ACKNOWLEDGEMENTThe Conference Organizers gratefully acknowledge the generous financial support of the followings:

Dr. Hilary Koprowski

Dr. Koprowski, a virologist who died on April 11, 2013 at 96, inoculated himself against polio, years before the vaccines of Jonas Salk and Albert Sabin.

Dr. Koprowski was one of the world’s foremost biomedical researchers, helping usher in a spate of innovations, including a safer, less painful and more effective rabies vaccine that remains widely used. His most noteworthy innovation — developing the first viable vaccine against polio and testing it successfully on humans

Besides his own work on the improved rabies vaccine, which he helped develop in the ’60s, Dr. Koprowski was known for significant early work on the therapeutic use of mono-clonal antibodies.

Hilary Koprowski was an extraordinary person. He excelled as an innovative scientist, a director of a research institute, a classical pianist, a composer of music, a connoisseur of art, and a polyglot world traveler. Born in Warsaw, Poland, where he obtained a medical degree, the Nazi invasion forced him and his wife, Irena, to flee to Italy, where he studied piano at the Accademia Nazionale di Santa Cecilia in Rome. During the Second World War, he managed to emigrate to Brazil, where he became a research assistant in the Rockefel-ler Foundation Laboratories. There, his work on yellow fever and several arboviruses so impressed the senior staff that a position was found for him at the Lederle Laboratories in Pearl River, New York. At Lederle, he began work leading to improved rabies vaccines and on attenuation of polio virus, the work for which he will be remembered most.

Koprowski’s scope in virology was breathtaking: his bibliography includes articles on at least 25 different viruses, including polio virus, rabies virus, simian virus 40 (SV40), parainfluenza virus type 1, herpes simplex virus, and many flaviviruses. His publication record includes over 900 articles.

When the technology to make monoclonal antibodies became available in the late 1970s, Koprowski founded the Centocor biotechnology company to make antibodies that could be used practically to treat viral infections and cancer. Late in his career, Koprowski set up the Biomedical Foundation to channel research toward making vaccine antigens in plants. Despite his age, he was actively promoting this field until the last year of his life.

Dr. M.K. Sudarshan, MD, FAMS, Hon. FFPH (UK) President, Rabies in Asia Foundation Dean/Principal and Professor of Community MedicineKempegowda Institute of Medical Sciences, Bangalore, India

FOREWORDIt is with great pleasure and honour I wish to place on record the commitment, planning

and excellent work of Drs. Thavatchai Kamoltham and Apirom Puanghat of RIA, Thailand Chapter which ensured the successful conduct of the 4th Rabies in Asia conference, RIACON, held from September 11 - 13, 2013 at Chatrium Hotel Riverside , Bangkok. The organizational and communication efforts of Dr. Onpirun Sagarasearanee & her team are duly appreciated. The relentless and untiring work of Drs. D.H.Ashwath Narayana, N.R.Ramesh Masthi & H.S.Ravish from the headquarters of the foundation and at the venue of the conference and sustained support of Dr.B.J.Mahendra were of great help.

The pursuit to prepare the proceedings of the conference by Dr. B.J.Mahendra and his team is gratefully acknowledged. The conference proceedings provide a good coverage of the presentations and inclusion of photographs is a valuable addition. It is sincerely hoped that this document provides an update on rabies in Asia and the professionals and scientists find this interesting and useful. This can also be freely downloaded from the website of Rabies in Asia Foundation viz. www.rabiesinasia.org for wider dissemination.

I sincerely thank Government of Thailand for giving us an opportunity to organize this scientific event at Bangkok. The support of Novartis Vaccines, Sanofi Pasteur and others is gratefully acknowledged. Lastly, the help of chairpersons of country chapters and advisors of RIA Foundation is sincerely acknowledged.

Dr. M. K. Sudarshan, MD, FAMS, Hon.FFPH (UK) President, Rabies in Asia (RIA) Foundation

THAILAND CHAPTER COMMITTEEAdvisory Group

Minister of Public Health Ministry of Public Health1. Permanent Secretary Ministry of Public Health2. Prof. Dr. Prasert Thongcharoen Mahidol University3. Director Queen Saovabha Memorial Institute, the Thai Red 4.

Cross Society5. Director World Health Organization Collaborating Centre for Research and Training on Viral ZoonosesSteering Committee

Director-General Department of Disease Control, MOPH (Chair)1. Director-General Department of Livestock Development, MOAC 2.

(Co-chair)Dr. Thavatchai Kamoltham, MD Ministry of Public Health3. Director Bureau of General Communicable Diseases, DDC,MOPH4. Director Bureau of Disease Control and Veterinary Services, 5.

MOACDr. Plaiyong Sagaraseranee, DVM Department of Disease Control, MOPH6. Dr. Darika Kingnate, DVM Department of Disease Control, MOPH7. Dr. Apirom Puanghat, DVM Department of Disease Control, MOPH8.

Dr. Pornpitak Panlar, DVM Department of Disease Control, MOPH9. Dr. Saowapak Hinjoy, DVM Department of Disease Control, MOPH10. Dr. Supaporn Wacharapluesadee, PhD World Health Organization Collaborating Centre for 11.

Research and Training on Viral ZoonosesDr. Wirongrong Hunsuwan, DVM Department of Livestock Development, MOAC12. Dr. Pongtep Eakudomchai, DVM Department of Livestock Development, MOAC13. Dr. Veera Tepsumethanon, DVM Queen Saovabha Memorial Institute, the Thai Red Cross 14.

SocietyOrganizing Committee

Dr. Thavatchai Kamoltham, MD Ministry of Public Health (Chair)1. Dr. Plaiyong Sagaraseranee, DVM Department of Disease Control, MOPH2. Dr. Apirom Puanghat, DVM Department of Disease Control, MOPH3. Dr. Pornpitak Panlar, DVM Department of Disease Control, MOPH4. Dr. Teerasak Chuxnum, DVM Department of Disease Control, MOPH5. Dr. Wimwiga Sakchainanon, DVM Department of Disease Control, MOPH6. Dr. Onpirun Sagaraseranee, DVM Department of Disease Control, MOPH7. Mrs. Rattana Theerawat Department of Disease Control, MOPH8.

Mrs. Ratchanee Theerawitayalert Department of Disease Control, MOPH9. Mr. Watthanasak Sornroong Ministry of Public Health10. Dr. Pranee Panichabhongse, DVM Department of Livestock Development, MOAC11. Dr. Pornpirun Chinson, DVM Department of Livestock Development, MOAC12. Dr. Pawin Padungtod, DVM Thailand MOPH - U.S. CDC Collaboration13.

Message .... FromDr. Bernadette Abela

“In the World Health Assembly of 2013, Member States requested the

WorldHealth Organization to (Resolution WHA66.12 http://apps.yeho.int/

gb/ebyeha/pdfJilesfWIU66/A66 R12-en.pdf) to sustain WHO’s leadership in

the drive to overcome neglected tropical diseases (NTD). Rabies is one of the

listedpriority NTDs. The goal for Latin American countries South EastAsia is

to attain elimination of human rabies transmitted by dogs by 2015 and2020

respectively and then to maintain this status over time. Other countries

and regions are following suit.

Rabies is preventable! It is possible to eliminate rabies using the available

tools such as safe and efficacious vaccines, but elimination ofrabies needs more than tools. More than 50,000people, mostly in Asia and Africa, Still

die ofrabies every year; a large proportion ofwhom are children. Dogbites

are theprimary source of human rabies. Human rabies prevention needs a

partnership approach complemented by consistent and sustainedpolitical and

resource commitment. It also requires strengthened health and Veterinary

systems.

Prevention is possible through mass dog vaccination, promotion of

responsible dogownership and dog population control. Advocacy, awareness

and education remain key to assure that bite victims promptly clean wounds and

seek medical attention. There is still need to improve access and availability

of affordable post-exposure rabies prophylaxis to people who are bitten in

endemic areas.WHO is working with strategic partners to strive to improve

coordination and encourage countries and the wider community, including

donors, Pharmaceutical companies, agencies, NGOS, Philanthropists and

universities, to maintain and expand their commitments to eliminating rabies

in humans.”

MESSAGE FROM RIA THAILAND CHAPTER

Rabies is a major public health issue that remains wide spread around the globe. Over 55,000 deaths from more than 150 countries per annum occur mostly in Africa and Asia. Over 30,000 mortalities were reported in Asia alone. Although the prevention and control activities have been undertaken there is a lack of efficient methods to control the incidence of Rabies.

We hope that this conference will promote the chance to exchange the skills and experiences in prophylaxis, epi-demiological

surveillance and control amongst the participating countries leading to rabies elimination in Asia by 2020 accord-ingly the theme of this year’s conference “Road to Rabies Free in Asia by 2020”.

We are extremely pleased to welcome all international delegates and wish a nice stay in Thailand and a successful conference.

Assist. Prof. Dr. Thavatchai Kamoltham, MD., FRCS., Dr.P.H. Inspector General, Ministry of Public Health

4th RIA International Conference, Bangkok, 11-13 September 2013

I wish to thank Dr. M.K. Sudarshan, President of Rabies in Asia Foundation (RIA) as well as the local organizers Drs. Thavatchai and Apirom and their respective teams for inviting me on a personal basis to participate and speak at the occasion of this 4th International Conference on rabies in Asia held this yeai in Bangkok, Thailand.

It is always a pleasure for me take part in these international conferences, meeting ‘old’ and younger colleagues and friends and sharing information and experience. Much of the progress recorded over the past few years in human and dog rabies prevention and control has actually been occurring in Asia.

The number of human rabies deaths is reported to be on the decline in many Asian countries such as China, India, the Philippines, Sri-Lanka and Thailand. There is however a need to better document this decreasing trend by reassessing the rabies burden in these countries particularly China and India.

Most Asian countries have now successfully managed the challenging transition from neural tissue to cell-culture rabies vaccine production and/or use and the others such as Myanmar and Pakistan have developed plans to do so in the short term.

Asian countries which have approved the use of the intradermal route for PEP are providing a continuously increasing proportion of total number of PEP by that route thereby facilitating patients’ access to prophylaxis and reducing the economic burden that human rabies prevention represents.

Most Asian countries including Bhutan & Nepal are very committed to achieving the goal of eliminating human dog transmitted rabies by 2020.

I am convinced that international RIA conferences, have played an important role in the making of these improvements by facilitating the sharing of updated information and experi-ence

on human and animal rabies prevention as well as supporting special studies and projects. Dr. M.K. Sudarshan should be commended for his dedication and untiring efforts since the first RIA conference was held in Bangalore in 2007, to achieving the goal of the foundation which is to eliminate human rabies from Asia.

Francis meslin (retired)Formerly Team Leader - Zoonotic Diseases (Neglected) (NZD) Department of Neglected

Tropical Diseases (NTD) WHO Headquarters, Geneva, Switzerland

MESSAGE FROM DR. F.X. MESLIN

Scientific ProgramThe 4th Rabies in Asia Conference: RIACON 2013

Road to Rabies Free in Asia by 2020”

Day 1 : Wednesday, 11- September 2013

08:00 - 09:00 a.m. : Registration09:00 - 09:40 a.m. : Inauguration

Opening Speech : Deputy Minister of Public Health- Report : Deputy Director-General, Department of Disease Control- Foundation Speech : President - (Dr. M.K. Sudarshan)

Launch of Rabies in Asia Foundation (video film) - “One Health for One Goal - Elimination of Rabies”

Dr. K. Mahadev, CEO, KIMS, Bangalore, India

09.40 – 10:20 a.m. Group photo + Tea / Coffee

Time Topic Speaker

10:20- 10:55 a.m. Global and Regional Situation of Rabies Dr. Dubravka Selenic Minet, WHO, Thailand

10:55 - 11:30 a.m. 25 Years of Experience in Rabies Control Dr. F.X. Meslin, Switzerland

11:30- 12:00 p.m. Thailand : Road to Rabies Free in Thailand by the Year 2020

Dr. Opart Karnkawinpong Department ofw Disease Control, MOPH, Thailand Dr. Wirongrong Hoonsuwan, Department of Livestock Development, MOAC, Thailand

12:00-01:00 p.m. Lunch

01:00 - 01.30 p.m.Pre-Exposure Prophylaxis for Children in Rabies Endemic Countries using PCECV - A Clinical Overview

Dr.Claudius Malerczyk, Novartis

01.30-01.50 p.m. Verorab Vax1M: The Next-Generation Rabies Vaccine Dr. Alain Bouckenooghe, Sanofi Pasteur

01:50-02:05 p.m. Afghanistan Dr. Hidayatullah Alnoor, Afghanistan

02:05 - 02:20 p.m. Bangladesh Dr. Be-Nazir Ahmed, Bangladesh

02:20 -02:35 p.m. Cambodia Dr. Chheng Kannarath, Cambodia

02:35 - 02:55 p.m. Tea / Coffee

02:55 - 03:10 p.m. China Dr. Yong Zhen Zhang, China

03:10 -03:25 p.m. India Dr. G. Sampath, India

03:25 -03:40 p.m. Lao PDR Dr. Bounlay Phommasack, Lao PDR

03:40 -03:55 p.m. Myanmar Dr. Soe twin Nyein, Myanmar

Scientific Session II : Road to Rabies Free in Asia by 2020 : Progression/Success Stories ( Country Reports) Chair Person : Dr. Dubravka Selenic Minet, WHO Thailand Co-Chair Person : Dr. G. Sampath, India

Scientific Session I : Road to Rabies Free : Global and Regional Perspectives Chair Person : Dr. F.X. Meslin, Switzerland Co-Chair Person : Dr. Naseem Salahuddin, Pakistan

Time Topic Speaker

03:55 - 04:10 p.m. Nepal Dr. Krishna. B. Shrestha, Nepal

04:10-04:25 p.m. Pakistan Dr. Naseem Salahuddin, Pakistan

06:00 - 09:00 p.m. Welcome Dinner

Dav 2 : Thursday, 12m September 2013

Time Topic Speaker

Scientific Session II : Road to Rabies Free in Asia by 2020 : Progression/Success Stories (continued)

Country Reports

09:00-09:15 a.m. Philippines Dr. Beatriz P. Quiambao, Philippines

09:15 -09:30 a.m. Sri Lanka Dr. P.A.L. Harishchandra, Sri Lank:

09:30 - 09:45 a.m. Vietnam - Human Rabies Dr. Nguyen Thi Hong Hanh, Vietnam

09:45 - 10:00 a.m. Vietnam - Animal Rabies Dr. Van Dang Ky, Vietnam

Scientific Session III : Best Practices in Rabies Prevention and Control in Humans Chair Person : Prof. Emeritus Dr. Prasert Thongcharoen, Thailand

Co-Chair Person : Prof. Dr. Madhusudana, India

10:00- 10:20 a.m. Perspective of Rabies Control in the Future Prof. Emeritus Dr. Prasert Thongcharoen, Thailand

10:20- 10:40 a.m. The Future of Rabies Post-exposure Prophylaxis Prof. Dr. Henry Wilde, Thailand

10:00- 10:20 a.m. Tea / Coffee

10:20 - 10.50 a.m.Human Rabies : Neuropathogenesis, Diagnosis and Management

Prof. Dr. Thiravat Hemachudha, Thailand

10:50 -11:10 a.m.Dual Role of Immune Response in Rabies Encephalitis : Studies in Murine Model and Its Implications in Human Rabies

Prof. Dr. S.N. Madhusudana, India

Scientific Session IV : Rabies Control and Immunization Chair Person : Prof. Dr. Henry Wilde, Thailand

Co-Chair Person : Dr. Agnes Poirier, OIE, Thailand

11:10- 11:30 p.m. Pre-exposure Prophylaxis for Children Assist. Prof. Kriengsak Limkittikul, Thailand

11:30- 11:50 p.m. Epidemiological Principle of Rabies Control Dr. Eric Brum, FAO, Indonesia

1 1:50- 12:10 p.m. Success History of Rabies Elimination in Malaysia Dr. Asiah Naina bind Mohd Alim, Malaysia

12:10-01:10 p.m. Lunch

Scientific Session V : Rabies Control and Management : Strategy Chair Person : Dr. Lea Knopf GARC, France Co-Chair Person : Mary Joy Gordoncillo, OIE, Thailand

01:10-01:30 p.m. Paradigm Shift in Rabies Control Dr. Thavatchai Kamoltham, Thailand

01:30 - 01:50 p.m. Update from the Global Alliance for Rabies Control Dr. Lea Knopf GARC, France

01:50-02:10 p.m. The Best Practice on Rabies Free Zone Established in a Local Level: A Case Study in Wiang Hao Sub-district

Dr. Pranee Rodtian andDr. Jamnong Sankvau, Chiang Rai.Thailand

02:10-02:30 p.m. OIE International Standards and Guidelines on Rabies and the South-East Rabies Strategy

Dr. Agnes Poirier and Dr. Maty Joy Gordoncillo, OIE, Thailand

Time Topic SpeakerScientific Session VIII : Rabies In Asia Conclusion Chair Person : Dr. M.K. Sudarshan, RIAFCo-Chair Person : Dr. B.J. Mahendra, RIAF

12:00- 12:15 p.m. Conclusions and Recommendations Dr. Thavatchai Kamoltham, Thailand

12:15 - 12:30 p.m. Concluding Remarks and Valedictory Function Dr. B.J. Mahendra, RIAF

12:30- 13:30 p.m. Lunch

13:30 - 15:30 p.m. Advisory Board Meeting Dr. M.K. Sudarshan, RIAF

End of the Conference

Time Topic Speaker

02:30 - 02:50 p.m. Rabies Free in Japan and Future Plan (Rabies Prevention in Japan) Dr. Santoshi Inoue, Japan

02:55 -03:15 p.m. Tea / Coffee

Scientific Session VI : Free paper presentationChair Person :Co-Chair Person : Dr. B.J. Mahendra, RIAF

03:15 - 03:35 p.m. Profile of Human Rabies Cases Admitted at Epidemic Diseases Hospital, Bangalore, India Dr. Harish B.R., India

03:35 - 03:55 p.m. Mitochondrial Dysfunction in Rabies Virus Infection Dr. Alan C. Jackson, Canada

03:55 - 04:15 p.m. Five Years of Intradermal Vaccination & Adherence at ARV OPD, Grant Medical College, Mumbai : A Review Dr. Ranjit Mankeshwar, India

04:15 - 04:35 p.m. Effectiveness of Telephone Reminders for Increasing Compliance to Intradermal Rabies Vaccination Schedule Dr. M. Vinay, India

04:35 - 04:55 p.m. Comparison of Immunogenicity to Anti-rabies Vaccine in Dogs of Different Age Groups Dr. R.M.S. Pimburage, Sri-Lanka

Day 3 : Friday, 13™ September 2013

Time Topic Speaker

Scientific Session VII : Innovation of Rabies and New Research Chair Person :Co-Chair Person : Dr. D.H. Ashwath Narayana, Bangalore, India

09:00 - 09:20 a.m. Global Positioning System : A New Tool for Measurement of Animal Bite Cases Dr. N.R. Ramesh Masthi, India

09:20 - 09:40 a.m. One Shot Immunization and Pre Exposure Rabies Vaccination in Short Term Traveler Dr. Pakamatz Khawplod, Thailand

09:40- 10:00 a.m.Interchangeability of Route or Type/Brand of Anti Rabies Vaccines in Post Exposure Prophylaxis: Safety & Immunogenicity Study

Dr. H.S. Ravish, India

10:00- 10:20 a.m. Tea / Coffee

10:20 - 10:40 a.m.

Assessing Safety and Immunogenicity of Rabipur and Verorab: Results of a Randomized Control Trial using One Week Intradermal Regimen (4-4-4-0-0) in Cases of Suspect Exposure to Rabies

Dr. D.H. Ashwath Narayana, KIMS, India

10:40- 11:00 a.m. Lessons Learned : Evidence of Transferable Maternal Immunity against Rabies in a Newborn Water Buffalo Dr. Pranee Panichabhongse, Thailand

11:00- 11:20 a.m. Neuropathological Correlation of Neuroimaging Features in Human Rabies Encephalitis Dr. Anita Mahadevan, India

11:20- 11:40 a.m. Thl and Th2 T-cell Responses to Rabies Vaccination : A Preliminary Study Dr. M. V. Manjunatha , India

1 1:40 - 12:00 p.m. Genetic Characterization and Assessment of Purity of Commercial Human Rabies Vaccines Available in India Dr. Mani Reela, India

OPENING SESSION

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OPENING SPEECH

H.E. Mr. Sorawong Thienthong

Deputy Minister of Public Health, Thailand

Dr. M. K. Sudarshan, President of Rabies in Asia Foundation, Director – General, Depart-ment of Disease Control, Director – General, Department of Livestock Development, the Com-

mittee of Rabies in Asia Foundation, Chairman of the Organizing Committee, Distinguished Participants,Ladies and Gentlemen,

I am pleased to welcome all representatives from Afghanistan, Bangladesh, China, India, Pakistan, the Philippines, Sri Lanka, Vietnam, Nepal and Thailand as well as the speakers and specialists from international organizations and agencies.

Rabies is recognized for its incurable nature and has remained one of the major public health issues causing over 50,000 deaths worldwide every year or approximately 150 deaths every day. Though prophylaxis averts deaths due to Rabies, the prophylaxis consumes a large amount of money.

The support from Rabies in Asia Foundation allows the country representatives and experts to collaborate and exchange experiences at this meeting which is a forwarding positive step into ASEAN Economic Community (AEC) in 2015. It is encouraging to note that the contribution

towards the eradication of rabies for more safety of passengers within ASEAN countries is considered.

It is thus both an honor and pleasure to our country to have an opportunity to host the 4th Rabies in Asia Conference in Bangkok. I would like to extend my gratitude to all experts and specialists

who are here to share their valuable time and experiences with all participants. I would also like to thank the Foundation of Rabies in Asia and the Organizing Committee who have made this Conference possible.

I wish you all a fruitful meeting whereall the objectives be achieved successfully. On this auspicious occasion, I would like to declare the 4th Rabies in Asia Conference open.

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Dr.M.K.Sudarshan, President, Rabies in Asia Foundation

Honourable Deputy Minister of Health, Government of Thailand, Chairman of the conference

Dr.Thavatchai Kamoltham, other dignitaries on the stage, delegates, invitees, ladies and gentlemen.

I welcome all of you to the 4th rabies in Asia conference, RIACON, held from 11th -13th September, 2013 here at Bangkok. The aim of Rabies in Asia foundation is to work for establishing “rabies free Asia” and support for “elimination of rabies from the world”. Its important objectives include - holding conferences, seminars, symposia, workshops, other scientific meetings and ensuring dissemination of information on rabies in Asia; publishing scientific periodicals, developing audio- visual aids on rabies and distributing to improve awareness of rabies in Asia; offer consultation and other expert services for elimination of rabies in Asia and the world. The RIA Foundation was established in Bangalore, India on 1st April, 2006 and is registered under Indian Trust Act. The headquarters of the foundation is located at Kempegowda Institute of Medical Sciences, Bangalore, India.

The RIA Foundation has nine chapters in nine countries of Asia i.e. Afghanistan, Bangladesh, China, India, Pakistan, Philippines, Srilanka, Thailand & Vietnam and the chairpersons of these chapters are Drs. Sayed Gul Safi, Be-Nazir Ahmad, Yang Zhen Zhang, S.N.Madhusudana, Naseem Salahuddin, Beatriz Quiambao, P.A.L Harischandra, Thavatchai Kamoltham and Nguyen Thi Hong Hanh respectively. Besides the RIA Foundation has eight advisors viz. Dr.F.X.Meslin, Charles Rupprecht, Deborah Briggs, Alexander Wandeler, Thiravat Hemachudha, Henry Wilde, Herve Bourhy and R.L.Ichhpujani.

Some important accomplishments done till date include - organized the first international conference on Rabies, RIACON, March 3 & 4, 2007, at National Institute of Mental Health and Neurosciences [NIMHANS], Bangalore, India; observed World Rabies Days in 2007, 2008, 2009, 2010, 2011 & 2012;supported the second international conference on Rabies, RIACON 2009, September 9 – 11, 2009, at National Institute of Hygiene and Epidemiology, Hanoi, Vietnam; produced a video film on rabies [45 minutes, English, for Medical and Veterinary personnel], 2009;coordinated - Adopt a village(one health) project in collaboration with Commonwealth Veterinary Association and funded by Global Alliance for

Rabies Control, 2009-11;produced a video film on rabies [14 minutes, English for general public], 2010; organized RIAF - Zydus Cadila Symposium on rabies at Cairo, Egypt , December,

THE FOUNDATION SPEECH

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2010;organized SAARC – ICM on rabies, Mysore, India, Feb, 2011; provided technical support to training of health staff in Tanzania on assessment of post exposure rabies prophylaxis (PEP) and proper use of rabies immunoglobulin (RIG), at Dar- Es-Salaam, Tanzania, May, 2011; provided technical support to MOH,

Bhutan to modify National Guidelines on Rabies Prevention, September, 2011; conducted RIAF - Zydus Fortiza Symposium on rabies at Bintan islands, Indonesia, April, 2012; the president and the director ( publications ) of the foundation and the chairpersons of India, Pakistan and Philippines participated in the WHO expert consultation on rabies at Geneva, September, 2012 and produced a video film on “one health” for rabies prevention and control [20 minutes, English], 2013.

The DVD on “one health “to be released now has been provided to all the delegates and the same video film will be launched now as a short clip. The video film and reports of other activities of the foundation can be freely downloaded from its website: www.rabiesinasia.org I wish the conference a grand success.

SCIENTIFIC SESSION IRoad to Rabies Free :

Global and Regional Perspectives

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GLOBAL AND REGIONAL SITUATION OF RABIES

Dubravka Selenic Minet1, Gyanendra Gongal2 and Bernadette Abela3

World Health Organization

Rabies remains a public health concern in the world as it still kills more than 50,000 people every year. Dog-mediated rabies is the major mode of transmission in most endemic countries of Asia and Africa. It is estimated that approximately 15 million people in countries of the Asia Pacific region take at least one dose of rabies vaccine for post-exposure rabies prophylaxis due to exposure to suspected or rabid animals annually. These figures will continue to increase unless rabies is controlled at source. The investment for governments and the financial burden families of victims is substantial. The economic impact of rabies in livestock production is considered high but surveillance data are missing.

Although rabies is 100% preventable and the tools and methods for rabies prevention and control are well known, it is still a significant public health problem in many countries of Asia.In general, there has not been any substantial decrease in the rabies incidence in Asia except in a few island countries and territories.

Fortunately, over the last decade there had been a positive trend towards rabies control. World Rabies Day events and involvement of professional organizations in rabies control have created mass awareness at public and policy levels. Sri Lanka and Thailand have registered a sharp decline in the number of human rabies deaths through mass dog vaccination campaigns, improved accessibility to human post-exposure prophylaxis (PEP) and an effective vaccine delivery system.All countries in the South East Asia region have phased out production and use of nerve tissue vaccine by introducing cost-effective intradermal rabies vaccination to improve accessibility, availability and affordability of tissue-culture rabies vaccine to people for PEP and

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pre-exposure prophylaxis. ASEAN and SAARC countries have expressed political commitment for elimination of human rabies by 2020 provided that there is a regionally coordinated rabies elimination programme in place.

To attain the goal of eliminating human rabies transmitted by dogs, well-structured and coordinated regional rabies eliminationstrategy are required. The international organizations, including FAO, OIE and WHO will need to increase advocacy and continue to provide guidance on best practices for the implementation of cost-effective rabies elimination activities.WHO Regional Office for South East Asia has drafted a regional strategic framework for elimination of human rabies transmitted by dogs in the South-East Asia Region. ASEAN and SAARC country involvement in a regionally coordinated rabies elimination programme is crucial to sustain the progress made in a coordinated anti-rabies drive.WHO has facilitated development of a proposal ‘SAARC Rabies Elimination Project’ to be submitted to the SAARC Development Fund for consideration. FAO, OIE and WHO have established a tripartite coordination mechanism at regional level and are working together to provide technical support to rabies endemic countries.

1 Medical Officer, WHO Country Office Thailand

2Scientist, Disease Surveillance and Epidemiology, WHO Regional Office for South East Asia, New Delhi

3Team Leader, Neglected Tropical Zoonoses, WHO HQ, Geneva

8

25 YEARS OF EXPERIENCE IN RABIES CONTROL

F.X. MeslinEx- Team Leader, Neglected Zoonotic Diseases,

WHO Headquarters, Geneva, Switzerland.

The Author who worked in WHO Headquarters for more than 25 years will describe achievements,advances, drawbacks and failures which occurred when promoting and advocating for human and animal rabies control and elimination at the national, regional and international level over the past 25 years. A list of selected documents published during this period is attached for reference and further reading. None of this work could have taken place without strong collaboration with and support from national and international rabies experts, the network of WHO Collaborating Centres on rabies, other international governmental and non-governmental organizations and staff from the WHO Regional and Country Offices.

From the late 80s to the late 90s WHO rabies-related activities were progressively re-directed towards control and ultimate elimination of the disease in dogs as a way to prevent most human rabies deaths occurring worldwide. To this purpose new lines of research were promoted on (a) the feasibility and cost effectiveness of dog rabies control and elimination (b) dog population studies to improve knowledge of the dog population structure and other characteristics in varioussocio-cultural settings particularly to assess and improve dog accessibility to interventions (c) oral immunization of dogs. This seminal work demonstrated the cost-effectiveness of human rabies elimination through dog rabies control and that a majority of dogs were accessible in most settings making dog elimination feasible through mass vaccination. These initial results inspired the rabies community and research on many of those subjects is still today being refinedby many scientists. In 1993 the Author brought the issue of safety and efficacy of intradermalapplication of rabies vaccines for human pre and post exposure treatment to the WHO Expert Committee

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which endorsed it unanimously and recommended its use in all places where ‘rabies vaccines and/or money to acquire them were in short supply’. A number of National Regulatory Authorities (NRAs) reviewed this recommendation and later introduced the use of the intradermal route in their national guidelines for post-exposure prophylaxis (PEP). This number however remained limited considering the advantage of the technique in particular considerablesavings incurred when using intradermal PEP. During these years oral vaccination of dogs was studied in a number a countries including Mexico, South-Africa, Sri-Lanka, Thailand, Tunisia, Zimbabwe but never became but on a small scale in Sri Lanka, a regular component of any national rabies control programme.

