dna Conversations: How to deal with rabies

Rabies is one of the deadliest diseases known to man for several reasons. First, because it has no cure. It can be prevented. But once it sets in, you can only watch the patient die. Second, because of the rapidity with which the body collapses. Unlike AIDS which can kill a person over years, rabies kills in just 10-12 days once it sets in. The third reason why it is dreaded is the manner in which the afflicted person becomes a threat to everyone around, and must therefore be isolated.

The good part is that rabies can be prevented – through vaccines and oral hygiene.

But it is sad that very little attention is given to this disease, thus providing amble scope for misinformation and even myths.

In order to clear the fog surrounding rabies, dna called in a panel of experts, comprising (in alphabetical order) Dr. Akil Contractor, Senior Family Physician, Mumbai; Dr. Dhanashree Kelkar, Specialist, Infectious Diseases, Global Hospital, Mumbai; Dr. Jayesh M. Lele, Honorary Secretary, Indian Medical Association, Maharashtra State; Dr. Ranjit Mankeshwar, In-charge, Anti-rabies Vaccination Centre, Sir J.J. Group of Hospitals (and Head, Department of Preventive and Social Medicine, Grant Medical College), Mumbai; Dr. Parthiv Sanghvi, General & Laparoscopic Surgeon, Criticare Hospital, Mumbai.

The discussions, moderated by dna's RN Bhaskar, with editorial support from Maitri Porecha, threw light on several issues that most people are unaware of.

Given below are edited excerpts:

Kelkar: Rabies, though a notifiable disease, is still quite under-reported in India. And currently, there is not much literature. There are varying studies about its incidence – right from 0.05% to 1,700 per 1 lakh population [1.7%] , which is a hugely varying figure.

I think we need better documentation and better studies to actually let us know what the burden is and the extent of the problem we are facing. And most importantly, there is no treatment for it. It’s a fully vaccine-preventable disease, and we should be aggressive about preventing it.

Lele: As it is said, it is much underreported. Probably, it is not even fully diagnosed. I have some documentation thanks to a number of RTI [right to information] applications filed by an NGO 'Voice of Dogs'. From there I have come to learn that there were 540 cases in 2004. .

Number two, vaccination can help – not just vaccination of humans, but also of dogs. The menace of stray dogs has increased to a great extent, which is one of the reasons why we are not able to control this dreaded disease. As far as I am concerned, whoever comes to me for advice, I just tell them, whether it’s a stray dog or a home dog, you must get vaccinated. This is an insurance policy they must have. .

DNA: Yes.

Lele: So I insist that every patient who walks in with a dog bite is vaccinated. That is my policy for the last 35 years. Formerly, it was poking injections in the stomach, but nowadays we have a better choice. And there should be vaccination of the stray dogs as well.

Mankeshwar: I’ve been running what could probably be the only specialized anti-rabies vaccination clinic in Bombay for more than 10 years. In today’s world, we look for big data for everything. And this is where we fall desperately short of expectation is rabies is concerned in India. The only recognized study on prevalence was done in 2003 by the Association of Prevention and Rabies Control (APRC) in India and WHO [World Health Organisation].

DNA: Oh! So, after 2003, there has been no serious study? And is this an original study?

Mankeshwar: Yeah, this is an original study. This study is documented. And, remember, it was based on a sample survey. So the numbers that came out, which WHO estimates to be the final number, are based on mathematical modeling. That number is 20,500 deaths a year. Okay.

DNA: 20,500 deaths each year!

Mankeshwar: Yes. And 17.4 million dog bites. And out of these 17.4 million dog bites, possibly only 5 to 8 million patients take any vaccination.

One thing you have to remember is that when this study was done, it was 2003. Till that point of time we were giving the neural tissue vaccine which is the vaccine administered in the stomach. In December 2004, this type of vaccine was outlawed and the production at CRI Kasauli and Haffkine Institute in Mumbai were halted. Since then vaccines were extracted from chick embryo, Vero Cells, Duck Embryos. All these started in dead earnest only after 2005, after May or June.

So this study reflects the position of uptake of vaccine during the era when 14 painful injections were given in the stomach

All this has changed. But do we really know the number of deaths accurately? I doubt it. Do we know how many dogs are there? I doubt it. The last census that the BMC [the Municipal Corporation of Greater Mumbai] carried out was in 2008. At that time the BMC reported about 78,000 stray dogs. The BMC gets these dogs sterilized as a measure of controlling their numbers – a type of animal birth control.

