RABIES
Dr. Tapan Kr Ghosh*
Scientific Coordinator, Institute of Child Health, Kolkata Chairperson, Infectious Diseases Chapter of Indian Academy of Pediatrics (IAP) Founder Secretary, Association for Prevention & Control of Rabies in India (APCRI)*
Rabies is primarily a zoonotic disease. The name, 'Rabies' has derived from a Sanskrit word 'Rabhas', meaning "To do violence". Rabies is known to mankind since time immemorial. This is one of the most dreaded diseases known to mankind.

Rabies is an acute viral encephalitis caused by exposure to rabid animals and by the term 'exposure' we mean bite, scratch or lick directly on mucous membrane or on broken skin and also aerosol infection by infected animals. But rabies is not seen in India.

Though rabies has invariably a fatal outcome, this is a vaccine preventable disease. Rabies is endemic in many of Asian and African countries except the island countries and also in the islands of many countries as it is not prevalent in islands. During the past decades Sri Lanka, Thailand and Philippines have reduced the number of rabies deaths to a great extent implicating proper anti-rabies measures and newer vaccination policy.

Rabies ranks 12th on the WHO's list of major mortality causing disease, a level comparable to hook worm disease or ascariasis (1), and this is the 10th most common cause of death among infectious diseases .(2)

According to latest WHO estimates, about 50,000 human deaths due to rabies is reported every year in the world. The only available authentic and recent surveillance is WHO-sponsored National Multicentric Rabies Survey undertaken by Association for Prevention and Control of Rabies in India (APCRI) (3), which was published in May 2004. This surveillance shows annual incidence of human rabies deaths as 17,137 (14109 to 20165 with 95 per cent confidence), and if an additional of 20 per cent is included for paralytic/atypical form of rabies, an estimation of annual 20,566 human rabies deaths from India is available. (3) This report also indicates that the animal mainly responsible for human rabies deaths are dogs (96.3 per cent). Overall the cats accounted 1.7 per cent of deaths due to rabies in human. Part from the dog, the other common animals reservoirs of rabies based on laboratory evidence are cattle, cat, pigs and among the wild animals are mongoose and jackals. (4)
Causative Virus
The causative virus is a single stranded RNA virus belonging to the genus Lyssavirus of the family Rhabdoviridae. The rabies virus is a typical bullet-shaped virus. Rabies virus is a neurotropic virus, has phospholipid envelop which has glycoprotein spikes on surface. The surface projection of glycoprotein, helps in attachment of virus to susceptible cells, also carries the antigen which elicits the production of neutralizing antibody when isolated in animals and hence affords protection against the disease.(8) The rabies virus is resistant to cold temperature, dryness and decays but is rapidly inactivated by the action of oxidizing agents, solvents, quaternary ammonium compounds, soap and detergent as presence of lipid in the outer coat of rabies virus particle makes it relatively easy to disrupt them simply by addition of a lipid solvent.(6)

Bat Rabies (7): Rabies virus was first isolated from insectivorous bats in Florida and Pennsylvania in 1953. The free tailed bat was particularly important in Texas and New Mexico. Bats undoubtedly infect each other and there are few well established incidences of bats infecting men or other animals. Apart from bites direct infection by the virus in aerial route, (that is breathing) is reported. Bats may therefore infect each other not only by direct fights in roosting place, but also by breathing in contaminated dust. This mode of transmission is never reported from India.(7)

Rabies has become a reemerging disease in North America, Canada and also in Australia, which was considered a rabies free continent. Australia has also reported a few human rabies cases, mainly because of bites by bats .(5)
Modes of Transmission
The following are the modes of transmission of rabies infection:
  1. Bite
  2. Scratch
  3. Lick on damaged skin and intact mucous membrane by rabid animals
  4. Organ transplant - Cornea transplant mainly
  5. Aerosol spread
Course of Virus after getting Entry in the human body
After entering the human body, the virus replicates in muscles in and around wound, then gain access to nerve endings and starts traveling at the rate of 3 mm per hour towards central nervous system, ascends passively in the axoplasm of the nerves and reach dorsal root ganglion where they again replicate and reaches the anterior horn cells of spinal cord and then spreads to neurons of the spinal cord. Once CNS is involved, there is rapid and extensive replication of virus in brain and spinal cord. Initially some areas like hippocampus, hypothalamus and limbic system are involved predominantly.

