TRAINING MODULE

ON RABIES
FOR
MEDICAL OFFICERS

National Centre for Disease Control

Directorate General of Health Services
Ministry of Health and Family Welfare
Government of India
 TABLE OF CONTENTS

SESSION 1 - EPIDEMIOLOGY AND PATHOGENESIS 15

SESSION 2 - ANIMAL BITE MANAGEMENT, PEP, PrEP 22
SESSION 3 - DIAGNOSIS AND CASE MANAGEMENT 39
SESSION 4 - RECORDING, REPORTING AND SURVEILLANCE 49
SESSION 5 - LOGISTICS FOR RABIES BIOLOGICALS 59
SESSION 6 - HEALTH FACILITIES AS ANTI-RABIES CLINIC 61
SESSION 7 – RISK COMMUNICATION 65
SESSION 8 - RABIES IN ANIMALS 69
SESSION 9 - UNDERSTANDING ONE HEALTH FOR RABIES 71

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 ABBREVIATIONS
ABC-AR Animal Birth Control- Anti Rabies
AEFI Adverse Event Following Immunization
AIDS
ARC Anti-Rabies Clinic
ARV Anti-Rabies Vaccine
CCV Cell Culture Vaccine
CD4 Cluster of differentiation 4
CHO Chinese Hamster Ovarian
CNS Central Nervous System
CSF Cerebrospinal Fluid
DCGI Drug Controller General of India
DNA Deoxyribonucleic Acid
DRIT Direct Rapid Immunohistochemical test
ELISA Enzyme-linked Immunosorbent Assay
ERIG Equine rabies immunoglobulins
FAO Food & Agricultural Organization
FAT Fluorescent Antibody Test
GARC Global Alliance for Rabies Control
HDCV Human Diploid Cell Vaccine
HIV
HRIG Human Rabies Immunoglobulins
ID Intradermal
IDRV Intradermal Rabies Vaccination
IM Intramuscular
IU International Units
MoHFW Ministry of Health & Family Welfare
NCDC National Centre for Disease Control
NIMHANS National Institute of Mental Health & Neurosciences
nm Nanometre
mL Millilitre
NRCP National Rabies Control Programme
OIE

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PCECV
PCR Polymerase Chain Reaction
PDEV
PEP Post Exposure Prophylaxis
PrEP Pre-Exposure Prophylaxis
PVRV
RFFIT Rapid Fluorescent Focus Inhibition Test
RIG Rabies Immunoglobulin
RmAb Rabies monoclonal Antibodies
RNA Ribonucleic Acid
SST Skin Sensitivity Test
TRC Thai Red Cross
TT Tetanus Toxoid
UIP Universal Immunization Programme
WHO World Health Organization

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Session No. Topic Duration
Session -1 Epidemiology and Pathogenesis 45 Minutes

Session -2 Animal Bite Management, PEP, PrEP 90 Minutes

Session -3 Diagnosis And Case Management 60 Minutes

Session -4 Recording, Reporting And Surveillance 60 Minutes

Session -5 Logistics For Rabies Biologicals 30 Minutes

Session -6 Health Facilities as Anti-Rabies Clinic 45 Minutes

Session -7 Risk Communication 30 Minutes

Session -8 Rabies In Animals 30 Minutes

Session -9 Understanding One Health For Rabies 30 Minutes

Frequently asked questions (FAQs)

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SESSION 1 - EPIDEMIOLOGY AND PATHOGENESIS
Learning objectives

• To provide brief information about the National Rabies Control Program.

• To provide a brief introduction on Epidemiology of Human Rabies, Disease burden of Human

Rabies (Global & National) and its pathogenesis.

• To describe the major clinical features of Rabies

1.1 INTRODUCTION- NATIONAL RABIES CONTROL PROGRAMME (NRCP)

Rabies is an acute viral disease that causes fatal encephalomyelitis in virtually all warm-blooded animals
including humans. The virus is found in wild and some domestic animals and is transmitted to other
animals and humans through their saliva (following bites, scratches, licks on broken skin and mucous
membrane). In India, the disease is mainly transmitted by the bite of a rabid dog (dogs are responsible
for about 97% of human rabies cases), followed by cats (2%), jackals, mongooses, and others (1%).

invariably fatal and perhaps the most painful and dreadful of all communicable diseases. Fortunately,
the development of rabies can be prevented to a large extent if animal bites are managed appropriately
and in time.

National Rabies Control Programme (NRCP) is being implemented in the country since the 12 Five Year
Plan with an objective to prevent deaths due to rabies in humans. National Centre for Disease Control is
the nodal centre for implementation of the programme. The key strategies of the programme are:

• Provision of Rabies Post Exposure Prophylaxis

• Strengthening surveillance of animal bites and human rabies

• Capacity building of health care professionals for appropriate management of Animal Bite Victims

• Strengthening laboratory diagnosis of Rabies

• Increase awareness about Rabies in the general community

• Strengthening Inter-Sectoral Collaboration with other Sectors

1.2 RABIES EPIDEMIOLOGY

Rabies is present on all continents, except Antarctica, with over 95% of human deaths occurring in the
Asia and Africa regions.

Rabies is one of the neglected tropical diseases that predominantly affect poor and vulnerable populations
who live in remote rural locations. Although effective human vaccines and immunoglobulins exist for
rabies, they are not readily available or accessible to those in need. V fc Globally, rabies deaths are rarely
reported and children between the ages of 5–14 years are frequent victims. Treating a rabies exposure,
where the average cost of rabies post-exposure prophylaxis (PEP) is US$ 40 in Africa, and US$ 49 in

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1.3 GLOBAL BURDEN

The number of human deaths globally due to dog-mediated rabies is estimated to be 59 000 annually,
with an associated loss of 3.7 million DALYs. Majority of deaths are estimated to occur in Asia (59.6%)
and Africa (36.4%), and most DALYs are due to premature death (> 99%) and a few adverse events
after administration of nerve tissue vaccines (0.8%). The overall economic cost of dog-mediated rabies

2.9–21.5billion) not including psychological trauma for victims and communities.

Figure 1 – Breakdown of the economic burden of rabies as Zero by 30: the global strategic plan to end
human deaths from dog-mediated rabies by 2030. https://apps.who.int/iris/handle/10665/272756

1.4 BURDEN IN ASIA

An estimated 35 172 human deaths (59.6% of global deaths) and loss of approximately 2.2 million DALYs
occur per year in Asia due to dog-mediated rabies. The cost of PEP is highest in Asia, with estimates up
to US$ 1.5 billion per year. Despite widespread underreporting and uncertain estimates, rabies is a
major burden in Asia, particularly for the rural poor.

General Aspects & Laboratory Diagnostic Techniques, NCDC-WHO, 2007

Figure 2: Global burden of Rabies. A: Human deaths from rabies; B: Death rates per capita (per 100 000
population); countries shaded in grey are free from canine rabies

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1.5 BURDEN IN INDIA

For India, it is estimated that per year 20,000 human deaths are caused by rabies and 17.4 million
animal bites occur per year. Dog mediated rabies is a major public health problem accounting for about
96% of the human deaths by rabies. An enhanced verbal autopsy survey within the Million Deaths Study

India. India accounts for the most deaths in Asia (59.9% of human rabies deaths) and globally (35%
of human rabies deaths). Rabies is endemic in India except for Andaman & Nicobar and Lakshadweep
Islands. (2: Suraweera W et. al.; Million Death Study Collaborators. Deaths from symptomatically

2012;6(10):e1847. doi: 10.1371/journal.pntd.0001847. Epub 2012 Oct 4. PMID: 23056661; PMCID:

PMC3464588.)

In India, rabies is transmitted most commonly by dogs and cats (~97%), followed by wild animals (2%)
such as mongoose, foxes, jackals, and wild dogs, and occasionally by horses, donkeys, monkeys, cows,
goats, sheep, and pigs. Rodents, rats and bandicoots, squirrels, rabbits etc. birds and bats are generally
not known to transmit rabies in India. In the past seven years, there has been an increasing trend of
animal bites reported to IDSP. 21.80 lakhs animal bites were reported in 2012 to IDSP-IHIP.

Figure 3: State wise Reported Human Rabies Cases 2018 Figure 4: State wise Animal Bite prevalence Year
to 2022 2021

1.6 RABIES VIRUS

Lyssaviruses are negative-sense, single-stranded, enveloped, bullet-shaped RNA viruses. They are
composed of two structural and functional units:

(i) The outer envelope covered with spike-like projections (10 nm in length) corresponding to G-protein

lyssavirus is attributed to protein G.

(ii) The internal helically packaged ribonucleocapsid, which is composed of the genomic RNA
intimately associalted with protein N, polymerase L and its cofactor protein P (formerly named M1).
The ribonucleocapsid complex ensures genome transcription and replication in the cytoplasm. Finally,
protein M (formerly named M2) occupies an intermediate position between the ribonucleocapsid and
the envelope and is responsible for virus budding and the bullet-shaped morphology.

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 Figure 5: Rabies virus
1.7 MODE OF TRANSMISSION

RABV enters the body through open skin (scratches, bites or other open wounds) or by direct contact
with mucosal surfaces; it cannot cross intact skin. RABV may replicate in muscle or other local tissues
after exposure and gain access to motor endplates and motor axons to reach the central nervous system.
Virions are carried in transport vesicles to the central nervous system exclusively by fast retrograde
transport along motor axons, with no uptake by sensory or sympathetic endings (Viruses can also enter
motor axons in peripheral nerves directly during a penetrating injury).
Table 1- Animals transmitting rabies in India
Frequent Occasionally Not reported

Dogs & cats Monkeys Bears Bats *

Mongoose, shrew Pigs Rodents *
Cows & buffaloes Donkeys Birds
Foxes, wolves & jackals Horses Squirrel
Sheep & goats Camels
Note: All exposures with wild animals are considered Category III exposures.
* Bite by bats or rodents do not ordinarily necessitate rabies vaccination in India. However, bites by
bats or rodents in unusual circumstances may be considered for vaccination in consultation with an

1.8 PATHOGENESIS
On entering into the human body through wounds or direct contact with mucosal surfaces, the rabies
virus either multiplies at the local site of inoculation in non-nervous tissues or directly enters peripheral

the brain via the nerves. It does not follow the hematogenous route of spread.
The movement of the virus is extremely slow (5–100 mm per day) which results in a long incubation

amount of virus in the saliva of the biting animal, the virus strain, and the age and immune status of
the victim. It is shorter in case the bite is closer to the brain and a massive dose of the virus has been
inoculated.
Human rabies can manifest as a spectrum of disease, from furious to paralytic manifestations, which

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salivary glands and other organs. The virus is widely disseminated throughout the body at the time of
clinical onset. This has practical implications as organ transplantation has resulted in the transmission
of the disease to the recipient.

The incubation period of the majority of cases is 2–3 months, while 2–3% of cases have had an incubation
period > 1 year, with an exceptional case of 8 years. Because of the wide range of incubation periods,
post-exposure prophylaxis should be given as soon as possible, however, it should not be denied
to persons reporting late.

Figure 6: Schematic representation of the pathogenetic events following peripheral inoculation of

the disease and its management, 3rd ed., AC Jackson [ed], Oxford, UK, Elsevier Academic Press, 2013, pp
269–298; with permission.)

1.9 CLINICAL SIGNS AND SYMPTOMS

Human rabies can manifest in various different ways, from furious to paralytic manifestations, which

Rabies usually presents as atypical encephalitis with preservation of consciousness; the disease may be

Recording, reporting and surveillance.

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 Hyperactivity, Confusion, Agitation

Fever, Pruritis, Paraesthesia Hypersalivation, piloerection,

periodic dilatation of pupils,
hydrophobia, acrophobia,
dysphagia, inspiratory spasms,
hyperventilation, haematemesis Coma
Exposure First Symptom Clinical Expression

20-90 days Prodrome 1-2 days Acute Neurological Phase (1-4 days) Death (1-7 days)

Paralytic Rabies
Fever, Pruritis, Paraesthesia
Quadriplegia, dysarthria,
dysphagia, hypersalivation,
inspiratory spasms, respiratory
failure, hydrophobia or
acrophobia (in -50% of cases)

Behaviour

Clinical Symptoms
Drowsiness

Figure 7: Two types of presentation of the Acute Neurologic stage of rabies in humans (Source: Gaillard F,
Baba Y, Sharma R, et al. Rabies encephalitis. Reference article, Radiopaedia.org)
Before CNS manifestations, dorsal root ganglionitis can result in localized neuropathic pain in the region
of exposure (bite) 3.
Involvement of the CNS by rabies can take two forms, which do not appear to correlate with the site of
the bite, previous immunization, vector (bat, dog or other) or any other clinical feature 1-3:
1. classic rabies encephalitis (80%); equivalent to ‘furious rabies’ in dogs
2. paralytic rabies (20%); equivalent to ‘dumb rabies’ in dogs
Classic rabies encephalitis: Encephalitis is by far the most common presentation of CNS involvement by

anorexia, irritability, inspiratory spasms and cough, autonomic dysfunction and altered mental status.
With time classic symptoms and rabies encephalitis develop including hydrophobia, aerophobia and
hypersalivation, agitation and even priapism.
Paralytic rabies: Paralytic rabies is relatively uncommon accounting only for 20% of CNS infections in
humans. It is characterized by bilateral global motor weakness resulting in bilateral facial weakness
and quadriparesis, with relative sparing of the sensory system 1,3. It clinically resembles Guillain-Barré
syndrome

retrogradely up the axons to the dorsal root ganglia, which can result in neuropathic pain 3. Once it reaches
the central nervous system dissemination is rapid accounting for the fulminant clinical course 2,3.
Radiographic features : As is the case with other encephalitis, MRI is the only modality of any use in the
diagnosis of CNS rabies, as CT is usually normal. Unfortunately, the very rapid progression of symptoms

MRI : Magnetic resonance imaging, performed with adequate precautions for potentially infectious

hippocampus, hypothalamus, deep and subcortical white matter and deep and cortical grey matter are

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evident, regardless of clinical type. Gadolinium enhancement may appear clearly only in later stages when
patients lapse into a coma. Such patterns can help differentiate rabies from other viral encephalitis, not in
terms of location, but in the appearance of the T2 image and in the pattern of contrast enhancement, when
compared with consciousness status. Computerized tomography of the brain is of little diagnostic value.
Angiography: Reports of narrowing of terminal internal carotid arteries and distal basilar artery may
be related to arterial spasm .
Differential Diagnosis: Rabies should be included in the differential diagnosis of all patients who present
with unexplained, acute, progressive viral encephalitis, even in areas where the disease is rare, as it can
occur locally in wildlife (e.g. jackal, fox, mongoose).

of animal bite exposure is required in cases of substance abuse. The presentation of rabies is usually
quite different from that of acute viral encephalitis due to most other causes, including herpes simplex
encephalitis and arboviral (e.g., West Nile) encephalitis. Early neurologic symptoms may occur at the
site of the bite, and there may be early features of brainstem involvement with the preservation of
consciousness. Anti–N-methyl-d-aspartate receptor (anti-NMDA) encephalitis occurs in young patients
(especially females) and is characterized by behavioural changes, autonomic instability, hypoventilation,
and seizures. Many other antibodies are associated with autoimmune encephalitis. Post-infectious

may also occur as a sequela of immunization with rabies vaccines derived from neural tissues, which are
used only in resource-limited and resource-poor countries.
Differential Diagnosis for Human Rabies
• Guillain-Barré syndrome
• Viral encephalitis
• Poliomyelitis
• Transverse myelitis
• Cerebrovascular accident
• Psychosis
• Intracranial mass
• Epilepsy
• Atropine poisoning
• Creutzfeldt-Jacob disease
POINTS TO REMEMBER
1. Rabies is an acute viral disease that causes fatal encephalomyelitis in virtually all warm-blooded
animals including man.
2. The number of human deaths globally due to dog-mediated rabies is estimated to be 59,000 annually.
3. The majority of deaths are estimated to occur in Asia (59.6%) and Africa (36.4%).
4. As per estimates, India has the highest burden of Human Rabies Cases. It is estimated that the annual
incidence of Human Rabies Deaths is 20,000.
5. Rabies virus enters into the human body through inoculation of infectious saliva into wounds,
scratches or direct contact with mucosal surfaces from where it spreads to the central nervous system
towards the brain.
6. The incubation period of the majority of cases is 2–3 months, while 2–3% of cases have had an
incubation period > 1 year, with an exceptional case of 8 years.
7. Human Rabies Case may be presented as 1) Encephalitic or furious type, which is present in 80% of
rabies cases, and 2) Paralytic or dumb type, which is seen in 20 %.
8. Classical signs of rabies include spasms in response to tactile, auditory, visual or olfactory stimuli (e.g.
aerophobia and hydrophobia) alternating with periods of lucidity, agitation, confusion and signs of
autonomic dysfunction.