Now they have given a reply to the RTI application Dr. Lele was talking about. According to this reply, during the past 10 years, the BMC has spent Rs.2 crore on the sterilisation of dogs over 10 years.

So what are the figures are we talking about? Since then our population has grown.

Sanghvi: I agree. The incidence of dog bite is very much under reported. So many times patients may have bites not only from stray dogs, but we have pet dogs also, and are likely to have gone to a private vet to get vaccinated. And you know, cases would not get reported because usually treatment at private clinics are not reported. The figures we get are only from government hospitals or the public sector.

DNA: What’s the ratio of private to public?

Sanghvi: In the urban areas I would estimate that at least 22 to 25% would be private sector clinics. Add to this the numbers that are treated by pediatricians, because they too administer the vaccines to children. So all that goes unreported because this is notifiable only when it becomes a disease.

All dog bites are not notifiable nor are pet bites. Secondly, in the slum population, we usually talk only about dog bites. But they say that cat bites are more lethal than dog bites.

And if one were to add rat bites . . .

Mankeshwar: Indian rats don’t cause rabies.

Kelkar: I agree. Indian rats do not cause rabies.

Sanghvi: But basically rat bites too come under the category of the infection diseases which must be treated with the same modality. And since rabies is a deadly disease, where there is no cure, why take a chance. So if we go to admit every patient, it is not going to be financially viable. Because once the bite takes place that is transmission of infection. They may not be rabid infection, but microbials are definitely transferred. So treatment has to be administered in that direction too.

Moreover, I see so many stray dogs around. I see stray dogs which have bitten so many individuals, but still roam around.

And when the BMC appoints contractors to transfer stray dogs outside the city then animal welfare organisations come into the picture and they stop this activity.

Now sterilization is not feasible everywhere. The veterinary hospital is only located in Parel [in Mumbai]. Do you have the logistics to support sterlisation of all stray dogs?

And even those animal ambulances are few in number. So the problem stays at as it is. We are all trying to treat the individual or dogs after the bite. We are not taking any preventive action at all.

Contractor: Dog bite is one thing but we normally get people even with scratches. A scratch from a dog or a lick on a doubtful abrasion on the skin is equally serious. Now, what happens when they come to us? We either treat them privately, in our clinics, or we have to send them to a municipal hospital. Earlier, we used to give them abdominal subcutaneous injections. So people were afraid. But now we administer the injection in the deltoid (arm muscle). So it is more acceptable and quite convenient. But here we can face a problem. Suddenly, the owner of the dog also comes and says “my dog has been vaccinated properly”. But the problem is that even if the dog has been vaccinated, I still have to give injections to the person who has been bitten because many times our vaccines for dogs have been found to be ineffective. So you cannot take a chance.

DNA: Is that so?

Contractor: Yes

Mankeshwar: In fact, studies presented three years ago, showed that of the sample vaccines picked up from veterinary clinics, only 50% were potent. Only 50% of the vaccines were thermostable.

Kelkar: Unfortunately that’s the problem we do face in India. The reason why we cannot guarantee the vaccine is because we don’t know whether the cold chain is well maintained or not. If the cold chain is inadequately maintained, your vaccine, even if you have the best company's vaccine, or you know the company which has the most studies with a proven track record, it may still be ineffective if your cold chain is inadequate.

In humans there are ways of checking whether your person has actually responded to the vaccine. All that is needed is one antibody level test.

DNA: So you can check on humans.

Kelkar: You can check on humans. If you respond by generating antibodies [it means that the vaccine has worked]. There may be certain tests for animals also, but I am not sure about whether those tests are easily, commercially, available or not. So, in case there are some tests which we can run, and you know that okay, your animal has responded very well to the vaccination, then in those cases you may not have to vaccinate anyone who has been bitten by that animal.

Contractor: I have to just counsel them that even if 0.0001% possibility is there, don’t take a chance. If you can afford the vaccine, I give it.

DNA: Suppose I’ve been vaccinated for anti-rabies, what is the duration for which I am protected because of the vaccines?

Mankeshwar: When it comes to modern cell culture vaccines, if you have taken all five doses by the intramuscular route or four doses by the intradermal route, that’s a different route of administration and a different technique– if you’ve taken the entire course, and it is certified that you’ve taken the course, then you are protected for a lifetime…

DNA: Oh it’s a lifetime protection.