Clinical Presentation of Rabies in Human

Incubation period - Highly variable, may be as short as 4 days to as long as 3 years. Average incubation period varies between 3 weeks and 3 months. Prolonged incubation period is reported in very few cases. The size of inoculum of virus and the bites in head and neck region due to proximity to brain, in hands due to excess innervations may have some significance in the early causation of the disease.

Clinical Forms of Rabies in Human (Fig. 1)

There are 2 distinct clinical forms: (1) Furious rabies (2) Dumb rabies
  • Furious type - Seen in 80% cases, characterized by symptoms related to spasms of gullet, namely hydrophobia, aerophobia and others aggressiveness leading to coma and death in 3-5 days after the onset of symptoms.
  • Dumb or paralytic type - Seen in 20% cases, characterized by progressive onset of ascending paralysis, in order of involvement of lower limbs, abdominal muscles, upper limb and thoracic muscles, followed by coma, respiratory failure and death which is delayed and patient may live little longer, sometimes as long as a month.
    Figure 1. Clinical Forms of Rabies

    Encephalitic Type (80%)

    Paralytic Type (20%)

    Hyperactivity,
    Hydrophobia,
    Aerophobia

    Paralysis

    Coma

    Death (respiratory failure)

    Complete Paralysis

    Coma

    Death (respiratory failure)



Prevention of Rabies
The most important is the prevention of rabies infection after exposure, or even before exposure. With the availability of safe and effective modern tissue culture vaccines (MTCV) and the concept of sero-vaccination (Immunoglobulin and vaccine - both), prevention of rabies is mostly assured in post-exposure cases. As canine rabies control is a difficult, complex and longterm activity, the immediate concern of health authorities should be to provide modern rabies prophylaxis to victims of animal bites.(12)

Clinical categorization of the exposure as per WHO recommendation is a useful tool to treat an animal bite case (Table 1)(13). A transdermal wound in any place of the body or a mucous membrane contamination with saliva is to be dealt with most seriously with the following steps(14) and each of the steps is very important.

Majority of wounds and exposure are of Category III type. A total treatment procedure in Category III cases is also very important medicolegally. The following protocol is more or less cent percent effective for prevention of rabies in a fresh exposed case irrespective of the fact of extension of exposure or the animal concerned. The steps are described below:

Step I: Local washing of the wound thoroughly with soap and water - This step invariably reduces the virus load of the wound physically (running water) and inactivating the remaining particles of virus chemically (soap or detergent).

Step II: Application of 70% alcohol, tincture of iodine, povidone iodine, or any other suitable disinfectant after removing all traces of soap, alcohol and other disinfectants - This leads to further inactivation of remaining virus by chemical disruption. The animal bite wound(s) is (are) not to be covered. Any suturing of the wound(s) should be avoided. When the suturing is unavoidable for the purpose of hemostasis, it must be ensured that immunoglobulins have been administered in the wound(s) prior to suturing. Unnecessary application of counter irritants like chilly or carbolic acid or lime is to be avoided strictly.

Step III: Proper infiltration of the wound(s) with rabies immunoglobulins of human (HRIG) or equine (ERIG) origin - The dose of HRIG is 20 IU per kg of body weight and that of ERIG is 40 IU per kg of body weight. In case of ERIG, skin test for sensitivity is essential. But in HRIG no skin test is necessary. As much as anatomically feasible, the RIG should be infiltrated thoroughly into and around the wound. The remaining portion of the calculated amount of the RIG if any is to be injected in the deltoid region in older children and adults or anterolateral surface of thigh in newborns, infants and smaller children away from the site of vaccine administration to prevent on site neutralization of vaccine antigen. If the administration of the RIG is delayed initially it can be administered up to 7th day after the 1st dose of vaccine i.e., along with 3rd dose of vaccine (12), but in a separate site.