From the early 2000 up to 2008 WHO turned its attention to (a) evaluating the health and economic burden of rabies using modern techniques in order to ensure rabies visibility among other endemic and epidemic infectious diseases whose burden had already been assessed. WHO organized the first meeting of the WHO Working Group on the Health Burden of Rabies in 2003. This meeting led to the publication in 2005 of the article on the reassessment of the burdenof rabies in Africa and Asia ( Knobel et al ) and other burden estimates such as for India (Sudarshan et al , 2007) and Cambodia (b) promoting intradermal application of rabies vaccines for pre exposure prophylaxis (PrEP) and post exposure prophylaxis (PEP) by having its safety and efficacy described in the 2002 and then 2007 WHO position papers on rabies vaccines. WHO position papers are designed for use mainly by national public health officials and immunizationprogramme managers and since 2006 are reviewed and endorsed by WHO’s independentStrategic Advisory Group of Experts on vaccines and immunization (SAGE) to ease their adoption by National Regulatory Authorities (NRAs). A small number of countries have however, adopted intradermal PEP as part of their national guidelines in 2013 although ever increasingnumbers of bite victims today are receiving intradermal PEP in countries like India, the Philippines, Sri Lanka and Thailand. c) supporting research on alternative dog vaccination techniques:for example WHO with its WHO Collaborating Centre in Nancy, France facilitated testingof an oral vaccine for dogs (SAG2 in its dog bait) under laboratory conditions in India. The vaccine finally received approval in 2008 but the technique was only used sporadically in the field in some major Indian cities mostly due to the lack of funds to procure the large quantities of vaccine needed to carry out the ambitious ‘rabies free India’ project of the Animal Welfare Board for India. Safer oral vaccines available produced at low cost are necessary to ease adoptionof the technique as part of national programmes. (d) mobilizing the global rabies scientific community to attract international funding community’s attention on rabies. To this goal the term ‘neglected’ was attached to these endemic zoonotic diseases insufficiently addressed by governments and the international community and affecting poor people living in remote rural areas or urban slums of the developing world. The first international conference on ‘Neglected Zoonotic Diseases’ was held at WHO headquarters in September 2005 and the NZD concept was reinforced at international conferences held in 2007 and later in 2010. The

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term is now well accepted internationally. Rabies has all the features of a neglected zoonotic diseases though the disease is most amenable to control, as the tools are available. These efforts succeeded in 2008 in securing a major grant from the Bill and Melinda Gates Foundation (BMGF) for coordinating selected field projects in Asia and Africa to redefine in the current context and different settings the conditions of human and dog rabies elimination feasibility and cost effectiveness.

From 2009 to mid-2013 WHO worked mostly on (a) advocating for rabies prevention and striving to increase the visibility of this disease as the neglected zoonotic disease most amenableto elimination in the medium term. For example rabies is now recognized as the first zoonosis on the list of neglected diseases targeted for regional and eventually global elimination.An interagency meeting WHO, FAO and OIE held in WHO in 2011 proposed investment in a ‘priority neglected zoonotic diseases portfolio’, comprising regional elimination of human–dog transmitted rabies in Latin America and Asia. (b) ensuring that rabies was acknowledged as an important neglected zoonotic disease by the international community as well as within WHO and well embedded into a WHO strategy and plan of work. In this relation an updated WHO position paper on rabies vaccines reviewed and endorsed by (SAGE) gave its full supportto the wider use of the intradermal route for both PEP and PrEP, rabies was discussed in the first and second WHO reports on Neglected Tropical Diseases and is included in the shorter list of targeted diseases for regional elimination in the executive summary of the ‘Roadmap for Implementation’ published in 2012. Rabies is one of the 17 priority diseases mentioned resolution (WHA66.12) on Neglected Tropical Diseases prevention, control and elimination endorsed by the 66th World Health Assembly on 27 May 2013 (c) providing international coordination of the field projects supported by the BMGF to provide new data on feasibility and cost-effective control of dog rabies control and facilitate transfer of this experience and expansion of rabies elimination activities throughout the continents suffering most from dog rabies.

In conclusion WHO had been denouncing and combating the ‘cycle of neglect’ with regard to rabies for decades. Since the 8th report of the WHO Expert Committee on Rabies, in 1992, WHO and its network of Collaborating Centres on rabies, specialized national and international institutions, members of the WHO Expert Advisory Panel on Rabies and new partners such as the Gates Foundation, the Global Alliance for Rabies Control and the Partnership for Rabies Prevention, have been advocating and promoting the feasibility of rabies elimination regionally and globally and promoting basic and implementation research into strategies. Results of the large scale operational project aiming at demonstrating the feasibility of human and dog rabies elimination in 3 sites supported by the Gates Foundation and coordinated by WHO are expected by the end of 2015. All those joint efforts and individual projects have begun to break the cycle of rabies neglect, and rabies is becoming recognized as a priority for investment.

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Selected WHO references (period 1988-2013 by chronological order):

World Health Organization. Report of a WHO consultation on dog ecology studies related to rabies control. Geneva, 1988 (WHO/Rab.Res./88.25)

World Health Organization. Height report of the WHO expert committee on rabies. Geneva, 1992 (WHO Technical Report Series, No. 824).

Laboratory techniques in Rabies, fourth Edition, F.X. Meslin, M.Kaplan and H.Koprowski Editors, WHO, 1996.

Rabies Control in Asia, Third International Symposium on Rabies Control in Asia, Symposium Proceedings, 11-15 September 1996, Wuhan, China. Edited by B. Dodet and F.X. Meslin. Elsevier 1997.

World Health Organization. Field application of oral rabies vaccines for dogs: report of a WHO consultation organized with the participation of the Office International of Epizooties, Geneva, Switzerland, 20–22 July 1998. Geneva, 1998 (WHO/EMC/ZDI/98.15).

Rabies Control in Asia, Fourth International Symposium on Rabies Control in Asia, Symposium Proceedings, 5-9 March 2001, Hanoi, Vietnam. Editors B. Dodet, F.X. Meslin, E. Heseltine.J. Libbey, Eurotext 2001.

World Health Organization. First report of the WHO expert consultation on rabies. Geneva, 2005 (WHO Technical Report Series, No. 931).

World Health Organization. The control of neglected zoonotic diseases: a route to poverty alleviation. Report of a joint WHO/DFID-APHP meeting with the participation of FAO & OIE. Geneva, 2006 (WHO/SDE/FOS/2006.1).

World Health Organization. Integrated control of neglected zoonotic disease in Africa: applying the ‘one health’ concept. Report of a joint WHO/EU/ILRI/DBL/FAO/OIE/AU meeting. Geneva, 2008 (WHO/HTM/NTD/NZD/2008.1).

World Health Organization. Working to overcome the global impact of neglected tropical diseases, first WHO report on neglected tropical diseases. Geneva, 2010 (WHO/HTM/NTD/2010.1).

World Health Organization. Rabies vaccines, WHO position paper. Weekly Epidemiological Record, 2010, 32(85):309–320.

World Health Organization. The control of neglected zoonotic diseases (NZDs): community-based interventions for prevention and control. Report of the third conference organized by

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WHO/ICONZ/DFID-RIU/SoS/EU/TDR/FAO with the participation of ILRI and OIE. Geneva, 2011 (WHO/HTM/NTD/NZD/2011.1).

World Health Organization. Interagency (FAO,OIE,WHO) meeting on planning NZDs prevention and control. Geneva, 2011 (WHO/HTM/NTD/NZD/2011.3).

World Health Organization. Report of the 3rd meeting of the international coordination group of the Gates Foundation/WHO project for human and dog rabies elimination in low-income countries, 19–21 October 2011, PieterMaritzburg, Kwa Zulu Natal, South Africa. Geneva, 2011 (http://www.who.int/rabies/bmgf_who_project/en/).

World Health Organization. Sustaining the drive to overcome the global impact of neglected tropical diseases, second report on neglected tropical diseases. Geneva, 2012.

World Health Organization. Report of the 4th meeting of the international coordination group of the Gates Foundation/WHO project for human and dog rabies elimination in low-income countries, 2–4 October 2012, Cebu, Philippines. Geneva, 2013 (http://www.who.int/rabies/bmgf_who_project/en).

World Health Organization. Second report of the WHO expert consultation on rabies. Geneva, 2013 (WHO Technical Report Series, No. 982).

World Health Assembly Resolution on 17 Neglected Tropical Diseases (WHA66.12) www.who.int/neglected_diseases/mediacentre/resolutions/en/ accessed 09 October 2013.

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ROAD TO RABIES FREE IN THAILAND By THE yEAR 2020

Opart Karnkawinpong,M.D.1Apirom Puanghat, D.V.M.3

Apai Suttisunk,D.V.M.2Wirongrong Hoonsuwan, D.V.M.4

Deputy Director General, Department of Diseases Control, MoPH1.1.

Deputy Director General Department of Livestock Development , MoAC2.2.

Public Health expert, Department of Diseases Control, MoPH 3.3.

Veterinary expert, Department of Livestock Development , MoAC4.4.

Introduction

Rabies is one of the most important zoonotic diseases that causes public health impact in Thailand and costs approximately 30 million US$ per year to prevent and control Rabies in humans and animals. Dogs still remain the major reservoir in Thailand . Since 1992, the Department of Disease Control (DDC), Ministry of Public Health, the Department of Livestock Development (DLD), Ministry of Agriculture and the Cooperatives and relevant organizations have been collaborating to control rabies and rabies situations in the country has tended to decrease. Dog bites remain one of the most important public health concerns. According to the data from both state and private health facilities, each year an estimated 400,000 people visited health facilities to get rabies vaccination.

Rabies situation in Thailand

Rabies in humans:

In Thailand, based on the data provided by the Bureau of Epidemiology (BOE), Human rabies deaths have steadily decreased; as of 370 deaths in 1980 (0.78 per 100,000 population), 185 deaths in 1990 (0.33 per 100,000 population), and 50 deaths in 2000 (0.08 per 100,000 population).

In the year 2001, there were 37 of rabies cases (0.06 per 100,000 population) that occurred in Thailand, 20 in the Central Region, 8 in the Southern Region, 6 in the Northeastern Region and 3 in the Northern Region.

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From 2001-2008 a total of 178 deaths caused by rabies infection were reported. Of these 178 rabies fatalities, 88 (19, 9, 10, 8, 8, 18, 11, 5) are from the central region, 41 (6, 11, 7, 5, 2, 2, 5, 3) from the northeast, 37 (9, 5, 3, 5, 9, 4, 1, 1) from the south, and 12 (2, 5, 1, 1, 1, 2, 0, 0) from the northern region of the kingdom.

In the previous year 2012 human rabies death has declined to 4 cases (0.006 per 100,000 population) of these number, 2 cases occurred in the Central Region, 2 cases in the Southern Region and no occurrence in the Northern Region. and the Northeastern Region.

Prior to 1995, most deaths occurred in the Central Region especially in Bangkok and its surrounding areas. During the past decade, 2001 – 2012, there is a progressive decline of deaths in the Northern Region. Rabies deaths occur year round although there is a slight increase in January of every year. In general, deaths are due to bites from rabid dogs, although other animals have also been implicated.

From year 2008 – 2012 most of rabies cases (64%) caused by the unvaccinated owned dogs and 54% of which were puppies.

Rabies in animals:

Based on laboratory examination on animal heads by the Bureau of Disease Control and Veterinary Services (BDCVS), DLD , Queen Saowapa Memorial (QSMI) and MoPH, from 1995-2012, rabies detection rates had steadily declined from 44.5 % (4,263/9,576) in 1995 to 9.8 percent(155/1,583) in 2012. Rabies is more prevalent in the central and southern regions.

From 2000-2010, data showed that dogs (90.1%) are still main reservoir in Thailand, followed by cats (4.6 %) cattle (4.4%) and the others(0.9% ). Rabies occurs in animals of all ages, in owned and stray dogs that had not been vaccinated and furious type is still the main obvious symptom.

Rabies Control in Thailand

Human Rabies control :

Safe and efficient human rabies vaccine and RIG are supplied by Ministry of Public 1. 1. Health.All victims with exposure to suspected rabid animals must receive proper rabies post-2. 2. exposure prophylaxis following clinical practice guideline (CPG) of Department of Diseases Control (DDC)Clinical practice guideline(CPG) for rabies is being updated by rabies expert human . health 3. committees of Thailand for several times.suspected rabies cases must be confirmed by laboratory 4. Improved database management for rabies: Post-exposure prophylaxis (PEP) reporting 5. systemSupervise support and provide health education for Medical (CPG), Public awareness to 6. avoid dog bite, animal bite practice : first aid and visit doctor immediately.To publish document e.g. handbook, poster, brochure, video and produces mass media on 7. TV, radio spot, local broadcasting towers and interview

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There have been major advances in the treatment of persons with suspected rabies exposure. In 1988, HDCV, PCEC, PVRV and PDEV became available and the abolishment of nervous tissue vaccine, in 1993. The Ministry of Public Health had started to recommend the use of RIG (rabies immunoglobulin) in combination with rabies vaccine application for severe wounds in 1994, even though the number of rabies death appeared to decline. However, the number of suspected rabies-expose victims are increasing from 160,443 in 1995 to 400,000 in 2002.

Animal Rabies Control:

Survey and registration of dogs :To implement dog registration campaign by www.thairabies.1. net and only vaccinated dogs (both owned and stray dogs) can be registered.

Immunization: To ensure at least 80 percent of rabies immunization coverage among animal 2. populations, and 100 percent coverage in high-risk areas (rabies incidence reported).To secure enough animals rabies vaccines by local administrative organizations, private clinic and Department of Livestock Development supplies for outbreak control and supplementary.

Dog population control: To control and minimize stray dog populations;Dog population is 3. about 7 millions and about 10% are stray dogs. Birth control by sterilization in both male and female dogs and hormonal injection in female dogs through extension services and sterilization campaign in provinces.

Laboratory surveillance: 8 DLD animal rabies diagnostic laboratories and Queen Saowabha 4. Memorial Institute (QSMI) submit all samples from suspected cases.

Outbreak management : Disease investigation conducted by human health and animal health 5. after disease notification.

Animal shelter: To Set up and implement DLD shelters for stray dogs around the outbreak 6. area and dogs that are abandoned by owners.

Road to rabies free in Thailand

Thailand’s strategic plan for rabies elimination by 2020 is jointly developed by the Department of Disease Control (DDC), the Department of Livestock Development (DLD), Department of Local Administration (DLA), Provincial Health Office (PHO), Queen Saovabha Memorial Institute, Bangkok Metropolitan Administration (BMA), Office of the Basic Education Commission (OBEC) and universities. This plan has been focused through problems and constraint surveys, brainstorm, the SWOT analysis by representatives from the regional and the local centers of human and animal health sectors, veterinarians, physicians and local administrative. Continued efforts made to prevent and control rabies transmission over nearly half a century have resulted in a significant drop in mortalities due to rabies. Following the government’s decentralization program back in 1999, which resulted in the establishment of local administrative bodies like Tambon Administration Organization (TAO), these local administration organizations have recently become actively involved in eliminating rabies from the communities nationwide.

Thailand has taken the issue seriously and a Memorandum of Understanding (MoU) has

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recently been signed between the Department of Disease Control (DDC), Department of Livestock Development (DLD), and Department of Local Administration (DLA) so as to foster interagency efforts to eliminate rabies from Thailand. This strategic plan was developed to serve as the guidelines for multisectoral collaboration to advance the rabies elimination campaign with the ultimate goal to make Thailand free from rabies by the year 2020.

The National Rabies Control Strategy comprised of 6 Missions and 5 core strategies to eliminate rabies in Thailand by the year 2020 as follow:

Vision: Thailand will become a rabies-free country by 2020.

Mission:

Foster multi-sectorial efforts and collaboration to prevent and control rabies in local 1. 1. communities nationwide

Promote rabies vaccination of all dogs2.2.

Control and minimize the number of stray dogs3.3.

Continued rabies surveillance prevention and control in both animal and human 4.4.

Raise public knowledge, understanding and awareness on rabies prevention5.5.

Enforce applicable laws related to rabies prevention and control6.6.

Goals: To achieve a long-term goal of zero rabies fatality both in human and animal 7. 7. populations

Five core strategic strands for rabies elimination by 2020:Strategy 1: Efficient management and integrated approach to prevention and control of rabiesObjectives:

To foster interagency collaboration and concerted efforts to prevent and control rabies1.1.

To push for mobilization of resources by local administration organizations so as to 2. effectively address the rabies threat and rid local communities of Rabies

To effectively enforce existing laws regarding rabies control and prevention3.

To develop new approaches and technologies for rabies prevention and control by 4. 4. supporting research

Strategy 2: Increased role and active engagement from local administration organizations in rabies prevention and control

Objectives:

To ensure local administration organizations (LAOs) have clear and sustainable roles in 1. rabies prevention and control in their local communities

To encourage LAOs to establish a partners network that is actively involved in rabies 2. prevention and control in their local communities and neighboring areas

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To encourage LAOs to issue and vigorously enforce municipal rules and regulations 3. governing rabies prevention and control

To enable LAOs to efficiently implement rabies prevention and control strategies4.

To encourage LAOs to work closely together with health and livestock officials in rabies5.

prevention and control6.

Strategy 3: Surveillance, prevention and control of rabies in human and animal populations

Objectives:

To develop disease surveillance system which ensures comprehensiveness, accuracy, 1. timeliness, and practical

To develop and improve rabies prevention and control strategies in humans and animals 2. with the aim to achieve a rabies-free community

Strategy 4: Multi-sectoral engagement and public participation

Objective:

To strengthen capacity of multi-sectoral partners network to ensure active engagement in rabies prevention and control in both human and animal populations

Strategy 5: Efforts to raise awareness, increase knowledge and skills, and influence behavior changes among the public for rabies prevention and control

Objectives:

To equip people and authorities with knowledge and skills for disease prevention and 1. control

To ensure members of the public have good hygiene and health practices to prevent rabies 2. infection

The Manual for rabies free areas based on WHO and OIE recommendations has been distributed. The manual has recognized areas into the rabies free area and 3 other controlled areas regarding the severity of the impact. The mild, medium, and severe areas are represented by levels A, B and C respectively.

Rabies control level A ; refers to areas that have no incidence of human and animal rabies.

Rabies control level B ; refers to the risk areas where animal rabies is found but nohuman rabies deaths.

Rabies control level C ; refers to the high risk areas where both human and animal rabies is found.

In 2011-2012 :More than 62% of local administrative organizations from the entire country have attended the program. DDC and DLD have strengthened the co-ordination and co-operation

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of the personnel in both health and livestock of their regional levels for rabies control.

Way forward

Regional centers of DDC and DLD will integrate rabies control strategies to provincial and 1. local administrations nationwide.

Establishing and extending the numbers of rabies free area to achieve at least level A in 2. 2017 in all 77 provinces.

Every province nationwide will be able to eliminate rabies by year 20203.

Acknowledgement

Dr. Pawin Padungtod , Director of Animal-Human Interface Program ,Thai MoPH-US 1. CDC Collaboration.

Mr. Manoon Hirunsalee, Thai MoPH-US CDC Collaboration.2.

Dr. Choompon Bunrod, Director of non-ruminant Section, Bureau of Disease Control and 3. Veterinary Services, DLD, MoAC.

Dr. Pornpiroon Chinson, Veterinary officer, non-ruminant Section , Bureau of Disease 4. Control and Veterinary Services, DLD , MoAC.

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VERORABVAx™: THE NExT-GENERATION PuRIFIED VERO CEll RABIES VACCINE

Alain Bouckenooghea (presenter), Françoise Guinet-Morlotb, Sylvie Pichonb, Anvar Rasulic

Affiliationsa Sanofi Pasteur, 6 Raffles Quay, Singapore

b Sanofi Pasteur, 1541 Avenue Marcel Mérieux, 69280 Marcy-l’Étoile, France c Sanofi Pasteur, 2 Avenue Pont Pasteur, 69367 Lyon, France

Since the successful development of the first vaccine against rabies by Louis Pasteur in 1885, a number of new improved rabies immunobiologicals have been developed. These new products improved with regards to their production processes, their respective safety profile and efficacy, as well as cost and broad availability. Rabies has been a vaccine-preventable disease for over 100 years, yet the disease remains enzootic in most parts of the globe and the number of human cases remains stubbornly high. The continued improvement of the current products and their production methods are of further benefit to achieve sustained rabies control worldwide.

Sanofi Pasteur’s current Vero cell rabies vaccine Verorab™ has a well-established safety and immunogenicity profile and has long been recognized as a reference vaccine for rabies preven-

tion. Verorab™ was licensed in 1985 for both pre- and post-exposure prophylaxis of rabies. As a result of the continuous improvement of its vaccine manufacturing process, Sanofi Pasteur has developed VerorabVax™, an improved highly-purified Vero cell rabies vaccine. VerorabVax™ was developed with innovative technology. It is still making use of qualified Vero banks cell substrate and established Pitman Moore rabies virus seed strain, and has an inactivation process using beta-propiolactone. However, VerorabVax™ is the first rabies vaccine to be produced

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without any human or animal components (in particular, serum and human serum albumin); it is produced free from antibiotics. In addition, the process involves the reduction of residual cell substrate DNA to ≤100 pg/dose. The comparability of VerorabVax™ to Verorab™ was estab-

lished through extensive biochemical characterization studies and through preclinical evalua-

tion. The clinical development is in progress and a number of studies have been completed.

We performed a Phase II clinical study in adults in France (NCT00948272) to assess the im-

munological non-inferiority and clinical safety of VerorabVax™ for pre-exposure prophylaxis. In this trial, 384 healthy adult subjects were randomized (2:1) to receive a three-dose primary series (D0, D14, and D28) of VerorabVax™ or Verorab™. One year later (M12), the Verorab-

Vax™ group received a VerorabVax™ booster vaccination while the Verorab™ group partici-pants were randomized to receive a booster dose of VerorabVax™ or Verorab™. In terms of immunogenicity, the criterion for non-inferiority was met; in the full analysis set (FAS) a total of 99.6% and 100% of subjects had rabies virus-neutralizing antibody (RVNA, measured in RF-

FIT) titers ≥0.5 IU/mL in VerorabVax™ and Verorab™ groups, respectively; the one individual who did not seroconvert was immunodeficient. While RVNA levels gradually decreased over the 12-month period, at 6 and 12 months after vaccination >89% and >77% vaccinees, respec-

tively, in both groups had RVNA titers ≥0.5 IU/mL. The VerorabVax™ booster induced a strong response, irrespective of the vaccine given for the primary series. VerorabVax™ was safe and well tolerated and its safety profile was similar to Verorab™ for unsolicited adverse events and solicited systemic reactions. The incidence of solicited injection-site reactions was lower with VerorabVax™ than with Verorab™ after the primary series and the booster dose.

Subsequently, a randomized controlled Phase III study (NCT01339312) was conducted in China in a simulated post-exposure setting in 408 adults aged >18 years and 408 children aged 10-17 years who were randomized (2:1) to receive a standard five-dose intramuscular regimen (D0, D3, D7, D14, D28) with VerorabVax™ or Verorab™. The primary objective of non-inferi-ority after 3 doses of the respective vaccines, as measured by the comparative RVNA titer ≥0.5 IU/mL of VerorabVax™ versus Verorab™ by D14, was reached in both age cohorts. The two vaccines had similar safety profiles within each age cohort. Unsolicited adverse events were similar in the 2 vaccine groups; unsolicited adverse reactions were marginal in the 2 vaccine and age groups. No SAE related to VerorabVax™ or Verorab™ was reported during the study period.

In conclusion, in both studies, VerorabVax™ was shown to be at least as immunogenic as Verorab™ and to have a similar safety profile. This next-generation highly-purified serum-free rabies vaccine VerorabVax™ is an evolution over the current reference vaccine Verorab™; it offers an improved alternative for the pre- and post-exposure prophylaxis of rabies.

SCIENTIFIC SESSION II Road to Rabies Free in Asia by 2020:

Progression / Success Stories

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Umme Ruman Siddiqi1,

SM Emran Ali2, Aung Swi Prue Marma3, Rashidun Nessa4, M. Salimuzzaman5, Sohrab Hossain6, Be-Nazir Ahmed7,*

ABSTRACT

Background: Rabies is endemic in Bangladesh with over 2000 annual human rabies-death affecting mostly poor and children. It is transmitted by dog-bite in 99% cases. Ignorance, poverty, negligence, ineffective animal bite management and lack of political commitment are the major causes of persistence of rabies.

Objective: Assessment of the national Rabies control and elimination program by 2020 by Government of Bangladesh (GoB).

Methods: A national strategy comprising of advocacy, dog-bite management (DBM), mass dog vaccination (MDV, aimed to create herd-immunity in dog population and interrupt transmission) and dog population management has been developed, adopted and is under implementation by GoB through multi-sectoral approach. Production of nerve-tissue vaccine has been stopped in October 2011 and effective tissue-culture vaccine along with rabies-immunoglobulin was introduced free of cost that is being used by trained health care providers for DBM through one national and 64 district rabies prevention and control centers (NRPCC started from 2010 & DRPCCs respectively). A national rabies survey (NRS) was also conducted in 2012. 1st round of MDV in 54/64 district municipalities (DM) and 2nd round in 2 DMs have been accomplished by June, 2013.

Results: More than 272801 dog bite cases were managed in the NRPCC since July 2010 to July 2013. A total 70634 of 81434 dogs were vaccinated (coverage: 85%) under MDV campaign. Number of rabies cases in the NRPCC was 104 and 109 in 2010 and 2011 respectively. It was 88 in 2012 and was 40 in 1st half of 2013 indicating marked reduction of rabies cases in recent years. Approximately 1400 cases were estimated by NRS, 2012.

In conclusion, the decreasing trend of rabies-death could be the impact of intensive rabies-control activities through multi-sectoral collaboration that should be strengthened further for a sustainable control program and elimination of the disease from the country within the time

RABIES IN BANGlADESH: NATIONAl CONTROl PROGRAM AND ACHIEVEMENTS

23

frame.

Key word: Dog bites management, Mass dog vaccination, National rabies prevention and control center, National rabies survey.

Authors affiliations:

1,2 • Medical Officer, Emerging & Re-emerging Disease Control Program, Communicable Disease Control Division, Directorate General of Health Services, Dhaka, Bangladesh

3• Residential Medical Officer, Bandarban Sadar Hospital, Bandarban, Bangladesh

4• Deputy Director, MIS, Directorate General of Health Services, Dhaka, Bangladesh

5• Senior Scientific Officer (Medical Sociology), IEDCR, Dhaka.

3• Medical Officer, Communicable Disease Control Division, Directorate General of Health Services, Dhaka.

4 • Medical Officer, Communicable Disease Control Division, Directorate General of Health Services, Dhaka.

6• Veterinary Officer, Tongi Muicipality, Gazipur,

7• Director, Disease Control & Line Director, Communicable Disease Control Division, Directorate General of Health Services, Dhaka, Bangladesh

Contact Author:

Director, Disease Control & Line Director, Communicable Disease Control Division, Directorate General of Health Services, Dhaka, Bangladesh

Introduction

Rabies is a neglected topical zoonotic disease, which claims more than two thousand lives annually in the country. Now-a-days no other single infectious disease is responsible for so many deaths like Rabies. The disease is nearly 100% fatal but 100% preventable by taking appropriate preventive measures. Once the disease manifests there is no curable treatment. On the other hand, the disease can be eliminated through various ways and means. There are about two to three hundred thousand dog bites annually and 95% of rabies cases in the country are due to dog bite. Only suspected rabid dogs are thought to be responsible for rabies as dogs rarely can remain as healthy reservoir. Other animals that occasionally transmit the disease in Bangladesh are cat, fox, monkey, jackal, and mongoose. Other than humans, cattle heads numbering more than twenty five thousand (approx) succumb to rabies every year1.

Goal, Objectives and Strategies

National strategic plan for rabies elimination by the year 2020 has been adopted. The objectives include reduction of rabies cases by 90% within 2015 and elimination of rabies within 2020. The strategies are advocacy, communication and social mobilization (ACSM),

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ment of dog bite, mass dog vaccination (MDV) and dog population management (DPM). For implementation of the elimination program a number of committees including the national steering committee (STC) headed by the minister of health and family welfare and the technical working group (TWG) headed by director, disease control are functioning.

Coordination and Functioning

The rabies elimination program has been included in the operational plan of communicable disease control in health, population and nutrition sector development program (HPNSDP) with allocation of fund up to 2016. A multisectoral approach involving health, livestock and local government along with development partners like WHO, FAO, OIE, SDF-SAARC and other organizations like world society for protection of animals (WSPA), humane society internationale (HSI), Ovoyaronno have been working together

Activities

ACSM is regarded as the cornerstone of the rabies elimination program. Various approaches have been under taken for ACSM. Advocacy meetings are arranged from national to district level on different issues related to rabies and its elimination. Seminar, symposium, workshop etc are arranged on different occasions including world rabies day, inauguration of mass dog vaccination and dog bite management. Use of media including press conference, talk show, interview and video show in electronic media, road show with mobile van, campaign by folk lore teams is contributing in opinion building. Child to child health education through 100 thousands school targeting 25 million primary school children is underway. A number of national and international workshops were held in 2012. Program specialists, public health and rabies experts from home and abroad attended the workshop. The aims of the workshops were raising awareness about rabies (ACSM), capacity building in terms of policy development and implementation.

