Rabies in India - a Shocking Overview

Introduction

• Rabies negatively affects the poor living in remote rural areas and slum-dwellers of developing countries.
• Rabies is the deadliest virus-caused disease, where nearly 100 % of the patients die after developing symptoms - but it isnt even notifiable in India. 
• An estimated 17.4 million animal bites occur in India annually.
• Dogs are the source of the vast majority of human rabies deaths, contributing up to 99% of all rabies transmissions to humans.
• By 2010 India had vaccinated just 15% of its dogs. 
• A large number of reported rabies cases and deaths in India occur in children under the age of 15 years.
•  Rabies immunoglobulin is undergoing a critical shortage worldwide. It is also prohibitively expensive for many victims in a country where 60% of the population lives on under US$2 a day: In India it costs about US$7, for each vial. Only three companies produce it, with relatively high manufacturing costs.
• Less than a third of the animal bite cases in India recieve post-exposure rabies prophylaxis.
• A mere 0.33 % of the dog population of India is sterilized every year. An unsterilized female dog can result in 67,000 pups in seven years. 
• In fact, India has not implemented any of the rabies-prevention strategies successfully, be it vaccination, sterilisation of dogs, or providing free medicines to all rabies victims.
• If the level of vaccination in the dog population can be kept at 70 percent over a period of seven years, the variant of the rabies virus that thrives in dog populations will disappear.

The 2020 New Year did not start on a good note for young Praveen and his family at Ballari : The twenty-six-year-old’s eyes are feverish and wild as he hyperventilates on a hospital bed. As his words tumble out in a breathless babble, he explains to a doctor that months earlier, a three-month-old puppy had bitten his leg. Showing the scars, the youth says he was given injections at that time by a local doctor. 

He tries hard to drink water, but screams at the very sight of it. Tormented by thirst, he brings it to his lips again and again, only to convulse and gag at the last moment. Lying alone in a dark room of Isolation Hospital in Bengaluru, Praveen pleads for the lights to be switched off, as they hurt his eyes. It’s a horrible sight for his family, as they watch him suffer. The hospital staff knows there is nothing they can do now. A few hours later, Praveen passes away.

Many countries have gained an efficacious governmental control over rabies, mainly by vaccinating a wide number of human and dog populations, and by implementing other interventions and policies. Only a few countries have managed to completely eradicate the disease. Unfortunately, this is not the case with India. Here the situation has not changed for a decade.

Rabies is a neglected disease, which is insufficiently addressed by the national and international community. Rabies negatively affects the poor living in remote rural areas and slum-dwellers of developing countries. 

Once clinical symptoms appear, rabies is virtually 100% fatal. It spreads to people and animals via saliva, usually through bites, scratches or direct contact with mucosa (e.g. eyes, mouth or open wounds).

Managing a rabies exposure, where the average cost of rabies post-exposure prophylaxis is currently estimated at an average of US$ 108 (along with travel costs and loss of income) can be a catastrophic financial burden on affected families whose average daily income may be as low as US$ 1–2 per person.

Vaccinating dogs, including puppies, is the most cost-effective strategy for preventing rabies in people because it stops the transmission at its source.

India has more than 30 million stray dogs (this figure mentioned in this article also). By 2010 India had vaccinated just 15% of its dogs. The Animal Welfare Board of India was quoted in 2016 as stating that 'Over one lakh stray dogs are sterilized and vaccinated against rabies every year.' - that would be a mere 0.33 % of the dog population of India. 

An article states : 'If a female dog is sterilized, effectively it prevents 67,000 births over seven years.' But since the effort at sterilization is so small, we are adding these dog numbers endlessly to india. 

Once given a vaccination shot, a dog should be safe from catching or spreading Rabies for at least a year. The consensus among rabies experts is that if the level of vaccination in the dog population can be kept at 70 percent over a period of seven years, the variant of the rabies virus that thrives in dog populations will disappear.

In fact, India has not implemented any of the rabies-prevention strategies successfully, be it vaccination, sterilisation of dogs, or providing free medicines to all rabies victims.

An estimated 17.4 million animal bites occur annually (the figure in 2012 was 15 million annual bites a year), and about 5 million post-exposure rabies prophylaxis (PEP) are provided. 

Over the years, India’s stray dog population has grown.

For example, stray dog population has gone up by 65% within seven years in Chandigarh. This was revealed in the 2019 animal census conducted by the UT animal husbandry and fisheries department. 

Between January and March 2015, Chandigarh registered 1,200 cases of dog bite. 

On an average, nearly 6,000 cases of dog bites are being reported in Ahmedabad every month. This means roughly 200 people are bitten by dogs every day in the city.

A study showed that dog sterilizations in Ahmedabad reduced bites by only 8.5 %. 

Statistics from Pune Municipal Corporation reveal that, “at least 28 citizens were bitten every day by stray dogs making for an average of 10,000 dog bite cases in 2017. 

Nearly 50 per cent of those bitten by a dog in India do not receive rabies vaccine. 

INDIA'S HEALTH CARE SYSTEM HAS BEEN FAILING US FOR RABIES

Cases of Rabies are invariably fatal once symptoms manifest. More than 20,000 people die of rabies every year in India, three-quarters of them in rural areas. 

