ALL FOR 1 ONE HEALTH FOR ALL

ALL FOR 1 ONE HEALTH FOR ALL

“Together we can make this the final Rabies generation”.

RABIES FACTS; NOT FEAR

Rabies is 100% fatal but 100% preventable viral disease. It is caused by the Lyssavirus of the family Rhabdoviridae. Rabies is one of the oldest infectious diseases known to people. Its name comes from “Rabhas”, the Sanskrit word for violence, and from “Lyssa”, the Greek goddess of fury. The history of rabies dramatically changed in 1885, when the French chemist and microbiologist Louis Pasteur developed the first vaccine against this incurable disease. Rabies is a disease of warm-blooded mammals, including dogs, foxes, wolves, coyotes, jackals, cats, lions, mongooses, skunks, bats, monkeys, and humans etc. Monkeys are susceptible to Rabies, their bites necessitate post-exposure anti-rabies prophylaxis (Menezes, 2008). Every year, Rabies kills more than 59,000 people worldwide and around 20,000 people in India (WOAH, 2018). Most victims of rabies are children below the age of 15 years. Rabies is transmitted via bites and scratches from infected animals. In India, most human rabies deaths are due to infected dog bites. Dog-mediated rabies is an important public health concern in developing countries like India. According to WHO, India accounts for 36% of the global deaths and 65% of the deaths due to rabies in South-East Asia. World Rabies Day is celebrated every year on 28^th September since 2007 to mark the death anniversary of Louis Pasteur. This day aims to raise awareness and advocate for rabies elimination globally. This event aims to make all individuals inclusive, uniting people, organisations, and all stakeholders across all sectors against the deadly monster rabies. This year, we will mark the 17^th World Rabies Day. This year’s theme ‘All for 1, One Health for All’ highlights that One Health is not for a selected few but for everyone. It is very important to ensure equitable access to health services and rabies post-exposure prophylaxis for impoverished communities not only saves lives but also strengthens national health systems. This theme reiterates the significance of equality, and strengthening overall health systems by ensuring that One Health is not for a selected few but rather something that should be available to everyone.

Rabies Transmission:

In India, the presence of unvaccinated free- roaming dogs, amidst human settlements is a major contributor to the high incidence of Rabies. Rabies virus is transmitted through infectious saliva – most commonly through a bite, and sometimes through a scratch or direct contact with the eyes, mouth, or an open wound. It spreads slowly from the entry point along peripheral nerves to the central nervous system (that is, the spinal cord and brain). When the virus reaches the brain, it causes clinical signs, replicates, and spreads to the salivary glands where it is excreted in the saliva and can infect others.

Rabies Clinical Signs
            In people, the incubation phase typically takes between 4 and 12 weeks. Some rare cases have been documented to develop in less than 1 week or more than 1 year. The incubation phase is driven by how long it takes for the virus to spread from the site of entry to the brain. Where there is less distance to travel – for example bites in small children, or bites to the face or head – the incubation phase is shorter; hence prompt medical care is even more critical to prevent rabies. Upon medical consultation, post-exposure prophylaxis should be started as soon as possible but – unless clinical signs are already evident – it is never too late to successfully start it. Once clinical signs appear, rabies is almost always fatal. Clinical signs in people typically start with generic symptoms for up to one week, such as fever, malaise, fatigue, lack of appetite, and tingling at the wound site, and the disease progresses to “furious” or “paralytic” rabies. Furious rabies involves altered behaviour, hallucinations, incoordination, aerophobia, hydrophobia, excessive salivation, and aggression. This can last for up to five days. Paralytic rabies involves growing paralysis and can last for up to 14 days. Both furious and paralytic rabies leads to acute encephalitis, or inflammation of the brain, followed by coma and death. In dogs, clinical signs follow a similar pattern.

