ELIMINATION OF DOG MEDIATED RABIES IN INDIA BY 2030: Road Map Ahead
This article is a compilation of work by a human medicine student Kalyani Talluri from Andhra Pradesh and a veterinary science graduate Dr. Jeeta Dash from Odisha giving a detailed view of the deadly zoonotic disease "RABIES". In this article, you will know the complete information on different strategies and programs that are successful in fighting against this hydrophobia and are being implemented in different countries and states of India.
Rabies which has been known to mankind since 2000 BC is a fatal zoonotic viral disease that has great public health, agricultural and economic significance. There is a loss of over 1.8 disability-adjusted life years which accounts for more than $5.5 billion every year only due to dog-mediated rabies. The direct and indirect costs associated with post-exposure prophylaxis, animal testing, vaccination costs, livestock losses, human mortality, and all other costs add up to $120 billion per year. Even though it can be transmitted by both domestic and wild animals like dogs, bats, ferals, foxes, etc., it is the dog- mediated rabies that has raised major concern all over the world due to its 99% contribution as a source. Being an acutely fatal disease, it is killing one person every nine minutes. Once affected, the cure is always a question mark. The problem lies in considering it as one of the neglected tropical diseases for decades which explains its grave threat to rural populations. Dogs being the most preferred companions, pose a silent threat too. Understanding the reasons behind the failure of mass vaccination campaigns, missions, training, demonstrations, everything that is tried out to mitigate dog-mediated rabies over the years is the need of the hour.
INTRODUCTION TO THE DISEASE
The disease which is caused by Lyssavirus type 1 (RNA virus) is transmitted by direct contact mostly through saliva, inhalation of aerosols with the virus or by organ transplantation. It is called hydrophobia because of its effect on the throat muscles causing spasms, triggering difficulty in swallowing even water. The incubation period of the disease in humans is variable and is commonly 1-3 months following exposure. The prodromal symptoms include headache, malaise, and fever for 3-4 days with the majority of the people complaining of pain and tingling sensation at the bite site. In dogs, rabies has an incubation period of 3-8 weeks. The clinical picture in affected dogs is represented in two forms-Once the symptoms flare up, survival of the animal more than week is uncertain.
The dog-mediated virus has spread to nearly 150 countries and territories to date. As per World Health Organization (WHO) report, on an average rabies death toll reaches a mark of 59,000 world-wide and 20,000 in India every year. India accounts for 59.9% of deaths in Asia due to rabies with 40% percent of the victims being children under 15 years of age. The growing importance on public health has brought a collaborative outcome of a strategic plan for zero human deaths from dog mediated rabies by 2030. The framework behind this pursuit has begun with the integration of WHO (World Health Organization), OIE (World Organization for Animal Health), FAO (Food and Agricultural Organization of the UN), GARC (Global Alliance of Rabies Control). These organizations act as pillars in bring together human, animal and environmental health sectors, the government, private and civil sectors to fight this deadly disease. The collective "United Against Rabies" to drive progress towards "Zero human deaths from the dog- mediated rabies by 2030" is led by WHO. The objectives formatted by WHO to achieve this goal are:
“AN OUNCE OF PREVENTION IS WORTH A POUND OF CURE”
As ancient as it may seem the mantra for any preventable communicable disease has been IEC –Information, Education and Communication. Every year Rabies Vaccination Campaign is observed throughout September and the World Rabies day on 28 th September with the global strategic plan to engage, empower and enable countries to eliminate rabies. In the unforeseen pandemic conditions of this year 2020 "END RABIES, COLLABORATE, VACCINATE" has been the incantation of the campaign. Recently in 2019, Mexico has been declared as rabies eliminated country by the WHO confirming that it is not an unachievable goal.
