Rabies is a fatal viral disease entrenched in history, dating back to ancient Egypt and killing around 59,000 people each year with the majority of deaths befalling in Asia and Africa. Rabies is a zoonotic viral disease infecting an array of domestic and wild animals and transmitted through close contact with the saliva of infected animals either through bites, scratches, licks on broken skin, and mucous membranes. Rabies is always fatal once symptoms develop in humans and animals, particularly kids being at the highest risk. Globally about 563 million US dollars are spent yearly on measures to avert rabies, yet in countries of south-eastern Asia, the disease is still important public health delinquency with an estimated death rate of 45%. The situation is especially pronounced in India, which reports about 18,000 to 20,000 cases of rabies a year and about 36% of the world’s deaths from the disease. In India, the incidence of rabies has been continuous for a decade, without any noticeable declining tendency, and reported incidence is perhaps an underestimation of accurate incidence because in India rabies is still not a notifiable disease. In India, urban expansion has caused an upsurge in a human-animal conflict that has caused an increase in cases of wild animal attacks all across India including Jammu and Kashmir. In Kashmir valley, dog menace is a burning issue now and last year Hindustan Times reported 55,000 animal bite cases registered in the Srinagar city to the anti-rabies clinic from 2009 to 2019. Stray dog menace has remained a persistent issue in Kashmir, particularly in the capital Srinagar, where conservative estimates put the dog population anywhere around 60,000. The escalation in rabies cases is rooted in a general lack of awareness vis-à-vis preventive measures, which translates into scarce dog vaccination, an uncontrolled dog population, the poor familiarity of correct post-exposure prophylaxis on the part of many medical mavens, and a lop-sided supply of anti-rabies vaccine and immunoglobulin, principally in primary-health-care facilities. In India, rabies mainly affects people of lower socioeconomic status and kids between the age group of 5 and 15 years. Indian kids often play near stray dogs, sharing their eatables with them, resulting in frequent bites. There are some reports from India revealing that some children are often unaware of dog bites and the jaw-dropping fact is their parent’s response, where they just treat these bite wounds by the application of indigenous products like hot peppers or turmeric. According to one study, only 70% of the people in India have ever heard of rabies, only 30% know to wash the wounds after animal bites and, of those who get bitten, only 60% receive a modern cell-culture-derived vaccine. Ironically, in this era of advanced health systems and mass communications, even physicians sometimes know little about proper post-bite prophylactic measures. A recent report from a Kolkata-based medical college exposed that most medical interns were not very well acquainted with proper post-exposure prophylaxis because during training they encountered few cases of an animal bite, which were managed in other super-specialty hospitals. It is pivotal to administer anti-rabies immunoglobulin immediately after a bite branded as severe (grade III), but erroneous wound categorization by healthcare providers, especially in cases presenting late for treatment, greatly surges the chances that rabies will progress.
For the prevention of rabies, two types of vaccines to protect against rabies in humans exist – nerve tissue and cell culture vaccines, and WHO has recommended replacement of nerve tissue vaccines with the more efficacious, cheap, and safer vaccines developed through cell culture. Cell-culture-based rabies vaccines involve the use of Intradermal immunization which is an acceptable substitute to usual intramuscular vaccine administration. Intradermal vaccination is as safe and immunogenic as intramuscular vaccination, yet requires less vaccine, for both pre-and post-exposure prophylaxis, leading to lower direct costs. This alternative should thus be considered in settings constrained by cost or supply issues. Intradermal vaccination, recommended by the WHO in low-resource settings, has been practiced just in India because of its lower price and high immunogenicity. However, it requires special training to diminish the risk of inadequate vaccine dosing. Pre-exposure prophylaxis is recommended for anyone at continual, frequent, or increased risk of exposure to rabies virus (like veterinarians), either by nature of their residence or occupation. Periodic booster vaccines are suggested as an extra precaution only for people whose profession puts them at continual risk of exposure. If possible, antibody monitoring of workers at risk is preferred to the administration of routine boosters. Recommendations for post-exposure depend on the type of contact with the suspected rabid animal. For category I exposure (touching or feeding animals, licks on unbroken skin), no prophylaxis is required; for category II (nibbling of exposed skin, minor scratches or abrasions without bleeding), instant vaccination; and for category III (single or multiple transdermal bites or scratches, contamination of mucous membrane with saliva from licks, licks on broken skin, exposures to bats), direct vaccination and administration of rabies immunoglobulin are suggested. Occasionally patients are also directed to monitor the felonious animal for abnormal behaviour for about 10 days after a bite before seeking any prophylactic treatment, but because animals can be asymptomatic carriers, such interruption can be perilous. It would be safer to administer the whole course of anti-rabies vaccination to everyone who gets bitten by an animal.
Given the conditions that prevail in our country India, several measures must be taken to control rabies effectively. Free public education campaigns need to be conducted to make people aware of the existence of rabies, especially in far-flung areas, and of the vital importance of seeking health care immediately after an animal bite. Immediate action must be taken to certify the uninterrupted availability of vaccines and anti-rabies immunoglobulin in all hospitals, clinics, and remote primary-health-care centres. Primary care providers should be trained to administer correct prophylaxis, including intradermal vaccination. Medical schools need to deliver sufficient training and exposure to interns regarding animal bite management. State and central Govt authorities must include rabies awareness in their primary school curriculum. All dogs should be given oral (i.e., dog foods mixed with oral rabies vaccine) and injectable vaccines against rabies, and stray animals should be sterilized to reduce the dog population. Rabies should be declared a notifiable disease and merged into a “one health program” in a coordinated manner at all national and international levels. Lastly, in light of the availability of highly efficacious, safe, and cost-effective cell-culture-derived anti-rabies vaccines, all kids, who are the most frequent victims, should be vaccinated against rabies as pre-exposure prophylaxis, principally in zones with an uncontrolled canine population.
Dr. Abrar Ul Haq Wani is Assistant Professor, Department of Medicine, Khalsa College of Veterinary and Animal Sciences, Amritsar (GADVASU -Punjab).