Dogs are infected with rabies through exposure to infectious saliva through bites, scratches or contact with the eyes, mouth, or open wounds. The incubation phase is typically 3-11 weeks, and occasionally longer, before developing into generic signs for up to one week, such as fever, vomiting, weakness, and lack of appetite. Now, the dog may develop furious or paralytic rabies for around one week, before progressing to acute encephalitis, coma and then death. Signs of furious rabies in dogs include altered behaviour, aggression, incoordination, difficulty swallowing, dropping jaw, excessive salivation, and a change in the tone of a bark. Aerophobia and hydrophobia are not present in dog rabies. As in people, paralytic rabies involves growing paralysis. Rabies virus is present in the saliva after the incubation phase, meaning rabid dogs can be infectious even when their clinical signs are still mild. In people, clinical rabies can be managed but very rarely cured.

Diagnosis and Surveillance:

There are four milestones on the path towards rabies elimination. Surveillance is crucial in every step. The precise human and animal case definitions allow consistent data collection and reporting. Integrated bite case management enables a more targeted use of rabies biologicals. No diagnostic tool exists to detect rabies before the onset of clinical disease, and lab testing remains challenging in many countries. Standardized global reporting, based on minimum indicators, helps to assess the burden of rabies. Strengthening rabies surveillance systems also benefits other diseases because it strengthens health systems and reporting, both centrally and in marginalized regions; and builds trust with at-risk populations. It also builds lab capacity, which can be used for other diseases apart from rabies – and supports better collaboration between human and animal health sectors as part of a One Health approach. Vaccination of dogs is much cheaper than providing care to people after exposure to a rabid animal.

Rabies is almost always fatal once clinical signs appear, but it can be prevented through prompt wound washing and post-exposure prophylaxis. Post-exposure prophylaxis consists of a series of rabies vaccines and, in some cases, rabies immunoglobulin (RIG).

Tens of thousands of people are estimated to die of rabies each year. Almost all cases are spread by rabid dogs, and almost half of the victims are children under the age of fifteen. It is not possible to test people for rabies before the onset of symptoms, but all cases are preventable if post exposure prophylaxis is given promptly after exposure. The burden of rabies is greatest in Africa and Asia, and many countries in the world have already eliminated rabies in dogs. Rabies deaths are widely underreported. In Asia, deaths are estimated to be 20 times more and in Africa by up to 160 times more than reported. This means that estimates of the exact disease burden vary widely – from 25,000 to 159,000 deaths globally each year. Underreporting can occur because rabies is misdiagnosed as another condition with similar symptoms – such as viral encephalitis, or cerebral malaria – without laboratory confirmation. Many deaths are also not reported because they occur at home when victims are too ill to travel and know that there is no treatment available even if they do seek care or it is too expensive. This is compounded by weak surveillance systems in many endemic countries, especially in poor and rural communities that are chronically underserved and experience the greatest burden of rabies. Children are at greater risk of developing rabies because they play with animals and may not report bites to their parents. So, they may not receive prompt care. They are also smaller, and more likely to receive multiple and severe bites, especially to the face or head. This increases the risk of rabies developing fast.

Rabies is estimated to cost 8.6 billion US dollars globally each year and incalculable psychological trauma for individuals and their communities. Of the financial cost, around 40% is for medical care – including direct costs of care, which are often borne out-of-pocket by patients and can be catastrophic; lost income while seeking care; or travel costs incurred to access care – and control measures such as dog vaccination and surveillance. In case of animals, 54% is incurred through productivity losses due to premature death, and 6% through loss of infected livestock. Rural and poor communities are disproportionately affected because of less access to care and rabies control programmes. These communities have fewer buffers to pay for medical care and travel expenses. When an income earner dies of rabies, families can spiral deeper into poverty. In addition, animals and livestock are also lost to rabies which reduces the income and livelihood of communities. Rabies also particularly impacts low-income families. In one study, over 70% of low-income bite victims relied on loans, or selling property, to pay for post-exposure prophylaxis – while most high-income victims used family savings. Similarly, over 60% of low-income bite victims delayed seeking post-exposure prophylaxis by four days or more – which may increase their chance of getting clinical rabies – while 100% of high-income bite victims sought prophylaxis within three days of being bitten. This becomes vicious cycle.

Rabies is preventable through wound washing and post-exposure prophylaxis for suspected exposures.