Prevention can be done mainly at two levels
Pre-exposure prophylaxis (PrEP)
Post-exposure prophylaxis (PEP)
PrEP is a course of rabies vaccination given prior to an exposure that does not include rabies immunoglobulin (RIG). Pre-exposure prophylaxis has become a prime take-off action plan and has shown prompt results in many countries. It is the responsibility of every dog owner to get their pet vaccinated annually without fail to save both their pet and family. Dogs should receive primary immunization at the age of 3-4 months followed by booster doses as per the schedule of the type of vaccine used (Beta propiolactone inactivated or modified live virus vaccine). Any dog suspected of being rabid should be isolated and quarantined. Launched in 2013 mass vaccination campaigns like the MISSION RABIES in Africa and Asia followed by the post-vaccination surveys in rabies hotspots are done to ensure we reach the golden 70% vaccination of dog population to make our generation the end to rabies. Volunteers of this mission rabies work with local communities, police, NGO’s, and other related professionals to handle the dogs and carry out proper vaccination and sterilization. Following the current trends of the smart network, mission rabies allows the public to track their Mobile Veterinary Clinics and educate people the importance of dog population control and vaccination.
An example from India - the Sikkim Anti-Rabies and Animal Health program 2005 (SARAH) is a state government initiative for animal birth control (ABC) and anti-rabies (AR). They followed a method of dog ownership by taking responsibility for the stray dogs in the community to get them vaccinated and sterilized. Sikkim became the first state to make rabies a reportable disease in both humans and animals in 2015. They have reported zero human deaths due to dog-mediated rabies in 2006. Measures exclusively followed by the state government of Sikkim along with other stakeholders are:
Controlling the dog population through surgical sterilization
Constantly running the mass vaccination programs in all hotspot areas
Involving all health sector workers (animal and human), civil services, environmentalists, forest department, and local communities in awareness campaigns, training to prevent the disease from prevailing.
Pre-exposure prophylaxis for viruses is given to anyone with increased risk of exposure like veterinarians, laboratory workers, animal handlers, travellers and also children in rabies endemic areas. Intramuscular doses of 1ml or Intradermal 0.1 mL per site on days 0, 7 and 21 or 28 as per schedule are given as prophylaxis. Booster doses are recommended only for those who are under continues exposure as a precaution. Monitoring by antibody testing is advised every two years to occupational professionals.
POST- EXPOSURE PROPHYLAXIS
PEP is a dose of human rabies immune globulin (HRIG) and rabies vaccine given on the day of rabies exposure, and then a dose of vaccine given again on certain days according to certain regimens like Essen, Zareb, and 2-site intradermal. The resolve of post-exposure prophylaxis is to neutralize the inoculated virus before entering the nervous system. The primary occasion of using PEP is the treatment for a bite by a suspected rabid animal. Owing to this uncertainty the case detection in case of the rabies is of utmost importance to know the statistical prevalence in a given area. The best specific PEP treatment is the administration of vaccine together with local treatment of the wound.
LOCAL OR IMMEDIATE TREATMENT OF THE WOUND
Awareness about prompt and proper local treatment in case of scratches and bite wounds is the essential learning aspect in control of rabies. It is the basic prerequisite management step every professional, pet owner, lab workers, the population at risk, etc. under exposure conditions to be well conscious about to prevent rabies from spreading. Immediate local management after exposure as mentioned below (if possible within minutes) has shown reduced chances of developing rabies by up to 80% in animal experiments.
Timely immunization/vaccination play an important role in mitigating vaccine preventable diseases like rabies. Different available vaccines to combat rabies spread are; concentrated and purified cell-culture vaccine (CCV) and embryonated egg-based vaccine (EEV) which are used for pre-exposure as well as post-exposure prophylaxis.
HURDLES IN THE WAY
Lack of proper awareness, education, training about dog behaviour, the importance of vaccination and sterilization, immediate care and prophylaxis etc. paves the main hurdle in reaching the goal. Dog owners must be sensitized to get their pets immunized and keeping an eye on their pets’ interaction with the stray dogs. Proper record maintenance on the number of stray dogs, their vaccination status, birth control measures, etc., in a community is the responsibility of every official concerned. Proper infrastructure in the rabies hot-spot areas like primary health centres; transport facilities; availability of required medicines, vaccines, immunoglobulins in case of emergency; recruitment of the staff concerned etc., are far ahead in achieving. Lack of financial aid encouraging incomplete treatment course is another major concern. Increasing demand for the stockpile of vaccines is always an unheard concept. Targeting on increasing the number of studies, research laboratories, technology improvement, instruments, health care facilities, etc. are left out each time. In a country like India where rabies is still not considered as a notifiable disease, extra efforts are the only way out.
