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India fights rabies
Newsdesk
India fights rabies A new rabies control programme in India aims to tackle the serious but under-recognised public-health burden caused by this disease. Sanjeet Bagcchi reports. For more on rabies deaths worldwide see http://www.ncbi. nlm.nih.gov/pmc/articles/ PMC2626230/pdf/15976877.pdf For more on the rollout of the Indian programme see http:// timesofindia.indiatimes.com/ city/pune/Anti-rabiesprogramme-rolled-out-in-state/ articleshow/45289664.cms For the incidence of rabies in India see http://www.ijidonline. com/article/S12019712%2806%2900011-7/ fulltext For the number of cases reported in India see http:// www.who.int/bulletin/ volumes/92/4/14-136044/en/
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An estimated 55 000 deaths are caused by rabies across the world each year, and almost half of those deaths occur in one country: India. Roughly 18 000–20 000 cases of rabies are reported in India each year. To address this dismal situation, the Government of India has rolled out its National Rabies Control Programme, which will soon be implemented in nine states. The government, in its 12th 5-year plan, has allocated 500 million rupees (about £5 million) to the programme, with the aim of substantially reducing human deaths from rabies and also reducing disease transmission in dogs. In India, rabies predominantly spreads through dog bites. Jai P Narain, senior advisor to the Government of India (National Centre for Disease Control, New Delhi), told TLID that the focus of the National Rabies Control Programme is to prevent human deaths by timely post-exposure prophylaxis; improving the use of rabies immunoglobulins; increasing community awareness through information, education, and communication; and making postexposure prophylaxis available beyond subdistrict levels. The National Centre for Disease Control will oversee control of human rabies and the Animal Welfare Board of India and the Ministry of Environment and Forests will coordinate the animal health component. According to Narain, the animal health strategy will consist of surveys of dog populations, training for veterinary surgeons and para-veterinary surgeons, mass vaccination of dogs, and animal birth control. “These measures we hope will, over the 5-year period, bring about substantial reduction in the
burden of rabies in India and bring down the human rabies mortality which at present is around 20 000 each year”, he said. T Jacob John, president of the Child Health Foundation (New Delhi) told TLID that if done well, the programme could become a model for the entire country. “The encouraging aspect is the idea that National Centre for Disease Control, Animal Welfare Board, and the state governments will work together, which of course is the right way to go forward— with dog rabies and human rabies controlled in unison.” “There is no doubt that there is an immediate need [for] the implementation of a national programme for rabies prevention and control”, Shampur Narayan Madhusudana, head of the Indian WHO collaborating centre on reference and research on rabies, told TLID. He said that insufficient funding and a possible lack of cooperation between human and veterinary sectors (both officials and caregivers) could hamper the programme. “My suggestion is [the] Government of India ([including] both human and veterinary [departments]) should call for a national level workshop involving key persons and discuss the possibility of an early epidemiological survey to find out the exact burden of human and animal rabies.” “Surveillance for rabies involving direct rapid immunohistochemical test in animals should be given priority”, he added. According to Madhusudana, when a substantial amount of money is being spent in India to increase awareness of HIV, malaria, and tuberculosis, spending just a tenth of that money on education about rabies treatment could make a substantial difference in containing rabies in India.
According to a survey published in 2007 in the International Journal of Infectious Diseases, some Asian countries, including Thailand, Sri Lanka, and Philippines, have reduced the incidence of rabies. However, countries such as India, Pakistan, and Bangladesh still report thousands of rabies deaths each year. The incidence of rabies in India has remained unchanged for the past 10 years, as pointed out in a 2014 editorial published in the Bulletin of the World Health Organization. Because rabies is still not a notifiable disease in India, the incidence might be underestimated. Rabies is a problem in India because of a general lack of knowledge about preventive measures, which, according to the editorial, “translates into insufficient dog vaccination, an uncontrolled canine population, poor knowledge of proper postexposure prophylaxis on the part of many medical professionals, and an irregular supply of anti-rabies vaccine and immunoglobulin, particularly in primary-health-care facilities”. Indian people from lower socioeconomic groups and children aged 5–15 years are mainly affected by rabies in the country. Children are often bitten by dogs because many stray dogs roam freely near the areas where children play. Some children share their food with stray dogs, which also makes them vulnerable to dog bites. As the editorial pointed out, “In one study, most children attacked by dogs were unaware of having been bitten and their parents often ignored the attacks or simply treated the wounds by applying indigenous products such as hot peppers or turmeric. Only a few parents sought medical advice, usually with delay”.
