Rabies: All for 1, One Health for All

September 25, 2023

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Rabies: All for 1, One Health for All

Dr. Kriti Singh & Dr. Prateek Jindal

Guru Angad Dev Veterinary & Animal Sciences University

Rabies is a viral zoonotic disease that affects the central nervous system and fortunately, can be prevented with a vaccine. However, once symptoms appear, rabies is almost always deadly with a survival rate of only < 0.1%. Household dogs are responsible for spreading the rabies virus to people up to 99% of the time, although both pets and wild animals can contract and transmit this disease. The virus is typically transmitted through saliva, primarily via bites, scratches, or direct contact with mucous membranes, such as the eyes, mouth, or open wounds. Children between the ages of 5 and 14 are often the most vulnerable to these incidents, due to their frequent interaction with animals, increased chances of being bitten on the face or neck, and a tendency not to report bites or scratches received during play.

Rabies has a wide host range including, dogs, bats, raccoons, skunks, foxes etc., and is therefore has a worldwide distribution. It is found on every continent except Australia and Antarctica, but it has a particularly devastating impact in Asia and Africa, where >95% of the human deaths occur. Worldwide, there are an estimated 59,000 mortalities per year in humans with 1 death occuring every 9 minutes. In India, over 20,000 human rabies deaths are reported per year. Despite the severity of the disease, rabies cases are underreported, and the actual number of cases often differ significantly from the officially recorded figures.

The rabies virus mainly spreads through the saliva of an infected animal when it bites or scratches a person. It can also be transmitted if an infected animal licks open wounds, cuts, or the inside of the mouth and nose of a person. There is no solid evidence to suggest that people can get rabies from consuming milk, including breast milk, or properly cooked meat. Nevertheless, it’s highly recommended to avoid eating meat or drinking milk from an animal with rabies. It’s extremely rare for rabies to pass from one person to another, but if someone is taking care of a rabies patient, they should be careful not to touch the patient’s saliva or other bodily fluids. It’s crucial to practice good hand hygiene and personal cleanliness when caring for someone with rabies.

When a dog has rabies, it may act differently than usual. Some signs of rabies in dogs include: acting aggressively without any reason, biting people, animals, or even objects; behaving strangely, being restless and unable to coordinate its movements; feeling very tired and sluggish, making unusual sounds, like growling or having trouble barking; having too much saliva in its mouth or foaming at the mouth. When a person has rabies, they might feel uncomfortable, itchy, or painful around the area where they were bitten, they can have problems with their brain and nerves, which can make them anxious, confused, or agitated. As the disease gets worse, they might start experiencing delirium, might become afraid of air (aerophobia) and water (hydrophobia). Just looking at water can make their neck and throat muscles spasm. They could become very sensitive to noise or bright light. In some cases, they might become overly active and have difficulty swallowing, leading to nausea and vomiting.

They may also experience muscle weakness or paralysis in certain areas. In severe cases, the person could slip into a coma and pass away. This usually happens within 7-10 days after the first signs of rabies, and there is no effective treatment once symptoms appear.

The most cost-effective approach to preventing rabies in humans is by vaccinating dogs, including puppies, as it eliminates the transmission of the virus at its source. Dog vaccination not only safeguards human health but also reduces the necessity for post-exposure prophylaxis (PEP) in people who have been potentially exposed to rabies. Highly effective vaccines are readily available for both PEP, administered after an exposure, and pre-exposure prophylaxis (PrEP), recommended for individuals in high-risk occupations like laboratory workers, veterinarians, and wildlife rangers. This comprehensive vaccination strategy plays a pivotal role in rabies prevention. PEP is a critical regimen for individuals who have potentially been exposed to the rabies virus. It involves thorough washing of the wound with soap and water for at least 15 minutes and prompt local wound treatment after a suspected exposure. Additionally, it includes a series of potent rabies vaccines meeting WHO standards and in specific cases, rabies immunoglobulin may be administered directly into the wound to enhance the immune response.

Rabies, while being a preventable disease, is on the rise and posing a major concern in both developing and developed countries. The low-income countries are disproportionately affected by rabies due to limited vaccination coverage, expensive post-exposure treatment, and a lack of public awareness. Additionally, the zoonotic nature of rabies makes its control and prevention more complex. The COVID-19 pandemic and its long lasting effects serve as a stark reminder that one sector alone cannot efficiently tackle zoonotic threats. This year’s World Rabies Day, under the theme ‘All for 1, One Health for all,’ aims to emphasize and reinforce this message. Therefore, to tackle the challenge of rabies control effectively, adopting a multi-sectoral One Health Approach appears to be a more promising strategy. This approach recognizes that the health of humans is connected to the health of animals and their shared environment.