Advocacy, Communication and Social Mobilization (ACSM)

Dog Bite Management

Dog bite management (DBM) has been selected as the principal approach for preventing rabies and reduction of the burden by 90% within 2015. Washing wound, assessment of category of bite by trained physicians and management with tissue culture vaccine and RIG acording to indication have been included as the components of PEP. Complete phasing out

25

of NTV was the first step that was done in September 2011. The DBM is done through rabies prevention and control centre. The ‘National Rabies Prevention and Control Center’ (NRPCC) has been established at Infectious Diseases Hospital (IDH), Mohakhali, Dhaka. A total of 350-450 dog-bite patients have been attending this center daily. This is the national model dog-bite management center. Anti-Rabies Vaccine (ARV and Rabies Immunoglobulin (RIG) are given free of charge from this center. Since its beginning, a total of 65 of Rabies Prevention and Control Center (DRPCC) have been established at 64 districts in the country, where dog bite patients are getting modern dog bite management facilities. Animal bite cases, within the district are attending the facility and receiving free ARV and RIG.indication have been included as the components of PEP. Complete phasing out of NTV was the first step that was done in September 2011. The DBM is done through rabies prevention and control centre. The ‘National Rabies Prevention and Control Center’ (NRPCC) has been established at Infectious Diseases Hospital (IDH), Mohakhali, Dhaka. A total of 350-450 dog-bite patients have been attending this center daily. This is the national model dog-bite management center. Anti-Rabies Vaccine (ARV and Rabies Immunoglobulin (RIG) are given free of charge from this center. Since its beginning, a total of 65 of Rabies Prevention and Control Center (DRPCC) have been established at 64 districts in the country, where dog bite patients are getting modern dog bite management facilities. Animal bite cases, within the district are attending the facility and receiving free ARV and RIG.

Views of the National RPCC

26

Map: DRPCC established and functioning in 65 centers of 64 districtsTable : Dog bite management cases of the centers and Infectious Diseases

Hospital, Dhaka

yearDog bite

management

Rabies

(IDH Report)

2010 43,259 104

2011 45,536 109

2012 97,310 88

2013 (Jan-July) 86,696 46

Total 2010-13 272,801 347

Mass Dog Vaccination (MDV)

Mass dog vaccination is essential for achieving elimination of rabies. Bangladesh has started (MDV) and it was first piloted at Cox’s Bazaar Sadar municipality area in 2011, where 2nd round of MDV was also conducted in 2012. Utilizing lessons learned from Cox’s Bazaar updated and revised version of 2nd and 3rd MDV were piloted in two other municipalities, Satkhira and Dhamrai, Dhaka. MDV activities were scaled up and until June 2013, 54 district municipalities were covered (Dhaka, Rajshahi, Sylhet, Rangpur, Khulna and Chittagong) divisions. Our ultimate aim of conducting MDV is creating herd immunity among dog population by ensuring over 70% coverage of all of the projected 1.2 million dogs of the country.Mass Dog Vaccination in Municipalities

Division Year Number of Districts

Round of MDV

Dogs counted

Dogs vaccina-

ted

Covera-ge (%)

Cox’s Bazaar 2011 1

1st

4500 3285 73.0Satkhira

2012

1 1245 Rangpur 8 10784 9001 83.5Rajshahi 8 15974 13632 85.3 Sylhet 3 1658 1513 91.3Dhaka 17 25257 21554 85.3

Cox’s Bazaar 1 2nd 5000 4315 86.3

Khulna 2013

81st (2nd in Satkhira) 9806 8826 90.0

Chittagong 8 1st 8455 7263 85.9Total 54 81434 70634

27

MDV: Planning, Advocacy and Campaign

Achievements

Since 2010, there has been paradigm shift in rabies prevention and control activities. For the first time, the country adopted the national strategy for prevention and control of rabies. NSC and TWG for rabies were formed and made functional. Five decade old NTV production was stopped in 2011 and tissue culture vaccine along with RIG was introduced. Within one year, rabies prevention and control centers were established in all the 64 district municipalities of the country with trained physicians and nurses, updated national guideline and ID-RV free vaccines and RIG. Number of patients attending national rabies prevention and control center, located at IDH, Dhaka is ranging from 350-450 daily. Now all 65 rabies prevention and control centers have been offering animal bite management services at 64 districts. One fascinating thing is happening; the dog bitten rural people have started to seek modern dog bite management instead of superstition led management. More and are people are attending the centers. From 2010 to July 2013, about 300 thousand people sought management from the centers and that is increasing. The number of deaths due to rabies is gradually declining in the recent years. In the centre of the capital >50% reduction is observed in annual number of rabies cases. Preliminary findings of the national rabies survey carried out in 2012 and review of attendance of rabies patients in district hospitals throughout the country also suggest continued decline in number of rabies cases. Mass dog vaccination has been started and scaled up reaching 54 municipalities. Still there is a daunting task of covering 3 rounds vaccination of all the dogs of the country. We are trying hard to achieve completion of 3 rounds MDV within 2016 and there by elimination within 2020.

28

By Chheng Kannarath,

National Institute of Public Health

Abstract

Rabies is a disease under early warning system. Weak surveillance system, lack of diagnos-ticcapability, competing priorities have made rabies politically and economically less visible compared to other emerging public health threats. Estimated to have been around 800 cases per year, an average of 6 cases reported per year during 1997 to 2007; and none were reported ever since. Activities addressing rabies in Cambodia have been limited in scope and in space. Aside from some educational activities, the rabies control has been mainly on providing post exposure treatment which is in itself limited to the region around Phnom Penh.

Having been committed to the regional drive to eliminate rabies by the year 2020, the Mi-nistry of Health has established a coordinating mechanism to mobilize efforts, expertise and resources to control rabies. However,

RABIES SITUATION IN CAMBODIA

29

Presented by Dr.G.SampathHyderabad, India

Historically, Rabies has been known for thousands of years in India. The word Rabies is derived from the Sanskrit ‘Rabhas’ which means ‘to do violence’. Dog is depicted in Indian mythology also, as a faithful animal and as a reservoir of a fatal disease.

Rabies is a reportable disease, but NOT a notifiable disease in India.

As per the WHO-APCRI Survey, the number of animal exposures per year, in India, is 17.4 per 1000 population. The current population of India is around 1.27 billion and presently the number of exposures would be about 22 million per year. The frequency of animal exposures is 1 exposure per 2 seconds. Importantly, the annual man days lost due to exposures to animals is 38 million.

The Survey revealed that Human Rabies is endemic throughout the mainland and only the islands of Andaman & Nicobar and Lakshadweep are free of Rabies.

The main animal reservoir of Rabies in India is the Dog . The Pet/Owned dog Population in India is estimated to be about 28 million. (The stray dog population may be 2 to 3 times that of the pet dogs).

Due to a high dog: man ratio the incidence of animal bites is high in India.

As per the WHO-APCRI Survey, the number of deaths due to Human Rabies is about 20,000 per year in India. This data has been reaffirmed in the WHO position paper 2010.The maximum no. of deaths in the world due to human rabies (36%), are reported from India.

The main reasons for human deaths due to rabies are : 1. No Post Exposure Prophylaxis ta-ken after exposure to an animal and 2.Use of Indigenous forms of treatment, instead of modern PEP.

The main reasons for deaths due to rabies in animals is the huge stray dog population in India and also due to the fact that the pet dog care, vaccination and management practices are factory

COUNTRy REPORT- INDIA

30

and the municipal licensing of pet dogs is inadequate.

The common animal reservoirs of Rabies, after dogs, are cats , cattle, goats, and pigs and mongoose and jackal among the wild animals.

Use of Rabies Biologicals in India

Rabies Vaccines:

Semple (Sheep Brain derived) Vaccine was used in India from 1919 to 2004. The production of NTV was discontinued on 31st December 2004 and use of the same in the country stopped in 2005.

Cell culture vaccines were introduced in the government sector in 2005.

The various human Rabies vaccines available in India are

Type Brand names

PCEC Rabipur, Vaxirab-N

PVRV (Imported) Verorab, XPRab

PVRV (Indigenous) Indirab, Abhayrab

HDCV (liquid) Rabivax

The Drugs Controller General of India (DCGI) recommended the introduction of Intra der-mal route of administration of Cell culture Rabies Vaccine (IDRV) in India in the year 2006.

Presently IDRV is being used in about 21 states (provinces) in India.

The following vaccines are approved by DCGI for IDRV in India: Rabipur(PCEC),Verorab (PVRV), PII,Coonoor (PVRV) , Indirab (PVRV),Abhayrab (PVRV) and Vaxirab-N (PCEC).

Rabies Immunoglobulins

The different brands of Rabies Immunoglobulins available in India are

Equine (300 I.U./ml):

Equirab ( Bharat Serums)

Vinrig (Vins Bioproducts )

ARS (CRI Kasauli)

Abhayrig

Human: ( 150 I.U./ml) (imported)

Kamrab

Berirab-P

Equine Rabies Immunoglobulins are being used in the government sector in 12 states in the country.

Pilot Project

A pilot project on prevention and control of Human Rabies was initiated by the Government

31

of India in the XI Five Year plan with the main objectives of 1. Reducing human deaths due to Rabies and 2. Reducing transmission of disease in animals. The project was implemented from 2008 to 2012 in 5 citiesviz., Ahmedabad, Bangalore, Delhi, Pune and Madurai, by the National Centre for Disease Control (Directorate of Health Services) in co-operation with the Municipal Corporations of the respective Cities.

The Strategies planned under this project were 1.Enhancing awareness regarding timely and appropriate Post exposure treatment 2.Training of health professionals 3. Strengthening Animal Bite Management Facilities and Ensuring availability of vaccines and sera 4. Operationalize IDRV in selected centers, 5.Strengthen diagnostic capabilities and 6.Interface with the animal husbandry department and Involvement of NGOs and Community

The outcome is that the Strategy for prevention & control of human deaths is ready to be rolled out in the country and a National Rabies Control Program may be started in future.

Non Governmental bodies and Professional Associations which are active in the field of Rabies prevention/control in India are

Association for Prevention and Control of Rabies in India (APCRI)1.1.

Rabies in Asia (RIA) Foundation2.2.

Commonwealth Veterinary Association (CVA)3.3.

Indian Veterinary Association (IVA)4.4.

Laboratory facilities for rabies diagnosis in animals and humans are available at the following places:

For rabies diagnosis in animals: Laboratories in different states

For rabies diagnosis in humans: NIMHANS, Bangalore, NCDC, Delhi and NIV, Pune

Animal Welfare Activism in India

Various organizations are active in this field. Some of them are

1. Animal Welfare Board of India , New Delhi

2. Animal Welfare Organizations viz., SPCA, CUPA, Blue Cross, PETA, ARF, PFA and Others

Animal Birth Control (ABC) program for stray dogs in urban areas is being implemented in some cities and towns.

Conclusions

Rabies is endemic in mainland India. India reports the maximum number of human rabies cases in the world. Rabies is not a notifiable disease in India.

There is no National rabies prevention/control program for humans or animals.

Dog is the main reservoir of infection. The incidence of dog bites continues to be high.

The main reasons for deaths due to rabies are – large population of stray dogs; poor vaccination coverage of domestic dogs and cats; and poor PEP coverage of human victims of dog bite.

The social ethos and laws protect the street dogs.

32

The animal welfare activism is prevalent mostly in urban areas. Animal Birth Control pro-gram for street dogs has not been effective in controlling the huge stray dog population.

Inter sectoral co-ordination is needed to reduce the burden of the disease.The Pilot Project of Government of India is expected to be a forerunner for the launch of

national rabies prevention/control program.The introduction of Cell Culture Vaccines in 2005 and IDRV in 2006 and increased use of

Rabies ImmuneGlobulins have definitely resulted in a reduction in the mortality due to human Rabies in the country. Data from different cities confirm this.

A fresh survey is needed for re-assessing the burden of Rabies in India.Animal bite cases in some centers in various cities in India

year Delhi (H.R.H)

Kolkata (2Centers)

Mumbai BMCCenters year Bengaluru

(BNP)

Hyderabad

(IPM)

2002 6000 2002-03 18884 47893

2003 6586 2003-04 22940 48378

2004 7894 2004-05 32967 49975

2005 4000 2005-06 28006 53437

2006 7000 2006-07 17798 53540

2007 8000 2007-08 21121 50211

2008 9000 60322 62763 2008-09 17123 499722009 8000 55,867 77652 2009-10 20555 494972010 9000 51830 77484 2010-11 24120 501842011 11000 50915 80889 2011-12 21681 522712012 19230 46875 82274 2012-13 22913 44906

2013 13636 (<July) 2013-14 4386 (Apr-Jun) 18605(Apr-Aug)

Note: In cities like Delhi and Kolkata additional ARCs are functioning for the past few years

The Human Rabies cases reported from ID Hospitals in different cities in the past few years are given below:

year Delhi Kolkata Hyderabad Mumbai year Bengaluru2001 149 95 2001-02 50

2002 192 172 85 2002-03 45

2003 217 130 78 2003-04 37

2004 215 111 90 2004-05 43

2005 188 106 76 2005-06 47

2006 122 80 59 2006-07 33

2007 144 79 61 2007-08 22

2008 155 79 56 6 2008-09 312009 150 66 40 5 2009-10 162010 120 60 37 6 2010-11 232011 67 59 35 1 2011-12 362012 54 42 21 1 2012-13 14

33

Names of Authors B. Phommasack1,2,

R. Vongkhamsao1,2, S. Phiphakkhavong 1,3, W. Thepphangna4, K. Soutthalack5.

National Emerging Infectious Disease Coordination Office (NEIDCO).1.

Department of Communicable Disease Control (DCDC), Ministry of Health.2.

Department of Livestock and Fisheries (DLF), Ministry of Agriculture and Forestry. 3.

National Animal Health Laboratory (NAHL), Department of Livestock and Fisheries, Ministry 4.

of Agriculture and Forestry.

National Center for Laboratory and Epidemiology (NCLE), Ministry of Health.5.

Background: Rabies is a fatal zoonotic disease cause by virus; it is one of reportable diseases of the World Organization for Animal Health (OIE). The Association of Southeast Asian Nations is promoting rabies elimination by 2020. In Lao People Democratic Republic, Rabies is one out of five zoonose to be addressed under the collaboration between Ministry of Health and Ministry of Agriculture and Forestry. The development of the national strategic plan for rabies prevention and control is a critical step toward rabies elimination in the future.

Objectives: To have a national strategic plan to prevent human rabies and control rabies in animal in Lao People Democratic Republic.

Methods: Technical staff and decision makers of the key collaborating partners from various sectors met to develop the draft strategy based on information on animal and human rabies. The strategy would then be proposed for endorsement and promulgation by the Lao National Committee for Rabies Prevention and Control.

Results: There were 10 strategies with 21 objectives and 47 activities proposed in the draft of Lao Na-tional Strategic Plan for Rabies Prevention and Control in Lao People Democratic Republic for implementation from 2013 to 2020.

Conclusion: The draft strategy for rabies prevention and control was developed based on current situa-tion by responsible partners. The successful implementation of this strategy will pave the way towards elimination of rabies in animal and human.

TITlE – DEVElOPMENT OF THE NATIONAl STRATEGIC PlAN FOR RABIES PRE-VENTION AND CONTROl IN lAO PEOPlE DEMOCRATIC REPuBlIC.

34

Dr. Krishna Bahadur ShresthaPrincipal and Adjunct Professor

Himalayan College of Agricultural Sciences and Technology (HICAST)Kalanki, Kathmandu, Nepal.

Email: Krishna_shrest@hotmail.comThe Country

Federal Republic of Nepal, located between India and China is a land locked, multiethnic, multicultural, and multireligious country with 26.5 million of population and 147,181 square kilometer of areas. Nepal occupies 0.3 and 0.03 percentage of land area of Asia and the world respectively. The altitude ranges from a minimum of 70 meters to a maximum of 8,848 meters whereas climate varies with its topography. Mt. Everest – the top of the world – is both the identity and the glory of this Himalayan country. Administratively, the country has been divided into 5 development regions, 14 zones and 75 districts. Likewise there are 58 municipalities and 3,915 village development committees. Kathmandu is the capital city and Nepali stands for the official language. The average life expectancy is 64.1 years and the per capita income is US$ 717:00. It possesses 8 out of 10 highest mountains of the world and is an unique destination for mountaineering, trekking, rafting and jungle safari. Tourism is the largest industry, but the agriculture on which 65.6 percentage of the population depends is the highest contributor to the National Gross Domestic Product, 34.33 percent.

The Rabies situation

Rabies, fatal but preventable viral zoonotic disease of mammals is endemic in Nepal. It is maintained in urban and sylvatic cycles by community and stray dogs, cats and mongoose, jac-kalsand other wild canines and felines respectively. More than 95 percent of the reported cases of human rabies are due to dog bite. Therefore, canine rabies has significant role to play in the epidemiology of the rabies in Nepal. The three physiographic regions of the country; mountain, hill and terai is categorized as low risk, moderate risk and high risk zones of rabies (Fig. 1)

A COUNTRY REPORT ON : THE RABIES SITUATION IN NEPAL

35

Human rabies

Annually more than 38,000 suspected exposure cases of rabies are estimated in human. About 20 percent of the suspected exposure cases do not receive post exposure treatment (PET) and 30 to 35 percent take PET without proper risk assessment due to fear, myths or easy ac-cessibility to free tissue culture anti rabies vaccine. Very few patients take Rabies Immunoglo-bulin/Anti-Rabies Serum. It is estimated that more than 30,000 patients take PET. Number of PET cases and PET cases by source of exposure is given in fig. 2 and fig. 3. This is based on the cases reported by the sentinel hospitals only and do not include the treatment at private hospi-tals. The lowest cases reported in 2006 are due to shifting of Nerve Tissue Origin Anti-Rabies Vaccine to Cell Culture Anti-Rabies Vaccine and cases of 2009 and 2010 are estimated based on the vaccines supplied. Percentage of PET cases according to the age groups and sex groups are given in fig. 4 and fig. 5. The number of hydrophobia cases reported during 1992 to 2010 and the same based on the source of exposure and sites of exposure are given in fig. 6, fig. 7 and fig. 8 respectively. The figure is based on the cases diagnosed clinically at the hospitals by the medical practitioners and do not include those died at home and published in the newspapers. The number of hydrophobia cases is estimated to be about 200 per annum.

Animal Rabies

Rabies is reported throughout the year in the animals. There were 53 outbreaks and 75 ani-mals dead in 2012 (Table 1). Among the dead animals, highest number was of buffalo and lowest was of goat (Fig. 9). During 2012/2013, 41 samples of different animals were tested in the Central Veterinary Laboratory, the only laboratory having facility for the diagnosis of the rabies and 20 were found positive for the rabies virus. Rabies was confirmed in dog, cattle, buffalo, goat and mongoose. Arctic related and Indian sub-continent clades of rabies virus have been detected in Nepal (Panta et. al., 2011)

Fig. 1. Rabies Risk Categorization of the Districts, NEPAL

NCHINA

Bhaktapur

Patan

INDIA

High Risk: Terai ->20 Districts

Moderate Risk: Hill -> 39 Districts

Low Risk: Mountain -> 16 Districts

Humla

Mugu

SankhuwaSolu

Sindhu

Rolpa

Dolpa

Mustang

Manang

JumlaDoti

Baitadi

Rukum

Kaski

Kavre

Tanahu

Palpa

Kanchanpur

Kailali

36

Anti-Rabies Vaccine Production

Nepal has phased out production and use of nerve tissue rabies vaccine in 2006. Commercial batch of Cell Culture Origin Anti-Rabies Vaccine (CCO ARV), NeJaRab, was released in the market in January 27, 2006 (Dr. J. N. Rai and Dr. S. Ide, JICA). At present, 50,000 doses of CCO ARV are produced annually. Trial batches of CC ARV for human use are produced and sent for potency test to the WHO reference laboratory, but are yet to be approved for commer-cial use. Department of Health Services imported 229,851 doses of CC ARV for human use in 2012. Panta et. al. produced first batch of 510 ml Hyper-Immune Serum (Ig G) from sheep against Rabies virus in Nepal in April 3, 2009. It had the potency of 10 IU per ml (Pasteur Ins-titute) and could be used for post exposure prophylaxis in animals.

Control/Eradication Initiatives

World Rabies Day event has been celebrated every year jointly by all stakeholders in • cluding government organizations.

Many animal welfare organizations such as Kathmandu Animal Treatment Center, Animal • Nepal, Himalayan Animal Rescue trust, Kennel Clubs etc. are involved in dog population management and rabies control through animal birth control, vaccination and awareness programs especially in the metropolitan cities.

Rotary Club International has taken initiative to launch mass dog vaccination and animal • birth control program in co-ordination with government organizations, Nepal Veterinary Association and Academic institutions.

Nepal Veterinary Association and major stakeholders have developed a comprehensive • • rabies control program.

Nepal supports SAARC Rabies Elimination Initiatives through public private partnership•

Task Ahead

Diagnostic facilities should be developed at least one in each regional diagnostic labora-• tory.

Vaccine production should be increased to meet the internal demand.••

Active disease surveillance program should be implemented.••

All pet dogs and cats should be regularly vaccinated against rabies and program should • be • launched to vaccinate at least 80 percent of the community and stray dogs.

Use of cost effective intra-dermal rabies vaccine should be encouraged to sustain afford••

ability and availability of the vaccine.•

37

Source: Epidemiology and Disease Control Division (EDCD), Department of Health Services, 2013.

Source: Dr. J. M. Shrestha, EDCD, 2012

Source: Dr. J. M. Shrestha, EDCD, 2012.

Fig. 2. Post Exposure Treatment (PET) of Rabies, 1992-2010

05,000

10,00015,00020,00025,00030,00035,00040,00045,00050,000

Num

ber

of c

ases

Year

Fig. 3. PET Cases by Sources of Exposure, 1992-2010

* Domestic Animals ** Wild AnimalsSaliva contact is mostly with Dog saliva

38

Source: Dr. J. M. Shrestha, EDCD, 2012

Source: Dr. J. M. Shrestha, EDCD, 2012

39

Source: Dr. J. M. Shrestha, EDCD, 2012

Source: Dr. J. M. Shrestha, EDCD, 2012

Source: Dr. J. M. Shrestha, EDCD, 2012

Table 1. Animal Rabies

Disease 2010 2011 2012Outbreak 52 52 53Affected 143 84 75Dead 143 84 75

40

Source: Veterinary Epidemiology Center (VEC), Animal Health Directorate, 2013

Source: Dr. K. C. Thakuri, VEC, 2013

41

Dr. Naseem SalahuddinHead, Department of Infectious Diseases

The Indus Hospital, Karachi Pakistan

Pakistan has had a late start in its Rabies Prevention Program, mostly related to government apathy. Rabies is still not a notifiable disease and there is no accurate surveillance. Most ra-bies deaths occur in rural areas where poverty and disease are a lethal combination, made still worse with ignorance fanning and promoting “grandmother’s remedies” of oil, salt, pepper, turmeric or red chillies, in the belief that the searing sensation will kill germs inside the wound. Although most health care providers know and use the modern cell culture vaccines, only few have ever injected rabies immune globulin (RIG). It is commonly held that RIG infiltration is either fraught with danger, or is too expensive to be used. Hence only few centers across the country use RIG for serious wounds.

Despite setbacks, several positive developments have taken place in the past several years through intensive campaigning and advocacy. The Indus Hospital in Karachi, which runs an ac-tive department of Infectious Diseases, opened the Dog Bite Management Center in the Emer-gency Room in January 2008. Since then it is catering to a rising number of dog bite victims from different parts of the city, who receive prompt and correct treatment and at no cost to the patient. Wound toilet is performed, the wounds are categorized according to WHO table. Cu-mulative numbers of the past five years reveal 55% were category 2 and 43% were category 3. Nearly 73% received RIG and all were given PCEC vaccine with TRC id regimen. All patients are counseled for follow up injections.

Secondly, Eastern Mediterranean Regional Organization (EMRO)/WHO has taken heed of the problems with access to proper post exposure prophylaxis (PEP) throughout the country. It has selected 10 centers in each of the four provinces for delivery of PEP. We believe that rabies deaths would be considerably reduced if there were centers with trained health care workers and available biologicals within range of patients’ needs. To that end there has been networ-king between RIA (Pakistan chapter), EMRO and Society for Neglected Tropical Diseases who have collaboratively planned to establish Rabies Prevention Centers. These centers will be in

COUNTRY REPORT ON RABIES FROM PAKISTAN

42

existing hospital or clinic facilities and will be refurbished, and provided sufficient vaccine and ERIG for at least a year. Thereafter, the centers will purchase the biologicals through govern-ment funds. The Indus Hospital in Karachi is the officially designated training center for the ten centers in Sindh province. A 2-day hands- on training workshop for PEP is being conducted for a medical doctor and a nurse in each center.

The first such center was inaugurated in the city of Hyderabad on WRD September 28, 2013 amid fanfare with meeting with the press, awareness slogans and distribution of pamphlets to over 100 participants. In Karachi, too, a video on rabies played continually in the large waiting room of the Indus Hospital along with displays of banners, pamphlets and speeches. At least the neighborhood of Indus Hospital with a population of 2.5 million slum dwellers has become savvy about wound toilet and early PEP.

Since demand for Semple vaccine has diminished because of greater use of cell culture vac-cines, its production has dwindled considerably. Hopefully it will see extinction in due course of time.

University of Veterinary and Animal Sciences, Lahore, has recently undertaken an active role in animal rabies control. We hope to hear some encouraging results from a pilot study that they are engaged in.

We have come a long way in raising awareness and improved PEP. We still have along way to go before considering Rabies Control in Pakistan

43

Beatriz P. Quiambao, MD

The National Rabies Prevention and Control Program is a multi-agency program headed by the Department of Agriculture, in coordination with the Departments of Health, Education and Local government. It is supported by legislation, notably the Anti-Rabies Act of 2007 among others, and aims to declare a rabies free Philippines in 2020.

In order to achieve this goal, the program has several strategies: (1) Animal Rabies control - Dog registration and vaccination, Control of Dog population and movement; (2) Human rabies prevention - improving access to post-exposure prophylaxis (PEP), ensuring quality of PEP service, reducing the incidence of animal bites among children; (3) Education and Public Awareness; (4) Legislation; (5) Surveillance and reporting; (6) Identification and evaluation of “Rabies free zones” and (7) Support of rabies elimination projects.

Animal Rabies Control

Dog vaccination and population control are implemented by local governments and is largely dependent on the political will of the local chief executive. The number of laboratory confirmed animal rabies cases have come down from 1415 in 2005 to less than 500 in 2012. However, the decrease may be due, in part, to the reduction in submission of animal heads for testing and not entirely to an actual reduction in the animal rabies cases.

Human Rabies Prevention

Access to rabies PEP is provided through a network of government animal bite treatment

PHILIPPINES: COUNTR y REPORT ON RABIES

44

centers (ABTC) where the first dose of vaccine is given for free. Private run bite centers also exist all over the country. In addition, since 2012, the government medical insurance system has implemented an out-patient benefit package that provides for PEP to animal bite victims with Category III exposures. Over the past few years, with the increase in number of ABTCs, a corresponding increase in the number of bite patients accessing treatment is noted, with a decreasing trend in number of human rabies deaths (Fig 1).

Figure 1. Animal Bites versus human rabies deaths

Aside from providing access to PEP, the program strives to ensure that high quality PEP service is provided by bite centers. Towards this end, a certification process is now in place that accredits and monitors the performance of bite centers. A bite center can only be accredited if the staff have been properly trained on PEP and treatment of adverse events, have appropriate cold chain maintenance system, follow the recommended PEP management guidelines and treatment algorithm and comply with required reporting.

Education and Public Awareness

Education remains an integral component of the rabies control program. Rabies has been integrated into the curriculum of the elementary grades in selected high incidence areas of the country. This has led to the reduction in the incidence of animal bites.

Celebration of World Rabies Day (Sept 28) and Rabies Awareness month (March) has also increased awareness among the public about this deadly disease.

Surveillance and reporting

Surveillance of animal rabies continues to be carried out through a network of Animal Disease Diagnostic Laboratories in 14 regions and 4 provinces. Human rabies surveillance, on the other hand, is largely case-based since there is only one center providing laboratory confirmation of human rabies.

Because of frequent delays in reporting, a national rabies information system (NaRIS), an internet based information system, has been developed and is expected to provide timely and accurate data, information on rabies prevention and location of PEP services.

45

Declaration of Rabies free Areas

As part of the control strategy, areas with no reported cases of human and animal rabies are continuously being evaluated and are declared as rabies free if they satisfy the requirements of a rabies free area. As of 2012, 8 small islands have been declared rabies free.

Public-private partnership

Over the years, non-government organizations have supported the program through their various projects on rabies prevention and control. Notable among these are the ‘Rabies-free Visayas project” funded by the Bill and Melinda Gates Foundation, which aims to declare the Visayas region rabies free, and the projects supported by the Global Alliance for Rabies Control in Bohol, Ilocos Norte, Sorsogon and Cainta-Marikina.

The goal of a rabies free Philippines in 2020 is an ambitious one. Much work and coordination are still needed towards the realization of this goal.