Step IV: Vaccination against Rabies - It is advisable to administer a potent modern tissue culture rabies vaccine (MTCV) following an approved schedule which results in production of systemic antibodies against rabies after a lag period of 7 to 14 days from the 1st dose of ARV. These antibodies are capable of neutralizing remaining virus particles. The use of modern tissue culture antirabies vaccines (MTCV) is only available at present.
Rabies Immunoglobulin (RIG)
There are 2 types of rabies immunoglobulin namely, (i) Human rabies immunoglobulin (HRIG) and (ii) Equine rabies immunoglobulin (ERIG). RIGs are specific rabies virus neutralizing antibodies that immediately neutralize rabies virus on contact. RIG gives a coating to the virus so that it cannot enter the nerve endings resulting reduction or total obliteration of inoculated virus.

Choice of RIG - Though HRIG represents the gold standard for passive immunization, the cost of HRIG is exorbitantly high. ERIG is an acceptable alternative. One study shows that the incidence of adverse reaction in ERIG is as low as 2.4% with anaphylactic reaction of 0.2%.(16) Another study shows 1.7% serum sickness reaction in a series of 297 cases.(17) In Thai population it was reported by Wilde et al as low as 0.81%.(18) Presently, the purified ERIG preparation has been available and produced by Indian manufacturer. CRI, Kasauli also produces a small quantity ARS which is not sufficient for a vast country like India.

Table 1. WHO Recommendations for Management of Animal Bites (13)
Category Type of contact with suspected or confirmed domestic or welding animals* or animal unavailable for observation Recommended treatment
I Touching or feeding of animals, licks on intact skin None, if reliable case history is available
II Nibbling of uncovered skin, minor scratches or abrasions without bleeding, licks on broken skin
Administer vaccine immediately**
Stop treatment if animal remains healthy throughout an observation period of 10 days, ***
Or, if the animal is euthanised and found to be negative for rabies by appropriate laboratory technique.
III Single or multiple transdermal bites or scratches, contamination of mucous membrane with saliva (i.e., licks)
Administer rabies immunoglobulins and vaccine immediately **
Stop treatment if animal remains healthy throughout an observation period of 10 days***
Or, if the animal is euthanised and found to be negative for rabies by appropriate laboratory technique


* Exposure to rabbits, rodents and hares seldom if ever requires specific antirabies treatment.
** If an apparently healthy dog or cat in or from a low risk area is placed under observation it may be justified to delay specific treatment.
***This observation applies only to dogs and cats.
Antirabies Vaccines(9)
  • Neural Tissue Vaccine (NTV): The use of NTV is now abandoned after the Supreme Court Ruling, so this is not discussed in detail.
  • Duck Embryo Vaccine: Used since 1956. To prepare this vaccine, embryos from infected eggs are harvested and homogenized in a sterile solution, which is filtrated, centrifuged and ultimately inactivated with BPL. A purified version of this vaccine has been prepared from embryonated duck eggs. The final product has no detectable myelin basic protein. This vaccine is presently available in India as purified duck embryo cell vaccine (PDEV).
  • Immunogenicity - The purified duck embryo cell vaccine is claimed to be as immunogenic as the modern tissue culture vaccines.
  • Modern Tissue Culture Vaccine (MTCV): Considered as the gold standard in the treatment of rabies prevention. These vaccines satisfy all criteria of safety, potency and convenience of use.
  • Vaccine strains in use - (i) Pitman - Moore strain (Human diploid cell, vero cell), (ii) Flury - LEP - C25 strain (Purified chick embryo cell).

    The cell cultures are derived from tissues of healthy animals free from all organisms like Salmonella, Mycobacterium avium, etc. The cell lines are infected with vaccine virus and incubated after which the cells are tested for hemadsorbing virus and extraneous agents. The harvest obtained are homogenized and inactivated by BPL. The purification and concentration are done, after which the vaccine is lyophilized and subjected to quality test. Each final dose of MTCV must contain 2.5 IU. Now-a-days one type of MTCV, namely HDCV is also available in liquid preparation also.

