The Question of Availability of Rabies Biologicals

Most of the available rabies vaccines are indigenously produced in the country. The rabies vaccines are procured by the state governments - the scenario of their availability varies from 24 × 7 availability in Gujarat and Kerala, to occasional supplies in Manipur and Bihar. In fact, there is a 20-80 per cent shortage in anti-rabies vaccines across all States, barring Kerala and Gujarat. However, this is contradicted in an article in 2019, that stated that rabies vaccines had been in short supply in Ahmedabad for nine months.

A 2018 article said that India sees 1.75 million dog bites every year, yet we face up to 80% shortage of anti-rabies vaccines. The government is dragging its feet over controlling dog population, vaccinating them or even making enough shots available for victims.

There was no immunoglobulin for almost a month in Panaji in March 2015. 

Manufacturers remained cold to three tenders floated by Karnataka in 2019 and the State Government had to seek help from neighbouring States. Kerala government responded by providing 10,000 shots of anti-rabies injection and 2,000 vials of immunoglobulin injection.

Recent reports suggest that human rabies vaccine shortage is a common problem also in Punjab (it is a problem even in Delhi Government hospitals, as this report of 2019 shows). 

Rabies biologicals, i.e., vaccines and immunoglobulins are life saving for humans in all rabid animal exposures. These biologicals should be continuously available throughout the year, in the entire country to prevent human rabies.

A 2018 article said that while on the one hand the production is low, states are not procuring enough either due to shortage of funds or maladministration. There is an urgent need for central procurement of rabies vaccines.

In Sep 2019, manufacturers and marketers informed that lack of firm orders by State governments and late payments led to the shortage. The Health Ministry advised State governments to issue quantity based tenders and place long-term firm orders with specific quantity and supply schedule.

A welcome news late in 2019 was that a Gujarat-based plant of Rabies vaccines, shut for a few years, was re-starting production. It had commanded the lion's share of the vaccines market previously. 

Shortages were also caused from Aug 2018 onwards when a major rabies vaccine maker based in China was caught out for fraudulent practices in their manufacture. He had to withdraw vaccines from the market (including those exported to India) and subsequently shut down. 

Looking at reports further back, even in 2008, it was said that the post treatment immunoglobulin was almost impossible to obtain in most of India.

INDIA'S HEALTH CARE SYSTEM HAS BEEN FAILING US FOR RABIES

Cases of Rabies are invariably fatal once symptoms manifest. More than 20,000 people die of rabies every year in India, three-quarters of them in rural areas. 

Incidence of rabies in India has been constant for the last few years, without any declining trend.

Every animal bite is potentially suspected as rabid exposure as rabies is endemic in India. The exposed individuals should seek early health care and prophylaxis (PEP) should be started immediately at the healthcare facility as it is lifesaving. 

Unfortunately, availability, accessibility, and usage of PEP are limited in India. 

There are many primary healthcare centres in Karnataka where the staff lacks knowledge on how to administer the vaccine, even if it is available, say doctors. 

A study in 2019 showed that in over half of the anti-rabies clinics surveyed in Bengal, Bihar, Gujarat, Himachal Pradesh, Kerala, Madhya Pradesh and Manipur, even facilities for washing wounds and antiseptics -- a critical first step in treating animal bites -- were inadequate. 

Over half the clinics did not have Immunoglobulin which could be critical in preventing rabies if there was blood from the bite wounds, especially on the neck, face or head. 

Two studies carried out in New Delhi and Jodhpur showed many disparities in the knowledge and practices of doctors in regard to rabies. Less than half of them were unaware of the intradermal rabies prophylaxis schedule, and only 45% of them knew about HRIG (immunoglobulin). 81% of them knew of the prophylaxis in unimmunized patients, but only 40% were familiar with the guidelines for previously immunized patients. 

More importantly, public doctors had markedly better knowledge than private doctors in regards to the prophylaxis. This is very concerning, when taken into account that India has the biggest private sector of doctors in the world, accounting for 93% of the hospitals and 85% of doctors.

Post-exposure treatment (HRIG) is simply unaffordable, costing around 30,000 rupees ($447) for an average person. 

Moreover, India notoriously experiences local and national shortages of HRIG, causing the patients who are willing to pay, to wait for it, for weeks or even months, which can eventually lead to death.

A 2018 WHO report said that dog-mediated rabies has been eliminated from western Europe, Canada, the USA, and Japan. 28 of the 35 Latin American countries report no human deaths from dog transmitted rabies.

Great strides have been made in reducing rabies deaths in countries such as Bangladesh, the Philippines, Sri Lanka, Tanzania, Vietnam, and South Africa.