Incidence of rabies in India has been constant for the last few years, without any declining trend.

Every animal bite is potentially suspected as rabid exposure as rabies is endemic in India. The exposed individuals should seek early health care and prophylaxis (PEP) should be started immediately at the healthcare facility as it is lifesaving. 

Unfortunately, availability, accessibility, and usage of PEP are limited in India. 

There are many primary healthcare centres in Karnataka where the staff lacks knowledge on how to administer the vaccine, even if it is available, say doctors. 

A study in 2019 showed that in over half of the anti-rabies clinics surveyed in Bengal, Bihar, Gujarat, Himachal Pradesh, Kerala, Madhya Pradesh and Manipur, even facilities for washing wounds and antiseptics -- a critical first step in treating animal bites -- were inadequate. 

Over half the clinics did not have Immunoglobulin which could be critical in preventing rabies if there was blood from the bite wounds, especially on the neck, face or head. 

Two studies carried out in New Delhi and Jodhpur showed many disparities in the knowledge and practices of doctors in regard to rabies. Less than half of them were unaware of the intradermal rabies prophylaxis schedule, and only 45% of them knew about HRIG (immunoglobulin). 81% of them knew of the prophylaxis in unimmunized patients, but only 40% were familiar with the guidelines for previously immunized patients. 

More importantly, public doctors had markedly better knowledge than private doctors in regards to the prophylaxis. This is very concerning, when taken into account that India has the biggest private sector of doctors in the world, accounting for 93% of the hospitals and 85% of doctors.

Post-exposure treatment (HRIG) is simply unaffordable, costing around 30,000 rupees ($447) for an average person. 

Moreover, India notoriously experiences local and national shortages of HRIG, causing the patients who are willing to pay, to wait for it, for weeks or even months, which can eventually lead to death.

A 2018 WHO report said that dog-mediated rabies has been eliminated from western Europe, Canada, the USA, and Japan. 28 of the 35 Latin American countries report no human deaths from dog transmitted rabies.

Great strides have been made in reducing rabies deaths in countries such as Bangladesh, the Philippines, Sri Lanka, Tanzania, Vietnam, and South Africa.

Bangladesh, with almost 10.000 deaths per year and less than six % dog vaccination coverage, has adopted a very successful national strategic plan for the elimination of rabies by 2020. Through the establishment of the District Rabies Prevention Control Centres in almost every district, they provided facilities for mass dog vaccination, dog population management, care of bitten patients, all of whom receive anti-rabies vaccine and immunoglobulin for free. 

Furthermore, local champions were appointed to convince political leaders, policymakers and stakeholders for political commitment and technical leadership and partnership for this assignment. As a result, rabies deaths have reduced by 50% between 2010 and 2013. 

Such an outcome contrasts with the slow progress made in India.

It has been demonstrated in multiple research studies that India’s poor position in rabies elimination is rooted in a lack of knowledge about the disease, uncontrolled canine population, the insufficient vaccination programme, irregular supply of vaccines and inadequate training of healthcare professionals. 

The WHO estimates that investing in rabies elimination globally will eventually free up an estimated US$8.6 billion in economic resources each year. Since over a third of the rabies burden is in India, it should save about US$3 Billion a year by eliminating rabies. 

 The Question of Availability of Rabies Biologicals

Most of the available rabies vaccines are indigenously produced in the country. The rabies vaccines are procured by the state governments - the scenario of their availability varies from 24 × 7 availability in Gujarat and Kerala, to occasional supplies in Manipur and Bihar. In fact, there is a 20-80 per cent shortage in anti-rabies vaccines across all States, barring Kerala and Gujarat. However, this is contradicted in an article in 2019, that stated that rabies vaccines had been in short supply in Ahmedabad for nine months.

A 2018 article said that India sees 1.75 million dog bites every year, yet we face up to 80% shortage of anti-rabies vaccines. The government is dragging its feet over controlling dog population, vaccinating them or even making enough shots available for victims.

There was no immunoglobulin for almost a month in Panaji in March 2015. 

Manufacturers remained cold to three tenders floated by Karnataka in 2019 and the State Government had to seek help from neighbouring States. Kerala government responded by providing 10,000 shots of anti-rabies injection and 2,000 vials of immunoglobulin injection.

Recent reports suggest that human rabies vaccine shortage is a common problem also in Punjab (it is a problem even in Delhi Government hospitals, as this report of 2019 shows). 

Rabies biologicals, i.e., vaccines and immunoglobulins are life saving for humans in all rabid animal exposures. These biologicals should be continuously available throughout the year, in the entire country to prevent human rabies.

A 2018 article said that while on the one hand the production is low, states are not procuring enough either due to shortage of funds or maladministration. There is an urgent need for central procurement of rabies vaccines.

In Sep 2019, manufacturers and marketers informed that lack of firm orders by State governments and late payments led to the shortage. The Health Ministry advised State governments to issue quantity based tenders and place long-term firm orders with specific quantity and supply schedule.

A welcome news late in 2019 was that a Gujarat-based plant of Rabies vaccines, shut for a few years, was re-starting production. It had commanded the lion's share of the vaccines market previously. 

