Global Alliance for Rabies Control still says there are at least 120 times more rabies deaths than found by 14 years of annual body counts
NEW DELHI––New national rabies survey data from the Central Bureau of Health Intelligence, the Indian equivalent of the U.S. Centers for Disease Control & Prevention, shows for the 15th consecutive year that India––and therefore the world––has magnitudes of order fewer human rabies deaths than the Global Alliance for Rabies Control and other agencies raising funds for rabies control commonly claim.
Because India is believed by the World Health Organization and the Global Alliance for Rabies Control to have the vast majority of human rabies deaths worldwide, the new Indian data suggests that the overall contribution of rabies to human disease mortality has been greatly exaggerated.
Numbers validate Animal Birth Control program
The most important implication of the new data, however, and of the 14 previous annual surveys showing similar, is that the Animal Birth Control anti-rabies programs promoted since 1997 by the Animal Welfare Board of India, funded since 2003 by the Indian federal government, are succeeding spectacularly in eliminating “rabies menace,” if not all “dog menace,” including attacks by non-rabid dogs.
Also succeeding spectacularly is the British-funded nonprofit Mission Rabies project, which since mid-2013 has vaccinated more than 265,000 dogs in target areas surrounding recent confirmed rabies cases.
324 human rabies deaths in three years
Summarized the June 14, 2017 edition of the Times of India, lumping together data from 2014, 2015, and 2016, “As per the figures given by the Union Health Ministry, India has reported 324 fatalities due to animal bite. With 146 deaths, West Bengal reported highest number of deaths due to rabies followed by Delhi (39), Jharkhand (34) and Madhya Pradesh (23). Gujarat state,” one of the states where the Animal Birth Control programs have been working longest, “reported 7 deaths in 2014 and 8 in 2015, respectively. The figures came down in 2016 when the state reported only 1 death due to rabies.”
The actual annual totals reported by the Central Bureau of Health Intelligence were 125 human rabies deaths for all of India in 2014, up from an initial report of 98 due to late-arriving case reports; 113 in 2015; 86 in 2016; and 97 in 2017.
India had 132 human rabies deaths in 2013, after averaging 249 since 2005, according to Central Bureau of Health Intelligence data.
“In need of elucidation”
Cautiously commented Program for Monitoring Emerging Diseases senior technical editor Maria Jacobs, from Zurich, Switzerland, “India’s human rabies statistics have been subject to discussions in the past, and are certainly in need of elucidation. The official annual number of human fatalities has been counted in 3-figure numbers, while 5-figure numbers are generally cited by international organizations.”
The Global Alliance for Rabies Control, based in Edinburgh, Scotland, continues to allege persistent under-reporting of rabies in India to a degree almost unparalleled for recognized diseases in the annals of medicine. The chief exception would be reporting of HIV infection in nations with strong taboos and even severe criminal penalties against promiscuity and homosexuality.
Theoretical & extrapolated data
Despite the evidence amassed since 2005 by the Central Bureau of Health Intelligence, the Global Alliance for Rabies Control argues that the actual Indian human rabies death numbers should be in the range of 12,700 to 20,565.
The Global Alliance for Rabies Control bases this projected case range on theoretical and extrapolated data, rather than confirmed body counts.
Baseline data from 1911
Much of the input data for the extrapolated numbers favored by GARC appears to originate with a national survey of government hospitals published in 1911 by David Semple and William F. Harvey, done just before they introduced post-rabies exposure vaccination to India. The same 1911 survey furnished the baseline data still used for projections of rabies deaths in Pakistan, Bangladesh, Nepal, Afghanistan, and Sri Lanka, all of which were also then under British administration as part of colonial British India.
The Central Bureau of Health Intelligence uses essentially the same survey method, but expedited by the use of electronic communications.
2003 study found 235 human rabies deaths
Studies funded by the World Health Organization have supported both the high and the low numbers––the high number coming from literature reviews tending to recycle the older estimates, the low number from an actual hospital study done in 2003 by M.K. Sudarshan, director of the Kempegowda Institute of Medical Sciences in Bangalore.
Sudarshan found 235 human rabies deaths for the whole of India.
Improved access to treatment needed
Whatever the actual number of human rabies deaths in India, it could plummet further just by improving access to state-of-the-art post-exposure treatment, according to an August 2016 audit of 128 suspected human rabies cases by scientists at the National Institute of Mental Health & Neurosciences in Bangalore.
Explained The Telegraph, “Immunization procedures seek to exploit the slow pace at which the rabies virus spreads through the body. The virus infects only nerve cells, and can take anywhere from days to months to move from the site of the bite [transmitting the virus from a rabid animal] to the brain, where it causes inflammation, or encephalitis, that leads to death.”
Locally manufactured descendants of the post-exposure vaccines developed by Semple and Harvey are widely available in India––but not always where and when they are most urgently needed.
The major difference between then and now is that the vaccines produced by Semple and Harvey were cultivated by injecting live rabies virus into sheeps’ brains, a process which made accepting post-exposure vaccination unacceptable to some Jains and strictly observant Hindus and Buddhists, whose religious beliefs eschew using any animal products or byproducts.
“Current vaccines are produced by injecting killed rabies virus into chicken embryos or into cultures of various cells,” explains Colorado State University professor of veterinary medicine and biomedical science Charles Calisher. “The final products produce immune responses in humans, pets, and livestock, albeit multiple doses are sometimes used. This production process is unacceptable to some Jains, but generally accepted by Hindus, Buddhists, and most Jains.