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SESSION 2 - ANIMAL BITE MANAGEMENT, PEP, PrEP

Learning objectives
• To describe the principles of Animal bite management and Rabies post/ pre-exposure prophylaxis
• To understand the Categorization of Animal Bite cases and their recommended treatment as per
guidelines
• To demonstrate the administration of Intra-dermal Rabies vaccine and Rabies Anti- Serum
• To understand contraindication and precautions for Rabies vaccine and Rabies Antiserum and
special situations
• To understand adverse reactions associated with for Rabies vaccine and Rabies Antiserum
• To describe the principles of counselling animal bite victims
In a Rabies endemic country like India where there is sustained dog-to-dog transmission, every animal
bite is suspected as a potentially rabid animal bite, and treatment should be started immediately after
exposure. As Rabies is practically 100% fatal, bites by dogs and cats, in particular, must be considered as
a “medical emergency” and the “life-saving” post-exposure prophylaxis should be provided immediately.

POST EXPOSURE PROPHYLAXIS (PEP)

Since rabies is 100% fatal, PEP following an animal bite is life-saving and provides great relief to
bite victims and apprehensive attendants. Pregnancy, infancy, old age and concurrent illness are not
contraindications for anti-rabies treatment. Post-exposure prophylaxis is a three-pronged approach as
given below. All three carries equal importance and should be done simultaneously as applicable to the
exposure category.

Table 3: Steps in Management of Animal Bite Cases

A. Management of animal bite wound(s) (including exposure assessment and wound washing)
B. Active immunization with Anti-Rabies Vaccines (ARV)
C. Passive immunization with Rabies Immunoglobulin (RIG) if indicated

2.1 MANAGEMENT OF ANIMAL BITES WOUNDS

Since the Rabies virus enters the human body through a bite or scratch, the risk of rabies infection can be
reduced if the wound is properly taken care of, however, it is often neglected. Prompt local treatment of
all bite wounds and scratches is an important step in PEP. It is imperative to wash the wound thoroughly

management that should not involve additional trauma.

2.1.1 ASSESSMENT OF EXPOSURE

The most common modes of exposure to rabies virus are the following: Bite, Scratches and Licks on

treatment thereafter as provided in Table 4.

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Table 4: Category of Exposure/ Bite

Type of contact, exposure and recommended post-exposure prophylaxis

Category of Type of Exposure Recommended Post Exposure
Exposure Prophylaxis
Category I • Touching or feeding •None (if reliable case history is
of animals available)
• Licks on intact skin •Wash exposed areas with
• Contact of intact skin soap and running water for
with secretions/ 15 minutes and then apply
excretions of rabid antiseptic
animal or human case

Category II • Nibbling of uncovered skin •Wound Management - Wash

• Minor scratches or exposed areas with soap and
abrasions without running water for 15 minutes
bleeding and then apply antiseptic
•Rabies vaccine

Category III • Single or multiple transdermal •Wound management

bites or scratches •Rabies Immunoglobulin
• Licks on broken skin •Rabies Vaccine
• Contamination of
mucous membrane
with saliva
eg. from licks

NOTE: Bites by wild animals and all bites in forest areas should be considered as
Category III exposure and treated accordingly.

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2.1.2 WOUND MANAGEMENT

Washing of all wounds-

wound(s) for up to 15 minutes with soap and running water. This should be carried out as soon as
possible followed by application of Povidone Iodine or another substance having virucidal activity.
• If soap or a virucidal agent is not available, the wound(s) should be thoroughly and extensively
washed with water. Eyes and mucosa should be thoroughly rinsed with water.

obtained when fresh wound(s) are cleaned immediately.

• Since the Rabies virus, however, can persist and even multiply at the site of the bite for a long time,
wound(s) management must be performed even if the patient reports late.
• The application of irritants (like chillies, oil, turmeric, lime, salt, etc.) is unnecessary and damaging.
In case irritants have been applied on the wound(s), gentle washing with soap or detergent should

Application of antiseptics:

• After thorough washing and drying of the wound(s), any one of the available antiseptic agents such
as alcohol, etc. should be applied.
• Tetanus and antibiotic prophylaxis should be given if required. To prevent sepsis in the wound(s),
a suitable course of an antibiotic may be recommended.
Suturing of wounds:
• Most severe bite wounds are best treated by a daily dressing, followed by secondary suturing when
necessary.
• Secondary sutures are less likely to become infected and present better cosmetic results if done
under optimal conditions.
• In case of need for suturing, cleansing of the wound cannot be avoided and the wound(s) should

several hours to allow diffusion of the immunoglobulin through the tissues before minimal sutures
are done.
• Cauterization of wound(s) is no longer recommended as it leaves a bad scar and does not confer
any additional advantage over washing the wound(s) with water and soap.

Table 5: Steps and rationale of wound management

Steps in wound management Rationale

Physical Wash each wound with running water up to Mechanical removal of virus
15 mins from the wounds.
Chemical Clean the wounds with soap and Water Apply Inactivation of the virus.
antiseptics.
Biological Neutralization of the virus
wound in Category III exposures and immuno-
compromised patients with Cat II bite

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SUMMARY
Dos:
• Washing of each wound(s) is/are desirable for up to 15 minutes and should be carried out as soon
as possible.

• Gently clean wound/s with a detergent or any soap available.

• Apply available veridical topical preparation available antiseptic agent preferably Povidone Iodine.
If unavailable alcohol may be used

Don’ts:

• Do not apply irritants to the wound(s) like lime, chilli powder, turmeric, tobacco coffee powder,
plant saps etc. as these will propel the virus deeper to cause nerve infection and ultimately leading
to rabies encephalitis and death.

• Avoid bandage or covering of the wound (wherever practicable or as far as possible) and open
dressing is recommended.

• Do not cauterize the animal bite wound(s).

• Avoid primary suturing of the wound. If needed, loose sutures can be done after proper RIG

wounds after two weeks to develop seroconversion on Day 14 i.e. 0.5IU/ml.

2.2.1 ADMINISTRATION OF ANTI-RABIES VACCINES IN POST-EXPOSURE PROPHYLAXIS

Active immunization against Rabies is achieved by the administration of safe and potent cell culture
vaccines (CCVs). Currently available CCVs could be administered by IM regimen and CCVs approved

either route.

PrEP. Every batch of CCVs must have minimum potency of 2.5 IU per IM dose, irrespective of whether
the vaccine is administered by IM or ID route. ( Annexure-9)

2.2.2 Site of Vaccination:

Anti-Rabies Vaccine should be administered into the upper arm (deltoid region) in adults and into the
anterolateral thigh region of young children and never injected into to gluteal region. The gluteal region
is not recommended because the fat present in this region retards the absorption of antigen and hence
impairs the generation of the optimal immune response.

The injection sites for ID and IM vaccination are the same.

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 Figure 8 – Injection sites for anti-rabies vaccines.
2.2.3 Route of Administration
National Rabies Control Program strongly advocates use of intradermal route of Rabies vaccine. The use
of the intra-dermal route leads to considerable savings in the total amount of vaccine needed for full
pre- or post-exposure vaccination, thereby reducing the cost of active immunization. Multiple studies
show that the intradermal route of vaccination has an equal immunogenic response compared to the
Intramuscular route of injection.
INTRADERMAL ROUTE OF VACCINE (IDRV) ADMINISTRATION
Updated Thai Red Cross (TRC) regimen (2-2-2-0-2):
0.1 ml of anti-rabies vaccine administered at 2 sites each on the deltoid area on days 0, 3, 7 & 28. There
is no vaccine dose on day 14.

This is the only regimen approved by the Drug Controller General of India (DCGI) for intradermal usage
of an anti-rabies vaccine in the country.

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ID injection technique

Using the aseptic technique, reconstitute the vial of lyophilized vaccine with the diluent supplied by the
manufacturer. Some vaccines have 0.5ml diluents while others have 1 ml diluents as per the approval
of brand, which cannot be altered. After reconstitution with sterile diluent, the vaccine should be used
immediately or within 6 hours if kept at 2-80C.

First report. Tech rep series 931. Geneva (Switzerland): World Health Organization; 2005)

With a 1 ml syringe, draw 0.2 ml (up to 8 units if the syringe is 40 units or 20 units in 100 units syringe)
of vaccine needed for one patient (i.e. 0.1 ml per ID site for 2 sites).

Expel the air bubbles carefully from the syringe thereby removing any dead space in the syringe.

Using the technique of BCG inoculation: stretch the surface of the skin and insert the tip of the needle
with bevel upwards, almost parallel to the skin surface (Fig-8A) and slowly inject half the volume of
the vaccine in the syringe (i.e. 0.1ml; 4 units/10 units) into the uppermost dermal layer of skin, over
the deltoid area an inch above the insertion of the deltoid muscle. A raised bleb should begin to appear
immediately causing a peau d’orange (orange peel) appearance (Fig-8B). Inject the remaining volume
of vaccine (i.e. 0.1ml; 4 units/10 units) on the opposite deltoid area 1 inch above the deltoid insertion.

Figure 9: A & B: Intradermal administration of anti-rabies vaccines

• If the needle is incorrectly placed inside the dermis, resistance is felt while injecting the vaccine.
• If the vaccine is injected too deeply into the skin (subcutaneous), bleb (Peau d`orange) is not seen.
• Then the needle should be withdrawn and reinserted at an adjacent site and ID vaccine given once
more.
If for some reason the deltoid region cannot be used for injection, then the alternate sites are the
suprascapular area or the anterolateral thigh.

Once opened, vials should be stored at +2 ºC to a maximum+ 8 ºC for no longer than 6 hours. Rather than
discarding vaccine after this time, any remaining vaccine in a vial could be used for PrEP, particularly
for professionals active in animal disease control or for staff at health facilities who regularly attend to
clinical rabies patients. Scheduling follow-up PrEP visits forpatients within similar periods may help to
minimize wastage.

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Mode of action of IDRV:

Figure 10: Mode of action of intradermal rabies vaccination

The anti-rabies vaccine is picked up by the antigen-presenting cells (Langerhans cells) present in the
skin and presented to local regional lymph nodes which in turn elicit both humoral immunity (B cell-
mediated) or cell-mediated immunity (T cell-mediated).
IDRV elicit an equal and effective immune response comparable to intramuscular administration of
rabies vaccine.
THE INTRAMUSCULAR ROUTE OF VACCINE ADMINISTRATION
Essen regimen (1-1-1-1-1):
One dose of anti-rabies vaccine administered intramuscularly on days 0, 3,7,14 & 28.
Anti-Rabies Vaccine is administered into the deltoid region in adults and into the anterolateral thigh
region of young children and never injected into to gluteal region.
This is the only regimen approved by the Drug Controller General of India (DCGI) for intramuscular
usage of the anti-rabies vaccine in the country.

Note: Switching the route of administration from IM to ID or vice versa and switch over from one type
of modern rabies vaccine to other during PEP is not recommended.
Irrespective of route of administration completing the full course of PEP is essential to prevent the
disease. Evidence suggests incomplete PEP may progress to Rabies disease.

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2.3.1 ANTI-RABIES IMMUNOGLOBULIN (RIG)
• Rabies Immunoglobulin (RIG) are anti-rabies antibodies with the ability to bind rabies virus. When
injected locally into and around the wound(s), RIG will neutralize the rabies virus directly at the
site of the bite providing passive immunity and immediate protection.
• Even the best of modern vaccines takes 10-14 days (or three injections minimum on days 0,3 and
7) to elicit the protective antibody titre (or more than 0.5 IU/mL of serum) and thus RIG cover this
vulnerable short incubation (or window period) following exposures /severe wounds before it is
physiologically possible for the victim to begin producing his/her antibodies
• Currently, two types of RIGs (ERIG & HRIG) are available for passive immunization (Annexure-1).

Figure 11: Rabies virus neutralization by RIG

Indications for RIG:

• RIG should be administered to all patients with Category III exposure.

• Exposures to all wild animals should be treated as Category III exposure.

• In immunocompromised individuals such as HIV/AIDS patients, patients on immunosuppressive

therapy (steroids/cancer chemotherapy), congenital agammaglobulinemia etc., RIG should be
administered in both Category II and III exposures.

Figure 12: Category III exposures

RIG is administered only once if indicated, preferably at or as soon as possible after initiation of post-
exposure vaccination.

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• However, RIGs alone (without vaccine) should never be used.
• An infected bite wound is not a contraindication to the injection of RIG.
RIG is not indicated for bite victims that have ever received rabies vaccination (e.g. PrEP, PEP) beyond

on days 3 and 7, because an active antibody response to the rabies vaccine has already started, and this
would represent a waste of RIG.

Equine rabies immunoglobulin (ERIG):

Equine Rabies Immunoglobulin (ERIG): ERIG is of heterologous origin produced by hyper-immunization
of horses. ERIG is produced in the country in the public and private sectors. (Annexure 1: Currently
available ERIG in India).

anaphylactic reaction (1/150,000).

A skin test before administering ERIG is generally not required because testing does not accurately
predict adverse reactions, and ERIG should be given irrespective of the result of the test. However, some
manufacturers of ERIG still recommend performing a skin test.
The treating physician should be prepared to manage anaphylaxis which, although rare, could occur
during any stage of administration, even when the skin test is negative.
Human rabies immunoglobulin (HRIG):

weight. There is no need to perform a skin sensitivity test (SST) as HRIG is homologous.
Table 6: Dose of Rabies immunoglobulin:

Generic Name Preparation available Dose

ERIG 300 IU per ml 40 IU per kg bodyweight

HRIG 150 IU per ml 20 IU per kg body weight

Mode of administration of the full dose of RIG

• The RIG should be brought to room temperature (25°C to 30°C) before administering to the patient.

• The maximum dose of human RIG is 20 IU/kg of body weight, while that of equine immunoglobulin
products is 40 IU/kg of body weight.
• In case of multiple wounds, the amount of RIG should not exceed the maximum permissible dose
• To cover all the wounds RIG can be diluted maximum with normal saline. Initially, the focus on
these patients should be on proper wound toilet before administration of RIG.
• No wound should be missed for RIG administration.
• The entire immunoglobulin dose, or as much as anatomically possible (but avoiding possible

as close as possible to the wound(s) or exposure sites till traces of RIG oozes out.

30
 with RIG provided the injection is not done with excessive pressure, which can cause compression
syndrome.

Figure 13: Administration of Category III wounds with RIG

into the wound should be avoided as far as possible.

• RIG should never be administered in the same syringe or at the same anatomical site where the
vaccine was administered.
• For mucosal exposure with no wound, rinsing with RIG can be considered.
• Systemic [intramuscular] administration of RIG is of very little value and evidence suggests that
injecting the remaining RIG volume intramuscularly at a distance from the wound provides little or

• However, there is a high likelihood that there are additional small wounds (e.g. if a child does not
report all wounds), injection of the remaining RIG volume intramuscularly as close as possible to
the presumed exposure site, to the degree that is anatomically feasible, is indicated.
• In the case of suspected exposure to RABV via aerosols, an intramuscular injection of RIG is still
recommended.
• As for all immunizations, animal bite victims should be kept under observation for at least 15–20
min after administration of RIG and there is no need to admit the patient.
• It is advisable to also provide Inj. Tetanus Toxoid (TT) or Td (adult dT) vaccine 0.5 ml intramuscularly
and course of antibiotics with analgesics if required.
Note: RIG must never be given intravenously
Summary of Rabies Post-Exposure Prophylaxis

31
2.4 MANAGEMENT OF RABIES PEP DURING RE-EXPOSURE FOR PREVIOUSLY IMMUNIZED
PEOPLE:
a) For exposed or re-exposed patients who can document previous complete PrEP or PEP the following
applies:
• Wound washing (Good wound management)
• One-Site Intradermal vaccine administration on days 0 and 3 or
• One-site Intramuscular administration of an entire vaccine vial on days 0 and 3.
• No RIG indicated
b) People, who cannot document previous PEP equivalent to PrEP or a complete PrEP , should receive
a full PEP, including RIG if indicated.
c) If after completion of a complete course of PEP or PrEP, a re-exposure happens within 3 months
then only thorough wound washing is to be done. The rabies vaccine is not required. If the duration
of the last dose of the complete rabies vaccine regimen is more than 3 months then the Rabies
vaccine is to be given as described in the schedule above.

Figure 14: Flow of Post Exposure Prophylaxis

2.5 RABIES PEP FOR IMMUNOCOMPROMISED PATIENTS

immune-compromised conditions (HIV/AIDS, patients on chemotherapy, long term steroid therapy,

antibody response to Rabies vaccination.

• In most settings, it is not possible to determine the source or severity of immune suppression when
patients consult for PEP.
• Whenever possible, the best PEP options available (the most immunogenic regimen, high-
quality vaccines and RIG) should be used, regardless of the route of vaccine administration.

immunocompromised patients.
• If required, the RABV neutralizing antibody response should be determined 2–4 weeks/after 14
days of the last dose of vaccination to assess whether an additional dose of vaccine is required.