Shortages were also caused from Aug 2018 onwards when a major rabies vaccine maker based in China was caught out for fraudulent practices in their manufacture. He had to withdraw vaccines from the market (including those exported to India) and subsequently shut down. 

Looking at reports further back, even in 2008, it was said that the post treatment immunoglobulin was almost impossible to obtain in most of India.

The Animal Birth Control Programme as a way of managing problems with Street Dogs is a Resounding Failure

The Animal Birth Control Programme (ABC) is being implemented in only 60 big cities of India. Only Tamilnadu and Goa have attempted the programme in the entire State. 

Sterilization programmes for street dogs began in India around 2001, yet still cannot be called a success. In Coimbatore, for instance, around 43 % of the street dogs were sterilized till 2017. 

A female-centric approach is the most efficient for dog population control. As even one unspayed female in the population can give birth to as many as 20 pups a year. 

There are many who disagree with India's failed policy on street dogs - A Jul 2019 article says : It is wholly and completely the Animal Welfare Board of India’s (AWBI) cruel and illegal ABC (Animal Birth Control ) policy because of which homeless dogs exist in such numbers today.

The article goes on to say that WHO guidelines state that 'Control of reproduction of feral dogs is rarely worthwhile. If feral dogs are captured and unclaimed they should be humanely killed.'

The WHO and animal welfare organisations around the world promote and encourage free/low-cost neutering for PET dogs. A municipality in Taiwan offers $5 to owners to get their dog sterilised. That is how much cheaper and more practical it is for the government and animal organisations to neuter and vaccinate pets and prevent surplus animals from ending up on the streets in the first place.

The article adds that : 'The clueless AWBI’s ABC policy is the complete opposite of what needs to be done — ignore pets and randomly sterilise and vaccinate some homeless dogs. In fact, this policy has failed so spectacularly, that the AWBI has now changed its own goal post — invented ‘street/Indian/community’ dogs that are supposedly meant to live on the streets anyway !

Another article asks : Who are the beneficiaries of keeping the dogs on the streets?

In the cities, municipal authorities are blamed for the growing numbers and growls on the streets. While the authorities want to remove dogs from the streets, people representing animal welfare organisations insist on carrying on an “unworkable programme” to reduce the conflict between man and mongrel. 

Victims are blamed for the attacks. The ABC programme legalises straying, puts dogs in direct conflict with people, and is a perversion of public policy.

The AWBI, the functioning of Animal Welfare Organizations (AWOs), and the implementation and efficacy of the ABC programme have been studied and reviewed by the Ministry of Environment & Forests multiple times, most notably in 1999, 2008, and 2015. It is not for no reason that the reviews and audits have never been made public.

The reviews expose corrupt practices by the AWBI, mismanagement and misappropriation of funds by AWOs in the name of “animal welfare”, and an appalling lack of even rudimentary knowledge of dog control and welfare on the part of the AWBI and NGOs.

The AWBI and AWOs carrying out the ABC programme must be disbanded and held culpable for criminal misconduct for this blatant and deliberate deception of the public and courts, deaths of hundreds of citizens, and cruelty to animals.

The threat from feral dogs is not restricted to human life. Feral dogs are posing a serious threat to Indian wildlife. Conservation India lists several instances of dogs attacking, hunting, and chasing away wildlife, including several endangered species, in different parts of India.

Livestock and wildlife are now increasingly under attack from hungry and homeless dogs, which also spread diseases to wild populations. 

Unwanted, homeless dogs suffer and die due to accidents, diseases, and starvation. They are now even subject to retaliatory attacks from people, who have no other recourse but to take matters into their own hands. The only beneficiaries of the ABC programme are the AWOs, which get taxpayer money to build private hospitals and boarding for pets and leave homeless animals on the streets.

The current policy is illegal and unconstitutional as it goes against its own parent Act – the Prevention of Cruelty to Animals Act, Article 21 – Right to Life, Municipal State Laws, the Police Act, and Public Nuisance Laws. While the Prevention of Cruelty to Animals Act (PCA), 1960, talks about culling street dogs, the Animal Birth Control (Dogs) Rules of 2001 allows stray dog population. 

“PCA clearly says stray dogs should be ‘destroyed’. But AWBI through its ABC rules insists that they live on the streets. 

In 2015, AWBI issued a circular that blames the victim for a dog attack.

Developed nations do not allow dogs on the street. Those which are found are put up for adoption. When no one adopts them, they are euthanised. Only two Japanese have died of rabies in last 50 years, that too after being bitten in India and the Philippines. Japan does not allow dogs on the street. Those which are found are put up for adoption. When no one adopts them, they are euthanised. Same is done in the US and Ireland.

There is no focus in India on Rabies Vaccinations for dogs - the emphasis is on birth control

There is no rabies component in India’s only official rabies control programme. Prevention of human rabies deaths by post-bite vaccination of every person that is bitten, is not rabies control. 

While WHO mandates that at least 80 per cent of dogs need to be vaccinated annually to break the cycle of transmission of Rabies, only 2.4 per cent have been vaccinated by the Animal Welfare Board of India from 2008-2017.

The ABC programme, however, mandates that ownerless dogs be left back on the streets under no supervision – how such dogs are to be identified and accurately re-immunised annually has neither been defined nor ever been attempted by the AWBI. Neither the AWBI nor the ABC programme has ever mentioned any methodology for rabies control.