Mankeshwar: If you are bitten by any dog, you just have to take two doses at day zero and day three. Like a booster.

Kelkar: And generally three to five years is when after which [we say you may need a booster]…

Mankeshwar: There is absolutely no evidence [which says that you do not need a booster]. If you complete a vaccination today there is enough evidence that for one year or two years your immune levels are high. But because we cannot be sure, depending on which vaccine has been given, whether the vaccine was in cold chain or not, you have to take those two doses again.

DNA: So, effectively it is advisable that irrespective of having taken the entire dose, when you are bitten do take the vaccine to make sure to protect you just for life?

Sanghvi: Absolutely, because rabies has got no cure.

God forbid, place yourself in that position or your kith and kin. If your child is to get a dog bite, even if it has been a lick, now what does a book say, whether there is a break in continuity of the skin. Now are you going to see with a magnifying lens or a microscope whether there is break in continuity? It’s your kith and kin. You will now want the entire schedule to be given. So, that is the way you should treat your patients as well. I am just going to vaccinate him.

Kelkar: If you are bitten, yes. If you are not bitten, you should take the vaccine only if you are a high risk person – for instance if you are working in a veterinary area or as a dog handler. Those are the people who should get vaccinated irrespective.

Contractor: And even postmen…

Kelkar: Everything does not come without side effects. There are vaccine related side effects also. So, whether your risk of getting the disease outweighs your benefit is what you have to consider.

DNA: If there are side effects, what are the side effects?

Kelkar: The side effects can be your injection side effects. If the site is not adequately chosen or if the site is not adequately clean, you can have redness, you can have an abscess there -- basically just injection related side effects. Sometimes patients can get fever after the vaccine. And in rare cases you can have what we have call is neural side effects also, which are vaccine related. But that is not very common. The risks of rabies are certainly much higher when compared to vaccine-related side effects.

Mankeshwar: Modern cell culture vaccines are actually pretty safe. Most other side effects are site-related or related to pain and local discomfort. I have spent 20 years in rabies related studies. We’ve hardly seen any vaccines side effects.

DNA: Why can’t vaccination then be made mandatory?

Mankeshwar: In fact, the Association of Prevention and Control of Rabies in India has indeed recommended to the Indian Association of Pediatrics that because 50% of all those who are bitten by animals are children. So we and other associations recommended that children should get the pre-vaccination schedule -- it’s just three doses on day zero, day seven, and on day 21 or 28.

DNA: Whenever one looks at rabies, there is a class of population that cannot afford the vaccines. So there is a class that goes to municipal hospitals. And there’s a class that goes to a private clinic. What is the cost of those doses?

Mankeshwar: Rs. 300 to Rs.400 a dose. This is the pure vaccine cost. The pure vaccine cost is INR1,500 for all the five doses.

Lele: In municipal corporation dispensaries, you get it for free.

Mankeshwar: In fact, what we have done, and what the Government of India recommends is to roll out an intradermal regimen, where you have to give 0.1 ml on two arms, basically 0.2 ml per dose. Most vaccines come in a full dose of 0.5 to 1 ml. So, if you are using a vaccine like purified chick embryo cell culture vaccine, you can do four patients in that one dose, which is what we do in our clinic. Because of this, when we see our vaccine completion rate, we have achieved 95% plus vaccination completion rate in the last four years. Because the use of the vaccine has spread, we have a uniform supply of all the vaccines. All the patients get vaccination in our OPD and get it completely free of charge.

DNA: How does Rs.1,500 compare with the cost of other vaccines?

Kelkar: Oral polio is free of cost. But the Injectable Polio Vaccine cost is around Rs.400 to Rs.500…MMR is cheapest. It is around Rs.80 – 90.

Sanghvi: Rs.70.

Kelkar: Chickenpox, Hepatitis B -- these are the little more expensive. Chickenpox is somewhere between Rs.700-Rs.800 and Hepatitis B is somewhere around Rs.300.

Lele: So far, the WHO has not declared rabies as a mandatory or optional vaccine? So unless the WHO declares it is unlikely to become a mandatory vaccine.

Sanghvi: Cost factor is very high.

DNA: Can't the costs go down?