46

Dr.P.A.L.HAriscHAnDrA Director PubLic HeALtH VeterinAry serVices, Ministry of HeALtH sri LAnkA

Background:

Sri Lanka is an island with an area of 65 000 Sq Km. As per to 2011 census the total population of the country is 20 million. Rabies is an endemic public health problem in the country over a century. The government has been concerned about the rabies menace over the decades and Public Health Veterinary Services (PHVS) of the Ministry of Health (MoH) was established in 1953 to entrust the rabies control programme in the country. Presently PHVS of Ministry of Health is the main body responsible in preventing human and animal rabies and controlling other zoonotic diseases in Sri Lanka. The programme functions in collaboration with different health and non-health institutions at central as well as provincial level.

Epidemiology of rabies:

Dog is the main animal reservoir of rabies in Sri Lanka. The estimated dog population in the country is 2.5 million. In the year 2012, 38 human rabies deaths were reported (figure1).

Figure. 1

Out of all human rabies deaths, 94% were due to rabid dog bite. (Figure 2). During first half of the year 2013, 12 rabies deaths had been reported.

PROGRESS AND PATH TO REACH DOG RABIES ELIMINATION By 2020 IN SRI LANKA

47

Figure 2

The evidence from laboratory findings indicates that high numbers of rabies positives are reported among pet animals (table1). There is no visible trend in rabies among wild and farm animals.

Table 1 Reported rabies positives among different types of animals

Rabies in Domestic Animals

Type of animal Year

2006 2007 2008 2009 2010 2011 2012

Dog 705 659 681 709 579 548 608

Cat 66 42 62 88 57 53 78

Rabies in Wild Animals

Type of animal Year

2006 2007 2008 2009 2010 2011 2012

Rock Squirrel 0 1 0 2 1 1 2

Pole Cat 1 1 0 1 1 1

Mongoose 2 2 1 3 3 3 5

Jackal 0 1

Bandicoot 0 1 0 0 0

Rabies in Farm Animals

Type of animal Year

2006 2007 2008 2009 2010 2011 2012

Sheep 0

Goat 2 4 2 2 2 0 2

Cow 8 10 13 11 15 13 18

Buffalo 2 0 1

Treating animal bites has become a major economical burden to the country. Estimated number of Post Exposure Treatment (PET) Initiated in the year of 2012 was 276,000. (14 per 1000 human population). Guidelines were issued in 2002 for screening of animal responsible for a bite and stray dog vaccination and animal birth control programs have been conducted during last decade. These actions had led to reduction of consumption of Anti Rabies Vaccine (ARV) since 2002 (figure 3)Figure 3 consumption of Anti Rabies Vaccine (ARV) since 2002

48

Achievements

Rabies control measures launched in Sri Lanka since 1975 had a tremendous effect on the incidence of human rabies. The number of human rabies deaths declined from 377 (1973) to 55 (2005) and then to 38 in 2012. Mass immunization of dogs, surgical and chemical sterilization, habitat control, mass awareness campaigns and easy accessibility for human rabies post exposure treatment all together contributed largely for the achievement of reduction of human rabies incidence as low as 0.19 per 100,000 populations (Figure 4).

Figure 4 Human Rabies deaths from 1970 to 2012

49

Reduction in human rabies deaths can be seen with the increasing trend of annual dog vaccination (Figure 5).

Figure 5 Association between human rabies deaths and annual dog vaccination

The dog rabies positivity has also come down since year 2000 with the introduction of vaccination of stray dogs using Auto vaccinators (Figure 6). Reduction of dog rabies positivity is significantly associated with stray dog vaccination (p=0.025, r=-0.64)

Figure 6 Dog rabies positivity from 2000 to 2011

It was possible to vaccinate 50% of dog population in the island which also includes vaccination of free roaming dogs (Figure 7).

Figure 7 Dog vaccination coverage in 2012

50

Pilot project was conducted to study the feasibility of achieving 70% dog vaccination coverage (figure 8). Continuous three day program which include, mass vaccination of household dogs with identification mark (dog color) on first day , mass vaccination of free roaming dogs with identification mark (spray paint) on second day and counting of sample of dogs with and without identification mark on 3rd day by cycling along transect line was conducted. Performance data and survey information were recorded daily at divisional office of health (table 2). The programme continued as a cycle until the whole area is covered. This mechanism is useful to locate low coverage villages for follow up action to enhance coverage.

Figure 8 Pilot project of mass vaccination programme

Table 2 Results of daily target evaluation

Daily counting of free roa-ming

Dat

e

Publ

ic H

Ieal

th

area

No:

of v

acci

na-

tion

poi

nts

Ow

ned

dog

va

ccin

ation

Stra

y do

g va

c-ci

nati

on

Colla

r

Pain

t

No

mar

k

Tota

l Rec

aptu

-re

d

Free

roam

ing

dog

cov

erag

e

6-Aug-12 Demanhandiya 12 532 85 42 17 25 84 70%

6-Aug-12 Mahahunupitiya 12 432 49 18 8 12 38 68%

7-Aug-12 Demanhandiya 12 766 44 31 8 11 50 78%

7-Aug-12 Katana 12 549 57 44 9 16 69 77%

7-Aug-12 Mahahunupitiya 12 372 45 36 20 24 80 70%

7-Aug-12 Welihena 12 372 47 29 12 12 53 77%

8-Aug-12 Demanhandiya 12 538 34 32 12 14 58 76%

8-Aug-12 Katana 12 561 57 30 8 15 53 72%

8-Aug-12 Mahahunupitiya 12 577 75 31 12 27 70 61%

8-Aug-12 Welihena 12 461 45 25 9 11 45 76%

Total 216 8188 929 563 223 287 1073 73%

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Milestones in 2012:

After the 3rd RIACON held in Colombo, on the request of Ministry of Health, W.H.O country office sponsored a national workshop to develop partnership collaboration to eliminate dog rabies. Recommendations developed at the workshop received approval of the cabinet of the government of Sri Lanka. Thus, National strategy for Rabies Elimination based on regional strategy and cabinet recommendation was developed and finalized during the year 2012.

National strategy 2012 for rabies elimination in Sri lanka

Rabies is an example of a zoonotic infection which does not fit into the domain of one single agency with the responsibility of control. Hence the input of various agencies responsible for both human and animal health is essential for eradication of rabies. National Strategy 2012 provides the platform for collaborative partners to implement their social responsibility towards rabies elimination. Some of major activities to be implemented are

One Health Approach for Cost effective Human Rabies prevention by Ministries of Health, Livestock and Local Government includes,

Training of professionals in health and animal health sectors on animal bite 1. management.

Establishment of rabies PET Clinics in all hospitals providing rabies prophylaxis.2.

Reference of owners dog responsible for the bite to nearest government veterinary 3. surgeons (VS) from PET clinics.

Provision of health education on responsible dog ownership and rabies vaccination by 4. Veterinary surgeon.

Implementation of quarantine services for rabies suspected animals by the Local 5. Authorities.

One Health Approach for Dog Rabies elimintion by Ministries of Health, Livestock, Local Government, Universities and NGOs includes,

Establishment of decentralized network of rabies surveillance and diagnosis

Strengthening of existing laboratories that provide services for rabies diagnosis.1.

Establishment of five new laboratories in five identified districts with Direct Rapid 2. Immuno-histochemistry Test (DRIT).

Promotion of notification of Human and Animal Rabies.3.

Planning and conduction of Annual Island wide mass vaccination campaign to achieve 4. and sustain 70% herd immunity against rabies within three month.

52

Way forward

Project proposal has been submitted to SAARC Development fund t to ensure effectiveness of One Health Rabies Elimination, from 2014. Major activities proposed are

Establishment of Country Alliance for Rabies Elimination (CARE)o

Conduction of National and sub national workshop / meetingso

Provision of essential logistics to stake holders and Capacity buildingo

New approach with major stakeholders may lead to reach the destination of dog rabies elimination by 2020.

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ROAD TO RABIES FREE IN VIETNAM, CHAllENGES

Nguyen Thi Hong Hanh, MD., PhD.National Institute of Hygiene and Epidemiology, Hanoi, Vietnam

Email: hanhkhuyen@gmail.com

ABSTRACT

Rabies has been a major threat for public health in Vietnam. Since 2007, human rabies cases have been increasing with approximately 100 human deaths and an average of 400,000 people receiving post exposure prophylaxis annually. Most human rabies cases occurred in the North and Highland. The main transmitters are domestic dogs (98%) and cats (2%). Towards call for action of ASEAN +3 on elimination of rabies in the region by 2020, Vietnam has established the national program for rabies control and prevention with the legislation supports of Govern-ment. In this report, we mainly focus on rabies control in human health. Since 1996, a program for human rabies control and prevention which has been set up by Ministry of Health, has in-cluded surveillance (reporting dog bites, investigation of human rabies cases); Post exposure prophylaxis (PEP) has been carried out mostly as services at commune level, and some areas, PEP has been free for the poor people; Conducting awareness to policy makers, health pro-fessionals, public and specific target population such as children, mothers; Socializing rabies control and prevention has been implemented in some model areas. However, this program has not yet beentightly linked and collaborated with animal health, especially on awareness and community involvement. Currently, control of human rabies is facing challenges such as weak enforcement of Government laws concerning to dog rabies control; limited involvement of lo-cal authorities; lack of funding leading to difficulties in control rabies in animals. In addition, inadequate public health resources, not enough and ineffective communication to the ethnic groups, limited access to preventive treatment, especially at the remote and mountainous areas. Therefore it is really hard to control human rabies unless more resources are devoted to control canine rabies through program of animal vaccination and elimination of stray dogs.

Human rabies in recent years

Despite a national program for the control and eradication of human and animal rabies in

54

Vietnam, the burden of rabies in Vietnam has been increasing in recent years with the num-ber of human rabies cases reported in Vietnam from 2009 to 2012 being 68, 78, 110 and 98, respectively (figure 1) and an average of 387,000 people receiving post exposure prophylaxis annually. The disease is considered to be of major public health concern with 98% of reported human rabies cases occurring following bites from domestic or roaming (street) dogs. The main endemic zone of this disease has been identified as being in the northern provinces of Vietnam, which account for more than 84% of reported deaths from rabies (figure 2).

Figure 1: Vaccination rate and mortality of human rabies, 1992 – 2012.

Figure 2. Number of human deaths due to rabies in Vietnam,

1995 – by June, 2013.

55

Human rabies has been reported in 25 – 27 provinces in Vietnam. However, most of human deaths due to rabies mainly occurred in Northern mountainous provinces of the country. They were Yen Bai, Son La, Dien Bien, Lai Chau, Cao Bang, Tuyen Quang, Phu Tho, Ha Giang, Thai Nguyen and Nghe An (figure 3).

Figure 3: Distribution of human rabies cases by geographical regions

Action towards rabies control and elimination in Vietnam

Response to the ASEAN +3 call for action towards rabies control and elimination by 2020. Vietnam volunteers to be the lead country on rabies control and elimination in ASEAN mem-ber states. For the first step, a co-ordinated human and animal health working group has been established by Ministry of Health and Ministry of Agriculture and Rural Development. This working group is responsible for technical consultation and development of a regional strategy for rabies control and elimination by 2020, this strategy then will be revised and endorsed by all country member states for implementation. Briefly, the draft strategy for rabies control and elimination includes 4 objectives: (1) To create/strengthen government and community com-mitment to the rabies control efforts; (2) To strengthen capacities of the veterinary and human services to ensure effectively delivering technical supports for rabies elimination, particularly for canine vaccination, stray dog management and Post Exposure Prophylaxis; (3) To establish and continuously strengthen the coordinating and supporting mechanism among stakeholders involved in rabies control; and (4) To obtain and sustain high-level governmental engagement, providing an enabling political environment in support of rabies elimination initiatives. And 4 key elements should be involved in the framework to successfully control rabies in the region are (1) Social – cultural framework: advocate at regional, national, sub national, local levels and stakeholders for legislation support and allocation of budget to control rabies at differ-ent administrative levels; public awareness on rabies and public commitment to rabies control efforts;positive behavior of public towards “one health approach” (2) Organization and one health framework: regional, national and sub nation collaboration; cross sectoral coordination; public – private partnership; (3) technical framework: vaccination; dog management and con-trol, monitoring dog movement; diagnosis capacities; surveillance and epidemiology; research supports for rabies control and elimination; (4) Political framework: high level political sup-port; legislation and enforcement.

56

Based on the available WHO strategic framework for elimination of human rabies transmit-tedby dogs in the South East Asia Region, and call for action towards rabies control and elimi-nation, Vietnam has strengthened the program for rabies control and prevention from national to local levels. To support that, Vietnam has improved the existing legislation as well as issued the supplemented legislation to ensure sufficient and effective supports for rabies control and prevention such as 03/2007/QH12 law for control and prevention of communicable diseases is-sued by National Assembly, dated on 21, November, 2007; Decree 05/2007/ND-CP on control of dog rabies issued by the Prime Minister, dated 9 January, 2007; and Circular 16/2013/TTLT-BYT-BNN&PTNN on integration, collaboration between Ministry of Health (MOH) and Min-istry of Agriculture and Rural Development (MARD) for control and prevention of zoonosis diseases, issued by two Ministries, dated on 27 May, 2013. Beside the support of legislation, the collaboration, integration among relevant sectors to control animal and human rabies has been carried out rather well at different levels in some big cities/provinces such as involvement of local government in enforcement of legislation, allocation of budget, socialized rabies control, free vaccine for dogs and for poor people, sharing information, integrated education and com-munication between human and animal health to the professionals and targeted population at risk … Some models of rabies control and prevention have been identified and proved their ef-fectiveness such as in Ho Chi Minh city and some southern provinces. However, in most areas, particularly in remote and mountainous areas, the rabies control and prevention is still neglect-ed or untightly collaborated/integrated among relevant sectors that lead to the high incidence of human rabies. Challenges to rabies control and prevention in Vietnam currently has been identified as (1) Weak enforcement of Government legislation concerning to dog rabies control; (2) Limited involvement of local authorities of most areas; (3) No public commitment on rabies control efforts in most areas; (4) Inadequate public and animal health resources; (5) Not enough and ineffective communication to the ethnic groups, and at remote areas; (6) Limited access to preventive treatment, especially in the remote and mountainous areas; (7) Limited diagnostic support for rabies control in animals; (8) National program integrated human and animal health sectors for rabies control has not been available; (9) Difficult to access to ethnic/mountainous areas for dog management and vaccination due to its social – cultural – geographical character-istics; (10) Lack of funding leading to difficulties in control rabies in animals.

57

Nguyen Thi Kieu Anh et al

National Institute of Hygiene and Epidemiology, Hanoi, Vietnam.

Rabies is an acute encephalitis caused by a lyssavirus. Currently, twelve distinct species of lyssavirus have been classified and three putative lyssaviruses have been identified and still awaiting for classification globally. In Asia, RABV has been reported as the main cause of fatal rabies in humans with the main reservoirs being dogs. Bat lyssaviruses associated with fatal hu-man rabies cases have been reported in certain parts of the world. However, to date no human rabies deaths associated with bats or lyssaviruses has been reported in Asia. Surveys for lys-saviruses in bat reservoirs have been carried out in several South -East Asian countries such as the Philippines, Cambodia and Thailand showed that bat lyssaviruses are naturally circulating in both insectivorous and fruit bats in the region. In Vietnam, rabies is endemic, and transmitted mainly by dogs. Since 2006, approximately 100 human rabies cases have been clinically diag-nosed annually, and 89 fatal human cases of rabies were reported from 23/63 provinces in 2012, no human rabies cases associated bats or lyssaviruses reported. However, it does not exclude their occurrence. To establish a baseline, we conducted a survey to determine the prevalence of bat-specific lyssaviruses in Northern Vietnam.

A total of 926 bat sera were collected in 6 provinces of Northern Vietnam for determi-nation of bat lyssavirus neutralization antibodies by rapid fluorescence inhibition test (RFFIT). The results showed that ninety (11.4%) of the 789 bat sera had evidence of neutralizing anti- results showed that ninety (11.4%) of the 789 bat sera had evidence of neutralizing anti-(11.4%) of the 789 bat sera had evidence of neutralizing anti-bodies against rabies virus, 71 (9%) against Duvenhage virus, 42 (24.1%) against European bat lyssavirus-1, and 4 (0.75%) against Lagos bat virus by virus neutralization assay. No bat serum was positive for neutralizing antibodies against Mokola virus. The overall presence of neutral-izing antibodies against lyssaviruses of bat population in this study was 193/789 (24.4%). This study provides serological evidence of the presence of lyssavirus neutralizing antibodies in bats from Northern Vietnam.

SuRVEy FOR BAT lySSAVIRuSES IN VIETNAM.

58

The information on lyssavirus circulation in bat populations in Vietnam should be made available to policy makers. The information should also be provided to healthcare workers of the Vietnam Preventive Medicine System to facilitate the reporting of bat bites, recognition and documentation of bat exposure as a potential source of rabies infection besides dogs and cats and support prevention and control measures. Concurrently, information about the need for post exposure prophylaxis after receiving a bat bite should be provided. The public, especially those who have close contact with bats such as bat hunters, guano collectors and fruit pickers should be educated about the risk of rabies transmission from bats, and encouraged to safely capture sick bats for laboratory testing of rabies. Additionally, further investigation is required to de-termine whether the circulation of lyssavirus in bat populations in Vietnam impacts on human health. Similar research should be extended to other geographical regions, and in locations with high prevalence of seropositive bats.

Hunting bats for food

SCIENTIFIC SESSION IIIBest Practices in Rabies Prevention

And Control in Human

60

Henry Wilde, MD and Pakamatz Khaowplod, PhDChulalongkorn University and Queen Saovabha Memorial Institute, Bangkok

A large proportion of human rabies deaths worldwide occur in rural parts of less developed countries. This is largely because of a lack of facilities capable of providing WHO standard postexposure prophylaxis, particularly, outside larger population centers and in rural regions. This aspect of rabies control efforts in less developed rabies endemic countries has been no-tably neglected in the past. Poor villagers with a dog bite have to travel to a distant hospital up to 3–5 times to obtain postexposure prophylaxis (PEP). This is a major expense and instead of seeking distant access to proper care, they may obtain treatment from native healers or none at all. The high cost of rabies vaccines was reduced by about 70% using the WHO approved Thai Red Cross intradermal schedule [1]. It has the disadvantage that the saving can only be achieved in clinics that see several rabies exposed patients daily. This is because reconstituted lyophili-zed vaccine must, under current WHO recommendations, be used within 6–8 hours. If there is only one patient, the remnant will have to be discarded. Ironically, this is in spite of proof that reconstituted inactivated rabies tissue culture vaccine can be stored safely in a refrigerator and will maintain potency for more than one week [2,3,4].

The long duration of antibodies after previous pre- or postexposure intramuscular or intra-dermal rabies vaccination, using modern WHO recognized rabies vaccines, has now been well documented [5]. This led to efforts to shorten the old lengthy postexposure prophylaxis sche-dules. The original standard intramuscular “Essen Regimen” required 3 months to complete, was shortened to one month, and now to 2 weeks. The Thai Red Cross intradermal regimen also required a 3 month booster and is now completed with 4 injections within one month. It is now understood that the fate of an exposed patient is mostly settled in the first few days when virus may enter the partly immune protected environment of a peripheral nerve. It is then, that a neutralizing antibody level is lifesaving. New research focuses on schedules with earliest possible neutralizing antibody response, shortest time needed towards reaching a lasting anti-body response, simplification of regimens, and reduction of the cost of biologicals. Effors to reduce the need for travel to distant vaccination centers have been neglected. Two studies

CAN RABIES POSTEXPOSURE PROPHyLAXIS BE EXPANDED TO PERIPHERAL CLINICS IN CANINE ENDEMIC RURAL COMMUNITIES?

61

[6,7] have shown that an early and lasting immune response can be achieved in one week by administering, at 4-sites each, 0.1 mL of intradermal vaccine injections on days 0, 3 and 7 with and without immunoglobulin administration. This “One Week 4-4-4 PEP” was favorably dis-cussed at the 2009 WHO rabies expert consultation at Annecy, France and is apparently being considered for WHO approval. It is clearly an advance because it shortens the treatment time and eliminates at least one clinic visit from the WHO approved intradermal PEP schedules. However, it is not the final answer because it is not suitable for use in small clinics seeing only one rabies exposed patient at a time.

It has long been apparent to health care providers in rabies endemic countries, that we need a method that can be used economically and is effective in more remote regions of less prospe-rous countries where today’s vastly under-reported human rabies deaths occur. We do have the experience, potent vaccines and shortened postexposure regimens and should be able to expand availability of PEP to where it is still badly needed. This could be done by modifying the “One Week 4-4-4 PEP” under consideration by WHO for approval, so that one 1.0 mL reconstituted ampoule of rabies vaccine is adequate for treating one patient within one week. Animal bite cli-nic nurses tell us that it is difficult to recover more than 0.9 mL from a 1.0 mL vaccine ampoule. Three times 0.4 mL requires 1.2 mL of vaccine. It is therefore economically suitable only for large animal bite centers that see many patients daily and are able to use the residual vaccine within 6-8 hours in the next patient. One solution might be to modify the originally proposed and shown highly immunogenic “4-4-4 PEP” to become a “4-2-2 PEP” which requires only 1.0 mL ampoule of vaccine per patient. Experience at the Queen Saovabha Memorial Institute of the Thai Red Cross Society and at Petchaboon’s Provincial Public Health Department, suggests that this reduction would still result in an acceptable immune response[3].

This hypothesis should undergo a controlled immunogenicity study comparing “One Week 4-4-4” with “4-2-2” using a WHO recognized rabies vaccine reconstituted in 1.0 mL diluent. If this hypothesis is proven, “One Week 4-2-2” would be the more efficient regimen for WHO approval. It could bring PEP to small clinics in under-resourced remote regions and potentially reduce the remaining vastly underreported human death rate from rabies. The goal of such a project would be to have smaller community health centers empowered to handle single cases of rabies-exposed patients who now must travel to a distant center or, often, receive no treat-ment at all. If such clinics could also keep immunoglobulin on hand to inject the wound sites, many additional deaths might be prevented.

Corresponding Author: Professor Henry Wilde, WHO-CC for Research and Training in Viral Zoonoses, Faculty of Medicine, Chulalongkorn University, Bangkok 10330, Thailand. E-mail: henrywilde27@gmail.com

Conflict of Interest Statement: The authors have accepted support from rabies vaccine manufacturers for travel expenses to present papers at international conferences. Dr. Khawplod is a senior staff member of QSMI which manufactures equine and anti-snake rabies immuno-globulins. Neither author have any conflicts of interest to report.

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REFERENCES

1. WHO. Rabies Vaccines. Position Paper. Wkly Epidemiol Rec. 2010;85: 309–22.

2. Khawplod P et al. Potency, sterility and immunogenicity of rabies tissue culture vaccine after reconstitution and refrigerated storage for 1 week. Vaccine 2002; 20: 2240–423.

3. Kamamoltham T et al. Rabies intradermal post-exposure vaccination of humans using reconstituted and stored vaccine. Vaccine 2002; 20: 3272–76.

4. Khawplod P et al. Use of rabies vaccine after reconstitution and starage. Clin Infect Dis 200234: 404-6

5. Suwansrinon K et al. Survival of neutralizing antibodies in previously rabies vaccinated subjects: a prospective study showing long lasting immunity. Vaccine 2006;24: 3878–80.

6. Shantavasinkul P et al. Postexposure rabies prophylaxis completed in 1 week: preliminary study. Clin Infect Dis 2010; 50: 56–60.

7. Sudarashan MK et al. Evaluation of a one week intradermal regimen for rabies post-expo-sure prophylaxis. Human Vaccine and immunothera. 2012; 8: 1077–81.

63

Madhusudana SN, Manjunath MV, Reeta Mani, Ashwin YB

Department of Neurovirology,WHO CC on Research and Reference on Rabies

NIMHANS, Bangalore

Introduction

Rabies is an acute and fatal viral encephalitis which is preventable by timely vaccination and immunoglobulin administration. The protection offered by vaccine is mainly due to induction of neutralizing antibody responses but cell mediated immune responses may also play a role .For many years it has been observed that in experimental mice , inadequate or inappropriate immune responses will actually enhance rabies infection and may contribute to mortality rather than offering protection. This is also seen in humans where half hearted attempts to vaccinate enhances rabies mortality compared to un immunized persons .It is also now clear that immune responses may be produced with in the brain and these may play a role in virus clearance or enhancement of infection In this series of experiments we have addressed these issues by de-signing challenging and vaccination studies in Swiss albino mice and street rabies virus

Materials and Methods

Groups of mice were initially challenged with 100 LD 50 of SV by peripheral route and one group was administered 3 doses of rabies vaccine on day 0 ,3 and & 7 and another group was started vaccination on day 4. Another control group was challenged and used as control. The RVNA responses in these mice was determined by RFFIT. The brains of each group was harvested after developments of symptoms , homogenized and subjected to FACS analysis for T cell phenotyping. The spleen was also homogenized and subjected to FACS analysis. The virus quantification in brain was done by FAT and also by real time TaqMan PCR.

Results:

In Groups of mice challenged IM with street virus ( 100 LD 50) and vaccinated 6 hours later on day 0,3,7, the survival rate was 100%. In groups of challenged mice where vaccination was delayed for up to 4 days, symptoms appeared at least 5 days earlier than control mice where as groups of challenged but unvaccinated mice developed symptoms by day 14 and died with in 2-3 days after development of symptoms. The RVNA response was significantly higher in mice which developed symptoms compared un vaccinated mice, though they had just received 2 doses of vaccine at that timed point. The distribution of virus antigen in several areas of the brain was markedly increased as revealed by FAT in comparison to un vaccinated mice. Simi-larly, by Taq Man real time PCR, it was found the quantity of virus in several regions of brain of delayed vaccinated mice was at least 4 fold higher compared to control mice. It was found that there was a marked increase in CD3, CD4 and CD8 cells in brain of mice which received

DUAL ROLE OF IMMUNE RESPONSE IN RABIES ENCEPHALITIS.STUDIES IN MURINE MODEL AND ITS IMPLICATIONS IN HUMAN RABIES

64

delayed immunization and died earlier than control mice ( Figure 1). There was a marked in-crease in the levels of Proinflammatory cytokine such as IL 4, TNF alpha , IL 10 and chemokine Rantes in the brains of these mice. ( Figure 2). Virus replication also occurred much faster in immunized mice though there was no significant difference in the quantities produced among the different groups. There was marked splenic atrophy in both control mice as well as mice with delayed immunization and succumbing to the disease

Conclusions:

Taken together, these findings suggest that immune responses offer protection only till the virus is in periphery and once virus reached CNS, the local and systemic immune responses may actually flare up the infection and cause early development of the disease process rather than offering protection. The probable implication of these findings in human rabies needs to be further investigated.

Figure 1: Distribution of T cell phenotypes in different groups of mice. There was marked increase in CD4 ,CD8 but marked decrease in double Negative cells in symptomatic group

65

Figure 2: Interferon Gamma profile in different groups of mice

The cytokine interferon gamma was markedly increased in mice

With delayed vaccination which succumbed to the disease process

A B

Figure 3: Gross atrophy of spleen in symptomatic

Mice ( B) compared to normal spleen (A).

SCIENTIFIC SESSION IVRabies Control and Immunization

67

PRE-EXPOSURE PROPHYLAXIS FOR CHILDREN IN RABIES ENDEMIC COUNTRIES USING PCECV – A CLINICAL OVERVIEW

Claudius Malerczyk, MD.Novartis Vaccines and Diagnostics, Medical Affairs Vaccines International Region

Human rabies remains a major public health problem in Asia, mainly transmitted by dog bites. In Asian countries, where large stray dog populations exist, the human death toll stays high [1]. Children under the age of 15 years are at particular risk, representing up to half of the dog bite victims. While pre-exposure prophylaxis is commonly used in travelers from devel-oped countries visiting areas of high endemicity, it is rarely used to protect children, the most vulnerable group in high endemic countries.

Purified Chick Embryo Cell Vaccine (Novartis Vaccines & Diagnostics) is WHO-recom-

mended for pre- and post-exposure prophylaxis by intradermal and intramuscular routes [2]. During more than 30 years of use, it has been widely used for pre- and post-exposure prophy-

laxis in all age groups. This includes the use in children in pre-exposure prophylaxis settings, either intramuscularly (IM) or intradermally (ID) in countries where ID use is licensed.

In clinical trials PCECV has been administered to more than 1000 children from toddler to schoolchildren age using intradermal and intramuscular schedules. PCECV has been dem-

onstrated to be safe and immunogenic in these studies. This paper reviews the pediatric pre-exposure studies conducted with PCECV.

Study 1 – Pengsaa et al. [3]

In a phase II, pilot, randomized, open-label, single-center study, performed in Bangkok, Thailand, 180 toddlers aged 12-18 months received intramuscular or intradermal doses of PCECV in a pre-exposure schedule, concomitantly with Japanese encephalitis (subcutaneously administered on Day 0 and 7) vaccine as follows:

PCECV 1.0 mL IM•

68

PCECV 0.5 mL IM half dose•

PCECV 0.1 mL ID 3-doses•

PCECV 0.1 mL ID 2 doses (0-28)•

JE only (0-7)•

By Day 49 all subjects had achieved adequate RVNA concentrations (equal or above 0.5IU/mL). Immunogenicity results are depicted in Figure 1.

The vaccines were well tolerated. Local and systemic reactions and systemic reactions are presented in Figure 2.

