Rabies: A forgotten disease?

In many European countries, rabies, one of the oldest and deadliest known viral infectious diseases, is considered practically extinct.1 Rabies is not a disease that people in the UK worry about on a daily basis. However, the picture is very different in wide parts of Asia and Africa, where the rabdovirus is responsible for almost 60,000 deaths every year, equivalent to almost six people every hour.2 India is especially heavily affected by the burden of the disease.3 Rabies is transmitted by an injury caused typically by an infected animal. Today, over 95% of cases can be traced back to dog bites.4 The disease is entirely preventable, with both pre- and post exposure prophylaxis (PREP and PEP) being available and highly effective.5  Through vaccination programmes of wild animals, the disease has been almost eradicated in wide parts of Europe and the United States.6 But why has this not worked in other places? Why are people not receiving the lifesaving PEP?  Which structures are still causing preventable human suffering? To answer these questions, we will take a closer look at who exactly is still so strongly suffering from the burden of rabies and how we can tackle this global health problem.

Firstly, in order to receive PEP, one needs to know about the dangers of rabies and the possibility of PEP. If someone is unaware of the disease, they will not know when to seek treatment. This is likely a major factor contributing to preventable human suffering. A survey in Bangalore, India showed that 1/4th of the population had not heard of rabies at all and only 54% knew that rabies was a fatal infection.7

Simple as this may sound, the problem lies even deeper within. For many, even knowledge would not prevent the disease. This becomes clear when we take a look at the areas in which the most people are affected. Evidently, these are typically socially marginalised areas that lack sanitary infrastructures.8 Especially the slums of India carry the heavy burden of thousands of rabies-related deaths every year.9 While highly effective, PEP is not available to these populations. Even though over 29 million people receive treatment after an animal bite yearly, likely preventing hundreds of thousands of deaths, many people still do not receive adequate medical attention.10 PEP is a highly complex procedure which includes a thorough rinse of the bite wound, an array of vaccinations and sometimes the treatment with antibodies.11 For PEP to be effective, it is crucial for it to be applied as soon as possible after exposure to a potentially infected animal. The vaccine regime is extremely prone to errors and requires exact timing between exposure and multiple vaccinations.12 While already being complex in ideal medical settings, it becomes nearly impossible in areas of low healthcare accessibility. For instance, Indian slums have a ratio of person to hospital of 1:193,000, the WHO goal being 1:50,000.13 Access to hospitals that are able to treat wounded people adequately is difficult or even impossible to some. On top of accessibility, a full PEP is expensive, at around 108US$ per person14, a significant investment for people without health insurance. Even further, travelling to a hospital is not always possible, as missing work due to sickness means loss of job for many people in affected regions.15 These factors limit people’s access to healthcare and may lead to the decision not to seek treatment at all, likely causing thousands of preventable deaths.

Another major factor that contributes to the frequency of rabies in South Asia, especially India, is the amount of free roaming, unvaccinated dogs (about 80% of dogs in India do not have an owner).16  These dogs are attracted to rubbish and food scraps, which are common in areas of high population density.17 Contact between potentially infected dogs and humans are a lot closer than in other regions, as there are less fences and dogs live closely alongside humans.18 This affects children in particular, as they play on the streets amongst dogs. And, evidently around 40% of all deaths from rabies are children.19 Due to the sheer number of dogs and their close interaction with humans, the likelihood of a dog bite is very high in areas with high dog populations.

Another significant issue, that is less noticeable to the public is the lack of transparency and cooperation between health departments and the WHO. The infection is in most cases not properly recorded, leading to lack of data. This causes issues in preventative care and it becomes difficult to overview the status of infection in different regions.20

Now, we might ask how to tackle the problem of rabies. Due to the complexity and structural nature of the issue, there are several steps that need to be taken to solve the problem of rabies in Southern Asia. The WHO has begun introducing the promising concept of One Health to wipe out rabies at its root.21 The idea is to unite veterinary and human medicine and work together with authorities in order to holistically tackle the problem. Due to the high cost of vaccination and the large population, providing a pre-exposure prophylaxis to the entire Indian population is not a realistic option. Instead, it is key to eliminate rabies at the first entity: the dog. Studies have shown that vaccination and sterilisation of free roaming dogs has the potential to successfully reduce the burden of rabies. The WHO suggests that vaccinating around 70% of free roaming dogs would provide herd immunity against the virus.22 When combined with sterilisation of around 40% of all dogs, this positive effect could be achieved sustainably.[23] On top of this, human geographers and public health experts will need to provide their expertise in the ways in which the disease spreads through populations and who is especially strongly affected. While considering these ideas, it is absolutely crucial to improve sanitation and living conditions in Indian slums is a necessary step to tackle all infectious disease, including, but not limited to rabies.

