Comment

Emergence of rabies among vaccinated humans in India: a

public health concern
Kapil Goel,a,e Arunima Sen,a,e Prakasini Satapathy,b Pawan Kumar,a Arun Kumar Aggarwal,a,** Ranjit Sah,c,d and Bijaya Kumar Padhia,*
a
Department of Community Medicine and School of Public Health, Postgraduate Institute of Medical Education and Research,
Chandigarh, India
b
Department of Virology, Postgraduate Institute of Medical Education and Research, Chandigarh, India
c
Department of Clinical Research and Global Health, Harvard Medical School, Boston, MA 02115, USA
d
Department of Microbiology, Tribhuvan University Teaching Hospital, Kathmandu, Nepal

Rabies is transmitted through the bite of animals has also reported an alarming number of deaths from The Lancet Regional
infected with rabies, primarily dogs. Globally, dog- rabies. The disease has claimed the lives of 18 people in Health - Southeast
Asia 2023;9: 100109
mediated rabies causes an estimated 59,000 human the last eight months which is of major concern.
deaths annually.1 According to WHO, India accounts for The current rabies crisis in many countries including Published Online 21
November 2022
36% of the global deaths due to rabies. India also ac- India is not controlled because stray dogs and other rabid
https://doi.org/10.
counts for 65% of the deaths due to rabies in the South- animals roam freely and attack people. Local munici- 1016/j.lansea.2022.
East Asia region. The National Rabies Control Program palities need to be strengthened in terms of resources 100109
reported 6644 clinically suspected cases and deaths of and funding in the development of effective control
human rabies between 2012 and 2022. In India, the measures. Concerns have been raised about the
sudden spike in the number of cases of rabies is a major mismanagement of street dogs in terms of disruption in
public health concern. Deaths due to rabies among vaccination and birth control activities during the
vaccinated and unvaccinated individuals, especially in COVID-19 lockdown.9 In India, an increase in aggres-
the State of Kerala, have caused great public concern.2 In sion among dogs has been observed post-pandemic
Kerala, the number of infected dogs has doubled in the (Fig. 1), probably resulting from food shortages, aban-
past five years. Among 300 samples taken from dogs, donment of pets, and a decrease in human–dog inter-
168 samples (56%) were found to be positive for rabies, action.8,9 The inaction of the authorities would lead to
compared to 32% in a similar study conducted in 2016.3 people harming innocent dogs not involved in any attack
The state has reported more than 200,000 dog bite cases on humans. Despite the Prevention of Cruelty to Ani-
and 21 deaths (12 deaths were laboratory confirmed), mals Act of 1960, which protects stray animals, and the
which is almost double the deaths reported during the Animal Birth Control (Dogs) Rules of 2001, which makes
last year.2 Six of the victims, including a 12-year-old it illegal to remove or relocate dogs, mass killing of dogs
child, died despite receiving anti-rabies immunoglob- have been reported. The government should develop
ulin (RIG) and vaccine.2 Due to a severe shortage of more stringent policy measures to protect innocent stray
vaccines resulting from an increase in rabies cases, 250 animals. The Supreme Court of India directed the State
anti-rabies vaccines were allegedly administered without of Kerala to take strict measures after a public interest
being subjected to the required quality tests.4 However, litigation (PIL) was filed. Animal rights activists allege an
the authorities later obtained a letter from the inefficient implementation of the Animal Birth Control
manufacturing company alerting them of the comple- (ABC) program and vaccination of pet and stray dogs as
tion of quality inspections and the certificate from the main issues for the rising dog menace.
Central Drugs Laboratory (India). Antibodies against Rabies is a vaccine-preventable disease. India
rabies were later detected in one of the six victims.5,6 Till currently follows the updated Thai Red Cross Schedule
now, the expert panel constituted to investigate deaths for intramuscular (IM) and intradermal (ID) vaccination.
has not reported any concern regarding the effectiveness The current regimen for post-exposure prophylaxis (PEP)
or potency of biologicals or the emergence of rabies vi- includes eight ID doses (two sites per visit on days 0, 3, 7,
rus strains that evade the protective effects of vaccine.7,8 28) or five IM doses on days (0, 3, 7, 14, and 28).10
Unfortunately, the neighbouring state of Tamil Nadu Improper or non-administration of RIG or poor wound
management provides more time for the virus to spread.
*Corresponding author. Despite receiving the proper PEP, an unfortunate
**Corresponding author. outcome might be possible. After the vaccine is admin-
E-mail addresses: bkpadhi@gmail.com (B.K. Padhi), aggak63@
istered, it is a race between the body to produce antibodies
gmail.com (A.K. Aggarwal).
© 2022 The Author(s). Published by Elsevier Ltd. This is an open access and the virus to reach the brain. It has been suggested
article under the CC BY-NC-ND license (http://creativecommons.org/ that when parts of the body rich in nerves or close to the
licenses/by-nc-nd/4.0/). brain are affected, the vaccine would not have sufficient
e
Contributed equally.

www.thelancet.com Vol 9 February, 2023 1

 Comment

Fig. 1: Choropleth map showing dog-bite cases in the states and Union Territories of India between January–October 2022, as reported by local
media reports. The map was created using QGIS 3.26.3. The base layer map was used from Survey of India.