Figure 2a. Local reactions

* Erythema in ID group is more common than IM group (P<0.05)

Figure 2b. Systemic reactions

69

Study 2 – Shanbag et al. [4]

In a phase IV, randomized, observer-blind, comparative study, performed in Mumbai, India, 175 Children aged 3-12 received intramuscular pre-exposure doses on days 0, 7 and 28 of rabies vaccine as follows:

PCECV 1.0 mL•

PCECV 0.5 mL (full antigen/half vol.)•

PVRV 0.5 mL•

All children achieved adequate RVNA concentrations by day 49, as measured by RFFIT

See figure 3:

Both vaccines, regardless of the volume of reconstitution/administration were well toler-ated.

See Figure 4:

70

Study 3 – Kamoltham et al. [5;6]

In a phase II, randomized, open label study performed in Petchabun, Thailand, 703 school-children age 5-8 received 2 or 3 intradermal 0.1 mL doses of PCECV on days 0, 28 or days 0, 7, 28 as primary series. One, three or five years after primary vaccination two booster doses (0.1mL PCECV) were administered on Days 0 and 3, simulating that a rabies exposure had occurred requiring the two booster doses. The (simulated) PEP boosters resulted in fast anam-

nestic immune responses, resulting in adequate immune responses (RVNA conc. >=0.5IU/mL), and GMC above adequate levels in all groups one year later

Figure 5:

In summary, PCECV (Rabipur®) has been studied in clinical trials in

Pre-exposure studies in different age groups (toddlers / schoolchildren)•

Immunogenicity has been assessed in more than 600 subjects •

Safety has been assessed in >1200 subjects •

In all trials, all children achieved rabies virus neutralizing antibody concentrations above 0.5 IU/mL, which is considered adequate for protection.

Extensive clinical experience supports intradermal and intramuscular pre-exposure prophy-

laxis with PCECV in children as one pillar of human rabies prevention in developing coun-

tries

71

References

Knobel DL, Cleaveland S, Coleman PG, et al. Re-evaluating the burden of rabies in Africa 1. and Asia. Bull World Health Organ 2005 May;83(5):360-8.

Novartis Vaccines. Rabipur Product Monograph. 1-52. 2008. 2.

Pengsaa K, Limkittikul K, Sabchareon A, et al. A three-year clinical study on immunoge-3. nicity, safety, and booster response of purified chick embryo cell rabies vaccine adminis-tered intramuscularly or intradermally to 12- to 18-month-old Thai children, concomitantly with Japanese encephalitis vaccine. Pediatr Infect Dis J 2009 Apr;28(4):335-7.

Shanbag P, Shah N, Kulkarni M, et al. Protecting Indian schoolchildren against rabies: 4. pre-exposure vaccination with purified chick embryo cell vaccine (PCECV) or purified verocell rabies vaccine (PVRV). Hum Vaccin 2008 Sep;4(5):365-9.

Kamoltham T, Thinyounyong W, Phongchamnaphai P, et al. Pre-exposure rabies vaccina-5. tion using purified chick embryo cell rabies vaccine intradermally is immunogenic and safe. J Pediatr 2007 Aug;151(2):173-7.

Kamoltham T, Thinyounyong W, Khawplod P, et al. Immunogenicity of Simulated PCECV 6. Postexposure Booster Doses 1, 3, and 5 Years after 2-Dose and 3-Dose Primary Rabies Vaccination in Schoolchildren. Adv Prev Med 2011 Jul;2011:e1-e6.

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Kriengsak LimkittikulDepartment of Tropical Pediatrics,

Faculty of Tropical Medicine, Mahidol Universitytmklk@mahidol.ac.th

Because human rabies is a fatal disease without specific treatment, the emphasis is placed on vaccination. Administering pre-exposure rabies vaccine by cell culture based vaccines is aneffective tool to prevent diseases in high risk population, including children living in endemic area. The standard pre-exposure vaccine regimen with 3 doses of intramuscular rabies vaccine on D0, D7 and D28 has been applied for many years and its efficacy is proven. Furthermore to minimize the cost of pre-exposure regimen, several studies of intradermal pre-exposure regimensin adults and children were conducted. The results showed that intradermal and intramuscular pre-exposure regimens could elaborate rabies antibody above the protective level and induce the anamnestic response after booster with 2 doses (D0, D3). It is noted giving 2 booster doses to pre-exposure individuals raise higher level of protection than those receiving only post exposure vaccination. Unfortunately, preventive strategies in most countries especially rabies endemic areas still more focus on post exposure than pre-exposure prophylaxis. This presentationwill emphasize on the effectiveness and benefit of pre-exposure prophylaxis in children..

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RABIES ELIMINATION IN MALA ySIA

Introductioni)

Malaysia consists of all states in the Peninsular Malaysia, the Federal Territory of Kuala Lumpur, Labuan and Putrajaya as well as the states of Sabah and Sarawak in the north-western coastal area of Borneo Island . Malaysia’s population, as of July 2010[update], is estimated to be 28,334,000, Of these, 5.72 million Malaysians live in East Malaysia and 22.5 million live in Peninsular Malaysia. According to latest 2010 census, the Malay population is 60.3%, Chinese 22.9%, and the Indians 7.1% of the total population. The population distribution is uneven, with

PRE-EXPOSURE PROPHyLAXIS FOR CHILDREN

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some 20 million of 28 million citizens concentrated in Peninsular Malaysia, which has an area of 131,598 square kilometers.

Challengesi)

Malaysia shares a land border with Thailand in the North, Sabah and Sarawak share a land border with Kalimantan of Indonesia. The Islands of Indonesia and the off-shore islands of the Sulu archipelago of the Philippines are within 50km and 100km from Sabah and Peninsular Malaysia. Rabies continues to be a disease of concern to Malaysia, although control measures employed thus far have reduced the prevalence to a zero level in the border states of Malay-sia.

Social patterns and cultural normsii)

Malaysia is a multiracial society comprising several ethnic groups with their own ethnic groups own customs and cultural norms. Muslims (Malays) are less tolerant to dogs because of religious beliefs and fear of dog bites.

Historical backgroundiii) of Rabies cases in Malaysia

In Malaysia, the disease has been known to occur as early as 1884 when a ship’s captain imported a large number of dogs into the country of which some had shown signs of “madness” However it was not untill 1924 when the disease was first officially recorded. In Kedah, rabies was first detected in 1925. The outbreak which started from North Kedah was traced to a case of rabies in a dog in Perlis. A total of 60 rabies cases in dogs were recorded later in the 1930s.

Rabies situation after 1954 iv)

In 1955, an immune-belt was established of 50 to 80km along the Malaya/Thailand border, comprising of the entire state of Perlis, Northern Kedah, Perak and Kelantan especially in the border areas of Malaya/Thailand where intensive control measures could be carried out continuously as a safeguard against the spread of rabies from Southern Thailand. From the years 1930 to 1986 a total number 1,194 cases were recorded. The last recorded animal Rabies case in Malaysia was in 1999 and since then there are no case of rabies being reported up till now.

B) DISEASE CONTROl ACTIVITIES FOR RABIES:

i) Methods of Rabies Control

The success of rabies control in Malaysia is the result of a national effort to eradicate the disease through a programme of destruction of stray dogs, mass vaccination and licensing of dogs as well as nationwide awareness campaign. The Department of Information and the mass media also played a significant role in the awareness campaign.The present methods of rabies control have been developed over a number of years. The primary objective is the prevention of canine rabies which is based on the belief that dogs are the only significant species involved in the transmission of the disease.

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ii) National Rabies Control Programme

The National Rabies Control Programme includes licensing of dogs, maintenance of an im-mune-belt along the Malaysian side of the Malaysia/Thailand border, compulsory vaccination of all dogs in the immune-belt and in any rabies infected area, destruction of stray dogs, the en-forcement of stringent rules and regulations for the importation and movement of dogs and pu-blic education through mass media on its zoonotic nature and the need to control the disease.

The control programme is carried out jointly by the Department of Veterinary Services, Mi-nistry of Agriculture and the Medical Department, Ministry of Health. The former deals with the prevention and control of the disease in animals and the latter deals with cases of animal bites in human suspected of rabies. The Institute for Medical Research in Kuala Lumpur and the Veterinary Research Institute in Ipoh are responsible for the diagnosis of the disease in humans and animals respectively. In addition, the co-operation of other relevant agencies and community leaders are also obtained so as to give sufficient publicity on the control measures.

iii) Number of animals vaccinated and licensed

In the year 2008 a total of 5,664 dogs were vaccinated ,141 dog head samples were taken to rule out rabies, number of dogs destroyed were 30,981 and those licensed amounting to 36,254. As for the years 2006-2010 the number destroyed were 105,884 (unlicensed and stray dogs) numbers vaccinated amounted to 25,416, and those licensed to that of a total of 173,642. As from 2011 to as of August 2013,number of dogs destroyed stands at 12,589,vaccinated:10,301 and licensed at a total of 29,613 dogs.

From 1993-to the year 2013 a total 351 cases of dog bite were reported for all the states in West Malaysia and in Labuan.

C) Maintenance of an Immune-Belt

In 1955, an immune-belt of 50 to 80 km wide was established along the Malayan side of the Malaya/Thailand border. The purpose of the immune-belt is to delineate an area where intensive control measures could be carried out continuously as a safeguard against the spread of rabies from the border areas. At the same time, it would serve as an area for containment of the disease should there be any outbreak in the border areas. Compulsory licensing and vacci-nation of dogs are carried out annually in the immune-belt, while the destruction of unlicensed and stray dogs is carried out from time to time as deemed appropriate. Movement of dogs out of the immune-belt is only permitted following vaccination at least one-month prior to the date of movement. Similarly, a dog moving into the immune-belt is subjected to immediate vaccination on arrival and kept in quarantine.

Destruction of stray dogsi)

There is a permanent programme for the destruction of unlicensed and stray dogs throu-ghout the country . It is carried out jointly by the Department of Veterinary Services and the municipalities in some urban areas. Destruction of stray dogs in specific locality will be further intensified should there be an outbreak of the disease. Shooting is the most common method employed in the destruction of stray dogs. In more densely populated cities, a capture method

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using restraining loop is preferred. At the same time, dog population control by antifertility procedures (castration and spaying) are also encouraged.

D) LICENSING OF DOGS IN THE RABIES IMMUNE BELT

The National Rabies Control and Eradication Programme includes measures such as Licens-ing of dogs, maintenance of Rabies immune-belt (to delineate an area ) where intensive con-trol measures could be carried out continuously as a safeguard against the spread of rabies from border areas along the Malaysian side of the Malaysian/Thai border. Licensing of Dogs is compulsory throughout the country. The Department of Veterinary Services(DVS) undertakes the licensing of dogs in the immune - belt areas. For the rest of the country, during the period of freedom from disease, dog license can be obtained from certain municipalities.However, when an area or state is declared rabies infected, the Department of Veterinary Services will imme-diately undertake the entire responsibility of dog licensing.

Legislation

In Peninsular Malaysia, legislative powers providing the necessary authority to make rules and orders to control the disease are firmly embodied in the Animals Ordinance, 1953 of the Federation of Malaya. These include provisions for the declaration of an area as rabies-infected, maintenance of an immune-belt along the Malaysia/Thailand border, licensing and vaccination of dogs and destruction of stray dogs. In addition, certain municipalities in the country, have their own by laws particularly with regard to licensing dog.

Import and Quarantine Regulations

The Animals Rules, 1962 and Animals (Importation) Order, 1962 were enacted under the provision provided by the Animals Ordinance, 1953, for the control of animal movement in and out of Peninsular Malaysia.

In Peninsular Malaysia, dogs and cats imported from rabies-infected countries are vaccina-ted upon arrival and quarantined for a minimum period of thirty days. Young pets are detained until they reach the vaccination age of 3 months when they are then vaccinated and further quarantined for thirty days thereafter.

Public Awareness

The agencies involved in Public awareness include the related universities which have a Veterinary curriculum, (SPCA) Society for prevention of Cruelty to animals , (MSAVA) Malaysian Small Animal Veterinary Association, District veterinary Offices and Municipal Council, State Veterinary Offices, Private veterinarians and Non Governmental Organisations. Pet registration with a passport has been initiated and encouraged with licensing and vaccination.World Rabies activities have been initiated in the border states and zoonotic disease campaigns have been carried out in the various states..

CONCLUSION

The provisions for the control of rabies in Malaysia are designed to prevent the entrance of rabies into the country, to reduce the population of stray dogs up to a satisfactory level, and to

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limit the spread and transmission of the disease from a focus of infection in any outbreak.

The implementation of a Rabies Control Programme based on stray dog control and vaccina-tion has enabled Malaysia to reduce the incidence of the disease to a low level. Many factors such as social, cultural, religious and political jurisdiction have favoured the implementation of the control programme. The endemicity of the disease in border countries poses a constant threat to Malaysia on the reintroduction of the disease into the country.

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Author :Eric Brum, DVM

ABSTRACT TEXT :

A fundamental goal of infectious disease control is to decrease the rate of new infections over time. The epidemiological concept used to describe the rate of new infections over time is the basic reproductive number, R0. The R0 refers to the expected number of secondary (new) infections resulting from one single infection in a completely susceptible population. For ex-ample, if, on average, one person infected with measles spreads the disease to 10 other people in a naïve population, then the R0 would be 10. When the basic reproductive number is greater than 1, then the number of new infections will increase and continue spreading within the population over time. If R0 is equal to 1, then one infected individual will lead to exactly one more infected individual, and the disease will remain stable over time. However, if R0 is less than 1, then the number of new infections will decrease over time, leading to eventual extinc-tion of the infectious disease within the population. Thus the objective for disease controllers when attempting to progressively control and eliminate an infectious disease from a population is to design and implement interventions which will lead to a productive number less than 1. Upon an examination of the factors which influence the productive number as well as the epi-demiologically relevant characteristics of the canine rabies virus and dog population dynamics, further insight may be gained in how to most effectively and efficiently apply the various tools available for controlling the rabies virus within canine populations.

TITLE : EPIDEMIOLOGICAL PRINCIPLES OF RABIES CONTROL

SCIENTIFIC SESSION VRabies Control and Management :

Strategy

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Assistant Professor Dr. Thavatchai Kamoltham, MD.,FRCS.,Dr.P.H. Inspector General, Ministry of Public Health Dr Wirawan Thinyounyong B.Sc., MPA., PhD.,

Senior expert in public health, Phetchabun, Thailand.

Abstract Text – Since 1993 neural vaccine was replaced by TCV, which result in number of human rabies death decline rapidly. In the meantime, due to the budget constraints and the rapid increase in demand for TCV, the IM regimen was changed to intradermal regimen in 1994.After that, many researches done gave recommendations on on stability of storage vaccine, immunogenicity, efficacy, and sterility criteria launched in 1999. Till this day, paradigm shift from post-exposure in human to Pre-exposure in children (2001)

Strategic base policies developed as a five year plan rabies elimination reported in WHO bulletin in 1966, in order to increase cooperation, awareness, improved surveillance, monitoring efficacy (1998) and as a rabies elimination strategy of 10th National Health Development plan(2003-2007). In 2008 CDC developed area base plan policy to eliminate rabies by introducing free rabies zone. To overcome a hard core left over rabies in Thailand needs a new paradigm. In 2010, Kamoltham et al. introduced a model of Rabies elimination strategy by community people and their network using Strategic Route Map Model. There are six steps in the SRM plan i.e.: community context analysis, destination statement, strategy route map model formation, strategic linkage model formation, 11 columns of operation plan and implementation of those policies and evaluation. Situation of Human Rabies Death in Thailand since 1991 up to now, after each paradigms found that we are reaching Zero deaths in a few years.

TITLE – PARADIGM SHIFT IN RABIES CONTROL

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UPDATE FROM THE GLOBAL ALLIANCE FOR RABIES CONTROL

L.Knopf* & C.Rupprecht

The Global Alliance for Rabies Control (GARC) is a non-governmental, independent not-for-profit organisation. Founded more than 6 years ago, it identified the urgent need to bring together major international partners to build political commitment, to speak with one voice, to launch needed research initiatives and to better coordinate efforts to free people and animals from the threat of rabies at both, a local and a worldwide scale. Since then encouraging progress has been made in slowly breaking the cycle of neglect for rabies via increased advocacy, proof of concept studies, renewed education, and enhanced collaboration of all stakeholders involved in rabies prevention and control. Today and in particular in Asia, there are promising regional and national initiatives underway, roadmaps established or specific programmes already being implemented successfully. However, despite the growing body of evidence supporting canine rabies elimination and the increasing range of resources and tools provided to the community of rabies control, these do not necessarily translate into needed policy changes or the other way round, existing policies are still not put into practice in rabies affected countries. A few weeks ago GARC and its partners held their annual meeting. The group looked among others at prime successes and challenges in the area of rabies control and elimination around the world to find the most effective ways forwards how to overcome the major remaining obstacles, be it at local or up to global level. General consensus revealed that political commitment, long term funding strategies, intersectoral and regional collaboration and local champions are key to successful rabiescontrol and elimination. Research priorities identified include focus upon enhanced decentralizedlaboratory-based surveillance systems, risk assessments, and measurement of programimpact, testing of new biologics, regimens, and delivery models for improved prevention and control, humane synergistic methods of animal population management, and a comparative health economic evaluation for the most ideal strategies to consider for implementation. corresponding author lea.knopf@rabiesalliance.org

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THE BEST PRACTICE ON RABIES FREE ESTABLISHED IN A LOCAL LEVEL:A CASE STUDY IN WIANG HAO SUBDISTRICT

Jamnong San-kwan1 Pranee Rodtian2*Chiang Rai Provincial Livestock Office, Chiang Rai, Thailand, 57000.1. The Fifth Regional Livestock Office, Huay Kaew Rd, Chiang Mai, Thailand, 50300. 2. *Corresponding Author: pranee.rodtian@gmail.com

ABSTRACT

Upper Northern Thailand is one of the most popular destinations for cultural and eco-friend-ly tourism. There are plenty of visitors coming to this area throughout the year. There has been no rabies reported both in human and animal for several consecutive years. However, dog movement control efficiency and mass immunity has not reached the benchmark for dec-laration as rabies free area (RFA). Based on the criteria specified in Thailand National Rabies Elimination Strategy 2020, the road map to create rabies free areas in upper northern Thailand 2009 – 2018 were developed and implemented by local administrative organizations (LAO). This road map has been used to advocate the national government for political support to be provided to regional and provincial rabies partners. In order to encourage LAOs to establish and maintain rabies free area, the Fifth Regional Livestock Office, the Tenth Regional Office of Disease Control and Prevention callaboratedcollaborated with Chiang Mai University set up a committee to appraise LAOs’ effort in establishing rabies free area annually. Up to September 2013, more than 90 percent of 815 LAOs in upper northern Thailand have fulfilled rabies free area criteria.

Wiang Hao sub-district local administrative organization demonstrated a best practice in developing the road map to create rabies free area, which integrated livestock and public health volunteers including schools, temples and community. Activities under the road map included annual dog population surveys, dog registration, mass dog immunization, surveillance, public awareness campaign. These activities were conducted for three years before fulfilling rabies free criteria. The achievement was recognized and Wiang Hao Sub-District received Thailand Rabies Award Competition in 2012.

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Key words; Best Practice, Rabies Free Established, Local Level, Wiang Hao Subdistrict

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BACKGROUND: Rabies is a vaccine preventable viral zoonosis. It was widely distributed throughout the world and presenting in more than 150 countries including Thailand. About 60,000 people die of rabies every year, mostly were in Asia and Africa. Rabies control has not been effective in South-East Asia due to it is not a priority disease, inadequate resource, lack of political support and public cooperation, lack of consensus on strategy, weak inter-sector co-ordination and inadequate management structure (WHO, 2005). Dog continues to be the main hosts and is responsible for most of the human rabies deaths. Most of all rabies deaths (30-50%) occur in children under the age of 15 years. (http://www.who.int/rabies/home_more/en/index.html, 2013). It is time for us to start “Working together to make rabies history”.

Upper Northern Thailand is one of the most popular destinations for cultural and eco-friend-ly tourism. There are plenty of visitors coming to this area throughout the year. There has been no rabies reported both in human and animal for several consecutive years. Sporadic human and animal rabies cases have been reported in other parts of country. A rabies imported case from Bangkok to Chiang Mai was notified in 2010. However, the outbreak did not spread and post exposure prophylaxis was provided in time owing to the local administrative organization efforts to create rabies free area. Upper northern part of Thailand has a long boarder with neigh-bor counties, which allow animal and people movement, which is a challenge to create rabies free area in upper northern part of Thailand.

OBJECTIVE: To encourage sub-district administration organizations (SAOs) to develop road map to rabies elimination by 2020. A best practice case study in Wiang Hao Subdistrict is presented.

MATERIALS & METHODSTools:

1. Guideline of the National Strategic Plan for rabies elimination by 2020. (Department of Disease Control Administration, 2009) , which composed of 5 strategies (Fig. 1),

1st strategy: Efficient management and integrated approach to prevention and control of rabies,

2nd strategy: Increased role and active engagement from local administration organizations in rabies prevention and control,

3rd strategy: Surveillance, prevention and control of rabies in human and animal popula-tions

4th strategy: Multi-sector engagement and public participation,

5th strategy: Efforts to raise awareness, increase knowledge and skills, and influence behav-ior changes among the public for rabies prevention and control.

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Fig. 1 Strategic plan for rabies elimination by 2020 and

Fig. 2 Guideline of rabies free area establishment criteria

Fig. 3 National Guideline of Rabies Prophylaxis

2. The National Guideline of Rabies Free Area Establishment (Fig. 2) is a standard proce-dure of rabies free area establishment criteria (Fig. 4).

3. The National Guideline of Rabies Prophylaxis (Fig. 3).

Fig. 5 Rabies free area certification steps

Implementation at regional, provincial and district level

1. Assess the current situation then certify each area for rabies free area (Fig. 5).

2. Develop upper northern regional rabies free area project along with roadmap to rabies free by 2020.

2.1 In 2009, develop one rabies free area (LAOs) in each province. (8 provinces 8 LAOs certified as rabies free areas.)

2.2 In 2010, develop one rabies free areas (LAOs) in each district. (103 districts, 103 LAOs certified as rabies free areas.)

2.3 In 2011, develop two rabies free areas (LAOs) in each district. (206 LAOs certified as

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rabies free areas.)

2.4 In 2012, establish three rabies free areas (LAOs) in each district. (309 LAOs certified as rabies free areas.)

2.5 In 2013 develop the remaining 189 LOAs to be certified as rabies free areas (total of 815 LAOs).

2.6 In 2014 – 2016, connect all rabies free areas LAOs and declare upper northern Thailand as rabies free zone.

3. Annual work plan was developed, using all the tools mentioned earlier, to advocate provincial governor to promote multi-sector collaboration based on MOU.

4. Strengthen rabies surveillance by target sampling. At least one sample from each LAO (815 suspected animals) was submitted for rabies diagnosis

5. Committees were set up at district and provincial level to assess the participated local administration organizations for rabies free certification (excellent, very good, good or pass).

6. A regional committee was set up to determine best practice for developing rabies free area competition.

7. The best local administration organization in each province was selected for national rabies award contest.

Evaluation index,

1. Participatory LAOs set up the working group or committer by multidiscipline collaboration of all sectors which signed MOU to cooperate surveillance, knowledge, and behaved modification of rabies prevention and control.

2. Network set up for communication and implementation, such as livestock and public health volunteer, school, temple, etc

3. Training of livestock and public health volunteers in villages to assist veterinarian and medical doctor for monitoring and following

4. Annual coverage dog population surveys.

5. Mandatory registration of dog age two months up.

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6. Mass vaccination not less than 80%.

7. No stray dog or cat by removal of free roaming/ownerless dogs in public places.

8. Dog population control by spaying and castration

9. Active epidemiological surveillance by sampling suspected dogs for rabies diagnostic.

10. Active surveillance in human by pre protection exposure in risk group such as livestock volunteers.

11. Passive surveillance on post protection exposure in rabies suspected bite or scratch both human and animal. Quarantine the suspected animal.

12. Public relations and education for public awareness about rabies through media such as television and radio target with school, temple and community.

13. Issuing of ordinance for animal control based on national legislation (Public Health Act 1992, Rabies Act 1992, Animal Diseases Act 1956, revised 1999) and use of Legislatures supporting rabies prevention and control.

14. Animal welfare and Environment.

RESULT and DISCUSSION: The 5th Regional Livestock Office collaborated with the 10th Regional Disease Prevention and Control Office including Chiang Mai University could establish rabies free areas in 76.93 % of the 815 sub-district local administrative offices in upper northern part of Thailand since 2009 to 2012. The remaining SAOs will be covered in 2013 to allow declaration of Rabies Free Areas by 2020. Wiang Hao sub-district is a case study of success SAO as following.

1. The Wiang Hao Sub-district administrative organization (SAO) has an area of 68 km2 which located in Phan District, Chiang Rai Province, the Northern part of Thailand, about 739 km far from Bangkok. Wiang Hao SAO was established in February, 23, 1997. There were 3,413 peoples under 1,270 Households living in 16 villages. Most people are Agriculturists such as rice farmerscorn farmer and livestock raisers. The Wiang Hao sub-district has no rabies report in human and animal since 2003 to 2013 (Phan district hospital, 2013; Chiang Rai Provincial Livestock Office, 2013). Therefore, the evaluation for rabies free area was in rabies free control level A.

2. Cooperative agreement or Memorandum of Understanding (MOU) were signed to enhance participation from all sectors. The first agreement covered the coordination and cooperation among nine associated networks including livestock office, public health office, schools and the other networks to create a rabies free area in Wiang Hao Sub-district. The second agreement covered the coordinated and cooperated renovations

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among the four adjacent Sub-district Administrative Organizations regarding epidemic in animals surveillance and animal moving in and out control measures under One Health concept

3. Under the guidance of Wiang Hao SAO’s chief, his team realized the importance of the rabies affected on living quality of the people in this area. Thus rabies free area development working group was set up. Regular meetings were held to prepare for each aspect of the national strategy in rabies elimination by 2020 on three years budget preparation to train and integrate the network including

support and provided vaccine as well as dog-cat population control.

4. Task village Health Volunteers and Village Livestock Volunteers with conducting a complete registration survey of the dog and cat population coverage in all areas.

5. Registration of owned dogs in the area

6. Mass vaccination was 100 % in dog since 2009 and continuing since then.

7. From the past record, 1% of those animals had a history of biting people, 9% had bitten other pets, and 5% exhibited ferocious behavior. Thus, risk assessment for the exposures were dominated for educated.

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8. Conduct active epidemiological surveillance by sampling suspected dogs for rabies diagnostic. All samples showed negative result by FAT at Lampang Diagnosis Center.

9.Active surveillance in human by pre- exposure immunization in risk group such as livestock volunteers. (PEP for risk exposed persons)

10.Dog population control by spaying and castration

11. Public relations and education for public awareness about rabies through media such as television and radio target with school, temple and

12. The effective control of dog movement was done by livestock and public health volunteers, children, elder volunteers, schools, temples and communities.

13. Prevention and Control to all network and community. Wiang Hao Sub-district SAO training and rabies control exercise has determined methods, steps to look for the persons who have had contact with or been bitten by the suspected animals so they can be properly treated with correct vaccines and detained those animals for observation at least ten days.

14. ”Youth volunteers to be aware of rabid dog project” facilitate youth volunteer networks in schools and communities and train the older children to teach the younger ones to know about rabid dogs.

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Those children can teach their younger friends about how dangerous the rabies disease is and how to take care of their dogs and safeguard themselves from the disease. A publication was distributed continuously throughout the year using various media both within and outside the area focusing on the target group and high risk one.

15. There was a code of law to control keeping and abandoning dog or cat populations with approval of the council and community’s forum in every village.

16. A local innovation, Wiang Hao Model, which was a mobile cage with double safety locked. The first small door is used for feeding by the owner or authority, while the second big door is used to contain animal. The key will be kept by the authority awaiting animal release permission.

CONCLUSION:

The collaboration of multi-sector, public participation, (MOU) to develop the national rabies control policy based on the national strategic plan for rabies elimination by 2020 and the national guideline of rabies free area establishment. The role of local administration organizations in rabies prevention and control was enhanced to establish rabies free area in upper northern part of Thailand. Wiang Hao SOA has integrated multi-sector networks, especially the livestock volunteers, public health volunteers including schools, temples and communities to conduct dog population surveys, dog registrations, mass immunity creations, passive and active surveillances, publication, and raising public awareness systemically. The activities were reviewed for additional funding every three years. The achievement has been guaranteed by receiving the Thailand National Rabies Award in 2012.

ACKNOWLEDGE:

We would like to thank to Mr.Sorn Srivichaician, Chief of the Wiang Hao SOA. Mr.Nopadol Phinit, Head of Phan districted livestock office, Mr.Vittaya Chintanawat, Chief of Chiang Rai provincial livestock office and all network members working together making rabies a history. Thanks to Dr Pawin Padungtod for kindly furnishing this paper. We are also gratefulness to the owner of the pictures and some beautiful words in this document that we could not refer all.

REFERENCE:

Department of Disease Control. 2009. The National Strategic Plan for rabies elimination by 2020. 1 – 31

Department of Disease Control. 2009. The National Guideline of Rabies Free Area Establishment. 1 – 41.

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Department of Disease Control. 2012. The National Guideline of Rabies Prophylaxis. 1 – 59.

Department of Disease Control. 2012. The Memorandum of Understanding between Department of Disease Control, Department of Livestock Development Administration, Department of Local Administration and the Sub-district Administration Organization Association of Thailand, Provincial Administration Organization Council of Thailand, the Municipal League of Thailand. 1 – 4.

Department of Livestock Development. 2009. The Road Map of National Rabies Free Zone Establishment. Bangkok. Thailand. 1.

