Control and Eradication of Rabies in India
Dr. Lipismita Samal
Assistant Professor
College of Veterinary Science and Animal Husbandry,
Odisha University of Agriculture and Technology (OUAT), Bhubaneswar, Odisha
Introduction
Rabies is an acute infectious viral disease affecting all the warm-blooded mammals including human. It is a viral zoonotic disease primarily infecting domestic and wild animals and spreads to human through close contact with infected saliva from rabid animals via bites/licks/scratches on broken skin and mucous membrane. Once transmitted, the incubation period is generally between 20 to 90 days, but it can also be of 4 days to several years in extreme cases. Rabies virus belongs to the Lyssavirus genus of the Rhabdoviridae family. While dogs are the principal host and transmitters in India, others responsible for the disease are cat, wolf, fox, jackal, raccoon, mongoose, monkeys, weasels, cattle, pigs, groundhogs, bat, bears and wild carnivores. In India, about 97% of the mortality is associated with dog bites (Sudarshan, 2017) and rural areas account for 76% of human rabies cases.
Incidence
It is estimated that rabies kills 55,000 people worldwide every year. India reports about 18,000-20,000 cases of rabies a year (about 36% of the world’s deaths from rabies) and the incidence is 2 in 1,00,000 population a year (0.002%). It is endemic throughout India with the exception of Andaman & Nicobar and Lakshadweep Islands. In India, rabies affects mainly people of lower socio-economic status and children between the ages of 5 and 15 years (Kole et al., 2014). The incidence of rabies in India has been more or less constant for more than a decade without any obvious declining trend and is probably an underestimation as rabies is not a notifiable disease.
Cause of High Incidence
Worldwide, India has the highest rate of human rabies in the world. It is primarily due to the large population of stray dogs (around 25 million). Because of a decline in the number of vultures due to acute poisoning by the anti-inflammatory drug diclofenac, animal carcasses that would have been consumed by vultures instead became available for consumption by feral dogs, resulting in a growth of the dog population and thus a larger pool of carriers for the rabies virus. Another reason for the great increase in the number of stray dogs is the 2001 law that forbade the killing of dogs. Another source of rabies in India is the pet boom. The most affected populations within India are those suffering from poverty or the uneducated. According to one study, only 70% of the people in India have ever heard of rabies, only 30% know to wash the wounds after animal bites and, of those who get bitten, only 60% receive a modern cell-culture-derived vaccine (Kole et al., 2014).
Symptoms
Two forms of rabies– furious/encephalitic and paralytic are recognised in humans. The furious form constitutes about 80% of human rabies cases and is clinically diagnosed based on classical signs and symptoms (Mani et al., 2016). Rabies virus is neurotrophic which affects the nervous system of human and animals. As the virus spreads in the central nervous system (i.e. brain), progressive encephalitis develops. The initial symptoms of rabies are often pain, mild fever or abnormal sensation of the skin like pricking, tingling or numbness (paraesthesia) of the limb. Once symptoms develop, rabies is fatal to both animals and humans, if not treated immediately. Advanced symptoms include hydrophobia, aerophobia, photophobia and paralysis. Rabies with atypical manifestations, and the paralytic form of rabies, which may be clinically indistinguishable from Guillain-Barre syndrome (GBS), pose a diagnostic dilemma and require ante-mortem laboratory confirmation (Mani et al., 2016).
Precautions
What not to do:
Do not touch the wound with bare hand.
Do not apply limestone, hot peppers, turmeric, coffee powder, ekke halu (white aak) plant liquid, cow dung on the wound.
Do not apply irritants like soil, chilies, oil, herbs, chalk, betel leaves to bite wound.
Do not tie a cloth or bandage above the bite.
Do not consume alcohol while on medication.
What to do:
Wash the wound with soap under running water for 15 minutes.
Apply antiseptic solution and seek medical treatment immediately.
Take post-exposure anti-rabies vaccine and injectable solution of immunoglobulin on the wound.
Treatment and Prevention:
World Health Organization (WHO) recommendations for post-exposure treatment divide rabies exposure into three categories.
Category I (least serious): when the victim has been touching or feeding infected animals, but shows no skin lesions.
Category II: when the victim has received minor scratches without bleeding or has been licked by an infected animal on broken skin.
Category III (severe): when the victim has received one or more bites, scratches or licks on broken skin or has had other contact with infected mucus.
Anti-rabies vaccine is recommended for category II and III, while anti-rabies immunoglobin should be given for category III contact, or to the people with weak immune systems.