• Washing the wound with water and soap for 15 minutes is the first life-saving measure to prevent rabies.
• The need for post-exposure prophylaxis depends on the health status of the animal; the severity of the wound; and whether the animal has already received a rabies vaccine.
• Rabies vaccines can be administered intra-dermally (recommended) or intra-muscularly, and the shortest course involves three visits to the doctor over the course of one week.
• Severe exposures may also require rabies immunoglobulin, which must be administered in all wounds – although vaccination should not be delayed if rabies immunoglobulin is not available.
• Traditional medicine is ineffective and will not prevent rabies.

ONE HEALTH – “Connecting human, animal, and environmental health”.

One of the first conditions of happiness is that the link between man and nature shall not be broken.                                                                                  -Leo Tolstoy

One Health is a collaborative, multisectoral, and trans-disciplinary approach- working at the local, national, and global levels- with the goal of achieving optimal health outcomes recognising the interconnection between people, animals, plants, and their shared environment. – CDC, ATLANTA

One Health is an approach that recognizes the health of people is closely connected to the health of animals and our shared environment. The very purpose of One Health is to encourage collaborations in research and sharing of knowledge at multiple levels across various disciplines like human health, animal health, plants, soil, environmental and ecosystem health in ways that improve, protect, and defend the health of all species. One Health approach is critical for the control of priority zoonotic diseases such as rabies, avian flu or viral haemorrhagic fevers and COVID-19. Rabies requires collaboration with the animal health sector for animal assessment, surveillance and to address disease in dogs.

https://www.woah.org/app/uploads/2022/10/one-health-infographic.jpg

New One Health Joint Plan of Action was launched by the Quadripartite Food and Agriculture Organization (FAO), the United Nations Environment Programme (UNEP), the World Health Organization (WHO), and the World Organisation for Animal Health (WOAH).

Rabies is an excellent model of One Health collaboration. The WHO and the World Organisation for Animal Health work together to set standards for all aspects of rabies elimination. WHO is responsible for human diagnostics, surveillance, prevention, vaccines, and vaccine production, and for validation of rabies elimination. The World Organisation for Animal Health is responsible for animal vaccine production, aspects of animal disease prevention, and officially endorsing dog rabies control programmes. WHO and the World Organisation for Animal Health jointly set standards for animal diagnostics, surveillance, prevention, vaccines, and defining and verifying country freedom from rabies. Both organizations work closely with the Food and Agriculture Organization of the United Nations to support countries in their efforts towards the elimination of dog-mediated human rabies. Rabies also shows the inclusivity of the One Health approach. In rural communities, livestock are important economically, socially, and culturally. In countries with a high burden of dog rabies, livestock are exposed to rabies mainly by dogs. Therefore, eliminating rabies in dogs will reduce rabies in livestock and other domestic species as well.

“The ‘Zero by 30’ rabies elimination strategy”

Eliminating rabies is a global public good. If we do not act now, over one million people will die of rabies before 2030. The demand for post-exposure prophylaxis will also grow because more people will be exposed, and poor and rural populations will continue to be disproportionately affected by systemic inequities. This means that the cycle of neglect of rabies and its impact on people and animals will continue. Eliminating rabies also aligns with global goals, such as the WHO’s goal to control 20 Neglected Tropical Diseases – including rabies – by 2030; and the United Nations’ Sustainable Development Goals (SDGs) about the achievement of good health and well-being, the elimination of poverty, the reduction of inequalities, and the creation of partnerships to reduce disease burden. Eliminating rabies also strengthens health systems. Achieving elimination would mean that the need for post-exposure prophylaxis decreases; that expensive rabies biologicals are used in a more targeted way; that healthcare providers are better equipped to administer care to patients for rabies and other ailments; and that the appropriate logistics are in place. This contributes to universal health coverage, that is, where everybody has access to the health services they need without financial hardship, which in turn strengthens primary health care. Eliminating rabies is possible through increased access to post-exposure prophylaxis for people, and mass vaccination of dogs. In 2019, Mexico successfully eliminated dog-transmitted rabies as a public health problem, which means no more human deaths from dog-transmitted rabies, through sustained mass dog vaccination. Human and dog rabies cases reduced to zero following sustained high rates of dog vaccination. In Sri Lanka, human rabies cases significantly reduced following an increase in both mass dog vaccination and the provision of post-exposure prophylaxis. Globally, around 50% of animal rabies cases are in dogs, and around 40% are in wildlife such as bats. Dogs are responsible for approximately 99% of human rabies cases. Because rabies is present in more than one animal species, it is virtually impossible to eradicate. Eradication would mean permanently reducing to zero the worldwide incidence of any infection caused by rabies. However, dog rabies and dog-mediated human rabies can be eliminated, so that no more endemic cases occur, which would prevent almost all human rabies deaths. Eliminating rabies requires a “One Health” approach. A One-Health model refers to the collaboration between different disciplines and sectors to recognize the connection between humans, animals, and the environment – and the impact this has on health outcomes. Because dogs are responsible for transmitting most rabies cases to people, the number of rabies cases in dogs is clearly correlated to the number of rabies cases in people. Therefore, to successfully eliminate rabies, we need to vaccinate dogs to stop rabies transmission between dogs, and from dogs to people. “Zero by 30” is a global strategic plan to reach zero human deaths from dog-mediated rabies by 2030, worldwide. The plan, which was developed by WHO, the World Animal Health Organisation (OIE), the Food and Agricultural Organization of the United Nations (FAO), and the Global Alliance for Rabies Control (GARC) in close consultation with countries and other actors, points a common goal of Zero by 30 and drives to coordinated action against rabies.