    WHO has recommended abandoning NTV and replace it by MCTV. The Supreme Court of India also gave ruling in the same direction. There is no other option left now except the use of MTCV. Three types of MTCV are available in India. Those are:

  1. Purified chick embryo cell vaccine (PCEC - Rabipur manufactured by Chiron)
  2. Human diploid cell vaccine (Lyophilized HDCV - Merieux inactivated rabies vaccine manufactured by Sanofi Pasteur and Liquid HDCV - Available in the name of Rabivax manufactured by Serum Institute of India)
  3. Purified vero cell vaccine (PVRV - Verorab manufactured by Sanofi Pasteur, and Abhayrab by Human Biologicals Ltd)
Schedules of Vaccinations against Rabies
There are various schedules for use of the cell culture vaccine or MTCV in already exposed cases of which 2 intramuscular (Essen protocol, Zagreb protocol) and 2 intradermal regimens (Warell and Nicholson or Oxford regimen, Thai Red Cross or TRC-ID regimen) are accepted by WHO. Now there are some modified and updated schedule which are also recommended, of which two are important in our country, namely, updated TRC-ID schedule and KIMS (Bangalore) schedule. Pre-exposure schedule is also discussed, both IM and ID.
I. Intramuscular Regimens
  • Essen Protocol (Table 2) - Of various schedules "WHO standard schedule" commonly known as "Essen Protocol" which comprises 5 IM injections on days 0, 3, 7, 14, 28 or 30 (The 6th dose on day 90 is optional which is administered in selected cases viz, in extremes of ages, with debility and protein energy malnutrition, in immunocompromised patients, with neoplastic diseases.
  • Undergoing antimalarial treatment, suffering from viral hepatitis, presently taking steroid containing drugs for long time, etc.) is practiced in our country as we are in the highest endemic zone of rabies till today.
  • Zagerb protocol (Short Course IM Schedule) (Table 3) - The alternative schedule known as "Zagreb schedule" comprising 2 injections on day 0 at 2 different sites, 1 injection on day 7 and 1 injection on day 21 is also an effective schedule. This schedule induces early and enhanced immune response initially but when given along with RIG leads to poor development of antibodies on long term.(3)

Table 2 : Essen Protocol (IM Schedule)

Days of Vaccination

No. of
doses

d0

d3

d7

d14

d28

d90

1 IM
dose

1 IM
dose

1 IM
dose

1 IM
dose

1 IM
dose

Dose
optional



5 doses, 5 visits, doses on day 90 is optional for immunocompromised patients, cancer patients, taking anticancer and anti-malarial drugs, post-malarial cases of post-hepatitis infection extremes of ages.

Table 3: Zagreb Protocol (IM Schedule)
Days of Vaccination
No. of doses d0 d7 d21

2 IM doses in 2
separate site

1 IM
dose

1 IM
dose



4 doses, 3 visits
II. Intradermal Schedules
Four intradermal schedules are discussed here:
  • 8-0-4-0-1-1 ID schedule (Warell and Nicholson schedule or Oxford schedule) (Table 4) 19 - One ID dose is 001 ml each given on 8 sites on day 0 over deltoid, lateral thigh, suprascapular region, lower quadrant of abdomen on either side; then on 4 sites in deltoid and thighs on either side on day 7, and on 1 site over deltoid of one side of the body on day 28 and 90.
  • 2-2-2-0-1 ID schedule (Thai Red Cross ID schedule or TRC-ID schedule) (Table 5) 20 - Two ID doses given on day 0, day 3 day 7 on two deltoids, and one ID dose on one site of deltoid on day 28 and 90. No dose is given on day 14. One ID dose should be 1/5th of quantity of IM dose depending on vaccine though 0.1 ml of purified chick embryo cell vaccine is also used successfully in community practice. With the extensive use of this most cost effective schedule (TRC-ID schedule) Thailand has brought down the incidence of rabies death drastically in last one and half decade. In India we should think of this cost effective schedule, should plan to give training to the personnel to become a skilled worker in vaccine centers and help our country to avail this opportunity of using cell culture vaccine in animal bite cases in a cheaper cost


Table 4: 8 Site ID Regimen or Oxford ID regimen: (8-0-4-0-1-1)

Days of vaccination

No. of
Dose

d0

d3

d7

d14

d28

d90

8 ID
dose in
8 separate site

No
dose

4 ID
doses

No
dose in
4 separate site

1 ID
dose

1 ID
dose



1 ID dose = 1/5 of IM dose both in PBRV and PCEC
Only for community practice 0.1 ml of PCEC per dose is also used.

Table 5 : TRC-ID Schedule (2-2-2-0-1-1)

