By Dr. Sagarika Borah
Every year, September 28 is celebrated as “World Rabies Day” to create awareness among people about the impact of Rabies on humans and animals and to control it globally. Rabies is one of the oldest and the most terrifying zoonotic (transmits from animals to humans) disease that spread by mostly dog biteswhich kills 59000 people worldwide yearly. It is a serious public health issue prevalent in 150 countries in the world and predominant in Africa and Asia affecting mainly poor rural people. One third of the global rabies cases exist in India alone resulting about 20,000 deaths in a year. WHO reported that about one rabies death occurs in every 15 minute and over 40% of these deaths happens in children aged less than 15 years. Almost 99% human rabies cases are caused by dog bites. In India, the number of dog bite cases increased from 2.18 million in 2022 to 2.75 million in 2023.
The Lyssavirus, causative agent of rabies, remains in saliva of infected animals. All mammals are susceptible to rabies and can transmit the disease including cats, other domestic animals but rarely monkeys. Rabies spreads to people and animals via saliva, usually through bites, scratches, or direct contact with mucosa (e.g. eyes, mouth, or open wounds). The incubation period for rabies is usually 2–3 months but may vary from one week to one year, depending on factors such as the site of virus entry and the viral load. Initial symptoms of rabies include fever, pain, nausea and unusual or unexplained tingling, itching or burning sensations at the wound site. As the virus moves to the central nervous system (brain and spinal cord), neurological symptoms develop which results in furious form of rabies with hyperactivity, excitable behaviour, hallucinations, lack of coordination and hydrophobia (fear of water). Death occurs after a few days due to cardio-respiratory arrest. About two-thirds of people suffer from furious rabies. Others have paralytic rabies in which muscles gradually become paralyzed, starting from the wound site, then coma develops and eventually death occurs. The paralytic form of rabies is often misdiagnosed, contributing to the under-reporting of the disease. Once clinical symptoms appear, rabies is fatal in 100% of cases.
Though rabies is fatal, it can be prevented completely through timely immunization, even after exposure to the infectious agent. People continue to die of rabies because of negligence and limited awareness about the disease, no control in dogs and lack of basic medical care, such as post-exposure prophylaxis (PEP) following an exposure. The best ways to prevent rabies include mass dog vaccination, post-exposure prophylaxis (PEP) and awareness among people.
Mass dog vaccination is the most cost–effective way to prevent the spread of rabies to humans as it stops transmission at its source. While a variety of animal species can host rabies, dogs serve as the main reservoir hosts, being responsible for transmitting the infection in the majority of human cases worldwide. It is reported that vaccination of 70% of dog populations is sufficient to stop transmission of the disease between dogs and from dogs to humans.
The main aim of post-exposure prophylaxis (PEP) is to eliminate or neutralize the rabies virus at the bite site, thereby preventing its entry into the nervous system. PEP vaccination should be initiated as soon as possible following exposure and should be accompanied by appropriate wound care. Pre-exposure prophylaxis (PrEP) is also another way to prevent the human rabies but it is not currently included in India’s national immunization schedule.
Studies have shown that not only general public is not aware about rabies prevention, but even healthcare workers (HCWs) are not aware. Due to lack of knowledge, individuals often choose to use ineffective and harmful remedies instead of seeking proper PEP after animal bites. It is reported that a significant percentage of animal bite victims, ranging from 64.2% to 80%, rely on household preparations like chilli, lime, kerosene, turmeric, herbal medicines, and homemade oils for wound treatment. So, awareness empowers people to save themselves by seeking the care they needwith an understanding of how to prevent rabies in animals, when to suspect rabies, and what to do in case of a bite.
Integrated bite case management (IBCM)
Dog bites, licks and scratches are common, but not all dogs are rabid. Even in areas where canine rabies is endemic, most of these exposures are not from rabid animals. Integrated bite case management, or IBCM is a way to determine whether a dog bite is likely to constitute exposure to rabies or not and therefore if post-exposure prophylaxis is, or is not, indicated. IBCM provides a strategy for countries to reduce human treatment costs for rabies, as they concurrently reduce transmission risk through control of rabies in dog populations.
The world is united with a goal to eliminate human rabies deaths by 2030. In February 2015, the World Health Organization (WHO), the Food and Agriculture Organization of the United Nations (FAO), the World Organisation for Animal Health(OIE) and the Global Alliance for Rabies Control (GARC) united to launch the End Rabies Now campaign, which proposed a goal of zero human rabies deaths by 2030, worldwide. In December 2015, a global conference of international stakeholders endorsed the vision of zero human rabies deaths by 2030, or Zero by 30.
National plan to eliminate rabies
Aligned with the global objective of eliminating human deaths caused by dog mediated rabies by 2030 (Zero by 30), India introduced its National Action Plan for the Elimination of dog-mediated Rabies (NAPRE) in 2021.The government has issued a directive for human rabies to be made a notifiable disease in all states, which is a vital landmark in establishing effective reporting and surveillance systems. Subsequently, it will enhance the availability of diagnostic services and vaccines while allowing for the adaptation of rabies control policies to identify and address any existing gaps.
(The writers serves at ICAR-KVK, West Garo Hills; Email: [email protected])