Bangladesh, with almost 10.000 deaths per year and less than six % dog vaccination coverage, has adopted a very successful national strategic plan for the elimination of rabies by 2020. Through the establishment of the District Rabies Prevention Control Centres in almost every district, they provided facilities for mass dog vaccination, dog population management, care of bitten patients, all of whom receive anti-rabies vaccine and immunoglobulin for free. 

Furthermore, local champions were appointed to convince political leaders, policymakers and stakeholders for political commitment and technical leadership and partnership for this assignment. As a result, rabies deaths have reduced by 50% between 2010 and 2013. 

Such an outcome contrasts with the slow progress made in India.

It has been demonstrated in multiple research studies that India’s poor position in rabies elimination is rooted in a lack of knowledge about the disease, uncontrolled canine population, the insufficient vaccination programme, irregular supply of vaccines and inadequate training of healthcare professionals. 

The WHO estimates that investing in rabies elimination globally will eventually free up an estimated US$8.6 billion in economic resources each year. Since over a third of the rabies burden is in India, it should save about US$3 Billion a year by eliminating rabies. 

How Kerala beat back one of the first hotspots in India in Pathanamthitta District

On 8th April, the health ministry recognised the containment efforts in coronavirus hotspots like Pune in Maharashtra and Pathanamthitta in Kerala as best practices adopted by states that were worthy of emulation.

On March 11, Pathanamthitta, a migration hotspot in Southeastern Kerala, became the district with the highest number of cases in the state.

Most of those who were infected had travelled widely across the district before they were diagnosed with the infection, it was later found.

But over nearly two weeks to March 23, the district managed to limit the cases to 10 (from then till April 8th, the number has slowly gone up to 16 - mostly people who returned from abroad or other States).

Through contact tracing, the team was able to track nearly 98% of all primary and secondary contacts, who have been advised home- or hospital-isolation.

An extraordinary video conference

It was 2 am on March 8, the day after the first set of diagnoses, when an extraordinary video conference was held at the collectorate between the collector, the district surveillance officer and the state health secretary. 

There was a reason for the panic: When swabs had been taken from a family of five for diagnosis, no one had expected every one of them to test positive.

“We were so taken aback that most of the team [was] here by 7 am the next morning. There was no time to lose,” said AL Sheeja, the district medical officer in charge of coordinating the efforts at the district level.

By 7 am on March 8, calls were already going out to doctors, medical staff, drivers and vehicles to gather by 8 am at the collectorate so that 10 teams could trace the travel history of the patients. Every contact of the infected family that had returned from Italy was to be traced from the time it landed in India on February 29, to the time of its isolation.

From then on, how the team worked on surveillance, gathering travel history, contact tracing, and ensuring quarantine by providing essential and psychological support offers an insight into how the district managed to control the spread of the virus.

On March 8, the teams went to locations visited by the affected family. “We did two things – got their travel history, and got the field teams to visit every location and check as many CCTV footages as possible to ascertain their primary and secondary contacts,” said Resmi, a Doctor who leads the surveillance team. 

As of April 7, 2,575 persons who came from abroad and 4,583 persons who came from other States are in home quarantine. This is besides 401 primary and secondary contacts of the infected persons in the district.

According to the District Medical Officer, all of them will have to remain in quarantine for 28 days.

The Teams at District Level

The district control cell includes multiple teams – surveillance, call centre, psychological support, training and awareness, community-level volunteers, media monitoring among others.

The district has mobilised a 1,000-strong field team of ASHAs (Accredited Social Health Activists), junior public health inspectors and nurses, to ensure widespread awareness about the disease and provide ground support. This is in addition to the surveillance team of 450 led by Dr. Resmi.

The field staff go from home to home, seeking travel details. These home surveillance squads make more than 2,300 home visits in a day, as per data from March 25.

Testing asymptomatic cases

On 7th Apr, two persons in Kerala, who earlier did not exhibit symptoms of the Covid-19 infection, tested positive for coronavirus in Pathanamthitta district. Out of the two cases, one is a 60-year-old man who recently travelled from Dubai to the district, while the other is a 19-year-old student who travelled from Delhi in March.

The 60-year-old man who tested positive was quarantined between March 19 and April 6. He had flown back from Sharjah to Thiruvananthapuram on March 19 and then travelled to Pathanamthitta by road. He was asymptomatic but was still tested as he had returned from a country with a number of Covid-19 cases.

Meanwhile, the college student, who recently travelled to Pathanamthitta, had also completed her mandatory 14-day quarantine at home. The student boarded a train from Delhi to Ernakulam on March 15 and reached her home on March 17. She was asymptomatic all this while. However, she was tested for the coronavirus after Delhi emerged as an infection hotspot.

The authorities in the district have started to test people with a history of travelling to high-risk zones, or those who fall in the vulnerable category even if they may be asymptomatic, Pathanamthitta District Medical Officer AN Sheeja said.

