Indmedica Home | About Indmedica | Medical Jobs | Advertise On Indmedica
Search Indmedica Web
Indmedica - India's premier medical portal

Indian Journal of Community Medicine

Assessing Burden of Rabies in India: WHO Sponsored National Multicentric Rabies Survey, 2003

Author(s): M.K. Sudarshan

Vol. 30, No. 3 (2005-07 - 2005-09)


Both sylvatic and urban rabies have been present in India since ancient times. Rabies present throughout the country, except in the islands of Lakshadweep, Andaman and Nicobar. There is no organized system of surveillance of rabies cases, and hence there is a lack of reliable data.

From 1985, India reported every year about 25,000 to 30,000 human rabies deaths, which accounted to about 60% of the global report of 50,000. However, these figures were an estimate worked out, based on the projected statistics of isolation hospitals in the country. But many improvements were reported during this period viz. modern rabies vaccines, which were imported initially in 1970's, were later manufactured indigenously and subsequently exported too. Even the production and use of equine rabies immunoglobulin (ERIGs) gathered some momentum. With the socio-economic development and an improved usage of rabies vaccines the human rabies incidence was expected to be on the decline. But there was no data available to prove this point. Only a few studies conducted in different parts of India were available and their results could not be genralized or extrapolated. Some even postulated that the true incidence of human rabies could be even ten times more than those officially reported.

Even worse was the information about rabies in animals.The reporting of rabies in animals was initially from 128 of the 507 districts in 1990s, which was reduced to 30 districts later in 2000. Large geographical areas of the country did not report animal rabies in the last 10 years. The dog population was estimated to be about 25 million, most of which are ownerless and not immunized against rabies.The estimated animal bite load per year was 2.28 million.Thus, the current statistics of animal bites, rabies in animal population were scanty, unreliable and controversial due to poor surveillance/reporting system.

In this background, to clarify the above situation of ignorance, conflict and confusion. Association of Prevention and Control of Rabies in India (APCRI), a registered scientific society with technical and financial assistance from World Health Organization undertook this multi-centric survey.The survey was done with the aim of providing a comprehensive data on rabies and its related aspects in the human and animal populations in India.The specific objectives were to estimate the annual incidence of animal bites and human rabies deaths; to know the animal bite management practices, the common animal reservoirs of rabies and the time trends of disease in human and animal populations in the last decade.

The summary of this survey is presented below which mainly had three components viz. medical, veterinary and survey of rabies free areas.

1. Medical

Twenty-one Medical Colleges with geoscatter distribution of the country were identified. In each medical college, the survey was done under a Principal Investigator (with minimum MD qualification) with the help of 3 to 4 medical postgraduates/ interns with aptitude for surveys work. The Principal Investigators were trained in a One-day Workshop on 24th February 2003 at APCRI HQ's, KIMS. Bangalore. The Departments of Community Medicine, of 21 medical colleges did the community based household survey covering a total of 8,500 households (2,194 urban and 6,306 rural) from 84 randomly chosen communities (21 urban and 63 rural @ 1 urban and 3 rural for each medical college) and cases of animal bites and their management information was obtained. The total population covered was 52,731 (as against a target population of 40,000 at 90% confidence level and 10% permissible error). Also information about pet/household dog and cat and aspects of their care was enquired. Additionally, data about hospital incidence of human rabies was obtained from the isolation hospitals of the medical colleges for the last 10 years (1992-2001).

Besides, the medical colleges (Each medical college to search atleast 500,000 populatiion viz. 125,000 urban and 375,000 rural) covered about 10.8 million population (as against a target of 10 million population at 90% confidence level and 10% permissible error) through an active community search involving the local health staff and other community informants and looked for human rabies deaths in the last 3 years in urban and last 5 years in rural areas.The search was done for a 6 week ± 2 weeks period during March to May 2003. All the households having human rabies deaths were visited and medical college team collected the clinico-epidemiological information through a verbal autopsy.


The Commonwealth Veterinary Association, a collaborating agency through postal questionnaire obtained the data on rabies in animals during 1992-2001 from 18 Veterinary Colleges and 5 Premier Institutions in the country.

3. Rabies Free Areas

The islands of Andaman & Nicobar and Lakshadweep were personally visited by the APCRI survey team members in July and August 2003 (4 days each) and data was obtained from both medical and veterinary departments.

