Rabies, a neurotropic lyssavirus, is a vaccine-preventable zoonotic disease, estimated to cause between 40,000 to 100,000 human deaths annually worldwide.1 The main cause of rabies transmission is through dog bites2 and the vast majority of reported deaths (84%) occur in rural areas3. Over a third of deaths occur within India, the widely acknowledged global hotspot for rabies in the world, and a country which has annually reported an estimated 25,000–30,000 human deaths from rabies since 1984.4 The disease occurs in more than 150 countries and territories worldwide and is regarded as the world's deadliest zoonosis.
Sadly, the majority of people who die of rabies are people of poor or low-income socioeconomic status,2 30–60% being children under the age of 165. Without post-exposure prophylaxis, prognosis is incredibly poor with only a very small handful of humans ever surviving once the onset of clinical symptoms has occurred.
Access to treatment is often extremely limited in many global rabies hotspots and if available, cost is a huge issue for impoverished victims. A lack of understanding leads to many patients not completing their treatment course or using regimens that are not recommended. Previous estimates have indicated that a full course of post-exposure prophylaxis represents as much as 3.87% of the gross national income for a person in Asia and 5.80% for a person in Africa (equivalent to 51 days wage for an average African and 31 days wage for an average Asian).6
In many countries where the disease is endemic, rabies is not notifiable and there is no organized surveillance system of human or animal cases. The issue of effective surveillance is compounded by the fact rural families will not always insist on the cause of death being officially registered and it is incredibly difficult to ascertain the exact scale of a problem which is generally regarded as being vastly underestimated in endemic areas.
In Malawi, a country where at least one child dies from rabies every day, the Queen Elizabeth Hospital in Blantyre annually reported the highest incidence of child rabies deaths from any single institution in Africa,7 but it is estimated that for every child officially recorded as having died of rabies, the doctors estimate at least 100 others have suffered the same fate. In the same hospital, a paper was also published identifying 11.5% of child deaths attributed to cerebral malaria were in fact a result of the rabies virus.8
In poor countries, where infrastructure is often lacking, rabies is endemic and lethal. It typically devastates impoverished rural communities, affecting mainly children, who simply don't know what to do when bitten by a rabid dog and have no access to proper treatment.
Economically, the estimated global cost of rabies is in the region of USD$ 8.6 billion and 3.7 million disability-adjusted life years (DALYs).3 Approximately USD$2 billion (∼40%) is annually attributable due to lost productivity after premature deaths and a further USD$ 1.6 billion is spent directly on global post-exposure prophylaxis.6
In India, which has a population exceeding 1.02 billion, it is estimated that 15 million people are bitten by animals annually.9 That equates to at least one person being bitten by a dog every two seconds and the estimated annual cost of post-bite treatment in this country totals approximately USD$25 million.2
In Malawi, annual cost of PEP is USD$2.1 million with indirect costs calculated to be at least US$13.2 m. Mission Rabies have calculated it would cost them USD$6.5 million a year for three years to eliminate canine-transmitted rabies from Malawi with a predicted maintenance cost of surveillance and response totalling USD$1.3 m a year. Aside from the human and animal motivations to eliminate the disease, there is clear economic advantage for Governments to initiate national rabies vaccination programmes.
Despite all the above, there is still very little investment in strategic dog vaccination in most endemic countries3 which, by targeting 70% of a resident dog population over a sustained period (2–3 years) is regarded as the most effective way to eliminate the disease.
One Mission
Notwithstanding the detailed academic debates around rabies and its control, the current rabies situation can be summarized as follows:
At least one child dies every ten minutes as a direct result of canine-transmitted rabies
Rabies kills a higher proportion of children than adults
The main cause of rabies in Asia and Africa is through dog bites
Many cases of rabies in Asia and Africa are not reported, specifically in rural areas, suggesting the true incidence of this fatal disease is unknown and is likely to be significantly higher than official figures
Hundreds of thousands of dogs are culled regularly, often brutally and indiscriminately, for fear of a rabies epidemic in many areas throughout the world
Annual vaccination campaigns, combined with focal concurrent humane population control programmes, public education and national surveillance programmes are proven ways to address a rabies endemic crisis and if implemented efficiently, will not only be economically advantageous for Governments but save thousands of lives (both animal and human) every year
Mission Rabies and WVS, thanks to the huge support from key sponsors and individual volunteers, spearhead programmes globally to eliminate rabies from some of the world's worst affected areas. Whilst Mission Rabies targets mass vaccination and education campaigns utilising unique epidemiological surveillance with smart phone technology, WVS works synergistically to run concurrent humane population control, treatment programmes and trains local vets boosting core veterinary infrastructure.
To date, Mission Rabies has vaccinated over 330,000 street dogs at 7 international project sites globally, educated over 400,000 children and is on the cusp of eliminating rabies from Blantyre in Malawi and Goa in India.
That said, this is only the beginning and the next steps are to integrate the core infrastructure and disease surveillance technologies of Mission Rabies and WVS into a wider platform which could effectively tackle a multitude of infectious and zoonotic diseases around the world.
One Mission is about to begin.
References
1. Knobel DL, Cleaveland S, Coleman PG, et al. Re-evaluating the burden of rabies in Africa and Asia. Bull World Health Organisation. 2005;83:360–368.
2. Ghosh TK. Rabies. In: Proceedings of the IX National Conference of Pediatric Infectious Diseases; 2006; Chennai, India.
3. Hampson K, Coudeville L, Lembo T, Sambo M, Kieffer A, Attlan M, et al. Estimating the global burden of endemic canine rabies. PLoS Negl Trop Dis. 2015;9: e0003709. doi:10.1371/journal.pntd.0003709.
4. Sudarshan MK. Assessing burden of rabies in India. WHO sponsored national multi-centric rabies survey (May 2004). Assoc Prev Control Rabies India J. 2004;6:44–5.
5. Human rabies deaths - 2004, Geneva. Department of Food Safety, Zoonoses and Foodborne diseases, World Health Organisation; 2008. Available www.who.int/rabies/rabies_maps/en/index.html (VIN editor: link cannot be accessed on 01/25/17).
6. WHO Expert Consultation on Rabies 2013.
7. Depani S, et al. World Rabies Day: evidence of rise in paediatric rabies cases in Malawi. Lancet. 2012;380(9848):1148.
8. Mallewa M, Fooks AR, Banda D, et al. Rabies encephalitis in malaria-endemic area, Malawi, Africa. Emerg Infect Dis. 2007;13(1):136–139. doi:10.3201/eid1301.060810.
9. Menezes R. Rabies in India. CMAJ. 2008;178(5):564–566.
10. Expert Consultation on Rabies held in Geneva, October 2004 (TRS 931, WHO 2005).