Rabies Surveillance Dr Suresh Gupta Consultant Pediatric Emergency

Rabies Surveillance Dr Suresh Gupta Consultant Pediatric Emergency Medicine Sir Ganga Ram Hospital, New Delhi

WHO Recommended Surveillance Standards for Rabies

Rationale for Surveillance WHO promotes • Human rabies prevention though PET • Disease Elimination through vaccination of dogs and other animal reservoirs Surveillance is essential for • Detection of high risk areas • Detection of outbreaks quickly • Monitor use of vaccine

Recommended Case Definition Case Classification: (Based on Clinical Description & Laboratory Criteria) Human Rabies : -Suspected -Probable -Confirmed Human Exposure to rabies: -Possibly Exposed -Exposed

Recommended types of surveillance • Surveillance in human population: – Human exposure to rabies – Human rabies case – Outbreak investigations • Surveillance in animal population – Wild and Domestic species reservoirs

Rabies Indicators 1. Presence/absence of rabies 2. Human rabies a. Number of human deaths b. Human deaths according to animal species source of exposure c. People bitten by suspected dogs 3. Animal rabies a. Total number of dog cases b. Total number of other domestic animal cases c. Total number of wild animal cases d. Total number of bats cases 4. National rabies vaccine production and importation a. Veterinary vaccine according to vaccine types b. Human vaccine according to vaccine types c. Human rabies immunoglobulin 5. Rabies vaccine administration a. Dogs vaccination b. Human vaccine application - Post-exposure treatment c. Number of patients treated according to vaccination regimen d. Number of persons receiving treatment according to animal species source of exposure

Recommended minimum data elements • Human Rabies Exposure – Case based data – Aggregated data • Surveillance of Deaths from Human rabies

Recommended data analysis, presentation and reports • No of human rabies death and rabies cases in animal(by species), by date of presentation • Human exposure by location, date of animal biting/scratch episode animal species, outcome in human and animal populations • Cases by geographical area and dates of biting, type of animal, occupation and outcome

Principal uses of data for decision making • Detect outbreaks in endemic areas and new cases in rabies free area • Determine high risk areas for intervention • Rationalize the use of vaccine and immunoglobulins • Evaluation of intervention for animal reservoirs and exposed human population

Special Aspects Intersectoral cooperation of medical and veterinary services, community involvement and participation required for targeted response and control in animal reservoir.

Presence/Absence of rabies 2000 No information Absence Presence

Rabies trends in 2000 No information Rabies free Stable Decreasing Increasing

Geographical Distribution 2000 No information Rabies free Limited area Border area Most parts

Epidemiological pattern 2000 No information Dog Rabies free Bat Wild

Rabies situation and trend • Human Rabies 35 -50, 000/Year – Asia and Africa are the main • Animal Rabies – Africa 2344, USA 8509, Europe 5098, Asia ? ? • General Trends – Europe reporting decrease in rabies cases – Animal rabies Dog 57%, Wild life 33%, Bat 10%

Rabies and Prevention • Human PET – Exposure to Dog- Africa 87%, Asia 97%, Europe 4% – Vaccine alone Africa 82%, Asia 88%, Europe 80% • Vaccine – Human Vaccine: 76% vaccine on cell culture – Animal Vaccine: 99% cell culture, • Vaccine application in Dogs – Compulsory in 13/25 African countries, 3/10 American countries, 18/33 European countries, 3/10 Asian countries

Reported Human Rabies Cases in India

Reported Human Rabies Cases in India

Reported animal rabies cases in India

Reported animal rabies cases in India

Reported No of PET

Human and animal rabies vaccine produced or imported Not available at Rabnet

Rabies Vaccination for dogs and other animal species Not available at Rabnet

Current country information on rabies in India at Rabnet Last update of this informations : 1999 -12 -01 • Region : Asia Country : India WHO Region : EURO 1) Presence of rabies and disease surveillance • Is rabies a notifiable disease? • Does a surveillance system exist? • Is it operational? • Does rabies occur in the country? yes • Does rabies exist in the entire country? If No, please specify infected areas. 2) Reservoir species • First rabies reservoir Second rabies reservoir • not applicable • Third rabies reservoir Other reservoir • not applicable 3) Rabies vaccine used for human postexposure treatment • Primary cell line Diploid cell line Continuous cell line • Treatment schedules not applicable • Other Schedules • Is vaccine also applied intra-dermaly ? Nervous tissue not applicable

Contact address on rabies diagnosis, prevention and control in human and animal in India For questions on rabies prophylaxis and treatment in human please contact or For questions on rabies diagnosis, surveillance and control in animals please contact Last name First name Title Position Institution Department Street Quarter POBox City Postal code State Phone 1 Phone 2 Fax Email Address