All the data was obtained by using structured, pretested, appropriate survey instruments. The survey duration was 6 months viz. March-August, 2003. The survey was monitered independently by WHO in May 2003 wherein 4 medical colleges were visited. The data was analyzed by Centre for Research in Health and Social Welfare Management (another collaborating agency) using SPSS Software.

The decadal (1992-2001) data from the isolation hospitals showed human rabies to be endemic and stable in the mainland India consequently, the community search for human cabies from 21 medical colleges revealed a total of 235 cases. The majority of human rabies deaths occurred in adults (64.7%) males (71.1%) and from poor/low income group (87.6%).The main animal responsible for human rabies was dog (96.2%), and sites of bite were lower limb (56.2%), upper limb (20.9%) and hands (17%). About 79% of rabies victims did not receive any anti-rabies vaccination and of those who took the vaccine (NTV/TCV) most of them did not complete the full course.The incubation period ranged from 2 weeks to 6 months duration in the vast majority (85%); it was lowest in bite on hands (8 days) and head & face (12 days). About 60% of victims had resorted to indigenous treatment and 55% sought hospital admission. Hydrophobia (95%) and aerophobia (66.4%) were the predominant clinical case features observed. About 50.6% died at home and autopsy was not done in any. A projected estimate of annual human rabies incidence based on the survey worked out to 17,137 (14, 109 to 20,165 with 95% confidence) for the country or 1.7 per 100,000 population. An addition of 20% to include paralytic/atypical form of rabies provides an estimate of 20,565.

The animal bite survey revealed that majority (75%) of animal bite victims belonged to poor and low-income group.The main biting animal was dog (91.5%) of which 62.9% were strays and 37.1% pets. About 17% households had pet dogs and the pet dog: man ratio was 1:36.The dog care practices were not satisfactory viz. veterinary consultation (35.5%), ARV usage (32.9%), Dog Collar (35.5%), Dog leash (38.9%) and Municipal licence (4.3%).The overall situtation was better in urban areas.

The annual incidence of animal bite was 1.7%; it was more in children (2.5%) and 68% of them were males. Only 39.5% of bite victims washed the wounds with soap and water and about 46.9% took anti-rabies vaccinatiion.The usage of TCV was higher (50.1%) as compared to NTV (46.9%) and compliance to the full course was about 40.5%. However, the use of RIGs was low (2.1%).The local applications to wound (36.8%) and indigenous remedies (45.3%) were quite popular. The main source (59.9%) of treatment was Government and each animal bite involved an average of 4.4 treatment visits and costed Rs. 252/- (vaccine and other medicines) and resulted in a loss of 2.2 days of work (man days lost). The annual animal bite load was estimated to about 17.4 million for the country.

The veterinary survey showed a high proportion of positivity (laboratory confirmation) among dogs (48.4%), cats (21.9%), cattle (61.4%), goats (48.7%) and horses (45%) and among the wild animals it was predominantly mongoose (87.5%) and jackals (92.9%).The veterinary data revealed a stable situation of rabies in dogs and cats during the last decade of 1992-2001.

The survey of rabies free areas of Andaman & Nicobar and Lakshadweep islands revealed both the areas to be rabies free. Additionally, the islands of Lakshadweep were also dog free. But the monitoring of occasional import of dogs into Andamans and cats into both islands was poor and there was no laboratory surveillance of rabies in both islands.

In conclusion, rabies is endmic and enzootic in the mainland but the islands of Andaman & Nicobar and Lakshadweep are rabies free. Dog is the principal reservoir of the disease and most victims belong to poor and low-income group. The use of rabies vaccination was low and or rabies immunoglobulins very negligible.The overall situation was lightly better in urban areas.

It is recommended to improve the coverage and usage of modern rabies vaccination by replacing NTV with cost effective intradermal modern rabies vaccination. It is also recommended to introduce a more effective management of dog population. An effective monitoring of entry of dogs/cats into the islands of Andamans and Lakshadweep and laboratory surveillance for rabies is essential to maintain their rabies free status. A coordinated 'National Rabies Elimination Programme' will ensure a Rabies Free India by 2020.

Department of Community Medicine,
Kempegowda Institute of Medical Sciences, Bangalore.

Access free medical resources from Wiley-Blackwell now!

About Indmedica - Conditions of Usage - Advertise On Indmedica - Contact Us

Copyright © 2005 Indmedica