We need to change the status quo, put rabies-endemic countries at the centre, and create a unified coalition for success through three main objectives:

1. To effectively use vaccines, tools, and technologies to reduce the risk of human rabies
2. To generate and measure impact, to provide reliable data and guidance
3. To sustain political and financial commitment through engaging stakeholders

“Zero by 30” takes a phased approach to elimination –

• By building a strong foundation (‘Start Up’)
• Engaging most countries in rabies elimination (‘Scale up’)
• By ‘last mile’ efforts to engage remaining countries (‘Mop up’)

The United Against Rabies Forum – led by WHO, the World Animal Health Organisation, and the Food and Agricultural Organization – provides an inclusive, country-centric, and cross-sectoral “One Health” platform for rabies stakeholders to work together to achieve the “Zero by 30” goal.

There are three main pillars for successfully eliminating rabies:

• By expanding access to rabies post-exposure prophylaxis
• By building awareness of rabies through “Awareness and community empowerment”
• By implementing mass dog vaccination to stop the disease at its source

Rabies elimination and the United against Rabies Forum itself – involves many global, regional, national, and local stakeholders. It involves from international organizations; to regional partners, rabies networks, and One Health networks; to national stakeholders in human health, animal health, environmental health, and education; to local governments; media; and communities. The “Zero by 30” plan is complemented by a range of global initiatives – including Gavi’s support for increased availability of human vaccines; the animal vaccine bank of the World Organisation for Animal Health for increased availability of dog vaccines; and the Revolving Fund of the Pan American Health Organization in South America for both human and animal biologicals. Gavi, The Vaccine Alliance, has included human rabies vaccines in their investment strategy 2021- 2025. Although due to the COVID-19 pandemic, there will be delays in the rollout of rabies vaccines, this support from Gavi will help increase access to safe and effective and WHO-prequalified vaccines. It will also support the uptake of the cost- and dose-saving intradermal vaccination regimen. Gavi’s support will also help countries improve data collection, vaccine forecasting and procurement, and accountability for their use. The vaccine bank of the World Organisation for Animal Health is a virtual bank that provides countries with access to high-quality dog rabies vaccines. Countries can apply for vaccines through their Chief Veterinary Officer to the Director General of the World Organization of Animal Health. Vaccines will be delivered in a timely manner and in flexible quantities and this will allow countries to kick off their rabies elimination programmes. The vaccine bank aims to convert demand for dog vaccines from a vicious cycle – where demand is low, production is low, and vaccines are costly – to a virtuous one, where demand is high, production is high, and vaccines can be provided at a lower cost.

What we can do on World Rabies Day, individually, locally and globally

Every individual in the community should play a vital role in eliminating rabies. Being a veterinarian, she/he is an integral part of the One Health. It is the primary duty to protect and promote public health and the environment. The veterinarian is also an extension personnel, wherein we can indulge ourselves in imparting professional training and should be involved in teaching school children and increasing awareness among them about rabies.