time to act.11 Hence, the vaccine alone is not sufficient to implemented to differentiate between rabies-infected
prevent rabies in category III exposure, and RIG must be and noninfected dogs, and infected ones need to be
given for passive immunity as soon as possible. In rare managed accordingly. Effective mass media campaigns
cases, instances of cold chain failure and substandard or are required to educate the public about rabies, first aid
fake vaccines, have also been documented. measures, and the importance of seeking timely care.
In Kerala, rabies deaths among vaccinated in- Considering the increase in animal bite cases and
dividuals were due to the nature of wounds and failure rabies deaths, Kerala should consider using PrEP as a
to seek prompt care. Awareness about first aid measures temporary measure until canine control is achieved. All
after an animal bite in the country is inadequate. In a children in endemic regions must also be provided
survey in six Indian states, only 38% of victims of ani- PrEP. Cross-state sharing of vaccines and RIG during
mal bites reported washing wounds after biting with the crisis period should be adopted. The availability of
soap and water.12 WHO recommends flushing and critical supplies should be displayed on e-Portals such as
washing the wound with water, soap, detergent, e-RaktKosh in various hospitals in endemic regions. To
povidone-iodine, or other virucidal agents for a mini- keep dogs off the streets, it is also important to promote
mum of 15 min. Preexposure prophylaxis (PrEP) should the adoption of street dogs and enforce strict regulations
be advocated for high-risk populations and children on pet ownership. In summary, there is a need for in-
having less access to PEP and where incidence of tegrated and comprehensive management of street dogs
dog bite is greater than 5%. Surveillance should be and bite management.

2 www.thelancet.com Vol 9 February, 2023

 Comment

Contributors 5 Kerala asks Union government to test quality of anti-rabies vaccine

B.K.P., P.S., K.G. and A.K.A. conceptualised the study. A.S. and P.S. [internet]. Mathrubhumi. Thiruvananthapuram. Available from:
wrote the first draft of the manuscript. P.K. curated the data and pre- https://english.mathrubhumi.com/news/kerala/kerala-asks-union-
pared the choropleth map. R.S., A.K.A. and B.K.P. edited the draft. All government-to-test-quality-of-anti-rabies-vaccine-1.7854560; 2022.
Accessed September 7, 2022.
authors reviewed subsequent versions and approved the final version of
6 Antibodies against rabies found in Abhirami’s body, bite to head
the manuscript. cause of death [internet]. Kaumudi Online. Pathanamthitta. Avail-
able from: https://keralakaumudi.com/en/news/news.php?
Editor note id=899997&u=antibodies-against-rabies-found-in-abhiramis-body-
The Lancet Group takes a neutral position with respect to territorial bite-to-head-cause-of-death-899997; 2022. Accessed September 8,
claims in published maps and institutional affiliations. 2022.
7 Rabies immunoglobulin serum samples from Kerala pass quality
test, result of vaccine awaited [internet]. The Hindu. Available from:
Declaration of interests https://www.thehindu.com/news/national/kerala/rabies-immunog
None. lobulin-serum-samples-from-kerala-pass-quality-test-result-of-vaccine-
awaited/article65959450.ece; 2022. Accessed October 2, 2022.
8 Rabies deaths in Kerala not due to ineffective vaccines: central team
References to health ministry [internet]. Hindustan Times. Available from:
1 Hampson K, Coudeville L, Lembo T, et al. Estimating the global https://www.hindustantimes.com/india-news/kerala-rabies-deaths-
burden of endemic canine rabies. PLoS Negl Trop Dis. 2015;9(4): not-due-to-ineffective-vaccines-govt-panel-101666119344835.html;
e0003709. 2022. Accessed October 19, 2022.
2 21 rabies deaths, nearly 2 lakh dog bites this year in Kerala: report 9 Nadal D, Beeching S, Cleaveland S, et al. Rabies and the pandemic:
[internet]. Onmanorama. Thiruvanathapuram. Available from: lessons for one health. Trans R Soc Trop Med Hyg. 2022;116(3):
https://www.onmanorama.com/news/kerala/2022/09/25/twenty- 197–200.
one-rabies-deaths-two-lakh-dog-bites-in-kerala-reveals-report.html; 10 National Centre for Disease Control. National Guidelines for Rabies
2022. Accessed September 25, 2022. Prophylaxis, 2019 [internet]. National Rabies Control Program.
3 Thomas J. Massive rise in rabies cases in Kerala; virus found in 168 Available from: https://ncdc.gov.in/WriteReadData/linkimages/
out of 300 samples [internet]. Onmanoram. Thiruvananthapuram. NationalGuidelinesforRabiesprophylaxis2019.pdf; 2019.
Available from: https://www.onmanorama.com/news/kerala/2022/ 11 Tinsa F, Borgi A, Jahouat I, Boussetta K. Rabies encephalitis in a
09/05/massive-rise-in-rabies-cases-kerala.html; 2022. Accessed child: a failure of rabies post exposure prophylaxis? BMJ Case Rep.
September 6, 2022. 2015;2015:bcr2014206191.
4 Menon J. 250 anti-rabies vaccines without quality checks injected 12 Haradanhalli RS, Anwith HS, Pradeep BS, Isloor S, Bilagumba G.
into patients in Kerala. Onmanorama. Available from: https://www. Health-seeking behavior and compliance to post exposure prophy-
onmanorama.com/news/kerala/2022/09/16/250-anti-rabies-vac- laxis among animal bite victims in India. Indian J Public Health.
cines-quality-checks-humans.html; 2022. 2019;63(Supplement):S20–S25.

www.thelancet.com Vol 9 February, 2023 3