ThePrint has a copy of the recommendations made following the consultation meeting.
“This was especially required as the public awareness on how to prevent rabies and what to do following animal bites is very low in India despite having prescribed protocols in place,” Dr Simmi Tiwari, who is in-charge of the National Rabies Control Programme under the National Centre for Disease Control, an agency under the health ministry, told ThePrint.
The data indeed looks worrying.
By early December this year, India had recorded a total of 27.5 lakh cases of dog bites — considerably higher than the nearly 21.8 lakh cases reported in 2022.
According to the National Action Plan for Dog Mediated Rabies Elimination 2030, released by the government earlier this year, about 96 percent of the mortality and morbidity due to rabies is associated with dog bites.
The same document says that India recorded an estimated 20,847 rabies deaths in 2015, the highest globally. Nearly 60,000 deaths caused by the incurable disease are reported across the world annually.
And, say experts, while India faces an uphill battle against vaccine-preventable rabies, often called a neglected zoonotic disease, which is nearly 100 percent fatal once its symptoms appear in humans, awareness about preventing it remains woefully poor.
“Awareness regarding the disease among masses and even healthcare providers is woefully inadequate, leading to delayed or insufficient treatment, underreporting, and stigma,” Dr K. Madan Gopal, advisor, public health administration at the National Health Systems Resource Centre under the health ministry told ThePrint.
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Rabies in humans
The rabies virus enters the body through wounds or by direct contact with mucosal surfaces as it cannot cross intact skin.
It may replicate in muscle or other local tissues after exposure and gain access to motor endplates and motor axons to reach the central nervous system. The incubation period ranges from three weeks to three months (rarely four days to two years) and once the virus reaches the central nervous system, its replication occurs primarily in the neurons or brain cells through viral budding. The virus thus spreads and infects nearby brain cells.
Further, dissemination through the cerebrospinal fluid (CSF) occurs in the late stages of infection and the virus affects brain stem function, causing hydrophobia (fear of water), aerophobia (fear of breeze), and photophobia (fear of light) finally resulting in respiratory paralysis and death.
While 80 percent of human rabies manifests as the furious type, the remaining manifests as the paralytic or dumb type. Furious rabies manifests as hyperactivity — anxiety, agitation, running, biting and other bizarre behaviour that alternates with periods of calm, which may occur spontaneously or may be precipitated by tactile, auditory, visual or other stimuli.
Paralytic or dumb rabies, on the other hand, manifests as acute progressive ascending inflammation of the spinal cord, pain in the muscles leading to complete loss of muscle movement in the legs, and eventually fatal paralysis.
The national guidelines on rabies diagnosis and prevention say that based on vaccine utilisation, it is estimated that almost 2.3 million people annually receive post exposure prophylaxis against rabies after being bitten by, or exposed to, a rabid or suspected rabid animal.
But they also concede that due to widespread underreporting and uncertain estimates, it is likely that this number is a gross underestimate of the true burden of the disease.
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Anti-rabies vaccination protocol
Rabies may be a death sentence once the symptoms are evident in a human bitten by a rabid animal, but thankfully prevention is possible just after a bite.
“Because of the long incubation period, which is typical in most cases of human rabies, it is possible to institute prophylactic post-exposure treatment,” say the government guidelines.
These guidelines recommend post-exposure treatment against rabies based on categories of exposure. The first category includes touching or feeding animals, licks on intact skin and contact of intact skin with secretions or excretions of rabid animals. No vaccination is required in such cases, although it is suggested that the exposed area be washed properly.
For patients in the second category, which include those who have suffered nibbling of uncovered skin, or minor scratches or abrasions without bleeding, a full course of anti-rabies vaccine (ARV) is suggested after wound management.
The full course of ARV includes shots given on days 0, 3, 7 and 28 after being bitten when it is given intradermally, but if the vaccine is administered through the intramuscular route, five doses of the vaccine should be administered on days 0, 3, 7, 14 and 28.
For patients in category three — who include those who have received single or multiple transdermal bites or scratches, licks on broken skin or contamination of mucous membrane with saliva — an additional layer of protection in the form of Rabies Immunoglobulin (RIG) is advised, apart from a full course of ARV and wound management.
RIG is a solution containing ready-made antibodies against the rabies virus that swiftly act against the viral antigen, before the vaccine prompts the dog bite patient to generate their own antibodies against the pathogen.
But unfortunately, in many cases the due schedule of vaccination and administration of RIG is not followed, say clinicians and specialists.
“There are numerous challenges in the management and prevention of rabies,” said Dr Tushar Tayal, consultant, department of internal medicine with CK Birla Hospital in Gurugram.
“And the primary one is a lack of awareness of first-aid measures that need to be taken in case of a bite,” he said, adding that the World Health Organization recommends flushing and washing the wound with water, soap, detergent, povidone-iodine, or other virucidal agents for a minimum of 15 minutes.
Secondly, said Tayal, there is a lack of awareness of the need to take RIG in case of a deep wound, which helps in neutralising the virus immediately.
“Third, there is ignorance in the general population about completing the vaccine schedule as prescribed, which is absolutely necessary for proper immunity,” he also said.
Gopal said that even when post-exposure prophylaxis exists, high costs and limited access, especially in rural areas, leave many exposed individuals untreated.
Government guidelines also suggest pre-exposure prophylaxis — even before a dog bite — for high-risk groups like laboratory staff handling the virus and infected material, clinicians and paramedicals attending to hydrophobia cases, veterinarians, animal handlers and catchers, wildlife wardens, quarantine officers and travellers going to rabies-endemic areas from rabies-free areas.
As part of this regimen, a total of three ARV doses are recommended for pre-exposure prophylaxis.
Additionally, the Indian Academy of Pediatrics — the largest network of child specialists — recommends pre-exposure rabies shots for children in infancy.
Dr Khan Amir Maroof, professor of community medicine at the University College of Medical Sciences, Delhi, who is also attached with the Consortium Against Rabies, said, “This recommendation has merit but since the vaccination so far is not offered through the government’s Universal Immunization Programme, hardly any child receives an anti-rabies shot before an actual dog bite.”
But, said Dr Mukund Singh, consultant, internal medicine with Accord Superspeciality Hospital, Faridabad, in many cases even medical care providers do not have full information about the protocol to be followed in case of pre-exposure prophylaxis.
The government is currently considering introducing pre-exposure prophylaxis for all children aged around one through the Universal Immunization Programme, ThePrint had reported earlier.
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