Rabies – a viral zoonosis– is recognized as a priority disease for global and national level control measures.¹1 Food & Agriculture Organization, World Organisation For Animal Health, World Health Organization. High Level Technical Meeting to Address Health Risks at the Human-Animal-Ecosystem Interfaces: Mexico City, Mexico: 15-17 November 2011. Geneva: World Health Organization; 2012. Available from: http://www.fao.org/docrep/017/i3119e/i3119e.pdf [cited 2014 Dec 15].
http://www.fao.org/docrep/017/i3119e/i31... ^–33 Rana UVS. Meeting of Standing Committee on Zoonoses; 2011 May 31; India. New Delhi: National Centre for Disease Control; 2011. pp. 1–7. Key interventions for rabies control include vaccination for high-risk individuals, surveillance of human cases, post-exposure prophylaxis following animal bites, vaccination and/or culling of the canine population and other animal reservoirs. Despite the known effectiveness of these interventions,⁴4 WHO expert consultation on rabies. Second report [Technical Report Series 982]. Geneva: World Health Organization; 2013. PMID: 24069724 many national policy-makers across Africa and Asia hesitate to introduce them.⁵5 Lembo T, Hampson K, Kaare MT, Ernest E, Knobel D, Kazwala RR, et al. The feasibility of canine rabies elimination in Africa: dispelling doubts with data. PLoS Negl Trop Dis. 2010;4(2):e626. doi: http://dx.doi.org/10.1371/journal.pntd.0000626 PMID: 20186330
https://doi.org/10.1371/journal.pntd.000... ^,66 Kakkar M, Venkataramanan V, Krishnan S, Chauhan RS, Abbas SS; Roadmap to Combat Zoonoses in India (RCZI) initiative. Moving from rabies research to rabies control: lessons from India. PLoS Negl Trop Dis. 2012;6(8):e1748. doi: http://dx.doi.org/10.1371/journal.pntd.0001748 PMID: 22880139
https://doi.org/10.1371/journal.pntd.000... We argue that this hesitation may be caused by advocacy for technical solutions that do not account for local requirements of policy-makers and implementers.

There has been a considerable amount of research on rabies in India, but key questions remain unaddressed.⁶6 Kakkar M, Venkataramanan V, Krishnan S, Chauhan RS, Abbas SS; Roadmap to Combat Zoonoses in India (RCZI) initiative. Moving from rabies research to rabies control: lessons from India. PLoS Negl Trop Dis. 2012;6(8):e1748. doi: http://dx.doi.org/10.1371/journal.pntd.0001748 PMID: 22880139
https://doi.org/10.1371/journal.pntd.000... For example, while policy-makers need evidence for social, political and economic outcomes of control programmes, most rabies research is done in the basic sciences.⁶6 Kakkar M, Venkataramanan V, Krishnan S, Chauhan RS, Abbas SS; Roadmap to Combat Zoonoses in India (RCZI) initiative. Moving from rabies research to rabies control: lessons from India. PLoS Negl Trop Dis. 2012;6(8):e1748. doi: http://dx.doi.org/10.1371/journal.pntd.0001748 PMID: 22880139
https://doi.org/10.1371/journal.pntd.000... We aim to illustrate the research–policy disconnect in rabies control and describe how this disconnect contributes to the lack of effective rabies-control policies in India.

Over the past decade, intradermal administration of rabies vaccine for post-exposure prophylaxis has heralded a major change in rabies-control measures. The World Health Organization recommends this route when vaccines are in short supply, citing the 60–80% reduction in direct costs and vaccine consumption, compared with standard intramuscular injection.⁴4 WHO expert consultation on rabies. Second report [Technical Report Series 982]. Geneva: World Health Organization; 2013. PMID: 24069724^,77 Rabies vaccines: WHO position paper. Wkly Epidemiol Rec. 2010 Aug 6;85(32):309–20. While intradermal administration makes efficient use of limited vaccine supplies, the costs saved by using this strategy at a programme level have not been fully ascertained.

We conducted a cost analysis of rabies-control programmes in India and showed that the choice of vaccination route contributed the least to government cost‒savings compared to other drivers of programme costs, such as procurement costs and wastage rates of different vaccine formulations and the incidence of dog bites.⁸8 Abbas SS, Kakkar M, Rogawski ET; Roadmap to Combat Zoonoses in India (RCZI) initiative. Costs analysis of a population level rabies control programme in Tamil Nadu, India. PLoS Negl Trop Dis. 2014 Feb;8(2):e2721. doi: http://dx.doi.org/10.1371/journal.pntd.0002721 PMID: 24587471
https://doi.org/10.1371/journal.pntd.000... Thus, cost-savings from a centralized procurement and supply-chain management system might be outweighed by the costs of uniform adoption of intradermal vaccination in an Indian setting. Through discussion with the programme managers, we found that they favoured the intradermal route in urban hospitals and the intramuscular route in peripheral health facilities. Peripheral facilities, which have fewer patients than urban hospitals, treat one to two dog bites per week, hence, the multi-dose vaccine vials are discarded after use in one patient. Therefore, the intradermal use policy does not always lead to vaccine savings but could increase the transaction costs of the vaccination due to the increased need for training and supervision of vaccinators.⁸8 Abbas SS, Kakkar M, Rogawski ET; Roadmap to Combat Zoonoses in India (RCZI) initiative. Costs analysis of a population level rabies control programme in Tamil Nadu, India. PLoS Negl Trop Dis. 2014 Feb;8(2):e2721. doi: http://dx.doi.org/10.1371/journal.pntd.0002721 PMID: 24587471
https://doi.org/10.1371/journal.pntd.000... ^,99 Abbas SS, Kakkar M. Systems thinking needed for rabies control. Lancet. 2013 Jan 19;381(9862):200. doi: http://dx.doi.org/10.1016/S0140-6736(13)60082-3 PMID: 23332953
https://doi.org/10.1016/S0140-6736(13)60...