A nerve tissue vaccine (NTV) was first developed by French scientist Louis Pasteur during19th century but it has serious side effects in human such as paralysis. Modern cell culture vaccines (CCV) were introduced in the early 1980s, and from 1995 onwards there has been a significant increase in the use of these vaccines. Modern rabies vaccines such as, cell culture rabies vaccines (CCRV), purified chick-embryo cell vaccine (PCECV), purified Vero cell rabies vaccine (PVRV) and human diploid cell vaccine (HDCV) are in common use and administered by intra-dermal or intra-muscular routes. Higher cost of intra-muscular administration of CCV is a limiting factor for its wider use. The Government has banned the production and use of NTV in December 2004. Intra-dermal vaccination, recommended by the WHO in low-resource settings, has been practiced in India from 2006 because of its lower cost and high immunogenicity (NCDC, 2015). However, it requires special training to reduce the risk of insufficient dosing. It would be safer to administer the complete course of anti-rabies vaccination to anyone who gets bitten by an animal. Pre-exposure vaccination is advised to high risk groups like laboratory staffs handling the virus and infected material, clinicians and persons attending to human rabies cases, veterinarians, animal handlers and catchers, wildlife wardens. All children should be vaccinated against rabies as pre-exposure prophylaxis particularly in areas with an uncontrolled dog population (Mani et al., 2016). On the veterinary side, the focus should be on sterilisation and vaccination of dogs, with a larger involvement of civil society and municipal bodies. It is necessary to vaccinate 70% of the total dog population in a short period of time, maintain that immune coverage and protect the area from spill over through control of dog movement from affected adjacent areas (Taylor et al., 2017). Mandatory vaccination of animals is less effective in rural areas, especially in developing countries like India where pets are considered as community property and their destruction is unacceptable. Oral vaccines can be safely administered to wild animals through bait, a method initiated on a large scale in Belgium. Dog licensing, euthanasia of stray dogs, muzzling, and other measures contributed to the elimination of rabies from U.K. So, these promising strategies may be started in India to combat rabies. The WHO at a global rabies conference held at Geneva, Switzerland in December 2015, called for the elimination of dog-mediated human rabies by 2030 and recommended the strategy of ‘one health approach’ that involves an effective coordination and cooperation of medical, veterinary and other related sectors (WHO, 2016).
Challenges in India:
There are several reasons for continued human rabies deaths in India. Rabies is a disease of low public health priority and there has never been a nationwide epidemiological survey, and early estimates of rabies mortality have been based on regional hospital data projected to the total population of the country. The WHO says prevention of human rabies is possible through mass dog vaccination, promotion of responsible dog ownership and dog population control programmes with a partnership approach. However, this is a challenge for India as it has a large population of stray dogs and very low vaccination coverage. Various organisations are involved in control activities without any inter-sectoral coordination. The true disease burden and public health impact due to rabies in India may remain underestimated due to several factors. Facilities for laboratory diagnosis of human rabies, and surveillance for animal and human rabies, are restricted. Moreover, even in laboratories with existing facilities, rabies diagnosis poses a challenge due to lack of simple, sensitive and cost-effective methods. The low level of commitment to rabies control is partly attributable to lack of accurate and extensive surveillance data to indicate the disease burden. One of the reasons the disease has been neglected is because of scattered deaths. This situation is aggravated due to lack of awareness of preventive measures, which translates into insufficient dog vaccination, an uncontrolled canine population, poor knowledge of proper post-exposure prophylaxis of medical professionals, and an irregular supply of anti-rabies vaccine and immunoglobulin, particularly in primary-health-care facilities (Kole et al., 2014; Mani et al., 2016). Moreover, as India shares borders with six countries that are all rabies endemic, it is essential that India’s rabies control efforts are coordinated regionally. According to the WHO, an estimated 65% of the population in India lacks access to essential medicines. India also tacks on some of the highest taxes and tariffs to retail medicine in the world, with the combined impact of duties and taxes on retail medicine prices estimated at 55%, compared to the global average of 18%. Moreover, government spending priorities that siphon money away from healthcare infrastructure is also an issue. People living in poverty are less likely to be educated or have money for treatment, and more likely to live in less-than-ideal conditions like poor sanitation or restricted access to healthcare.
Steps taken by the Government:
Under 11th Five Year Plan (FYP) (2007-2012), a pilot project was launched by the National Centre for Disease Control (NCDC) in 2008 in Ahmedabad, Bangalore, Pune, Madurai and Delhi to reduce rabies deaths in humans by at least 50 percent. The pilot project includes training of health professionals in animal-bite management and raising public awareness about the need to seek post-exposure treatment, notably through posting messages on buses and in other public places. It includes training medical professionals on animal bite management, and raising awareness through social campaigns about post-exposure treatment.