There is no legal mandate in India for anti-rabies vaccinations, which would shield street dogs from contracting rabies. Instead, ‘animal birth control’ — the mass sterilization of street dogs to ensure their long-term population decline — is the status quo solution. 

However, sterilized dogs can still bite people, passing on the virus to humans and other animals. The Union health ministry continues to subsidize extremely expensive post-bite treatment for patients. These expenses should instead be directed toward animal vaccination, which has proved to be around 100 times cheaper and more effective in Asia.

Delhi's first animal welfare policy does not refer to mass anti-rabies vaccination of street dogs. 

However, the 2021 National Action Plan for Dog-mediated Rabies Elimination mentioned that the Department of Animal Husbandry & Dairying under the Government of India, is assisting State Governments for canine anti Rabies vaccination under ASCAD and RKVY Schemes.

The plan aims at systematic reduction of Rabies risk through sustained mass dog vaccinations, pre- and post-exposure prophylaxis and public education until the country is completely free of dog-mediated Rabies.

There is no attempt to compile an Accurate National Data on Rabies

In India, the deadliest virus-caused disease - Rabies, where nearly 100 % of the patients die after developing symptoms - has not been notifiable until recently. In 2021, India declared rabies a notifiable disease.  

The national figures from a study in 2005 showed 12,700 cases of the furious rabies type. The numbers of paralytic and atypical rabies were not estimated but the authors refer to a total rabies estimate by other studies of 20,000. 

91% of the rabies deaths were in rural areas and only 16% of the deaths occurred in health facilities. 62 % of thsoe who died were males and 50 % were children under 15 years. 

The median time from bite to death was 8 weeks. 

Two-thirds of the deceased rabies patients had not sought hospital treatment. The third who did, received one or more vaccines after their most recent bite. However, only one patient completed the then recommended course of 14 injections. 

“The true burden of rabies in India is not known. The reported incidence (in Government data) is probably an underestimation because in India rabies is still not a notifiable disease,” said the WHO representative to India in 2018. “The government figures are way lower than the actual figures,” says M K Sudarshan, founder member of the Association for Prevention and Control of Rabies in India.

The compilation of national data on rabies cases has been so poor as to be laughable. According to the National Health Profile 2017 of the health ministry, there were 86 rabies cases in the country and no survivors, so the fatality rate was 100 per cent. 

In a single Infectious Disease Hospital in Delhi however, in January 2017, of the nine patients admitted, seven were categorised under 'Left Against Medical Advice (LAMA)' and the other two were reported dead. The situation was identical every month. This implies that the LAMA patients too would have died for sure, but were not categorised as such.

So the Rabies patients in just one hospital were 25 % more than the claimed national total !

Just one state - Karnataka, saw 789 cases of rabies between 2016 and 2018.

In 2021, India created a One Health network that will not only serve rabies but will also strengthen surveillance and health systems for multiple health risks at the human-animal-environment interface.

The aim of the network is to study the prevalence of ten selected zoonotic diseases (throughout the country) and five trans-boundary animal diseases (mainly from northeast boundary states) and analyse risks so as to provide forewarning.

Residents in India have no recourse from conflict with dogs in public spaces

Health is a state subject and it is the statutory, civic duty of local authorities as defined by Municipal Acts across the country to keep the streets free of straying animals, check the spread of diseases, and prevent public nuisance. The ABC programme transfers this responsibility of the government to voluntary organisations with no liability.

State governments and the Centre continue to spend crores of rupees on post-bite treatment/vaccination, rabies deaths, man hours lost, and accidents. Local authorities spend taxpayer money on maintaining dog vans and pounds and manpower. 

Citizens, especially the poor, continue to face dog attacks in public places, with children being attacked regularly. 

Many citizens troubled by biting dogs and have approached courts in all parts of the country, filed petitions with corporations / other authorities, and given press interviews - with no impact on the ground, it seems. See here too. 

In fact, hearing of such petitions came to a stand still because of an interim order dated November 18, 2015 passed by the Supreme Court of India in the case related to Animal Welfare Board of India Vs. People for Elimination of Stray Troubles and others. The order requested all high courts not to pass any order relating to 1960 Act and 2001 Rules, pertaining to the stray dogs.

Yogesh Bhardwaj, veterinarian at the Nainital zoo, said, “Dogs being territorial animals will attack any outsider entering their areas, including pets and its owners. Some dogs are also agitated as speeding vehicles pass by and tend to attack drivers. During mating season, high levels of testosterone in males also incite them to attack humans.”

Expert advice on aggressive dogs: Not all stray dogs are aggressive. Most do not bother any human around them. However, an aggressive dog can disturb harmony. One such dog can form a pack of two, three or more dogs as it becomes the alpha of a pack.

Dogs in his pack tend to become aggressive and become dangerous for humans and other animals, including pet dogs and stray bovines. If any dog feeder spots the first sign of aggression in any stray dog, it should be immediately reported to the civic agencies. If the dog's behaviour continues to be aggressive, it should be sent to a dog shelter for the safety of others.