“The vaccine of choice,” however, “remains that produced in human diploid cells,” rarely available in India, while “the chicken embryo vaccine and other forms are also available and may be less expensive.”
Hospitals don’t stock enough vaccine
Rabies post-exposure vaccinations are by law supposed to be provided by government hospitals free of charge to victims of bites by suspected rabid animals.
Unfortunately, as Shivani Azad of The Times of India reported from Dehradun on June 6, 2017, echoing countless similar reports from around India in recent years, government hospitals often fail to keep supplies of post-exposure vaccine in stock sufficient to keep pace with unexpected surges in animal bites.
Animal Birth Control brings surge in bites
In Dehradun the numbers of dog and monkey bites rose 50% in early 2017 over 2016, coinciding with the success of a start-up Animal Birth Control program in sterilizing about 7,000 of the estimated 20,000 free-roaming dogs in the city.
This was not an unusual or unforseeable result, since sterilized, vaccinated dogs are more likely to become adopted as outdoor pets by regular feeders, and become territorial in defense of their feeding locations. At the same time, reduced street dog populations are less able to form spontaneous packs to roust marauding macaques.
Hundreds of Indian cities have experienced similar surges in dog bites and macaque invasions in the wake of successful Animal Birth Control programs, even as actual rabies cases drop.
Little coordination among animal & human health agencies
The catch is, Animal Birth Control programs are rarely if ever coordinated with government hospital administrations. Meanwhile, with any rabies still at large, post-bite vaccination is still essential.
Currently in Dehradun, and recently in many other cities, “For most patients, the ordeal of getting an anti-rabies vaccine is worse than the trauma of being attacked,” Shivani Azad wrote, “with several city hospitals failing to provide vaccines. In the past two weeks, none of the government hospitals had a stock of anti-rabies injections,” forcing bite victims to turn to relatively expensive for-profit medical service providers.
RIG could save half of victims
Meanwhile, explained The Telegraph, “current standard treatment “requires the bite victims to be injected as soon as possible with rabies immunoglobulin (RIG), a substance that helps neutralize the virus near the bite wounds in the early hours after the bite. This is followed by four or five doses of the anti-rabies vaccine to be taken on the day of the bite,” if possible, “and on the 3rd, 7th, 14th and 28th days after the bite.
“But RIG is not widely available in India,” The Telegraph observed, “and a significant proportion of patients do not receive it.”
The National Institute of Mental Health & Neurosciences found that 13 of the 24 patients in the study who developed laboratory-confirmed rabies had received fewer than half of the recommended number of post-bite vaccinations. At least 10 of the 24 rabies victims had not received RIG at all.
“All but 3 of the 24 patients were dog bite victims,” The Telegraph added. “The exceptions were a 45-year-old woman bitten on her toe by a mongoose, a 15-year-old girl scratched on her nose by a cat, and a 47-year-old man bitten on his hand by a monkey.”
The National Institute of Mental Health & Neurosciences found five patients who had apparently survived rabies infections since 2011, all with severe brain damage.
But the case reporting in India is often somewhat suspect, tending to identify rabies as the cause of very high fevers leading to mental impairment or death, rather than much more common yet less widely known mosquito-borne diseases such as Japanese encephalitis, which can produce lookalike symptoms.
For example, rabies rarely takes longer than two months to incubate and become lethal to infected humans. Nonetheless, the June 15, 2017 edition of The Times of India declared that “A scratch from a pet dog 11 years ago led to the death of a 45-year-old Army jawan [soldier] in Pune’s Command Hospital” on March 31, 2017.
Though the bite was ascribed to an incident in 2006, victims of bat rabies and mosquito-borne diseases often do not know they have been bitten.
Posted Program for Monitoring Emerging Diseases animal disease and zoonoses moderator Arnon Shimshony, “The following commentary by ProMED moderator Eskild Petersen, published in response to a human case in Nepal said to had undergone a 53 year incubation period, is applicable here: ‘Such incubation period is so long that a healthy bit of skepticism seems appropriate.
At a minimum, we need two additional pieces of evidence: 1) viral isolation as a proof of diagnosis; and 2) genetic evaluation of the virus to determine its origin, such as dog or bat, etc. Even if it is of dog origin, a minor exposure over such a long duration could have been forgotten, such as petting a dog with saliva on its fur.’
Non-rabid fatalities surge
Ironically, as the threat of rabies recedes from India and the Indian street dog population declines, as in Dehradun, the threat of non-rabid attack from insecurely kept owned dogs has exploded.
Indian dog attack reportage seldom includes any information about the breeds of the dogs involved, instead attributing attacks to “strays” who are presumed to be the free-roaming mongrels long ubiquitous throughout the nation.
But among 18 non-rabid fatal dog attacks reported by Indian mass media in 2016 and the first half of 2017, believed to be a fraction of the total, the only two attributed to dogs of any specific breed were inflicted by Rottweilers who attacked their owners. The Rottweiler attacks were 11% of the known cases.
Rottweilers in the U.S. and Canada have killed 98 people since 1982, 14% of all dog attack fatalities, second only to pit bulls, who have inflicted 382 fatalities (56% of the total.)