostly the agricultural workers and they are, many a times, left with life long disabilities affecting their production capabilities. Considering this fact, the economic impact of these debilitating envenomings is sure to raise an alarm.

Can you think of some other reasons of why this area is neglected and why a concerted effort to deal with these envenomings must be undertaken?

kunda

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[Guest guest]

Hi Kunda,

I am sorry if my words seemed strong but they were from the heart. I

will heed to your advice and try to soften, sugar coat and make them

more palatable in future.

Vijay

[Guest guest]

hello,

Anupama has posted an article on use of herbal medicine in Snake bite. I am further giving gist of one more article on assessment of the optimum dose of ASVS.

It was a clinical trial of high dose against low dose of ASV in the treatmrnent of poisonous snake bite.This was undertaken since it iwas thought relevant since the cost of one vial of ASV is about 400 INR. The parameters studied were mortality.dialysis required,ventilatory support, and hospitalstay. high dose used was 12 vials and low dose was 6 vials.In high dose the M was 14%,D was 26%,V was 6% and H was 9.02 days.In low dose, M=10%,d=18%,v=6% and H=8.42 days.All parameters indicatefavourable results with low dose.In conclusion it was said that while there was noadditional advanyage in following high dose regime, there was considerable financial gain in low dose regime.

I am giving this specifically, so you can appreciate the irrational use being followed in our hospital which is about10 vials t.i.d.and this regime is followed for average 2-3 days.

Please dont ask me what the rationalists are doing to prevent this!

kunda

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[Guest guest]

Hi

There are many papers published about the indradermal(ID) use of ARV.

Through ID route the dose requirement in one tenth of the usual dose.

Obviously the pharmaceutical companies manufacturing ARV will not

disseminate this information because it will hurt their business badly.

I hope our NetRUMians will search and comment on this before the

current discussion winds up.

Vijay

[Guest guest]

Hello all,

Intradermal antirabies vaccine is in picture since more than 20 years. Following abstract gives us idea about the same.

Clin Exp Immunol. 1986 March; 63(3): 491–497.

An effective economical intradermal regimen of human diploid cell rabies vaccination for post-exposure treatment.

S Ubol and P Phanuphak

Abstract

A closely-spaced multisite intradermal regimen of human diploid cell rabies vaccine (HDCV) was evaluated in 39 patients after low-risk exposure to rabies, in comparison to full-dose intramuscular HDCV and sheep brain-derived rabies (Semple) vaccine. The regimen consisted of four intradermal injections, 0.1 ml each of HDCV on days 0, 3 and 7, followed by two booster doses of only 0.1 ml each on days 28 and 91 administered intradermally. Although the total amount of HDCV used in this intradermal regimen was 1.4 ml or one-quarter of the conventional intramuscular regimen, a higher proportion of the recipients of this economical intradermal regimen, as compared to the full-dose intramuscular regimen, developed neutralizing antibodies above the hypothetical protective level of 0.5 iu/ml 7 days after starting immunization. Besides the earlier antibody response, the peak antibody level of the intradermal regimen was also satisfactorily high and not significantly different from that after the intramuscular regimen. Simultaneous administration of inosiplex, an antiviral and immunopotentiating agent, during the first 10 days of intradermal immunization resulted in an even higher antibody response for as long as 91 days. In contrast, but not unexpectedly, Semple vaccine evoked lower, more sluggish and inconsistent antibody responses. The side-effects of intradermal HDCV were mild, mainly local and self-remitting. We therefore recommend our intensive intradermal regimen of HDCV vaccination for safe, effective and economical use in post-exposure rabies immunization.

Our neighbor country has already replaced the traditional NTV by intradermal ARV.

Elimination of NTV and Introduction of Intradermal Rabies Vaccination:

"A Success Story from Sri Lanka"

Omala Wimalaratne

Corresponding Author: Omala Wimalaratne, Dip.Med.Micro.

, MD., Consultant Virologist & Vaccinologist, Medical Research

Institute Ministry of Health, Sri Lanka. Email: omala@...

Sri Lanka is an island in the Indian Ocean which has a land extent of 64,000 sq. km. with a population of 20.2 million.