It was reported on 8th Apr that a home-quarantined youth who came from Dubai on March 21st, tested positive. With that, the number of cases rises to 16 in Pathanamthitta.

Why Kerala has a high rate of recovery from Covid-19

The records of Covid-19 patients who tested positive between March 9 and 20 show Kerala as having a high rate of recovery at 84 per cent.

In all, the rate stands at 17 per cent so far when one takes into account all cases in the state till date.

In comparison, Maharashtra has a recovery rate of 5.5 per cent, while the rate for Delhi is 4.04 per cent.

Healthcare experts have cited Kerala's early identification system and its specialised Covid-care wards as the main reasons behind the state's good recovery rate.

Along with Kerala, Maharashtra has also seen a decent rate of recovery, but it lags significantly behind Kerala in one parameter. As of Apr 6th, Kerala has managed to avert spikes in number of cases since the first spurt in March, but Maharashtra has not been able to do so.

Kerala's rate of sample collection  is higher than all major states, where it lags only behind Rajasthan.

Tamil Nadu's Bhopal - or how Unilever dumped Mercury waste

I wandered into reading on Tamil Nadu's Bhopal - or how Unilever dumped Mercury waste on Kodaikanal's pristine environment for 18 years..  and refuses to clean up even after it was forced to shut down its factory in the wake of the public uncovering of its dumped waste.

Kodaikanal is a hill station at 7000 feet on the Palani Hills in Tamil Nadu. It is part of the Shola eco system across Karnataka, Tamil Nadu and Kerala, which itself is a part of the Western Ghats.

Its hills are always kissing the clouds resulting in a high amount of precipitation.. the trees are short due to high winds, and there are extensive grasslands.. which make this ecosystem unique.

Mercury is one of the most toxic elements known. Ponds moved its factory  (later acquired by Unilever)  to make mercury thermometers from New York to its present site in 1983 as the temperature was low year round.

Legislation on mercury handling in the U.S. had begun to change after toxic side effects began to be publicised. The Ponds India management got special permission from the Central government in India to set up at Kodaikanal on the grounds that it was a non-polluting glass manufacturing unit (!). No formal site selection or screening process was undertaken to assess and minimise the impact of a mercury thermometer plant in an eco-sensitive area.

The Tamil Nadu Factories Inspectorate and the Pollution Control Board found nothing amiss in their periodic inspections of the factory including on workers' health. In 2001, it was citizens - the Palani Hills Conservation Council and Greenpeace, which caught the management selling mercury-contaminated glass to a local scrap dealer. Faced with the evidence, the Tamil Nadu Pollution Control Board asked the factory to close.

Toasted Pineapple !

I have always loved pineapple. I was introduced to it in my teenage years but only pieces from a can. After I was married and experimented with food in my kitchen, we started having raw, fresh bought pineapple. But we usually had to put it in a sugar solution or add cheese.

Else the raw pineapple would give me a bad throat leading to flu sometimes. But when out eating at Barbecue Nation with my father perhaps a couple years ago, we were served with lots of baked pineapple smeared with oil, salt and red chilly. It was va-va-voom !

Now we bake cut pineapple pieces in our oven regularly - no oil, but with some salt and chilly smeared on it. 7-8 minutes in the oven is enough.

Apparently, there are tremendous benefits from eating pineapple : https:/ including for asthma, cancer, blood pressure and diabetes.

On sharing the above information on whatsapp with friends, the following exchanges were interesting.. Friend 1 : 'Try grilling it ; you will love it more.' Me : 'Smile.. well the oven has the heating rod on above and below. That setting in my oven is called 'toast'.'

Friend 2 : 'Yeah you can do it in a pan too. If it’s a bit tart, few sprinkles of sugar gives nice caramelising and smokiness. Oven is more like cooking through and pan depending on heat is either cooking through or just charting and caramelisation.' Me : 'Ah !'

Friend 3 : 'Pineapple is a great food all round- like papaya it has a good digestive enzyme and it's great for metabolism. But like you I have some difficulties with it. It's almost always too tart for me and causes mouth ulcers, rashes, sore throat, tummy ache, etc.

It's the reason I love pineapple on pizza because its one of the few times I can eat it. But your idea of baking it is interesting and I will try it when I get back to Oz. When we were in Egypt many years ago, the hotel had fantastic breakfast buffets including lots of pineapple.

To my delight, the pineapple was uniformly so sweet that I had no difficulty eating it at all and ate lots every day. Have never encountered pineapple like that since even though Queensland is a big pineapple growing state in Australia.'

Me : 'Yes.. such sweet pineapple in india is only from Kerala in my experience.. no problem eating it raw there !' Friend 4 : 'But cooking fruits spoils vitamins.' Me : 'Not necessarily, as these links would show you : here, and here.