"According to law, such dogs can only be sent back to their locality if they show a change in behaviour. Ignoring signs of aggression, defending aggressive dogs and preventing their removal from the area can lead to a disastrous situation," said Kaveri Rana Bhardwaj, an animal rights activist and rescuer.

 Feeding dogs at places that are away from homes is important. Dogs have a territorial tendency and it's their nature to protect the human who is providing food. If a person is feeding the strays in front of her home, she is treating the dog like her pet and the stray dogs react like one despite being out on the street.

They will protect her house at any cost, and this leads to a dispute with other groups of dogs or even humans that are just passing by. Any suspicion can lead to a disaster if there is a pack of such dogs.

The People for Elimination of Stray Troubles blogspot makes an interesting point : Ensure that the citizens’ rights are upheld by clearing the streets of stray animals. Basically, this includes public areas free of stray animals as provided for by the municipal and panchayat acts - a demand that the existing law be implemented and enforced.

WHO AND CDC Guidelines for Bites

WHO Document

WHO Document

WHO Document

WHO Document

WHO Document

WHO Document

WHO Document

Postexposure prophylaxis consists of a dose of human rabies immune globulin (HRIG) and rabies vaccine given on the day of the rabies exposure, and then a dose of vaccine given again on days 3, 7, and 14. For people who have never been vaccinated against rabies previously, postexposure prophylaxis (PEP) should always include administration of both HRIG and rabies vaccine. The combination of HRIG and vaccine is recommended for both bite and non-bite exposures, regardless of the interval between exposure and initiation of treatment.

People who have been previously vaccinated or are receiving pre-exposure vaccination for rabies should receive only vaccine.

For many types of bite wounds, immediate gentle irrigation with water or a dilute water povidone-iodine solution has been shown to markedly decrease the risk of bacterial infection.

Wound cleansing is especially important in rabies prevention since, in animal studies, thorough wound cleansing alone without other postexposure prophylaxis has been shown to markedly reduce the likelihood of rabies.

You should receive a tetanus shot if you have not been immunized in ten years. 

Some pointers by the National Centre for Disease Control

A history of rabies vaccination in an animal is not always a guarantee that the biting animal is not rabid. Animal vaccine failures may occur because of improper administration or poor quality of the vaccine, poor health status of the animal, and the fact that one vaccine dose does not always provide long-lasting protection against rabies infection in dogs/cats. Hence, appropriate documentation of vaccination status of dog/cat and proper history should be elicited before deciding to defer post-exposure prophylaxis after bite by vaccinated dog/cat. 

National Centre for Disease Control, 2015

A provoked dog bite should also be managed as an exposure and PEP started immediately. A provoked bite does not mean that the biting animal is not rabid. Washing of wound(s) should be carried out as soon as possible with soap and water (for a minimum of 15 min). Since the rabies virus can persist and even multiply at the site of bite for a long time, wound(s) must be washed even if the patient reports late.

After thorough washing and drying the wound(s), any one of the available chemical viricidal agents should be applied, such as povidone iodine, alcohol, etc. 

In category III exposures (which result in drawing blood through the skin) rabies immunoglobulin should be infiltrated in the depth and around the wound(s) to neutralize the locally present virus. Suturing of wound(s) should be avoided as far as possible.

Rabies Immunoglobulin should never be administered in the same syringe or at the same anatomical site as vaccine.

A Times of India article mentions that the Rabies Vaccine, administered after a dog bite to prevent infection, works only 14-15 days later. Immunoglobulin, meanwhile, is administered in cases where the victim has grievous injuries accompanied by bleeding.

Goa has become the first state in India to eliminate rabies in humans

Goa has become the first state in India to eliminate rabies in humans, with no cases since 2018. The project, led by the NGO Mission Rabies, began in 2014. 

The NGO's approach consists of remote teams of dog vaccinators, who systematically work their way through towns and villages vaccinating dogs.

Vaccination teams rotated through the talukas of Goa, re-starting the state campaign cycle on an approximately annual basis. A combination of door-to-door and capture-vaccinate-release (CVR) methods were used to access dogs for vaccination. 

CVR involves catching street dogs in large nets, before vaccinating them and marking them in non-toxic green paint, and then releasing them again.

Their progress was recorded in a smartphone app, which collects data on dog sightings, geographical areas covered by the team, and the details of the vaccinated dogs. 

The annual vaccination output increased, both in terms of geographic extent and a total number of dog vaccinations, through program refinement from 2013 to 2017. Intensive state-wide vaccination was achieved for the first time in 2017, vaccinating 97,277 dogs in an estimated total population of 137,353 dogs. Thus, a 70% dog vaccination coverage rate was achieved for the first time in 2017 using this method. This output was sustained through 2018 and 2019.

Both ownership and confinement data were available for over 90% of dog vaccination records. 52% were owned dogs and 48% were unowned dogs. Unowned dogs were inherently always roaming, while owned dogs were either always roaming (17.9%), allowed to roam for some of the time (50.3%) or always confined (never roaming) (31.7%). Consequently, most dogs vaccinated (83.5%) were among the roaming dog population for some or all of the time.

Smaller two-person vaccination teams were introduced in 2018 to more efficiently vaccinate dogs that could be restrained by hand, which was the case for 64.2% of all dogs vaccinated.

