Jay Prakash Yadav* and Maninder Singh

Introduction

Rabies is a zoonotic (disease transmitted naturally from vertebrate animals to humans and vice a versa) disease caused by Lyssa virus of Rhabdoviridae family. The disease has a high case fatality rate (~ 100%). However, at the same time, the disease is 100% vaccine preventable also. Rabies is prevalent in more than 150 countries and continents, and causes around 60,000 human deaths each year.  India is endemic for rabies and has one-third (36%) of annual rabies deaths in the world. Around 40% of rabies victims are children under 15 years of age. Warm blood animals, mostly dogs (~99%) are the main source of rabies transmission to humans. The virus is present in the saliva of rabid animals and inserted into the body through the bite of the animal. For the first time in the country, the National Rabies Control Program (NRCP) was implemented by the Ministry of Health and Family Welfare, Government of India in 2008 (an initiative under the 11th Five Year Plan). NRCP reported 6644 clinically suspected cases and deaths of human rabies between 2012 and 2022. To make people aware about this deadly disease, World Rabies Day (WRD) is celebrated every year on 28th September. This day is also important because it is the death anniversary of French microbiologist, Louis Pasteur, who discovered the first rabies vaccine in 1885. This year, the theme of WRD is “All for 1, One Health for All” which emphasises the need for an inter-sectoral and multidisciplinary approach to combat this fatal disease involving coordination, communication, and cooperation between human, animal and environmental health science professionals. The United Against Rabies Forum takes a multi-sectoral, One Health approach bringing together governments, vaccine producers, researchers, NGOs, and development partners to one platform. This campaign is supported by international health agencies including the World Organization for Animal Health (WOAH), the World Health Organization (WHO) and the Food and Agriculture Organization of the United Nations (FAO).

Clinical Symptoms of Rabies

The incubation period (the time interval between the bite and occurrence of clinical symptoms of the disease) of rabies varies from 4 days to 2 years, sometimes even more. The initial symptoms of the disease are headache, fever, nausea, vomiting, anxiety, confusion, hyper-excitability, hallucinations, and insomnia. Later, it turns into difficulty in swallowing (hydrophobia), excessive salivation, partial nerve paralysis, and aero-phobia. The death due to the disease invariably occurs in 4 days to 2 weeks due to cardio-respiratory failure.

Prevention and Control:

  1. Creating awareness about the disease in the society: Effective mass media campaigns are necessary to educate the public about rabies (especially children who have the highest occurrence of dog bites), first aid measures, and the importance of seeking timely care.
  2. Anti-rabies mass vaccination and sterilization of stray dogs as a means of population control.
  3. Provision of rabies vaccine and immunoglobulin through national free drug initiatives.
  4. Training of health care workers on appropriate pre-and post-exposure prophylaxis:
    1. Pre-exposure prophylaxis: It should be advised in high-risk populations and children having less access to post-exposure prophylaxis and where the incidence of dog bite is greater than 5%.
    2. Post-exposure prophylaxis:
      1. Animal bite wound management: After the dog bite, the wound should be flushed and washed with water and soap for a minimum of 15 minutes. After washing antiseptics such as povidone-iodine should be applied on the site of the bite.
      2. Post-exposure rabies vaccination: After proper washing of the wound, there is a need to take an effective rabies vaccine that meets WHO standards with the following schedule: Eight intradermal (IM) doses, two sites per visit on days 0, 3, 7, 28; or five intramuscular (IM) doses on days 0, 3, 7, 14, and 28. Administration of rabies immunoglobulin should also be carried out in case of a severe dog bite (WHO Category III of Post-exposure prophylaxis measures).
    3. Strengthening surveillance of animal bites and rabies deaths reporting involving inter-sectoral, multidisciplinary approach.
    4. Proper disposal of solid wastes and dead animal carcasses – as it attracts stray dogs and leads to an increase in dog bite cases.
    5. States and Union territories should participate to declare rabies a notifiable disease (any disease that is required by law to be reported to government authorities).

One Health Approach to Reduce the Disease Burden

Rabies control programme offers a great example to operationalize the One Health approach which is crucial to establishing systems for the control of zoonotic diseases, including those that are pandemic-prone. One Health Approach involving equality and strengthening overall health systems involving collaboration and joining forces across sectors is also essential to achieve a Global Strategic Plan for the elimination of dog-mediated human rabies deaths by 2030. In the year 2021, the Ministry of Fisheries Animal Husbandry & Dairying and the Ministry of Health & Family Welfare, Government of India jointly launched the ‘National Action Plan for Dog Mediated Rabies Elimination (NAPRE)’ from India by 2030, emphasizing the need for One Health Approach to achieve this target. The Central Government also framed the Animal Birth Control (ABC) Rules, 2023 to control the stray dog population. The main focus of the ABC rules is on anti-rabies vaccination and neutering of stray dogs as a means of population control. 

In conclusion, mass canine vaccination at the regional level and raising awareness about disease in society is considered to be the most effective tool for the prevention of dog-mediated rabies. Ensuring equitable access to health services along with timely and complete post-exposure rabies vaccination is of prompt importance to save lives and strengthen national health systems. Along with this, effective epidemiological disease surveillance is crucial to reduce disease burden.

References

  1. Goel, K., Sen, A., Satapathy, P., Kumar, P., Aggarwal, A.K., Sah, R. and Padhi, B.K., 2023. Emergence of rabies among vaccinated humans in India: a public health concern. The Lancet Regional Health-Southeast Asia, 9: 1-3.
  2. World Health Organization, Food and Agriculture Organization of the United Nations & World Organisation for Animal Health. (‎2019)‎. Zero by 30: the global strategic plan to end human deaths from dog-mediated rabies by 2030: United Against Rabies Collaboration: first annual progress report: global strategic plan to end human deaths from dog-mediated rabies by 2030. World Health Organization. https://iris.who.int/handle/10665/328053
  3. National action plan for dog mediated rabies elimination from India by 2030 | National Centre for Disease Control, 2021 Available from: https://ncdc.gov.in/WriteReadData/linkimages/NationalActiopPlan.pdf
  4. World Health Organization, 2023. Rabies. https://www.who.int/news-room/fact-sheets/detail/rabies

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