Rabies is a serious disease that affects millions worldwide, but it is preventable. Dr S Mohd Salim Khan brings us some lessons learned at the 3rd Rabies in Asia Conference in Sri Lanka.
Rabies is widely distributed across the globe, with only a few countries being free of the disease. It is practically 100 per cent fatal, yet it is preventable. Rabies has the highest fatality rate of any disease known to infect humans. Once clinical signs are evident, death is virtually inevitable.
Throughout the world, rabid dogs cause more than 99 per cent of all human deaths, 60 per cent of which are children under the age of 15. Out of the current global estimate of 55,000 human rabies deaths every year, about 31,000 (56 per cent) occur in Asia, 25,000 (45 per cent) in SAARC countries while 20,000 (36 per cent) deaths occur in India alone. Dog-mediated rabies is a major public health problem in Asian countries.
Rabies is not a notifiable disease in many countries including India, and more than 1.4 billion people are at potential risk of a rabies infection. Each year, an estimated 19 million people are bitten by dogs; of which about four million receive anti-rabies vaccinations.
I had the opportunity to attend the 3rd Rabies in Asia Conference: RIACON 2011 in Colombo, Sri Lanka from 28-30 November 2011 on the invitation of Rabies in Asia Foundation. The Foundation, established in 2006, is a non-profit scientific organization with its headquarters at Kempegowda Institute of Medical Sciences in Bangalore.
The aim of the foundation is to work for ensuring “rabies-free Asia” and support for the elimination of rabies from the world. Presently, it has chapters in nine countries—Afghanistan, Bangladesh, China, India, Pakistan, Philippines, Sri Lanka, Thailand and Vietnam. The members include medical and veterinary professionals, scientists, administrators, academicians and others. The first conference of the foundation [RIACON] was held in March 2007 in Bangalore; the second in 2009 in Hanoi, Vietnam and the third one recently in Colombo, Sri Lanka. Around 130 delegates from Asia and beyond including USA, UK, France, Switzerland, Germany, South Africa, Italy, and organizations including WHO, FAO and WSPA attended the conference.
Deliberations were held on rabies control-global & regional perspective; role of international and private partnership; country reports from Asia; rabies biological & their usage; pre- and post-exposure prophylaxis against rabies; veterinary perspective including animal welfare; rabies in Americas, Africa & Asia; challenges for the new generation; rabies research followed by free paper-oral & poster presentations.
The dog population, especially stray community dogs has been a challenge all over the world. But political commitment and public cooperation have proven essential for reducing the economic and social burden of rabies in Asia. Necessary tools and methods for control of dog rabies and prevention of human rabies have been made available and the proof of the feasibility of rabies elimination has been demonstrated through the implementation of regionally coordinated rabies elimination programmes in some regions like ASEAN and countries like Sri Lanka, Thailand, Philippines and others.
Sri Lanka has proven itself in managing the stray dog population very effectively. There is strong evidence to suggest that the menace of rabies had been in existence in Sri Lanka as the Colonial Rulers had been compelled to adopt legislation to combat the disease. The Rabies Ordinance of 1893 and the Dog Registration Ordinance of 1904 are clear indicators of this. In 1965, the first Anti-Rabies Dog Vaccination campaign was conducted in the Western province.
Rabies was declared as a notifiable disease in 1971, as a result, 377 Human Rabies deaths were reported in 1973. In 1975, Cabinet approval was given to launch an island-wide five-year Rabies Control Program (1976-1980). During 1985-1991 AGFUND/RB/WHO Assisted Rabies Control project was launched in 7 districts. Mass vaccination of Dogs, Elimination of Stray dogs was the major strategies of the program. Dog population survey was conducted under this project. In 1989, a nationally conducted rabies control program was decentralized to provinces under the provincial council system.
The implementing strategies included mass rabies vaccination of dogs, dog population control, habitat control, surveillance on animal and human rabies, awareness and training on rabies control, monitoring and evaluation. Islandwide prompt garbage removal program also launched in mid-2010. These activities led to reduction of human rabies from 58 in 2009 to 49 (0.2 per 100,000 population) in 2010 and dog rabies reported were reduced to 579 in 2010 against the 709 in 2009. Similarly, several projects (supported by the Global Alliance for Rabies Control) have successfully utilized a One Health inter-sector approach to prevent and control canine rabies. For example, in the province of Bohol, Philippines, a collaborative project with the governor managed to eliminate dog rabies within four years.
The project included: a mass information and educational campaign aimed at the general population; the development of teaching modules that integrated rabies education into the elementary school curriculum; the vaccination and registration of 70 per cent of the dog population; the enforcement of existing rabies control laws; and the involvement of more than 15,000 community volunteers. Like-wise, the Philippines has developed the National Rabies Prevention and Control Program (NRPCP). Under the NRPCP, the components of the program are canine rabies vaccination, information and education campaign, disease surveillance, laboratory diagnosis of canine rabies, animal bite treatment centres, post-exposure treatment for the dog-bite victims, and establishment of rabies-free zones.
A multi-pronged strategy needs to be developed which include:
As a large number of the unvaccinated dogs is the major threat of human rabies, thus only immunizing most of the dogs national and state-wide can be a solid barrier to prevent rabies from spreading to humans.
Sterilization: Surgical sterilization of female dogs while using chemical agents for sterilization of male dogs.
Pre-exposure prophylaxis against rabies among high-risk professionals and population like the municipal staff especially dog catchers, veterinary staff etc.
Incorporation of rabies vaccination in universal immunization programme wherein an infant can receive rabies vaccine along with polio, DPT, hepatitis-B vaccines.
Establishing anti-rabies clinics at district and sub-district (CHC/PHC) levels with the provision of free anti-rabies vaccines and rabies immunoglobulins (RIG).
Training of medical staff on management of animal bites and rabies cases including hands-on training on much economical intra-dermal (updated Thai Red Cross) regimen for rabies prevention.
Effective and targeted education to reduce rabies by increasing community engagement in dog vaccination and sterilization, by improving behaviour around dogs to reduce dog bites, by seeking timely and appropriate medical treatment if bitten, and by improving responsibility towards dogs to improve dog welfare and to reduce nuisance.
Incorporating this rabies education program in school curriculum at national/ state level will help the country and state to eradicate rabies.
Habitat control of dogs and proper scientific collection and disposal of municipal waste so as to ‘starve’ the dogs by making waste collection and dumping sites highly restrictive by way of fencing etc.
Lastly, as there is no comprehensive rabies control programme and coordination mechanism for prevention and control of rabies in most of these countries, there is an urgent need to formulate rabies prevention and control programme in our country and state.