Days of vaccination

No. of
doses

d0

d3

d7

d14

d28

d90

2 ID
doses in
2 separate sites

2 ID
doses in
2 separate sites

2 ID
doses in
2 separate
sites

No
dose

1 ID
dose

1 ID
dose



1 ID dose = 1/5 of IM dose both in PBRV and PCEC
Only for community practice 0.1 ml of PCEC per dose is also used.
  • Updated TRC-ID schedule - 2-2-2-0-2 ID schedule (Table 6) 21 - Here two ID doses are given, one on either side of deltoid or anterolateral surface of thigh on day 0, day 3, day 7, and day 28. No dose is given on day 14 and day 90.
  • Kempegowda Institute of Medical Sciences, Bangalore schedule (21) or KIMS schedule - 2-2-2-2-2 ID schedule (Table 7) - Here two ID doses are given, one on either side of deltoid or anterolateral surface of thigh on day 0, day 3, day 7, day 14 and day 28. No doses is given on day 90.


Table 6 : Updated TRC-ID Schedule (2-2-2-0-2)

Days of vaccination

No. of
doses

d0

d3

d7

d14

d28

d90

2 ID
doses in
2 separate sites

2 ID
doses in
2 separate sites

2 ID
doses in
2 separate
sites

No
dose

2 ID
doses in
2 separate sites

No ID
dose



1 ID dose = 1/5 of IM dose both in PBRV and PCEC
Only for community practice 0.1 ml of PCEC per dose is also used.


Table 7 : KIMS Modification of TRC-ID Schedule (2-2-2-2-2)

Days of vaccination

No. of
Dose

d0

d3

d7

d14

d28

d90

2 ID
doses in
2 separate sites

2 ID
doses in
2 separate sites

2 ID
doses in
2 separate
sites

2 ID
doses in
2 separate sites

2 ID
doses in
2 separate sites

No
dose



1 ID dose = 1/5 of IM dose both in PBRV and PCEC
Only for community practice 0.1 ml of PCEC per dose is also used.
III. Pre-exposure Schedule (Table 8)
Pre-exposure vaccination: Rabies is the infectious disease where active immunization is administered after the exposure. This group of vaccination is termed as post-exposure vaccination. But with the advent of safe cell culture rabies vaccines, it is possible to start administering pre-exposure vaccination to protect individuals at risk of rabies even before the exposure has occurred, namely, to the veterinary doctors, municipal workers, postmen and women, taxidermists, laboratory and research workers in the field of rabies, dog handlers, etc.

Table 8: Pre-exposure Schedules (IM and ID)

Days of vaccination                                                          Booster

-

d0

d7

d 21 or d 28

-

No. of
doses
(IM)
(For Endemic
countries)

1 IM
dose

1 IM
dose

1 IM
dose

1 IM
dose after
1 year and then
1 IM dose
every 3 yearly

No. of
Doses
(IM)
(France, UK)

1 IM
doses

No
Dose

1 IM
dose

-

No. of
Doses
(ID)

1 ID
doses

1 ID
dose

1 ID
dose

1 ID
dose
yearly



The volume per intradermal site is usually one-fifth of IM dose:
  1. 0.1 ml of PVRV (Purified vero cell vaccine 0.5 ml vial)
  2. 0.2 ml of PCECV (purified chick embryo cell vaccine 1 ml vial)
  3. 0.1 ml of PCECV may also be considered for use by national health authority only. As approved by WHO.

Each vial of MTCV must have the potency of at least 2.5 IU
  1. IM pre-exposure schedule - Three IM doses are to be given on day 0, 7 and 21 or 28 intramuscularly. A booster dose is needed after 1 year of 1st dose and then booster doses every 3 yearly to keep an effective antibody titer against rabies. There is another schedule practiced in some developed countries like France and UK with 2 doses on day 0 and day 21. But this 2 dose pre-exposure schedule is not recommended in our country as this country is highly endemic zone of rabies. Pre-exposure routine rabies vaccination in children is really a necessity and must be thought seriously.
  2. ID pre-exposure schedule - Now a days 0.1 ml ID of MTCV does are also accepted scientifically as pre-exposure does on days 0, 7, 28 then 0.1 ml ID dose of MTCV every yearly.
Adverse Reactions of MTCV
The tissue culture rabies vaccines are safe and well tolerated in children and adults in contrast to the NTV. Mild local effects such as pain, redness and swelling may be observed in 10-20% of the recipients. Systemic manifestations such as fever, malaise, headache, abdominal pain may be seen transiently in a few vaccines and can be minimized by the use of anti-inflammatory drugs. Very rarely immune complex reactions and neurological illness resembling Guillan-Barre syndrome have been reported in temporary association with HDCV

