CONTROL AND ERADICATION OF RABIES IN INDIA
Dr. Smruti Smita Mohapatra
PhD Scholar
Dept of Veterinary Physiology
WBUAFS, Kolkata
Rabies is a zoonotic disease which is fatal yet preventable. About 55,000–60,000 persons die of rabies, of which 20,000, that is nearly one-third are from India alone each year. About 99% (97% in India) of these deaths are following bites/exposures to dogs, i.e., dog-mediated human rabies. Rabies is classified widely under the neglected tropical and zoonotic diseases. However, in December, 2015, the World Health Organization (WHO) at a global rabies conference held at Geneva, Switzerland, 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. Consequently, as a responsible nation of the global community, India needs to drastically reduce its burden of human rabies. Hence, in July, 2016, at the 18th national conference of rabies organized by Association for Prevention and Control of Rabies in India (APCRI) at National Institute of Mental Health and Neurosciences, Bengaluru, it was resolved to support and work for accomplishing the global goal by ensuring a dog-mediated human rabies-free India by 2030. Rabies is primarily a disease of terrestrial and airborne mammals, including dogs, wolves, foxes, coyotes, jackals, cats, bobcats, lions, mongooses, skunks, badgers, bats, monkeys and humans. The dog is the main reservoir of rabies in India. Monkeys, jackals, horses, cattle and rodents, seem to bite incidentally on provocation, and the fear of rabies leads the victim to seek postexposure prophylaxis. The number of cases involving monkey bites has been increasing in the last few years. Monkeys are susceptible to rabies, and their bites necessitate postexposure prophylaxis. It is an acute viral disease that causes fatal encephalomyelitis in humans. Rabies, though a disease of low public health priority, still continues to be a major public health problem in India. In humans, rabies is almost invariably fatal once clinical symptoms have developed. WHO reports around 50 000 rabies deaths every year, out of which 20 000 are estimated to occur in India alone. There is often gross under-reporting of human rabies deaths in India. Despite potent anti-rabies vaccines and immunoglobulins available, rabies is far from control and elimination. An effective strategy for control of rabies takes into account the epidemiology of animal bites, rabies and factors influencing post exposure treatment. Hence it becomes pertinent to review the current status of rabies and strategies for its control in the country. Thus it is important to discuss the epidemiology of Rabies, pathogenesis, diagnosis and its prevention and control including the various regimens of anti-rabies vaccines and immunoglobulins available for post-exposure prophylaxis. The importance of primary preventive measures like Animal Birth Control (ABC) and vaccination of dogs needs to be highlighted. It is emphasized that rabies should be recognized as priority public health problem and cell culture vaccines should be made available free of cost at all government health facilities. Other important measures include generation of awareness about rabies and first aid of animal bites. Rabies is one of the oldest recognized diseases affecting humans and one of the most important zoonotic diseases in India. It has been recognized in India since the Vedic period and is described in the ancient Indian scripture Atharvaveda, wherein Yama, the mythical God of Death, has been depicted as attended by 2 dogs as his constant companions, the emissaries of death. Rabies is endemic in India, a vast country with a population exceeding 1.02 billion and a land area of 3.2 million square km. The present estimate of human rabies burden of 20,000 per year is based on a WHO-APCRI national multicentric survey done in 2003 that is now redundant. Because at that time (of the survey), the rabies postexposure prophylaxis (PEP) mainly consisted of sheep brain vaccine which was not only reactogenic but also less efficacious, and the use of lifesaving rabies immunoglobulins was negligible (≈2%). However, in 2005, the Semple vaccine was discontinued and replaced by modern vaccines that are very safe and highly efficacious. In 2006, cost-effective intradermal rabies vaccination was introduced in the government hospitals in the country. Besides, the overall socioeconomic improvements have led to more literate masses and better rabies awareness, improved roads, transport and communications leading to better access, and utilization of vastly improved health-care facilities. The resultant better availability, access, and use of rabies biologicals have shown a remarkable reduction in the human rabies incidence in the isolation/infectious disease hospitals that serve as sentinel centres for disease surveillance in the country. The onus of reassessing the burden of rabies in India is now vested under the leadership of National Centre for Disease Control, Delhi, WHO collaborating centre for rabies epidemiology that also serves as the WHO/national focal point for rabies in India. It is recommended that this activity is done in collaboration with APCRI, the organization that did the first rabies burden survey of India in 2003 and has the necessary expertise and experienced public health professionals in its fold. Incidentally, the APCRI in the first half of 2017 under a WHO project is assembling new evidence in support of dog-mediated human rabies elimination in India considering cost-effectiveness, feasibility, and impact of improving access and coverage to rabies PEP and aspects of rabies vaccination policies. This will provide the much needed information, support, guide, and strengthen the initiatives of the government. It is important to immediately galvanize and relaunch the National Rabies Control Programme (NRCP) 2012–2017 by revising its strategy in consonance with the new global goal of the WHO by incorporating the “effective one health approach” and with the vision of achieving “dog-mediated human rabies-free India” by 2030. The revised NRCP shall have a clear action plan, road map, and a task force to drive it. It is time now to make “human rabies a notifiable disease” as it ensures a continuous surveillance of the disease. Initially, the disease may be made “reportable” based on clinico-epidemiological assessment (probable case/rabies) as sociocultural practices and practical feasibilities do not permit a laboratory diagnosis of confirmed cases of rabies in the humans. The rabies biologicals, vaccines and immunoglobulins as lifesaving drugs must be exempted as applicable from the goods and services tax by the Central/State Governments. At present, the single-handed approach to prevention of human rabies and the reduction of its burden by focusing mainly on medical interventions has not been fruitful. Hence, as an effective “one health approach,” it is recommended to target the source of infection, i.e., control the problem of rabies in dogs. Consequently, through well-organized communication campaigns and participatory approach, renewed efforts must be made to popularize and enforce compulsory licensing of pet dogs in urban areas to begin with and later on to cover other areas; ensure accountability of Animal Birth Control programme for dogs in urban areas through periodic dog population surveys; and introduce annual mass dog vaccinations campaigns. There is an urgent and immediate need for improving the availability, accessibility, and networking of rabies diagnostic laboratories in the veterinary sector. Management of stray dog population, diagnosis of rabies and use of vaccines and immunoglobulins are important methods to control rabies. The international support of UN agencies such as the WHO, UNICEF, OIE (World Organization for Animal Health), and others may be solicited for this marathon effort. The national and international nongovernmental organizations 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. To ensure a strong platform of information on one health, a network of all medical, veterinary, and other organizations working for the elimination of rabies in the country must be established through “RABINet,” the rabies network of India. Rabies is caused by a virus that is transmitted to humans through the infected saliva of a range of animals. But most human deaths follow a bite by, or exposure to, an infected dog. Between 30% and 60% of the victims of dog bites are children under the age of 15 in countries where rabies is endemic. the government is doing more to promote rabies awareness with initiatives such as a pilot project to prevent human rabies deaths launched by the National Centre for Disease Control (NCDC) – formerly the National Institute of Communicable Disease – in 2008 in five Indian cities. The pilot 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. Launched in collaboration with WHO, the pilot also aims to ensure that anti-rabies vaccines and anti-rabies serum are available and to boost the ability of hospitals and health centres to diagnose cases. A significant part of the pilot is close cooperation with the national animal husbandry department and partners in other sectors. The contribution of nongovernmental organizations has also been a crucial part of an improving picture, 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.
