A study of Rabies and Antirabies Vaccine in the infectious disease Hospital, Mohakhali, Dhaka, Bangladesh & some comments & suggestion:
By
Dr. Md. Rafiqul Islam
President
Association for Prevention
and Control of Rabies, Bangladesh (APCRIB)
M.Sc (CA), Infectious Diseases, London
Infectious Diseases Hospital
UH & FPO,Nabigong,Habigong
Rabies is a zoonotic infectious disease and it is in 10th positions among the death of infectious diseases in the world. This disease distributed all over the world except some developed countries & 99% death occure in Asia and Africa due to Rabies. In Bangladesh Infectious Diseases Hospital Mohakhali, Dhaka is the largest Hospital in the country. It’s outdoor section mainly deals with bite or scratch responsible for Rabies and also Rabies cases. Daily 150 to 200 bite case attended in the outdoor for Anti Rabies Vaccine. The outdoor Doctor Prescribe Anti Rabies Vaccine, Nerve Tissue Vaccine 80% to 90% and cell culture Vaccine Rabipur & verorabe 10 to 20% Daily and they also take the history Rabies cases for admission average more than 100 rabies patients attended in this hospital in each year. The disease caused in Bangladesh by the bite of the dog, cat, jackle, mongoose but mainy dog.
Retrospective data study of 500 rabies patient attended in the hospital shows that 455 were dog bite, 37 - cat bite, 4 - mongoose bite, 3 – jackle,1 – unknown.
Table shows the different types of animal bite responsible for Rabies in Bangladesh.
Dog Cat Moongose Jackle Unknown
455 37 4 3 1
91% 7.4% 0.8% 0.6% 0.2%
Total number of bite case attendant in this hospital in a year is 30,000.
25000 thousand people received local made Nerve Tissue Vaccine, 2500 hundred people take France made Verorab and other 2500 hundred people received India made Rabipur cell culture vaccine shown in a table:
Period Nerve tissue Verorab Rabipur
1 Year 25000 2500 2500
83.33% 8.33% 8.33%
Regarding the rabies carrier and 10 days observation: Data study of 500 hundred rabies cases attendant in the infectious diseases hospital, Dhaka I found 75 dog were alive 35 – Died, 147 – Killed, 243 – Unknown.
The table shows 500 rabies cases & the condition of the dogs responsible for Rabies.
Dog bite rabies cases Alive dog Died dog Killed dog unknown dog
500 75 35 147 243
15% 7% 29.4% 48.6%
The victims developed rabies in between 20 days to 120 days and observed the dogs, they did not show any sign and symptom of rabies. The number of alive - dogs could be more as in the killed and unknown dogs.
On the other hand the incubation period of rabies is as short as 4-10 days and as long as 20 years but average one month.
Prof. Nazul Islam one of the renowned Virologist of BSMMUH, Dhaka randomly he tested the brains of five street dogs those did not show any sign-symptom of rabies and he found the Negribody (evidence of Rabid animal) in their brain of two dogs, out of five.
This study shows that the dog is definitely rabies carrier as well as rabid. That’s why 10 days observation of the dog is no longer practice in our country and we advise anti rabies vaccine for any bite or scratch of animal responsible for rabies.
Total number of bitten patient attendant and received vaccine in 5 years is 30000x5 = 150000
I have studied 500 rabies patent attended in the hospital and I found rabies developed in 420 dog bite cases those did not receive any Anti Rabies vaccine and 80 rabies case in case of dog bite those received Anti Rabies vaccine, Nerve tissue, Verorab and Rabipur.
The result of the vaccinated and unvaccinated rabies cases shows below.
Total No Rabies case in 5 yrs Unvaccinated Vaccinated i.e. failure of vaccine
500 420 80
Now the vaccine failure 80 cases is found in 150000 vaccinated cases in 5 years. Bangladesh made nerve tissue vaccine failure – 70, Out of 125000, France made verorab – 1 out of 12500, India made Rabipur – 9 out 12500
This is shown in the table below
Total no. of vaccination pt. Total no. of failure Nerve tissue Verorab Rabipur
150000 80 70 1 9
No vaccinated person 125000 12500 12500
Per thousand 0.56:1000 1:12500 0.72:1000
Reactions of the different types of vaccine in 5 year.
Total number of vaccinated person is 150000 in five years. Total number of reactions in 5 years – 140. Nerve tissue vaccine: reactions – 110 out 125000 and they developed –G.B.S. that is Gulin Bari Syndrome & most of them Survive – and rarely dies.
In case of cell culture vaccine Verorab reaction- 3 out of 12500 and they developed post vaccinal Encephalitis and all of them died.
In case of Rabipur reaction 27 out of 12500 and also develop post vaccinenal encephalitis and died.
Anti Rabies Vaccine reaction in 150000 vaccinated person due to different types of vaccine used in Bangladesh like Nerve tissue Verorab Rabipur are shown below.
