INTRA-DERMAL

ANTIRABIES VACCINATION
TRAINING OF TRAINERS
BY
DR. OMESH BHARTI
M.B.B.S.,D.H.M,M.A.E.
(Epidemiology)

HIMACHAL PRADESH

OMESH BHARTI
Background (1/2)
Globally:
– An estimated 55,000 persons die of rabies every year.
– 31,000 deaths are reported from the Asian continent.
In India*:
– 40 % of global rabies deaths ( 20,000 deaths)
– The frequency of human rabies deaths:
1 case every 30 minutes
– Animal bite incidence rate: 17.4 per 1000 population
17.4 million bites every year.
– Annual man-days lost due to animal bite : 38 million.
– Annual medicinal (vaccines + other drugs) cost for animal
bite treatment: $ 4 Million (2003)
* WHO-APCRI study -OMESH
Assessing
BHARTI
burden of Rabies in India
Background (2/2)
Access:
NTV production banned by the Supreme Court of India
(2004).
Access to TCV for rabies restricted - High cost.
Cost of ARV Rs. 2220/- (6 IM injections ).
Led to poor patients not getting themselves vaccinated and
even resulting in their deaths.
Alternative
Intra-dermal technique (IDRV) started in Thailand (1979)*.
WHO recommended its use (1992).
Adopted- Philippines (1993), Sri Lanka (1996), India* (2006).
• *Harverson G, Post-exposure intradermal antirabies vaccine: a cheaper
alternative for developing countries, Trop Doct. 1984 Apr;14(2):67-70.
• * 8 states started in India.

OMESH BHARTI
Rabies
Rabies is practically 100% fatal disease.
There are only 4 survivors who recovered
following intensive life support.
In India Andeman-Nicobar and Lakshadweep
are free of rabies.
IAP has recommended the pre-exposure
vaccination of children with anti-rabies vaccine.
Rabies can be prevented by pre-exposure or
post-exposure prophylaxis.
Thorough wound wash, correct use of vaccines
and rabies immunoglobulins, rabies is fully
preventable.
OMESH BHARTI
Animal reservoirs in India
Dogs and cats= 98%.
Monkey, donkey, horses, Cows, Buffaloes,
goats, sheep and pigs=1%
Wild animals like Mongoose, Foxes,
Jackals, Camels or Elephants=1%
Not reported in : Rodents, Rats, Squirrel,
and birds.

OMESH BHARTI
Transmission of rabies
The saliva and urine are the main source of virus
contamination.
The bites, even scratches and licks are
dangerous.
The virus multiplies locally and travels inside
nerves and not in blood- so there is no viremia.
No body demonstrated rabies virus in cow’s milk
even if it was rabid!
30% of people get rabies of a rabid dogbite!

OMESH BHARTI
Modes of exposure
Bites.
Scratches.
Licks.
Drinking raw milk from rabid animal viz.
Cow, buffalo etc.
Even pet vaccinated animals carry a risk.

OMESH BHARTI
Classification of rabies
Category-I: (No Risk)
Touching or feeding of animal.
Licks on intact skin.

Category-II: (Moderate Risk)

Minor scratches or abrasions without bleeding.
Licks on broken skin*.
*Application of spirit or alcohol to the skin causes burning sensation if it is broken.

Category-III: (High Risk)

Wounds with bleeding.
Licks on mucus membrane.
Drinking raw milk of rabid animal.

OMESH BHARTI
Treatment of rabies
Wound wash and treatment.
Administration of modern vaccines.
Administration of rabies
immunoglobulins.
Counseling of patients and
attendants.

OMESH BHARTI
Wound wash and treatment
Wash all wounds under running water for
15 minutes to flush virus load and saliva.
Gently clean all wounds with soap or
detergent, soap is viricidal.
Apply povidine Iodine or any other
household antiseptic like Betadine, dettol
or savlon.
If nothing is available alcoholic
preparations like aftersave lotion can be
applied.
OMESH BHARTI
DON’Ts
Do not bandage or dress the wound.
Do not use tincture iodine.
Do not suture the wound.
Do not cover the wound.
Do not apply any local applicants like
chilli powder, turmeric, neem, plant
juices etc as their irritation speeds
virus movement along the nerve.
OMESH BHARTI
Treatment of rabies
Administration of modern vaccines
– Calculate day 0 as the day of first dose
of vaccine and not the day of bite.
– All category II and III wounds/
exposures require immediate starting of
vaccination.
– Never inject vaccine into gluteal region.