Sanghvi: You are putting into the machinery a vaccine which is not required by hundreds and millions of people. If you compare the number of dog bites versus the population of the country then that is a very small percentage. So you cannot justify immunizing everybody. Whereas other diseases are such that the need is greater, and the numbers larger. There are two aspects that should be considered: First you have to justify a vaccination going into a program for mass adoption, and the second is the cost which the government or private bodies will have to bear. Now private bodies you can say “okay fine”. They may be willing to bear any cost, but what about the government machinery, whether it is in a position to bear the cost?

Mankeshwar: I think rabies needs to be looked at even as an animal problem. You can’t just look at rabies as a human problem. You have to make sure that sterilization of dogs is working in the population.

And then even in the treatment there are two issues. There are three classes of animal bite wounds; class one, class two and class three. Class one is when there is no evidence of any injury and you don’t do anything. Somebody may say that he has got a dog bite or a dog has scratched him. But you see no mark and you see nothing in the mucous membrane, that’s class one.

Class two, is an abrasion, or something where there has been no bleeding.

And category three, which is about 50% of all dog bites, is when there is either a lick to a broken skin surface or a mucous membrane or where there is bleeding. Now in this you also have to give what is called as immunoglobulin. An immunoglobulin is for local immunity, I’ll tell you the reason why.

The incubation period is the – to put it crudely -- the entry of the virus getting fixed in the central nervous system and producing the first symptom of rabies. It can last – it is typically 10 to 60 days. In rare cases, up to 90 days. But if there is a known rabid dog, there are multiple bites, the incubation period can be as short as four days. Now, if like a good citizen you go to vaccinate yourself, zero, three, seven days, demonstrable ability is at day 12, or day 14.

So there is a period in which a person is not protected and theoretically, though it is very rare, theoretically the virus can still go to the brain.

To prevent this, somebody has to give immunoglobulin to the local wound within 96 hours. We do this systematically – and we are one of the very few people who do this systematically because we have trained physicians who do this. Again, there are two issues to this. There is a human rabies immunoglobulin and there is a equine rabies immunoglobulin. Now for a typical adult person, it takes two vials of the equine. Equine meaning horses.Where you have to do a skin sensitivity test like you do for penicillin, used to do for penicillin before, so for that reason alone it is cheaper. We ourselves use it. But many private physicians are reluctant to use it, because they don’t want a risk of anaphylactic reaction. Now, I myself have not seen any anaphylactic reaction because these modern immunoglobulins are extremely purified. And they have very few protein fragments, which give rise to the anaphylactic – that is the allergic reaction. But still there is this doubt. Now, if you take the human rabies immunoglobulin, it’s about six to seven times more expensive. And so for an adult it would typically take INR15,000 for such an immunoglobulin.

Contractor: But these are for bites which are near the neck.

Mankeshwar: Now WHO says for any bite, even in the leg if there is bleeding, you have to give immunoglobulin.

Kelkar: If I may add, there are studies from Asian countries which have proven that rabies vaccine have failed because immunoglobulin was not given at the time. Because of the window, so you can still get infected. As I said, there have been reports from Asian countries of vaccine failure because of this reason.

DNA: Is rabies the only disease that can’t be cured or are there other diseases also?

Contractor: There are so many.

Kelkar: Dengue is one example. There is no cure and no vaccine.

Mankeshwar: Hepatitis C is there.

Kelkar: It has no vaccine. Then there is encephalitis which has caused over 105 deaths of children during the last three months in UP [Uttar Pradesh]. Encephalitis has no vaccine.

Mankeshwar: Chikungunya.

Kelkar: Chikungunya does not cause death as such, but you cannot prevent it with a vaccine.

Mankeshwar: Malaria. You can cure it, but you don’t have a vaccine there.

Kelkar: But rabies is a disease which can’t be cured but has a vaccine to prevent it. There are so many diseases which can’t be cured and have no vaccine.

DNA: But it is a disease which demands a person to be quarantined if he is found infected with this virus, right?

Kelkar: Yes, you have to put the patient in isolation. It is like a quarantine but a quarantine with everyone else having some protective things. To prevent getting infection

Lele: Formerly dog bites in many places used to be medico legal cases. It was there in olden hospitals like KEM and Nair

Mankeshwar: Yes, there was a medico legal case paper issued and it was a medico legal case to report…

Kelkar: Currently at hospitals they still do that.

Lele: In rabies they put the person into quarantine because he may bite doctors and others as well.

Mankeshwar: I would also like to add that rabies has not only no cure, but also that there is no treatment.

