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

Surveillance Standards WHO Recommended Surveillance Standards for Rabies

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

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

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

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

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

Reported Human Rabies Cases in India

Reported Human Rabies Cases in India

Reported animal rabies cases in India

Reported animal rabies cases in India

Reported No of PET

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

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

Current country information on rabies in India at Rabnet Last update of this informations : 1999-12-01 Region : Asia Country : India WHO Region : EURO 1) Presence of rabies and disease surveillance Is rabies a notifiable disease? Does a surveillance system exist? Is it operational? Does rabies occur in the country? yes Does rabies exist in the entire country? If No, please specify infected areas. 2) Reservoir species First rabies reservoir Second rabies reservoir not applicable 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 name First name Title Position Institution Department Street Quarter POBox City Postal code State Phone1 Phone2 Fax Email 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 Human 234/258 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* 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. bite cases with reference to animal involved 1998-2002* 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 11 Horse-Mule 30 (0.5%) Mongoose 34 (0.5%) Pig 6 Goat 23 (0.5%) Sheep 1 Others 4 Unknown 4 Contact Cases 131 (02%) No. bite cases with reference to animal involved 1998-2002* Total : 6190 * 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 1998 Antirabies 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 1998 PET 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 ??