WHO. 2005. Rabies Elimination in South-East Asia. Report of Workshop. Columbo, Sri Lanka, 10 – 12 November 2002, World Health Organization, Regianal officer for South-East Asia, New Delhi. 19 p. (online available: Sept 24, 2013: http://apps.searo.who.int/pds_docs/B0329.pdf)

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Dr. Agnes Poirier and Dr. Mary Joy Gordoncillo OIE, Thailand

Founded in 1924, the World Organisation for Animal Health (OIE) is the intergovernmental organization responsible for improving animal health worldwide, and has 178 Member Countries in 2013. Recognised as a reference organisation by the World Trade Organization, the OIE set international standards on animal health, veterinary public health and animal welfare.

Criteria for rabies free countries, provisions regarding the control of rabies in dogs and recommendations for the importation of live animals are laid out in the OIE Terrestrial Animal Health Code. The OIE Code also includes recommendations on stray dog population control, which should be part of rabies control programmes including the promotion of responsible dog ownership, registration, identification, movement and reproductive control, waste management and, where necessary euthanasia with rapid and humane methods. The requirements for diagnostic techniques and for rabies vaccines are set in the OIE Manual of Diagnostic Test and Vaccines for Terrestrial Animals.

Grounded on these International Standards relevant to rabies, the South-East Asia Rabies Strategy (SEARS) was developed to provide a strategic framework for the reduction and ultimate eradication of rabies in South-East Asia. Focusing on canine rabies elimination, which is by far the largest source of human rabies infections, the strategy recognises the critical importance of Veterinary Services, ‘One Health’ approaches, and the application of OIE standards and recommendations relevant to rabies control and prevention. The South-East Asia Rabies Strategy outlines the socio-cultural, technical, organisational and political aspects relevant to rabies control that will need to be considered and integrated into the rabies elimination programmes in ASEAN Member States.

OIE INTERNATIONAL STANDARDS AND GUIDELINES ON RABIES AND THE SOUTH-EAST RABIES STRATEGy

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Dr. Satoshi Inoue Japan

Japan has been rabies free for more than half century. The last case of indigenous human and animal rabies were in 1954 and 1957, respectively. In Japan, under Rabies Prevention Law (MHLW, 1950), Domestic Animal Infectious Diseases Control Law (MAFF, 1951) and Infec-tious Diseases Control Law (MHLW, 1998), substantive efforts to prevent rabies have been adopted by central and local governments, veterinarians, and physicians (e.g. registration and control of stray dogs, rabies vaccination of dogs, import and export quarantine of animals, noti-fication system for importation of animals, rabies diagnosis in suspected cases, appropriate PEP for human). The follow-up amendment and drill of measures and contingency plan is deemed necessary, because any inappropriate public health response or delay at an early stage of rabies cases, even in doubt, leads to unnecessary, excessive social anxiety. Two imported human ra-bies cases reported in Kyoto and Yokohama in November 2006 were dealt in accordance with The Guideline for Rabies Control in Japan 2001 (MHLW) in terms of the initial response and medical practice. These revealed the importance of validated rabies diagnostics. And earlier this year, The Guideline for Rabies Control in Japan 2013 was newly developed focusing on an ac-tion plan after the confirmation of rabid animals in Japan. Taking into these guidelines, the local governments are elaborating their own action plan and conducting tabletop and field exercises based on it. The network has also been strengthened among laboratories of rabies diagnosis, veterinarians in clinical diagnosis and medical doctors in PEP. The enlightenment program for general public is also held on WRD by The Japan Society of Clinical Study for Rabies backed up by the Ministry of Health, Labour and Welfare. For making use of our experiences in Japan, further enhanced networking in experts and laboratories of rabies is effective and valuable in Asia.

RABIES FREE IN JAPAN AND FUTURE PLAN (RABIES PREVENTION IN JAPAN)

SCIENTIFIC SESSION VIFree Paper Presentation

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Mahendra B J1, Harish B R2, Nagaraja Goud B3, Thimma Reddy4

Introduction:

Rabies continues to be a major public health problem in Asia and Africa. An estimated 36% of the global deaths due to Human rabies is said to occur in India alone, 17.4 million animal bites are estimated to occur every year in India. There is some disparity in the estimation of burden of human rabies in India. The APCRI-WHO survey of 2004 estimated that 20,000 deaths occurred due to rabies every year in India. Knobel and others in 2005 estimated that 19,713 deaths due to rabies occur in India every year and Suraweera and others in a recent study published in 2012 estimated that 12,700 deaths occurred in India every year due to furious rabies. Official figures of rabies deaths in India for 2011 as given by National Health Profile is 253. This low figure quoted by the government of India is due to lacunae in the reporting system as rabies is not a notifiable disease in India. Most of the human Rabies cases in India are said to occur in rural areas and majority of these cases may die at home and may not come to the notice of the health authorities.

The epidemic diseases hospital in Bangalore, the capital of Karnataka state is one of the hospitals to which suspected human rabies cases are referred, from not only the state but also from the neighboring states of Tamil Nadu and Andhra Pradesh. The present study was taken up at the EDH Bangalore with the following objectives:

To describe the socio demographic profile of human rabies cases admitted to 1. epidemic diseases hospital, Bangalore

To describe the pattern of clinical profile2.

To assess the quality of data in the case record forms3.

1 Professor and Head 2 Associate Professor 3 Assistant Professor of Statistics

1,2 &3 Department of Community Medicine, Mandya Institute of Medical Sciences, Mandya, Karnataka, 4. Medical Superintendent, Epidemic Diseases Hospital, Bangalore, Karnataka, India

PROFILE OF HUMAN RABIES CASES ADMITTED AT EPIDEMIC DISEASES HOSPITAL, BANGALORE, INDIA

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Material and Methods:

The present study was a hospital based retrospective study. Case records of all suspected human rabies cases admitted in the epidemic diseases hospital, Bangalore for the period April 2009 to March 2012 were analysed. Data was entered into MS Excel, analysed and presented as proportions.

Results:

A total of 75 suspected human rabies cases were admitted to the epidemic diseases hospital, Bangalore from April 2009 till March 2012. 64 (85.3%) of the cases were from the state of Karnataka.11 (14.7%) were from neighboring states of Andhra Pradesh (8%) and Tamil Nadu (6.7%)). 25 cases had reported in 2009-10, 21 cases had reported in 2010-11 and 29 cases had reported in 2011-12.

61 (81.3%) of the victims were males and 17(22.7%) were children aged ≤ 15 years. 42 (56%) of the cases were from urban areas. In 71 (94.6%) of the victims, the exposure was to dogs and 2 (2.7%) were to cats and 2 (2.7%) were exposed to wild sheep. In the 71 who were exposed to dogs, 56 (78.9%) were exposed to strays and 15 (21.1%) were exposed to pet dog.

In 43 (57.3%) of the victims, category of wound was ascertained. 40 (93%) of the cases had cat III exposure and 3 (7%) had cat II exposure. Site of exposure had been entered in the case record forms of 41 (54.7%) victims and of them, 26 (63.4%) had lower limb exposure, 11 (26.8%) upper limb exposure and 4(9.8%) had exposure on the face.

In 61 of the case sheets, entry about wound toilet had been made. Only 12(19.7%) of the 61 had performed wound toilet.

In 64 (85.3%) of the 75 case records, the history of post exposure prophylaxis had been entered. Only 1 (1.5%) of the victims had received rabies immunoglobulin.43 (67.2%) had not received any post exposure prophylaxis. Route of administration of the vaccine had not been documented in any of the cases.43 (67.2%) of the 64 victims had not received any vaccine. Only 4(6.3%) had received 4 doses of the vaccine and 1(1.5%) had received 5 doses of the vaccine.

Clinical signs and symptoms were entered in only 68 of the case sheets. All 68 had hydrophobia.59 had only hydrophobia and aerophobia.19 had hydrophobia aerophobia and breathlessness. 19 had hydrophobia, aerophobia, breathlessness and fever.10 had hydrophobia, aerophobia and parasthesia.2 had hydrophobia, aerophobia, breathlessness, fever and convulsions. 1 victim had hydrophobia and photophobia. Of the 75 victims, 26 (34.7%) were discharged against medical advice. Time since bite to seeking admission at hospital was 117.89 ± 80.48 days (Range: 7 days to 1 Year 6 months). Average time of death from admission was 25.98± 21.3 hrs (Range: 30 minutes to 6 days 19 hrs 15 minutes). Cause of death was not mentioned in any of the case sheets. Postmortem confirmation of clinical diagnosis was not done in any of the cases.

From the above study, we conclude that most of the suspected human rabies cases

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admitted had not received post exposure prophylaxis and in those who had received post exposure prophylaxis the PEP was incomplete, except for one case. The data entered into the case record forms of the patients was mostly incomplete.

Recommendations:

Rabies should be made a notifiable disease in India at the earliest 1.

Standard case record forms should be used in order to ensure uniformity of data 2.

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Alan C. Jackson, MD,a,b* Thamir Alandijany, MSc,b,c Wafa Kammouni, PhD,a Subir Roy Chowdhury, PhD,d Heidi Wood, PhD,b,e Ali Saleh, PhD,d and Paul Fernyhough, PhDd,f

aDepartment of Internal Medicine (Neurology), University of Manitoba, Winnipeg, Manitoba, Canada

bDepartment of Medical Microbiology, University of Manitoba, Winnipeg, Manitoba, Ca-nada

cDepartment of Medical Laboratory Technology, Faculty of Applied Medical Sciences, King Abdulaziz University, 21589 Jeddah 8324, Saudi Arabia

dDivision of Neurodegenerative Disorders, St. Boniface Hospital Research Centre, Winni-peg, Manitoba, Canada

eZoonotic Diseases and Special Pathogens, Public Health Agency of Canada, Winnipeg, Ma-nitoba, Canada

fDepartment of Pharmacology and Therapeutics, University of Manitoba, Winnipeg, Mani-toba, Canada

# Corresponding author:Dr. Alan C. JacksonHealth Sciences CentreGF-543, 820 Sherbrook StreetWinnipeg, Manitoba, Canada R3A 1R9Office 204-787-1578 FAX 204-787-1486e-mail: ajackson2@hsc.mb.ca

MITOCHONDRIAl DySFuNCTION IN RABIES VIRuS INFECTION

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September 30, 2013

Rabies is a an acute viral infection with severe clinical disease in humans and animals that is virtually always associated with a fatal outcome (2). A variety of techniques have demons-tratedthat neurons are infected with rabies virus (5). Neuropathological changes are typically relatively mild with a variety of inflammatory changes and degenerative neuronal changes are not prominant (5), which has led to the understanding that neuronal dysfunction underlies the neurological disease (1). A variety of abnormalities, including impaired neurotransmission, electrophysiological alterations, ion channel abnormalities, and nitric oxide toxicity, have been reported in rabies virus infection (3), but none have provided a satisfactory explanation for the postulated neuronal dysfunction.

In 2008 we published a report of experimental rabies with the CVS-11 strain of fixed rabies virus (CVS) administered by hindlimb footpad inoculation into adult transgenic mice expres-sing the yellow fluorescent protein (YFP) in a subpopulation of neurons (7) . Fluorescent mi-croscopy allows a detailed evaluation of neuronal processes in neurons expressing YFP. In both dendrites and axons of pyramidal neurons in the cerebral cortex of infected mice with severe disease we observed degenerative changes with beading and axonal swellings with involve-ment of about 41% of axons. More severe involvement was also observed in mossy fibers of the cerebellum. We felt that the changes explained the severe clinical disease of the mice, although histopathology studies showed only mild inflammatory changes.

We studied potential mechanisms explaining the degeneration of neuronal processes in CVS infection in cultured adult rodent primary dorsal root ganglion (DRG) neurons because these neurons are permissive for CVS infection, which allowed us to evaluate the axons. Because of a similarity of changes in diabetic neuropathy in which oxidative stress is known to play an important role (6), we hypothesized that the neuronal process degeneration is due to oxidative stress. After CVS infection we observed axonal swellings (β-tubulin staining) and reduced axonal growth occurring at 48 hours and increasing at 72 hours post-infection (p.i.) (4). We also observed immunostaining of amino acid adducts of 4-hydroxynonenal (4-HNE) in axons and in axonal swellings of infected neurons, which is a marker for lipid peroxidation and, hence, oxidative stress (4). Hence, we concluded that neuronal process degeneration in CVS infection is likely a consequence of oxidative stress.

Because mitochondria are considered the main site for the generation of reactive oxygen species (ROS), we evaluated a variety of mitochondrial parameters in CVS- versus mock in-fection in different cell types. Our hypothesis was that CVS infection leads to mitochondrial dysfunction, resulting in oxidative stress and neuronal process degeneration. We evaluated ac-tivities of the Krebs cycle enzymes citrate synthase in DRG neurons and both citrate synthase and malate dehydrogenase also in differentiated rat PC12 cells, mouse neuroblastoma (MNA) cells, and baby hamster kidney (BHK) - S13 cells. Activities were similar in CVS- and mock-infected cells at 72 hours p.i., indicating that there was no major effect on mitochondrial mass or intactness, and these findings shifted our attention to respiratory chain components.

Next, we evaluated the mitochondrial electron transport chain. Complex I, Complex III, and Complex IV pump protons from the mitochondrial matrix into the intermembrane space, ge-

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nerating a proton gradient. ATP synthesis consumes these protons in the conversion of ADP to ATP. At 72 hours p.i. we found that Complex I activities were increased by 35 - 75% (p<0.05) in CVS- versus mock-infection and that the increases were related to the susceptibility of the cell types to CVS infection, suggesting a direct viral effect on Complex I. Complex II-III activities were similar (p>0.09) in CVS- and mock-infections. Complex IV (cytochrome c oxidase) ac-tivities were increased by 29 - 44% (p<0.02) in CVS- versus mock infection, but the increases did not correlate with the susceptibility of the cell type to infection, suggesting an indirect and possibly a compensatory effect on Complex IV activity.

We performed mitochondrial respiration assays with the addition of several substrates and inhibitors in order to assess various mitochondrial states. Seventy-two hours after CVS- and mock infection of permeabilized PC12 cells we found no change (p=0.9) in the rate of proton leak or on coupled respiration, whereas in CVS infection there was a 33% increase (p=0.02) in maximal uncoupled respiration and a 49% increase (p=0.03) in Complex IV respiration.

Upon entering Complex I, NADH is converted to NAD+. We measured NADH and NAD+ in CVS- and mock infected PC12 cells at 72 hours p.i. We found an increase in NADH but not in NAD+, which resulted in a 36% increase (p=0.018) in the NADH/NAD+ ratio and alteration of the redox state. Because Complex I activity was increased, this provides evidence of reverse electron transport, in which electrons transfer from Complex III to Complex I, generating a high mitochondrial membrane potential and superoxide formation at Complex I.

We observed an increased mitochondrial membrane potential in CVS- versus mock infections at 72 hours p.i. (29% increase in PC12 cells, p=0.028; 47% increase in MNA cells, p=0.0009). This can be explained by the increased activities of Complex I and Complex IV with a normal proton leakage rate.

The intracellular ATP level was reduced in PC12 cells (24%) (p=0.007) and MNA cells (39%) (p=0.0006) in CVS- versus mock infection at 72 hours p.i. This reduction in the ATP level could be either due to a defect in ATP production (e.g., ATP synthase) as a direct or indirect effect of the viral infection or to an increase in ATP hydrolysis (e.g., utilized for viral replication).

We measured hydrogen peroxide production fluorometrically in CVS- and mock infected MNA cells 72 hours p.i. with the addition of substrates (pyruvate + malate or succinate), with or without ADP, and with or without rotenone (inhibits Complex I). We found increased ROS levels with the addition of pyruvate, malate, and ADP, and also with succinate with and without ADP and with succinate with and without rotenone. These findings suggest that ROS are pro-duced at multiple sites, including Complex I, Complex III, and possibly Complex IV.

We hypothesize that a rabies viral protein may induce the mitochondrial dysfunction of infected cells, possbly mediated by an interaction with Complex I. We have evaluated proteo-mic expression (by nano-LC MS/MS) of rabies virus proteins in mitochondrial extracts. We predominantly detected the presence of the rabies virus phosphoprotein; the rabies virus matrix protein was not detected. We have transfected HEK-293T cells with plasmids containing the rabies virus proteins. Only the plasmid expressing the rabies virus phosphoprotein produced an increase (94%) in the activity of Complex I. We are now evaluating which rabies virus phos-

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phoprotein sequences are important in producing the increased Complex I activity.

In summary, we have found evidence of mitochondrial dysfunction in CVS infection of a va-riety of cell types. We believe that the mitochondrial dysfunction results in oxidative stress and severe structural abnormalities affecting neuronal processes in experimentally infected mice, which explains the severe clinical disease and fatal outcome. The rabies virus phosphoprotein may play a fundamental role in inducing the mitochondrial dysfunction.

References

Fu, Z. F. and A. C. Jackson. 2005. Neuronal dysfunction and death in rabies virus infection. 1. J. Neurovirol. 11:101

Jackson, A. C, ed. Rabies: scientific basis of the disease and its management, Third Edition. 2. 2013. Oxford, UK, Elsevier Academic Press.

Jackson, A. C. and Z. F. Fu. 2013. Pathogenesis, p. 299-349. 3. In A. C. Jackson (ed.), Rabies: scientific basis of the disease and its management, Third Edition. Elsevier Academic Press, Oxford, UK.

Jackson, A. C., W. Kammouni, E. Zherebitskaya, and P. Fernyhough. 2010. Role of oxida-4. tive stress in rabies virus infection of adult mouse dorsal root ganglion neurons. J. Virol. 84:4697-4705.

Rossiter, J. P. and A. C. Jackson. 2013. Pathology, p. 351-386. 5. In A. C. Jackson (ed.), Ra-bies: scientific basis of the disease and its management, Third Edition. Elsevier Academic Press, Oxford, UK.

Russell, J. W., D. Golovoy, A. M. Vincent, P. Mahendru, J. A. Olzmann, A. Mentzer, and E. 6. L. Feldman. 2002. High glucose-induced oxidative stress and mitochondrial dysfunction in neurons. FASEB J. 16:1738-48.

Scott, C. A., J. P. Rossiter, R. D. Andrew, and A. C. Jackson. 2008. Structural abnormalities 7. in neurons are sufficient to explain the clinical disease and fatal outcome in experimental rabies in yellow fluorescent protein-expressing transgenic mice. J. Virol. 82:513-521.

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Dr. RANJIT MANKESHWAR, Associate ProfessorDr. PRIYA WARBHE, Assistant Professor

Dr. SULABHA AKARTE, Professor and HeadDepartment of Preventive and Social Medicine, Grant Medical College, Mumbai

Background: Intradermal vaccination was initiated at the Anti Rabies Vaccination (ARV) OPD at Sir JJ Hospital, Mumbai on 1st July 2008. This OPD is the only dedicated anti-rabies vaccination clinic in Mumbai. In 2012, 82,274 animal bite cases were reported in Mumbai.

Objectives: To evaluate the performance of the ID route in terms of Adherence and Cost.

Methodology: Hospital OPD based study. A five-year review of animal bite cases receiving TCV (PCECV & PVRV) by the ID (intradermal) route was studied. All animal bite cases, who were advised the PEP schedule, were the study population. Data thus obtained, was compiled and analyzed. For comparison, the 2007 data of vaccination by the IM route was compared with the latest completed year by the ID route i.e. 2012. Adherence to intradermal regimen was assessed from July 2008 to June 2013. 2 vaccines were used in the above period: PCECV (Rabipur) & PVRV (Indirab)

Statistical Methods: Odds ratios and 95% CI were calculated. Pearson’s Chi square test was used. Stata 12.1 was the analytical tool.

Results: A total of 2414 animal bite patients received TCV by the ID route in 2012. A dou-bling of Patient enrolment was seen in the 5-year period.

93.6% of cases receiving the ID route in 2012 completed the schedule as compared to 40.2% in case of those receiving TCV by the IM route in 2007, which is very highly significant (OR 21.7, 95%CI (17.6 – 26.8); p<0.00001). Adherence to all 4 doses by the ID route remained over 90% over the last 5 years. Adherence in those <18 years of age was 92.6%, in those who were 18-60 years of age was 93.7%, and in those >60 years of age, was 85.4%. Older patients had statistically significantly poorer adherence (p<0.0001). Females had statistically significantly lower adherence (91.8%), as compared with males (93.6%) (OR 1.3, 95%CI (1.06 – 1.59); p=0.009). Using 2012 data, a clear cost advantage of more than Rs. 16,00,000 is apparent when exclusive ID use is compared with IM use (2012 data. Vaccine @ Rs. 198 per vial)

FIVE yEARS OF INTRADERMAl VACCINATION & ADHERENCE AT ARV OPD, SIR J.J. HOSPITAl, MuMBAI: A REVIEW

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Discussion: In two studies from India where updated TRC, IDRV is given in government hospitals, the completion/compliance rate to full course or taking 4 doses of vaccine including the one on day 28 was found to be 38.5%1 in Mandya and 75.5%2 in North Kerala. Our results show adherence of >90% over a 5 year period. Innovative methods of recalling patients were tried in our setting. We used the Hospital Management Information System as a patient tracker. A staff nurse counseled patients on adherence, and telephone reminders were used to recall defaulting patients.

Conclusions: The use of the ID route has resulted in a dramatic improvement of the adhe-rence (>90%) as compared to the IM route. Patient enrolment has increased from 1075 in 2007 to 2414 in 2012. The improvement in adherence has been sustained over the last 5 years. The immense cost savings have a positive public health implication. Perhaps the most important single intervention, given its simplicity and effectiveness, is recalling patients who miss ap-pointments, making every effort to keep them in care, coupled with effective counseling.

References:

1. Mahendra BJ, Harish BR, Vinay M. A study of factors influencing compliance to IDRV at anti-rabies clinic of Mandya Institute of Medical Sciences, Mandya. APCRI Journal 2009; 11:18-20.

2. Jesha M, Martin J, Bina T, Raphel L. Lailabi, Jayadev. Compliance to IDRV at the anti rabies clinic in a tertiary care hospital in North Kerala. APCRI Journal 2011; 12:21-4.

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AuthorsVinay M*, BJ Mahendra

Introduction

Rabies is virtually a 100% fatal disease. Annually 20,000 deaths occur in India. Approxi-mately 17.4 million exposures occur in India annually, most of which are dog bites.1 Deaths due to rabies can be prevented by appropriate post exposure prophylaxis (PEP) consisting of wound care, administration of immunoglobulin and administration of the complete schedule of rabies vaccine.2 Intradermal Rabies vaccination is widely followed in India which requires a much lesser quantity of vaccine and the change in the route of administration has made Rabies vaccine affordable to a majority of the dog-bite victims3. In spite of the affordable prices of the vaccine, the compliance to intradermal Rabies vaccine was low in various studies done in India4. Lack of PEP and non-compliance to vaccination schedule are common factors in people dying due to rabies.5,6

The Anti Rabies Clinic in Mandya Institute of Medical Sciences (ARC-MIMS), a govern-ment teaching hospital, has a dedicated anti-rabies clinic which has been providing pre-exposure and post-exposure prophylaxis since 2007. Intradermal vaccination is administered. Previous studies on compliance showed a high drop-out rate and the majority of drop outs did not receive the fourth dose of the vaccine7. In a bid to increase compliance, a telephone call was made to the victims, when they did not come to ARC-MIMS on the scheduled date. This study assesses the effectiveness of telephone reminders increasing compliance to intradermal rabies vaccination and the other factors which influence the compliance with regard to telephone reminders

Objective

To determine the effectiveness of telephone reminders for increasing compliance to IDRV •schedule.

To determine the association between increase in compliance and the socio-demographic •characteristics of the victims.

TITLE : EFFECTIVENESS OF TELEPHONE REMINDERS FOR INCREASING COM-PLIANCE TO INTRADERMAL RABIES VACCINATION SCHEDULE

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Methodology

This is a hospital based, before and after comparison study. The vaccine administered in the Anti-Rabies clinic is cell culture vaccine. The regimen that is followed is WHO recommended ‘Updated Thai red cross regimen’ which is 0.1ml on injected intradermally over the deltoid regions of both the arms on days 0, 3, 7 and 28 of the exposure. The compliance of the victims to the regimen during the years 2008 and 2009 was studied. The compliance was low. In a bid to increase, telephone reminders were started in the year 2010.

At the end of each working day the people who had missed their dose which was due on that working day would be called and reminded to receive their dose on the following day. We were not able to remind some of the victims who did not have a phone. The compliance of all the animal bite victims who reported to ARC-MIMS during the years 2011 & 2012 was studied and compared with the compliance of victims who had reported in 2008 & 2009. Some victims received the first dose of the vaccine and Rabies immunoglobulin at ARC-MIMS and intended to take the rest of the doses in other government facilities where IDRV was available. These victims were excluded from the analysis.

The association of sociodemographic factors like as age, sex, residence, education and other factors such as the category of bite with the change in compliance was also analysed. Analysis was done using proportions and Z test was used to derive the statistical significance of the dif-ference between proportions.

Results:

The number of victims who had received post exposure prophylaxis during the years 2008 and 2009 was 7747 and the number of victims who received post exposure prophylaxis during the years 2011 and 2012 was 8005. The number of people who received all the four doses in the period before the introduction of telephone reminders was 2797 (36.1%) and 4890 (63.1%) had received 3 doses. The number of people who received the four doses after the introduction of reminders increased to 4353 (54.4%) and 5807 (72.5%) had received 3 doses. The increase in compliance to both the third and the fourth dose was statistically significant (P<0.0002).

With regard to the compliance to 3 doses, an increase in compliance was statistically signi-ficant among different age groups, education, residence, occupation, nature of bite (provoked / unprovoked), time since bite and site of bite (P<0.05). Statistically significant increase was not seen in females, socioeconomic status (SES) I, II & V, exposed to animals other than dogs, non-pets & category 2 exposures. (table 1)

Table 1: Factors associated with increase in compliance to third dose after the introduction of telephone reminders

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Factors

influencing

compliance

Before the introduction of telephone reminders

After the introduction of te-lephone reminders

Percent increase in com-pliance

Z value P valueNo. com-pleted

To t a l No.

Percent No. com-pleted

To t a l No.

Percent

Total 4890 7747 63.1 5807 8005 72.5 9.4 12.662 <0.0002

Age

<15 years

1782 2688 66.3 2278 3058 74.5 8.2 6.81 <0.0002

>15 years

3106 5059 61.4 3527 4947 71.3 9.9 10.47 <0.0002

SexMale 2733 4617 59.2 3735 5035 74.2 15.0 15.643 <0.0002

Female 2157 3130 68.9 2073 2970 69.8 0.9 0.74 0.749

Education

Illiterate 946 1611 58.7 962 1537 62.6 3.9 2.220 0.0264Primary 1612 2750 58.6 1473 2361 62.4 3.8 2.747 0.0060

High school

1318 2115 62.3 2054 2594 79.2 16.9 12.767 <0.0002

College 1014 1271 79.8 1321 1513 87.3 7.5 5.381 <0.0002

ResidenceUrban 1071 1697 63.1 1472 2033 72.4 9.3 6.068 <0.0002Rural 3818 6050 63.1 4336 5972 72.6 9.5 11.146 <0.0002

Occupa-tion

Agricul-ture

1116 1763 63.3 1232 1694 72.7 9.4 5.935 <0.0002

Others 411 655 62.7 482 695 69.4 6.7 2.563 <0.0104

Socio-economic

status

I 304 380 80.0 368 448 82.2 2.2 0.786 0.4319II 792 1185 66.8 959 1425 67.3 0.5 0.251 0.8018III 1488 2332 63.8 2127 2730 77.9 14.1 11.07 <0.0002IV 1855 2983 62.2 1926 2610 73.8 11.6 9.254 <0.0002V 452 867 52.1 429 792 54.2 2.1 0.821 0.4071

Animal causing

exposure

Dog 4732 7499 63.1 5154 7613 67.7 4.6 5.942 <0.0002

Others 180 248 72.7 259 329 78.6 6.4 1.712 0.0869

Nature of bite

Provo-ked

2603 4145 62.8 3154 4339 72.7 9.9 19.01 <0.0002

Unpro-voked

2447 3860 63.4 2651 3666 72.3 8.9 8.273 <0.0002

Time since bite

<1 day 714 1116 64.0 1186 1641 72.3 8.3 4.619 <0.00021 – 2 days

3628 5686 63.8 4073 5579 73.0 9.2 10.498 <0.0002

> 2 days 546 945 57.8 546 785 69.5 11.7 5.054 <0.0002

Site of Bite

Lower limb 2963 4772 62.1 3428 4755 72.1 10.0 10.414 <0.0002

Upper limb 1658 2611 63.5 2071 2842 72.9 9.4 7.434 <0.0002

Others 240 364 65.9 306 408 75 9.1 5.535 <0.0002

Pet / non-pet

Pet 1621 2649 61.2 2333 3074 75.9 14.7 12.000 <0.0002Non-pet 3411 5098 66.9 3294 4931 66.8 -0.1 - 0.114 0.9092

CategoryII 787 1209 65.1 882 1341 65.8 0.7 0.359 0.7196

III 4106 6538 62.8 4922 6660 73.9 11.1 13.717 <0.0002

With regard to the compliance to 4 doses, an increase in compliance was statistically significant among different age groups, sexes, education, residence, occupation, nature of bite (provoked / unprovoked),

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time since bite, site of bite and pet / non-pet. (P<0.05). Statistically significant increase was not seen in SES I, exposed to animals other than dogs and non-pets. (table 2)

Table 2 : Factors associated with increase in compliance to fourth dose after the introduction of telephone reminders

Factors

influencing

compliance

Before the introduction

of telephone reminders

After the introduction

of telephone remindersPercent increase in com-pliance

Z va-lue

P valueN o . c o m -pleted

To t a l No.