OMESH BHARTI
Treatment of rabies
Administration of rabies
immunoglobulins(RIGs)/antirabies
serum.
– RIGs are life saving in rabid animal bite.
– All category-III exposures resulting from
high risk category of animals need life
saving RIGs in addition to vaccines.
– RIGs should only be given after test
dose.

OMESH BHARTI
Treatment of rabies
Counseling of patients and attendants:

To take prescribed tetnus toxide,analgesics

and antibiotics.
Reassure and alleviate the fear and anxiety
of the patient and attendants.
Emphasize the lifesaving value of antirabies
treatment.
Not to apply any applicant on the wound or
any dressing or bandage.

OMESH BHARTI
Mechanism of action of Intradermal
ARV
Day 0
Vaccine Antigen

lymphatics

Antigen presenting Cells

lymphatics

Lymph nodes

Reticulo-endothelial system

Cell mediated immune response

OMESH BHARTI
Day 7
Clinical Trials for Intra-dermal ARV

OMESH BHARTI
Intra-dermal vaccines approved by
DCGI
Rabipur(PCEC),1ml.
Virorab(PVRV),0.5ml.
Abhayrab(PVRV),0.5ml.
PII,Coonoor(PVRV),1ml.

OMESH BHARTI
Regimen for intradermal ARV
Thai Red Cross Schedule 2-2-2-0-2.
For post exposure an injection of 0.1ml of
reconstituted ARV per I/D site and on two such
sites per visit just an inch above the deltoid
insertion on day 0,3,7,--,28.
For pre exposure vaccination say for school
children or health workers the 0.1ml dose on
single deltoid on day 0,7,21/28 with one 0.1ml
booster after one year and subsequent single
0.1ml boosters every five years.
All the ARVs are given intradermally using 40 unit
insulin syringe, 4 units (0.1ml) of vaccine given on
each deltoid.
3-4 mm blister should form after I/D ARV.
OMESH BHARTI
Administration of RIG
Skin test must be performed before we give eRIG/ARS.
(not for HRIG).
All severe wounds and category-III wounds require RIG.
In case of eRIG dose is 40 IU/kg body weight and for
HRIG it is 20 IU/kg body wt
Using 26G needle we should preferably infiltrate around
the wound and at the base of the wound and if volume
is small dilute the calculated dose with sterile normal
saline to a vol. enough to infiltrate all wound.
If the vol. is more say in children, then inject the
remaining RIG I/M away from vaccine site in a single
dose preferably in thigh region.

OMESH BHARTI
Immunoglobulins a must !

OMESH BHARTI
Where there is no Immunoglobulins
It is important to know that there is no substitute for Rabies
immunoglobulins as they neutralize the virus and give passive
immunity as it takes about 7-10 days time for the vaccine to initiate
active immunity in the patient against rabies virus .
Abbreviated multisite schedule( WHO Guide for PEP 2010):
In the abbreviated multisite IM schedule approved by WHO,
( 2-1-1 ), one dose is given in the right arm and one dose in the
left arm at day 0, and one dose applied in the deltoid muscle on
days 7 and 21. The 2-1-1 schedule induces an early antibody
response and may be particularly effective when post-exposure
treatment does not include administration of rabies
immunoglobulin.
The ID scheduled approved by WHO is 8 site Intra-dermal
regimen (8-0-4-0-1-1) and this regimen infers superior
immunity in short time and can be of help in case there are no
immunoglobulins available.
OMESH BHARTI
8 site intra-dermal regimen (WHO)
One dose of 0.1 ml is administered intradermally at
eight different sites,(8-0-4-0-1-1 regimen).
(upper arms, lateral thighs, suprascapular region, and lower
quadrant of abdomen)on day 0.
On day 7, four 0.1 ml injections are administered
intradermally into each upper arm (deltoid region)
and each lateral thigh. Following these
injections,one additional 0.1 ml dose is
administered on days 28 and 90. This regimen
lowers the cost of vaccine administered by
intramuscular regimens .
This regimen generally produces a higher antibody
response than the other recommended schedules
by day 7.
OMESH BHARTI
8 site intra-dermal regimen (WHO)