Rabies is an endemic disease in the country and the dog is the main reservoir for transmission of this fatal disease to humans. Human rabies is a notifiable disease and there were 74 reported deaths due to rabies in year 2006. In Sri Lanka, it is estimated that there are 375,000 animal bites each year, out of which 77% are due to apparently healthy animals, 2% sick animals, 9% had died subsequently and 12% were unknown.

Human diploid cell rabies vaccine (HDCV) was introduced in Sri Lanka in 1986 and was issued by the Ministry of Health (MOH) only to the Teaching and General hospitals. Nerve tissue vaccine (NTV) produced in goats was used in all other hospitals.

In 1988, HDCV was replaced with Purified Vero Cell Vaccine (PVRV) and Purified Chick Embryo Cell Vaccine (PCEC). For all category II exposures 2:1:1 Zagreb schedule and for category III exposures Rabies immunoglobulin and the 05 dose Essen schedule were used.

In 1995, the MOH took a policy decision to stop the production of NTV and since then, only rabies cell culture vaccine is used for post exposure therapy (PET) in all hospitals.

About 200,000 animal bite victims are administered anti rabies PET annually. At present 50,000 animal bite victims are administered rabies immunoglobulin (RIG) and anti rabies cell culture vaccine (TCV) for category III exposures and 150,000 are administered rabies TCV only for category II exposures. In 1997, WHO recommended economical intradermal (ID) administration of anti rabies TCV1, 2 which was introduced in 02 Teaching hospitals in Colombo and over the years it was gradually introduced in a phased manner to other hospitals in the country. In 2003, ID regimen was implemented in the entire country. At present, 85% of patients seeking PET are administered anti rabies TCV intradermally3.

Recommendations for ID regimen

· More than 05 patients seeking PET/day

· 02 day training programme for medical officers and nurses on correct ID technique

· Conduct awareness programmes through out the country for health care staff.

· Close supervision and monitoring.

· Use 01ml disposable insulin syringe with 27G – 29G fixed needle for each patient

· Minimum potency of 0.7IU/0.1ml of rabies TCV

The MOH spends over 3 million US dollars for PET in Sri Lanka annually, which is offered free of charge to patients in government hospitals. To reduce wastage of RIG and TCV and for better management of patients, anti rabies PET units are established in most major hospitals, manned by specially trained staff. A responsible medical officer is appointed to each unit for supervision and to give confidence to the staff as well as to the patients. A 24 hour hot line is made available for health care personnel from any part of the country to obtain expert advice when faced with management problems related to PET. An anti rabies PET specialized advice clinic is also conducted daily in the Medical Research Institute.

Key factors for the success of the ID regimen in Sri Lanka were dedicated staff who cared for the patients, good patient compliance due to fewer adverse events following immunization, health educational programmes conducted island wide, cost effectiveness of the ID regimen, and commitment and support from the policy makers in the Ministry Of Health. This has proved to be safe and effective and at the same time saves a considerable amount of foreign exchange for the country

References

1. Chutivonse S, Supich C, Wilde H. Acceptability and efficacy of purified verocell rabies vaccine in Thai children exposed to rabies. Asia-Pacific Journal ofPublic Health 1988; 2:179-184.

2. Chutivonse S, Wilde H, Supich C, et al. Postexposure prophylaxis for rabies with antiserum and intradermal vaccination.Lancet 1990;335:896-8.

3. Suntherasamai P, Chaiprasithikul P, Wasi C, et al. A simplified and economical intradermal regimen of purified chick embro cell rabies vaccine for postexposure prophylaxis. 1994 Vaccine, 12: 508-12

Jul-Sep 2007. 89NICATION

In our country it has been appearing in few of the hospitals. Following URL gives information about the changing condition in Andhra.

http://www.hindu.com/2007/07/07/stories/2007070756600200.htm

Regards,

Dr Smita Mali,

JRII, GMC,

Nagpur.

[Guest guest]

Hello all,

It is well established and evidence based to use intradermal ARV. Route itself says about the small quantity needed per patient but at the same time it is equally immunogenic.

Following URL gives the guidelines recommended by KIMS institute.

www.kimscommunitymedicine.org/IDRV.pdf

Regards,

Dr Smita Mali,

GMC, Nagpur.

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