When Rabies Immunoglobulins are not affordable or not available

We are experiencing a severe artificial shortage of Rabies Immunoglobulins (RIGs) in India because companies are not producing enough of them. In Shimla (Himachal Pradesh, India) and also in other parts of the country there are currently no RIGs available in the local market. This may be in part due to the Drug Price Control Order of Government of India which limits the price that companies can charge for essential medicines. Whilst this makes drugs more affordable for patients, it also makes the market less attractive for pharmaceutical companies who may reduce or stop production. Compounding this problem is also the low demand for RIGs in India – a low volume of prescriptions by doctors and then even lower numbers of patients actually purchasing them due to the unaffordable costs involved. Faced with low demand due to the cost, the chemists find that expensive RIG stock expires before it is sold, and tend not to store it in future.

Whilst RIGs is not necessary for patients who have previously been fully immunized against rabies, it is a critical part of PEP for unvaccinated patients. As it takes about 7-10 days for the vaccine to initiate active immunity in the patient, there is no substitute for RIG’s ability to immediately neutralize the virus in the wound. Abbreviated courses of rabies vaccine alone have been shown to stimulate more rapid immune responses, but these are only recommended for previously vaccinated people.

Whilst the use of rabies vaccine is high, the use of RIGs is very low amongst bite patients. At the Shimla anti-rabies clinic at DDU hospital, 1,834 people presented with animal bites in 2013, including 1,168 dog bites and 580 monkey bites. All of these received vaccine, but even after counseling over its importance, only 4 patients opted to receive RIG, because of the expense of the product: a cost of around 1200 Rupees (around $20) for equine RIGs or 30,000 Rupees (around $500) for human RIGs for an average patient. The vaccine is now given free as a result of the shift to low cost intra-dermal vaccination, but RIGs have to be purchased from the market. There was no active follow up after the patients who received PEP in 2013.

A 38 year old woman, from a family that could have afforded the RIG, died following a dog bite in Shimla district in 2009. She had received a full course of rabies vaccine, but was not prescribed RIGs as it was not available either in the hospital, or in chemist shops.

Recently, a woman tourist died in Delhi when she was bitten by a stray dog in Manali, a tourist town in Himachal Pradesh. She was given a full course of vaccine IM (intra-muscularly) but not immunoglobulins, as they were not available.

In another case that was referred to IG Medical College from a distant civil hospital, a 32 years old male who was bitten on the lower lip by a suspected rabid dog on September 5, 2014 developed rabies within 2 weeks of bite. He was given all doses of rabies vaccine IM but RIGs were not available in the market. He succumbed to the disease later in the medical college.

Local medics are also frustrated as Post Graduate Students of Tanda Medical Collage Kangra could not find RIG for themselves after they were bitten by a suspect rabid dog.

Due to the scarcity, we at DDU hospital and the medical college here are now left with no option but to experimentally give RIGs only locally in the wound, as limited quantities of RIGs are being made available from the government Central Research Institute in Kasauli for this purpose. We are following such patients and no deaths have been reported after three months of follow-up even in patients bitten by suspected rabid animals. The follow up will continue for one year and results will be shared on a wider scale so as to make RIGs affordable for poor patients and available in situations of scarcity.

Submitted by Dr. Omesh Kumar Bharti, an Epidemiologist and Corporation Health Officer in  Shimla, Himachal Pradesh, India. A presentation by Dr Bharti on this subject is available here.