When it comes to rabies isolation wards, one place which we know is Kasturba (hospital for infectious diseases at Chinchpokli (in Mumbai).

Kelkar: J.J. Hospital also has similar facilities.

Lele: Even KEM has got them, KEM has got a rabies ward as well.

Mankeshwar: I think the whole paradigm of looking at a rabies patient has changed over the years. What is happened is that now we don’t so much worry about quarantining a patient, but what we worry about is caring for the patient because these seven days till the patient dies are absolutely painful for the patient. Just 7-10 days from the course of the illness.

But he has hydrophobia and now a lot of people think hydrophobia means drinking a glass of water. But if you show a bottle of water there is a severe spasm right from the head to the diaphragm. The person is also photophobic. Intense photophobia is there. That means any light is intolerable to the patient. What we do is that our critical care people will intubate such a patient, put that patient in a kind of an artificial coma with deep muscle relaxants and anesthetics and make sure this person stays like that till he dies.

Kelkar: I agree with that. What happens – generally – is that these patients also have respiratory problems. They are unable to manage to their own secretions, even their own saliva can initiate a severe gasp. It can make them go into a spasm where they can stop breathing just because of their own saliva. So, in such cases you do intubate the patient. You do put them under anesthesia. And I must tell you that there is one case report – of a 15-year old girl – the only case in the world who seems to have survived rabies. She was treated using this protocol of complete sedation, anesthesia and certain medication. But other than that single person there is no other person in the world who has improved with this protocol.

Basically, all anesthetic medications are administered to keep the patient calm and the nervous system quiet. And so, we try and do that. There is a lot of autonomic dysfunction. If your patient is agitated, if your patient is highly active, he is going to be spewing saliva all over and everyone else in your critical care unit or whichever unit you have placed the patient in is going to get infected. So for the patient’s safety, for the environment’s safety, as well as for the only probable treatment which is there, you use all of this.

DNA: But when you have this kind of situation, doesn't it make sense to advise people staying in slums or anywhere else where the risk of stray dogs is immense, to take the anti-rabies vaccines?

Mankeshwar: I would never advise it because for one thing our cost benefit study and our cost effectiveness study has not been conducted as yet. In fact, I think this is one of the problems with health sector planning in India is that we are not very research driven in the sense that we don’t look for evidence as a basis of forming policies. Is there any evidence that rolling out such a thing will help?

In any case, all municipal hospitals and dispensaries and government clinics will give this vaccine free of charge. But, unfortunately, on account of ease of timing and for comfort that many slum dwellers too approach private practitioners.

One of the things that we do, because we want to – a lot of people will think that if they tell them that the dog is vaccinated or if the dog is observable, they can escape any injection. So what we practice as a universal truth is that we ask the person to start the vaccination immediately. And we say that produce the vaccination certificate because all dog vaccination certificates have a sticker from the vaccine which says till when is this vaccination is effective. …

So we know that the dog vaccination certificate is valid. Then we try to coax them that you have taken one injection, might as well take the rest and finish the course.

Lele: Many times what happens is in private practice in our dispensaries, they are not interested in taking any injections. Even for simple injuries, making them take the anti-tetanus injection can be a problem. In fact, in the case of a dog bite we give the anti-tetanus injection also…

If there is something like a tablet, it is acceptable. But there is resistance to taking injections. So making him take five injections, and that too within the course of one month, you know, increases the effort of convincing him; sometimes they are not convinced.

Kelkar: On my part I would not recommend the vaccination to all slum dwellers. To high-risk veterinarians, dog handlers, pet handlers okay, or people who are working with dogs daily in-and-out, yes, I would recommend [the preventive vaccine] to those people. But to the general public, no I would not, because even one case of a vaccine related side effect is worse than your benefit from that vaccine. If you have been bitten by an animal, you should take it, yes.

Mankeshwar: One clarification: modern vaccines, especially for purified chick embryo cell culture vaccine, there is a 10 year observation study which confirms that with purified chick embryo cell culture vaccine there is absolutely no side effect. There are local side effects, but there is no serious side effect. It’s a study published by NCDC, National Centre for Disease Control in New Delhi.

