Drs Omesh K Bharti, Uppinder Kumar, Adarsh Kumar & Archana Phull Intra-dermal rabies vaccination (IDRV) alongwith local wound infiltration of rabies immunoglobulins (RIG) in bovine - A life saving protocol Drs Omesh K Bharti, Uppinder Kumar, Adarsh Kumar & Archana Phull

2 Years of Local RIG Infiltration in Humans This pilot study strongly indicates that “Local wound infiltration of RIG with IDRV” is life saving as well as cost -saving protocol, which is clinically efficacious as studied in more than 15,000 human patients out of which 26 were lab confirmed dogbite victims followed for one year, showing that there is significant saving of life and costly RIG. - We named this protocol in the memory of stalwart in rabies research, late Dr. Shampur Narayan Madhusudana as; “Madhusudana- Bharti Protocol”

Dead Animal Brains for FAT/BT at Kasauli found positive

Immunoglobulins a must ! OMESH BHARTI

Three Methods of Local administration of RIG in Human

Local RIGs Study- Local Infiltration in the Gaping Wound keep the bevel of needle towards wound OMESH BHARTI

Suspected Rabid dogbite patient, bitten on face and lips, before and after more than a year of follow up of local RIG with IDRV

IDRV with Local Wound Infiltration of RIG in Bovine - Cattle are the backbone of household economy in rural areas of India and many of them die after bites by potentially rabid dogs, despite being given recommended five shots of intramuscular rabies vaccination as PEP. This scenario prompted the authors to look for a suitable protocol, based on human studies, to protect the bovine. IDRV has shown its superiority over the IM regimen of rabies vaccination in humans.

Animal Rabies Burden of cattle rabies in Asia has been estimated to be 5/1,00,000 Exact Burden of animal rabies in India is not known as rabies in animals is not properly notified. There are no programme for preventive rabies vaccination of bovine in India despite rabies in bovine being endemic. Can we save them on analogy of human PEP with IDRV and local wound infiltration of RIG?

ID Rabies vaccination in a Cow on middle third of Neck .

Local wound infiltration with RIG in Bovine using insulin syringe

Local wound infiltration with RIG in Equine using insulin syringe

ID vaccination in Bovine - We found that high titers were attained in majority of domestic bovine with even single dose of 0.2 ml intra-dermal rabies vaccination. - Subsequent responses were not vaccine dose dependent but had desired protective levels of antibodies by day 14, even in animals having natural antibodies above 0.5 IU/ml on day 0.

IDRV with Local Wound Infiltration of RIG in Bovine We tested various schedules of intra-dermal rabies vaccination in bovine and found that a schedule of 0.2 ml given in middle 1/3rd of neck on day 0,3,7,14 and 28 alongwith local wound infiltration of RIG is sufficiently immunogenic and life saving in all of them, even if bitten by lab confirmed rabid dogs. Brain samples of suspected rabid animals (2dogs/2 mongoose)were tested by FAT at CRI Kasauli and were found positive for rabies.

ID vaccination in Bovine It was observed that not all bovine were attaining required antibodies level of 0.5 IU/ml by day 14 when vaccinated intramuscularly and this may be a reason towards observed vaccine failures by IM route in bovine in our settings. -Many animals were given five doses of ID PEP with local wound infiltration of RIG after their exposure to clinically or lab confirmed rabid dogs/ mongoose and all survived for more than nine months.

IDRV with Local Wound Infiltration of RIG in Bovine - The aim of RIG injection into bite wound/s is to neutralize the rabies virus in situ and thus prevent infection / onset of rabies, as the course of anti rabies vaccination takes about 10 – 14 days to provide full protection. - Many recent expert consultations on rabies have opined that systemic injection of RIG may not be useful but this practice continued due to lack of any new scientific evidence (personal communication).

IDRV with Local Wound Infiltration of RIG in Bovine A total of 62 animals were given five doses of ID PEP with 0.2 ml given in middle 1/3rd of neck on day 0,3,7,14 and 28 alongwith local wound infiltration of RIG after their exposure to clinically or lab confirmed rabid dogs/ mongoose and all had survived. The RFFIT titers of 55% bovine in all groups were more than adequate at day 365 and all had adequate anamnestic response by day 7, to a single 0.2 ml booster given at one year.

IDRV with Local Wound Infiltration of RIG in Bovine Serum samples from 15 animals bitten by lab confirmed rabid dogs were collected on day 14 and tested for RVNA by RFFIT from NIMHANS Bangalore and all had required antibody titers above 0.5 IU/ml by day 14 after IDRV and local RIG injection in and around the wound/s. No immunosuppression was observed with local RIG as we tested RFFIT titers in all bovine with minimal dose of RIG as 0.5 ml and maximum dose given was 4 ml locally in the wound.

IDRV with Local Wound Infiltration of RIG in Bovine Pre-exposure prophylaxis was found to be effective as 0.2 ml dose of vaccine on day 0,3,7 and all bovine had titers higher than desired by day seven after single 0.2ml vaccine booster at one year. Our study points towards possibility of having short schedules of three shots ID vaccination with or without local RIG as PEP and single shot ID as Pre Exposure Prophylaxis (PrEP) but require further studies on large number of animals.

ID vaccination in Bovine This protocol of local RIG infiltration into wound/s with intra-dermal vaccination have saved lives of bovine or even of equine and we named it in honour of our beloved Guru Late Dr. Shampur Narayan Madhusudana as: “Madhusudana-Bharti-Uppinder” Protocol.

Age/sex Animal/ weight in Kg Lab confirmed Biting animal Site of bite IDRV with 0.2ml at neck on days 0,3,7,14 & 28 RIG vol in wound/ RFFIT at D 14 IU/ml 4/F Cattle/300 rabid dog A Head & muzzle As Above 4 ml/ 3.75 1/F Cattle/ 50 Rabid dog A Lower mandible 2 ml/ 15 Ear/Eye As above 2/F Cattle/ 250 Neck 1 ml/30 Buffalo/ 50 Head 1 ml/ 7.5 6/F Cattle/ 400 upper muzzle 2 ml/ 30 8/F 1 ml/ 15 Buffalo/ 600 Rabid dog B muzzle 3 ml/ 7.5 Cow/ 400 Head & ear 5/F Cow/ 300 Both jaws 1 ml/ 30 Muzzle 7/F Buffalo/ 700 Neck & ear 2 ml/ 15 Buffalo/ 200 Both ears 3 ml/ 15 <1/F Calf/ 7 Days rabid mongoose Muzzle wound 0.5 ml/ NA

Acknowledgements Thanks to the Animal Ethics Committee members who realized the urgency of such a study in circumstances of non compliance of PEP in bovine and granted approval. Thanks to NIMHANS Bangalore & CRI Kasauli for doing RFFIT & FAT/BT tests free of cost and all my veterinary friends who supported the cause. Lastly, thanks to my family members for all their support.

For any clarification please contact bhartiomesh@yahoo.com Mobile: 094181-20302 Address: Set-9, Block-1, US Club Shimla, Himachal Pradesh, India-171001