PercentN o . c o m -pleted

Total

No.

P e r -cent

Total 2797 7747 36.1 4353 8005 54.4 18.2 23.030 <0.0002

Age<15 years 952 2688 35.4 1905 3058 62.3 26.9 20.333 <0.0002>15 years 1847 5059 36.5 2449 4947 49.5 13.0 13.13 <0.0002

SexMale 1441 4617 31.2 2870 5035 57.0 25.8 25.459 <0.0002Female 1355 3130 43.3 1482 2970 49.9 6.6 5.172 <0.0002

Education

Illiterate 480 1611 29.8 558 1537 36.3 6.5 3.883 <0.0002Primary 888 2750 32.3 1178 2361 49.9 17.6 12.785 <0.0002High school 764 2115 36.1 1603 2594 61.8 25.7 17.527 <0.0002College 666 1271 52.4 1017 1513 67.2 14.8 7.965 <0.0002

ResidenceUrban 602 1697 35.5 1104 2033 54.3 18.8 11.495 <0.0002Rural 2196 6050 36.3 3249 5972 54.4 18.1 19.941 <0.0002

OccupationAgriculture 633 1763 35.9 901 1694 53.2 17.3 10.225 <0.0002Others 240 655 36.6 381 695 54.8 18.2 6.698 <0.0002

Socio-eco-nomic sta-tus

I 251 380 66.1 309 448 68.9 2.8 0.895 0.3708II 547 1185 46.2 735 1425 51.6 5.4 2.757 0.0058III 812 2332 34.8 1550 2730 56.8 22.0 15.608 <0.0002IV 993 2983 33.3 1535 2610 58.8 25.5 19.134 <0.0002V 194 867 22.4 223 792 28.1 5.7 2.711 0.0067

A n i m a l causing ex-posure

Dog 2700 7499 36.0 4111 7613 54.0 18.0 22.229 <0.0002

Others 9 22 40.7 187 329 56.9 16.2 1.457 0.1451

Nature of bite

Provoked 1488 4145 35.9 2369 4339 54.6 18.7 17.290 <0.0002Unprovoked 1405 3860 36.4 1983 3666 54.1 17.7 15.421 <0.0002

Time since bite

<1 day 413 1116 37.0 903 1641 55.0 18.0 9.298 <0.00021 – 2 days 2036 5686 35.8 3013 5579 54.0 18.2 19.419 <0.0002> 2 days 351 945 37.1 436 785 55.6 18.5 7.651 <0.0002

Site of BiteLower limb 1704 4772 35.7 2563 4755 53.9 18.2 17.855 <0.0002Upper limb 953 2611 36.5 1557 2842 54.8 18.3 13.534 <0.0002Others 141 364 38.7 232 408 56.9 18.2 5.031 <0.0002

Pet / non-pet

Pet 948 2649 35.8 1783 3074 58 22.2 16.777 <0.0002Stray 1871 5098 36.7 2377 4931 48.2 11.5 11.657 <0.0002

CategoryII 468 1209 38.7 552 1341 41.2 2.5 1.263 0.2066III 2328 6538 35.6 3796 6660 57.0 21.4 24.636 <0.0002

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Discussion:

Telephone reminders, post card reminders and computer generated ‘short messaging service’ have been used to increase compliance to vaccination. Some of these have been shown to be effective in increasing compliance to vaccination8, 9, 10. Phone contact ensures that the message is understood and telephone reminders are hypothesized to be more effective in less literate victims. In our study statistically significant increase in compliance to the third and fourth dose were seen. The increase in compliance was not significant in the socioeconomic class I prob-ably because the compliance had attained a plateau as evidenced by the fact that the compliance is highest in this group compared to the other groups. Similarly, the increase in compliance to third dose was not significant among class V because most of these people did not have phones and it was not possible to remind them. There was no significant increase in compliance among those who had category II exposure which underlines the need to educate those with category II exposures about the necessity to complete the vaccination schedule at the first contact with the victim.

This increase in compliance cannot be purely attributed to telephone reminders alone. Sepa-rate data of compliance among those who received telephone reminders was not available. Other factors which could have contributed to the increase in compliance include increase in awareness about the disease & vaccination and availability of improved transportation facili-ties (city buses have been started). The costs avoided due to the need to re-start the vaccination schedule and the deaths due rabies that have been potentially averted also adds to the scope of effectiveness of the telephone reminders.

Conclusion:

Telephone reminders increases compliance to intradermal vaccination against rabies.

References

Sudarshan MK, Madhusudhana SN, Mahendra BJ, et.al.”Assessing the burden of human 1. rabies in India: Results of a national multicenter epidemiological survey. International Journal of Infectious Diseases 2007; 11: 29-35.

World Health Organization. Expert consultation on Rabies. WHO Technical Report Series 2. 982: Geneva: WHO 2013; pg 37.

World Health Organisation. India’s ongoing war against rabies. Bulletin of the World 3. Health Organization Past issues; 87: 885-964.

Satapathy DM, Reddy SSS, Pratap AK, Behera TR, Malini DS, Tripathy RM, Mahapatra 4. HH. “Drop out” cases in IDRV: A cause for concern. APCRI journal 2010; 12: 40-1.

Suraweera W, Morris SK, Kumar R, et.al., ”Deaths from symptomatically identifiable 5. furious rabies in India: a nationally representative mortality survey”. PLoS Neglected Tropical Disease: 6 (10): e1847: 2012.

107

Kumar A, Pal D. “epidemiology of human rabies cases in Kolkata with its application to 6. post prophylaxis” Indian Journal of animal Research: vol 44 (4): 2010; 241-7.

Mahendra BJ, Harish BR, VInay M. A Study of Factors influencing compliance to IDRV 7. at Anti-Rabies Clinic of Mandya Institute of Medical Sciences, Mandya. APCRI Journal 2009:11;18-20.

Rosser WW,Hutchison BG,McDowell I, Newell C. Use of reminders to increase compli-8. ance with tetanus booster vaccination. CMAJ 1992; 146: 911–917.

Sellors J, Pickard L, Mahony JB, Jackson K, Nelligan P, Zimic-Vincetic M, Chernesky M. 9. Understanding and enhancing compliance with the second dose of hepatitis B vaccine: a cohort analysis and a randomized controlled trial. CMAJ 1997;157:143-148.

Larson B, BergmanJ, Heidrich F, Alvin BL, Schneeweiss R. Do Postcard Reminders Im-10. prove Influenza Vaccination Compliance? Medical Care 1982; 20: 639-48.

108

Pimburage RMS1, Gunatilake M2, Wimalaratne O3, Balasuriya A4, Perera KADN3

1Department of Public Health Veterinary Services, Ministry of Health 2Department of Physiology, Faculty of Medicine, University of Colombo

3Department of Rabies Research and Vaccine Quality control, Medical Research Institute, Colombo 08

4Faculty of Medicine, General Sir John Kotelawala Defense University

Introduction

Being an island, Sri Lanka has well accepted advantages in the elimination of rabies com-pared to several other countries. Currently dog vaccination, post exposure treatment and animal birth control activities are conducted as rabies control measures in the country. As a result of these, in last three decades reduction of human rabies deaths from 377 in 1973 to 38 in 2012 which was the lowest human deaths reported throughout the country to date, was possible.

Rabies has become a matter of great concern as the annual cost of anti-rabies serum and vaccines used for post exposure treatment are around 350 million rupees. It is stated that elimi-t is stated that elimi-nation of dog rabies can be achieved with sustained dog herd immunity (vaccination coverage) of 70%. Sri Lanka is conducting division wise mass vaccination and dog population control programmes. However, it was not possible to achieve and sustain the required level of immu-nization coverage due to lack of manpower and transport facilities to carry out the annual dog vaccination programme in each and every village in the country.

General Objectives

To measure the rabies neutralizing antibody titres in a representative canine population •following anti-rabies vaccination (ARV)

To determine suitable timing for booster vaccination.•

COMPARISON OF IMMuNOGENICITy TO ANTI-RABIES VACCINE IN DOGS OF DIFFERENT AGE GROUPS

109

Following groups (A to H) were included in the selected canine population.

Stray/Free roaming (male/female) adult dogs (more than 1 year old) without previous A. immunization history. (Identified by ear tattooing and red dog collars.)

Stray/free roaming (male/female) adult dogs (more than 1 year old) with previous im-B. munization history.

Young domestic dogs with previous immunization history. (age 3 months-1year)C.

Young domestic dogs without previous immunization history. (age 3 months-1year)D.

Adult domestic dogs with annual immunization history (age1-6years) E.

Adult domestic dogs with out regular annual immunization history. (age1-6years)F.

Puppies of previously immunized domestic mothers/ bitches. (age >6 weeks to 3 G. months)

Puppies of unvaccinated domestic mothers/ bitches. (age >6 weeks to 3 months) H.

Method

Stray/free roaming and healthy domestic animals (Sri Lankan local breed/mongrel breed) in Kalutara district were recruited for this study.

On the day of vaccination blood sample was collected from each animal (D0). After that single dose (1 mL) of anti-rabies vaccine recommended by World Health Organization (WHO) was injected. Post vaccination blood samples were collected on day 30, 180, 360 (D30, D180 and D360) from recruited dogs in all groups.

Serum were separated and stored at Medical research institute, Colombo (MRI). Serum-neutralizing antibody titers produced against rabies virus were determined by rapid fluorescent focus inhibition test (RFFIT). This method measures only the antibodies that will kill live rabies virus. In this method serum is diluted, and each dilution is mixed with live rabies virus. The mixtures are then put in to a cell culture to detect the virus that was not killed by the serum.

Results

Table 1:

The percentage of canines in Groups A to H who had antibody titres above the protective level of 0.5 IU/ml with the mean antibody titres on D0, D30, D180 and D360 are given in following table.

110

Table 1

Day 0 Day 30 Day 180 Day 360

% Mean % Mean % Mean % Mean

Free roa-ming

Unvaccina-ted (n=47) Group A 6.4

0.128

87.23

12.56

87.24

8.963

59.58

3.81

V a c c i n a -ted (n=47) Group B 70.21

6.663*

100

51.85*

100

22.89*

82.91

7.177

y o u n g domestic

V a c c i n a -ted (n=47) Group C 78.72

16.0*

95.74

34.78

93.62

27.09

78.72

21.59*

Unvaccina-ted (n=63) Group D 98.41

0.11

93.65

17.39

88.89

11.21

39.68

3.05

Adult do-mestic

V a c c i n a -ted (n=51) Group E 76.47

13.63

96

30.4

88

40.27

79

24.71

Unvaccina-ted (n=48) Group F 77.08

6.84

100

25.73

95.83

16.96

83.33

9.7

Domestic V a c c i n a -ted (n=40) Group G 0

0.1

97.5

10.67

82.5

4.64

7.5

0.24

Puppies Unvaccina-ted (n=37) Group H 0

0.07

94.59

12.57

78.38

4.77

10.18

0.32

Distribution of median antibody titres of dogs in different groups is shown in Figures1,2,3,4. These show that distribution of mean antibody titres in groups A to F except in group E (adult vaccinated) is more or less the same with the peak in day 30 and gradually declining thereaf-ter.

Figure 1: Distribution of means antibody titres of dogs in groups A to F.

111

Figure 2: Distribution of median antibody titres by groups A to F

The antibody titres in puppies (greater than 6 weeks of age) of both immunized and unim-munized bitches is very low on day 0 and it comes to very low levels by day 360 even after the 1st vaccination. Data in Group G indicates that puppies in that group do not get protection by maternal antibodies until the time of 1st immunization.

In the other six groups, the vaccinated animals have higher (2 IU/ ml) antibody levels to begin with and have a higher antibody level on day 360 too. They show a very good antibody level by day 180.

Unvaccinated animals start with low antibody levels and return to low levels by day 360, but have a satisfactory antibody level by day 180.

Discussion

This first descriptive and comparative study investigated antibody titre development in free roaming and domestic dogs and in puppies of immunized and unimmunized bitches after an an-ti-rabies immunization compared to the antibody titre on the day of immunization. In general, results of groups A to F showed that animals with previous immunization history have higher (2 IU/ ml) antibody titres to begin with and have a higher antibody titre on day 360 too. Animals without previous immunization history start with low antibody titres and return to low titres by day 360, but have a satisfactory antibody titre by day 180. Antibody titres on D30 of dogs in Groups B, C, D, E and puppies in groups G and H show that some animals have not responded to immunization and thus they are in danger if they expose to a rabid dog bite.

Humoral response induced by immunization has been identified as an important method of control and prevention of rabies which is a deadly zoonotic disease. Therefore, Government Rabies Control Programme with the private sector takes measures as much as possible to immu-nize higher percentage of free roaming and domestic dogs (over 70%). However, immunization cannot be carried out annually due to practical difficulties. Our data indicates that antibody levels are at a higher level at the time of booster immunization and also these dogs maintain a good level of immunity until the time of next immunization if dogs are immunized annually. However, we observed a large individual variation in the humoral response in animals irrespec-tive of immunization.

112

Many factors such as age, species, type of vaccine used, efficacy of the vaccine used, health status of the animal, nutritional status, parasitic infections, site of inoculation and history of exposure to the same antigen could affect the humoral response to the immunization. We used WHO recommended monovalent anti-rabies vaccine. After purchasing from the agent vaccine was stored under recommended conditions of the manufacturer until it is used. Therefore, type and efficacy of vaccine could not be a cause for the variation in the humoral response that we observed as there is a good response by the animals in certain groups for the immunization. We made every effort to recruit healthy dogs after a general examination of the animal which is the accepted method in animal as well as human immunizations. It is difficult to comment about the nutritional status of the animal by the general examination if it is not very obvious. Therefore, whether the discrepancy observed in the humoral response in dogs in different groups is due to the nutritional status of individual animals or not cannot be ruled out as we recruited both domestic and free roaming dogs. When grouping animals we considered similar age categories; even with this categorization we observed discrepancies in the humoral response. In villages most of dogs are not rearing as pets. Therefore they do not treat for external and internal para-sites. Parasitic infection could interfere production of immunity.

As we used intramuscular route for immunization this factor could not affect the humoral response in the recruited animals. The method we used for the determination of humoral res-ponse is RFFIT which has a higher sensitivity as recommended by the WHO and well esta-blished at the MRI. Therefore, sensitivity of RFFIT is not a factor for the differences observed in the humoral response among animals for the anti-rabies immunization. By evaluating all these we can conclude that several factors such as health status of the animal, nutritional status, parasitic infections and history of exposure to the same antigen may have contributed for the individual variation in the humoral response we observed in the study.

Although the dogs in groups A and D were without previous immunization history, the deve-lopment and maintenance of antibody titres above the recommended protective level could be acquired by a primary immunization in majority of dogs until D180. This is an indirect evidence for the efficacy of the vaccine used in the study. However, 40.42% and 57.14% dogs in group A and D out of 47 and 63 recruited for those groups did not have protective level of antibody titres by D360.

When we consider the animals in group D (62 out of 63 animals had antibody titres below the protective level), authorities should pay more attention during immunization programmes to animals in group D which included young domestic dogs without previous immunization history; aged 3 months-1 year and who are more active and have closer contacts with humans. They carry the greatest risk similar to the puppies in groups G and H. More than 50% of dogs in group D and more than 80% of puppies in groups G and H did not have antibody titres until the annual booster. Therefore, it is necessary to give two anti-rabies injections to animals in these groups at a suitable interval with annual boosters. Majority of dogs with a previous immuniza-tion history recruited to groups B, C, E and F were immunized previously by the Government Rabies Control Programme. They usually use monovalent anti-rabies vaccine multi-dose vials compared to the monovalent single dose vaccine vials we used in the study. Considering the cut off value of 0.5 IU/ml for antibody titres as recommended by the WHO for human sera, our

113

results show that a single immunization to stray dogs and domestic dogs without a previous im-munization history and to puppies fails to produce an adequate humoral response. There were animals in other groups with past immunization history who did not have adequate protection. It may be dangerous to rely on the previous immunization history of a biting dog when making post exposure treatment decisions.

Conclusions

A single dose of anti-rabies immunization is not sufficient for the maintenance of antibody ti-tres for a period of 1 year in 40.42% of canines in Group B. More than one immunization would help to maintain antibody titres above the protective level in majority of canines (82.97%) in Group A. Mean antibody titres of dogs in Groups C and D indicate immune responsiveness in animals in Group C with previous immunization history is higher than the animals in Group D. Irrespective of whether dogs in Groups E and F were regularly immunized or not, antibody titres were above the protective level in most of the dogs on day 60, 180 and 360. Maternal antibodies do not provide adequate protection to puppies in Group G until the first anti-rabies vaccination. Immunity development after immunization seems to be closely similar in both the groups of puppies. There seems to be many factors which affect development of antibodies following immunization against rabies

SCIENTIFIC SESSION VIIInnovation of Rabies and New research

115

N R Ramesh Masthi1,MalteshUndi2

1.Associate Professor ,2. Tutor cum PostgraduateDepartment of Community Medicine,

Kempegowda Institute of Medical Sciences (KIMS),Bangalore -560 070, Karnataka,India.

Email: ramesh.masthi@gmail.com

ABSTRACT

Mapping of animal bite cases has never happened in India. Global Positioning System (GPS) is a new tool available which can revolutionize measurement of morbidity and mortality of animal bite & human rabies cases and will provide an accurate map of animal bite cases. GPS mapping can be easily made available at local government public health centre level since it requires only a handheld GPS receiver, computer and google earth map without a need to have any sophisticated software like Geographic Information System (GIS) which are expensive.Objectives:1. To spatial map animal bite cases using GPS in a rural area.2.To find out the inci-dence and describe socio demographic profile of the animal bite cases. Materials &Methods :This exploratory study was conducted in villages coming under rural field practice area of KIMS, Bangalore, Karnataka, South India during the last quarter of 2012 .An household survey of sampled population was done to estimate the annual incidence of animal bite.A hand held GPS (GarminGPS72H instrument was used to record the GPS coordinates. Results: The hou-hou-sehold survey was completed and in front of each household which had reported animal bite cases, the GPS coordinate was noted for every subject who was included and North and East coordinates observed on the GPS instrument was recorded. All animal bite cases were recorded in a similar manner. These coordinates were subsequently plotted on the google earth map using a computer and spatial mapping of animal bite cases was done. The incidence of animal bite was 1.17%. Majority of the bite victims were in the age group of 15-60yrs ,males, category –III wounds and administered anti rabies vaccination. Conclusion : GPS was easy to use and can be used in epidemiological field studies for measurement of animal bite cases.

GLOBAL POSITIONING SySTEM : A NEW TOOL FOR MEASUREMENT OF ANIMAL BITE CASES .

116

Pakamatz Khawplod, Maneerat Benjawongkulchai1, Wipaporn Jaijaroensup1, Thira-pong Tantawichien1,2 and Henry Wilde2

1Queen Saovabha Memorial Institute; The Thai Red Cross Society, 2Chulalongkorn Uni-versity ; Bangkok, Thailand.

Travelers who are likely to have exposure to dogs or cats in canine rabies-endemic countries,rabies related lyssaviruses circulating in bats or rabies virus circulating in bats and others wildlife, are being advised to complete a preexposure rabies vaccine regimen (PREP) prior to departure. The World Health Organization (WHO) recommends PREP vaccine schedules consisting of one intramuscular (IM) full dose or one 0.1 mL intradermal (ID) dose of any WHO-recognized tissue or avian culture rabies vaccine injected on days 0, 7, 21, or 28 [1]. These schedules have been shown to result in an excellent and long-lasting immune response [2]. The traveler, however, may not have enough time to complete a series of three injections before leaving. They may receive one injection and are told to complete the series at their destination.This may not be possible or is neglected. Most tourist destinations in Asia and Africa are in high-risk canine rabies endemic countries where there may be total lack or short supply of quality vaccines and particularly rabies immunoglobulins. Administration of rabies immunoglobulininto and around all bite wounds on the first day of rabies prophylaxis should remain the optimal postexposure treatment [3, 4]. Travelers who received incomplete PREP rabies vaccination may cause a problem for further post-exposure prophylaxis at destination country if any rabies exposure occurs.

We propose to shorten course of PREP of 3 injections to one week on days 0, 3 and 7 which is the first 3 dose of PEP schedule when the travelers have at least 8 days before departure.Our data [5], suggest that 3 injections of 2 sites ID 0.1 ml or one full dose IM on day 0, 3 and 7 are as immunogenic as WHO pre-exposure schedule of three injections within 3-4 weeks of day 0, 7 and 21 or 28. All volunteers developed an adequate and accelerated neutralizing antibody response within seven days after they received two boosters at one year later. We also had a study group who received only ID 0.1 ml two sites on day one , all volunteers also had adequateand similar antibody response after receiving two booster vaccination one year later. The similar results in Khawplod P, 2012 [6], also suggest that one injection of one full dose IM or ID 0.1 mL 2 sites on a single day are adequate to prime the immune memory and obtain an acceleratedimmune response after booster with WHO recommendations of one clinic visit of ID 0.1 mL of 4 sites [1,7, 8] or 2 booster of IM on day 0 and 3 at one year later. Most travelers who travel to Asian or Africa had an average time of stay for less than one month [9].

ONE SHOT RABIES IMMuNIzATION AND PRE ExPOSuRE RABIES VACCINA-TION IN TRAVEllER

117

The travelers who receive short course of three injections within one week or single dose of rabies vaccination are enough to start immune response promptly after first vaccine injection and before leaving and protect them from rabies infection if any any exposure to a rabid animal occured after receiving WHO recommended booster vaccine schedule.

One or short course of three injections within one week are enough to prime immune respon-se. It is convenient and will be encourage more travelers to receive rabies vaccination before travel to endemic area where rabies vaccine or rabies immunoglobulin may not be available. Some of them might decided to receive delay PEP treatment days or weeks or ignored to receive any vaccination at original country.

Corresponding Author: Pakamatz Khawplod, Queen Saovabha Memorial Institute ,WHO-CC for Research on Rabies Pathogenesis and prevention, The Thai Red Cross Society, Bangkok 10330, Thailand. E-mail: pakamatz@yahoo.com

Conflict of Interest Statement: The authors have no conflict of interest.

References

WHO. Rabies Vaccines. Position Paper. Wkly Epidemiol Rec. 2010;85: 309–22.1.

Suwansrinon K, Wilde H, Benjavongkulchai M, Banjongkasaena U, Lertjarutorn S, 2. Boonchang S, Suttisri R, Khowplod P, Daviratanasilpa S, Sitprija V. Survival of neu-tralizing antibody in previously rabies vaccinated subjects: a prospective study showing long lasting immunity. Vaccine. 2006 May 1;24(18):3878-80.

Wilde H, Khawplod P, Hemachudha T, Sitprija V. Postexposure treatment of rabies infec-3. tion: can it be done without immunoglobulin? Clin Infect Dis. 2002 Feb 15;34(4):477-80.

Sriaroon C, Daviratanasilpa S, Sansomranjai P, Khawplod P, Hemachudha T, Khamo-4. ltham T, Wilde H. Rabies in a Thai child treated with the eight-site post-exposure regi-men without rabies immune globulin. Vaccine. 2003 Sep 8;21(25-26):3525-6

Khawplod P, Wilde H, Benjavongkulchai M, Sriaroon C, Chomchey P. Immunogeni-5. city study of abbreviated rabies preexposure vaccination schedules. J Travel Med. 2007 May-Jun;14(3):173-6.

Khawplod P;6. Jaijaroensup W; Sawangvaree A; Prakongsri S; Wilde H. One cli-nic visit for pre-exposure rabies vaccination (a preliminary one year study). Vacci-ne 2012;30(19):2918-20.

Khawplod P, Benjavongkulchai M, Limusanno S, Chareonwai S, Kaewchompoo W, 7. Tantawichien T,

Wilde H. Four-site intradermal postexposure boosters in previously rabies vaccinated sub jects. J Travel Med. 2002 May-Jun; 9(3):153-5.

Tantawichien T, Tantawichien T, Supit C, Khawplod P, Sitprija V. Three-year expe-8. rience with 4-site intradermal booster vaccination with rabies vaccine for postexposure prophylaxis. Clin Infect Dis. 2001 Dec 5;33(12):2085-7.

Phanuphak P, Ubolyam S, Sirichayakul S. Should travelers in rabies endemic area re-9. ceive pre-exposure immunization? Ann Med Interne 1994;145:409-411.

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Table1A. Secondary antibody response after 2 booster rabies vaccination one year later in volunteers who received 3 injections of rabies PREP vaccination on day.0,7 and 28 (Gr.A ) , ID 0.1mL at 2sites on day 0,3,7 (Gr.B )and one full dose IM on day 0,3,7 (Gr.C ) previously[5].

Group Booster 1 year later (ID 0.1 ml 2 sites on day 0, 3)

Day 360 Day 367 Day 374A

(n=16)

Age 18-35

M/F 5/11

GMT

Range

> 0.5 IU/ml

0.96

0.32-3.0

13/16

29.14

6.7-227.8

16/16

49.39

13.1-308.4

16/16

B

(n=16)

Age 18-32

M/F 4/12

GMT

Range

> 0.5 IU/ml

w1.12

0.30-4.8

15/16

22.99

5.9-295.4

16/16

105.08

26.11-496.7

16/16

C

(n=20)

Age 18-40

M/F 8/12

GMT

Range

> 0.5 IU/ml

0.97

0.3-4.8

16/20

35.16

12.0-191.5

17/17

125.0

29.73-800.0

20/20

Vaccine : Purified Vero Cell Rabies (PVRV), Batch 0525, potency 7.5 IU/0.5ml

Table 1B. Secondary antibody response after 2 booster vaccination one year later in volunteers who received one injection of ID 0.1 mL 2 sites rabies vaccination

previously [5].

Group Booster 1 year later (ID 0.1 ml 2 sites on day 0, 3)

Day 360 Day 367 Day 374D

(n=14)

Age 8-11

M/F 7/7

GMT

Range

> 0.5 IU/ml

0.41

0.06-3.67

5/13

9.15

3.4-22.6

10/10

51.96

13.6-141.4

9/9

PVRV , Batch 0525 Potency 7.5 IU/0.5ml

Table2. Geometric Means Titers and range of rabies neutralizing antibody responses after

pre-immunization and booster at one year later[6].

119

Group day 0 day14/35day 360 (before boos-ter)

day 367 day 374

Gr.1A Pre-exposure ID 0.1 ml day 0,7,21 booster IM day 0,3 neg 4.22 0.49 11.27 54.53

No. Subj. >0.5 IU/ml (%) 0 100% 35% 100% 100%

n=17 range 1.25-31.1 0.13-2.13 4.1- 40.4 13.6- 417.7

Gr.1B Pre-exposure ID 0.1 ml day 0,7,21

. booster ID 0.1mlx4 sites day 0

neg 4.37 0.30 42.49 114.28

No. Subj. >0.5 IU/ml (%) 0 100% 26% 100% 100%

n=19 range 1.36-11.89 0.06-2.71 20.5-104.5 32.4-423.2

Gr.2A Pre-exposure ID 0.1 ml x2 sites day 0

booster IM day 0,3

neg 1.07 0.15 9.71 46.23

No. Subj. >0.5 IU/ml (%) 0 81% 13% 100% 100%

n=16 range 0.4-5.69 <0.03-0.92 1.84.-130.5 5.96-324.2

Gr.2B Pre-exposure ID 0.1 ml x2 sites day 0

booster ID 0.1mlx4 sites day 0

neg 0.95 0.10 11.96 54.36

No. Subj. >0.5 IU/ml (%) 0 75% 13% 100% 100%

n=24 range 0.2-4.99 <0.03-1.07 2.1-77.6 10.1-402.6

Gr.3A Pre-exposue IM day 0 .

booster ID 0.1mlx4 sites day 0

neg 1.58 0.08 10.13 18.96

No. Subj. >0.5 IU/ml (%) 0 100% 6% 100% 100%

n=17 range 0.52-7.11 <0.03-2.18 2.97-18.34 5.49-124.2Gr.3B Pre-exposue IM day 0 .

booster ID 0.1mlx4 sites day 0

neg 1.50 0.11 13.33 46.92

No. Subj. >0.5 IU/ml (%) 0 94% 13% 100% 100%

n=17 range 0.4-7.71 0.03-1.69 1.81-130.5 8.84-237.8

120

Ravish H S, M K Sudarshan, S N Madhusudana, A R Rachana, D H Ashwath Narayana, Veena V, B Y Ashwin,

Corresponding author: Ravish Hardanahalli Shankaraiah, Associate Professor, Department

of Community Medicine, Kempegowda Institute of Medical Sciences (KIMS), Banashankari

2nd Stage, Bangalore 560070, India.

Phone: +91 9900562743; E mail: drravishhs@rediffmail.com

The World Health Organization recommends completing post-exposure prophylaxis against

rabies with the same cell culture rabies vaccine or embryonated egg rabies vaccine and any

deviation from this shall be an exception. In the present study safety and immunogenicity of

post-exposure prophylaxis was studied in ninety animal bite cases that had interchangeability

of rabies vaccines either by brand/type or route of administration. Among them, forty seven had

change in route of administration from intramuscular to intradermal or vice versa and forty three

had change in the brand/type of cell culture rabies vaccine. All of them had category III rabies

exposure and received equine rabies immunoglobulin along with the rabies vaccine. However,

in none of them, there were any adverse reactions. All of them had rabies virus neutralizing an-

tibody titers ≥ 0.5 IU per mL by day 14 which is considered as adequate for protection against

rabies. Thus, the present study showed that, post-exposure rabies prophylaxis was safe and im-

munogenic despite changes in the route of administration and brand/type of rabies vaccine.