32
• If possible, an infectious disease specialist or the patients’ treating clinician with expert knowledge
or the patient’s disease history should be consulted. The wide variation in the causes of a
compromised immune system and the limited information available indicate the need for targeted
studies.

In Immune Compromised Individuals and patients in whom the presence of immunological memory
is no longer assured, the following protocol should be followed-
i. Good wound management (including meticulous, very thorough wound washing and antisepsis)

exposures.
ii. After this, a complete course of Anti-Rabies vaccination by Intramuscular Route should be
undertaken in both Category II and III exposures.
iii. Preferably, if the facilities are available, Anti-Rabies Antibody estimation should be done 14 days
after the completion of the course of vaccination to assess the need for additional doses of vaccine.

2.6 ANIMAL CONSIDERATIONS FOR PEP

2.6.1 Observation of biting dog/cat:
Human health professionals are responsible for taking care of the bite victims while animal health
professionals evaluate the biting animal in parallel. In general, rabies PEP should be started immediately
after the exposure.
An observation period of 10 days is valid for dogs and cats only: the natural history of rabies in mammals
other than dogs and cats is not fully understood and therefore the 10-day observation period is not
applicable in such animals.

the end of the 10-day observation period and post-exposure prophylaxis can be converted to pre-
exposure vaccination by skipping the vaccine dose on day 14 and administering it on day 28 while
using Intramuscular regimen (Essen Schedule).

While using the ID route of administration complete course of vaccination should be given
irrespective of the status of the animal.

2.6.2 Vaccination status of the biting animal:

Although unvaccinated animals are more likely to transmit Rabies, vaccinated animals can also transmit
the virus in case of ineffective vaccination for any reason. Animal vaccine failure may occur because of
improper storage, administration or poor quality of the vaccine, poor health status of the animal, and
the fact that one vaccine dose not always protect against rabies infection in dogs/cats.
Therefore, in absence of laboratory documentation of immunization (antibody titre) a history of Rabies
vaccination in an animal does not guarantee that the biting animal is not rabid and the vaccination
status is not a factor for proper risk assessment.
Hence, irrespective of vaccination status of the biting animal, PEP should be given.
2.6.3 Provoked versus Unprovoked Bite:
A bite by a provoked animal does not mean that the animal is not rabid. Therefore, a provoked dog bite
should also be managed as an exposure thus PEP should be started immediately.
There are various factors in understanding the reason for the animal being provoked and hence it would

the earliest.

33
2.7 DEVIATIONS IN PEP SCHEDULE;
PEP should be started as soon as patients report to the health facility, irrespective of time-lapse after
the animal exposure. Health personnel are required to strictly follow recommended PEP schedule to
prevent PEP failure. The patient should be informed clearly about the schedule verbally and in a written
prescription. Once the decision to initiate rabies PEP has been made, the PEP regimen should be started
as soon as possible. Every effort should be made to adhere to the recommended PEP regimen schedule,

within 7-10 days to achieve effective immunity against the rabies virus.
One- or two-days’ deviation does not necessitate re-starting of the vaccination schedule. The remaining
doses should be as per the original schedule starting from the day zero dose. For most minor delays
or interruptions, the vaccination schedule can be shifted and resumed as though the patient were on
schedule.

misses one or more doses, the administration of an additional dose should be considered to obtain
effective immunity.
2.8 CONTRAINDICATIONS AND PRECAUTIONS TO BE TAKEN IN POST-EXPOSURE PROPHYLAXIS
There are no absolute contraindications for administration of PEP.
PEP can be safely given to infants, pregnant women and immune-compromised individuals, including
children with HIV/AIDS. It should be given as indicated by the nature of the exposure in a setting in
which the staff are adequately trained in its administration and the management of possible adverse
reactions, as for any other vaccination. As per all other vaccinations, recipients receiving ARV should be
kept under medical supervision for at least 15 mins to monitor any possible adverse reactions.
2.9 ADVERSE REACTIONS TO RABIES BIOLOGICAL ADMINISTRATION
In general, anti-rabies vaccines are safe and well-tolerated. Mild systemic adverse events, such as
transient fever, headache, dizziness and gastrointestinal symptoms, have been observed in 5–15% of
vaccinated people. Minor and transient erythema, pain or swelling may occur at the site of injection,
particularly following ID administration.
Once initiated, , it shouldn’t be stopped or altered due to local or minor systemic side effects from the

effective in treating such reactions.

Antihistamines can be given when a person who has a history of hypersensitivity to the rabies vaccine
needs to be revaccinated. Following vaccination, the person should be closely monitored and epinephrine
should be ready in hand to treat any anaphylactic responses.
In case of history of severe hypersensitivity reaction considering rabies is 100% fatal disease advice and
assistance on the management of serious adverse reactions for persons receiving rabies vaccines may
be sought from experts.

reported to the Adverse Effect Following immunization (AEFI) portal & Pharmacovigilance program of
India.
2.10 POST-EXPOSURE TREATMENT FAILURES: REASONS FOR FAILURE
• Late reporting by patients.
• Improper or inadequate wound washing, unnoticed wounds.
• Application of irritants to bite wounds.

34
• Non-administration of RIGs.

• Incomplete vaccination.
• Administration of rabies vaccines into the gluteal region.
• Inoculation of rabies virus directly into the nerve in extensive & deep bites.
• Immune compromised patients.
True vaccine failures are extremely rare when high-quality rabies vaccines are used in conjunction with
prompt, proper wound care, adherence to the cold chain and compliance with vaccination schedules.
Hence, early, appropriate and complete PEP shall be provided to all animal bite cases in the country to
prevent rabies.
2.11 NEWER ADVANCEMENT IN POST-EXPOSURE PROPHYLAXIS
WHO has recommended the use of Monoclonal Antibodies (mAb) as a “cocktail” containing at least two
antibodies against RABV, as alternatives for RIGs in PEP. A monoclonal antibody product is recently
licensed by DCGI in India. WHO recommends that a registry be maintained to monitor the clinical use
and outcomes of mAb products for rabies PEP. The expert group recommends that the role of Monoclonal
antibodies in the case of category III bites as a replacement to Rabies Immunoglobulin needs to be
studied with regards to its effectiveness and safety in multi-centric Indian settings before incorporation
in National Guidelines.
2.12 ADVICE & COUNSELLING OF ANIMAL BITE VICTIMS

the patients are very anxious and worried, especially children and pregnant women. Therefore, for every
case, at least 5-10 min must be spent by doctors to reassure them, alleviate anxiety and remove fear.

Other advice that should be given during the vaccination period:

• Do not rub the injection site.
• Do not apply anything to the injection site.
• Avoid excessive alcoholic drinks and restrict smoking.
• Avoid strenuous physical and mental work.

• Take bath regularly (but do not wet the wound).

• Discourage chilli paste, other irritants at bite site.
• Discourage home remedies and domiciliary practices.

• Do not apply any other cream to the wound or any dressing or bandage.
• Continue medications (if undergoing) for other prolonged treatments.
• Emphasize the life-saving value of anti-rabies treatment and the need for compliance to complete
the course of vaccination.
• Inform about schedule dates of vaccines and the importance of timely administration of rabies
vaccine.
• Wherever relevant and feasible: observe the dog/cat daily for 10 days and on suspicion, get a
veterinary examination done and inform the doctor.

35
 SPECIAL SITUATIONS
Rabies does not give second chance as it is 100% fatal once disease occur. Hence, it is better to over treat
rather than under treat animal bite cases.

Persons consuming raw milk of rabid animals: One should boil the milk before consumption in their
day-to-day practice which will kill the rabies virus. There are no documented cases of transmission
of rabies after drinking milk of rabid animal. Consumption of milk produced by rabid animal dose not
require rabies PEP.

Persons consuming meat of rabid animals: Rabies can be transmitted by ingestion of experimentally
infected animals; however, no human cases resulting from consumption of raw meat from a rabid animal
have been documented. It is not advisable to consume the meat from a rabid animal, particularly if it is
raw. If exposure occurs, PEP should be initiated.

Pregnancy and Lactation: Pregnancy and Lactations are not the contraindication for starting PEP as
rabies is a fatal disease. Vaccines are safe and effective in pregnant and lactating women. Dosage and
schedule remain same.

HIV/AIDS with low CD4 count <200: Thorough wound treatment + RIG (Category II & III exposures)
+ 5 doses of vaccine by IM only. If feasible RvmAb response should be determined 2-4 weeks after
completion of 5 doses to assess whether additional dose of vaccine is required.

Chloroquine therapy: Vaccination with IM route only.

Previous history of severe adverse reaction to ARV: Change the type of vaccine subsequently.

Switch over from one brand/type of vaccine to other: Shifting from one brand/type of CCV/PDEV to other
brand/type should not be encouraged in routine practice. However, under unavoidable circumstances,
available brand/type may be used to complete PEP.

Switch over from IM to ID route of administration or vice versa during PEP: Shifting from one route

evidence / study on vaccine immunogenicity following changes in route of vaccine administration during
PEP. As per WHO recommendations, such cases need not be restarted and regimen to be continued/
resumed as per new administration route.

Irregular and incomplete vaccination: As a general thumb rule, 3 doses of ARV have to be administered
by day 10 and 4/5 doses (either by IM or ID route) by day 28. There is no need to restart the vaccine, if
there is delay of few days.

Patient come very late (few weeks or months) after animal bite: PEP should be given as rabies has a
prolonged incubation period. If patient has not taken any dose of ARV, even RIG/ should be injected to
the site of bite, even though there are no bite marks seen.

Can Rabies vaccine be given with other UIP vaccines: Yes, it should be given at a site different from UIP
vaccine, but rabies vaccine should be given in deltoid/ thigh region by IM route or on both deltoid by ID
route.

36
2.13 PRE-EXPOSURE PROPHYLAXIS (PrEP)
Pre-exposure vaccination may be offered to high-risk groups such as:
1. Laboratory staff handling the virus and infected material, clinicians and persons attending to human
rabies cases.
2. Veterinarians, animal handlers and dog catchers.

4. Travelers from rabies-free areas to rabies endemic areas.

The Indian Association of Pediatrics (IAP) has recommended pre-exposure prophylaxis for children.
This may be considered voluntarily.
2.13.1 Schedule & Dosage
• Pre-exposure vaccination is administered as one full vial of vaccine by IM route or in the case of the
ID route, one site 0.1 ml on days 0, 7 and either day 21 or 28.
• High-risk groups should have their neutralizing antibody titers checked every 6 months during the
initial two years period after the primary vaccination. If it is less than 0.5 IU/ml a booster dose of
vaccine should be given. Subsequently, sero-monitoring is recommended every two years.
• Vaccine-induced immunological memory persists in most cases for years, a booster would be
recommended only if rabies virus neutralizing antibody titers have dropped to less than 0.5IU/ml.
• Vaccinated Individuals on being exposed after successful pre-exposure immunization would require
only two booster injections of vaccine given on days 0 and 3. RIGs is not required.

SUMMARY OF VACCINATION SCHEDULES

Table 8: Vaccination schedule

Number of
Type of Route of Dose of Total number Site of
Day of dose injections per
prophylaxis administration vaccine of visits injection
visit
0.1ml per Day 0, 3, 7 and
Intradermal 2 4
dose 28
Post-Exposure
Prophylaxis
1 entire Day 0, 3, 7, 14
Intramuscular 1 5
vaccine vial and 28

0.1ml per Day 0, 7, and

Intradermal 1 3 Adults:
dose 21 or 28
Pre-Exposure
Deltoid Muscle
Prophylaxis 1 entire Day 0, 7, and
Intramuscular 1 3
vaccine vial 21 or 28
Infants and
Re-exposure
Small Children:
(no vaccination
Anterolateral
needed if full 0.1ml per
Intradermal Day 0 & 3 1 2 Thigh
PEP has been dose
received in the
last 3 months)

Intramuscular 1 entire
Day 0 & 3 1 2
vaccine vial

37
 POINTS TO REMEMBER
• Stepwise approach in management of Animal Bite Cases consist of A) local treatment of wound(s)
including assessment of exposure followed by B) Administration of anti-rabies vaccination (either
by IM/ID route) and C) administration of Rabies immunoglobulin if indicated including advice and
counselling of patient & attendants.

• Risk of rabies infection can be reduced to an extent of 50% if wound is properly taken care and
washing of wound(s) is/are desirable up to 15 minutes and should be carried out as soon as possible
with soap and water. Suturing of wounds should be avoided.

• Touching or feeding of animals or licks on intact skin (Cat- I) require no further treatment besides
washing of the exposed skin surfaces if reliable history is available.

• Minor scratches or abrasions without bleeding or nibbling of uncovered skin (Cat- II) requires only
local treatment of wound(s) and administration of anti-rabies vaccine.

• Single or multiple transdermal bites or scratches with oozing of blood, licks on broken skin or
contamination of mucus membrane with saliva (Cat- III) requires wound management and
administration of rabies immunoglobulin (RIG) with anti-rabies vaccine

• RIG is also indicated after Cat II / III exposure of wild animals and in immunocompromised patients.

• There are no absolute contraindications for administration of PEP.

• Anti-Rabies Vaccine is administered into deltoid region in adults and into anterolateral thigh region
of young children and never injected into to gluteal region.

• Updated Thai Red Cross (TRC) regimen (2-2-2-0-2) for intradermal administration consist of 0.1 ml
of anti-rabies vaccine administered at 2 sites each on deltoid area on days 0, 3, 7 & 28. There is no
vaccine dose on day 14. This is approved by DCGI.

• Essen regimen (1-1-1-1-1) for intramuscular administration consist of one dose of anti-rabies
vaccine administered intramuscularly on days 0, 3,7,14 & 28. This is approved by DCGI.

• RIG is administered only once, preferably at or as soon as possible after initiation of post-exposure
vaccination. It is not indicated if PrEP or PEP has ever been administered before or beyond the

• Proper counselling and dialogue with the animal bite victims and attendants greatly build trust and

38
SESSION 3 – LABORATORY DIAGNOSIS AND CASE MANAGEMENT OF
HUMAN RABIES
Learning objectives
• To understand different possibilities for laboratory rabies diagnosis
• To be able to take most appropriate sample for rabies ante and post mortem diagnosis and to
understand the limitations
• To know about safety procedures and how to ship samples
• To provide palliative care for rabies patients
• To give recommendations for family members of rabies patients
3.1 LABORATORY DIAGNOSIS OF HUMAN RABIES
Rabies is characterized as an acute, progressive encephalitis caused by a lyssavirus. Often the diagnosis
of rabies is based on the clinical manifestations and a history of exposure to a rabid animal. In cases
where pathognomonic hydrophobia and/or aerophobia are present, the diagnosis is straightforward.

3.2 LABORATORY CONFIRMATION OF RABIES

In general, rabies diagnostics can be divided into tests that are performed when the patient is still alive
(ante-mortem diagnostics) and tests that are performed after the patient has died (post-mortem).

including hair follicles at the nape of the neck) can be used to diagnose rabies while still alive. For post-
mortem diagnostics, usually brain samples are used.
An overview of all the available standard diagnostic tests for rabies can be found in Table 9.
Table 9: Standard diagnostic tests for diagnosis of rabies in humans (as per World Health Organization.
(2018). WHO expert consultation on rabies: third report. World Health Organization. https://apps.who.
int/iris/handle/10665/272364)
Antigen
Species RNA detection Virus Isolation Antibody detection
detection
(Time of
Test) Sample Test Sample Test Sample Test Sample Test
a b a b a b a b
Skin/ Hair RFFIT,
Human Saliva,
Skin/ Hair follicles, RTCIT, Serum, FAVN- Test
(ante- FAT RT-PCRd Tears,
follicles Saliva, MI CSF IFA ELISA
mortemc) CSF
Tears CSF
Human Brain, FAT, Brain,
RTCIT,
(post- Skin/ Hair DRIT, Skin/ Hair RT-PCRd Brain NA NA
MI
mortem) follicles IHC follicles

samples; MI, mouse inoculation test; NA, not applicable; RTCIT, rabies cell culture inoculation test; RT-
PCR, reverse transcriptase-polymerase chain reaction; RFFIT, Rapid Fluorescent Focus Inhibition Test

39
a) If more than one sample type is listed, the one(s) shown in bold have the highest diagnostic
sensitivity.
b) If more than one test is listed, the one(s) in bold are preferred.
c) Positive results in antemortem samples are diagnostic, but negative results do not rule out rabies.
d) RT-PCR may be in the conventional or real-time format.
3.3 COLLECTING SPECIMEN FOR RABIES DIAGNOSTICS
The clinician who suspects that the case is compatible with the clinical description and has an

recommend for the Laboratory diagnosis.

