Dear TechNet viewers We wish you all a merry Christmas and happy new year to come. We wish to share the attached PPT on anti rabies vaccine administration presented in the integrated teaching session to the PGs & Faculties of departments of KVG Medical College. The ppt is free for editing for further fine tuning. As a routine Academic activity, I was asked to make a presentation on ARV administration. As we strongly believe in learning before teaching, learn by working together, learn while teaching; we visited the injection room where ARV is administered to the needy patients. We got very good opportunity to learn very crucial aspects. The planning unit is supplied with Abhayrab and equine Rabies Immuno-Globulin (eRIG) by the Government which is free for the Below Poverty Line (BPL) patients and chargeable for the Above Poverty Line (APL) patients as per norms acceptable to the community. ARV is administered through Intra-Dermal (ID) route as a routine policy: 0.1mL at 2 sites to the 2 upper arms. Nurses who are routinely administering the vaccine have the required skill but we found gap in the junior doctors regarding how much vaccine to draw using insulin syringe, proper I.D administration – too small a weal developed as vaccine got lodged subcutaneously. In one of the planning units with very few patient loads, staff revealed that the reconstituted vial was used till the last 0.1mL was administered, often for more than a week though kept in the cold chain and away from light but no vaccinees died sofar probably the dogs were non rabid. In view of this, we strongly recommend regular training and reorientation of treating Doctors on managing animal bites including administration of  TT, providing appropriate antibiotic, analgesics, assurance / counseling apart from specific ARV with or without RIG. Best wishes Holla n Team

Abstract
Presently the dose of rabies immunoglobulin (RIG) which is an integral part of rabies post exposure prophylaxis (PEP) is calculated based on body weight though the recommendation is to infiltrate the wound(s). This practice demands large quantities of RIG which may be un-affordable to many patients. In this background, we conducted this study to know if the quantity and cost of RIG can be reduced by restricting passive immunization to local infiltration alone and avoiding systemic intramuscular administration based on the available scientific evidence. Two hundred and sixty nine category III patients bitten by suspect or confirmed rabid dogs/ animals were infiltrated with equine rabies immunoglobulin (ERIGs) in and around the wound, the quantity of ERIG used was proportionate to the size and number of wounds irrespective of their body weight. They were followed with a regular course of rabies vaccination by intra-dermal route. As against 363 vials of RIGs required for all these cases as per current recommendation based on body weight, they required only 42 vials of 5ml RIG. Minimum dose of RIGs given was 0.25ml and maximum dose given was 8 ml. On an average 1.26 ml of RIGs was required per patient that costs Rs. 150 ($3). All the patients were followed for 9 months and they were healthy and normal at the end of observation period. With local infiltration, that required small quantities of RIG, the RIGs could be made available to all patients in times of short supply in the market. A total of 30 (11%) serum samples of patients were tested for rabies virus neutralizing antibodies by the rapid fluorescent focus inhibition test (RFFIT) and all showed antibody titers >0.5 IU/mL by day 14. In no case the dose was higher than that required based on body weight and no immunosuppression resulted. To conclude, this pilot study shows that local infiltration of RIG need to be considered in times of non availability in the market or un-affordability by poor patients. This preliminary study needs to be done on larger scale in other centers with long term follow up to substantiate the results of our study.

Read More free now courtesy PMC and Hum Vaccin Immunother. 2016 Mar; 12(3): 837–842. :

https://www.ncbi.nlm.nih.gov/pmc/articles/PMC4964710/pdf/khvi-12-03-1085142.pdf

This would drasticaly reduce costs and make PEP affordable to all in rabid animal bites,
Thanks
Omesh BHaeti, Shimla India

Presently the dose of rabies immunoglobulin (RIG) which is an integral part of rabies post exposure prophylaxis (PEP) is calculated based on body weight though the recommendation is to infiltrate the wound(s). This practice demands large quantities of RIG which may be un- affordable to many patients. In this background, we conducted this study to know if the quantity and cost of RIG can be reduced by restricting passive immunization to local infiltration alone and avoiding systemic intramuscular administration based on the available scientific evidence. Two hundred and sixty nine category III patients bitten by suspect or confirmed rabid dogs/ animals were infiltrated with equine rabies immunoglobulin (ERIGs) in and around the wound, the quantity of ERIG used was proportionate to the size and number of wounds irrespective of their body weight. They were followed with a regular course of rabies vaccination by intra-dermal route. As against 363 vials of RIGs required for all these cases as per current recommendation based on body weight, they required only 42 vials of 5ml RIG. Minimum dose of RIGs given was 0.25ml and maximum dose given was 8 ml. On an average 1.26 ml of RIGs was required per patient that costs Rs. 150 ($3). All the patients were followed for 9 months and they were healthy and normal at the end of observation period............here is the link......................

