Evidence Express: RABIES - A serious but preventable public health problem

www. who-rabies-bulletin.org

My childhood pets were always dogs of varied breeds. My dad was of the view that if you owned dogs, they had to be guard dogs (and guard dogs and many other dogs, for that matter, bite).

Having worked on a rabies vaccine trial earlier, I learnt that when you have dogs, getting bitten is inevitable. However, quite often, pet owners don’t take being bitten by pet dogs seriously and do not seek help following a bite. If pet dogs are not vaccinated regularly, then the risk of rabies is predictable.

Rabies is a lethal but preventable disease and is a grave public health problem in low income countries.

www.theguardian.com

The Global Scenario

The World Health Organization (WHO) estimates that nearly 55,000 people die annually due to rabies, and that the majority of deaths occur in Asia and Africa.(1) However, in comparison, in developed countries like the United States, only 2-3 deaths due to rabies are reported each year. The stark difference is owing to proper animal control and development of effective human rabies vaccine and immunoglobulins.

The majority (97%) of rabies infections in humans are as a result of dog bites (http://www.cdc.gov).The most common mode of transmission is from the saliva of an infected animal as a result of a bite.

Worldwide risk of contracting Rabies (2009) Image courtesy: WHO

Rabies in India

India has the highest rate of rabies in the world. Every year, approximately 20,000 people die due to rabies in India (http://rabies.org.in).The high numbers co-relate to the ever-increasing number of stray dogs in the nation .In 2000, an estimated 22 million stray dogs inhabited the streets of India (http://www.globalissues.org/news).Statistics reveal that every 2 seconds someone gets bitten by a dog and every 2 hours a child dies of rabies in India (http://www.missionrabies.com).

Dispelling the myths about Rabies

The public quite often lack a general awareness regarding rabies and several false notions have gained acceptance over time. A few common myths and related facts:

Rabies Control Programmes

Several programmes have been instituted with the objective to promote surveillance and prevent outbreaks of rabies by timely detection and control.

One such programme that has been proven to be effective is the Animal Birth Control (ABC) programme, wherein stray dogs are sterilized and vaccinated against rabies with the view to control dog population size and rabies. (2) ABC replaced the previous “catch & kill” policy as this was not successful in resolving the issue, since other stray dogs rapidly inhabited areas previously occupied by the killed dogs.

Global Alliance for Rabies Control (GARC) (http://rabiesalliance.org) aims to eliminate rabies in both humans and dogs by increasing awareness via education and campaigns on a global front for increased resources for rabies prevention and control. GARC has put together a guidelines (rabiesblueprint) to help enable countries eliminate animal rabies and thereby end human rabies.

In developing countries like India, young children are at an increased risk for developing rabies, it has been suggested that anti-rabies vaccine be included in the routine immunization schedule.(3)

Mission Rabies, (http://www.missionrabies.com) the brainchild of Luke Gamble was founded with a vision to save thousands of lives, of not only humans but also of dogs. Mission Rabies has embarked on an incredible journey starting in September of this year, venturing across India to its worst rabies-affected areas, with the mission of vaccinating about 50,000 dogs throughout the nation by the end of the month .It also endeavours to train vets to neuter dogs and run vaccination campaigns. The programme will return every September for mass vaccination drives to coincide with world rabies day.

Mission rabies has also taken the initiative to establish a national network (India National Rabies Network) along with the Association for Prevention and Control of Rabies in India (APCRI) and the Animal Welfare Board of India (AWBI).This will launch the first ever database in the country where details pertaining to canine rabies vaccination will be recorded .The network will also support the mass canine vaccination campaigns by supplying cost-effective vaccines.

Often the failure of rabies control programmes is owing to the minimal or total absence of commitment from major stakeholders such as the policy makers and legislators. In recent times, due to increased awareness political commitment is slowly increasing and several countries like, Thailand, Philippines and India are hoping that their nations would be rabies free by 2020.

Reliance on post-bite immunization alone is very expensive (estimated to cost India around 25 million $ per year), and will not effectively eliminate rabies, unless combined with measures to eliminate rabies virus in dogs by vaccinating them. Evidence shows that the most effective and successful measure for controlling canine rabies is mass canine vaccination drives.

Prevention of rabies

With rabies, prevention is the ONLY cure as, once symptomatic, it is fatal. Prevention can be an amalgamation of various interventions such as pre-exposure prophylaxis for those at risk, post exposure prophylaxis (PEP) for potentially exposed people, control of infection in animals, and control of stray dogs. Evidence shows that there is a considerable gap in the knowledge base in the community (both medical field and general public) regarding wound care following dog bites and post exposure prophylaxis.(4–6)

References:

1. Freuling CM, Klöss D, Schröder R, Kliemt A, Müller T. The WHO Rabies Bulletin Europe: a key source of information on rabies and a pivotal tool for surveillance and epidemiology. Rev Sci Tech Int Off Epizoot. 2012 Dec;31(3):799–807.
2. Totton SC, Wandeler AI, Zinsstag J, Bauch CT, Ribble CS, Rosatte RC, et al. Stray dog population demographics in Jodhpur, India following a population control/rabies vaccination program. Prev Vet Med. 2010 Oct 1;97(1):51–7.
3. Karande S. Update on available vaccines in India: report of the APPA VU 2010: I. Indian J Pediatr. 2011 Jul;78(7):845–53.
4. Sudarshan MK, Madhusudana SN, Mahendra BJ, Rao NSN, Ashwath Narayana DH, Abdul Rahman S, et al. Assessing the burden of human rabies in India: results of a national multi-center epidemiological survey. Int J Infect Dis. 2007 Jan;11(1):29–35.
5. Singh A, Ahluwalia S, Bhardwaj A, Mithra P, Siddiqui A. A cross-sectional study of the knowledge, attitude, and practice of general practitioners regarding dog bite management in nothern India. Med J Dr Patil Univ. 2013;6(2):142.
6. Singh U, Choudhary S. Knowledge, Attitude, Behavior and Practice Study on Dog-Bites and Its Management in the Context of Prevention of Rabies in a Rural Community of Gujarat. Indian J Community Med. 2005;30(3):81.
7. http://www.who.int/rabies/PEP_prophylaxis_guidelines_June10.pdf