High number of dog bites & poor post-exposure vaccination coverage drive India’s rabies crisis

Though the country launched a National Action Plan for Dog-Mediated Rabies Elimination by 2030, experts say that looks nearly impossible.

Representational images of stray dogs and rabies vaccine | ANI/Commons

New Delhi: Coupled with an alarmingly high number of dog bites, poor post-exposure vaccination adherence has put India at the top of the list of countries with most fatalities due to rabies, an endemic disease that cannot be treated once symptoms appear and kills all its victims. 

According to data presented by the Union government in Parliament last month, India last year recorded 37,15,713 dog bites, or over 424 every hour. This was over 21 percent higher than the reported number of dog bites in 2023—30,52,521—and nearly 70 percent more than the recorded number in 2022. 

Accompanying these worrying numbers are the high human rabies deaths in the country, which according to the World Health Organisation (WHO) is estimated at 18,000-20,000 annually, out of 59,000 global rabies deaths. 

The number of confirmed rabies deaths, according to the Union government, on the other hand stood at just 54 last year, indicating a huge gap in actual and recorded figures, while the Indian Council of Medical Research (ICMR) estimated that the country sees 5,726 rabies deaths annually. 

The government concedes that about 96 percent of the morbidity and mortality due to rabies is associated with dog bites, even though cats, rodents and monkeys apart from some other animals can also transfer the rabies virus to humans.

A vaccine-preventable, zoonotic, viral disease affecting the central nervous system, rabies is virtually 100 percent fatal once clinical symptoms such as hydrophobia and paralysis appear.  

And although rabies affects people of all age groups, children are the most vulnerable and constitute over 40 percent of the people exposed to dog bites in rabies-endemic areas, it is estimated. 

Though the Supreme Court order directing authorities to round up all the stray dogs of Delhi-NCR and put them in shelters has caused massive uproar, those working to prevent rabies occurrence say it is a good move.

“The massive debate and focus on the issue that the order has triggered will help stakeholders understand the extent of the problem and push us towards measures that balance both human safety and dog welfare,” Dr Khan Amir Maroof, director, community medicine at the University College of Medical Sciences and honorary secretary with Delhi’s Consortium Against Rabies, told ThePrint. 

According to Dr Narander Singla, lead consultant, internal medicine at the CK Birla Hospital in Delhi, a primary reason why India reports the highest number of rabies deaths globally could be low vaccination rates among dogs and inadequate post-exposure prophylaxis in humans.

Though the country launched the National Action Plan for Dog-Mediated Rabies Elimination by 2030, experts say that looks nearly impossible.

Poor post-exposure vaccination adherence

Rabies deaths are preventable with prompt post exposure prophylaxis (PEP) by stopping the virus from reaching the central nervous system.

PEP consists of thorough wound washing—with copious amounts of water and soap, administration of a course of human rabies vaccine and, when indicated, rabies immunoglobulins (RIG), explained Dr Rajesh Kumar, internal medicine specialist with Paras Health in Gurugram.

India follows a vaccination policy for rabies as suggested by the WHO and the national guidelines on rabies prevention suggest that in case of minor scratches without bleeding due to a dog bite in previously unvaccinated individuals, four doses of rabies vaccine (on days 0, 3, 7 and 28 from being bitten) should be administered when it is given intradermally.

But if the vaccine is given through the intramuscular route (depending on type or brand), five doses of vaccine should be administered on days 0, 3, 7, 14 and 28.

In case of multiple wounds or deeper bites, an additional layer of protection—rabies immunoglobulin, also called anti-rabies serum—is advised to be applied to the wound. This provides passive immunity in the form of ready-made anti-rabies antibodies to tide over the initial phase of infection.

But a survey by the Indian Council of Medical Research-National Institute of Epidemiology (ICMR-NIE) which came out last year suggested that though 80 percent of dog-bite victims receive one dose of anti-rabies vaccine, just about 40 percent complete the prescribed vaccination schedule.

This survey also found that only about 5 percent bite victims reported taking rabies immunoglobulin. And while nearly a fourth of the total households interviewed (78,807) reported having a pet or domestic animal, 18.6 percent of the households reported that they had a pet dog and only around half of the pet dogs were vaccinated.

Specialists and clinicians maintain that socio-economic disparities mean that the poor are also the most vulnerable. 

“The poor do not have access to PEP and vaccines and rabies immunoglobulin are usually unavailable or prohibitively expensive in remote locations,” pointed out Dr Sumit Mor, head, trauma and emergency with Aakash Healthcare.

Dr Singla blamed the continued rabies menace on the country’s substantial stray dog population that contributes to the spread of rabies, apart from insufficient public awareness about rabies prevention and the importance of seeking medical attention after a bite.

Challenges in vaccine availability

Apart from lack of awareness being a key challenge in the country’s fight against rabies, there is also an issue with the supply side. 

Another important ICMR-NIE survey published in The Lancet last month—based on an analysis of 534 health facilities across 60 districts in India, majority of which included government hospitals—found that rabies vaccine availability ranged from 60 to 93 percent in different geographic regions. 

Availability of the vaccine was lowest in urban primary healthcare centres (UPHCs) and rabies immunoglobulin was available in just about 20 percent of public sector hospitals, ranging from 1.8 percent in urban primary health centres to 69.2 percent in medical college hospitals.

“Rabies control efforts require significant resources and funding, which are not always available.

And different states in India have varying levels of progress in implementing rabies control measures,” Dr Singla underlined. 

Another emerging challenge fuelling the crisis is vaccine failure that can occur due to inadequate wound management and improper vaccine administration, he stressed.

Is pre-exposure vaccination an option?

India’s current rabies guidelines also advise that a certain group of people—categorised as high-risk individuals—should receive pre-exposure prophylaxis (PeEP) too.

Such high-risk individuals include laboratory staff handling the virus and infected material, clinicians and paramedics attending to hydrophobia cases, veterinarians, animal handlers and catchers, wildlife wardens, quarantine officers and travellers from rabies-free areas to rabies-endemic areas.

The Indian Academy of Paediatrics (IAP), the largest group of paediatricians, recommends that in a rabies endemic country like India, all children in their infancy should also receive rabies PrEP. 

The government, too, in the past, given the rise in dog bites, has discussed whether such a norm should be introduced across the country through its Universal Immunisation Programme (UIP), but a final decision in this regard is yet to be made. 

Dr Maroof said that till the time the government introduces it in its national programme, such a decision can be taken by parents for children based on their risk assessment. 

Children with PrEP for rabies, he said, typically need fewer vaccine doses in case of dog bites later and the IAP says these children will not need RIG even in case of deeper wounds. 

(Edited by Gitanjali Das)