Rabies Surveillance

Dr Suresh GuptaConsultant

Pediatric Emergency MedicineSir Ganga Ram Hospital, New Delhi

WHO Recommended

Surveillance Standards

for

Rabies

Rationale for Surveillance

WHO promotes

• Human rabies prevention though PET

• Disease Elimination through vaccination of dogs and other animal reservoirs

Surveillance is essential for

• Detection of high risk areas

• Detection of outbreaks quickly

• Monitor use of vaccine

Recommended Case Definition

Case Classification:(Based on Clinical Description & Laboratory Criteria)

Human Rabies :Human Rabies : -Suspected

-Probable

-Confirmed

Human Exposure to rabies:Human Exposure to rabies:

-Possibly Exposed

-Exposed

Recommended types of surveillance

• Surveillance in human population:– Human exposure to rabies– Human rabies case– Outbreak investigations

• Surveillance in animal population– Wild and Domestic species reservoirs

Rab

ies

Ind

icat

ors

1.Presence/absence of rabies2. Human rabies

a. Number of human deathsb. Human deaths according to animal species source of exposurec. People bitten by suspected dogs

3. Animal rabiesa. Total number of dog casesb. Total number of other domestic animal casesc. Total number of wild animal casesd. Total number of bats cases

4. National rabies vaccine production and importationa. Veterinary vaccine according to vaccine typesb. Human vaccine according to vaccine typesc. Human rabies immunoglobulin

5. Rabies vaccine administrationa. Dogs vaccinationb. Human vaccine application - Post-exposure treatmentc. Number of patients treated according to vaccination regimen

d. Number of persons receiving treatment according to animal species source of exposure

Recommended minimum data elements

• Human Rabies Exposure– Case based data– Aggregated data

• Surveillance of Deaths from Human rabies

Recommended data analysis, presentation and reports

• No of human rabies death and rabies cases in animal(by species),by date of presentation

• Human exposure by location, date of animal biting/scratch episode animal species, outcome in human and animal populations

• Cases by geographical area and dates of biting, type of animal, occupation and outcome

Principal uses of data for decision making

• Detect outbreaks in endemic areas and new cases in rabies free area

• Determine high risk areas for intervention

• Rationalize the use of vaccine and immunoglobulins

• Evaluation of intervention for animal reservoirs and exposed human population

Special Aspects

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

Presence/Absence of rabies 2000

No information Absence Presence

Rabies trends in 2000

No information Rabies free Stable Decreasing Increasing

Geographical Distribution 2000

No information Rabies free Border area Limited area Most parts

Epidemiological pattern 2000

No information Rabies free Bat Dog Wild

Rabies situation and trend

• Human Rabies 35-50,000/Year– Asia and Africa are the main

• Animal Rabies– Africa 2344,USA 8509, Europe 5098, Asia ??

• General Trends– Europe reporting decrease in rabies cases– Animal rabies Dog 57%, Wild life 33%, Bat 10%

Rabies and Prevention

• Human PET– Exposure to Dog- Africa 87%, Asia 97%, Europe 4%– Vaccine alone Africa 82%, Asia 88%, Europe 80%

• Vaccine– Human Vaccine: 76% vaccine on cell culture– Animal Vaccine: 99% cell culture,

• Vaccine application in Dogs– Compulsory in 13/25 African countries,3/10 American

countries, 18/33 European countries, 3/10 Asian countries

Reported Human Rabies Cases in India

Reported Human Rabies Cases in India

Reported animal rabies cases in India

Reported animal rabies cases in India

Reported No of PET

Human and animal rabies vaccine produced or imported

Not available at Rabnet

Rabies Vaccination for dogs and other animal species

Not available at Rabnet

Current country information on rabies in India at Rabnet

Last update of this informations : 1999-12-01Last update of this informations : 1999-12-01

• Region : Asia Country : India WHO Region : EURO

1) Presence of rabies and disease surveillance • Is rabies a notifiable disease?• Does a surveillance system exist?• Is it operational?• Does rabies occur in the country? yes • Does rabies exist in the entire country?If No, please specify infected areas.2) Reservoir species• First rabies reservoir Second rabies reservoir• not applicable not applicable • Third rabies reservoir Other reservoir• not applicable

3) Rabies vaccine used for human postexposure treatment• Primary cell line Diploid cell line Continuous cell line Nervous tissue• Treatment schedules not applicable not applicable not applicable • Other Schedules• Is vaccine also applied intra-dermaly ?

Contact address on rabies diagnosis, prevention and control in human and animal in India

For questions on rabies prophylaxis and treatment in human please contact or For questions on rabies diagnosis, surveillance and control in animals please contact

Last nameFirst nameTitlePositionInstitutionDepartmentStreetQuarterPOBoxCityPostal codeStatePhone1Phone2FaxEmail

Address

Epidemiology of Rabies#

• 30,000 Annual Deaths

• 10,00,000 PET annually

• 12 Govt.Institution (NTVs) for Human

• 9 Govt. Institution Veterinary NTVs,

• 1Pvt. Pharmas human TCV,

• 4 Pvt Pharmas veterinary TCVs.