Rabies has the highest case fatality rate of any currently recognized infectious diseases, therefore, safety
is of paramount importance when working with lyssaviruses. In general, biosafety level 2 practices are
adequate for routine activities. Collection, preparation and processing of samples should be done by
using appropriate personal protective equipment including mask, protective gloves, sleeved gowns and
safety glasses.
Professionals working with rabies patients, collecting samples and performing diagnostic tests, should
be vaccinated against rabies according to pre-exposure guidelines.
Table 10 provides an overview of the different type of samples that can be used for diagnostic purposes.
Table 10: Sample type and tests to be performed

TYPE OF SAMPLE LABORATORY TESTS TO BE

PERFORMED
I Saliva (Ante Mortem)
Using a sterile eyedropper pipette, collect saliva and place Detection of rabies RNA (by
it in a small sterile container that can be sealed securely. No reverse transcription and
preservatives or additional material should be added. polymerase chain reaction, RT/
Tracheal aspirates and sputum are not suitable for rabies tests. PCR, of extracted nucleic acids)
Take at least three saliva samples at 3hrs to 6hrs intervals. and isolation of the infectious
virus in cell culture.
II Nuchal Skin Biopsy (Ante Mortem/ Post Mortem)
A section of skin 5 to 6 mm in diameter should be taken from RT/PCR and immune
the posterior region of the neck at the hairline. The biopsy
specimen should contain a minimum of 10 hair follicles and be antigen in frozen sections of
the biopsy.
of the follicle.
Place the specimen on a piece of sterile gauze moistened with
sterile water and place it in a sealed container. Do not add

III
At least 0.5 ml of serum or CSF should be collected; no
preservatives should be added. Do not send whole blood. If no and virus neutralization.
vaccine or rabies immune serum has been given, the presence
of antibody to rabies virus in the serum is diagnostic and tests
of CSF are unnecessary. Antibody to rabies virus in the CSF,
regardless of the immunization history, suggests a rabies virus
infection.

40
IV Brain Biopsy (Post Mortem)
The rarity of rabies and the lack of an effective treatment make RT/PCR and immune
the collection of a brain biopsy unwarranted; however, biopsy
samples negative for herpes encephalitis should be tested for antigen in touch impressions.
evidence of rabies infection. The biopsy is placed in a sterile Post-mortem diagnosis of rabies

staining of viral antigen in touch

impressions of brain tissue.
Portions of the medulla (brain
stem), the cerebellum, and the
hippocampus
3.4 ANTE MORTEM DIAGNOSIS OF RABIES
• Ante-mortem diagnosis of human rabies
can be done by detection of viral RNA
by molecular methods like polymerase
chain reaction (PCR) in saliva, nuchal

in CSF and serum samples using ELISA

test (RFFIT) can also aid in diagnostic

individuals.
• A combination of several tests on multiple
clinical samples, with serial sampling
whenever feasible, is recommended to
increase the sensitivity of ante mortem
diagnosis.
• While a positive validated result is
indicative of rabies, a negative result
does not essentially rule out a diagnosis
of rabies in all cases, which is a major
limitation of ante mortem testing.

saliva, CSF, serum) and some tissues

(such as skin biopsy samples, including
hair follicles at the nape of the neck) can be used to diagnose rabies during life. Although serum
and CSF may not be very sensitive specimens for ante mortem diagnosis, particularly in the early
course of illness, a positive result provides valuable diagnostic information.
• The samples that afford the highest diagnostic sensitivity are at least three saliva samples, taken at
intervals of 3–6 h, and skin biopsies (including hair follicles). Ideally, samples should be stored at
-20 °C or less.

Figure 15 - World Health Organization (2018). Laboratory techniques in rabies, volume 1, 5th ed. World
Health Organization. https://apps.who.int/iris/handle/10665/310836 - Fig. 5.1. Algorithm for human
rabies antemortem diagnosis

41
3.5 POST MORTEM DIAGNOSIS OF RABIES
• Brain tissue is the preferred
specimen for post-mortem
diagnosis in both humans
and other animals. In many
situations, it may not be
possible to remove the brain
for post-mortem sampling
because of factors such
as family consent for post
mortem or practical and
biosafety issues related to the

• Some of these challenges can

be overcome by collecting
samples with effective, well-
established techniques that
require less invasive post-
mortem routes, such as
through the orbit or foramen
magnum.
• Ideally, brain tissue should
be kept refrigerated or
frozen until testing. If this
is not possible, samples can
be preserved at ambient
temperature in a 50%
glycerine–saline solution.
Freezing of samples in
glycerine is not recommended.

obtained post-mortem using the Fluorescent Antibody Technique (FAT). It is a rapid and sensitive
technique to identify viral antigens in fresh brain smears stained with anti-nucleoprotein antibodies

WHO for primary diagnosis, since a negative result cannot rule out rabies.
• Post mortem brain tissue can be obtained by craniotomy at autopsy or through the trans nasal,
orbital or trans foramen magnum route, when an autopsy cannot be performed.

Figure 16 - World Health Organization (2018). Laboratory techniques in rabies, volume 1, 5th ed. World
Health Organization. https://apps.who.int/iris/handle/10665/310836 - Fig. 5.2. Algorithm for human
rabies postmortem diagnosis

42
Table 11: Comparing the Laboratory techniques used for Diagnosis of Rabies in Post Mortem Examination
TEST SAMPLE Validity of the test
1 Fluorescent antibody technique (FAT) Fresh brain smears Gold standard

2 PCR Brain tissue Comparable to the FAT

3 - Fresh brain smears Can be useful as a com-
sion bodies (‘Negri bodies’) by plementary test but is not
Seller’s technique. recommended by WHO for
4 primary diagnosis, since a
bodies (‘Negri bodies’) by haematox- negative result cannot rule
ylin and eosin (H&E) staining tissues out rabies.

3.6 PACKAGING AND TRANSPORT

• All samples should be considered potentially infectious.
• All specimens should be collected in a primary container that is watertight and leak-proof and must
be securely sealed (tape around the cap will ensure that the containers do not open during transit).
• The primary container should be put in a secondary container such as a zip-lock plastic bag with
insulating material between primary and secondary containers.
• The secondary container should be put into a rigid outer packaging box during transport, in
accordance with national and International Air Transport Association (IATA) guidelines as ‘category
B’ necessitating UN 3373/650 packaging (only RABV cultures are considered ‘category A’).
• Nuchal samples are best shipped frozen but can be shipped simply with ice packs.
• Saliva samples should be shipped frozen.
• Brain samples can be frozen or preserved in 50% glycerol–saline solution if freezing is not readily
available.
• Samples should never be preserved in formalin.
• Please ensure maintenance of cold chain (2-8°C) while the sample is being transported.

as FTA also has the advantage of inactivating RABV, reducing the hazard and facilitating shipment
while preserving nucleic acids.
• If immediate transport is not possible, samples should be stored frozen at -20 °C or below.
• The reference laboratory must be contacted before the shipment of samples with suspected RABV.
• Sampling and shipping procedures must be well-established and communicated effectively to
laboratory staff before they have to be put into use.
3.7 RABIES ANTIBODY TITER ESTIMATION
A rabies antibody titre is essentially an estimation of an immune response against rabies virus (either
through exposure or vaccination). The ELISA is one method which provides a laboratory measurement
of the ability of an individual human or animal serum sample to neutralize rabies virus.
As Rabies vaccine has proven potency, rabies antibody titration is not recommended routinely. However,
the clinician may recommend the anti-rabies antibody titre estimation in following situations
• if any si
• deviation in the route or dose recommended for vaccination,
• immunocompromised patients receiving PEP
• probability of repeated occupational exposures

43
Humoral antibodies play an important role in protection against rabies. Anti-rabies neutralizing
antibody titre of 0.5 IU/ml or more in serum is considered as protective. This level is achieved in most
healthy individuals by day 14 of a post-exposure regimen, with or without simultaneous administration
of rabies immunoglobulin.
3.8 MANAGEMENT OF PATIENTS WITH RABIES
Although rabies is almost always fatal, health care providers still have an essential role to play in
providing prompt, effective, holistic, compassionate, culturally sensitive case management. This can be
done even with extremely limited equipment and drugs. In view of the inevitability of death in most
cases, treatment should be focused on palliative care, with heavy sedation (barbiturates, morphine) and
avoidance of intubation or life-support measures, especially once the diagnosis is certain.
In a disease as agonizing and terrifying as rabies encephalomyelitis, alleviation of distressing symptoms
is the primary concern and overriding responsibility of medical staff. However, in many clinics and
hospitals across rabies endemic areas of the world, patients suspected of having rabies are deemed
to be untreatable. They are either sent home without advice or drugs or are isolated and sometimes
abandoned in a remote part of the health facility and denied any medical attention. These practices
ignore the fundamental precept that a doctor’s responsibility is to relieve suffering even if there is no
expectation of cure.
3.8.1 Palliative care
Compassionate care to minimize the suffering of the patient is the key for palliative care.
To avoid provoking spasms on account of hydrophobia or aerophobia, calm, quiet environment, ideally
in a dimly-lit, draught-free, single-bedded room, should be created. Restraining the patient in bed can be
attempted initially with loose and comfortable ties and cot-sides, and ultimately by adequate sedation.
Relatives must be able to communicate with the dying patient with dignity, safety and privacy, according
to their cultural and religious traditions. Other visitors should be restricted, including hospital staff not
directly involved in management. However, frequent monitoring is needed so that patients can be given
adequate supportive treatment.
• Thirst/Dehydration
Hydrophobic patients cannot tolerate drinking, while those with paralytic rabies often cannot swallow.
As a result, these patients may become dehydrated and desperately thirsty. Some may be able to eat
fruit such as bananas and suck citrus fruits to combat thirst, and their lips and tongue may be moistened

rather than a needle. The IV site should be immobilized by splinting. Isotonic 5% glucose, 0.9% saline,
or Hartmann’s (Ringer’s lactate) solution (of sodium chloride, sodium lactate, potassium chloride,
and calcium chloride) can be used as appropriate. Other possible routes for parenteral rehydration,
depending upon available skills and equipment, include intraperitoneal, intraosseous, subcutaneous
(SC), or intrarectal.
• Fever
Since physical methods such as tepid sponging and fanning are intolerable to most patients with
furious rabies, antipyretic drugs are necessary to control fever. Aspirin, ibuprofen or diclofenac, and
paracetamol (acetaminophen) can be given by non-oral routes, such as IV, IM, or intrarectal (Table

leucocytosis) as a cause for fever. However, when the fever is central (neurogenic) in origin, antipyretics
may be ineffective. Drugs that have proved effective in individual cases of central hyperthermia include
baclofen, bromocriptine, amantadine, dantrolene, and propranolol, but these are unlikely to be widely
available in developing countries. Anxiety, Fear, Restlessness, Agitation, Seizures—Use of sedatives and
tranquillizers; benzodiazepines are drugs of choice as they are widely used in daily clinical practice in
most places and can be administered by various routes (Table 12). Diazepam can be given in the same
doses IV/IM or intrarectally.

44
Although rabies is a fatal condition, it is important to avoid depressing respiration by giving the diazepam
too rapidly by IV injection. Diazepam will alleviate the patient’s suffering while giving the family time
to adjust and consider the possibility of taking them home to die if that is their personal or cultural
preference.
Midazolam, an alternative benzodiazepine, has a much shorter half-life. When given IM, SC, or IV, it
should be ‘titrated’ against the patient’s clinical condition, which must be assessed frequently. Small
doses are injected IM at frequent intervals or by continuous IV infusion using an electric syringe.
Hypersecretion (Salivation, Lacrimation, Sweating) This may be reduced by anti-muscarinic
anticholinergic drugs, such as hyoscine (scopolamine) hydrobromide, that block parasympathetic
secretory activity.
Pain: There is a role for opioids and other powerful analgesics, when they are available, to relieve pain
and suffering in rabies victims. Morphine can be given IV, SC, IM, or intrarectally, and Fentanyl trans-
dermally by patch, which may be especially valuable for terminal management of patients after they
have returned home. As the infection progresses, coma and respiratory, cardiovascular, neurological,
endocrine, or gastrointestinal complications will eventually ensue. When the diagnosis is clear, palliative
care is the only compassionate strategy for treating previously unvaccinated patients infected by dogs
or other terrestrial mammals.
Table 12: Drugs for palliative care of rabies patients – published in Warrell M, Warrell DA, Tarantola A. The
Imperative of Palliation in the Management of Rabies Encephalomyelitis. Trop Med Infect Dis. 2017 Oct
4;2(4):52. doi: 10.3390/tropicalmed2040052

45
Table 12

encephalomyelitis that are included in the WHO Model List of Essential Medicines 20th List (March
2017) and WHO Model List of Essential Medicines for Children 6th List (March 2017). http://www.
who.int/medicines/publications/essentialmedicines/en/ Recommended doses are taken from
https://www.bnf.org/products/bnf-online/ and https://bnfc.nice.org.uk/.

46
3.9 RECOMMENDATIONS FOR HEALTH CARE PERSONNEL AND FAMILY MEMBERS OF PATIENTS
WITH RABIES

Most patients with rabies die, and families that seek care should be informed and counselled to receive
the news of the patient’s impending death. Care of people in whom rabies is diagnosed may cause
anxiety among medical and nursing staff, relatives and friends providing non-medical care and, in the
media, and the public. Human rabies does not pose a risk to health care staff if routine precautions are
taken, especially during intubation and suctioning.

The staff managing hydrophobia cases need to know that the rabies virus is not carried in the blood

and relatives coming in contact with the patient should be reminded of the importance of adhering to
barrier nursing and wear proper personal protective equipment (PPE), including a gown, gloves, mask
and goggles. PEP/PrEP should be provided for health care personnel considered to be at risk, after
careful assessment. Hospitals that are likely to receive rabies patients can consider PrEP for health care
staff who may be involved in their management (see section 2.17 Pre-Exposure Prophylaxis).

PEP may sometimes be necessary for the partners of patients, as close contact and sexual intercourse in
the early stages of the disease pose a hypothetical risk for transmission (infectious RABV is present in
saliva); however, no reports have established human-to-human transmission.

3.9.1 Management of the bodies of patients who have died of rabies

• The body of a patient suspected to have died of rabies should be labelled as ‘Infectious’ but not as
“contagious” (no airborne or droplet transmission).
• The risk of transmission to others is extremely low if standard precautions are observed. Blood

the central nervous system and salivary glands.

•
diseases such as tuberculosis and hepatitis.
• Disinfect the instruments used by autoclave or boiling after use.
• Discourage embalming.
• If embalming or autopsy is performed, it should be undertaken carefully, with appropriate

the same manner as for other infectious diseases.

• The body of the deceased should be allowed to be buried or cremated, depending on their religious
practice. Early disposal of human remains by burial or cremation is highly recommended.
• If the conditions permit and death has occurred in a health facility/hospital where lab facilities
for taking brain sample is available then efforts should be made to collect the sample as per the
standard protocols with strict infection control measures using proper personal protect equipment
(PEP), and laboratory result should be communicated to the concerned authority.
3.10 Transmission Via Organ Transplantation
RABV is present in many tissues in the terminal stages of the disease, and caution should be exercised
before transplanting organs from people who have died with neurological symptoms and signs of
rabies. Several cases of rabies due to organ and tissue transplantation have been documented. Testing
for common or highly fatal infections should be balanced against the urgency of transplanting a viable
organ. Corneal transplantation should not be performed without ruling out whether the deceased could
have died from rabies.

47
 POINTS TO REMEMBER
1. Often the diagnosis of rabies is based on the clinical manifestations and a history of exposure to a

and must be done whenever feasible.

2. Biosafety measures need to be implemented when taking samples, shipping or working in the lab-
oratory.

3. Ante mortem testing that has the highest diagnostic sensitivity requires at least three saliva sam-
ples, taken at intervals of 3–6 h, and skin biopsies (including hair follicles).

5. Hospital care for patients with clinical rabies is advisable, when possible, in order to reduce their
suffering and ensure that they receive adequate, respectful palliative care.

6. PEP/PrEP should be provided for health care personnel considered to be at risk.

7. As RABV is present in many tissues in the terminal stages of the disease, caution should be exer-
cised before organ transplantation from people who have died with neurological symptoms and
signs of rabies.