References: 

1. Fooks, A. et al. (2014) ‘Current status of rabies and prospects for elimination’. In: The Lancet, 384, pp. 12894.

2. Gautret, P. and Parola, P. (2011) ‘Rabies vaccinations for international travellers’. In: Vaccine, 30(2), pp.126-133.

3. Menezes, R.(2008) ‘Rabies in India’, In: Canadian medical association journal, 178(5).

4. Radhakrishnan, S. et al. (2020) ‘Rabies as a Public Health Concern in India - A Historical Perspective’. In: Tropical Medicine and Infectious Disease, 5(4), pp. 162.

5. NA. (2023) ‘Tödliche Durchbruchinfektionen nach Post-Expositions-Prophylaye gegen Tollwut. Eine systematische Literaturanalyse’, In: DER ARZTNEIMITTELBRIEF, 57(6).

6. Guertler, L. (2010) ‘Tollwut (Rabies, Lyssa)’, In: DoctorConsult- The Journal. Wissen für Klinik und Praxis, 1(2), pp. e145-e149.

7. Mrudu H., et al (2012) ‘Community perception regarding rabies prevention and stray dog control in urban slums in India’. In: Journal of Infection and Public Health, 5(6), pp. 374-380.

8. Soentjens, P., et al. (2021) ‘Vaccinating children in high-endemic rabies regions: what are we waiting for?’. In: BMJ Global Health, 6.

9. Menezes, R.(2008) ‘Rabies in India’, In: Canadian medical association journal, 178(5).

10. Gupta, I, and Guin, P. (2015) ‘Health Status and Access to Health Services in Indian Slums’. In:  Health, 7(2), pp. 245-255.

11. NA. (2023) ‘Rabies’, In: World Health Organisation, News Room, Fact sheet, Details: Rabies, Available at: https://www.who.int/news-room/fact-sheets/detail/rabies

12. Blumberg, L., and Knopf, L. (2019) ‘Rabies post-exposure prophylaxis: A systematic review on abridged vaccination schedules and the effect of changing administration routes during a single course’. In: Vaccine, 37 (1), pp. A107-A117.

13. Gupta, I, and Guin, P. (2015) ‘Health Status and Access to Health Services in Indian Slums’. In:  Health, 7(2), pp. 245-255.

14. N.A., (N.Y.) ‘Vaccinating against Rabies to save lives’. In: World Health Organisation, Prevent Rabies by Vaccine, Available at: https://www.who.int/activities/vaccinating-against-rabies-to-save-lives

15. Tarantola, A., et al. (2019) ‘Evaluating new rabies post-exposure prophylaxis (PEP) regimens or vaccines’. In: Vaccine, 37(1), pp. A88-A93.

16. Menezes, R. (2008) ‘Rabies in India’. In: Canadian medical association journal, 178(5).

17. Bhalla, S. et al. (2021) ‘Stray appetites: a socio-ecological analysis of free-ranging dogs living alongside human communities in Bangalore, India’. In: Urban Ecosyst,24, pp. 1245–1258.

18. Bhalla, S. et al. (2021) ‘Stray appetites: a socio-ecological analysis of free-ranging dogs living alongside human communities in Bangalore, India’. In: Urban Ecosyst,24, pp. 1245–1258.

19. N.A., (N.Y.) ‘Vaccinating against Rabies to save lives’. In: World Health Organisation, Prevent Rabies by Vaccine, Available at: https://www.who.int/news-room/fact-sheets/detail/rabies 

20. Fooks, A., et al. (2014) ‘Current status of rabies and prospects for elimination’. In: The Lancet, 384, pp.1289.

21. Gibson, D., et al. (2022) ‘Elimination of human rabies in Goa, India through an integrated One Health approach’. In: Nat Commun, 13( 2788).

22. N.A., (N.Y.) ‘Vaccinating against Rabies to save lives’. In: World Health Organisation, Prevent Rabies by Vaccine, Available at: https://www.who.int/news-room/fact-sheets/detail/rabies 

23. Totton, S. (2010) ‘Stray dog population demographics in Jodhpur, India following a population control/rabies vaccination program’ In: Preventive Veterinary Medicine, 97(1)pp. 51-57.