Rabies in India.
Our Lead Nurse Kamila Soltysik has published an article in the Journal of British Global and Travel Health Association. Read the full article below:
Every year more than 59,000 people in the world die of rabies. It remains an under-reported,
neglected disease ranking the 10th biggest cause of death due to infectious diseases globally.
It is a viral zoonotic disease spread via a bite, scratch or a lick from an infected animal, present
in more than 150 countries and poses a real threat to about 2.5 billion people. Despite Pasteur’s
discovery of the rabies vaccine 131 years ago, and the post-exposure treatment available,
thousands of people still die of rabies every year. Many countries have gained an efficacious
governmental control over rabies, mainly by vaccinating a wide number of human and dog
populations, and by implementing other interventions and policies. Only a few countries have
managed to completely eradicate the disease.
Unfortunately, this is not the case with India. Here the situation has not changed for a decade.
Almost 36% of rabies deaths worldwide happen in India. According to ‘End Rabies Now
Campaign every year 20,847 rabies deaths occur in India; while only 6002 deaths were
recorded in China, a neighbouring country with a similar number of human population. The
number accounts for one third of the world’s total. Despite many international and local
governmental initiatives to control rabies, India still struggles to ameliorate the situation.
Rabies is probably the oldest recorded infection affecting humans, first documented in Babylon
in 2300 B.C. Rabies virus can be found globally in domestic animals (dogs, cats) as well as in
wildlife (e.g. foxes, racoons, mongoose, skunks and bats). Humans are only accidental hosts.
They become infected when bitten or scratched by a rabid animal. After the exposure, the virus
enters the nerve or the muscle cells and thus reaches the spinal cord, where it replicates.
Subsequently the virus travels up to the brain and infects all its regions, causing death due to
the dysfunctional changes of neurons. It then runs down via the peripheral pathways to the
salivary glands, adrenals and skin. Infected patients suffer periods of uncontrollable shakes and
panic attacks, then fall into coma and eventually die of respiratory or cardiac failure.
Although fatal if not treated in time, rabies is 100% vaccine-preventable. Humans can receive
protection as a pre-exposure prophylaxis, given intramuscularly or intradermally. Animals can
also be vaccinated in a form of an injection (domestic) or orally, as bait in food (wildlife). For
previously vaccinated people who have been exposed to a rabid animal, the World Health
Organisation (WHO) recommends a post-exposure treatment that includes washing the wound
with soap and water and receiving boosters of the rabies vaccine. This is usually enough to
save the lives of victims. However, previously unvaccinated individuals that had been bitten or
scratched should be treated in a timely fashion with human rabies immunoglobulin (HRIG) and
vaccinations. This intervention can be very expensive, or even unavailable at the time in
particular region or country.
What is the problem and how big is it?
Only a few countries (Japan, United Kingdom, Australia, New Zealand, Andaman and Nicobar
Islands) have managed to completely eradicate the disease, mainly thanks to their geographical
isolation and excellent governmental initiatives to control rabies. Countries in Western Europe
and the Americas have made great progress in eliminating rabies. They have recognised it to be
a public health concern and acted upon it by improving surveillance, mass dog vaccination,
community engagement and education, pre-exposure prophylaxis for people at high risk and
long term, sustained investment.
Unfortunately, in Africa and Asia it still poses a huge public health threat. Rabies in India is still
not a notifiable disease, therefore the exact figure of rabies bites remains unknown.
Although it has the highest incidence of rabies globally, the true number is presumably grossly
underestimated. Some studies have estimated it to be as high as 17 million dog bites per year.
One of the main reasons for this is that rabies bites occur in the most deprived rural areas,
where access to medical facilities is limited. According to Hampson et al, most rabies victims die
at home (>75%), making the statistics impossible to record.
Even if dog-bite victims do reach hospitals, they can be misdiagnosed as having cerebral
malaria, Guillain-Barre syndrome or other neurological condition. Two studies carried out in New
Delhi and Jodhpur showed many disparities in the knowledge and practices of doctors in
regards to rabies. Less than half of them were unaware of the intradermal rabies prophylaxis
schedule, and only 45% of them knew about HRIG. 81% of them knew of the PEP 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 PEP. 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.
Awareness of the disease among communities is also very limited. According to ‘End Rabies
Now Campaign’ only 54% of survey respondents in Indian urban slums knew that rabies can be
fatal. In another survey 70% of people in India have never even heard of rabies and only 30%
knew about the importance of washing the wounds after animal bites. The majority of the victims
happen to be young children in poor rural areas, who have no resources or knowledge of how to
seek help. With their daily income ranging between $1 to $2 they are unable to pay to be
vaccinated. 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.