www.thelancet.com/infection Vol 15 February 2015
Newsdesk
There are other reasons for the substantial burden of rabies in India. Narain said that “the reasons include a large number (25–28 million) unprotected stray dogs, rabies not perceived as a priority public health problem, particularly in the animal sector, lack of awareness, inadequate funding, non-existent intersectoral collaboration and practically no postexposure prophylaxis facilities in the rural India, and prevalent myths and beliefs about the prevention and treatment”. He continued, “Moreover, rabies is a disease of the poor and vulnerable populations whose deaths are rarely reported. It occurs mainly in remote rural communities where measures to prevent dog to human transmission have not been
implemented. The under-reporting of rabies undermine efforts to mobilise political commitment and allocation of adequate resources”. To improve the situation of rabies in India, interventions should be comprehensively taken up: “India ought to take rabies control seriously”, said John. He pointed out that, while flagging rabies for control, it should be but one element in a comprehensive plan for control of major communicable diseases with objective measurements. “Obviously, ministries of health, animal welfare, agriculture, environment, local administration, roads and highways, education, etc, have to participate”, he added. Control and eventual elimination of human rabies must receive
greater attention and higher level of political support. According to Narian, all efforts should be made to break the cycle of neglect through advocacy using research and epidemiological data so that unnecessary and premature mortality can be prevented. “Human rabies prevention cannot however be achieved without the elimination of rabies in dogs or without wider use of the post-exposure prophylaxis using [the] intradermal route”, said Narain. “It is critical for India to take a leadership role and set a target for elimination of human rabies within next 5 years and cut the rabies mortality by half during the same period”, he added.
Sanjeet Bagcchi
Infectious diseases surveillance update Listeriosis in the USA As of the Dec 30, 2014, 32 people in 11 states have fallen ill with the outbreak strain of Listeria monocytogenes. Since the initial illness onset dates around Oct 17, 2014, 31 people have been admitted to hospital. Ten cases were associated with pregnancy, of which one led to loss of the fetus. Six people have died, with three deaths directly attributed to listeria disease. Of the remaining deaths one is unrelated to listeriosis, whereas the cause of the other two deaths is unclear. Commercially produced and pre-packaged caramel apples have been identified as the most probable source of the outbreak. Public Health Agency of Canada has also identified two cases of listeriosis that are caused by same strain as the US outbreak.
Hantavirus in Panama On Dec 30, a new case of hantavirus disease in Los Santos province, Panama, brought the total for 2014 to 75 cases. Of the confirmed cases of hantavirus infection and hantavirus www.thelancet.com/infection Vol 15 February 2015
pulmonary syndrome at least two patients have died from their illness. Of those whose illness status is known, 38 were febrile cases, eight had mild hantavirus pulmonary syndrome, and 24 had severe pulmonary syndrome. Los Santos province registered nine cases of hantavirus cardiopulmonary syndrome in 2013. These cases were probably caused by a species of hantavirus, Choclo virus, which is endemic to the Los Santos province and can cause hantavirus pulmonary syndrome.
H5N1 influenza in Egypt and Libya As of Jan 6, three cases of H5N1 influenza type A infection have been confirmed in Egypt this year. One patient, a 3-year-old girl from Giza governorate, died from the illness on the Jan 5 and is the second person to die from the illness this year. The two other cases were from Minya governorate: a 30-year-old man in a stable condition and an 11-yearold boy whose condition is critical after presenting with fever and a
sore throat. On Dec 31, the Ministry of Health in Egypt confirmed the country’s 11th death from influenza A H5N1 from 29 reported cases in 2014. On Dec 28, The Technical Committee of the National Center for Disease Control in Libya held an emergency meeting to discuss ten cases of severe pneumonia. The cases were all reported to have symptoms of “cough, fever, phlegm, accompanied by bleeding and with acute respiratory failure”. Five patients died from their illness. One case has been confirmed to be H5N1 influenza type A and at least one other case has been diagnosed as influenza type A without strain identification. Six cases were reported from the Tripoli Medical Center whereas the other four were reported from Tobruk, near the Egyptian border. If independently confirmed, Libya would become the 17th country with confirmed human infections, and the most westerly occurrence of human cases of avian H5N1 influenza virus.