Epidemiology of Rabies# • 30, 000 Annual Deaths • 10, 000 PET annually • 12 Govt. Institution (NTVs) for Human • 9 Govt. Institution Veterinary NTVs, • 1 Pvt. Pharmas human TCV, • 4 Pvt Pharmas veterinary TCVs. • 15 Govt Inst. rabies diagnostic facilities in animals and 5 for testing post vaccination antibody titers in humans. # Association for prevention and control of rabies in India (APCRI)

Annual Report at NICD 1997 Post-mortem diagnosis in animal 18/40 in samples by Negri body FAT & BT Diagnosis in hydrophobia cases by • Corneal Smear 0/15 • Serum Antibodies 2/15 Assessment of antibodies by modified CIEP test • Human 234/258 • Animal l 5/5

6 month incidence of animal bite cases in 4 selected urban communities* City Banglore Calicut Coonoor Rajamundry Total Population Bites 88469 85 79169 20 43577 70 71358 117 282573 292 Incidence/1000 0. 96 0. 25 1. 61 1. 64 1. 03 *Source: Based on reports of National Institute of Communicable Diseases

No of animal bite case reported by Municipal Medical Institutions in Delhi, 1995 -1998* Animal Dog Monkey Cat Horse Buffalo Unknown Total 1995 23852 1093 170 4 1 59 25179 1996 26395 1313 141 15 0 96 27960 * Source: Municipal Health Officer, Delhi 1997 27345 1008 121 6 4 125 28609 1998 29905 1198 182 8 8 182 31483

Total Case 5115 290 207 171 90 48 25 11 30 34 6 23 1 4 4 131 * Source: CRI, Kasauli, APRICON 2003 (Percentage) (83%) (05%) (3. 5%) (03%) (1. 5%) (. 75%) (0. 5%) (02%) Total : 6190 animal involved 1998 -2002* No. bite cases with reference to Animal Dog Monkey Buffalo Cow-Ox Cat Rat Jackal Leon/Leopard Horse-Mule Mongoose Pig Goat Sheep Others Unknown Contact Cases

Single animal biting many persons: Episodes reported from India* Year 1992 1995 1996 Animal Dog Wolf Dog Bitten 90 28 43 Died 0 8 8 * Source: Based on reports communicated to NICD RIG Yes No No

Classification of Animal bite cases reported (1998 -2002)* Year 1998 1999 2000 2001 2002 Total Class I 8 21 13 15 57(1%) Class II 243 153 279 120 157 952(15%) * Source: CRI, Kasauli, APRICON 2003 Class III 1384 1285 722 951 839 5181(84%) Total 1627 1446 1022 1084 1011 6190

No of Hydrophobia cases admitted to IDH, Delhi 1994 -1999* Year 1994 1995 1996 1997 1998 1999 No of Hydrophobia cases 224 210 151 222 215 241 *Source: Infectious Diseases Hospital, New Delhi

Rabies Cases Admitted to IDH 1998 Age 0 -4 5 -14 15+ Sex Male Female Total Number 13 85 117 Percentage 06. 0% 39. 5% 54. 5% 168 47 215 78. 1% 21. 9% 100% *Source: Jagvir Singh et al in Indian Pediatrics, Volume 38, 2001

Rabies Cases Admitted to IDH 1998 Antirabies Vaccination before hospitalization Age Number No. Received ARV 0 -4 13 6 5 -14 85 17 15+ 117 25 Sex Male 168 39 Female 47 9 Total 215 48 Percentage 46. 2% 20. 0% 23. 2% 19. 1% 22. 3% *Source: Jagvir Singh et al in Indian Pediatrics, Volume 38, 2001

Rabies Cases Admitted to IDH 1998 PET received by these cases* • Local wound care: – Only 2 cases • Vaccination: – Unvaccinated – Vaccinated 67/215 48/215 • 42 NTV( only 5 received>10 doses) • 6 TCV(all received < 3 doses) • Immunoglobulins: • Only 3 cases • 1 case received (Wound care + NTV+ ERIG) *Source: Jagvir Singh et al in Indian Pediatrics, Volume 38, 2001

Assessing Burden of Rabies in India* • • 1000+ million Population 24 million Dog Population Dog: Man 1: 12 to 1: 40 Animal Bites: 2. 1 million 90% due to dog ( 90% unvaccinated dog) 1. 1 million PET (0. 45 NTV and 0. 65 TCV) No. of Rabies death 30, 000/annually ? ? * Source: APCRI, Newsletter Volume III, Issue 1 & 2, 2003

Assessing Burden of Rabies in India A WHO-APCRI National Multi Centric Survey Initiative 2003 This survey involves • 20 Medical Colleges, • 32 Veterinary College, • 10 million Human Population • 32 Veterinary Pathology Laboratories

What could be the answer for Rabies Surveillance in India ? Integrated Disease Surveillance ? ?