ROAD MAP FOR MITIGATION
It is not the Covid-19 that has been recognized as the national emergency by many countries of the world including India, however it is the neglected tropical disease "DOG-MEDIATED RABIES" that has been endemic since decades, the most rueful. Let us not allow this pandemic to come in the way for attaining the Sustainable Development Goal 3 (to end the epidemics of neglected tropical diseases and combat other communicable diseases) by 2030. Rabies can become a role model for one health collaboration by:
Eliminate by awareness and Education:
The greatest barrier that India will have to tackle is Illiteracy, lack of awareness, prevailing myths, and taboos. According to a survey conducted, 54% of people in urban slums didn’t know about the disease Rabies and many didn’t know how to proceed if ever encountered with a rabid dog. This indicates that steps have to be taken by the Government as well as Non- governmental organizations to organize, educate & aware the people about this dreaded yet preventable disease through proper vaccination.
Proper and timely treatment:
Post-exposure vaccinations need to be timely available in clinics, the cold chain of vaccines has to be effectively maintained to maintain the efficacy of treatment, knowledge of animal bite management and necessary trained personnel have to be made available.
The stray dog population in India is around 25 million. So, it needs to maintain a vaccination status of around 70%of dogs to create herd immunity by routine vaccinations, breaking the transmission chain. It is vital on the part of veterinarians to see to the vaccination of pregnant bitches so that the immunoglobulins are transferred to the puppies through colostrum or by placental transfer.
Routine monitoring and Surveillance of slums and prone areas to decrease the number of cases and treat the affected cases within the golden tie frame. All the personnel who are susceptible to this virus knowingly or unknowingly and are in contact with rabid animals with or without choice such as veterinarians, forest officials, animal welfare workers, pet owners, people working in slaughterhouses, etc. have to get vaccinated at regular intervals to maintain the prophylactic immunity level in the body against the rabies virus.
Strengthening diagnostic techniques:
The labs have to be equipped with state of art diagnostic tools to diagnose the positive cases timely. The diagnostic tools should have proper specificity and sensitivity. The Gold standard test for detection of rabies in animals and human is Fluorescent antibody test (FAT), Lateral flow devices (LFDs), have been devised for rapid detection of rabies under field condition, Fluorescent antibody neutralization test (FAVN), Rapid fluorescent focus inhibition test (RFFIT) & ELISA are some of the serological diagnostic tests used widely.
Efforts by the Veterinary sector:
The department of Animal Husbandry, Dairying, and Fisheries develop schemes, assists the state regarding animal diseases, training of manpower, strengthening lab facilities, production of biological products, and immunologicals. Not just dogs but all livestock are susceptible to rabies, timely detection & isolation of rabid animals is necessary to prevent the economic loss of the marginal farmers of our country.
Various Municipal Corporations:
In Urban areas, they have taken the role of stray dog management under ABC Rules, 2001-which includes neutering and spaying of dogs, vaccinating them, and releasing them back into their respective localities.
NGOs and Private organizations:
Organizations such as Blue cross India, World Veterinary Services, Mission Rabies, APCRI, and consortium against rabies are some of the many private undertakings providing a helping hand to the Government to fight the viral enemy.
This is a really interesting time for India as Indian Immunologicals has been acting as a pioneer in making available anti-rabies vaccines at ease. IIL is one of the world’s largest producers of vaccines and consistent supplier of “Abhayrab” vaccines (for human use); “Raksharab’ vaccines (for animal use).
The introduction of the intradermal vaccine for rabies by Padmashree Dr. Bharti made the vaccine accessible country-wide reducing the burden caused by cell culture vaccine by 60-80%.
India has always been a role model to the world by eliminating smallpox, polio and now its role in preventing COVID-19 is commendable that the world is praising. Though the idea of eliminating rabies is imminent, it is a stepwise strategic process that involves a multifaceted approach to deal with.Unveiling the strength of unity in teamwork and collaboration is the platform where we all stand in this journey. As the pristine generation of this era let us embark our role to make ours the last generation to fight dog-mediated rabies.
4th year MBBS student
Kurnool Medical College
Dr. Jeeta Dash
BVSc. & AH, OUAT
Dr. Hemalatha Talluri
Dr. Amit Kumar Tripathy