48
SESSION 4 - RECORDING, REPORTING AND SURVEILLANCE
Learning objectives
• To understand the mechanism of Surveillance of Animal bite cases and Human rabies cases

• To understand data analysis and its use for the prevention and control of rabies in the community
4.1 SURVEILLANCE
Surveillance is an essential and integral part of any national programme as it provides the evidence base
for policy and strategy development. Effective control and elimination of disease require effective data
collection and reporting. In short, surveillance is the systematic on-going collection of information for
public health action. Recording& reporting each and every case of Animal bite and Rabies occurring in
the community is critical.
Rabies surveillance aims to establish quality data on disease burden in humans as well as animals (to
identify populations at risk and to implement necessary measures. Awareness and vigilance among
health professionals is necessary to establish effective surveillance.
4.1.1 Surveillance under NRCP
The existing mechanism of reporting animal bites and human rabies cases by IDSP/ IHIP mechanism

will be collected through NRCP monthly reports from health facilities/ District/State).
Surveillance under NRCP has two components
A. Surveillance of Animal Bite-Dog Bite and Animal Bite-Other cases
B. Surveillance of Human Rabies Cases
4.1.2 Surveillance of Dog bite/ Animal Bite cases:
A. Surveillance through IDSP/IHIP:
Following health conditions relevant to National Rabies Control Program are to be reported through
IHIP portal
A. Reporting of Dog Bite & Animal Bite Others Case through S form of IHIP portal:
• After Log in, select presumptive case form

49
• Enter patient details.

• Select provisional diagnosis Animal Bite- Dog/ Animal Bite Others as per the case

50
B. Reporting of Suspected Human Rabies Case P form of IHIP portal and reporting of Laboratory Con-

• After Log in, select presumptive case form

• Enter patient details.

• Enter Clinical details. Select Provisional Diagnosis

Rabies cases has been developed as under.

51
4.2 HUMAN RABIES CASES
4.2.1 Surveillance of Human Rabies Cases:
A person with a history of rabid dog /animal bite with symptoms as described in the rabies case

Wherever available, the details of such cases should be shared in a line list– Name, Age, Gender, Address

dominated by forms of hyperactivity (furious rabies) or a paralytic syndrome (paralytic rabies) that
progresses towards coma and death, usually due to cardiac or respiratory failure, typically within 7–10

The syndrome may include any of the following signs: aerophobia, hydrophobia, paranaesthesia or
localized pain, dysphagia, localized weakness, nausea or vomiting.
Suspect Case (To be reported in S Form by Health Worker): Death of a human with history of dog bite
few weeks/months preceding death.
Probable Case
history of exposure# to a (suspect¥ / probable€) rabid animal
#

also be lick exposure to open wounds, abrasion, mucous membranes of the patient.
¥
A suspect rabid animal is a rabies-susceptible animal (usually dogs) which presents with any of the
following signs at the time of exposure or within 10 days following exposure: unprovoked aggression
(biting people or animals or inanimate objects), hypersalivation, paralysis, lethargy, abnormal
vocalization, or diurnal activity of nocturnal species. Whenever the history of mentioned signs cannot
be elicited, the history of exposure to a rabies-susceptible animal would be considered adequate.
€
A probable rabid animal
bite by another suspect / probable rabid animal and/or is a suspect rabid animal that is killed, died or
disappeared within 4-5 days of observing illness signs.

specimens, preferably brain tissue (collected post mortem)

or
Detection by FAT on skin biopsy (ante mortem).
or
FAT positive after inoculation of brain tissue, saliva or CSF in cell culture, or after intracerebral inoculation
in mice or suckling mice.
or
The detectable rabies-neutralizing antibody titre in the serum or the CSF of an unvaccinated person.
or
Detection of viral nucleic acids by PCR on tissue collected post mortem or intra vitam in a clinical
specimen (brain tissue or skin, cornea, urine or saliva).

52
per standard format & accordingly necessary public health actions to be undertaken.
Remember that a patient attending an animal bite clinic for PEP is not to be labelled as a Human Rabies

Surveillance through NRCP Programme:

When people visit the health centre for treatment of Animal/Dog bites and information is collected
through different registers. Every facility providing Rabies post-exposure prophylaxis must have an
animal bite register. Reporting under NRCP is only facility-based reporting which are compiled and

route of administration etc.

4.3 RECORDING & REPORTING SYSTEM UNDER NRCP
Following Recordings and reporting formats should be available at the Animal Bite Management facility:
1. Animal bite exposure register (Annexure-3)
2. Rabies vaccination card/rabies treatment card in duplicate (one for the bite victim and another for
ARC record) (Annexure-4)

4. Monthly reporting format of animal bites for Health Facility (Annexure-8)

Table: 13: Data requirements under IHIP/IDSP/NRCP

Data elements IDSP-IHIP NRCP

Animal bite cases Person, Place & time details of Aggregate information of
• Dog bite • All animal bites, Category 1, 2 and 3
• Animal Bites Health facility monthly
summary report
Rabies cases NRCP monthly format
rabies cases line list Line list of rabies cases
ARV, ID & IM doses given NA Health facility monthly
summary report
ARS, Number of patients NA Health facility monthly
who received summary report
ARV stock NA Health facility monthly
summary report
ARS stock NA Health facility monthly
summary report
Data sharing with NA Health facility monthly
summary report
Clustering of animal bite Event alert form Health facility monthly
cases summary report
Frequency Realtime basis Monthly basis

53
4.3.1 Animal Bite Exposure Register (Annexure 3)
• Every Animal Bite victim attending the health facility should be provided requisite animal bite
management and post-exposure prophylaxis as per National Guidelines.
• All the information of the patient attending the Anti rabies Clinic should be noted down in the Ani-

• Animal bite exposure format also contains a monthly summary table that needs to be shared with

about the cases reported in that month.

• If Rabies PEP is being administered at different locations in the same health facility (e.g. OPD &
Emergency room/casualty) a separate register may be maintained at each location for an opera-

information from all the registers at the same facility is compiled.

4.3.2 Information required to complete the animal bite register:
* Patients Details: Name, Age, Sex, Contact Details, Address
* Type of patient (New/Old)

-
belled as an “old” patient.
* Animal bite Exposure History:

* Bite Details:

* Previous History of ARV Vaccination (Complete/partial/NA)

Complete post-exposure prophylaxis by modern vaccines is elicited then accordingly the regimen
of Rabies vaccine needs to be changed.

* Details of Post Exposure prophylaxis:

* Summary: At the end of every page there is a summary table which summarizes the following
information

4.3.3 Rabies Post-Exposure Treatment Card- Annexure 4

(to be retained at Anti Rabies Clinic)
• Each animal bite victim needs to be provided with a rabies post-exposure treatment card and one
copy of it needs to be retained at Anti Rabies Clinic. It is a vital document that can be used by health
workers for assessing the completion and dropout rates of animal bite victims from PEP.

54
• The treatment card contains information as described in the Animal bite register
• In addition to the information in the animal bite register, it also contains the schedule of Rabies
vaccines doses that needs to be administered.
• The treatment card will help the patient to know the dosage schedule. It will also be the record for
a future course.
•
monthly report on completion of PEP.

District, State & National level in a real-time basis by email.

• The NRCP line list format should be submitted with a monthly report. A nil report also needs to be
submitted.
• The line list format requires the following information
* Patients Details: Name, Age, Sex, Contact Details, Address
* Information about Biting Animal (Species)

* Address of place where bite incidence took place

* Exposure History: Category of Bite, Status of PEP (Complete/ Partial/ Nil/NA)
* Name of the health facility reporting the rabies case
* The outcome of the patient at the time of reporting (Death in Hospital/ LAMA/ Alive)
4.3.5 NRCP Monthly Reporting
• Under National Rabies Control Programs, a monthly report of the summary of activities needs to be
submitted by the following level
o Health Facility Monthly Report: to be submitted by all health facilities which are providing
Rabies Post Exposure Prophylaxis including PHCSs & Health & Wellness Centres. This also

this report is the responsibility of I/C of the Health facility by the 3rd day of every month. The
format of the report is at Annexure 8.
o District level Monthly NRCP Report:
Facility monthly NRCP report submitted by all health facilities including Medical College in the
concerned District’s jurisdiction. This compiled report plus district level additional information
will be submitted as District NRCP Monthly report. The District NRCP monthly report needs to

report. The format of the report is at Annexure 5.

o State Level Monthly NRCP report:
Level monthly NRCP report submitted by all the districts in the concerned state’s jurisdiction.
This compiled report plus state-level additional information will be submitted as a State NRCP
Monthly report. The State NRCP monthly report needs to be submitted to NPMU NRCP at NCDC

submission of this report. The format of the report is at Annexure 7.

• Following information is required to complete a Monthly NRCP report at any level
o Total no. of health facilities providing a facility for animal bite management/ number of
Facilities having submitted the report

55
 o No. of patients as per Category of bite, Details of patients as per Route of vaccination, suspected/

o Total Stock of Anti Rabies Vaccine (no. of vials) & stock used, total stock of ARS (no. of vials) &
stock used in the reporting period,

clustering of Animal Bite Cases observed? If yes write the details including locality, any other
remarks.

Annexure 3.
4.4 Role of Infectious Disease Hospitals/Medical Colleges
All the district hospitals/tertiary care hospitals/infectious disease hospitals/public medical colleges
having inpatient facility for rabies cases should share the line list as per Annexure 6 to District Nodal

Surveillance system for Animal bite and Rabies case reporting

IDSP/IHIP reporting – Under IDSP /IHIP, animal bite cases are reported through forms while rabies
cases are reported under S, P & L forms of IDSP/IHIP portal

NRCP reporting- Reporting under NRCP is only facility-based reporting and information collected till

information on animal bites, rabies cases, ARV/ARS status, route of administration etc.
Table: 14: Summary of the rabies reporting under IDSP/IHIP and NRCP
S. Level of Person Information to be reported Format for reporting
No reporting responsible
• Animal Bite – Dog bite IDSP/IHIP S form
• Animal Bite - Others (Annexure 5)
• Clustering of animal bites IHIP Event alert form
Health (Annexure 13)
1 Community Worker/
ANM/ASHA IDSP/ IHIP S form
• Deaths suspected due to (Annexure 5)
rabies Line list of Suspected Human
Rabies Case.
• Number of Animal bites IDSP weekly P form (Annexure
5)/IHIP portal (Annexure 14)
• Number of Animal bites
• Animal bites by category
of bite
• Number of ID/IM doses
given NRCP health facility monthly
• PEP completed patients
Medical • ARV and ARS stock & summary report (Annexure 8)
2 Facility
utilization
• Information sharing with

• Clustering of animal bites

• Number of clinically NRCP monthly line list of
suspected rabies cases and
deaths Suspected / Probable/

(Annexure 8)
human rabies deaths

56
 Facility IDSP L form (others) (Annexure
I/C of all 5)/IHIP portal
laboratories
diagnosing cases
rabies cases rabies cases
3 Lab (Human (Annexure 11)
NRCP Monthly report on
NRCP laboratory diagnosis of Rabies
cases (Human/Animal)
laboratories (Annexure 11)

Case Surveillance activity

Suspected A case that is compatible with Notify the appropriate local au-
thorities according to national
person presenting with an acute protocols.
neurological syndrome (i.e. En-
cephalitis) dominated by forms Collect appropriate samples
of hyperactivity (furious rabies) from the patient according to
or a paralytic syndrome (par- national protocols.
alytic rabies) that progresses
towards coma and death, usual- Conduct a verbal autopsy to
ly due to cardiac or respiratory collect a case history for the
failure, typically within 7–10 patient for further characteriza-
- tion.
sive care is instituted.

The syndrome may include any

of the following signs: aeropho-
bia, hydrophobia, paraesthesia
or localized pain, dysphagia,
localized weakness, nausea or
vomiting
Probable A suspected case + a reliable Identify contacts of the patient
history of contact with a sus- and/or animal involved for
follow-up.
rabid animal.
A suspected or probable case Systematically record the labo-
ratory diagnosis and link it with
verbal autopsy information.

Notify the appropriate author-

-
bies case according to national
protocols.

57
 POINTS TO REMEMBER

1. Recording & reporting every case of Animal bite and Rabies occurring in the community is a very
essential step for maintaining the surveillance of Animal bite and Rabies cases.
2. Recordings and reporting formats should be available at all health facilities providing Animal Bite
Management (PHC/Anti Rabies Clinic/CHC/Sub-divisional hospital/District Hospital/Medical col-
lege etc.)
3. At the village and sub centre levels, AHSA and ANM need to report animal bite cases through the S
form of IDSP/Event alert form under IHIP.
4. At PHC level/block level, animal bite and rabies cases are reported through monthly reporting
forms under the NRCP as well as through P forms of IDSP.
5. At the District level, animal bite and rabies cases are reported through monthly reporting forms of
NRCP as well as P forms of IDSP.
6. At the State level, animal bite and rabies cases are reported through monthly reporting forms of
NRCP as well as P forms of IDSP.
7. Medical colleges and infectious disease hospitals/tertiary care hospitals having patient facilities for
rabies case management should share the line list of the rabies cases with respective district nodal

8. At every level (sub-centre, PHC, District, State) coordination should be made with veterinary coun-
terparts for rabies vaccination of dogs and dogs population management.
9. Recording & reporting every case of Animal bite and Rabies occurring in the community is a very
essential step for maintaining the surveillance of Animal bite and Rabies cases.
10. Recordings and reporting formats should be available at all health facilities providing Animal Bite
Management (PHC/Anti Rabies Clinic/CHC/Sub-divisional hospital/District Hospital/Medical col-
lege etc.)
11. At the village and sub centre levels, AHSA and ANM need to report animal bite cases through the S
form of IDSP/Event alert form under IHIP.

58
SESSION 5 - LOGISTICS FOR RABIES BIOLOGICALS
Learning objectives
• To understand the principles of the logistic management of Rabies Biologicals
• To understand the principles of storage of Rabies Biologicals

5.1 Procurement of Rabies Biologicals At District/State Level

• The annual requirement of the Anti-Rabies Vaccine (ARV) & Anti-Rabies Serum (ARS) must be
calculated in advance. Accordingly, the tender/ purchase order needs to be placed.
• The requirement must include 10% wastage factor and a buffer stock for three months (as lead
time from order placement to actual delivery of vaccines).
• As per national guidelines, the preferred route of administration for the anti-rabies vaccine is
Intradermal. It is cost-effective and requires very little quantity (0.2 ml/ visit/patient for intradermal
route vs. 1 ml/visit/patient for intramuscular route).
• ARV and ARS are part of the essential drug list of the National Health Mission. Budget for ARV and
ARS may be proposed under NHM PIP under national free drug initiative.
• Procurement of the ARV and ARS is decentralized as per state policy.
• Procurement of the ARV and ARS by the Government agencies through the Anti-Rabies Clinics
(ARC) may be based on the number of animal bite cases with due consideration to be given to the
available resources/budget and support from the state government National Free Drug Initiative of
NHM and other sources.
• The number of patients with rabies exposures seeking anti-rabies vaccination per day cannot be
predicted. The risk of rabies infection as a consequence should prevail over the wastage of the
vaccine.
5.2 Calculation of Expected Demand of Rabies Vaccine & Rabies Immunoglobulin

No. of Rabies vaccine (Human) vials to be procured = Total number of animal bites reported in a year

No. of Rabies Immunoglobulin (RIG) vials to be procured = Total number of animal bites reported in a
year x 0.50 (assuming 50 % of patients as under cat-III animal bites attending health facility) + 10 %
wastage+ buffer stock for 3 months

To avoid wastage of vaccine, leftover ARV can be used for pre-exposure prophylaxis in high-risk groups.

5.3 Storage of Rabies Biological

Maintenance of the cold chain is of utmost importance to ensure that the potency of anti-rabies vaccines
is retained. If great care is taken with aseptic technique, an appropriate dose of vaccine may be withdrawn
from a vial and the remainder used for another patient, provided that the vial is kept cool and stored in
a refrigerator at 2-8°C.
A sterile needle and syringe must be used to draw up vaccines for each patient to prevent cross-infection
of hepatitis, HIV and other infections (open vial policy). Although the vaccine antigen is stable at 4°C,
there is a high risk of contamination of multidose vials by microorganisms, especially as the ARV does
not contain a preservative.
Reconstituted vaccines should be used as soon as possible and those without preservatives should be
used within 6 hours if kept at 2-8°C. All unused reconstituted vaccines at the end of 6 hours must be
discarded. To limit vaccine wastage, remaining vaccine in a vial could be used for PrEP and follow-up
visits should be scheduled accordingly.

59
As per UIP-Adverse Event Following Immunization (AEFI) guidelines, it is advisable to store ARV and
RIG in a separate refrigerator at 2°C-8°C. It is advisable to record the refrigerator temperature twice
daily once in the morning and once in the evening.

