Rabies: one health no death-ALL FOR ONE- ONE HEALTH FOR ALL
Dr. Aditya Pratap
PhD Scholar, Department of Veterinary Medicine
College of Veterinary Science & A. H., Jabalpur, NDVSU, Jabalpur
Rabies is an acute, progressive and fatal encephalomyelitis caused by Rabies virus belonging to the family Rhabdoviridae and genus Lyssavirus. All warm-blooded animals including livestock of different species are susceptible to the disease, which has Zoonotic importance in terms of its transmissibility to human beings. As per the available literature, about 96% of the mortality and morbidity of this disease is associated with dog bites.
This could make Louis Pasteur shake his head in disbelief. The French doctor had developed the first vaccination for rabies, a virus that inflames the brain and induces hallucination before death. According to the National Health Profile 2018, the virus is still India’s top killer 130 years later. According to the data, which was made public on June 25, every one of the 97 individuals who contracted the condition last year passed away. 36% of annual rabies deaths globally, according to the World Health Organisation (WHO), occur in India. While one can develop the disease if bitten or scratched by any rabid mammal, such as monkeys or bats, WHO says dogs contribute up to 99 per cent of all rabies transmitted to humans; and children are the usual victims.
The Sanskrit term “rabhas” (which means “to do violence”), which is where the word “rabies” first appeared, dates back to 3000 BC. This illness is known as rabies in animals and hydrophobia in people. A bite from an animal that injects the virus into wounds nearly always causes the disease to spread. Rabies has incredibly infrequently been spread through exposures other than bites that allow the virus to enter open wounds or mucous membranes. All mammals are thought to be vulnerable, but carnivores and bats are reservoirs. Even though canines are the primary carriers of the disease in poor nations, there are enough regional variations in the disease’s epidemiology.
As per World Health Organization reports, annually between 30000 and 70000 deaths occurred throughout the world due to rabies infection. Rabies is present on all continents, except Antarctica, with over 95% of human deaths occurring in the Asia and Africa regions. In India which accounts near about 36.0% of the world’s rabies death and true burden of rabies in India is not fully known but 18000-20000 deaths every year as per the available data.
Dogs are thought to be one of the main animal reservoirs for rabies transmission in urban areas and in Asian nations like ours. Once clinical symptoms start to show, the condition is virtually always fatal. Disease is primarily spread via an infected dog’s bite or scratches, or if a person has cuts or tiny scratches and comes into touch with the saliva of an infected animal. Aerosols harbouring the virus can be inhaled, and transplanting infected organs like the cornea has a very small risk of rabies transmission. The theoretical possibility of human-to-human transmission by bites, saliva, or intake of raw meat or milk from infected animals has never been proven.
The length of the rabies incubation period, which ranges from three weeks to three months, is determined by the location and intensity of the bite as well as the amount of virus that was transmitted. Once the virus has reached the bite site, it replicates there before moving on to neuromuscular junctions, where it subsequently travels to the brain, spinal cord, and peripheral nervous system. Once the virus has completed its CNS replication, peripheral nerves allow it to centrifugally move to the salivary glands and other organs. Adrenal glands, brown fat (interscapular gland) of bats, kidneys, bladder, ovaries, testicles, sebaceous glands, germinal cells of hair follicles, cornea, tongue papillae, and intestinal wall have all been found to have the virus.
Dog Bite can be categorized into three categories to decide line of treatment i.e. category I, II and III as per WHO.
Category I- touching or feeding animals, animal licks on intact skin (no exposure)
Category II- nibbling of uncovered skin, minor scratches or abrasions without bleeding (exposure)
Category III- single or multiple transdermal bites or scratches, contamination of mucous membrane or broken skin with saliva from animal licks, exposures due to direct contact with bats (severe exposure).
In human it is present in two forms one is classical rabies and another one is dumb rabies. In classical rabies most of the cases are go through three stages which are prodromal stage, sensory excitation stage and then coma and paralysis phase.
Prodromal form lasts from 2-10 days and presents in the form of fever, headache, malaise, fatigue, and also localized pain around area of initial infection.
Sensory excitation phase include signs like hyper reactivity, hallucinations, disorientation, seizures and bizarre behaviour. About 50% of infected individuals developed painful spasms of the pharynx and larynx resulting in a fear to eat or drink. Hydrophobia (fear of water) is pathognomonic feature of rabies.
The first-aid measure includes immediate and thorough flushing and washing of the wound for a minimum of 15 minutes with soap and running water, detergent, povidiene iodine or other substances that remove and kill the rabies virus. Suturing should be avoided and if required only after rabies immunoglobulin administration and at-least one shot of vaccine. Immunoglobulin and vaccine should not be injected at the same sites.
Prevention and control include vaccination in which Use of Cell Culture vaccines that will provide stable and long-lasting immunity is recommended. First vaccination of dogs and cats at the age of 3 months, the booster at the age of 12 months and subsequently, biannual vaccination is prescribed. The quickest and best approach to prevent this disease in society is to vaccinate your dog, which will protect not only your pet but also your family and society as a whole. Regular booster shots, stray dog population management, and awareness campaigns are also crucial.
Post exposure vaccines available are Human Diploid Cell Vaccine (HDCV); Purified Chick Embryo Cell Vaccine (PCEC); Purified Vero Cell Rabies Vaccine (PVRV) and Purified Duck Embryo Vaccine. These vaccines can be given intramusculary at five intervals i.e. day 0, 3, 7, 14 and day 28. The sixth injection (Day 90) should be considered as optional and should be given to those individuals who are immunologically deficient.
