1. Assessing the clinical efficacy of exclusive local infiltration of bite wounds with equine Rabies Immunoglobulin (eRIG) along with Intra-Dermal Rabies Vaccination (IDRV), following exposures to lab confirmed rabid dogs
Omesh Kumar Bharti

2. PEP as per WHO Guidelines
In all category III (severe) exposures to rabies it is recommended by WHO that along with rabies vaccine, rabies immunoglobulin (RIG) is to be injected into and around wound/s as much as anatomically feasible and any leftover RIG is to be injected intramuscular (IM) at a site away from the site of vaccine administration.
The dose of eRIG is calculated as 40 IU/Kg body weight.

3. PEP as per WHO Guidelines
- 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).

4. When RIGs are not available ?

5. Local RIG Infiltration
There were media reports of deaths elsewhere due to non availability of RIG; However, this study was sparked by the death of a 32 year old male whose lower lip was torn by a suspected rabid dogbite on September 5, 2014.
He was referred to IG Medical College (IGMC) Shimla from a distant Rampur civil hospital (120 Km) with symptoms of Rabies. The author was called by IGMC authorties to investigate into the case.
He was given rabies vaccine IM at Rampur but RIG was not available in the market or in the hospital.
He developed fatal rabies within 2 weeks of bite on the lower lip.

6. Local RIG Infiltration
Since April, 2014 there was continued acute shortage of RIG in Himachal. Consequently, limited quantity of eRIG produced / available at Central Research Institute (CRI), Kasauli, HP, was procured for only local infiltration of wounds, based on existing literature review, and the left-over RIG volume was shared with other rabies exposed patients to avert deaths.

7. 2 Years of Local RIG Infiltration with IDRV
From June 2014 to May 2016 more than 7000 patients have been registered at our clinics in DDU Hospital and IG Medical College Shimla. Out of them, 4202 were type III and were given only local eRIG in and around the wound/s with IDRV.
Of these, 231 patients were bitten by suspected rabid dogs. We captured three suspected rabid dogs alive and all three were later lab confirmed as rabid (FAT positive) at CRI Kasauli.

8. 2 Years of Local RIG Infiltration
- We followed 26 patients bitten by three lab confirmed rabid dogs for 9 months to more than a year and all were alive and healthy.
Minimum dose given was ml (1 unit of 40 units of insulin syringe) and maximum was 9 ml. Average dose given was 1.6 ml of eRIG. We were able to save 140 ml (28 vials) of eRIG in these 26 rabies exposed patients by not giving them RIG as per their body weight; We shared the left-over RIG among 87 patients during these times of scarcity of eRIG in the market.
93 re-exposed patients were given one-time 4 site 0.1ml vaccine booster without RIG (Saving RIG).
Vaccines we used in lab confirmed rabid dogbite patients were : Vaxirab-N (7.18 IU/1 ml) and Abhayrab (>2.5 IU/ml).
Rabies immunoglobulin (ARS) given were from CRI Kasauli, having potency of 550 IU/ (0.5/ 1 ml) Vial.

9. Lab confirmed rabid dogbite patients
Age (Yrs)
Sex
Site of bite
Weight in KG
Volume of ERIG
Time interval b/w bite & ERIG
Follow up in Wks
DDU/529 50 M
Rt. Leg 75
2 ml 1
54 Weeks
DDU/530 25 F
Rt. Thigh
1 ml
DDU/534 41
Rt. Knee 98
6 ml
DDU/536 16
Rt.Leg 56
0.5 ml
DDU/541 12 23
3 ml
DDU/542 06
Lt. Lumber area
2.5 ml
DDU/567 33
Lt. Thigh 80
6.5 ml 3
DDU/1531 40
Leg 65
5 ml
42 Weeks
DDU/1534 32
Arm 60
DDU/1535 20 53
DDU/1542 34
Chest
DDU/1554 48
Lt Hand
DDU/1566 57
Back 70

10. Lab confirmed rabid dogbite patients
Age (Yrs)
Sex
Site of bite
Weight in KG
Volume of ERIG
Time interval b/w bite & ERIG
Follow up in Wks
DDU/1568 30 M
Lt. Leg 65
2 ml
42 Weeks
DDU/1582 51
Rt. Abdomen 64
1 ml
DDU/1585 35
Rt. Arm 60
0.5 ml
IGMC/ 56 2 F NA
9.8
400 IU
IGMC/ 01 5
12.4
250 IU
IGMC/ 04 58 70
40 IU
IGMC/ 09 15
40 IU
IGMC/ 10 38
Rt. Feet 55
IGMC/ 11 34
IGMC/ 12 7 23
460 IU
IGMC/ 16
IGMC/ 25 46
Both Legs
600 IU
IGMC/26 17
LT. Leg
300 IU

11. Rabies is a dynamic reality in Shimla City
For the last two years, all the six dog brain samples (suspected Rabid or not) sent for examination were tested positive for rabies (FAT/BT) despite ABC programme in Shimla.
Rabies has now travelled from stray dogs to wildlife as brain samples of recently dead monkey, Langoor and Himalayan Palm Civet in Shimla have been found to be positive for rabies (FAT/BT).
Till June this year, 9 cows have died in Shimla city and around due to clinical rabies after rabid dogbite/s.
These rabid dogs are moving around the city and may have bitten many people as well. But the lives of human victims, including tourists, are saved as PEP is free at our clinic including eRIG.
We continue with local wound infiltration of eRIG with IDRV as RIG are still not available in the market.

12. Dead Animal Brains for FAT/BT at Kasauli found positive

13. Three Method of Local administration of RIG

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

15. 2 Years of Local RIG Infiltration
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 and needs to be studied in a larger sample of lab confirmed dogbite victims with long term follow up before definite conclusions are drawn.
- We name this protocol in the memory of stalwart in rabies research, late Dr. Shampur Narayan Madhusudana as;
“Madhusudana- Bharti Protocol”

16. Universal Access to Affordable Treatment”
“Our Vision -
Universal Access to Affordable Treatment”
“Sometimes Less can be More
– Intra-Dermal Rabies Vaccination and Local RIG”
Our journey started on ……..