Table 16: Health Facility wise Availability of Rabies Biologicals as per NHM Essential Medical List (EML)

Level Rabies Vaccine (Human) Rabies Immunoglobulin (RIG)

• Medical Colleges Mandatory/ Yes Mandatory/ Yes
• Infectious Disease Hospital
• District Hospitals
• Secondary & tertiary Care
Hospital
Community Health Centre Mandatory/ Yes Mandatory/ Yes
Primary Health Centre Mandatory/ Yes
Health & Wellness Centre Mandatory/ Yes

POINTS TO REMEMBER

• Provision of an uninterrupted supply of ARV/RIG is essential for protecting animal bite victims
against deadly rabies disease.
• Procurement of the ARV and ARS (RIG) is to be done as per respective state policy.
• Funds are provided for procurement of ARV & RIG under budget head National health Missions
Free Drug Initiative of NHM PIP
• ARV and RIG are included in the essential drug list under NHM and may be procured under the
National Free Drug Services Initiatives of NHM.
• A decentralized purchase system by the state may be based on the number of animal bite cases
attending the health facilities.
• Maintenance of cold chain and proper storage is of utmost importance to ensure that potency of
Anti-Rabies vaccines is retained.

60
SESSION 6 - HEALTH FACILITIES AS (ARC )
Learning objectives
• To understand the concept of health facilities as Anti-Rabies Clinics.
• To understand requirements for running an Anti-Rabies Clinics.

information as under –
Information to be gathered includes:
• Total number of health facilities i.e PHCs / CHCs / sub-divisional hospitals / district hospitals having
animal bite management facility
• Staff position and their training status on animal bite management
• Infrastructure / basic facilities available for management of Animal Bite Victims (ABV) and rabies cases
• Monthly Data of animal bite victims
• Availability of ARV, ERIG and lab facilities
• Name & Contact details of Hospitals admitting suspected rabies cases
• Need to establish new Anti-Rabies Clinics and laboratory facilities for rabies diagnostics
Based on the above information, appropriate logistics (recordings/reporting formats, guidelines),
infrastructure (wound washing facility in health facility) and procurement of ARV&ARS should be done.
6.1 Wound Washing Area
Wound management is an important component of post exposure prophylaxis (PEP), but often ignored
by the bite victims. Hence, establishing a dedicated wound washing area in health facilities is essential
to support these efforts. This document provides guidance on the importance of wound washing, the
rationale behind it, and recommendations for establishing such facilities in healthcare settings
Importance of wound washing for animal bite cases
Reducing the risk of rabies infection: Rabies is a deadly viral disease, transmitted through the saliva of
infected animals, primarily following bites.
• Washing wounds with copious amounts of water is a vital step in the post-exposure prophylaxis for
rabies. It helps in removing saliva containing the rabies virus from the wound site. The removal of
the virus eliminates the risk of infection. Also, the use of soap by its lipolytic action inactivates the
rabies virus.
• Wound washing also cleanses the dirt, reduces bacterial load and thus minimizing the chances of
secondary infection.
• The National Rabies Control Programme (NRCP) recommends immediate wound washing with
soap and water upto15 minutes and applying disinfectant to the wound/s to minimize the risk of
rabies infection.
Guidance on establishing wound washing area
Requirements: To establish an effective wound washing area, the following aspects need to be considered:
1. Location: Identify an appropriate location within the healthcare facility, preferably near the
emergency department, casualty, dressing room, or dedicated animal bite treatment area/ anti-
rabies clinic (ARC). Avoid locating it adjacent to or in the toilets.
2. Spacious room:

control practices, including providing hand hygiene facilities and personal protective equipment
(PPE).

61
3. Water supply: Continuous clean running tap water supply should be available for wound washing
procedures. Adequate plumbing, drainage, and access to clean water are essential.
4. Medical supplies: Ensure there is a plinth or bench for proper wound management and attending
medical procedures.
5. Ventilation:
patients and staff.
6. Waste management: Proper high-rise drainage (no stagnation) of water, and biomedical waste
management should be followed as per standard protocol /guidelines.

Standard Operating Procedures (SOPs)

Step-by-step instructions for wound washing procedure:

minutes.
2. Use soap to wash the wound/s.
3. After thorough washing and drying the wound with sterile gauze, apply a disinfectant such as
povidone iodine or chlorhexidine.
4. Do not touch the wound with bare hands.
5. Wound washing procedure must be performed even if the patient reports late.
6. Application of irritants such as chili, soil, oils, turmeric, lime, salt, ash, plant juice, etc. by the patient
is strictly prohibited

Important: Cauterization

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6.2 Anti-Rabies Clinics (ARC)
Anti-Rabies Clinics / Centres are the health facilities manned by trained doctor/s and nurse/s where
individuals with rabies exposure are evaluated and managed.
• Generally, PHCs / CHCs / sub-divisional hospitals / district hospitals having animal bite management
facilities will act as Anti Rabies Clinics (ARC).
• Strengthening of existing and establishment of new ARCs based on community needs assessment
is an important objective of the National Rabies Control Program.

Health facilities (PHC / CHC / district hospital or other tertiary level health institutes)

facility to treat animal bite victims or rabies cases.

be carried out by SNO.

Figure 17: Model Anti Rabies Clinic

POINTS TO REMEMBER
• Anti-Rabies Clinics / Centres are the health facilities manned by trained doctor/s and nurse/s
where individuals with rabies exposure are evaluated and managed.

• Generally, PHCs / CHCs / sub-divisional hospitals / district hospitals having animal bite management
facilities will act as Anti Rabies Clinics (ARC).
• Minimum requirements need to be met.

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National Rabies Control Program encourages the concept of model ARCs that should meet the minimum
requirements as presented in Table 16.
Table 16: Minimum Requirements to establish an ARC

A. Minimum available facilities at ARC

1. Management of Animal Bite Wounds: wound washing facility
2. Availability of Rabies biologicals for post-exposure prophylaxis: Anti-rabies vaccine and ERIG
3. Functional referral services for hydrophobia cases
4. Standardized recording and reporting systems
o Animal Bite register
o Rabies Post-Exposure Treatment Cards
o Stock Register
o Monthly reporting formats

1. One Physician
2. One Nurse (GNM) All trained in animal bite management and rabies Pre- and
Post-Exposure Prophylaxis
3. One Pharmacist
4. Others
C. Minimum infrastructure
1. Visible signboards outside and at the entrance of the centre
2. Visible organizational chart
3. Time schedule (functional hours of ARC)

of rabies prophylaxis Decision Tree: Guide to Post-Exposure Prophylaxis)

5. Visible Information, Education & Communication (IEC) messages
6. Separate wound washing facility with safe and clean water (preferably continuous tap water). If
tap water is not available the water should be stored in a clean, covered bucket.
7. Refrigerator with a calibrated thermometer, exclusive for vaccine/ RIG storage
8. Vaccine carrier for temporary storage
9. Facility for proper biomedical waste management with the availability of colour-coded waste bins
and medical waste sharps disposal containers
10. Weighing scale
D. Logistics
1. Equine Rabies Immunoglobulin
2. Tissue culture anti-rabies vaccine approved by DCGI for ID/IM route.
3. Consumables: self-mounted insulin syringes (AD), dressing kits, soap and gloves

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SESSION 7 – RISK COMMUNICATION
Learning objectives
• To describe the principles of risk communication for rabies
• To understand the principles for avoiding animal bites (Do’s and Don’ts to avoid dog bites)
7.1 Risk Communication for Rabies
The goals of risk communication are to share information vital for saving a life, protecting health and
minimizing harm to self and others; to change beliefs; and/or to change behaviour.
Risk communication assists stakeholders/departments and the public to understand the rationale for

cultural interpretations.
• Risk communication is a process of exchange of information and opinion among individuals, groups,
and institutions (e.g. scientists, communities, media professionals) about the nature, magnitude,

• Risk communication includes a risk assessment of the disease and risk management.
• Risk communication should not be restricted to negative messages and warnings but should include
positive ‘educational messages.
• The stakeholders involved during risk communications are government institutions, private
companies / industries, media, colleges, schools, professional organizations, watch groups, NGOs
and the community.
• Risk communication should be targeted to
o General public
o Experts
o Media
• Mode of communications:
o Radio Announcements, Posters, Fact Sheets, Face-To-Face Talks, Publications, Email, Videos,
Websites, Mobile Phone Messages, Social Media Campaigns, etc.
o Local radio, plays, rallies, street shows
o Using the rabies jingles and videos to play at schools, fairs, theatres.
7.2 Conducting Information, Education And Communication (IEC) Activities In The Community
7.2.1 Rabies Prevention through Information, Education and Communication
IEC is a process of working with individuals, communities and societies to develop communication
strategies to promote positive behaviour which are appropriate to their settings and provide a
supportive environment that will enable people to initiate and sustain positive behaviour (Behavior
Change Communication).
Generating awareness is the key for rabies prevention, especially awareness about the disease, as
ignorance and myths still prevail in the community and among stakeholders. It is essential to prevent
rabies exposures and to encourage people to seek appropriate treatment post animal contact.
The population at risk is the population that is most likely to be exposed to rabies and should be the
target of the rabies IECs, like
• Audio and videos on Rabies that have been developed by NCDC and are available on the website.

65
• Video jingles on Rabies that are available in the below listed languages via the link- https://ncdc.
gov.in/index1.php?lang=1&level=2&sublinkid=302&lid=291
o General information: Hindi, English, Assamese, Bengali, Gujrati, Punjabi, Kannad, Kashmiri,
Malayalam, Marathi, Oriya, Tamil, Telugu
o Do’s & Don’ts: Hindi, English, Assamese, Bengali, Gujrati, Punjabi, Kannad, Kashmiri, Malayalam,
Marathi, Oriya, Tamil, Telugu
• Audio jingle in Hindi is available via this link - https://ncdc.gov.in/index1.
php?lang=1&level=2&sublinkid=300&lid=292
7.2.2 Target populations for IEC messages
Details about the gaps encountered in the different target populations and how to address them have
been summarized in Table 17 below.

Table 17: Target Populations for IEC and measures to be taken

Sr No Target Population Knowledge Gap Action Required
1 Medical Administrators, Type of vaccines and Training,
Professionals Doctors, Nurses, RIGs, vaccination, ID CMEs,
Pharmacists. route of ARV and RIG Workshops, Demonstrations,
administration. written material, Conferences

2 Veterinary Administrators, Type of Vaccines, Trainings, CMEs, Workshops,

Professionals Doctors, vaccination, Demonstrations, Written
Veterinary Population Control material, Conferences
Assistants, and Skill Gap about
Catchers Animal birth control
operations.
3 School Teachers of First Aid Instructions, contacting heads of nearby
Teachers Schools, Colleges Do’s and Dont’s, Bite schools or colleges and
prevention, Need for arranging Training, CMEs,
Treatment. Workshops, Demonstrations etc

4 Children Children of all agePlayful and Curious in School health education,

groups. nature. Plays, Quiz, Films,
Parents of Failure to report Cartoons
Children, animal bite cases
Caretakers, or any other kind
Siblings of Exposure, bite
prevention/animal
behaviour
5 General General Public, Ignorance, lack of Posters/Flyers in public places
Public Occupational seriousness of dog such as bus stops, railway
groups, bites. stations, zoos and parks
Resident welfare Wrong beliefs, Interactive sessions, Films,
associations superstitions etc. Documentaries,
(RWAs), Depending on hearsay Short Plays,
Other information rather Rallies
organizations. than health care Announcements Farmer Fairs /
experts Krishi Mela / Pashu Mela.
6 Exposed Bite Victims, Ignorance and Posters,
Persons Attendants of Bite Non-compliance to Flyers,
Cases, and Persons treatment. One on One interaction with the
with non-bite Fear of treatments care provider.
exposures.

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7.3 Myths Associated With Animal Bites And Rabies
In India, various cultural practices are followed after exposure to a dog bite, for example, application
of soil, chilli paste, oil etc. Such common practices are unnecessary and cause further damages to the
tissue. Many myths are associated with Rabies and these myths determine the way the individuals/
animal bite victims seek post-exposure treatment.
Myths about rabies and its treatment prevent people from seeking proper medical care and can cause
harm. For example:
• Many people still believe that Post Exposure Prophylaxis consists of a series of painful injections in
the stomach.
• There are many beliefs that witch doctors, herbal extracts, gemstones, a change in diet or religious
practices can also prevent rabies

effectiveness of the vaccine.

7.4 Tips to Prevent Dog Bites
Some of the following messages need to be communicated to the public about animal bites and rabies.
• Know the body language of dogs. Typical warning signs of unfriendly dogs are snarling or a stiff
stance and staring, ears laid back, lip retraction, and fur-hair on back standing up.
• Train pet dogs not to bite and to obey simple commands such as sit, stay, come, and no.
• Don’t play aggressive games like wrestling or tug-of-war with the pet dog.
• Do not stare at dogs or provoke any animal.
• Don’t leave children unattended with dogs as most of the bite victims are children under 12.
• Talk to your children about avoiding strange dogs and growling dogs.
• Teach children not to take food and toys away from dogs.
• Do not disturb dogs that are nursing or sleeping.

dogs – e.g. kicking a dog)

• Don’t run past a dog. They naturally love to chase and catch things. More attacks are seen with
joggers and people who go out walking.

distance from them.

due to arthritis, weak muscles, and poor eyesight.

• Neuter pet dogs, as neutered dogs are less likely to bite.

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 POINTS TO REMEMBER

• Risk communication aims at sharing information vital for saving a life, protecting the health and
minimizing harm to self and others; to change beliefs; and/or to change behaviour.
• Generating awareness is the key for rabies prevention, especially awareness about the disease, as
ignorance and myths still prevail in the community and among stakeholders.
• Information, Education and Communication (IEC) material needs to target different populations
with different knowledge gaps.
• Myths about rabies and its treatment still exist causing harm and preventing people from seeking
proper medical care.
• It is important to raise awareness and educate communities on preventing dog bites.

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SESSION 8 - RABIES IN ANIMALS
Learning objectives
• To describe the pathogenesis of rabies in animals
• To understand the clinical course of rabies in animals
Animal Rabies is a reportable disease in India as per the ‘Prevention and Control of Infectious and
Contagious Diseases in Animal Act, 2009’. Anyone who has reason to believe that an animal is infected
with rabies or has been exposed to rabies should inform the local veterinary authority.

Figure 18: Pathogenesis of animal rabies

Dogs are the principal reservoir of rabies in the country. Rabies in other domestic animals like cattle,
pigs, goats and horses has been reported since the 1930s, but were all traced back to the bite of a rabid
dog. Control and elimination of rabies in dogs prevent rabies at its source.

The pathogenesis of rabies in animals is similar to that occurring in humans (Figure 18). The incubation
period for rabies is highly variable depending on viruses, hosts and sites of entry, and the majority of
infected animals will develop disease within six months of exposure.

The infective period for rabies virus is variable and can start before the onset of clinical signs. In dogs,

until death.

8.1 Symptoms of Rabies in Animals

It is an acute almost invariably fatal disease in warm blooded animals characterized by signs of abnormal
behaviour, nervous disturbances such as motor nerve irritability, mania, an attacking complex, inability
to swallow, excessive salivation, impairment of consciousness, progressive ascending paralysis and
death due to respiratory paralysis.

Transmission

• The high concentration of rabies virus released from the salivary gland secretions before the onset
of clinical signs of rabies .

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• Virus in fresh saliva is transmitted via bite, scratch or abrasion by a rabid animal (rabid dogs shed
virus in saliva 5-7 days before showing signs and cat does so for only 3 days before signs).
• Contamination of skin wounds by fresh saliva from infected animals.
• Aerosol transmission has been documented in the laboratory and in caves where bats inhabit
(requires a high concentration of suspended viral particles).

8.2 Clinical Course of Rabies in Animals

The clinical course, particularly in dogs, can be divided into 3 phases: the prodromal, the excitative and
the paralytic.

The term “furious rabies” refers to animals in which the excitative phase is predominant and “dumb
or paralytic rabies” to those in which the excitative phase is extremely short or absent and the disease
progresses quickly to the paralytic phase. Aerophobia and hydrophobia are not present in dog rabies

disorder, injury, foreign body in the mouth, poisoning or an infectious disease. Temperature change is

may seek solitude. Frequently, the urogenital tract is irritated or stimulated as evidenced by frequent
urination, erection in the male and sexual desire. After the prodromal period of 1-3 days, animals either
show signs of paralysis or become vicious. Carnivores, pigs, and occasionally, horses and mules bite other
animals or people at the slightest provocation. Cattle bite any moving object. The disease progresses

domestic cats attack suddenly, biting and scratching viciously. Rabid foxes frequently invade yards or
even houses, attacking dogs and people. The rabid raccoon is characterized by its loss of fear of man, its
frequent aggression and incoordination and its activity during the day, being predominantly a nocturnal

Any other mammal that has bitten a human or is suspected of being rabid should also be reported to

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SESSION 9 - UNDERSTANDING ONE HEALTH FOR RABIES
Learning objectives
• To understand the principles of the One Health approach for prevention and control of rabies
• To understand the main interventions in animals to prevent and control rabies
9.1 One Health Approach for Prevention and Control of Rabies
‘One Health’ is an approach to designing and implementing programmes, policies, legislation and
research in which multiple sectors communicate and work together to achieve better public health
outcomes. The areas of work in which a One Health approach is particularly relevant include food safety,

Rift Valley Fever), and combatting antibiotic resistance (when bacteria change after being exposed to

9.1.1 Why do we need a One Health approach?

Many of the same microbes infect animals and humans, as they share the eco-systems, they live in.
Efforts by just one sector cannot prevent or eliminate the problem. For instance, rabies in humans is
effectively prevented only by targeting the animal source of the virus (for example, by vaccinating dogs).