Canine vaccination is the suggested strategy of choice towards elimination of rabies.⁴4 WHO expert consultation on rabies. Second report [Technical Report Series 982]. Geneva: World Health Organization; 2013. PMID: 24069724^,1010 Lembo T; Partners for Rabies Prevention. The blueprint for rabies prevention and control: a novel operational toolkit for rabies elimination. PLoS Negl Trop Dis. 2012;6(2):e1388. doi: http://dx.doi.org/10.1371/journal.pntd.0001388 PMID: 22389727
https://doi.org/10.1371/journal.pntd.000... However, we have found little documentation of the expectations of local communities or rabies-control programme managers as to how this strategy would work.⁵5 Lembo T, Hampson K, Kaare MT, Ernest E, Knobel D, Kazwala RR, et al. The feasibility of canine rabies elimination in Africa: dispelling doubts with data. PLoS Negl Trop Dis. 2010;4(2):e626. doi: http://dx.doi.org/10.1371/journal.pntd.0000626 PMID: 20186330
https://doi.org/10.1371/journal.pntd.000... ^,66 Kakkar M, Venkataramanan V, Krishnan S, Chauhan RS, Abbas SS; Roadmap to Combat Zoonoses in India (RCZI) initiative. Moving from rabies research to rabies control: lessons from India. PLoS Negl Trop Dis. 2012;6(8):e1748. doi: http://dx.doi.org/10.1371/journal.pntd.0001748 PMID: 22880139
https://doi.org/10.1371/journal.pntd.000... The cost of a canine vaccination programme is three to 10 times higher than the cost of human prophylaxis.⁸8 Abbas SS, Kakkar M, Rogawski ET; Roadmap to Combat Zoonoses in India (RCZI) initiative. Costs analysis of a population level rabies control programme in Tamil Nadu, India. PLoS Negl Trop Dis. 2014 Feb;8(2):e2721. doi: http://dx.doi.org/10.1371/journal.pntd.0002721 PMID: 24587471
https://doi.org/10.1371/journal.pntd.000... Modelling of pilot canine vaccination interventions in India showed that a coverage of 70% would have to be sustained over two decades in order for the intervention to be effective.¹¹11 Totton SC, Wandeler AI, Zinsstag J, Bauch CT, Ribble CS, Rosatte RC, et al. Stray dog population demographics in Jodhpur, India following a population control/rabies vaccination program. Prev Vet Med. 2010 Oct 1;97(1):51–7. doi: http://dx.doi.org/10.1016/j.prevetmed.2010.07.009 PMID: 20696487
https://doi.org/10.1016/j.prevetmed.2010... Even at a cost of 0.13 US dollars (US$) per vaccinated dog, the total cost per year for a national programme of canine vaccination would be US$ 23 million – 27% of the total budget of the State Department of Animal Husbandry in 2012. In addition, unless accompanied with dog population control, this strategy is not likely to reduce the number of dog bites or the costs of post exposure prophylaxis.

In India, eliminating a single-host disease such as polio has been logistically challenging and vaccination coverage is still less than 60% in many large states.¹²12 National fact sheet: 2009 coverage evaluation survey. New York: United Nations Children’s Fund; 2009. Available from: http://www.unicef.org/india/National_Fact_Sheet_CES_2009.pdf [cited 2014 Dec 16].
http://www.unicef.org/india/National_Fac... Eliminating rabies by vaccinating the entire canine population is understandably a low priority for most decision-makers in the country.

We do not have good estimates of transmission of rabies from dogs to humans and from dogs to cattle. In 2003, it was estimated that 14 000–17 000 human deaths were caused by rabies in India.¹³13 Suraweera W, Morris SK, Kumar R, Warrell DA, Warrell MJ, Jha P; Million Death Study Collaborators. Deaths from symptomatically identifiable furious rabies in India: a nationally representative mortality survey. PLoS Negl Trop Dis. 2012;6(10):e1847. doi: http://dx.doi.org/10.1371/journal.pntd.0001847 PMID: 23056661
https://doi.org/10.1371/journal.pntd.000... No nationally-representative epidemiological data have been collected since then. Similarly, official statistics report around 300 rabies-related cattle deaths annually for the entire country.¹⁴14 Department of Animal Husbandry Dairying & Fisheries. Annual report 2010-11. New Delhi: Ministry of Agriculture; 2011. The lack of more reliable information makes it difficult to plan and evaluate the success of any rabies-control measures.

What are the rabies-control solutions for India? Researchers and policy-makers need to jointly promote evidence-based policy-making. The landscape of rabies control is complex; with actors from multiple sectors – including animal welfare, public health, veterinary medicine and civil administration – with different perspectives and expectations of a rabies control programme. In such an environment simple intervention strategies are not likely to meet the needs of all stakeholders. Instead, an approach that recognizes – while seeking to improve – the interdependence of human, animal and environmental health, may bring multiple perspectives together. More epidemiological studies and implementation research should be conducted with a wider set of actors. For us, the recognition of the complexity of rabies control is the first step to developing more effective, acceptable and sustainable policy solutions.

References

Competing interests:

Publication Dates

History