Rabies in India: Current Trends, Challenges, Control Strategies and the Way Forward

Introduction

Rabies has been a deadly zoonotic disease affecting humans since ancient times, and it results from a bullet-shaped enveloped RNA virus that belongs to the family Rhabdoviridae and genus Lyssavirus. Saliva from an infected animal spreads the disease through wounds and mucosal surfaces. Dogs serve as the primary source of infection for rabies despite its ability to infect all mammalian species.  Throughout the world, rabies remains prevalent, and dog-mediated rabies leads to 59,000 human deaths each year, with 3.7 million disability-adjusted life years (DALYs) lost.  Rabies affects large numbers of livestock, including bovine as well as small animals apart from human victims. India experiences the highest rabies burden worldwide when considering both annual human fatalities and DALYs.  The World Health Organization data shows that 36% of all worldwide rabies fatalities occur in India.  The Southeast Asia region sees India responsible for 65% of its rabies-related fatalities.  Developing countries throughout Asia, Africa, and Central and South America face the highest risk of rabies. Modern rabies management underscores a One Health approach to control and prevent zoonotic diseases, but rabies continues to be a complex challenge because its persistence involves multiple factors.  It is essential to analyze the persistent factors that lead to rising rabies incidents in India.

Current Status of Rabies in India

Except for Andaman & Nicobar and Lakshadweep Islands, rabies is endemic in all the states and union territories of the country. An estimated 17.5 million people are bitten by animals in India every year. Since 2012, the Integrated Disease Surveillance Programme (IDSP) has reported an increase in animal bites from 4.2 million to 7.2 million in 2020. According to the National Health Profile 2018, West Bengal and Karnataka have more than half the total of Indian rabies cases. In 2021, India made human rabies a notifiable disease to generate accurate rabies incidence data, which is essential for designing and executing effective preventive and control measures. Between 2012 and 2022, the National Rabies Control Programme (NRCP) has recorded 6644 cases of human rabies, and in the National Health Profile (NHP), 2863 cases were recorded between 2005 and 2020. Back in 2005, the One Million Death Study estimated 12,700 deaths due to rabies while NHP reported 259 cases. In India, gross underreporting concerning rabies has been one of the biggest problems, likely due to deaths occurring outside hospital settings and people opting to visit traditional healers for treatment. To address this challenge, India has developed an Integrated Health Information Platform (IHIP), enabling the collection of real-time data through mobile applications.

Current Rabies Control Strategy in India

To control health risks through ‘One Health’ approach, the Tripartite of World Health Organization (WHO), World Organization for Animal Health (WOAH), and Food and Agriculture Organization (FAO) has been working together. In 2015, the WHO proclaimed a vision of Spatial elimination of dog-mediated Rabies by 2030 and launched the call for action by establishing a global objective of Zero human rabies deaths by 2030, thereby contributing to Sustainable Development Goals (SDGs)-2. Elimination of human Rabies deaths is also consistent with SDGs-1 to “end poverty in all its forms everywhere” and Member States’ commitment to ensure that “no one is left behind”. Since One Health has been recognized internationally as the best way and most logical method for addressing complex issues and challenges, the Rabies prevention and control through “One Health Approach” appears to be a daunting task in India due to the huge diversity in the administrative structures and priorities at the National and sub-national level. In response to these challenges, “The National Action Plan for dog-mediated rabies elimination” has been formulated, which integrates One Health Vision, detailing the role and responsibilities for the states/stakeholders to prepare their action plan specific to their context with an end-goal of eliminating human deaths due to dog-mediated rabies by 2030. Under its 12th Five-Year Plan, the Ministry of Health and Family Welfare sanctioned the National Rabies Control Programme (NRCP) for national-level implementation. The programme is being continued with enhanced vision and targets for elimination of Human Rabies by 2030 along with dedicated financial and technical assistance to the State Governments. Broadly, the programme is themed as follows:

• Advocacy on regular uninterrupted supply of Anti Rabies Vaccine (ARV) and Anti Rabies Serum (ARS) available up to Primary Health Centre (PHC) level for timely provision of Anti Rabies Post-exposure Prophylaxis (PEP) to all the animal bite victims.
• Model anti-rabies clinics to be established at district levels.
• Appropriate animal bite management, prevention, and control of rabies.
• Enhancing surveillance and notification for animal bites and rabies mortality.
• Awareness programs regarding prevention and control of rabies.
• Reinforcing inter-sectoral coordination with veterinary institutions, municipal corporations, and panchayat raj institutions.
• Grant to states under the National Health Mission (NHM) for district-level operationalization of the programme activities.

Why Does Rabies Still Have India in Its Grip?

Many countries in Western Europe and the Americas have already made tremendous progress in rabies elimination. Only a handful of nations, such as Japan, the UK, Australia, and New Zealand, have succeeded in wiping out the disease via their geographical isolation and strong state interventions. Being a public health issue, they are treating it as such, with long-term, sustained investment. Rabies remains underrepresented in both India and global public health discourses despite the significant burden of dog-mediated human rabies deaths in India. Even though rabies is known to be very difficult to eliminate, the following reasons are being held to account for less than successful outcomes of One Health initiatives:

• Poor awareness: A bulk of rural India remains unaware and uneducated about proper management of animal bite wounds and vaccine application. Their first aid measures become even worse after a dog bite, with some myths and misconceptions about the early management of the wound at home, with the application of red chili, lime, tobacco leaves, or the visit to a tantric to make some or the other religious customs.
• Uncontrolled Dog Population: Most of the human and animal bites in India are by stray dogs, and it is amongst the major reservoir hosts for rabies. The number of animal bites under the Integrated Disease Surveillance Project was reported to be 42 lakhs in 2012, which drastically increased by 72 lakhs in 2020. These bites include bites from animals such as dogs, cats, and monkeys, which require rabies post-exposure Exposure Prophylaxis. In India, according to a report (Rabies on the Indian Subcontinent) published in 2013, there was a dog for every 36 people, with only 20% of these dogs being pets. In India, rabies is transmitted commonly by dogs and cats (~97%), followed by wild animals (2%) such as mongooses, foxes, jackals, and wild dogs, and occasionally by horses, donkeys, monkeys, cows, goats, sheep, and pigs. It has been observed that vast numbers of unvaccinated free-ranging dogs (FRD) or street dogs present in human settlements are a predisposing factor for widespread rabies epidemiology in India, where it remains endemic.
• Insufficiency in rabies control programs: In India, the first step of the rabies control programme focused more on strengthening technical inputs and enhancing laboratory capacities as opposed to a holistic approach tailored to the epidemiological characteristics of the disease.
• Canine population strategies, including Animal Birth Control Programs, have been advocated to a number of states. But to make the Animal Birth Control approach effective, 70% of the stray dogs in the geographic area must be sterilized within six months. So while a few communities have implemented the ABC strategy, many of these communities have been unable to sustain it, since resources are limited.
•  In the affected areas, where other diseases are given higher priority, there is no proper evaluation and necessary information on the rabies control program and its vaccine campaigns. Animal interventions are found to be more lacking in rural areas, and where the urban regions also come under pressure from NGOs, the surveillance system struggles to identify all cases of dog bites due to the lack of accurate state-specific rabies burden research and insufficient inter-sectoral coordination.
• Underrating and Misdiagnosing: Most cases of human rabies remain unnoticed, misdiagnosed, or underreported, preventing an accurate assessment of the true burden of the disease and effective control measures.
• Geography and Socio-economics: It has been observed that the disease occurs more often (especially encephalitic forms) in rural populations with limited healthcare access and diagnostic options.
• Inconsistent Supply of Vaccines: The factors contributing to rabies endemicity in Indiaare several, including variable supply of immunoglobulin and anti-rabies vaccines, particularly in primary healthcare establishments. Although anti-rabies vaccines and immunoglobulins are manufactured in India, and one can avail both in public hospitals without spending, India must ramp up production of modern cell-culture vaccines to overcome procurement delays in receiving rabies antibodies. India needs 3.5 crore doses of yearly anti-rabies vaccine as per estimates but is facing an acute shortage. Rabies vaccines are comparatively difficult to access, and every year, 28 million doses of the anti-rabies vaccine are produced by national and international vaccine manufacturers. Manufacturers also demand that they need accurate figures ahead of time, as internal testing can take 45 days, and bulk production requires another 30-45 days. Moreover, the vaccine remains mostly available in urban areas and certain capital cities. Financial constraints in these centers result in insufficient procurements, an unmonitored regulatory environment, market prices, and stock-outs. Thus, the victims are either delayed to get pre- & post-exposure from the available centers or made to rush and get it from the private stakeholders and have out-of-pocket expenditure
• Vaccine Failure: Rabies is a disease that can be prevented through vaccination. The Indian regimen for rabies immunization has now adopted the revised Thai Red Cross Schedule for Intramuscular (IM) and Intradermal (ID) vaccination. The standard scheme of post-exposure prophylaxis (PEP) is eight ID doses (two sites per visit on days 0, 3, 7, and 28) or five IM doses on days 0, 3, 7, 14, and 28. Improper or no Rabies Immunoglobulins (RIGs) administration or poor wound management allows more time for the virus to propagate. Despite receiving the proper PEP, an unfortunate outcome might be possible.  After the vaccine has been given,  it is a race between the body to generate antibodies and the virus to invade the brain. In areas of the body best supplied with nerves or close to the brain, according to one theory, the vaccine wouldn’t have enough time to take effect.  Thus, the vaccine needs to be administered as soon as possible to prevent rabies, and passive immunity is also generated as soon as possible with the administration of RIGs. Some cases of cold chain failure and substandard or fake vaccines have also been documented, though more rarely. Different state-level trainings are being conducted on animal bite management and rabies prophylaxes to train medical officers and health workers; however, ineffective administration of intradermal rabies vaccine (IDRV) still stands as an uncommon cause of vaccination failure.

The Way Forward

As part of its plans, the Centre for One Health, which works under the National Center for Disease Control (NCDC), is also focusing on strengthening rabies prevention and control through the digitalization of rabies vaccinations with technical support from the United Nations Development Programme (UNDP). This digital initiative will include monitoring of rabies vaccine stocks in real time, tracking of beneficiaries, and ensuring that all doses of the rabies post-exposure prophylaxis regimen are administered in a time-bound manner. The proposed digital platform, under development, will facilitate information centralization, improving collaboration between healthcare providers, municipal authorities, and veterinary services. UNDP has had a longstanding partnership with the Government of India on supporting innovative and scalable digital solutions for health. This partnership has already resulted in scaled-up development of a couple of digital health solutions like the Electronic Vaccine Intelligence Network and Winning Over COVID, which has helped digitize information related to vaccine stocks,  registration, immunization, and digital vaccine certificates.

The journey towards rabies elimination is arduous; however, via sustained commitment to public awareness, vaccination, and digitalization, India is making progress towards its target. With the continued efforts of government agencies, healthcare professionals, and the public, India’s work is bound to be a global leader against rabies, ultimately leading to a healthier, safer future for everyone.

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