The central focus of the One Health program should be to decrease the rabies incidence within the canine population through widespread dog immunization. This goal can be accomplished through the deployment of mobile dog vaccination teams, striving for extensive coverage both within the population of freely roaming dogs and owned confined dogs. A blend of door-to-door (DD) and capture-vaccinate-release (CVR) approaches can be employed to reach dogs for injectable vaccinations. Door-to-door vaccination consists of teams visiting households and providing dog owners with the chance to have their pets vaccinated. On the other hand, capture-vaccinate-release involves teams using nets to capture and vaccinate dogs that cannot be restrained manually. Achieving a 70% vaccination rate among dogs can disrupt the rabies transmission cycle in a high-risk area. The utilization of oral rabies vaccination (ORV) for dogs, when combined with parenteral methods, presents an opportunity to enhance the existing approach by facilitating the intensive vaccination of dog populations, even in remote and hard-to-reach areas, within a relatively short timeframe.

Another important aspect is controlling the population of street or community dogs which can be achieved through procedures like spaying and neutering. The government should also strictly prohibit the inhumane killing and torture of rabid animals and, instead, establish lawful euthanasia methods. Responsible dog ownership which includes ensuring that pet dogs are registered, kept in confinement, and receive mandatory vaccinations against rabies should be encouraged.

The second pillar of the program should focus on enhancing public awareness, with a primary emphasis on educating school children about rabies. This educational initiative should encompass various topics, including gaining an understanding of rabies, learning how to prevent dog bites, acquiring knowledge about post-exposure prophylaxis (PEP), understanding first aid for animal bites, and effective animal bite management. By imparting this knowledge to the younger generation, we can establish a solid foundation of awareness and prevention.

The third pillar of the program should revolve around rabies surveillance within the dog population. This can be achieved through enhanced canine rabies surveillance, primarily by providing an accurate information on dog population and improving the reporting of suspected rabid dogs from both the public and private sectors. Implementing active surveillance measures to closely monitor the disease’s prevalence and spread would be instrumental in gaining a better understanding of the rabies situation in a given area. In simpler terms, it’s like keeping a watchful eye on the situation so we can respond better to keep everyone safe and healthy.

Another aspect to keep in mind to control rabies effectively is to consider not only domestic animals but also wildlife, as they live closely with humans and domestic animals. This means we should expand our rabies monitoring and control efforts to include wildlife. One way to do this is by organizing large-scale vaccination campaigns for wildlife which involve distributing special vaccines in baits across natural areas, like national parks and forests, where wildlife live. This has been successful in places like Europe for foxes, Canada for raccoons, and the United States for coyotes. This may be helpful to reduce possible spillover of rabies from wildlife to livestock to humans and vice-versa.

Furthermore, the successful implementation of the program hinges on the availability of essential infrastructure like hospitals, veterinary centers and advanced diagnostic laboratories. The establishment of rabies diagnostic centers within each regional laboratory would not only streamline the process but also alleviate the burden on the Central Reference Laboratory. Ensuring the presence of competent healthcare professionals at these regional laboratories is vital to maintain the quality and efficiency of the monitoring program. Moreover, effective coordination and communication among these health professionals play a pivotal role in the overall success of the rabies control and prevention program. Additionally, crucial steps must be taken by the human health sector, which includes providing access to medical care and post-bite treatment, especially in rural areas where access to healthcare education is limited or non-existent. PEP is currently the only way to prevent rabies in humans after they’ve been bitten by an infected animal. So, to reach the goal of no human deaths from rabies by 2030, it’s crucial to make sure that PEP is readily available to all who need it.

Managing a rabies exposure can be financially devastating for affected families. The cost of rabies PEP, including travel expenses and loss of income, averages around US$ 108. For families with daily incomes as low as US$ 1–2 per person, this expense is overwhelming. Globally, dog-mediated rabies costs an estimated US$ 8.6 billion per year, and it also leads to significant psychological trauma for individuals and communities. Utilizing a One Health approach to reduce animal-to-human transmission of rabies not only decreases the need for post-exposure vaccines but also alleviates the financial burden on human healthcare budgets, making it a cost-effective method for rabies control.

In conclusion, let us reflect upon these words that encapsulate the essence of unity, One Health, and the collective effort to combat rabies.

“In a world where health intertwines,

One Health, a bond that brightly shines.

Rabies lurking, a threat we face,

Together, we’ll win this noble race.

From dogs to wildlife, humans too,

In unity, we’ll break through.

Vaccines, education, a vigilant quest,

Rabies shall be put to rest.

And as we stand, hand in hand,

A safer world, we’ll understand.

In unity, we’ll conquer the fight,