Figure 19: One Health Approach

One Health is an integrated, unifying approach that aims to sustainably balance and optimize the health
of people, animals and ecosystems.
It recognizes the health of humans, domestic and wild animals, plants, and the wider environment
(including ecosystems) are closely linked and interdependent.
The approach mobilizes multiple sectors, disciplines and communities at varying levels of society to
work together to foster well-being and tackle threats to health and ecosystems, while
addressing the collective need for clean water, energy and air, safe and nutritious food, taking action on
climate change, and contributing to sustainable development.
9.1.3 Who makes the One Health approach work?
Many professionals with a range of expertise who are active in different sectors, such as public health,
animal health and the environment, should join forces to support One Health approaches. To effectively
detect, respond to, and prevent outbreaks of zoonoses, epidemiological data and laboratory information

local, national, regional and global levels should implement joint responses to health threats.
To achieve this, the Department of Health & Family Welfare, Ministry of Health and Family Welfare, Govt.
of India initiated a new scheme to be implemented in the 12th Five-year plan during 2012-13 to 2016-17
called as “Strengthening of Intersectoral coordination for prevention and control of zoonotic diseases”.

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Currently, the main stakeholders involved in rabies control viz. Health and Veterinary sectors are working
in isolation with weak coordination mechanisms. All other sectors viz. Urban development, Education,
Environment & Wildlife, Civic bodies, and more shall also extend cooperation and coordination for the
control of rabies in the country with the help and support of the World Health Organization (WHO), OIE,
FAO and Animal Welfare Organization. In the view of the ‘One Health Approach’, a ‘National Action Plan
for Dog Mediated Rabies Elimination from India’ is being drafted.

Table: 20: Intersectoral collaboration for rabies prevention and control at the district

Sr. Department Responsibilities

No.
1 Public Health Surveillance

Laboratory Services
Clinical Management of cases/ Referral arrangements.
Protocols for primary/secondary and tertiary care
Anti-Rabies vaccination
Animal bite control activities
Health Education to masses
Vaccination of vulnerable groups.
Reporting to SSU/State Health directorate.
Media management.
Engagement with all stakeholders.
2 Animal Husbandry Post-mortem investigation of suspected animal rabies cases
and Veterinary Collection of brain tissue samples from suspected rabid animals
Colleges/ IEC and Advocacy efforts in the district.
Institutes Support in animal rabies surveillance.
Participation in multidisciplinary RRT investigations.
Technical support for rabies control among domestic animals
3 Wildlife Arrangements for the autopsy of suspected rabid animals
Arrangements for capturing suspected rabid animals
Isolation and observation of rabid animals
Support to other departments.
4 Tribal welfare Tribal health promoters to support surveillance activities.
Ambulance support for referral of cases to Hospitals.

colonies.
5 Revenue Financial support for conducting anti-rabies vaccination for animal and
human component
6 Education Vaccination and IEC activities coordination in Schools
Information to the surveillance system
7 Women and Child Taking services of Anganwadi workers, where there is no availability of
Welfare ASHA
8 Information and Dissemination of IEC
Broadcasting
9 Local Self Support anti-rabies vaccination, dog population control activities,
Government animal vaccination and IEC activities
10 NGOs Support surveillance and IEC activities.

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9.2 Control of Rabies in The Animal Reservoir
Animal Rabies is a reportable disease in India as per the ‘Prevention and Control of Infectious and
Contagious Diseases in Animal Act, 2009’. Anyone who has reason to believe that an animal is infected
with rabies or has been exposed to rabies should inform the Local veterinary authority.
Rabies is an excellent model for One Health collaboration. Control and elimination of rabies in dogs
prevent rabies at its source. Only a combination of prompt post-exposure prophylaxis and large-scale
mass dog vaccination can eliminate dog-mediated rabies.
i. Dog census: Efforts shall be made by the district authorities in the Animal Husbandry department
to estimate the number of free-roaming/stray dogs and pet dogs. This would help in designing and
evaluating the canine mass vaccination programme.
a. Pet/owned dogs
b. Community/semi-owned dogs and
c. Feral/stray dogs.
ii. Responsible Pet Ownership: The strategy of promoting ‘Responsible Pet Ownership’ can prevent
the spread of rabies. The public is advised to get pet dog licensing from the local authorities, 1st
dose of anti-rabies vaccination when the puppy is about 2/3 months of age and yearly thereafter,
provide proper nutrition and shelter to their pet dogs and not allow their pet dogs to loiter to
prevent contact with infected animals.
iii. Mass Dog Vaccination: Dog vaccination is the most cost-effective single measure to protect humans
from rabies and the mainstay of dog-mediated rabies control. In addition, vaccinating a dog is much
cheaper than providing care to the victim of its bite.

Figure 20- Dog Vaccination

Completion of a mass dog vaccination drive, covering at least 70% of the dog population, within the
shortest period possible should be attempted to stop transmission between dogs and from dog to
human. Campaigns must be conducted recurrently (usually annually) to maintain the level of herd
immunity in the susceptible population despite dog population turnover (births, deaths, animal
movements) in the period between campaigns.
The Department of Animal Husbandry and Veterinary Services at the State and District level, local
government such as Municipal councils, corporations, should take the lead in mass dog vaccination
campaigns every year to cover at least 70% of dogs.
iv. Dog Population Management: This shall include stray dog population management by effective

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 implementation of the ‘Animal Birth Control and Anti rabies (ABC-AR) programme’ throughout the
country. ABC is undertaken by the Veterinary Department of Municipal councils, corporations in
urban/rural areas and this authority could be contacted for ABC. The objective of dog population
management in the context of dog-mediated
rabies control is to improve and maintain vaccination coverage by reducing population turnover
and risky dog behaviour. Mass culling of dogs has been proven ineffective and may even be
counterproductive.
v. Animal rabies: Stray or unwanted dogs, cats or any other domestic animal involved in an exposure

animal should be humanely euthanized in a way that does as little damage to the brain as possible,
and the head/brain sample submitted for laboratory examination and rabies testing.
vi. Risk of rabies transmission in other animals: A history of abnormal or aggressive behaviour
in any domestic animal, or potential exposure of a domestic animal to other animals that could
transmit rabies (including other domestic animals of unknown rabies vaccination status or wild
animals) would also have the likelihood of rabies exposure.

and behaviour. Achieving and maintaining a high dog vaccination coverage can be hampered by high
dog population turnover rates, when unvaccinated dogs quickly replace vaccinated dogs. Transmissions
cycles can further include wildlife which can be infected by dogs as well.
Open garbage disposal sites or solid waste accumulation in urban settlements can attract a high
numbers of dogs and increase the transfer of infectious diseases. Dogs competing for food at these sites
can increase overall aggression further leading to an increased risk of dog bites.

engagement beyond the veterinary and human health sectors.

9.4 Awareness And Education - IEC

Education on dog behaviour and bite prevention (for children and adults) can decrease both the

responsible pet ownership, bite prevention and immediate care measures after a bite is an essential
part of any programme and requires One Health collaboration between, at a minimum, the human and
veterinary health sector. Community engagement is critical in achieving and sustaining effective delivery
of rabies interventions. This is where One Health really starts. Improving the accessibility of these to
often remote communities thereby improves overall access to health care – an integrated approach to
strengthening health systems bottom-up.
The public education sector and available mass media (Television, Newspapers and Radio) should be
used for the dissemination of information on bite prevention and anti-rabies treatment for animal bites.

More information on IEC was already provided in Session 7 – Risk communication.

9.5 Training of Health & Veterinary Professionals in One Health

All levels of human (doctors, staff nurses, health workers and ASHAs) & veterinary (veterinarians and
veterinary inspectors) professionals in the district shall be trained in the prevention and control of
rabies. Coordination mechanisms between human health and the veterinary department for rabies
control in the community needs to be established.

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For Animal Bite cases For Human Rabies cases
• Identify areas of clustering of animal bite • Identify areas with human rabies
cases • Find out reasons (Incomplete treatment, NO
• Ensure the availability of ARV/ARS in cen- PEP taken by victims, low awareness etc.)
• Ensure the availability of ARV/ARS in cen-
• Notify Vet. Dept /Municipalities to initiate tres catering for the areas
appropriate measures such as Dog popula- • Intensify IEC activities in the area
tion management, MDV. • Notify Vet. Dept/Municipalities to initiate
• In case of any animal is suspected of Rabies, appropriate measures- DPM, MDV
Notify the local Vet. Dept /Municipalities • Conduct a meeting with the vet. Dept. as part
• Conduct a meeting with the vet. Dept. as part of zoonotic committees for joint action
of zoonotic committees for joint action • Follow up
• Follow up

9.6 Actions following human rabies cases reported by Health authorities

Epidemiological investigations of rabies cases are crucial to identify the source of infection, contacts,
and probable other patients who might be exposed etc. Investigations should ideally not only follow
rabies cases but also dog bites – and integrated bite case management (IBCM) combines many things.
It is an enhanced surveillance method that connects different sectors and includes timely sharing of
data between them. It could further improve detection of cases, remove dangerous animals from the
community, increase compliance with measures and vaccination and create better buy-in and support
using available resources in the best way.
• For suspected human rabies cases
• if possible, collect samples ante-mortem (e.g. saliva, skin, CSF, serum) and post-mortem (brain

• Conduct Verbal Autopsy to collect a case history for the patient

• For probable human rabies cases
• Identify contacts of patients and/or animals involved for follow up
• Ensure mechanism is in place for transportation of samples to reference laboratory

• Notify appropriate local authorities of a suspected rabid animal

• Provide PEP to close contacts
• Trace other animal bites and ensure PEP for other victims
IBCM showcases a One Health approach in action – it requires both human and animal health professionals
to work together. Human health professionals are responsible for taking care of the bite victims, while
animal health professionals evaluate the biting animal in parallel. Case investigation is shared and
reporting of information is two-way so that the treating physician can perform a risk assessment and
make further decisions based on that.

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 POINTS TO REMEMBER
• Main sectors involved in rabies control viz. Health and Veterinary sectors are working in isolation
and need to work in coordination
• All other sectors viz. Urban development, Education, Environment & Wildlife, Civic bodies, shall
extend cooperation and coordination for control of rabies
• Mass Dog Vaccination aiming at a 70% vaccination coverage is the most effective measure to control
canine rabies
• Dog population management can improve and maintain vaccination coverage by reducing
population turnover and risky dog behaviour.
• Environmental factors like open garbage disposal sites or solid waste accumulation in urban

• Coordination needs to be done with the veterinary department for rabies control in the community.

taken by victims, low awareness etc.)

appropriate measures- DPM, MDV

• Rabies (in man and animals) is fatal even today and there is no cure for it anywhere in the world.
• Rabies is enzootic (widely prevalent in animals) in India and hence, all animal bites/licks (such as
mongoose, shrews or any unknown animal bites) are dangerous.
• The Carrier state of rabies in dogs (and cats) is not yet conclusively proven and established. Hence,
both WHO and the Government of India recommend observation of animals during Post Exposure
Treatment.
• Immediate and early wound treatment to remove traces of saliva is very important.
• The physician should carefully go through the product information literature (of both vaccine and
serum) and use the immune biologicals accordingly.
• There is no contraindication for post-exposure immunization including pregnancy, lactation, HIV,
AIDS, other infectious diseases, and conditions.
• When in doubt of degree of exposure to rabies risk, it is safer to over treat than undertreat,
• Correct post-exposure immunization, more so use of RIG/serum in category III exposure is
lifesaving.
• Modern rabies vaccines are effective and safe and shall always be preferred and injected IM into
deltoid/thigh in young children and never in the gluteal region.
• There is no single-dose vaccine or vaccine that gives lifelong immunity.
• Pre-exposure vaccination of “at-risk ” individuals should be encouraged.
• Pet owners should be strongly advised to get their dog/cat vaccinated regularly and obtain a license
from local municipal authorities.

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 ANNEXURE- 1: DETAILS OF RABIES IMMUNOGLOBULIN: (SOURCE: DCGI)
S.no Strength Presentation of Shelf life and
vaccine storage condition
(Vial/PFS/other)
1 Each ml 5 ml/vials 24 Months
Corporation Ltd, Pimpri, Pune- contains Pack of Store between 2°
411018 300IU/ ml 10 Vials each box C and 8° C
2 M/s Serum institute Pvt ltd., 1500 IU/ 5mL 5 ml Vial 24 Months
212/2 Hadapsar, Pune-411028 1000 IU/ 5mL
3 M/s Bharat Serum and Vaccine 1000 IU/ 5mL 5ml Vial 24 months Store
Ltd Plot No: K-27/ Anand Nagar between 2° C and
Mumbai-400008 8° C
300 IU/ mL 5ml Vial 24 months Store
between 2° C and
8° C
4 M/s Central Research Institute Dist. 1500 IU/ 5mL 5ml Vial 24 months
Solan (H.P.) 173205
5 M/s Virchow Biotech Pvt Ltd Sy. 1500 IU/ 5mL 5 ml vial 24 months
No. 172 part, Gaglapur Village- Liquid
Quthbullahpur Mandal Reddy
District Telangana
6 M/s Vins Bioproducts Ltd Sy. 1500 IU/ 5ML 5ml vial 24 months
No.117 Thimapur Village Kothur Liquid vial
Mandal Mahbubnagar District 1000 IU/ 5mL
Telangana (For Export)
7 M/s Premium Serums and Vaccines 1500 IU/ 5mL 24 months
Pvt Ltd., S.No. 354-1 & 2A/1 Vial
Narayangaon, Tal. Junnar, Dist. 1000 IU/ 5mL
Pune-410504 Pune Liquid
ANNEXURE-2 DETAILS OF RABIES VACCINE, HUMAN (SOURCE: DCGI) AVAILABLE IN INDIA

Doses & Route of Administration Presentation

(Vial/PFS/
other)
ANNEXURE 3
M/s Human Biological Limited, Hyderabad 1 ml – 1 dose Intramuscular Vial
0.1ml- 1dose Intradermal
M/s Cadila Healthcare Limited, Ahmedabad 1 ml single-dose used for Vial
Intramuscular
0.1 ml / 10 doses used for
intradermal.
M/s Chiron Behring Vaccines Ltd., Gujarat Single-dose 1 ml dose Intramuscular Vial
Multidose 10 dose (0.1 ml/dose)
Intradermal
M/s Serum Institute of India Pvt. Ltd., Pune 1 ml – 1 dose Intramuscular Vial
0.1ml- 1dose Intradermal
M/s Bharat Biotech International Ltd. 1 ml – 1 dose Intramuscular Vial
Hyderabad 0.1ml- 1dose Intradermal

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 ANNEXURE 3
NATIONAL RABIES CONTROL PROGRAMME
ANIMAL BITE EXPOSURE REGISTER*
Name of the Health Facility: Type of Health Facility:

Address & Contact Details

Health Facility Code: Reporting Month Year

Registration Type Patient Detail Exposure History Exposure Post Exposure Prophylaxis
of Pa- details
tient
(New/
OLD)
S/N Date Name Age Sex Resi- Date Site of Biting Cate- Address Ade- Rabies ARV Pre- Biting Re-
(M/ F/ dential of Bite on Animal gory where quate Im- Route vious Animal marks
Other) Address Bite Body: Species of bite in- Washing muno- ID/IM History Status (Dose
(Ex- - dog/ Bite cidence of Bite globin of ARV after no/
trem- cat/ (I/II/ took wound Given Vac- 10 days PEP
ities/ mon- III) place Do- (Y/N) cina- (Dead/ status
Trunk/ key/ ne(Y/N) tion(- Alive/ com-
Head- others Com- Not plete/
Neck (speci- plete / trace- incom-
Face/ fy) par- able) plete)
Back) tial/
NA)

Any Clustering of cases Observed: if yes write the details

Category I: Touching or feeding of animals; Licks on intact skin; Contact of intact skin with secretions/
excretions of rabid animal / human case, Category II: Nibbling of uncovered skin; Minor scratches or
abrasions without bleeding, Category III: Single or multiple transdermal bites or scratches, licks on
broken skin; contamination of mucous membrane with saliva (i.e. licks)
*To be maintained by Health facility providing treatment to animal bite cases

Summary

Indicator Old New Total Indicator IM ID

Total Number of Pa- Route of ARV Administration
tients attended
I II III Total Number of Cat II pa-
tients receiving ARS
Category wise Number
of Patients