Under the 12th FYP (2012-2017), the government made it a priority disease for control. A comprehensive control strategy for both human and animal components was made. All 35 States/UTs were covered for the human component and the animal component was piloted in Haryana and Chennai. To address the issue of rabies in the country, ‘National Rabies Control Programme’ (NRCP) was implemented with an objective to prevent the human deaths due to rabies and to prevent transmission of rabies through canine rabies control. The strategies for the human component are training of health professionals, implementing use of intra-dermal route of inoculation of cell culture vaccines, strengthening surveillance of human rabies, information education and communication and laboratory strengthening. The strategies for the animal component are population survey of dogs, mass vaccination of dogs and dog population management.
The international support of UN agencies such as the WHO, UNICEF, OIE (World Organization for Animal Health), and others may be solicited to combat rabies (Sudarshan, 2017). The NCDC, Delhi and WHO Collaborating Centre for Rabies Epidemiology organized an expert consultation in 2002 to formulate national guidelines for rabies prophylaxis to bring out uniformity in post-exposure prophylaxis practices. These guidelines were revised in 2007 and again in 2013 (NCDC, 2015).
Contribution of Non-Government Organizations (NGOs)
The contribution of NGOs has also been commendable, notably from the Rabies in Asia Foundation, the Association for Prevention and Control of Rabies in India and the Animal Welfare Board of India, which is promoting the Animal Birth Control Anti-Rabies Programme in major metropolitan cities. The Schering–Plough Corporation, a global health-care company has sponsored two projects in 10 villages surrounding Bangalore and Pune and focused on educational awareness and the mass vaccination of dogs. The Association for Prevention and Control of Rabies in India (APCRI), with the technical and financial assistance from WHO undertook national multi-centric rabies survey in India during 2002-2004 and 2017. The national and international NGOs such as Rotary, Lions, Global Alliance for Vaccines and Immunization, APCRI, Indian Medical Association, Indian Veterinary Association, Indian Academy of Pediatrics, Indian Public Health Association and others must be actively involved in the national action plan (Sudarshan, 2017).
World Rabies Day (WRD)
It is celebrated annually on 28th September to raise awareness about rabies prevention. This date marks the anniversary of Louis Pasteur’s death, who developed the first rabies vaccine. It is an opportunity to unite as a community and for individuals, NGOs and governments to connect and share their work. This year’s (14th WRD) theme is “End Rabies: Collaborate, Vaccinate”. The theme focuses on the goal of zero mortality by 2030, importance of dog vaccination and post-exposure prophylaxis; and the need for a united effort towards achieving elimination of this trans-boundary disease.
Conclusions
Rabies continues to cause a significant number of human mortality in India. Increasing awareness about adequate post-exposure prophylaxis, additional rabies diagnostic facilities, and enhanced human and animal rabies surveillance to indicate the true disease burden are essential to control this fatal but preventable and treatable disease. Steps must be taken to ensure the uninterrupted availability of vaccines and anti-rabies immunoglobulin in all hospitals and in remote primary-health-care centres. Primary care providers should be trained to administer proper prophylaxis, including intra-dermal vaccination. There should be programmes for training health professionals to deal with animal bites. The primary school curriculum should include developing rabies awareness among students. Awareness should be created to vaccinate dogs, avoid dog bites and educate people, especially children, about dog’s behaviour and body language to prevent from bites. All dogs should be given the oral vaccine against rabies through baits and stray animals should be sterilized to reduce the vector population. Rabies should be declared a notifiable disease and incorporated into a ‘one health programme’ in a coordinated manner at all levels.
References
Kole, A.K., Roy, R. and Kole, D.C. (2014). Human rabies in India: a problem needing more attention. Bulletin of the World Health Organization. 92: 230.
Mani, R.S., Anand, A.M. and Madhusudana, S.N. (2016). Human rabies in India: an audit from a rabies diagnostic laboratory. Tropical Medicine and International Health. 21(4): 556–563.
National Centre for Disease Control (2015). National Rabies Control Programme. National Guidelines
on Rabies Prophylaxis. Delhi: National Centre for Disease Control. pp.1-17.
Sudarshan, M.K. (2017). Vision 2030: Dog-mediated human rabies-free India: Action must begin now. Indian Journal of Public Health. 61:1-2.
Taylor, L.H., Wallace, R.M., Balaram, D., Lindenmayer, J.M., Eckery, D.C., Mutonono-Watkiss, B., Parravani, E. and Nel, L.H. (2017). The role of dog population management in rabies elimination-a review of current approaches and future opportunities. Frontiers in Veterinary Science. 4: 109.
World Health Organization (2016). Weekly epidemiological record. Geneva, Switzerland: World Health Organization; 91: 13-20.