Types of vaccine No of. Vaccinated person No. of Vaccine Reaction Nature of reaction Level of consciousn-ess Fate of reaction Reaction per 1000
Nerve tissue 125000 110 GBS type of paralysis Pt. conscious All of them survive rarely dies 0.88:1000
Verorab 12500 3 Post vaccinal encephalitis Unconscious All them died 0.24: 1000
Rabipur 12500 27 Post vaccinal encephalitis Unconscious All them died 2.16:1000
Comparative study of three types of vaccine used infection disease Hospitals, Mohakhali, Dhaka shown as below:
Points Nerve Tissue Vaccine Rabipur Vaccine Verorab Vaccine
1. Regarding the vaccine failure per thousand 0.56: 1000 0.72:1000 1:12500
2. Reactions per thousand 0.88:1000 2.16:1000 0.24:1000
3. Nature of reaction GBS type Post Vaccinal encephalitis Post vaccinal encephalitis
4. Fate Most of them survive rarely dies Most of dies rarely survive Most them dies rarely survive
5. Production Bangladesh local India-foreign France-foreign
6. Price Only 35.00 per course very cheap 2200-2500 per course 2200-2500 per course
7. Foreign currency not involved involved involved
8. Yearly used 35000 course 100000 course 120000 course
9. Vaccine regarding pushing 5 cc 14 amp s.c. in the anterior abdominal wall 1 cc 5 amp in the deltoid muscle of the arm. 0-3-7-14-30 1 cc 5 amp in the deltoid muscle of the arm. 0-3-7-14-30
10. Regarding the import Not import dependent Import dependent and sometimes create crisis. Import dependent and sometimes create crisis.
11. Regarding poor people Poor people can easily afford Poor people easily can not afford Poor people easily can not afford
12. Regarding the use of cattle and goats Recommended not-recommended not-recommended
13. Pressure Pressure to stop production Increase dependency Increase dependency
14. Daily ARV prescribe in the outdoor of IDH 80-90% 5-10% 5-10%
Comments and suggestions to Bangladesh government to control of rabies in Bangladesh.
Rabies is a zoonotic endemic disease of the world in different country different types of animal is responsible for rabies transmission to human. On the other hand animal may be rabies carrier as well as rabid. So from the practical point of view rabies elimination is very difficult because besides the dog and cat other wild animal like jackal, monkey, fox, mongoose, vampire, bat are also responsible for rabies transmission to human but not rodent in our country.
So my comments & suggestions are:
a) Regarding the vaccine supply:
b) Regarding the control of animal responsible for rabies.
a) Regarding the vaccine supply:
1. Stop the import of India made cell culture vaccine Rabipor because its quality is below the Bangladesh made Nerve Tissue vaccine as the study shows mentioned above.
2. In this moment production of Nerve Tissue vaccine should be increase to meet the demand of the country.
3. After controlling of 90-95% rabies within 5 years by mass killing of unvaccinated stray dogs and cats then We should shift our strategy from Nerve tissue to Human diploid cell vaccine either by country production or by importing because HDCV is very much costly and it would be easily be possible for only 2-5% bite or scratch of the animal to human.
B) About the control of rabies in Bangladesh.
To save the 3-500 thousand human life, 1-2 lacs cattle and goats TK 2-3 hundred crores of foreign currency for A.R.V. vaccine we can drastically reduce the rabies bite upto 90-95% by mass killing of unvaccinated stray dogs & cats & banding of the petting of unvaccinated dogs & cats as the study shows that 91% rabies caused by dog and 7.4% due to cat in our country.
How to control the dog and cat throughout the country.
1. Govt. should fix up a target say 5 years plan to eradicate unvaccinated stray dog & cat. It is estimated in 64 district there is 64 lacs dogs and 64 lacs cats if govt. takes a coordinated program to eradicated unvaccinated dogs & cats by involving three ministry like health, LGRD & Fisheries & Livestock. Other than health ministry other two ministry can take the program for mass killing of dogs & cats throughout the country by involving the member chairman in the village & union level and Ward commissioner, Municipality chairman, chairman of city corporation and also govt. can involve the all media encouraging the people to kill unvaccinated dog & cats.
Health Ministry should take a training program for doctors upto zilla, upazilla level. At the same time awareness program for the people by postering, leaflet distribution, billboard hanging in the village market also in the population center for much involving the people to kill dogs & cats.
Suggestion to WHO
WHO can set up a program in all over the world for control the rabies worldwide.
a) To supply safe effective vaccine HDCV from a viable plant to all over the world like EPI.
b) WHO can take a worldwide program to eradicate unvaccinated stray dogs & cats to control the rabies all over the world. Our neighbor country Malaysia already has become rabies free country and Pakistan also following this policy.
References : Davidson’s Principals of Medicine 14th Edition.
Park’s : Community Medicine (13th Edition), India.
Modern Medical Microbiology 3rd Edition by Major General M.R. Chowdhury.
