Eliminating rabies in India through awareness, treatment and vaccination

September 2016

Rabies, passed to humans primarily through dog bites, is always fatal by the time its symptoms start, but it is entirely preventable.

A young girl kneeling next to a dog in Calcuta, India.
95% of the rabies cases in humans are transmitted by dogs.
E Parker

On a particularly hot afternoon in Bangalore, India, a couple carries their sick child into the emergency services of a public neurocare hospital. The woman holds the child in her arms, while her male companion follows with 2 more children in tow, all barefoot and wearing tattered clothes.

The child is diagnosed with rabies, and dies within hours of admission. Bitten by a stray dog a month before, the child did not receive life-saving medical care at the time.

Unable to afford a proper cremation, the family discreetly leaves the hospital shortly after the diagnosis, and are not seen again. The child’s body lays in the mortuary unclaimed for several weeks, and is eventually cremated by the police. *

Catastrophic out-of-pocket expenses and lack of transportation from rural areas prevent many of the poorest people in India from accessing primary health-care services, leaving them to carry the burden of rabies.

A preventable disease

Rabies, passed to humans primarily through dog bites, is always fatal by the time its symptoms start, but it is entirely preventable.

Washing wounds thoroughly with soap and water after a bite is an effective way of preventing infection, while both pre-exposure and post-exposure vaccinations for humans exist. Global elimination of the disease is feasible through mass vaccinations of dogs, which transmit 95% of rabies cases to humans.

Despite this, an estimated 59 000 people die from rabies across the world each year, with around 90% of these deaths occurring among children living in rural areas in Africa and Asia. In India alone, estimates range between 18 000 to 20 000 human deaths from rabies each year. Many of these deaths are children, often dying outside of medical facilities – meaning their deaths go unrecorded.

"The true burden of rabies in India is not known," says the WHO Representative for India, Hendrik Bekedam. "The reported incidence is probably an underestimation because in India rabies is still not a notifiable disease."

Ending human deaths from dog-mediated rabies by 2030

In December 2015, countries from across the world met with WHO, the World Organization for Animal Health (OIE), the Food and Agriculture Organization of the United Nations (FAO) and the Global Alliance for Rabies Control (GARC), and agreed to end human deaths from dog-mediated rabies by 2030. Dr Margaret Chan, WHO Director-General, acknowledged that elimination of rabies is within reach by using her own words: "Rabies belongs in the history books".

Under the One Health Initiative, WHO, OIE, FAO, and GARC are working on simultaneous campaigns to eliminate canine rabies through the vaccination of dogs, the treatment of human rabies exposures with wound washing and post-exposure prophylaxis, and the improvement of education about rabies prevention where it is needed most.

Ending human deaths from dog-mediated rabies by 2030 will require an active role from India, which has a high concentration of the disease but is also empowered by its rich technical expertise and resources to drive cooperation of other countries in the region.

"The elimination of rabies in India is a daunting task, but not an impossible one," says Dr Reeta Mani, Associate Professor of India's National Institute of Mental Health & Neurosciences (NIMHANS). "Control of canine rabies through vaccination and dog birth control is imperative, although with 25 million stray dogs in the country this is a formidable task."

While the sheer size of India’s dog population is a significant obstacle, Dr Mani also points out recent positive developments: "Collaborative efforts between the medical, veterinary, and public health sectors have already made a significant difference. We have seen improved rates of pre-exposure vaccination (PrEP) for vulnerable populations, such as children, and improved awareness of the need for post-exposure prophylaxis (PEP) after a bite."

Within recent years, India has overcome polio, yaws, and maternal and neonatal tetanus. Through a collaborative approach it is possible that this generation will also see the end of rabies in India.

A stockpile for human rabies vaccines

Many countries have difficulty measuring and forecasting demand for rabies vaccine, which in turn causes delays and stock shortages in the vaccine market. To address this, WHO is planning to create a stockpile of human rabies vaccine to match a stockpile of dog rabies vaccine recently created by the World Organization for Animal Health (OIE).

"WHO is seeking to better understand the unmet needs for human rabies vaccines, and the logistics to get these essential medicines to where they are needed most: to rural, underserved populations," says Dr Bernadette Abela-Ridder, WHO Team Leader of Neglected Zoonotic Diseases. "By assisting countries to forecast their needs, and aggregating these into global requirements, we will stabilize demand that manufacturers can respond to." The stockpile is expected to be in operation by the end of 2017.

The theme of this year's World Rabies Day, observed on 28 September, is "Rabies: Educate. Vaccinate. Eliminate."

* This story was originally told by Dr Reeta Mani and published in PLOS.