INTERCHANGEABILITy OF ROUTE OR TyPE/ BRAND OF ANTI RABIES VACCINES IN POST ExPOSuRE PROPHylAxIS: SAFETy &

IMMUNOGENICITy STUDy

121

Ashwath Narayana D H*, Madhusudana S N**, Sudarshan M K*, Gangaboraiah*, Aravind M*, Ravish H S*, Ashwin B y**

The currently practiced Updated Thai Red Cross ID regimen (2-2-2-0-2) is of one month dura-tion with dropout rate for the day 28 dose is up to 30-40% with poor compliance by the patients. Hence, based on results of study done in Thailand, World Health Organization (WHO) in 2012 has recommended research on shorter post exposure regimens for rabies prophylaxis and the “one week, four sites” intradermal regimen (4-4-4-0-0) has a practical and economic advan-tage over Updated Thai Red Cross regimen (2-2-2-0-2). An earlier study done in India found Rabipur & Verorab was safe and immunogenic when administered in healthy volunteers using “one week, 4 site regimen. Hence, a comparative, open label, phase III, randomized control trial was conducted to assess the safety and immunogenicity of two WHO approved vaccines for ID administration viz. Rabipur (purified chick embryo cell vaccine, PCECV) and Verorab (purified verocell rabies vaccine, PVRV) in cases of suspect exposure to rabies.

The study was conducted at anti rabies clinic, Kempegowda Institute of Medical Sciences (KIMS) Hospital & Research Centre, Bangalore, India. Institutional ethics committee approval was obtained and study was done according to ICH-GCP guidelines. After screening by using inclusion & exclusion criteria, ninety subjects in the age group of 18-55 years of age with category II and III animal bites/suspect exposures to rabies were enrolled into the study. Equine rabies immunoglobulin was administered to all category III exposures as per WHO recommendation. Marketed batch of either Rabipur or Verorab were administered to subjects after randomization. 0.1 mL of vaccine was injected intradermally to subjects at 4 sites i.e. in both deltoids (2 sites) & suprascapular areas (2 sites) on days 0, 3 & 7. Adverse drug reaction (ADR) to vaccines was recorded. Serum samples of subjects collected on days 0, 14 and 90 were analyzed for rabies virus neutralizing antibody titers (RvnAb) by rapid fluorescent focus inhibition test (RFFIT) at National Institute of Mental Health and Neurosciences (NIMHANS), Bangalore, India.

Majority (64%) of subjects were males, 73% of the subjects were employed, 91% be-longed to middle & higher socio-economic status. Majority (90%) of the subjects had dog bite

ASSESSING SAFETy AND IMMuNOGENICITy OF RABIPuR AND VERORAB: RESULTS OF A RANDOMIZED CONTROL TRIAL USING ONE WEEK INTRA

DERMAL REGIMEN (4-4-4-0-0) IN CASES OF SUSPECT EXPOSURE TO RABIES

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and 65 % of these bites were on lower limbs. All the bites were from suspect rabid dogs. 85 % of the subjects had category III bites and received ERIG. Skin sensitivity test was positive in 11.8% to ERIG. Full dose of ERIG was administered after premedication in all category III exposures and there were no immediate or delayed ADR to full dose of ERIG. The common ADR to vaccines were itching, redness, pain at the site of injection. The incidence of ADR in Rabipur group was 2.9 % (Local: 2.2 %; Systemic: 0.7%) & in Verorab group 1.1 % (Local: 0.9%; Systemic: 0.2 %). Majority of the ADR were mild & resolved without medication. The geometric mean concentration of RvnAb on day 14 was 14.5±1.27 and 11.8±1.15 on day 90 in Rabipur group; 14.4±1.27 on day 14 and 11.9±1.14 on day 90 in Verorab group. Both groups of subjects with or without ERIG had protective antibody titers from day 14 till day 90 and there was no significant decrease in antibody response after ERIG administration. The antibody response elicited by this new “one week 4 site” ID regimen is comparable to Essen & Updated TRC regimen from day 14 till day 90.

In conclusion, both Rabipur and Verorab were found to be safe and immunogenic when administered by using new shortened “one week, 4 sites” intradermal regimen (4-4-4-0-0) to individuals following suspect exposure to rabies.

*Department of Community Medicine, Kempegowda Institute of Medical Sciences, Bangalore, India

** Department of Neurovirology, National Institute of Mental Health and Neurosciences, Ban-galore, India

Corresponding author: D. H. Ashwath Narayana [dhashwathnarayana@gmail.com]

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AUTHORS:Pranee Panichabhongse1 Pornpiroon Chinson1 Supoj Noopattaya2

Chanis Leeteraprasert2 Thaiseri Jarroonpak2 Pakamasz Kowplod3

1Bureau of Disease Control and Veterinary Services, Department of Livestock Development, Ratchathewi, Bangkok, THAILAND

2Mukdahan Provincial Livestock Office, Amphur Muaung, Mukdahan, THAILAND

3Queen Saovabha Memorial Institute, Phatumwan, Bangkok, THAILAND

Introduction

Rabies is endemic in all regions of Thailand with a relatively high incidence, especially in dogs. It was suggested that the specimen from animals which died of Rabies be sent to nearest diagnosis lab under the supervision of the Bureau of Disease Control and Veterinary Services, Department of Livestock Development, Thailand. According to our data, the positive results were 87-91% in dogs, 4% in cats, 3% in cattle, and 1% in other animals and wildlife (Bureau of Disease Control and Veterinary Services, 2011). It is a fierce fact that those rabies positive dogs are responsible for more than 95% of human deaths. Thus, many vigorous rabies control programs have been largely conducted with expectation of becoming rabies free nation.

Generally, cattle and buffaloes are raised by farmers in rural villages either for their agricultural activities and meat. Thus, livestock is counted as the major asset of each family. The animals are typically kept in the poorly protectable pens or stables in or near the house yard. Every morning, they are released for grazing in the natural pasture or scavenging food elsewhere without any close attention. The vulnerability to being bitten either by normal dogs or in the worst case by rabid dogs straying around the villages is always high. Since rabies is an untreatable disease--for animal welfare with humane practice and safety of the peopleinvolved--any unvaccinated animals exposed to rabies should be euthanized immediately or within 7 days. In case of livestock having been early euthanized or slaughtered, their meat is believed to be consumable without any risk of infection. But for Thai farmers, livestock, particularly if pregnant, are so valuable and worth keeping rather than losing them that way. In this matter,

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effective post-exposure treatment of rabies in livestock is essential to save life of the animals and their offspring. Martell et al. (1973) reported that transplacental transmission of rabies virus could occur in rabid bovine after the natural infection as rabies antigens had been isolated in brain, placenta, heart, kidney and lung of the cow and her fetus. Such transmission could also be found in guinea pigs, sheep rabbits and bats. Nowadays, rabies immunization has become an alternative treatment since it is expected to build up a protective immunity--not only in the immunized animals but also their unborn fetuses via placenta and their newborns via colostrum.

Previously, an immediate booster dose of vaccine and 45-day observation is recom128 mended for the vaccinated animal being exposed to rabies. For the non-vaccinated animals, post-exposure vaccination is not really recommended. However, some countries may carry out various post-exposure treatment regimens for some valuable animals with recommendation that those animals should be kept under close observation for 6 months (Center of Disease Control: CDC 2001). Even immunization regimen with 1-, 3- and 4-day intervals have been studied, a definite guideline for the post-rabies exposure treatment in livestock is unavailable.

Thus, this study proposes a post-exposure protocol of five rabies vaccine injections at 4-day intervals in a pregnant buffalo. Evidence of transferable maternal immunity against rabies in a newborn water buffalo is also demonstrated.

Objectives

To investigate whether a series of post-exposure rabies vaccination can be an effective 1. 1. therapeutic method for a pregnant buffalo being bitten by a laboratory confirmed rabid dog.

To detect the existence of maternal immunity in the calf born from a buffalo having 2. post-2. exposure vaccination against rabies.

Buffaloes

Materials and Methods

A third-trimester-pregnant water buffalo (Bubalus bubalis) was bitten on the nose by a laboratory confirmed rabid dog. The bleeding wound was cleaned with plain water without applying any antiseptic. The buffalo gave birth to a healthy calf 75 days after the last shot during being observed for at least 6 months.

Vaccination

An immediate dose of rabies vaccine Dog-vac Rabia: Ovejero, Spain), followed by four consecutive doses of rabies vaccine (Rabisin® lot no. L372487, Merial, France) at a four-day interval, were injected intramuscularly.

Sera collection

The first serum sample of the mother buffalo was collected 7 days after being bitten and the second collection was done 61 days after receiving the last shot, equivalent to 86 days after being bitten. The following series of sera collection of the mother buffalo was exactly on the same days of the suckling buffalo which were 86, 152, 188, 202, 220, 271 and 285 days after being bitten. Sera of the suckling were consecutively collected 63, 79, 93, 115, 162 and 177 days after birth. After this, the mother buffalo and the calf have been left for free gazing on the hill during rainy season so the sera collection could not be continued.

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Neutralizing antibody titers

Neutralizing rabies antibody titres of all sera were checked at the Queen Saovabha Memorial Institute (QSMI) by the RFFIT (Rapid Fluorescent Focus Inhibition Test) method which is currently the gold standard as the Fluorescent Antibody Virus Neutralization (FAVN) test (Welch et al., 2009).

Results

The results were shown in Table 1 and Figure 1. The rabies neutralizing antibody titer 129 of the pregnant buffalo was earliest detectable at 0.04 IU/ml, on day 7, and rapidly increased to the maximum level at 13.05 IU/ml day 220 after being bitten then started decreasing. The titers in calf sera ranged between 1.14 and 3.38 IU/ml.

Table 1. Neutralizing antibodies against rabies in sera of the calf buffalo collected after birth and the mother buffalo collected after being bitten.

Days of serum collectionCalf (after birth) - - 63 79 93 115

162

7 86 152 188 202 220 271

177Mother (after being bitten) 285

Neutralizing antibodies (IU/ml)Calf (after birth) - - 3.38 3.24 1.35 1.14

1.84

0.04 1.61 4.2 8.1 11.97 13.05 2.08

2.01Mother (after being bitten) 1.83

Note: -: no serum collection

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Discussion

The neutralizing antibody titer of the pregnant buffalo having post-exposure treatment against rabies was 0.04 IU/ml at day 7 after the first injection. The titer on day 61 after the 5th injection or 86 days after being bitten (1.61 IU/ml) was higher than that of the protective level and the buffalo showed no sign of rabies for at least 6 months of observation. These evidences made us deduce these titers were from immunity production rather than the infection. The antibody titers of the mother buffalo have been increasing from day 7 after the first injection up to 13.05 IU/ml on day 220 then started decreasing to 1.83 on day 285. The antibody titers of the calf were 3.38 IU/ ml. on day 63 after birth which is higher than protective level (≥ 0.5 IU/ ml.) but decreased to 1.14 IU/ ml. on day 115 after birth. Such level of titers would indicate that maternal immunity is effectively transferable. Since this study was performed in an incidental case, colostrum of the buffalo was not collected for checking of immunity titer in parallel with that of her sera.

Auekingpetch and Onyon (2001) treated four beef cattle being bitten by laboratory confirmed dog at nose, eyelid, ear and foreleg with RabisinR (Merial) by 1-day interval for 4 injections. All these animals still survived 6 months after the last injection. Panichabhongse et al. (2003) reported that five consecutive injections of post-exposure rabies vaccine at three-day interval, in a gravid pig being bitten by a rabid dog, did not affect the health of her foetuses. In addition, the pig’s health was in normal status for at least 38 months. Filho et al. (2010) found that booster of rabies vaccine in pregnant cows could induce neutralizing antibody titer against rabies to a protective level which is directly transferable via colostrum to the calves. Nofs et al. (2010) found that the anti-rabies titers of the three newborn elephant calves lasting approximatelythree months after birth and being equal or higher than those of their mothers would suggest that the transplacental route of maternal immunity is valid. Filho et al. (2012) also reported in the following year that antibody titers of calves born to cows which received a booster of rabies vaccine during the third trimester were similar to those being transferred through colostrum; thus, rabies vaccination is recommended at the age of two months in the endemic area.

Conclusion

Five consecutive injections of four day-interval vaccination could be a viable and effective post- exposure treatment option against rabies in pregnant buffalo. Serum titers of the newborn buffalo being higher than that of the protective level indicate that transferability of maternal immunity to the calf could persist for at least six months. Further study on persisting duration of the protective immunity in buffalo and calf is crucial.

Acknowledgements

The authors would like to express gratitude to all supports including---Dr. Apai Sutthisang (Deputy Director General), Dr. Chuyos Chowsirikul (Chief of Mukdahan Provincial Livestock Office), Mr. Sutthipong Nempisut, Mr. Ronnarat Photepon and Ms. Varunee Metar (Mukdahan Provincial Livestock Office) for sample collection; Ms. Rattana Suttisri and Ms. Wachiraporn Saengsrisom (Rabies Laboratory, Queen Saovabha Memorial Institute) for serological diagnosis; and Dr. Prasarn Tangkawattana (Khon Kaen University), Mrs. Fiona Dickinson and Dr. F. X. Meslin for valuable suggestion.

References

Auekingpetch, W. and Onyon, T., 2002, Investigation report of beef cattle bitten by rabid dog

127

(unpublished). Sakonnakorn province.

Bureau of Disease Control and Veterinary Services, 2011, Animal rabies Situation in Thailand, Department of Livestock Development.

Center of Disease Control, 2001, Compendium of Animal Rabies Prevention and Control: Association of

State Public Health Veterinarians Inc. p.1-6 http://www.cdc..gov/mmwrhtm/22508a1htm. Martell, M.A., Geron Montes, F., and Raul Alcocer, B., 1973, Transplacental transmission of bovine rabies

after natural infection. J Infect Dis 27; 291.

Nofs, S.A., Atmar, R.L., Keitel, W.A., Hanlon, C., Stanton, J.J., Tan, J., Flanagan, J.P., Howard, L. and Ling, P.D., 2013, Prenatal passive transfer of maternal immunity in Asian elephants (Elephas maximus). Vet Immunol Immunopathol 153(3-4):308-11. doi:10.1016/j.vetmm.2013.03.008. Epub.

Filho, O.A. Megid, J. Geronutti, L. Ratti Jr, J., Kataoka, A.P.A.G. and Martorelli, L.F.A., 2010, Importance of antirabies revaccination for an adequate antirabies protection in bovine newborns. Clin Vaccine Immunol 17(7): 1159-1161.

Filho, O.A., Megid, J., Geronutti, L. Ratti Jr, J. Kataoka, A.P.A.G. and Martorelli, L.F.A., 2012, Vaccine

immune response and interference of colostral antibodies in calves vaccinated against rabies at

2, 4 and 6 months of age born from antirabies revaccinated females. Res Vet Sci 92:396-400. Panichabhongse P., Hoonsuwann W., Srisongmuang W., Prateepsook P. and Khawpload P.

Seroconversion of 3-day Interval Rabies Post-exposure Treatment in Three Pigs and One Dog. Proceedings of the 28th WSAVA 24-27 October 2003. Bangkok, Thailand.

Welch, R. J., Anderson, B.L. and Litwin, C.M. 2009, An evaluation of two commercially available ELISAs and one in-house reference laboratory ELISA for the determination of human anti-rabies. J Med Microbiol 58(6):806-810.

128

Anita Mahadevan, Maya D Bhat1, Chandrajit Prasad1, Madhusudana SN2, Satishchandra P3, Shankar SK

Departments of Neuropathology, Neuroimaging & Interventional Radiology1, Neurovirology2, Neurology3

National Institute of Mental Health & Neurosciences, Bangalore, India

Background

Rabies is a fulminant fatal viral encephalites. Antemortem diagnosis is a challenge particu-larly in paralytic forms of rabies that closely mimic Guillain Barre syndrome posing a diagnos-tic dilemma to the clinicians. Post-mortem demonstration of rabies antigen in brain remains gold standard for diagnosis. However, for the clinican antemortem differentiation between pa-ralytic form of rabies and Guillain Barre (GB) syndrome is critical as the former is fatal while the latter is treatable. Differentiation also has therapeutic implications and, if confirmed to be rabies, vaccination and isolation for preventing spread of infection has to be initiated.

In the course of the illness, several patients with paralytic rabies undergo MR imaging of the brain at the onset of altered sensorium/encephalon involvement to exclude other mimcs and evaluate cause of alteration in sensorium partculalrly to exclude acute disseminated encephalo-myelitis which will respond to steroids. It would be useful to review MRI findings in such cases to determine if there are features characteristic of rabies on MRI that will aid the clinician. Pu-blished literature on this subject in human rabies is limited and suggests varied patterns without specific patterns of involvement. The neuropathological correlate of these changes have not been addressed till date.

Objective

To study the spectrum of neuroimaging characteristics in histologically confirmed cases of human paralytic form of rabies. Recognition of these patterns will not only aid in early dia-gnosis but is also important for health care professionals to institute appropriate post exposure prophylaxis. The distribution of rabies viral antigen in neuroanatomical areas will provide an

NEUROPATHOLOGICAL CORRELATION OF NEUROIMAGING FEATURES IN HUMAN RABIES ENCEPHALITIS

129

insight into the pathophysiology and neurochemical anatomy.

Results

We present the MRI findings in five cases of paralytic rabies (four with histopathological confir-mation post-mortem) to determine if any specific patterns emerge.

Cranial MRI was performed in five confirmed rabies cases, in addition to spinal imaging in two. Imaging findings were inconsistent, varying from case to case with T2 and FLAIR hy-perintensities variably involving basal ganglia, thalami, brain stem, cerebellum, and cerebral cortex in one case. Another case revealed bilateral medial temporal lobe, gyrus rectus and cin-gulate gyrus involvement mimicking herpes simplex encephalitis. In one patient who recovered partially and succumbed two years after diagnosis, hyperintensities in grey matter of cerebel-lum and cerebrum was striking. MRI was relatively normal in one case. In two cases with MR imaging of spinal cord, enhancement of spinal nerve roots was seen. Post mortem examination in four cases revealed dusky discolouration in thalami and basal ganglia. One of the cases re-vealed small haemorrhages in brain stem and cerebellum corresponding to the hyperintensities on imaging.

Large mount sections of various neuroamatomical areas were sampled in correlation with neuroimaging changes and analysed for correlation with rabies viral antigen distribution, in-flammatory response and glial alterations.

Discussion

Reported literature on MR imaging in human rabies is scarce and without neuropathological correlation, limited to single case reports. Most studies published relate to dog rabies wherein serial MRI studies have been reported that reports enhancement only in terminal stages of disease and is correlated with onset of coma and opening of blood brain barrier. However neu-ropathological point to point correlates of these imaging findings has not been reported to the best of our knowledge.

Our findings suggest that neuroanatomical areas involved in producing MRI changes are not consistent. The areas showing hyperintensities on T2/FLAIR imaging do not correspond to areas showing rabies viral antigen as on anatomical mapping, rRabies viral antigen was found to be widespread in various neuroanatomical areas not restricted to the areas involved on neuroimaging. Neuroimaging abnormalities seemed to correlate better with zone of inflam-mation rather than glial response and probably reflect alteration in blood brain barrier and fluid dynamics following disease manifestation rather than viral antigen distribution. No consistent neuroimaging pattern are seen to assist in antemortem diagnosis of rabies viral encephalitis and discriminate from other viral encephalitides. Further extended studies are essential to confirm this.

130

Manjunatha MV*, Nandita Hazra, Shaheen Taj, Sampada Sanyal, Ashwin Belludi, Reeta Mani, Madhusudhana SN

*Contact author: manjuvswamy@gmail.comDepartment of Neurovirology, National Institute of Mental Health and

Neurosciences, Bengaluru, India

Background: Adaptive immune responses that comprise the cell mediated immunity (CMI) and the humoral immunity are crucial for protection against several viral infections. The key players in the CMI are the T cells which consist of CD4 and CD8 T cells. The CD4 or the Helper T cells are critical for CMI as well as humoral responses and they are classified into many types based on their function, namely Th1, Th2, Th17, TRegs, etc. The CD8 or cytotoxic T cells play a key role in immunity to viral infections. The humoral responses are mediated by B lymphocytes and the anti-viral neutralizing antibodies are known to provide protection against multiple viral infections.

In Rabies, a fatal encephalitis caused by the Rabies virus, the critical role of neutralizing antibodies for protection is well established, however, the role of CD4 Helper T cells in rabies-specific protective responses is not understood. Vaccination against rabies mainly induces pro-tective antibody responses, which are driven by the cytokine Interleukin-4 (IL-4) from T Helper 2 (Th2) CD4 T cells. Cell mediated immune (CMI) responses driven by Interferon -ϒ secreting T Helper 1 (Th1) T cells are not known to play a significant role in protective immune responses to rabies. Therefore in this study we planned to investigate the induction of Th1 and Th2 res-ponses in individuals receiving pre and post-exposure rabies vaccination, by determining levels of circulating antigen-specific IFN-γ or IL-4 producing CD4 T cells in peripheral blood.

Objectives: (a) To study induction oh Th1 and Th2 responses in human subjects recei-ving pre and post exposure rabies vaccination (b) To determine if these antigen specific T cell responses are enhanced after a booster dose

Materials and Methods:

Study Groups: (a) Healthy, rabies vaccine naive subjects with no history of dog bite (n=5), (b) Individuals given Pre-exposure prophylaxis by intradermal (ID) route: n=22 (Boos-

TH1 AND TH2 T CEll RESPONSES TO RABIES VACCINATION: A PRELIMINAR y STUDy

131

ted: 11, non-boosted: 11), (c) Individuals given Post-exposure prophylaxis by ID route (n=12), Intramuscular (IM) route (n=10)

Methods: Peripheral blood mononuclear cells were isolated from healthy controls and individuals receiving pre and post exposure rabies vaccination. Rabies virus neutralizing an-tibody (RVNA) titers were determined by Rapid Fluorescence Focus Inhibition Test (RFFIT). The antigen specific Th1 and Th2 T cell responses were determined by using IFN -ϒ and IL-4 ELISPOT assays.

Results:

Responses following pre-exposure prophylaxis: The rabies vaccine antigen specific IFN-γ and IL-4 producing T cells were detectable in peripheral blood even after few months following 3 doses of pre-exposure vaccination. A booster dose clearly induced proliferation of the antigen-specific Th1 and Th2 T cells with a significant increase in the numbers of INF-γ and IL-4 producing T cells. Figures (A) and (B). The Rabies Virus Neutralizing antibody (RVNA) levels correlated well with the number of Th1 (IFN- ϒ) and Th2 (IL-4) producing T cells.

(A)

(B)

(C)

GroupIFN

SFCs

IL-4

SFCs

RVNA titers

IU/ml

Pre-booster 42 10 3.5

Post- booster 138 58 7.4

132

Figure (A) IFN-ϒ and Figure (B) IL-4 T cell ELISPOT assay for individuals with pre-exposure vaccination (c) Correlation between Th1 and Th2 responses and the Rabies Virus Neutralizing Antibody (RVNA) titers. SFCs: Spot Forming Cells

Responses following post-exposure prophylaxis: The rabies vaccine antigen specific IFN-γ, Figure (D) and IL-4, Figure (E), producing T cells were elevated in peripheral blood fol-lowing post-exposure vaccination. There was significant proliferation of the antigen-specific Th1 and Th2 T cells with significant rise in levels of RVNA Titers. The Rabies Virus Neutrali-zing antibody (RVNA) levels correlated well with the number of Th1 (IFN- ϒ) and Th2 (IL-4) producing T cells, Figure (F).

(F)

GroupIFN

SFCs

IL-4

SFCs

RVNA titers

IU/ml

Intra-dermal 53 191 21.85

Intra-muscular 49 223 22.5

Figure (D) IFN-ϒand Figure (E) IL-4 T cell ELISPOT assay for individuals with pre-exposure vaccination (F) Correlation between Th1 and Th2 responses and the Rabies Virus Neutralizing Antibody (RVNA) titers.

Conclusion: Pre-exposure rabies prophylaxis by the intradermal route induces significant le-vels of Th1 and Th2 responses. A similar increase in these antigen specific Th1 and Th2 respon-ses was observed following post-exposure intradermal and intramuscular vaccination. In both scenarios high titers of neutralizing antibodies were detected. Therefore this preliminary study suggests that following anti-rabies vaccination there is induction of both antibody as well as T cell responses. Interestingly, the IFN-γ producing Th1 T cells were also elevated along with the Il-4 producing Th2 T cells suggesting that the hitherto unexplored role of the Th1 cells may be crucial for induction of protective immune responses against rabies. A booster dose clearly enhanced the antigen specific T cell and antibody responses, which probably suggests a role for these T cells in secondary responses.

133

Reeta Mani, Ashwin YB, Madhusudana SN, Vinuth P* and Keshava Prasad*

Department of Neurovirology, National Institute of Mental Health & Neurosciences (NI-MHANS) and Institute of Bioinformatics (IOB), Bangalore, India

Rabies, a fatal zoonotic viral encephalitis accounts for an estimated 55,000 human deaths worldwide; India accounts for almost 40% of these deaths. Vaccination is considered to be the most cost effective means of prevention and control of human rabies. Without the use of post-exposure prophylaxis, the total number of predicted human rabies deaths in Asia and Africa would be 3,30,300.

Enormous progress has been made in rabies vaccine production from the time Louis Pas-teur and his colleagues injected the first of 14 daily doses of rabbit spinal cord suspensions containing progressively inactivated rabies virus into 9-year-old Joseph Meister, who had been severely bitten by a rabid dog. Currently available modern human rabies vaccines are derived from rabies virus grown on cell cultures or embryonated eggs. As the demand for human rabies vaccines is increasing, more and more new vaccines are being manufactured in India, as well as several other countries. The World Health Organization (WHO) recommends the periodic evaluation of the purity of cell lines used in the production of rabies vaccines, and the genetic identity of the vaccine virus strains. We therefore evaluated six human rabies vaccines available commercially in India for purity by analyzing their viral and non-viral protein contents, and their genetic identity.

Material and Methods

Six human rabies vaccines, commercially available in India were procured for the study. These included three purified vero cell vaccines (PVRV), two purified chick embryo cell vaccines (PCECV) and one purified duck embryo vaccine (PDEV). The WHO Sixth International Stan-dard for Rabies vaccine was also procured from the National Institute for Biological Standards and Control (NIBSC, UK).

Total RNA was extracted from solubilized vaccines using the QIAamp Viral RNA Mini Kit (Qiagen). A 446 bp region in N gene and 800 bp region in G gene were amplified by one step

GENETIC CHARACTERIZATION AND ASSESSMENT OF PURITy OF COMMERCIAl HuMAN RABIES VACCINES AVAIlABlE IN INDIA

134

RT-PCR using SuperScript® III One-Step RT-PCR System with Platinum®Taq (Invitrogen). PCR products were purified using a commercial kit (QIAquick Gel purification kit, Qiagen) prior to sequencing and the PCR products were sequenced from Amnion Biosciences Pvt Ltd, Bangalore.

In order to compare the protein content of the vaccines total protein estimation was performed using the modified Lowry’s method.This was followed by separation of vaccines and analysis by SDS-PAGE and subsequent Coomassie staining using standard methods. As a preliminary study, Isobaric tags for relative and absolute quantitation ( iTRAQ) based quantitative proteo-mic analysis of three vaccines was carried out and the relative quantity of viral and non-viral proteins was estimated. The data obtained was searched against RefSeq 52 Human protein data-base and Rabies virus protein database using Proteome Discoverer, version 1.4.0.288 (Thermo Fischer Scientific, Bremen, Germany) workflow using SEQUEST search algorithm.

Results

Partial N and G gene sequencing confirmed the declared vaccine strain in all vaccines except one PVRV vaccine. All vaccines (except PCECV-1 and PDEV) demonstrated abundant protein signals at 60-70kDa, on Coomassie stained gels with substantial amounts of non-viral proteins like human serum albumin (HSA). (Figure-1) Mass spectrometry and data analysis identified 54 human proteins and 4 Rabies virus proteins in the three rabies vaccines tested. It also confir-med HSA as the most abundant non-viral protein in the vaccines.

Figure-1 SDS-PAGE Analysis of Vaccines

Conclusion

Minor discrepancies in genetic identification observed support WHO recommendation for mo-lecular characterization of vaccine seed strains. Presence of any other animal or human derived ingredients in vaccines may cause allergic/adverse reactions or may transmit infective agents. More studies are required to know the impact of high amounts of HSA and other non-viral proteins on the immunogenicity of the vaccine, and establish their role, if any, in causation of adverse effects. Further improvement in the presently available cell-culture vaccines can be achieved by reduction of non-viral protein content without loss of immunogenicity, and mini-mizing putative side effects.

ORGANIZING COMMITTEE

ChairmanDr. Thavatchai Kamoltham

Organizing SecretaryDr. Apirom Puanghat

RIA FOUNDATION

PresidentDr. M.K. Sudarshan

Vice – PresidentDr. S.N. Madhusudana

Executive DirectorDr. D.H. Ashwath Narayana

Director - PublicationsDr. S.N. Madhusudhana

International CoordinatorDr. B.J. Mahendra

Treasurer Dr. H. S. Ravish

RIA FOUNDATION ADVISORS

Dr. F.X. Meslin, SwitzerlandDr. Charles E. Rupprecht, USA

Dr. Deborah J. Briggs, USADr. Alexander I. Wandeler, CanadaDr. Thiravat Hemachudha, Thailand

Dr. Henry Wilde, ThailandDr. Herve Bourhy, FranceDr. R.L. Ichhpujani, India

LIST OF SPEAKERS AND PARTICIPANTS

137

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