Under-reporting of rabies cases, lack of education among Indian healthcare professionals,
unawareness of the disease in the communities and irregular vaccine distribution are not the
only problems the country needs to improve in its fight against rabies. India has an uncontrolled
canine population; some estimate it to be as high as 25 million. Only 15% of dogs have been
vaccinated, but in order to eliminate canine rabies the coverage needs to reach 70%. The
immune coverage must be maintained and protected from spill over from unvaccinated animals
in neighbouring areas. Until now, little has been invested in animal vaccination and great
measures need to be taken to vaccinate such a vast number of dogs.
So what has been done?
At the end of last year WHO launched a global framework with a target to reach zero human
rabies deaths by 203019. For the first time it collaborated with animal health sector, the World
Organisation for Animal Health (OIE), Food and Agriculture Organisation of United Nations
(FAO) and the Global Alliance for Rabies Control (GARC). In its Global Framework for the
Elimination of Dog-mediated Human Rabies, five main pillars were set. They included:
– Socio-cultural aspects (awareness, responsible dog-ownership, bite prevention and
treatment, post-exposure prophylaxis, community engagement)
– Technical aspects (vaccination, logistics, diagnostics, surveillance)
– Organisational aspects (good governance, promotion of One Health approach,
coordination and monitoring)
– Resources (investment and business plans)
– Political aspects (political and international support, regional engagement, legal
frameworks and demonstrating impacts)19
The federal government of India together with the National Centre for Disease Control (NCDC)
has also developed a pilot project to eliminate rabies. In its 12th five year plan, it included
strategies for training medical students and doctors, creating awareness in communities and
minimising animal bites. The NCDC has since collaborated closely with local business
companies to establish and develop more diagnostic facilities for surveillance purposes. This
resulted in increased attendance at anti-rabies clinics and the use of HRIG. Also, thousands of
doctors and nurses have been trained in animal-bite management.
Furthermore, in 2009, the government adopted national guidelines in favour of intradermal
vaccination, which is highly immunogenic and cheaper than intramuscular vaccine. Eight out of
India’s 28 states planned to introduce this regimen that year, yet special training still had to be
implemented across the country to avoid insufficient dosing. Additionally, in 2009, India was
producing around 15 million doses of human rabies vaccine annually – quantities that met the
national requirement in that period.
Over the years India has received a huge contribution for rabies control from non- governmental
organisations, such as the Rabies in Asia Foundation, the Association for Prevention and
Control of Rabies in India, the Animal Welfare Board of India and the Association for Prevention
and Control of Rabies in India22. With their aim to end rabies in India by 2020, they slowly make
a change for the better. An example of a great success is the Rabies Day established ten years
ago by The Global Alliance for Rabies Control. It comes on the 28th of September and its
purpose is to raise global public awareness about the disease.
After only three such yearly events, GARC has estimated that over 100 million people had been
educated about rabies in over 120 countries and around three million dogs had been vaccinated
during such events. Their annual activities continue to raise awareness about rabies nationwide
including local Indian communities.
Is it enough?
It is evident that India’s main obstacle to rabies elimination is the lack of a good, comprehensive
national programme and the deficiency in coordinating it. Its neighbouring countries, such as Sri
Lanka and Thailand have made tremendous progress by taking a nationally coordinated
approach. By contrast, 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. Funding was provided by the Ministry of Health and Family Welfare
(MoHFW) and the Ministry of Local Governance. Furthermore, local champions were appointed
to convince political leaders, policy-makers 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, where rabies remains a non-notifiable disease.
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 government and healthcare authorities seem to know where the
problems lie and are gradually addressing them, but the process to improve the statistics
remains slow. The Indian government needs to take the rabies situation seriously, recognise it
as a real threat to its citizens and act upon it on a national level. To date, public spending on
rabies control in India has been insufficient. As Madhusudana, a rabies researcher and a
Professor of Neurovirology in Bangalore points out, a considerable amount of money in India is
being spent on raising awareness of diseases like tuberculosis, malaria, and HIV. According to
Madhusudana, India’s deaths caused by rabies would be radically reduced, if only a tenth of
that sum was spent on raising awareness about rabies. The World Health Organisation wants to
eliminate rabies from South-East Asia by the year 2020. India has seen some improvement in
its battle against rabies; however with the progress seen so far, it is a goal that India is unlikely
Kamila Soltysik RN, PgDip, DipTN (LSHTM), DipTravMed AFTM RCPS (Glasg)