OMESH BHARTI
Re-Exposure
No immunoglobulins are required in persons who
have earlier been vaccinated.
Till date it was recommended to give one dose of
0.1ml of rabies vaccine is intradermally or
intramuscularly at day 0 and 3 on one side of the
deltoid for re-exposure.
New guidelines issued by WHO in 2010 say that we
can give 4 site 0.1ml intra-dermal vaccine at both
the deltoids and pre scapular areas. Therefore for a
re-exposed patient only single vial on single visit
shall be required to be given ID.
Ordinarily no booster doses are required except in
cases who are at risk like veterinarians etc as CCV
has long lasting immunity
OMESH BHARTI
Results (Pooling technique of Himachal)
On first visit patient is asked to bring a vial and
we share the vial with four patients and keep
rest of the vials in store for use next time.
Popular slogan in the clinic is, bring one vial rest
of the shots we would give free!
Many poor patients have been vaccinated with
the surplus vaccine available due to pooling.
We have a tie-up with CRI Kasauli and refer
poor patients to Kasauli for immunoglobulins.
We are trying to get vaccine directly from the
company to further reduce the cost from Rs.
370/- to Rs. 280/- per course for the patient.

OMESH BHARTI
Impact (Patient load of ARV clinic Shimla,
a month before and after I/D clinic started )

Patient load of ARV clinic,Shimla

80
70
60
num ber

50
40
30
20
10
0
Total Patients in July Total Patients in August
2008 2008
Months

OMESH BHARTI
Impact (Poor patients benefited a month
before and after the I/D clinic)
*does not include 255 poor patients of outreach camp
Poor patients benefited before and after
the I/D clinic

40
num bers

30
20
10
0
Poor Patients in July Poor Patients in August
2008 2008*
Months

OMESH BHARTI
Impact
Even those who otherwise could not have
afforded the vaccine, arrived at the clinic.
5769 animal-bite victims have been treated with
this low cost intradermal vaccnation technique in
Himachal
-12000 doses of vaccine given without failure
1.06 Crore Rupees mostly of the poor patients
and the government were saved in just two year.
Million will be saved in the years to come as a
new way of rabies treatment becomes a routine.
Many a deaths may also been averted, that we
can not measure.
OMESH BHARTI
GOI Letter for Free vaccination

OMESH BHARTI
Further scaling up
After starting clinics in all the districts of Himachal Pradesh,
we started training neighbouring states like Uttrakhand,
Rajasthan, and now Madhya Pradesh etc.
We have tied with CRI Kasauli lab for more experiments,
e.g.to store the vial for a week at 40C, to bring down the cost
further.
We hope to introduce this technique in entire country by
next year.
Support for Training ventures will accelerate this process.
Even neighbouring countries like Bangladesh and Pakistan
can be trained in this technique as they are still using NTV
vaccine.
We can explore the possibility of other vaccines being given intra-
dermal like Polio, hepatitis-B, yellow fever vaccines, influenza vaccines
including H1N1 etc., to cut costs and make them affordable.
OMESH BHARTI
“Our Vision -

Universal Access to Affordable Treatment”

“Sometimes Less can be More - Intra-dermal Route”

THANK YOU
OMESH BHARTI
OMESH BHARTI
OMESH BHARTI
Experiences of other states
In U.P. more than 35,000 patients given i/d ARV without even a
single failure , all the 71 districts have started I/D.
In Andhara all district hospitals giving i/d since June 2008 more than
50,000 patients given intradermal vaccine.
In Karnatka started on Sep 8,2007 more than 3432 patients given
7800 doses without any failure.
Kerala government started I/D this year in all the medical and
tertiary care hospitals.
West Bengal and Tamilnadu also started I/D ARV successfully.
In Calcutta I/D started on jan 2008.
In Bombay JJ Hospital started last year.
The national Human Rights Commission, New Delhi, has
recommended free treatment of animal bite and snake bite patients.
In U.S. 90% VACCINE USED FOR PREEXPOSURE only 10% for
post-exposure.
MP started from 20 September 2010 at Bhopal

OMESH BHARTI
OMESH BHARTI
OMESH BHARTI