I think toasting for 7-8 minutes would deliver only as much heat as steaming for a few minutes so loss of nutrients should be minimal.
Besides, vegetables too lose some nutrients in cooking, while gaining some others. But we do cook them, dont we ?

Lastly, I would fall sick if I had raw pineapple in Delhi (though it is fine for me in Kerala). So I have no other way to eat it !'

The Story of Two Indian States..

Two south Indian states, namely Kerala and Tamil Nadu, stand out as having developed more extensive transport facilities that have helped restrain the use of personal vehicles.

The bus and train network, the backbone of the public transport system, meets the transport requirements of 31 % of the workforce engaged in industry and services in Kerala and 26 % of the workforce in Tamil Nadu.

In contrast in 2011, the public transport system provided commuting facilities to only 18 % of the workforce at the national level. More than 50% of the workforce (excluding domestic and agriculture) continue to work at home or travel to their workplace by foot in the absence of adequate transport facilities. Citizens are largely dependent on private transport. 

The public transport system in Tamil Nadu and Kerala thus carries a higher percentage of workers than even in metros like Delhi, Chennai, Kolkata and Bengaluru, where the public transport systems cater to the needs of 25 %, 22 % 26 % and 25 % of the workforce.

Only Mumbai has a much larger public transport system than these two southern states. This is because the train network which transports 25 % of the workforce in Mumbai adds to the facilities offered by the bus transport system which carries another 16 % of the workforce and pushes up the total share of the public transport network in Mumbai to 41 %, which is the highest share in the country.

The Mumbai Suburban Railway is the first rail system in India which began services in Mumbai in 1853. It transports 6 million passengers daily and has the highest passenger density in the world.

What pushes the public transport network in Kerala and Tamil Nadu behind that in Mumbai is the minimal share of the train networks which carry only 2% of the workforce in these states. With the train network under the exclusive jurisdiction of the central government, the two states have hardly any leverage to expand train facilities until very recently when metro rail projects began to be implemented in the cities. However, the bus transport network in Kerala and Tamil Nadu is vastly superior to that in the other states or even in the metros.

Thus while the bus transport network in Kerala carries 29 % of the workforce, that in Tamil Nadu carries 23 % - while the share is only 11 % at the all India level.

The share of bus transport in these two states are also substantially larger than the bus transport facilities even in the metros where its share is 22 % in Delhi, 16 % in Mumbai, 19 % in Chennai, 22 % in Kolkata and 24 % in Bengaluru.

In fact, the rural public transport system in Kerala and Tamil Nadu, which carries 28 % and 29 % of the rural workforce in these states, are even better than that of the metros.

The extensive public transport facilities in Kerala and Tamil Nadu has helped them reduce their dependence on vehicles of personal use like two wheelers and cars. Thus we find that though Kerala and Tamil Nadu have much higher incomes than the all India average, the share of their workers using four wheelers like cars, van, taxi and tempos are either similar or sometimes even much lower than the all India share.

The scenario is also the same in the case of two wheelers with the use of bicycles for commutating in Kerala and Tamil Nadu lower than in the country as a whole.

The False stories about Kerala..

A relative wrote to me : ‘Kerala is going to be converted to a Muslim State just like Kashmir.’

I wrote back : I am again asking that you get out of the BJP failed classes and look up facts yourself –easily available to anyone on the net. In 2016, Kerala’s total fertility rate (TFR) was 1.8 which is not even enough to replace the present population, so it is set to shrink. 15 years BJP ruled Rajasthan’s total fertility rate is 2.7, a third more than Kerala’s. Should kerala feel threatened from Rajasthan as a result ? Are not such ideas ridiculous ?

The TFR for Kerala Muslims is 1.86, again below replacement level, which means the Kerala Muslim population is shrinking. Please note it is far below the fertility rate for Rajasthan as a whole, which is 88 % Hindu. The decadal growth rate of Kerala Muslims was 13 %, far below that of the country as a whole, at 18 %.

India’s Muslim population is growing slower than it had in the previous decades, and its growth rate has slowed more sharply than that of the Hindu population. The Muslim population still grows at a faster rate than the Hindu population, but the gap between the two growth rates is narrowing fast.

The Muslim population has grown faster as a result of higher Muslim fertility, higher child mortality among Hindus, and a greater life expectancy among Muslims. However, the Muslim community in India is expected to reach replacement levels of fertility by 2050.

Triple talaq par bhi baat karenge. But the sex ratio among Muslims is 951 females for every 1,000 males, while among Hindus, it is 939 females for every 1,000 males. This implies that Indian Muslims choose to birth more girls, and see through more of them to health and adulthood, than do Hindus.