Rabies - A challenge to "One Health" approach

Rabies is a highly infectious and fatal Zoonotic disease, which kills 59,000 people every year. India holds one third of the global burden and two third of the South-East Asia Rabies burden.

Rabies - A challenge to "One Health" approach
Photo by mark chaves / Unsplash

There are growing incidents of attacks on children and adults by stray dogs in India. Children are most vulnerable to dog bites in India. Stray Dogs refers to homeless canines. They live, eat and die on streets. The reasons behind their huge population are: their ability to scavenge, rapid reproduction, their affable nature. The prevalence of un vaccinated free roaming dogs is a major contributor to the high incidence of rabies in India.

The problems come when their countless population coincides with attacking people (humans). Their wild nature poses dangers to people and other pet animals. India bears 36% of the world's human rabies deaths. In India alone, there are two million dog bites every year. Most of them are by stray dogs. These painful biting causes the risk of rabies. Rabies is a highly infectious and fatal Zoonotic disease, which kills 59,000 people every year. In every 55000 deaths due to rabies, 49,500 deaths are from Asia. It is caused by lyssavirus. It affects brain stem functions, causing hydrophobia, aerophobia, photophobia, respiratory paralysis and death.

Huge burden of Rabies Deaths in India

Rabies is a zoonotic disease. India holds one third of the global burden and two third of the South-East Asia Rabies burden. In India it is an endemic and 96% of the mortality and morbidity due to rabies is associated with dog bites.

The number of animal bites reported under the Integrated Disease Surveillance Project, has increased from 42 lakhs in 2012 to 72 lakhs in 2020.

Figure 1: State wise cases of Dogs bites per million human population in year 2014, data source IDSP, GOI
Figure 2: State wise cases of Dogs bites per million human population in year 2020, data source IDSP, GOI
Figure 3: NRCP data for clinically suspected human rabies cases and deaths (2012- 2020) , data taken from 26 states
Figure 4: Number of reported deaths from rabies , source Central Bureau of Health

History of Rabies

While for 4000 years rabies has tortured human lives, however, it is only in the 1500s it was suggested that rabies transmits through broken skin through animal bites. In 1885, it was Louis Pasteur who created the first effective vaccine against rabies. In India the first Pasteur Institute in India started in 1900 became the center of attraction for treating rabies. In 1907, for the first time in India anti rabies vaccine was produced. However after many years, rabies control efforts in India have seen (under the 11th five-year plan) where there was a promise made to control rabies in animals and their vaccination was talked about.  In 2006, there was introduction to nerve tissue vaccine.

Economic loss

Rabies disease not only puts a burden on health systems, but it also imposes a heavy economic burden on the state.

Figure 5: Economic burden due to rabies disease, globally

Prevention is always better than the cure. Here there is a huge cost difference between vaccinating dogs and the treatment of a person after getting bitten by a dog. Indicative Rabies Treatment Cost per Patient( Average Cost) is US$ 108.07. Mass dog vaccination cost per dog is around US$ 4.03.

Every nine minutes, one person dies of rabies.

National Action Plan for Dog Mediated Rabies Elimination from India (NAPRE) by 2030

A year back, India came up with its first National Rabies Elimination Program. According to the 2021 press release by the WHO, India had launched its "New Action Plan for Mediated Rabies Elimination (NAPRE) by 2030. NAPRE has set up a action plan which aims at a systematic reduction of Rabies through mass vaccination,  uninterrupted supply of anti rabies vaccines, anti rabies serum, establishing model anti rabies clinic at district levels, strengthening surveillance of animal bites at all levels specially at panchyati raj institutions, pre and post-exposure prophylaxis and awareness.

India is signatory to 2015, a global alliance to eliminate rabies by 2030 (read below). India under its present rabies control methods falls under the stage 3 (total stages 5). These stages are based on the "United against rabies forum" which divides the endemic countries into 5 stages as per their efforts to control rabies. Stage 3 talks about the full scale implementation of the national rabies control strategy and no death due to indigenous acquired rabies death in past 12 months. However, the question here is to ask ourselves about the reality and evidence to back this promise and declaration.

Zero by Thirty, WHO initiative

In 2015, a goal was set to eliminate global dog mediated rabies death by 2030. It is for the first time wherein the entire world and its stakeholders (WHO, FAO, OIE, GARC) have join hands to work upon the elimination of rabies. Countries like Western Europe, Canada, the USA, Mexico, Japan, and Latin America have already eliminated dog mediated rabies. The big three objectives were constituted as a global strategy.

Objective 1 : Awareness

to effectively use vaccines, medicines, tools and technologies to reduce human rabies risk

Objective 2: effective policies and programs

to generate, innovate and measure impact to provide guidance and data

Objective 3: United Against Rabies

to sustain commitment and resources from multi stakeholders

Thus, Rabies elimination program is well consistent with sustainable development goal 1 to "end poverty in all forms' and the idea of leaving no one behind. However, rabies elimination efforts are not universal across various states and regions. The availability of standard animal vaccines (dog bites) are not available uniformally. There is an urgent need to understand once again the One health approach through sustained political, social and administrative support. It also requires interventions from the animal husbandry sector, human health departments. local governing bodies, communities, etc.