Nevertheless, specialist equipment was still needed to access a considerable proportion of dogs, with 16.3% of owned dogs and 56.5% of unowned dogs being restrained by a net.

Mission Rabies spends about $300,000 a year and has vaccinated 100,000 dogs a year since 2017, about 50,000 a year before that. Deaths of people from rabies in Goa fell to zero in 2018, from 15 in 2014, when the campaign started. 

Mission Rabies estimates the vaccination cost per dog, including salaries and other costs, at $2.50, far lower than the cost of treating humans, which involves not only a more expensive vaccine, but also potential hospital stays. By that accounting, every dog in India could theoretically be vaccinated for under $90 million. India now spends $490 million a year on post-bite treatment.

The Goa program for human rabies elimination consisted of three core areas of activity: dog vaccination; rabies education; and intensified human and animal rabies surveillance.

The second pillar of the program was an education initiative whose primary focus was on teaching school children about rabies, how to avoid dog bites and what to do if bitten. The program also emphasized the importance and social value of ensuring as many dogs as possible were vaccinated against rabies each year. 

In total, school-based rabies education classes were delivered to 694,271 school children and 31,251 teachers between 2014 and 2019. 

Activities to distribute rabies educational messages throughout communities intensified with a similar timeframe which resulted in the delivery of rabies lessons to 155,079 people through community groups, local authorities, and public events.

Seventy-three canine rabies cases were confirmed in the first 6 months of surveillance in 2014. The mean state-wide occurrence of canine rabies cases decreased from 10.6 cases per month in 2014 to 0.8 in 2019, a decrease of 92%.

Thus the Mission Rabies project in Goa was "very cost effective", not only saving the state government money on healthcare-associated costs, but also reducing economic loss from death.

As well as vaccinating dogs, the methodology emphasizes ramping up disease awareness in society, such as running education programs in schools across Goa. 

Children are taught how to avoid dog bites, as well as what to do if bitten. Currently, many rabies deaths occur due to incorrect post-bite treatment. 

The Kerala state government now plans to partner with Mission Rabies to replicate the Goa program. 

Applying the Goa project’s methods on a larger scale would require at least one technical piece that is missing — an oral vaccine. Western Europe eradicated rabies in foxes by dropping baits with oral vaccines, beginning in 1990 when rabies was widespread and lasting more than 20 years.

Himachal Pradesh revolutionized how immunoglobulin is administered in wounds

Since 2008, Himachal Pradesh has used a "pooling strategy" to help patients save money by pooling vials of anti-rabies vaccine at a centralized hospital and sharing them using the intradermal technique. 

It was Omesh Bharti, epidemiologist at the Himachal Pradesh State Institute of Health & Family Welfare, whose rabies immunisation treatment protocol has been notified as the global standard by WHO.

In 2014, there was an acute shortage of rabies immunoglobulins (RIG) and two patients died after four injections of rabies vaccine were administered without RIG, which was not commercially available. 

After an extensive literature review and technical and ethical committee clearances, in June 2014 Himachal started to infiltrate equine RIG (eRIG) into wound/s only without the recommended systemic intramuscular injection.

During the four-year period June 2014 to June 2018, 7506 of 10,830 patients exposed to suspected rabid animals were injected with eRIG in and around the wounds in a single clinic at DDU Hospital Shimla without any adverse outcomes. 

The average volume of eRIG used per patient was 0.75 mL and cost US$ 0.75. Of the 80% of patients who were followed up, all were healthy at the end of a year, including 26 patients bitten by laboratory-confirmed rabid dogs. The reaction rate after PEP administration also declined significantly. 

Since February 2018, Himachal has started following the new WHO recommendations on PEP regimens of three intradermal antirabies vaccines instead of four, thereby saving hundreds of vaccine vials that became useful during shortages of rabies vaccine in India. To date, more than 700 vaccine vials have been saved in a single clinic at DDU hospital during the past 6 months alone. 

Currently, 90 "pooling centers" have been established for sharing of vaccine and eRIG vials in Himachal State, generating huge savings that have enabled the government to provide PEP free of charge.

Studies on Rabies in Punjab

A study in Punjab India, showed that the proportion of confirmed rabid dog cases was consistent throughout the study period (2004-2014).

It is likely that rabies is maintained in dogs in an urban transmission cycle. Reports of dog- bites demonstrated increased incidence in humans over the years. Another study in 2016-'17 showed that the annual incidence of rabies in dogs in Punjab would be in the region of 190 cases. The incidence in pet dogs would be double that of stray dogs. But Stray dogs are responsible for most of the human bite cases in India (60 %).

Of rabid animals in which the biting history was known, there was no significant difference between the proportion of dogs that had a history of biting behaviour and those that had not. 

It is accepted that vaccination of dogs for canine rabies needs to consistently achieve high coverage to reduce incidence and potentially eliminate rabies in dogs. However, this is difficult to achieve even in well- resourced environments.

Some municipalities in Punjab try to control stray dog populations through Animal Birth Control- Anti- Rabies programmes but are unsuccessful due to insufficient resources. 