• 15 Govt Inst. rabies diagnostic facilities in animals and 5 for testing post vaccination antibody titers in humans.

# Association for prevention and control of rabies in India (APCRI)

Annual Report at NICD 1997

Post-mortem diagnosis in animal 18/40

in samples by Negri body FAT & BT

Diagnosis in hydrophobia cases by

• Corneal Smear 0/15

• Serum Antibodies 2/15

Assessment of antibodies by modified CIEP test

• Human234/258

• Animal l5/5

6 month incidence of animal bite cases in 4 selected urban communities*

City Population Bites Incidence/1000

Banglore 88469 85 0.96

Calicut 79169 20 0.25

Coonoor 43577 70 1.61

Rajamundry 71358 117 1.64

Total 282573 292 1.03

*Source: Based on reports of National Institute of Communicable Diseases

No of animal bite case reported by Municipal

Medical Institutions in Delhi, 1995-1998*

Animal 1995 1996 1997 1998

Dog 23852 26395 27345 29905

Monkey 1093 1313 1008 1198

Cat 170 141 121 182

Horse 4 15 6 8

Buffalo 1 0 4 8

Unknown 59 96 125 182

Total 25179 27960 28609 31483

* Source: Municipal Health Officer, Delhi

No.

bit

e ca

ses

wit

h r

efer

ence

to a

ni m

al in

volv

ed 1

998-

2002

*

Animal Total Case (Percentage)Dog 5115 (83%)Monkey 290 (05%)Buffalo 207 (3.5%)Cow-Ox 171 (03%)Cat 90 (1.5%)Rat 48 (.75%)Jackal 25 (0.5%)Leon/Leopard 11Horse-Mule 30 (0.5%)Mongoose 34 (0.5%)Pig 6Goat 23 (0.5%)Sheep 1Others 4Unknown 4Contact Cases 131 (02%) T

otal

: 6

190

* Source:CRI, Kasauli, APRICON 2003

Single animal biting many persons: Episodes reported from India*

Year Animal Bitten Died RIG

1992 Dog 90 0 Yes

1995 Wolf 28 8 No

1996 Dog 43 8 No

* Source: Based on reports communicated to NICD

Classification of Animal bite cases reported (1998-2002)*

Year Class I Class II Class III Total

1998 - 243 1384 1627

1999 8 153 1285 1446

2000 21 279 722 1022

2001 13 120 951 1084

2002 15 157 839 1011

Total 57(1%) 952(15%) 5181(84%) 6190

* Source:CRI, Kasauli, APRICON 2003

No of Hydrophobia cases admitted to IDH, Delhi 1994-1999*

Year No of Hydrophobia cases

1994 224

1995 210

1996 151

1997 222

1998 215

1999 241*Source: Infectious Diseases Hospital, New Delhi

Rabies Cases Admitted to IDH 1998

Age Number Percentage

0-4 13 06.0%

5-14 85 39.5%

15+ 117 54.5%

Sex

Male 168 78.1%

Female 47 21.9%

Total 215 100%

*Source: Jagvir Singh et al in Indian Pediatrics, Volume 38, 2001

Rabies Cases Admitted to IDH 1998Antirabies Vaccination before hospitalization

Age Number No. Received ARV Percentage

0-4 13 6 46.2%

5-14 85 17 20.0%

15+ 117 25 20.0%

Sex

Male 168 39 23.2%

Female 47 9 19.1%

Total 215 48 22.3%

*Source: Jagvir Singh et al in Indian Pediatrics, Volume 38, 2001

Rabies Cases Admitted to IDH 1998PET received by these cases*• Local wound care:

– Only 2 cases• Vaccination:

– Unvaccinated 67/215– Vaccinated 48/215

• 42 NTV( only 5 received>10doses)• 6 TCV(all received < 3 doses)

• Immunoglobulins:• Only 3 cases

• 1 case received (Wound care + NTV+ ERIG)*Source: Jagvir Singh et al in Indian Pediatrics, Volume 38, 2001

Assessing Burden of Rabies in India*

• 1000+ million Population

• 24 million Dog Population

• Dog:Man 1:12 to 1:40

• Animal Bites: 2.1 million

• 90% due to dog ( 90% unvaccinated dog)

• 1.1 million PET (0.45 NTV and 0.65TCV)

• No. of Rabies death 30,000/annually ????

* Source:APCRI, Newsletter Volume III, Issue 1 & 2, 2003

Assessing Burden of Rabies in India A WHO-APCRI National Multi Centric Survey Initiative 2003

This survey involves

•20 Medical Colleges,

•32 Veterinary College,

•10 million Human Population

•32 Veterinary Pathology Laboratories

What could be the answer for Rabies Surveillance in India ?

Integrated Disease Surveillance ??