For more on listeriosis in the USA see http://www.cdc.gov/ listeria/outbreaks/caramelapples-12-14/index.html For more on hantavirus in Panama see http://www. promedmail.org/direct. php?id=3063819 For more on H5N1 in Egypt see http://outbreaknewstoday.com/ egypt-moh-reports-3-h5n1influenza-cases-in-2015-sofar-79624/ For more on H5N1 in Libya see http://www.promedmail.org/ direct.php?id=3061029
Ruth Zwizwai 157
India fights rabies A new rabies control programme in India aims to tackle the serious but under-recognised public-health burden caused by this disease. Sanjeet Bagcchi reports. For more on rabies deaths worldwide see http://www.ncbi. nlm.nih.gov/pmc/articles/ PMC2626230/pdf/15976877.pdf For more on the rollout of the Indian programme see http:// timesofindia.indiatimes.com/ city/pune/Anti-rabiesprogramme-rolled-out-in-state/ articleshow/45289664.cms For the incidence of rabies in India see http://www.ijidonline. com/article/S12019712%2806%2900011-7/ fulltext For the number of cases reported in India see http:// www.who.int/bulletin/ volumes/92/4/14-136044/en/
156
An estimated 55 000 deaths are caused by rabies across the world each year, and almost half of those deaths occur in one country: India. Roughly 18 000–20 000 cases of rabies are reported in India each year. To address this dismal situation, the Government of India has rolled out its National Rabies Control Programme, which will soon be implemented in nine states. The government, in its 12th 5-year plan, has allocated 500 million rupees (about £5 million) to the programme, with the aim of substantially reducing human deaths from rabies and also reducing disease transmission in dogs. In India, rabies predominantly spreads through dog bites. Jai P Narain, senior advisor to the Government of India (National Centre for Disease Control, New Delhi), told TLID that the focus of the National Rabies Control Programme is to prevent human deaths by timely post-exposure prophylaxis; improving the use of rabies immunoglobulins; increasing community awareness through information, education, and communication; and making postexposure prophylaxis available beyond subdistrict levels. The National Centre for Disease Control will oversee control of human rabies and the Animal Welfare Board of India and the Ministry of Environment and Forests will coordinate the animal health component. According to Narain, the animal health strategy will consist of surveys of dog populations, training for veterinary surgeons and para-veterinary surgeons, mass vaccination of dogs, and animal birth control. “These measures we hope will, over the 5-year period, bring about substantial reduction in the
burden of rabies in India and bring down the human rabies mortality which at present is around 20 000 each year”, he said. T Jacob John, president of the Child Health Foundation (New Delhi) told TLID that if done well, the programme could become a model for the entire country. “The encouraging aspect is the idea that National Centre for Disease Control, Animal Welfare Board, and the state governments will work together, which of course is the right way to go forward— with dog rabies and human rabies controlled in unison.” “There is no doubt that there is an immediate need [for] the implementation of a national programme for rabies prevention and control”, Shampur Narayan Madhusudana, head of the Indian WHO collaborating centre on reference and research on rabies, told TLID. He said that insufficient funding and a possible lack of cooperation between human and veterinary sectors (both officials and caregivers) could hamper the programme. “My suggestion is [the] Government of India ([including] both human and veterinary [departments]) should call for a national level workshop involving key persons and discuss the possibility of an early epidemiological survey to find out the exact burden of human and animal rabies.” “Surveillance for rabies involving direct rapid immunohistochemical test in animals should be given priority”, he added. According to Madhusudana, when a substantial amount of money is being spent in India to increase awareness of HIV, malaria, and tuberculosis, spending just a tenth of that money on education about rabies treatment could make a substantial difference in containing rabies in India.
According to a survey published in 2007 in the International Journal of Infectious Diseases, some Asian countries, including Thailand, Sri Lanka, and Philippines, have reduced the incidence of rabies. However, countries such as India, Pakistan, and Bangladesh still report thousands of rabies deaths each year. The incidence of rabies in India has remained unchanged for the past 10 years, as pointed out in a 2014 editorial published in the Bulletin of the World Health Organization. Because rabies is still not a notifiable disease in India, the incidence might be underestimated. Rabies is a problem in India because of a general lack of knowledge about preventive measures, which, according to the editorial, “translates into insufficient dog vaccination, an uncontrolled canine population, poor knowledge of proper postexposure prophylaxis on the part of many medical professionals, and an irregular supply of anti-rabies vaccine and immunoglobulin, particularly in primary-health-care facilities”. Indian people from lower socioeconomic groups and children aged 5–15 years are mainly affected by rabies in the country. Children are often bitten by dogs because many stray dogs roam freely near the areas where children play. Some children share their food with stray dogs, which also makes them vulnerable to dog bites. As the editorial pointed out, “In one study, most children attacked by dogs were unaware of having been bitten and their parents often ignored the attacks or simply treated the wounds by applying indigenous products such as hot peppers or turmeric. Only a few parents sought medical advice, usually with delay”.