Unfortunately, despite the WHO mandate, I think India has been struggling to get a national program against rabies as is done with so many diseases. Under the 11th plan, there was a pilot project on prevention and control of rabies in humans. This pilot project has started in five cities -- Delhi, Ahmedabad, Madurai, Bangalore and Pune. But it’s just in a pilot phase. Now the 11th plan is ending this year, in 2013. We expected a national program to come out but there is no sign of a national program being rolled out. So as far as policy initiatives go, I think there are several gaps. One is that this is not moving from a pilot project to getting rolled out to a national level program. That would therefore entail a lot more aggressive effort in improving diagnostic facilities, improving management of dog bite cases, bettering surveillance and education efforts. None of this is happening properly as of now. You only have independent efforts. It’s an independent struggle. I don’t think that we should take 20,000 deaths lightly when all the deaths could be prevented by a vaccine.

Just because rabies doesn’t have the glamour of swine flu, it doesn’t mean that we should ignore it. We should take care of all infectious diseases.

DNA: I agree.

Mankeshwar: The one thing that we can be happy about is that all the vaccines we produce today are efficacious. We have a proven capacity to manufacture 15 million doses in one year. India is the only country in Southeast Asia, which can manufacture 15 million doses. There is no problem of ramping up doses, there is no problem with the vaccine.

But look at the 20,000 deaths, the 17 million dog bites, and the eight million people take treatment of which only around 50% of them complete the treatment. So, we have just one fourth of all people who are bitten by a dog actually completing their treatment. That is really shocking, absolutely shocking.

All one can say that if you have been bitten, or licked by an animal on an open wound, or even scratched, go as early as possible report to your nearest doctor.

Sanghvi: There is no cure, 100% fatal.

Mankeshwar: And the importance of immunoglobulin.

Kelkar: And most importantly, clean the wound, with soap and water.

Mankeshwar: Copious amounts of running water . . .

Sanghvi: Running soapy water.

Mankeshwar: For 10 minutes.

DNA: Oh! For 10 minutes?

Mankeshwar: Yes. For 10 minutes. This is like the boiling water. If you tell people that you have to boil water to make it potable, they’ll boil it for two minutes and once it start boiling, they’ll put it off, that’s not the right thing to do.

Kelkar: You have to clean the wound most importantly.

Mankeshwar: And there is a virological reason for this. All soap and surfactants have fat destroying properties. The outer layer of the rabies virus is made of glycoprotein which is fat derived protein.

DNA: Okay.

Mankeshwar: So it destroys the cover of the rabies virus, and thereby makes sure that the virus is also destroyed.

Kelkar: Less chances of the virus actually infiltrating the nervous system. So, the best thing you can still do at home, wherever you are is you can wash the wound with soap and water, and as soon as that is done, you go to your nearest health practitioner, take the immunoglobulin, take the vaccine and not on the hip, gluteal region, or anterolateral thigh. For adults it is recommended that you have to take it on your arm.

Mankeshwar: Only for childhood urbanization, if we give it on the thigh. But that is because the deltoid is not developed.

Kelkar: And even, children beyond the age of three to five years, we say that even those children should start taking all the vaccines on the arm and not on the anterolateral thigh.

Lele: I think one technical point, I really want to add here is that even for patients who are immune compromised or immune, or where immunity is depressed, right, or immunity is suppressed, we have to give them all the five dose regimen.

Mankeshwar: Complete.

Lele: The intramuscular regimen. In fact, many times they ask whether pregnant women can take the vaccines. But I think nowadays we have vaccine which is can be given to pregnant women as well.

Kelkar: Yes.

Contractor: All vaccines can be given to pregnant women.

DNA: One last question for closing, what do you think the government should be doing in this area?

Sanghvi: First, see we have two things -- one is government responsibility and the other is the social responsibility of every citizen.

If you see the epidemiology and the demographics of dog bites, almost 40 to 50% are children. Now children need to be educated that if you see a dog, don’t run away because that can provoke a dog. Secondly, don’t try to irritate a dog who is sleeping or sitting or feeding or nursing its pups because these are instances which provoke a dog which in turn bites.

The second is the government’s responsibility that whenever, in whichever area, a dog bite has been reported, at least visit the area, and then take a call whether the street dogs there need to be vaccinated or sterilized.

Normally you are told to observe the dog. But often these dogs are not available for observation. So, in such cases, it is better to randomly take all the dogs at least for sterilization, so in the future you are preventing their propagation. And dogs which have known rabid characteristics, like running around biting people, those should be silenced. That’s very important.

DNA: Is it possible that a rabid dog can pass on the rabies without becoming actively rabid?