Revaccination for repeat exposure in previously vaccinated persons:

Previously the recommendation was to repeat vaccinations with 2 booster doses, one on day 0 and another IM dose on day 3 if there is history of complete post-exposure or pre-exposure treatment previously within 3 years. There is no need of RIG administration during the repeat exposure when there is past history of complete pre or post-exposure vaccination during first exposure. Philippines uses this same schedule within 5 years of last vaccination. Any exposure after 3 to 5 years of vaccination, are treated with complete post-exposure vaccination excluding RIG administration in our country.

Park presently a view is coming up on the basis of anamnestic reaction that irrespective of time interval between 2 exposures, in previously immunized persons only 2 doses, one on day 0 and another on day 3 are sufficient. Though there is no clear-cut instruction from Drug Controller of India on this statement.
Is it possible to include rabies vaccines in EPI schedule?
Rabies vaccine had been administered along with DPT-IPV in Vietnamese infants at 6, 10, 14 weeks of age in a study and has been found to be safe and efficacious 22. This could lead to future integration of pre-exposure rabies vaccination into EPI of countries where rabies is enzootic.
Observation period of 10 days and improvisation or conversion of post-exposure schedule to pre-exposure schedule
Whether to observe the dog or cat (Biting animal) for 10 days following exposure or to start vaccination immediately after exposure is still a matter of controversy. It is better to start vaccination with early 2 doses (day 0 and day 3) of MTCV and parallel observation of the animal is to be continued. After 10 days of observation, if the animal continues to live, rest of the ARV doses are not given, only the last dose i.e., the dose on day 28 or 30 is to be advised. This is known as conversion of post-exposure schedule to pre-exposure schedule which will be either on days 0-3-28 (or 30) or on days 0-3-7-28 (or 30) i.e., a course of 3 or 4 doses depending on day of reporting after exposure in place of 5 doses.