www.thelancet.com/infection Vol 15 February 2015
Newsdesk
There are other reasons for the substantial burden of rabies in India. Narain said that “the reasons include a large number (25–28 million) unprotected stray dogs, rabies not perceived as a priority public health problem, particularly in the animal sector, lack of awareness, inadequate funding, non-existent intersectoral collaboration and practically no postexposure prophylaxis facilities in the rural India, and prevalent myths and beliefs about the prevention and treatment”. He continued, “Moreover, rabies is a disease of the poor and vulnerable populations whose deaths are rarely reported. It occurs mainly in remote rural communities where measures to prevent dog to human transmission have not been
implemented. The under-reporting of rabies undermine efforts to mobilise political commitment and allocation of adequate resources”. To improve the situation of rabies in India, interventions should be comprehensively taken up: “India ought to take rabies control seriously”, said John. He pointed out that, while flagging rabies for control, it should be but one element in a comprehensive plan for control of major communicable diseases with objective measurements. “Obviously, ministries of health, animal welfare, agriculture, environment, local administration, roads and highways, education, etc, have to participate”, he added. Control and eventual elimination of human rabies must receive
greater attention and higher level of political support. According to Narian, all efforts should be made to break the cycle of neglect through advocacy using research and epidemiological data so that unnecessary and premature mortality can be prevented. “Human rabies prevention cannot however be achieved without the elimination of rabies in dogs or without wider use of the post-exposure prophylaxis using [the] intradermal route”, said Narain. “It is critical for India to take a leadership role and set a target for elimination of human rabies within next 5 years and cut the rabies mortality by half during the same period”, he added.
Sanjeet Bagcchi
Infectious diseases surveillance update Listeriosis in the USA As of the Dec 30, 2014, 32 people in 11 states have fallen ill with the outbreak strain of Listeria monocytogenes. Since the initial illness onset dates around Oct 17, 2014, 31 people have been admitted to hospital. Ten cases were associated with pregnancy, of which one led to loss of the fetus. Six people have died, with three deaths directly attributed to listeria disease. Of the remaining deaths one is unrelated to listeriosis, whereas the cause of the other two deaths is unclear. Commercially produced and pre-packaged caramel apples have been identified as the most probable source of the outbreak. Public Health Agency of Canada has also identified two cases of listeriosis that are caused by same strain as the US outbreak.
Hantavirus in Panama On Dec 30, a new case of hantavirus disease in Los Santos province, Panama, brought the total for 2014 to 75 cases. Of the confirmed cases of hantavirus infection and hantavirus www.thelancet.com/infection Vol 15 February 2015
pulmonary syndrome at least two patients have died from their illness. Of those whose illness status is known, 38 were febrile cases, eight had mild hantavirus pulmonary syndrome, and 24 had severe pulmonary syndrome. Los Santos province registered nine cases of hantavirus cardiopulmonary syndrome in 2013. These cases were probably caused by a species of hantavirus, Choclo virus, which is endemic to the Los Santos province and can cause hantavirus pulmonary syndrome.
H5N1 influenza in Egypt and Libya As of Jan 6, three cases of H5N1 influenza type A infection have been confirmed in Egypt this year. One patient, a 3-year-old girl from Giza governorate, died from the illness on the Jan 5 and is the second person to die from the illness this year. The two other cases were from Minya governorate: a 30-year-old man in a stable condition and an 11-yearold boy whose condition is critical after presenting with fever and a
sore throat. On Dec 31, the Ministry of Health in Egypt confirmed the country’s 11th death from influenza A H5N1 from 29 reported cases in 2014. On Dec 28, The Technical Committee of the National Center for Disease Control in Libya held an emergency meeting to discuss ten cases of severe pneumonia. The cases were all reported to have symptoms of “cough, fever, phlegm, accompanied by bleeding and with acute respiratory failure”. Five patients died from their illness. One case has been confirmed to be H5N1 influenza type A and at least one other case has been diagnosed as influenza type A without strain identification. Six cases were reported from the Tripoli Medical Center whereas the other four were reported from Tobruk, near the Egyptian border. If independently confirmed, Libya would become the 17th country with confirmed human infections, and the most westerly occurrence of human cases of avian H5N1 influenza virus.
For more on listeriosis in the USA see http://www.cdc.gov/ listeria/outbreaks/caramelapples-12-14/index.html For more on hantavirus in Panama see http://www. promedmail.org/direct. php?id=3063819 For more on H5N1 in Egypt see http://outbreaknewstoday.com/ egypt-moh-reports-3-h5n1influenza-cases-in-2015-sofar-79624/ For more on H5N1 in Libya see http://www.promedmail.org/ direct.php?id=3061029
Ruth Zwizwai 157