Sanghvi: Yes. I mean, they can be silent. They can still be secreting the virus in the saliva.

Mankeshwar: The only documented human to human cases of rabies are through corneal implants.

Kelkar: And organ transplants. Actually if you suspect a patient has died of encephalitis, and the patient’s relatives are willing to donate the organs, you can actually do this test. You can do the rabies antibody test before the transplant. If your antibody is positive and patient has never never received anti-rabies vaccines, you can take it for granted that this patient had rabies, but the antibody test is not full proof. 95% to 97% of rabies in India is because of dog bites. But there are other animals also which can transfer rabies …

Mankeshwar: Cats.

Contractor: Horses…

Contractor: Monkey bites.

Kelkar: Foxes and bats.

Mankeshwar: And if you ask Rajasthan doctors they will report…

Kelkar: Camels. Pigs also.

Mankeshwar: Squirrels don’t nor do Indian rats. Both are not carriers of rabies. In fact, I’ll tell you this is how rabies circulates in the wild. When a wild animal -- a wild fox or a wild dog -- has rabies, and bites another dog, and circulates the virus is carried on. Otherwise, how do you think that the virus survives, if the host animal dies within 10 days. But the viruses don’t die. A dog bites another dog. It’s as simple as that, that dog dies then that dog bites 10 other dogs then that dog dies. And this also is very important because most of the cases are in the rural areas..

Issues regarding Polio
One of the most successful vaccination programmes in India has been tackling the polio problem.  During the discussions, views were also expressed about this programme.

Mankeshwar:  There is a reason for opting for oral polio vaccines. When you have to give a vaccine in a campaign mode, it’s very easy to give an oral vaccine where you just have to put two drops.  Now as the numbers of polio shrink – and we haven’t reported any for two years, any case of polio for two years in India.  If the numbers shrink, with a live vaccine there is a probability of acquiring what is called a vaccine associated poliomyelitis…

Kelkar:  Right.

Mankeshwar:  …which is one in three million doses.  Okay?
So the government itself is planning to shift to an inactivated polio vaccine.  India has not yet been declared as polio free by the WHO, because it does not normally look at countries but at regions. India has neighbouring Pakistan and Afghanistan in our region.

DNA: And Bangladesh?

Mankeshwar:  Bangladesh has really good polio control.

Kelkar:  Bangladesh has really good control.

Mankeshwar: Bangladesh has got a good public health system. The problem is with Pakistan and that hilly tribal area, Pakistan and Afghanistan…

DNA: Okay.

Mankeshwar:  There has been a significant increase in the number of polio cases in Pakistan over the last two years. 

Now what is the option for government of India?  Once – for a period of time – we are polio free, we will roll out inactivated polio vaccine, because the mechanics of scale will become relevant.  Inactivated polio vaccine will get cheaper and it will – it can also be marketed as a quadruplet DPTP kind of a vaccine which IAP has been suggesting and you give that vaccine with DPT.

It’s a very safe vaccine.  It is an inactivated vaccine, so there’s no chance of anybody acquiring any side-effects.

Kelkar:  In fact, there are good reasons why the oral polio vaccine is preferred over the injectible one.

The reason why we were still giving oral polio is because we want to achieve Herd Immunity.
Mankeshwar:  Exactly. Herd Immunity.

Kelkar:  There are a lot of infants, children who do not – in spite of our aggressive polio campaign – who do not get vaccinated often because they cannot be easily found. We may be unable to reach them. And if you’re living in slums, if you’re part of a shifting population, nomadic, it may be difficult to find them. What we are trying to achieve with the oral polio vaccine is that the oral polio vaccine is secreted in the stools.  Thus, everyone in the community is exposed to that.

So we hope that this exposure will help them develop an immunity by secondary means. So that is one reason we are trying to promote oral polio.

Mankeshwar:  Oral polio confers what is called as gut immunity which is a local immunity.

Kelkar:  Exactly.

We have been able to get rid of the polio for the last two years, which might not have been possible if we had shifted to injectable polio.

Mankeshwar:  Operationally, oral polio is magnificent.

Kelkar:  As Dr. Mankeshwar has said, vaccine derived polio virus, we can get that from oral polio vaccine.  So nowadays what some people are doing is taking the injectable, but they still take the oral also so that you are actually propagating Herd Immunity and you are at less risk for getting vaccine derived polio virus.