Rabies Response in India Suffers From Underreporting of Cases & Lack of Testing

Rabies kills up to 20,000 people every year in India. But it is not a matter of public attention.

You would think that a vaccine-preventable disease, one that is nearly 100 percent fatal and kills up to 20,000 people every year in India, would be the subject of much greater public attention.

Yet, rabies only rarely makes its way into the headlines on World Rabies Day or World Zoonoses Day or through an occasional news item concerning a person who contracted rabies after being bitten by a domestic or wild canine.

Rabies is a viral disease transmitted through bites or scratches by rabies-infected animals. The majority of human cases in India are the result of dog bites (although the disease can manifest in any mammal).

Despite its virulence, rabies is also one of the rare illnesses that can be easily prevented after exposure, through immunoglobulin and vaccine injections over the course of a month.

Sadly, the human deaths that result from rabies occur primarily because people do not get access to post-exposure attention or follow appropriate medical advice.

Why Do We Not Hear More About These Cases?

Rabies is a notoriously underreported disease due to factors such as lack of tests or diagnostic facilities, unrecognised or unreported cases, and issues with sample collection, storage, or transportation.

On top of all that, general awareness of how to manage, eradicate, and prevent this fatal disease remains lacking.

According to the Prevention and Control of Infectious and Contagious Diseases in Animals Act, 2009, rabies is a scheduled disease.

Suspicion of any scheduled disease must be reported to the village officer who may report it to the jurisdictional veterinary officer.

A veterinary officer who suspects rabies can order the animal to be isolated so that samples can be collected to test for rabies.

At present, there is no ante-mortem test recommended or available for rabies in animals. The animals should be kept under observation and they can be euthanised.

A post-mortem examination of the animal should be performed with collection of brain tissue for rabies testing. An alternative to this complicated process of testing the brain samples is a lateral flow test which is suitable for on-the-spot testing.

This is similar to the rapid antigen tests available for COVID-19, and it eliminates the need for special storage or transportation of samples in special conditions to faraway laboratories.

The tests have high sensitivity of 95 percent and a specificity of 100 percent. Test kits are easily available and cost about 500 rupees.

How Should Rabies Be Diagnosed and Managed?

A critical component to managing rabies is recognising behavioural changes in infected dogs. Notably, however, the early symptoms of rabies infection in dogs may be difficult to identify.

Clinical signs are often subtle at first as the disease progresses, behavioural changes may become more pronounced and easier to recognise.

A rabid animal may bite other animals, humans, or inanimate objects, exhibit hypersensitivity to light or noises, have difficulty in swallowing, excessive salivation, have uncoordinated gait, seizures, or develop paralysis.

The number of dogs reported with rabies is low in India due to lack of infrastructure for dealing with suspected cases as well as logistical difficulties in sample collection and testing.

Unfortunately, when dogs are suspected to have rabies, there is no universal protocol that is consistently followed which ensures the welfare of the animal. Observation of suspected animals placed in isolation, as recommended, is frequently a challenge.

The human resources and specific skill set required to handle these animals humanely is severely lacking as are the isolation and observation facilities.

All too often, suspected animals are tied up and abandoned, stoned/hit to death and their carcasses disposed of.

Even if safe capture, isolation, and observation are carried out, the collection of appropriate brain sample following the death of the animal must follow, and for that, veterinarians need adequate training and personal protection measures.

Any missing step in this chain of requirements will result in the lack of isolation, observation, collection, and testing of samples.

What Is the Status of Research for Rabies?

There are several scientific bodies working on zoonotic diseases in India including the National Animal Disease Reporting System, National Centre for Disease Control, which relies on its Integrated Disease Surveillance Program to bring relevant data onto one platform.

Of the few studies published about actual rabies incidence in India, one study from Punjab by Gill G.S et al. (2019) sampled suspected rabid animals from 4 subdistricts in 2016-17 and then extrapolated that data to estimate the rabies occurrence in the state.

Out of 33 suspected samples submitted, a total of 30 tested positive for rabies.

The authors conjecture that if similar testing was conducted state-wide, a total 458 animals (dogs, cattle, pigs, equids) might be found positive for rabies in Punjab annually.

The statistical tally of the disease is currently decided on basis of the number of human bite cases reported and not on the number of rabid dogs.

It’s unlikely that the disease or the economic burdens and consequences it brings with it will go away so long as the focus of the disease lies on treatment of bites and not on preventing disease in the host species.

The disease is prevalent in both urban and rural India. However, it’s easier for people to get vaccinated and get immunoglobulins in the cities whereas in rural areas, it involves travelling great distances – a key driver of non-compliance with medical advice.

For those in non-urban settings, this also means additional expense and loss of working hours.

The economic burden of treating bites will not change unless rabies is eliminated from the landscape. The strategy needs to shift to a preventative stance.

What Are Some Methods To Control the Spread of Rabies?

A preventative and effective measure for controlling rabies is to eliminate it in its primary host, the dog. This involves regular, effective dog vaccination programmes, involving both owned and street dogs.

That said, the urgent need for a strategic approach for disease eradication is not limited to just rabies.

The necessity of increased regional surveillance has long been identified regarding zoonotic diseases, with more than 75 percent of new diseases in humans having been identified to have animal origins.

Pathogens from any animal that have direct or indirect interaction with humans, directly or through a vector, can lead to transspecies transmission.

This must include animals we are in close contact with like dogs and cattle, animals who are reared in high volume like chicken and fish, as well as wild species that cohabit with humans like mongoose, rodents, pigeons, etc.

Periodic screening of samples from animals as well as monitoring of health and rapid identification of diseases can lead to faster diagnostic and control measures with minimal human and animal lives affected.

How Can Rabies Outbreaks Be Prevented?

The effects of an undetected outbreak of disease can be catastrophic for human health, cause large scale economic loss and result in the culling of millions of animals. Such outcomes can be avoided by early detection, reporting, and response to outbreaks.

Poor animal management practices such as intensive confinement husbandry also promote the emergence and spread of these pathogens.

The emerging One Health approach identifies animal health and human health as strongly interlinked and requiring an integrated approach for early identification and response strategies.

This would apply to the vast variety of health threats that affect humans, including rabies, brucellosis, influenza as well as vector-borne diseases and antimicrobial resistance.

Rabies as a challenge offers us a chance to examine our broad need for a range of enhanced capabilities and services tied to other threatening diseases that plague both humans and animals in India.

• We need easily accessible regional laboratories. We need to focus on building skills and encouraging mandatory streamlined reporting of infectious diseases.

• We should embrace the One Health model for disease surveillance and treatment, such that the same laboratories can process samples from various species and screen them for a wide range of pathogens.

Greater command of the facts about disease threats, an expanded data base that illuminates disease trends and enhanced responsible capacity in every region of the country will put us on a better footing and ensure a brighter future for India’s people and its animals.

(Dr Vineeta Poojary is the manager of the veterinary services programme at the Hubli-Dharwad project of Humane Society International/India. She's been working on wildlife and animal rescues for the past eight years. She currently manages a mobile veterinary clinic that provides emergency and critical care for unowned animals on the streets.)