The key message that we want to spread is that vaccinating people and dogs saves lives and stops transmission. Human rabies can be prevented through dog bite prevention and proper wound washing and, if indicated, immediate post-exposure prophylaxis. The first measure to prevent human rabies is to avoid dog bites, by understanding dog behaviour. For example, before biting, most dogs express discomfort through body language. In this slide, you can see how the body language of dogs changes from when they are playful and happy, to when they become suspicious, anxious, threatened, angry and – overall – more likely to bite. As a rule, we should avoid situations likely to upset dogs. For example, bothering them when they eat or sleep, putting our face right up to theirs and screaming, taking their toys away, grabbing their ears or tails, hugging and riding them, and of course hurting them in any way. If you ever feel threatened by a dog, remember to remain still – so no running away! – and keep quiet. If you perceive the dog as a threat, resist the temptation to run, avoid eye contact, speak softly, and try to slowly walk away without turning your back to the dog. If the dog growls, pretend to be a tree: stay still with your hands at your side. If the dog attacks, pretend to be a rock: curl into a ball and protect your face and body with your arms and legs.

Within the global rabies elimination plan, local communities are not just recipients of mass dog vaccination campaigns and awareness activities, but they are key stakeholders from the very beginning. It is crucial to always keep in mind that rabies elimination happens at the community level and that local settings are where a One Health approach to rabies in the real world can be seen and done. Because of their experience with rabies and dog bites, local communities should co-produce knowledge alongside experts, and not simply be told what to do. Finally, when we design strategies to increase access to post-exposure prophylaxis, we must remember that people’s health-seeking behaviours are often not – or not only – the result of individual choices, but of complex and broader structural drivers, such as poverty, political instabilities, and social discrimination.

The principle that should guide the design and implementation of awareness activities within local communities is that listening is as important as talking. Listening means comprehending how people live with dogs; understanding what animal welfare means to them and how they implement it; and paying attention to how people talk about rabies. Then, talking means asking what the local needs and concerns are; using culturally appropriate and sensitive examples, words, and narratives; and showing respect for the local knowledge about rabies and the role that healers play in the management of dog bites.

Each year, a key date for rabies awareness is the 28th of September, when we celebrate World Rabies Day. Each year on World Rabies Day, rabies-related events – from free dog vaccination drives and drawing competitions to puppet shows and events on social media – are organized worldwide around a common topic. World Rabies Day brings together communities, Non-Governmental Organisations, local and national governments, individuals, doctors, vets, and whoever wants to help inform people about rabies and how to prevent it. World Rabies Day catalyses action around three areas: global action, the so-called “rabies champions”, and local awareness.

With regard to global action, there are many tools for bringing people together to spread the word about our global goal to eliminate dog-mediated human rabies by 2030. We can use inspirational videos and video interviews, both with rabies experts and people who live in high-risk areas; posts on social media; articles in well-known newspapers; and in-person or virtual events such as webinars where rabies scholars share their work with the society at large.

On World Rabies Day and throughout the year, the so-called “rabies champions” are at the heart of at-risk communities. Rabies champions are people who do not necessarily work in the field of rabies, but because of their interest in rabies and their training, they are able to manage various common rabies-related situations and are looked at as focal persons within their community. Their role is crucial in many ways. For example, they may spread awareness, often together with teachers and vets; work together with the animal and human health sectors in their community; coordinate rabies control activities; assist with mass dog vaccination campaigns in the area; manage bite cases and possible rabies exposures within their community, in collaboration with physicians and hospitals; and help build trust among stakeholders, including local communities and their leaders. Increasing local awareness, not only on World Rabies Day but throughout the year, is a pillar of the current global rabies elimination strategy. Local newspapers, radio messages, and social media are great tools to reach as many different people as possible, while dog vaccination campaigns are a crucial moment to build trust with dog owners, make sure that they have their dogs periodically re-vaccinated, and that they spread the word to friends and neighbours.

Children are key players, for several reasons:

• Because of their close interactions with dogs and their short stature, they are at particular risk of being bitten and developing rabies fast, so it is essential that they know how to behave around dogs, how to prevent bites, and what to do in case of a dog bite.
• They often are the ones that bring the family dog to vaccination, it is important to make sure they continue to do so.
• They love learning about rabies at school.