http://www.ncbi.nlm.nih.gov/pubmed/26317441

Dr. Omesh K Bharti, Simla, HP, India
+91-9418120302

http://www.technet-21.org/en/resources/technet-resource-library/

Abstract Send to: Hum Vaccin Immunother.2015 Aug 28:0. [Epub ahead of print] Local infiltration of rabies immunoglobulins without systemic intramuscular administration: An alternative cost effective approach for passive immunization against rabies. Bharti OK1,Madhusudana SN,Gaunta PL,Belludi AY. Author information Abstract Presently the dose of rabies immunoglobulin (RIG) which is an integral part of rabies post exposure prophylaxis (PEP) is calculated based on body weight though the recommendation is to infiltrate the wound(s). This practice demands large quantities of RIG which may be un- affordable to many patients. In this background, we conducted this study to know if the quantity and cost of RIG can be reduced by restricting passive immunization to local infiltration alone and avoiding systemic intramuscular administration based on the available scientific evidence. Two hundred and sixty nine category III patients bitten by suspect or confirmed rabid dogs/ animals were infiltrated with equine rabies immunoglobulin (ERIGs) in and around the wound, the quantity of ERIG used was proportionate to the size and number of wounds irrespective of their body weight. They were followed with a regular course of rabies vaccination by intra-dermal route. As against 363 vials of RIGs required for all these cases as per current recommendation based on body weight, they required only 42 vials of 5ml RIG. Minimum dose of RIGs given was 0.25ml and maximum dose given was 8ml. On an average 1.26ml of RIGs was required per patient that costs Rs. 150 ($3). All the patients were followed for 9 months and they were healthy and normal at the end of observation period. With local infiltration, that required small quantities of RIG, the RIGs could be made available to all patients in times of short supply in the market. A total of 30 (11%) serum samples of patients were tested for rabies virus neutralizing antibodies by the rapid fluorescent focus inhibition test (RFFIT) and all showed antibody titers >0.5 IU/mL by day 14. In no case the dose was higher than that required based on body weight and no immunosuppression resulted. To conclude, this pilot study shows that local infiltration of RIG need to be considered in times of non availability in the market or un-affordability by poor patients. This preliminary study needs to be done on larger scale in other centers with long term follow up to substantiate the results of our study. KEYWORDS: Animal bites; Passive immunization; Rabies; Rabies Immunoglobulin

Background: Rabies is a dreaded disease and an estimated 55,000 people die of rabies every year. Himachal Pradesh is in the North bordering China and is predominantly rural and hilly. Villages are near forests, where wild reservoirs of rabies exist. Since health facilities are not accessible easily, we need to innovate on existing schedules of rabies vaccination keeping in view the compliance of the patients and affordability so as to give them the best possible option of treatment. In the year 2006 and 2007, we, at DDU Hospital Shimla, experienced a severe shortage of rabies vaccine and patients were running from pillar to post to fetch rabies vaccine. At the same time, we learnt that some of the patients died because either they were not able to purchase the vaccine, mostly because of its high cost, $35, or they ignored the animal bites and did not seek the treatment. Since last year, we have been experiencing non-availability of rabies immunoglobulins (RIGs) in the market and have to innovate new schedules and techniques to save lives of the patients. Methods: During shortage of rabies vaccine in 2008, we contemplated to start a low cost intra-dermal (ID) clinic so as to make rabies vaccine affordable as intramuscular (IM) vaccination cost five times more than ID vaccination. But, there were three main hurdles. One hurdle was the non-availability of rabies vaccine vials having written on them “For IM/ID use” and another hurdle was only fewer animal bite patients attending the DDU Hospital, sometimes only one or two per day, which was insufficient to open a vaccine vial and distribute among them. The third problem being faced was reluctance of the hospital doctors to prescribe ID vaccine as this was not the practice at higher teaching institutions, including medical colleges. We contacted a vaccine company and few vials labeled as “For IM/ID use” were sourced from Mumbai (1200 km away from here). We asked the Chief Medical Officer, Shimla district to write a letter to all health facilities around our Hospital to give first aid to animal bite patients and then refer them to DDU Hospital for vaccination. Now we were able to pool the patients and divide a single 1 ml vaccine vial among four patients. After continuous advocacy, our stress that WHO has given its approval for ID use of rabies vaccine and that subsequent approval has been granted by Government of India was enough for doctors to prescribe the vaccine as ID. Last Year, we got ethical approval to inject rabies Immunoglobulins (RIGs) only locally in and around the wound at times of scarcity of RIGs in the market. The subsequent follow up of patients proved life saving in crisis of shortage of RIGs. Due to shortage of RIGs we innovatively vaccinated people bitten by rabid dogs or people who had consumed rabid cow’s milk and followed them for outcome, apart from having Rabies Fluorescent Focus Inhibition Test (RFFIT) was done for few of the patiens for verification of protective titers. We innovated a technique of extraction of last drop of vaccine from the vial and also saved a drop of RIGs being used for test dose before giving RIGs to the patients. Results: The first low cost anti-rabies clinic was started on August 2, 2008 after long advocacy sessions with the authorities and the doctors. Since then, we have done many innovations based on local requirements and patients’ feedback and accessibility to treatment. We have given pre and post-exposure prophylaxis to more than 12,000 animal bite victims over more than five years period in this single clinic, saving lives as well as money without any failure even in difficult rabid animal bite cases. Our innovation helped us save the vaccine and immunoglobulins till the last drop. Conclusions: Innovative ways by health providers backed by extensive literature review and scientific evidence can help patients get low cost health deliverables that increase their compliance as medicines/vaccines become affordable to them. Third world countries need to innovate their own ways to solve their problems of scanty resources and find innovative solutions to conquer them, rather than looking elsewhere for solutions.

