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Rabies in India: An ongoing crisis

Stray dogs, rabies in India. Aliaksandr Mazurkevich
Stray dogs on the streets of New Delhi. Rabid dogs are contributing to the spread of rabies in India. Image credit: Aliaksandr Mazurkevich / 123rf

Few – if any – health issues are neglected without imperilling public health. Rabies in India, of course, is no exception.

Today marked World Rabies Day, where we address a public health crisis that claims many lives yearly. As noted in an article published today, rabies in the last five years caused more deaths than the novel coronavirus that causes COVID-19. Rabies is typically spread through the bite of an infected animal. In India, it is typically spread by rabid dogs. However, other species – such as bats – may also spread the disease.

Such is rabies’s severity that, in India, to contract it has the makings of a death sentence. As Health Issues India reported in 2018, rabies killed every person infected the previous year. A disease mortality rate of 100 percent in a single year is no doubt alarming. To emphasise that point, we noted “by comparison, mortality rates for Japanese encephalitis and swine flu were twelve and six percent respectively. Of the myriad of rare diseases in India feared for their lethal potential, no other disease was found to have a 100 percent risk of death.” 

Rabies, my colleague Nicholas Parry explained in a disease profile for this publication, carries a number of symptoms. “Among the first symptoms to occur following a rabies infection,” he wrote, “are fever and headaches. These are generic symptoms common to many infections and therefore easily mistaken for other conditions. 

“Medical attention should be sought after following a scratch or bite from an animal, as by the time symptoms begin to occur, the disease is nearly impossible to treat. A few days after the initial symptoms occur, more severe issues begin to arise. Confusion, irritability, or even hallucinations may begin to occur. These symptoms then combine with muscle spasms, paralysis and difficulty breathing and swallowing — a combination that typically results in fatality.” 

The World Health Organization (WHO) posits the death toll due to rabies in India over the previous five years at at least one lakh. This accounts for 36 percent of the global toll.

Writing for the WHO, Patralekha Chatterjee reports

“Dr Rajendra Singh, a senior doctor at Maharishi Valmiki Infectious Disease Hospital in Delhi, India, knows a thing or two about despair. And regret. He sees it every day in the faces of the parents who bring their children to him for treatment. The children are infected with the rabies virus, and most of them arrive too late. “Families come from far away,” says Singh. “They don’t know that past a certain point rabies is 100% fatal. Once they learn the truth, their first reaction is to go into a state of denial. A week ago, we had a family who started waving currency notes. They wanted us to save their son at any cost.”” 

All health issues come with an intimate angle. Rabies is no exception. Take Shannon Vanraes, who wrote for The Independent about “how a dog bite in India almost cost me my life.” Vanraes writes

“Instinctively, after being bitten, I slathered my knee in hand sanitiser as locals in the northwestern India city directed my partner and me to a small lean-to with a faded red cross painted on it. A man in a quasi-military uniform led us to an English-speaking doctor who prescribed antibiotics and a tetanus booster. So far, so good. But the wound wasn’t bad enough to transmit rabies, he said. I disagreed and asked the doctor to prescribe the vaccine. He refused. Panic gurgled into my throat – the doctor was terrifyingly wrong.” 

Vanraes fortunately survived. Nonetheless, at least one lakh people in the past five years were not so fortunate. This grim statistic ought to be a catalyst for a concerted, vigorous effort to fight rabies – including addressing rabies vaccine shortages.

A major shortcoming of the response to Vanraes’s infection was lack of access to the rabies vaccine. She wrote “several hours post-dog bite, hasty research and an English-speaking driver landed us at a private hospital in Amritsar where doctors politely explained they didn’t carry the rabies vaccine. Neither did the next hospital we visited. Rabies is not a profitable disease for India’s private healthcare facilities, I later learned. At about $6 per dose, the rabies vaccination is still too expensive for many Indians who are exposed to the virus – assuming they even know they need the vaccine in the first place.” 

That rabies is vaccine-preventable yet still yields well in excess of one-third of the global death toll is shameful. As I noted in an article published last year, “a four-shot course of an anti-rabies vaccine and rabies immunoglobulin – both of which are produced within India – is the standard treatment. However, there are many obstacles to accessing it: gaps in the supply chain leading to shortages in public hospitals, the cost of availing the vaccine and immunoglobulin from private providers, and a lengthy incubation period which can frustrate timely diagnosis and treatment. This has led to an overall vaccine shortage, of twenty to eighty percent in nearly every state and union territory.” 

To its credit, the Government has taken steps to address rabies vaccine shortages such as by capping or outright prohibiting exports. Writing in The British Medical Journal in January this year, Kamala Thiagarajan credits “building awareness, increasing vaccinations, better organisation, and an initial boost from a UK charity have led to improvements.”

The rabies crisis is far from as prevalent in the public health discourse as it should be – an issue COVID-19 has only exacerbated. Neglecting to use the occasion of World Rabies Day to initiate a sustained conversation about the disease only imperils public health further. A disease is only one part of the problem. Neglect and ignorance – wilful or otherwise – is another.

1 thought on “Rabies in India: An ongoing crisis”

  1. Most current articles on rabies comment on how India, with 21,000 human deaths from rabies annually, is responsible for around one-third of global deaths from rabies. However, that 21,000 estimate was produced in 2004 following the effort by KIMS in Bangalore to estimate total human deaths from rabies (which is still not a reportable disease) in India. But the number of deaths from rabies have been declining quite rapidly in India this century (and perhaps the 2001 Dog ABC order is a major reason for this decline). In Jaipur and Chennai, rabies deaths have fallen to zero since dog ABC programs were launched in the 1990s. It is possible that human rabies deaths in India have fallen as low as 2,000 annually today. And yet academics and politicians continue to refer to the 2004 estimates produced by KIMS. Goa may be the first state to report zero human deaths from rabies but Jaipur, Ahmedabad and Chennai have all achieved that status and it is possible that Sikkim and maybe Uttarakhand are also at zero human deaths from rabies or close to it.

    Andrew N Rowan, DPhil
    WellBeing International, USA

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