A study in the Philippines shows that school is the main source of information about rabies for children, more than television, relatives, friends, and posters.

The Philippines shows us that rabies prevention can be taught at school. Ideally, the ministry or department in charge of education should include rabies prevention in the national school curriculum, by developing rabies-related lesson plans – targeting children of all ages – and resources for their teachers. Rabies prevention can be a stand-alone lesson, or it can be delivered across different school subjects, from math to geography. When we design awareness activities and materials, for children or adults, we must make sure that we communicate effectively. The first way to do this is by having the materials translated into local languages by native speakers. Then, details such as colours, people’s clothes, dogs’ appearances, and homes must be culturally meaningful for local communities, because, for example in the case of comics, we want readers to identify themselves with the characters of the story. Finally, to engage with children it is fundamental to design activities where children can have fun, and not be passive recipients of a message that they will not remember and value. Looking at the rest of society, outside of schools, professionals in the human and animal health sector should always be trained regularly, to make sure that their knowledge is up to date and their actions can make the greatest possible, and positive, impact. Common challenges for human health care providers include performing wound washing for 15 minutes, with plenty of water and soap; administering intra-dermal and intra-muscular rabies vaccines, as well as rabies immunoglobulin, in an appropriate way; and being able to identify the symptoms of human rabies. In the animal health sector, common challenges include catching and handling dogs during vaccination in a safe and humane way; building organizational capacity and practical skills in the various dog vaccination methods; and being able to estimate vaccination coverage efficiently. Paraphrasing a famous saying, it takes a village to eliminate rabies. We need to raise awareness and create partnerships across a vast range of professionals, far beyond teachers and those who directly work on rabies. We need to involve the army, police, firefighters, midwives, pharmacists, sanitation workers, street vendors, and others to help us save lives and eliminate rabies. we need to focus our efforts on terms of awareness activities. The target must be vulnerable populations, so geographically, socially, and economically marginalised communities, and their children – because these are the populations most impacted by rabies, and who will experience the greatest benefit if they are more aware of rabies and how it can be prevented.

Initiatives for Rabies elimination

Celebrate World Rabies Day with

• Raising awareness in the community around us (People think only dog bite needs Post Exposure Prophylaxis while cat scratching does not necessitate it)
• Creating responsible pet ownership
• Strict supervision of registration of breeders
• Advocating Anti-Rabies Prophylaxis for Dogs
• Prophylaxis vaccination for occupational risk population
• Organising competitions like quizzes and elocution to establish facts about rabies.
• Performing skits in the schools to impart knowledge and to improve awareness about rabies.
• Proper implementation of The Animal Birth Control Rules (Dogs) for street dog population management, to ensure rabies eradication and to reduce man–dog conflict.

With the collaboration of all sectors by the contribution of each one, and by the One Health approach, we can work together as one towards one goal to eliminate that one disease RABIES. In case of Rabies, the swift march of India should begin from Neglected Tropical Zoonosis to a Priority Zoonosis.  Global, National, Regional and Individual collaboration and contribution are must to end Rabies.

Author’s Details

Dr. Ashwini A. Assistant Professor, Department of Veterinary Medicine, Veterinary College, Hassan, 573202. Karnataka.

ashvet.ias@gmail.com

Rabies: All for 1 , One health for One

“It’s everyone’s health. Together, we can find concrete solutions for a healthier, and more sustainable world.”   

Dr Monique Eliot, Director General, WOAH

 REFERENCES

1. Garg, S. and Banerjee, B., 2021. One world, one health. Indian Journal of Community Medicine: Official Publication of Indian Association of Preventive & Social Medicine, 46(4), p.581.
2. Menezes, R., 2008. Rabies in India. Cmaj, 178(5), pp.564-566.
3. National Action Plan for Dog Mediated Rabies Elimination from India by 2030. Ministry of Health and Family Welfare, Government of India.
4. One Health Basics, CDC.
5. Zero by 30. The Global Strategic Plan, by WHO, WOAH, FAO and GARC.

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