When rabies Immunoglobulins are not affordable or not available

Rabies vaccine is important aspect of post exposure prophylaxis but is not of sufficient help unless given with rabies immunoglobulins (RIGs) in type III wounds if the patient is not vaccinated previously.

We are experiencing a severe artificial shortage of Rabies Immunoglobulins (RIGs) in India because companies are not producing enough of them. In Shimla (Himachal Pradesh, India) and also in other parts of the country there are currently no RIGs available in the local market. This may be in part due to the Drug Price Control Order of Government of India which limits the price that companies can charge for essential medicines. Whilst this makes drugs more affordable for patients, it also makes the market less attractive for pharmaceutical companies who may reduce or stop production. Compounding this problem is also the low demand for RIGs in India – a low volume of prescriptions by doctors and then even lower numbers of patients actually purchasing them due to the unaffordable costs involved. Faced with low demand due to the cost, the chemists find that expensive RIG stock expires before it is sold, and tend not to store it in future.
Whilst RIGs is not necessary for patients who have previously been fully immunized against rabies, it is a critical part of PEP for unvaccinated patients. As it takes about 7-10 days for the vaccine to initiate active immunity in the patient, there is no substitute for RIG’s ability to immediately neutralize the virus in the wound. Abbreviated courses of rabies vaccine alone have been shown to stimulate more rapid immune responses, but these are only recommended for previously vaccinated people.
Whilst the use of rabies vaccine is high, the use of RIGs is very low amongst bite patients. At the Shimla anti-rabies clinic at DDU hospital, 1,834 people presented with animal bites in 2013, including 1,168 dog bites and 580 monkey bites. All of these received vaccine, but even after counseling over its importance, only 4 patients opted to receive RIG, because of the expense of the product (a cost of around Rupees 1200 for eRIGs and Rs.30,000 for HRIGs / 24 $ - 600 $ for an average patient). The vaccine is now given free as a result of the shift to low cost intra-dermal vaccination, but RIGs were to be purchased from the market. There was no active follow up of the patients who received PEP in 2013.
A 38 year old woman, from a family that could have afforded the RIG, died following a dog bite in Shimla district in 2009. She had received a full course of rabies vaccine, but was not prescribed RIGs as it was not available either in the hospital, or in chemist shops.
Recently, a woman tourist died in Delhi when she was bitten by a stray dog in Manali, a tourist town in Himachal Pradesh. She was given a full course of vaccine IM (intra-muscularly) but not immunoglobulins, as they were not available.
In another case that was referred to IG Medical College from a distant civil hospital a 32 years old male who was bitten on the lower lip by a suspected rabid dog on September 5, 2014 developed rabies within 2 weeks of bite. He was given all doses of rabies vaccine IM but RIGs were not available in the market. He succumbed to the disease later in the medical college.
Local medics are also frustrated as Post Graduate Students of Tanda Medical Collage Kangra could not find RIG for themselves after they were bitten by a suspect rabid dog.
Due to the scarcity, we at DDU hospital and the medical college here are now left with no option but to experimentally give RIGs only locally in the wound, as limited quantities of RIGs are being made available from the government Central Research Institute in Kasauli for this purpose. We are following such patients and no deaths have been reported after three months of follow-up even in patients bitten by suspected rabid animals. The follow up will continue for one year and results will be shared on a wider scale so as to make RIGs affordable for poor patients and available in situations of scarcity.
As scarcity of RIGs continues we are forced to give RIGs only locally in the wound/s and have given local RIGs to more than 1000 patients till date and surly must have saved some lives in times of scarcity of RIGs as reports of deaths continue to pour in from other parts of the state and the country.
Submitted by Dr. Omesh Kumar Bharti, an Epidemiologist and Corporation Health Officer in Shimla, Himachal Pradesh, India.
A presentation on this subject is available at:
http://www.authorstream.com/presentation/bhartiomesh-2288160-omesh-rabies-immunoglobulins-available-affordable/