There are increased cases of rabies in dogs in Punjab in March and August. It is not known if this is due to an increased seasonal breeding. Regardless of the reason —either increased exposure of the general public to dogs, or increased incidence in dogs—rabies elimination campaigns in the Punjab can gain more efficient resource allocation by targeting dog vaccination prior to March and August and rabies- awareness messaging during March and August.

Surveillance for rabies in animals in Punjab relies solely on passive data collection. There is no coordinated approach to surveillance such as a state sponsored testing scheme.

Factors such as poor dog population management and low standards of dog care (including infrequent veterinary consultation) are considered responsible for high endemicity of canine rabies in India. 

Some of the rabies-infected domestic and pet animals in the study (16%) had received rabies vaccination previously, but the recommended annual vaccination schedules were not subsequently followed. In 56% of the rabies cases, the animal owner noticed a bite wound on the animal’s body but only 31 % of the owners requested veterinary treatment or vaccination of the animal. All of these animals died before completing the course of post-exposure rabies prophylaxis vaccination.

Of the 16 rabid dogs reported in 2016-'17 in 4 sub-districts of Punjab, all had developed rabies after being bitten by other rabid dogs. A total of 20 humans were exposed to rabid cases sufficiently for potential rabies virus transmission. All of them received post-exposure prophylaxis, and were alive at the time of completion of the study.

But in an earlier study decades ago, 177 cases of clinically diagnosed rabies were reported from hospitals in Amritsar city over 6.5 years. 87 % of the patients had been bitten without any provocation.

All the patients died with varied symptomatology: hydrophobia, aerophobia and restlessness was observed in 100% of cases. Almost all the patients applied red chillies; only 18% had antiseptic dressing. 87 % of the deceased had not taken anti-rabid vaccine treatment.

A total of 18 cases, who also died, were given post-exposure treatment with anti-rabic vaccine but only 12 received 11 or more injections. They started the treatment from 1-35 days after exposure. 

Rabies studies in Rajasthan

In Kota city of Rajasthan, visiting the celebrated gardens now carries the risk of encountering packs of dogs. 

There was a rabies vaccination camp in Sirohi by an NGO where people got their dogs for vaccinations. 

A study in 2018 at an anti-rabies clinic in Jaipur on patients' information on rabies showed that over a fifth had good knowledge, another fifth had poor knowledge and the rest had 'fair' knowledge about rabies. But this cannnot be generalized to the general population of Rajasthan I feel, because :

• Residents of urban areas have access to greater knowledge than in rural settings. 
• Residents of big cities like Jaipur will be even more aware. 
• The patient has been bitten by animals so would have received counsel from family and friends already. 
• They had had the good sense or guidance to come to a specialized anti-rabies clinic rather than go to any doctor - so that shows a very heightened level of awareness. 

For these reasons, I feel that particularly in rural areas and among poor people in slums, the knowledge on rabies will be much lower than in this study. 

Even here with comparatively higher levels of awareness, just half the patients knew the name of the disease caused by a rabid animal. Only 40 % knew that bite from other animals (cat, monkey etc.) can also cause rabies. Over a third knew rabies is a communicable disease. Only a third knew that fear of water was one of the symptoms when rabies manifested in the patient. Only 25 % knew that once manifested, rabies isnt curable. Sadly, only 8 % knew that rabies can be transmitted via the saliva of an infected individual, dog or human. 

The good thing was, that more than 90 % of the patients knew that bite from a rabid dog caused disease. More than 80 % knew rabies could be prevented by vaccination. Over two-thirds knew that rabies was fatal. And nearly 60 %  knew that the site of the bite should be washed with soap and water.

Another study in Jodhpur stated : Dogs have to be immunised annually to maintain their immunisation status against rabies. This concept was not known to the residents it was the first time they were told about the same.

The supply of Ketamine Hydrochloride (an anesthetic agent) used for animal sterilization at veterinary clinics is inconsistent. Thus, Animal Birth Control activities are often interrupted.

Rabies and the Dog Issue in Gujarat

A study in 2010 in Ahmedabad found that the highest concentration of dogs was near garbage disposal areas, lower and middle income group housing societies, and areas where there were deliberate human feeders.

The density of dogs per km. across different wards, varied from 14 to 57.

Towards the end of the count (September- October) a high incidence of mating behavior was identified across Ahmedabad.

In 10 years of Animal Birth Control in Ahmedabad, less than 15 % of the dog population could be sterilized.

The number of dog bites peaks in winter and drops lower during summer. Winter is when the dogs are breeding. 

A concerted effort was made to sterilize a large number of dogs in 2006. It had the effect of reducing dog bites in Ahmedabad by 8.5%. 

Lots of pet dogs were also noticed during the survey. A high percentage of these “owned” animals were found roaming on the streets and were not sterilized.

The Dog Issue in Uttarakhand

Life has been difficult for many middle class residents of Dehradun because of many strays on the streets. a group of eminent persons have started a social media campaign on WhatsApp appealing residents to stop feeding dogs since it prompts canines to attack commuters on the streets. Coming out strongly against dog lovers who feed strays, members of the group also said that those wanting to give food should do in their homes and not endanger the lives of others.

Soumya Prasad, a group member and professor at the JawaharLal Nehru University in Delhi, said, “Stray dogs are territorial animals. They occupy the areas where they find food. With people feeding them, the canines tend to attack commuters. The elderly, children and women are more vulnerable.