78
 ANNEXURE 4
NATIONAL RABIES CONTROL PROGRAMME
RABIES POST EXPOSURE TREATMENT CARD (To be retained at Anti Rabies Clinic)
Name and address of the health facility
Patient Reg. No

Name
Age/ Sex
Patient Residential Address & Contact No
Category of Exposure
I. Touching or feeding of animals
Licks on intact skin
Contact of intact skin with secretions /excretions of rabid animal/human case
II. Nibbling of uncovered skin
Minor scratches or abrasions without bleeding
III. Single or multiple transdermal bites or scratches, licks on broken skin
Contamination of mucous membrane with saliva (i.e. licks)
Biting Site: Extremities/ Trunk/ Head-Neck Face/ Back

Date of Exposure/bite (DD/MM/YYYY) Past h/o vaccination

Site of Bite/ Bites If Yes
Type of animal Biting animal status
Dog Monkey Alive
Cat Other Dead Specify whether Partial / complete
Unknown
Date treatment started (DD/MM/YYYY)

Wound management
Washed immediately with water () Wound washed at facility ( ) Yes ( ) No
Yes ( ) No
Antiseptic application ( ) Yes ( ) No

Post exposure vaccination record Route of Administration ( ) ID ( )IM

Period Date due Date given Signature

Day 0

Day 3

Day 7

Day 14
(for IM only)
Day 28

Outcome: PEP Complete/ Incomplete

Signature

79
 ANNEXURE 5
RABIES POST EXPOSURE TREATMENT CARD (Patient’s Copy)
NATIONAL RABIES CONTROL PROGRAMME

Name and address of the health facility

Name
Age/ Sex
Patient Residential Address & Contact No
Category of Exposure
I. Touching or feeding of animals
Licks on intact skin
Contact of intact skin with secretions /excretions of rabid animal/human case
II. Nibbling of uncovered skin
Minor scratches or abrasions without bleeding
III. Single or multiple transdermal bites or scratches, licks on broken skin
Contamination of mucous membrane with saliva (i.e. licks)
Biting Site: Extremities/ Trunk/ Head-Neck Face/ Back

Date of Exposure/bite (DD/MM/YYYY) Past h/o vaccination

Site of Bite/ Bites If Yes
Type of animal Biting animal status
Dog Monkey Alive
Cat Other Dead Specify whether Partial / complete
Unknown
Date treatment started (DD/MM/YYYY)

Wound management
Washed immediately with water ( ) Wound washed at facility ( ) Yes ( ) No
Yes ( ) No
Antiseptic application ( ) Yes ( ) No

Post exposure vaccination record Route of Administration ( ) ID ( )IM

Period Date due Date given Signature

Day 0

Day 3

Day 7

Day 14
(for IM only)
Day 28

Outcome: PEP Complete/ Incomplete

Signature

80
 ANNEXURE-6
DISTRICT MONTHLY REPORT (NRCP-M02) *
Base line data collection at District Level (NRCP-BLD)
NATIONAL RABIES CONTROL PROGRAMME
District Monthly Report (NRCP-M02)*State Name:
District Name: District Focal Point
Name:
Address: Month and Year of Reporting:
Total no. of health facilities providing facility for animal bite management/ Number of Facilities submitted report
Mention no. of patients as per type of biting animal District Total
Dog
Cat
Monkey
Any other (specify)
Mention no. of patients as per Category of bite District Total
I. Touching or feeding of animals, Licks on intact skin Contact of intact skin with secretions
/excretions of rabid animal/human case
II. Nibbling of uncovered skin Minor scratches or abrasions without bleeding
III. Single or multiple transdermal bites or scratches, licks on broken skin Contamination of District Total
mucous membrane with saliva (i.e. licks)
Details of patients as per Route of vaccination
IM route (Essen schedule on day 0,3,7,14,28)
ID route (update Thai Red Cross Regimen: 2-2-2-0-2)
No. of Category III victims given ARS
Number of Patients completed PEP
District Total

No. of clinically Suspected Rabies cases seen at OPD (who refused admission)
No. of clinically Suspected Rabies cases admitted
No. of clinically Suspected Rabies cases left against medical advice
No. of clinically Suspect Rabies deaths in hospital
Total Vaccine (no. of vials) used in the District (monthly) District Total
Opening balance
Quantity received
Quantity utilized
Closing balance
Total ARS (no. of vials) used in the District (monthly)
Opening balance
Quantity received
Quantity utilized
Closing balance
Yes/ No
Any Clustering of Animal Bite Cases observed? If yes write the details including locality
Any other remarks

Date: Signature:
*Compiled Monthly report of Animal Bite Victims receiving treatment at all Anti Rabies Clinics/Health
facilities providing animal bite management

81
 ANNEXURE-7

NATIONAL RABIES CONTROL PROGRAMME

S. Name Age Sex Con- Vil- Sub Dis- State Bit- Sus- Ad- Cate- Status Name Out-
No. tact lage Dis- trict ing pect- dress gory of PEP of the come
Num- trict/ Ani- ed/ of of (Com- health of
ber Taluk/ mal Prob- place Bite plete/ facili- patient
Block/ able/ where Par- ty re- (Death
Man- Con- bite tial/ port- in Hos-
dal inci- Nil/ ed pital/
dence NA) Ra- LAMA/
took bies Alive)
place case

To be reported by Health facilities to district nodal person, State Nodal Person & National Pro-

82
 ANNEXURE-8
NRCP STATE MONTHLY REPORT
State Monthly Report (NRCP-M02) *
NATIONAL RABIES CONTROL PROGRAMME
State Name:
State Focal Point Name:
Address:
Month and Year of Reporting:
Total no. of health facilities providing facility for animal bite management/ Number of Facilities submitted report
Mention no. of patients as per type of biting animal District Total
Dog
Cat
Monkey
Any other (specify)
Mention no. of patients as per Category of bite District Total
I. Touching or feeding of animals, Licks on intact skinContact of intact skin with secretions /
excretions of rabid animal/human case
II. Nibbling of uncovered skin Minor scratches or abrasions without bleeding
III. Single or multiple transdermal bites or scratches, licks on broken skin Contamination of
mucous membrane with saliva (i.e. licks)
Details of patients as per Route of vaccination District Total
IM route (Essen schedule on day 0,3,7,14,28)
ID route (update Thai Red Cross Regimen: 2-2-2-0-2)
No. of Category III victims given ARS
Number of Patients completed PEP

No. of clinically suspected rabies cases seen at OPD (who refused admission)
No. of clinically suspect rabies cases admitted
No. of clinically suspected rabies cases left against medical advice
No. of clinically suspect rabies deaths in hospital
Total Vaccine (no. of vials) used in the District (monthly) District Total
Opening balance
Quantity received
Quantity utilized
Closing balance
Total ARS (no. of vials) used in the District (monthly) District Total
Opening balance
Quantity received
Quantity utilized
Closing balance

Any Clustering of Animal Bite Cases observed? If yes write the details including locality
Any other remarks
Date: Signature:
*Compiled Monthly report of Animal Bite Victims receiving treatment at all Anti Rabies Clinics/Health
facilities providing animal bite management
(to be submitted by Distric

83
 ANNEXURE-9
HUMAN RABIES CASES MONTHLY REPORT
FROM INFECTIOUS DISEASE/ ANY OTHER HOSPITAL TO STATE NRCP OFFICER.
NATIONAL RABIES CONTROL PROGRAMME
Health facility Monthly Summary report
District Name:
Name of Health Facility (PHC/CHC/District hospital/ Anti Rabies Clinic Etc) ______________________
Name of Focal Point
Address:
Month and Year of Reporting

Total no. of health facilities providing facility for animal bite management/ Number of
Facilities submitted report
Mention no. of patients as per type of biting animal Health Facility Total
Dog
Cat
Monkey
Any other (specify)
Mention no. of patients as per Category of bite Health Facility Total
I. Touching or feeding of animals, Licks on intact skin Contact of intact skin with
secretions /excretions of rabid animal/human case
II. Nibbling of uncovered skin Minor scratches or abrasions without bleeding
III. Single or multiple transdermal bites or scratches, licks on broken skin Contamination
of mucous membrane with saliva (i.e. licks)
Details of patients as per Route of vaccination Health Facility Total
IM route (Essen schedule on day 0,3,7,14,28)
ID route (update Thai Red Cross Regimen: 2-2-2-0-2)
No. of Category III victims given ARS
Number of Patients completed PEP
Health Facility Total

No. of clinically suspected rabies cases seen at OPD (who refused admission)
No. of clinically suspect rabies cases admitted
No. of clinically suspected rabies cases left against medical advice
No. of clinically suspect rabies deaths in hospital
Total Vaccine (no. of vials) used in the District (monthly)

No. of clinically suspected rabies cases seen at OPD (who refused admission)
No. of clinically suspect rabies cases admitted
No. of clinically suspected rabies cases left against medical advice
No. of clinically suspect rabies deaths in hospital
Total Vaccine (no. of vials) used in the District (monthly) Health Facility Total
Opening balance
Quantity received
Quantity utilized
ClosingTotal ARS (no. of vials) used in the District (monthly)

84
Total ARS (no. of vials) used in the District (monthly) Health Facility Total
Opening balance
Quantity received
Quantity utilized
Closing balance

Any Clustering of Animal Bite Cases observed? If yes write the details including
locality
Any other remarks
Date: Signature:

*Compiled Monthly report of Animal Bite Victims receiving treatment at all Anti Rabies Clinics/Health
facilities providing animal bite management
(to be submitted by in charge – Health facility (PHC/Anti Rabies Clinic /CHC/ Sub divisional hospital)

85
 ANNEXURE-10
GUIDE TO POST EXPOSURE PROPHYLAXIS

86
 ANNEXURE-11
ADDRESS OF HUMAN AND ANIMAL RABIES DIAGNOSTIC LABORATORIES IN INDIA

Human Rabies Diagnostic Laboratories

1 Department of Neurovirology, NIMHANS, Bangalore 560029
2 Zoonosis Division, National Centre for Disease Control, Sham Nath Marg, Delhi – 110 054
3 Pasteur Institute of India, Coonoor- 64310, Tamil Nadu
4 Central Research Institute, Solan, Kasauli, Himachal Pradesh 173204
5

Animal Rabies Diagnostic Laboratories

OIE Twinned Rabies Diagnostic Laboratory Institute of Animal Health and Veterinary Bio-
Dept. of Microbiology logicals
Veterinary college, KVAFSU Bellary Rd, Bengaluru, Karnataka 560024
Hebbal, Bangalore-560024 Phone: 080 2341 1502
Ph:080-23410509 / 09449992287
ICAR - National Institute of Veterinary Epidemiol- -
ogy and Disease Informatics, -
Ramagondanahalli, Post Box No. 6450, Yelahanka, bandry, Palode, Thiruvananthapuram-695562
Bengaluru, Karnataka 560064 Phone: 09446557186
Phone: 080 2309 3110
Department of Pathology, Department of Pathology, College of Veterinary
College of Veterinary and Animal Sciences is a and Animal Sciences, Kerala Veterinary and
veterinary college animal Sciences University, Pookode, Wayanad,
Santosh Nagar, Mannuthy, Thrissur, Kerala 680651 Kerala 673576
Phone: 0487 237 0451 Phone: 04936 256 640
Rabies Diagnostic Laboratory, Dept. of animal Bio- Department of Microbiology, Anand Agricultural
technology, Madras Veterinary college, TANUVAS, University,
Vepery, Chennai-600007 Anand 388 110, Gujarat, India
Contact: 09486784973 Ph: 09824243564
Department of Veterinary Microbiology, Bombay Department of TVCC, Veterinary college, KVAFSU
Veterinary college Shivamoga, Karnataka
Parel, Mumbai 400012 Contact: 08277270598
Contact Number: 09167493932
Rabies Laboratory, Department of Veterinary Department of Pathology
Pathology ICAR-Indian Veterinary Research Institute
Ludhiana - 141 004. Punjab. Izzatnagar, Bareilly-243122
Ph.: (O): 0161 - 401961 Uttar Pradesh

87
 ANNEXURE 12
MONTHLY REPORT ON LABORATORY DIAGNOSIS OF RABIES (HUMAN/ANIMAL)
National Rabies Control Programme
National Centre for Disease Control
Ministry of Health and Family Welfare
Government of India

Name & Address of the Laboratory:

Name of the in charge:
Contact Number: Email ID:
Period of Reporting: Date of Reporting:
A. Summary of Report on Diagnostic Services
Tests Available: Sellers/FAT/dRIT/PCR/ Virus Isolation/ Rapid test

Species Specimen Number Tested Number Positive Remarks

Human CSF
Brain Tissue
Saliva
Any Other
Dog Brain
Cat Brain
Monkey Brain
Other Animals
(Please Specify)

B. Summary of Anti Rabies Antibody Titres

Tests Available: ELISA (Name of the Kit: ____________________________________) /RFFIT/ any other (Specify)

Number Titre
Specimen Remarks
Tested >0.5 IU/ml <0.5 IU/ml

CSF
After
Complete
Vaccination
Humans Partial
Blood Vaccination
No
Vaccination

Blood (post
Animals
Vaccination)

88
 ANNEXURE 13
SUMMARY OF VACCINATION SCHEDULE

Type of Route of Number of Day of Dose Number of Site of Injection

Prophylaxis Administration Visits injections Per
Visit
Post Intradermal 4 Day 0, 3, 7 2 Adults: Deltoid
Exposure (ID) and 28 Muscle
Prophylaxis Infants and
Intramuscular 5 Day 0, 3, 7, 1 small Children:
(IM) 14 and 28 Anterolateral Thigh
Pre- Intradermal 3 Day 0, 7, and 1
Exposure (ID) 21 or 28
Prophylaxis
Intramuscular 3 Day 0, 7, and 1
(IM) 21 or 28
Re-exposure Intradermal 2 Day 0 & 3 1
(ID)
Intramuscular 2 Day 0 & 3 1
(IM)

Intradermal Dose: 0.1ml

Intramuscular Dose: 1 entire vial will be 1 full dose

89
 ANNEXURE 14
IHIP EVENT ALERT FORM

90
 ANNEXURE 15
P FORM (IHIP)

Data Entry of ‘Human Rabies’ case

[without ‘Lab test request’] on P
form on IDSP-IHIP

Patient
Details

Clinical
Details
Click on ‘Save’ to
save this case

91
 Myths and Misconceptions
• Any animal that has bitten humans should be killed because of the danger of rabies.

• First aid is not helpful for those who have been bitten or scratched by an animal suspected
of having rabies.

• There is one single, more costly injection to prevent rabies.

• Puppies do not transmit rabies.

• Vaccination is to be given in stomach and is very painful

92
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of endemic canine rabies. PLoS Negl Trop Dis. 2015;9(4): e0003709.
2. Suraweera W, Morris SK, Kumar R, Warrell DA, Warrell MJ, Jha P et al. Deaths from symptomatically

Dis. 2012;6(10): e1847

3. Fooks AR, Banyard AC, Horton DL, Johnson N, McElhinney LM,Jackson AC. Current status of rabies
and prospects for elimination.Lancet. 2014;384(9951):1389–99.
4. Amarasinghe GK, Bào Y, Basler CF, Bavari S, Beer M, Bejerman N et al. Taxonomy of the order
Mononegavirales: update 2017. Arch Virol.2017;162(8):2493–504.
5. Ugolini G. Use of rabies virus as a transneuronal tracer of neuronal connections: implications for
the understanding of rabies pathogenesis. Dev Biol (Basel). 2008; 131:493–506.
6. Ugolini G. Advances in viral transneuronal tracing. J Neurosci Methods. 2010;194(1):2-0.
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2011:79:165–202.
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mechanisms and diagnostic challenges. Lancet Neurol. 2002:1(2):101–9.
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rabies: neuropathogenesis, diagnosis, and management. Lancet Neurol. 2013;12(5):498–513.
10. Klingen Y, Conzelmann KK, Finke S. Double-labeled rabies virus: live tracking of enveloped virus
transport. J Virol. 2008;82(1):237–45.
11. Hemachudha T, Wacharapluesadee S, Laothamatas J, Wilde H. Rabies. Curr Neurol Neurosci Rep.
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12. Mitrabhakdi E, Shuangshoti S, Wannakrairot P, Lewis RA, Susuki K, Laothamatas J et al. Difference in
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3–10.
13. Dumrongphol H, Srikiatkhachorn A, Hemachudha T, Kotchabhakdi N, Govitrapong P. Alteration of
muscarinic acetylcholine receptors in rabies viral-infected dog brains. J Neurol Sci. 1996;137(1):
1–6.
14. Thanomsridetchai N, Singhto N, Tepsumethanon V, Shuangshoti S, Wacharapluesadee S, Sinchaikul S
et al. Comprehensive proteome analysis of hippocampus, brainstem, and spinal cord from paralytic
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