Assam Passes Historic Right to Health Bill
Assam, which in Sanskrit means unequalled, is living up
to its name. On 31st March 2010, the Assam Assembly passed the Assam
Health Bill which guarantees a right to health and well being to all its
citizens. It is now mandatory for all government and private hospitals in
Assam to provide emergency health care to all patients seeking medical
attention. The statute also seeks to bind the state health and family
welfare department legally to provide people with food, safe drinking
water, sanitation and access to basic housing facilities in coordination
with other departments. Legal steps will be taken for fixing
responsibility and accountability of departments and agencies concerned in
case of repeated outbreaks of communicable diseases in a particular area
which are proved to have taken place because of the failure to improve
sanitation and safe drinking water facilities. The critical barrier is of
course the implementation, but the step is positive and an inspiration for
the rest of the country (DNA 1 April 2010, The Times of India 12 March
2010).
US Approves a 4 Dose Schedule Against Rabies
The five dose schedule for post exposure prophylaxis
(PEP) against rabies is the standard practice. In view of severe shortage
of human rabies vaccine in the year 2007, an ad hoc National Rabies
Working Group was created in the United States (US) to reassess the need
for all five doses. Advisory Committee on Immunization Practices (ACIP)
Rabies Workgroup has now published updated recommendations regarding the
use of a 4-dose vaccination regimen in previously unvaccinated persons for
rabies PEP.
According to these recommendations, 1 mL dose of HDCV
or PCECV should be given intramuscularly on day 0, 3, 7, and 14 for rabies
PEP in previously unimmunized persons. Recommendations for the use of
rabies immunoglobulin (RIG) remain unchanged. For previously vaccinated
persons, the two dose (day 0 and 3) schedule, and for persons with altered
immunocompetence, the five dose schedule stands unchanged. Schedule for
pre-exposure prophylaxis also continues to be same (3 doses on days 0, 7,
and 21 or 28).
What was the evidence based on which they shortened the
schedule? In 12 published rabies vaccination studies during 1976-2008
representing approximately 1000 human subjects, all developed rabies
virus-neutralizing antibodies by fourteenth day. A series of 21 fatal
human cases, in which patients received some form of PEP, indicated that
20 patients developed signs of illness, and most died before day 28 of
exposure. Such cases in which widespread infection of the central nervous
system occurs before the stipulated fifth dose of vaccine, the utility of
last dose is anyway negligible. Data from 192 rabies cases from two
centers in India demonstrated that all deaths could be attributed to
failure to seek timely and appropriate PEP, and none could be attributed
to a failure to receive the fifth (day 28) dose. The ACIP Rabies Working
Group estimated that more than 1000 persons annually in the US receive
only 3 or 4 doses of PEP, with no resulting documented cases of human
rabies. Thus, reduction from a 5 dose to 4 dose schedule will save the US
government around $ 16.6 million in costs. (MMWR, March 19, 2010 /
59(02);1-9)