The deltoid region is ideal for the inoculation of these vaccines. Gluteal region is not recommended because the fat present in this region retards the absorption of antigen and hence, impairs the generation of optimal immune response. Rabies immunoglobulin (RIG) should be given for all class ІІІ exposures, irrespective of the interval between exposure and beginning of treatment.
Target zero death up to 2030
According to estimates, there are 1.7% more animal bites each year. Given the alarming statistics on dog-mediated rabies and the threat it poses to human health, it is clear that in a nation the size of India, we want a long-term plan with realistic future objectives in order to eradicate dog-mediated rabies by 2030.
The control and prevention of Rabies include two very important components which should work in a very coordinated and organized manner. The two components are– Animal Health Component and Human Health Component upon which we base our strategy to eliminate rabies.
Animal Health Component:-
Rabies, as we know, is a zoonotic disease caused by Lyssavirus (Family: Rhabdoviridae). The virus is transmitted by the bite of a rabid animal and generally enters the body via infiltration of virus laden saliva of the rabid animal. Thus, in order to eliminate the virus we must first identify and control its source i.e. the rabid animals.
- ABC for Dogs :-
Most animal bites in India are by dogs, of which about 60% are strays and 40% pets. Also among the people bitten by dogs, most of them belong to lower socio economic strata. Thus, Animal Birth Control (ABC) becomes even more crucial. Monitoring committees could be set up at state level to ensure a smooth running ABC programme. NGOs, activists and local corporations alike should be a part of these monitoring committees.
Surely, catching the dog in a humane way and conducting the neutering process would require much time, energy and manpower but once the population is under control, the incidences of rabies would eventually decrease (WHO, 2016).
- Anti Rabies Vaccination for dogs :-
According to OIE, mass vaccination of dogs in infected areas is the only way to permanently interrupt the disease’s infectious cycle between animals and humans. It is estimated that by vaccinating 70% of the dogs in infected areas, rabies could be eradicated in dogs and the number of human cases would rapidly drop to zero. Excellent anti rabies vaccine for dogs, developed according to the OIE standards are nowadays available.
The cost economy of vaccines is a constraint in such mass vaccination programme but the government should work with organizations such as WHO in order to economize vaccination. Also, the campus vaccination drives should be organized in Veterinary Science Universities and with the help of other government bodies. A sustainable vaccination development system should be established at immunological institutes.
- Responsible pet ownership :-
Those who pet dogs should take responsibility for annual vaccination of their dogs as well as to get their dogs registered under the local Municipal bodies which would help in surveillance.
- On site Treatment :-
If a dog is found bitten by another rabid or even non rabid dog , on site first aid should be provided. The WHO has classified these dog bites into three categories according to their severity so the treatment should be done accordingly. Also the bitten animal should be kept under observation for atleast 10 days. This would help in identifying rabid cases and controlling them at the source itself.
Human Health Component:- Our medical counterparts share an equally important role against the spread of the disease and its control .
- Education in Schools :- It has been observed that rabies affects mainly the people of lower socio economic strata and children between the age of 5 and 15 years . Thus, it becomes very important to make children aware of the disease- its transmission , diagnosis , first aid and treatment . This might help in spreading awareness and also prevention against Rabies . In a familiar environment like schools , children once get educated about the disease would become more responsible and alert against the cases of bite by animal.
- Counselling in Hospitals :- According to one study , only 70% people in India has ever heard of rabies while only 30% know to wash the wound after animal bites. Most people form lower socio economic classes do not even sought medical advice. In such condition, people who had been bitten needs counseling and right information about post exposure prophylaxis as well as about the severity of disease to prevent misinformation driven ignorance which may cost them their life. This would not only save human lives but also make public aware.
- Post bite care and observation :- Post bite care and Observation thereof is a crucial part as this disease is highly fatal.
In order to have a well-functioning co-ordination among these two components an intersectoral approach is required among the government and the public which would consist of the engagement of Community as well as Government .
Community Engagement :-
To work with local communities who are often parents to neighbourhood dogs, to develop a positive relation between dogs and people , to spread awareness regarding Rabies, to start campaigns against Rabies and vaccination of dogs the engagement of local community is needed .
Government Engagement:-
Given the conditions that prevail in India the above mentioned measures are only possible if the government plays an effectively active role. Government of India along with some international organizations such as WHO has started initiatives such as the Surveys conducted by Association for Prevention and Control of Rabies in India (APCRI) which aims to eliminate rabies from India by 2030 and also support rabies surveillance in Humans.
Also the government should emphasize on public health educational strategy at the community level within endemic region along with continuous education of veterinary professionals in rabies prevention and control. The provision to euthanize dogs suffering from rabies should be implicated more firmly and regular surveillance of dog population (both pet dogs and stray dogs) in an area by local municipal bodies should be done.
Collaborations of national and international as well as government and non-government organizations in order to create mass awareness about rabies and also to provide mass vaccination of dogs in an economic way in order to eliminate rabies could prove to be a revolutionary step.
WHO promotes organization of sustainable mass dog vaccination campaigns and dog population management through reduction of stray population as an effective measure for control of rabies and its eventual elimination.
The prevention of human rabies is dependent upon the effective and verifiable control of the disease within the domestic dog population, being the most common reservoir of virus and cause of 99% of human cases. Dog mediated rabies is completely preventable using biologicals and tools that could be accessible even in low resource settings. Public awareness, health education, dog vaccination and the accessibility and availability of Post exposure prevention are keys for rabies prevention and control.
The elimination of Rabies, however, requires several components in addition to Mass vaccination, including the effective engagement of communities and policymakers, dog population assessment and management, surveillance capacity and legislation.
In conclusion, it is safe to say that elimination of dog mediated rabies by the year 2030 could be a very difficult task yet not a feat impossible to achieve if we decide it in on our own and follow all the objectives and government rules and policies.