Saying that compassion for strays should not hold a society to ransom, Prasad said, “People feeding strays should take complete responsibility of their action and compassion should not end in harm of other people. They should either adopt the dogs or local authorities should make them liable to bear medical expenses of affected persons.”

Chief Justice G Rohini, during a plea filed last year by Om Prakash Saini, a resident of Malviya Nagar in the city, said “It was rather strange that people feed stray dogs and allow them in public spaces, causing nuisance and inconvenience to others. If you have a pet and you are feeding it, it is ok. But if you feeding stray dogs and they are causing inconvenience to others, it is not good.”

The Dog Problem in Karanataka

The dog census in all wards in Bangalore in 2019 estimated the stray dog population at 3.09 lakh, of which around 54% are neutered. 

It was in 2000 that the city’s civic body launched the birth control programme, touting it as a long-term solution to the stray dog menace. The programme calls for the systematic neutering of strays. Over two decades later, Bruat Bengaluru Mahanagara Palike officials said that the civic body is fighting an uphill battle against nature.

“Dogs have two annual breeding cycles, with pregnancy lasting 60-62 days, and they give birth to six to eight puppies per cycle. Of this, half of them are usually female. Within 10 to 12 months, the puppies reach maturity and start reproducing on their own. The rate of reproduction is rapid and the birth control programme can only slowly take effect,” admitted an official.

Rabies in Uttar Pradesh

In a 2005 study, one third of the national rabies deaths were found in Uttar Pradesh (the national number was estimated at 12,700 for furious type of rabies cases, and other studies mentioned a figure of 20,000 for all types of rabies cases in humans in India).

Dog bites affect over 27 lakh people in Uttar Pradesh every year. As per a rough estimate, not less than 100 people are bitten by dogs in each district every day.

The killing of more than a dozen children by feral dogs in Sitapur in back-to-back incidents in 2018, brought the problem to the fore in its worst form.

Dog Bites in Delhi

Over the past six months, the number of dog bites in the Indian capital has increased dramatically. Safdarjung and Ram Manohar Lohia, two referral hospitals for rabies in Delhi, reported 29,698 and 18,183 cases respectively, almost as many as in all of 2022, when there were 51,000 cases. This data is incomplete and does not take into account visits to other facilities or private clinics. 

In 2019, The Delhi government reported an “acute shortage” of rabies vaccines in its government-run hospitals. The Ram Manohar Lohia hospital reported 1,000 patients queuing for vaccines on a particular June day, compared to its usual 200 patients daily. 

In view of the increasing dog bite incidents in the city, Directorate of Education of Delhi has issued a circular directing schools to create awareness about rabies among students.

The Crazyness around the Stray Dog issue in India - Story 1

The poor state of india's government run health services for people is our daily experience. Even as they do a great service for all in need, especially the poor, they are plauged with lack of infrastructure and staff. Witness this news where several district level government hospitals in uttarakhand now dont even admit people in the summer as they do not have enough water supply !

April 2022 news : Every day, the district hospital in Champawat needs at least 67,500 litres of water to function. But as water becomes increasingly scarce across the north Indian state of Uttarakhand, the hospital in the Kumaon Himalayas is routinely left without the quantity of water it needs to safely provide healthcare for the local community.

“In peak summers, our villagers are refused admission as there is no water at the hospitals,” said Bhuwan Singh, the head of Ruiyan, a small Himalayan village in Champawat district. He said that during the peak summer months, three or four people out of Ruiyan’s population of 330 adults are refused entry to hospital. “Every year [during the summer], it gets really difficult to receive treatment at any of the nearby government health centres or even the district hospital,” he said. 

More than 300,000 people in Champawat district rely on the hospital; its average daily footfall is 250-300 people.

Parmanand Punetha, an engineer at the Uttarakhand water department, said: “Water reservoirs are drying each year, and it gets very difficult to maintain a continuous supply to the three major hospitals in Champawat, Lohaghat and Paati on a regular basis.

The Bureau of Indian Standards, the authority that sets standards for all products in the country, stipulates that hospitals with more than 100 beds should have a round-the-clock piped supply of up to 450 litres of water per bed per day. This excludes water required for air conditioning and firefighting.  

Champawat district hospital has 150 beds, and needs at least three tankers of water (10,500 litres) to function, Airy said. This means the average allocation is less than 50 litres per bed per day.

Yet Airy told The Third Pole that during the summer, the hospital receives only half the required quantity of water. On most days in the driest period it gets only two tankers (7,000 litres), and sometimes just one.

“When we order four tanks, we only get two and we are the main hospital in this district so I can imagine that the primary [or community] health centres would face even tougher situations.”

Tripti Bahuguna, director-general of State Health Services for Uttarakhand, said that healthcare provision is most affected in the Kumaon region (which encompasses Champawat district) and Pauri Garhwal district.

And witness here the ABC rules which stipulate AC operation theatres for dog sterilization !

In Jun 2023, Kerala State Minister for Local Self-Governments said that it was difficult to set up and run  Animal Birth Control centres as per the central norms as the rules stipulate that sterilisation should be done in an AC operation theatre, the dog should be treated there for four days and be released only after the wound is healed.