According to many authorities this 10 days observation period without giving any vaccine is to be completely condemned (23) as it may result in fatal outcome.
MTCV to Pregnant and Lactating mothers
Cell culture rabies vaccine can be used safely to pregnant and lactating mothers. Many studies proved the safety of use of cell culture rabies vaccine in pregnant and lactating mothers and there is no harmful effect either on fetus, newborn or infants on exclusive breastfeeding of mother receiving injections of cell culture rabies vaccines for animal bite exposure. (24)
WHO Rabies Vaccine initiative
Considering the magnitude of the problem of rabies in developing countries, the WHO, along with private industry, the scientific community and major funding agencies has formulated "WHO Rabies Vaccine Initiative". The objective is to reduce the cost of each effective course of treatment and make the modern vaccines more acceptable to poor people, the common victim of stray dog bites and scratches. They will help to prevent many of the estimated 50,000 rabies deaths.(15)
Use of Intradermal Route for Administration of MTCV: Opinion of Director General of Health Services (Drug Section)
Very recently a circular was issued regarding the above matter dated 28 February 2006 by DGHS (Drug Section) to M/s Sanofi Pasteur India Pvt Ltd and M/s Chiron Behring Vaccines Pvt Ltd stating that DGHS has approved use of MTCV in ID route in post-exposure treatment of patients in a phased manner. In the first phase, the schedules and vaccines endorsed by WHO for ID route and the schedule recommended by ICMR study may be permitted. TRC-ID schedule (2-2-2-0-1-1) and updated TRCID schedule 2-2-2-0-2) can be used and the vaccines recommended in the first phase of the ID route are: (i) Purified vero cell rabies vaccine of Sanofi Pasteur, (ii) Purified chick embryo cell of Chiron Behring. DGHS has approved this ID regimens in those clinics where there is a minimum attendance of 50 patients per day for post-exposure treatment and where there are adequate trained staff.
References :
  1. Ghosh TK. Prevention of rabies by vaccination and immunoglobulin therapy : Some controversies and solutions. In : Ghosh TK, Kalra A, eds. Infectious Diseases in Children and Newer vaccines. Part II. Kolkata, Agra : IAP Infectious Diseases Chapter Publication, 2003:171-6.
  2. Ghosh TK. Immunization against rabies. In : Thacker N. hah NK, eds. Immunization in Clinical Practice. Delhi : Jaypee Brother Medical Publishers, 2005:175-85.
  3. Dutta AK, Kanwal SK. Rabies and its prevention. J Assoc Prev Cont Rabies India 1999;1:5-13.
  4. WHO. WHO Drug Information 2002;16:405.
  5. APCRI. Burden of rabies in India. In : Assessing Burden of Rabies in India : WHO Sponsored national Multicentric Survey. Bangalore : Association for Prevention and Control of Rabies in India, 2004:44.
  6. Gongal GN, Rai JN. The rabies situation in Nepal. J Assoc Prev Cont Rabies India 2000;1:39-42.
  7. Madhusudana SN. Recent Advance in Rabies. In : Proceedings of the Conference II on Rabies Prevention and Management, Kathmandu, November 20-24, 2003;17-20.
  8. Kaplan C. Rabies The Facts. Oxford : Oxford University Press, 1977:11-31.
  9. Singh H, Bhatia R. Vaccines Prospects and Perspectives. Vol.1. Delhi : Forward Publishing Company, 1993;282-309.
  10. Satapathy DM, Behere TR. Rabies and current concepts in its prevention. APCRI J 2004-5;7:38-41.
  11. Briggs DJ. Understanding rabies serological testing. APCRI J 2004-5;7:17-9.
  12. Sudarshan MK. Prevention of human rabies : Emerging national concern J Assoc Prev Control Rabies India 1999;1:2.
  13. World Health Organization. WHO Expert Committee on Rabies, 8th Report. WHO Tech Rep Ser 1992;824:1-84.
  14. Bompart F, Dutta AK, Wood SC. Rabies immunoglobulins in WHO category III exposure. J Assoc Prev Control Rabies India 2000;1:7-11.
  15. Meslin FX, Stohr K. Human rabies vaccines : Current situation and foreseeable trends. J Assoc Prev Control Rabies India 2000;1:5-6.
  16. Tripathi KK, Madhusudana SN. Safety of equine rabies immunoglobulin. Vaccine 1989;7:372-3.
  17. Goswami A. Safety and tolerance of equine rabies immunoglobulin in the Indian population. J Assoc Prev Control Rabies India 2000;1:30-4.
  18. Wilde H, Chomchey P, Prakongsri S, Punyarathabandhu P. Safety of equine rabies immunoglobulin. Lancet 1987;2:1285.
  19. Warell MJ, Nicholson KG, Sitharasami P, Udomaskadi D. Economical multiple site intradermal immunization with human diploid cell strain vaccine is effective for post-exposure rabies prophylaxis. Lancet 1985;1:1059-62.
  20. Chutivongse S, Wilde H, Supich C, Baer G. Post-exposure prophylaxis for rabies with antiserum and intradermal vaccination. Lancet 1990;335:896-8.
  21. Ghosh TK. The beginning of the end of the Rabies in India. APCRI J 2006;7: 34-7.
  22. Lang J, Duong Q Hoa, Nguyen VG. Randomised feasibility trial of pre-exposure rabies vaccination with DPT-IPV in infants. Lancet 1997;349:1663-5.
  23. Goswami A. Observation of a stray animal can be fatal some times. APCRI J 2004-5;7:45.
  24. Sudarshan MK, Mahendra BJ, Ashwathnarayan DH, Gangaboriah. Clinical trials on newer antirabies vaccines : Results and some experiences. J Assoc Prev Control Rabies India 2000;1:21-5.
  25. Rangarajan PN, Biswas S. Reddy GS, Srinivasan VA. DNA vaccines for rabies. J Assoc Prev Control Rabies India 2000;1:12-3.
  26. Recommendation of First National Conference of the Association of Prevention and Control of Rabies in India (APCRI) held at Rotary Sadan, Calcutta, Sunday 25th July 1999. J Assoc Prev Control Rabies India 2000;1:53-4.
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