Deaths from Symptomatically Identifiable Furious Rabies in India: A Nationally Representative Mortality Survey

Abstract

BackgroundIt is estimated that India has more deaths from rabies than any other country. However, existing estimates are indirect and rely on non-representative studies.Methods and Principal FindingsWe examined rabies deaths in the ongoing Million Death Study (MDS), a representative survey of over 122,000 deaths in India that uses enhanced types of verbal autopsy. We estimated the age-specific mortality rates of symptomatically identifiable furious rabies and its geographic and demographic distributions. A total of 140 deaths in our sample were caused by rabies, suggesting that in 2005 there were 12,700 (99% CI 10,000 to 15,500) symptomatically identifiable furious rabies deaths in India. Most rabies deaths were in males (62%), in rural areas (91%), and in children below the age of 15 years (50%). The overall rabies mortality rate was 1.1 deaths per 100,000 population (99%CI 0.9 to 1.4). One third of the national rabies deaths were found in Uttar Pradesh (4,300) and nearly three quarters (8,900) were in 7 central and south-eastern states: Chhattisgarh, Uttar Pradesh, Odisha, Andhra Pradesh, Bihar, Assam, and Madhya Pradesh.Conclusions and SignificanceRabies remains an avoidable cause of death in India. As verbal autopsy is not likely to identify atypical or paralytic forms of rabies, our figure of 12,700 deaths due to classic and clinically identifiable furious rabies underestimates the total number of deaths due to this virus. The concentrated geographic distribution of rabies in India suggests that a significant reduction in the number of deaths or potentially even elimination of rabies deaths is possible.

One Health approach to cost-effective rabies control in India

“…where h = 65, the number of 2014 cases reported in Tamil Nadu; k = 3 and n = 6,264 parameterize the historical Tamil Nadu human rabies mortality from a regional autopsy study (2); and μ = 0.51 and σ = 0.03 are the mean and the variance of the bite rate, respectively, estimated from Tanzanian contacttracing data (20,32,33). The parameters λ and p represent the model estimates for human rabies under current and historical PEP coverage, respectively, and q represents the model estimate for the dog to human bite rate.…”

“…The parameters λ and p represent the model estimates for human rabies under current and historical PEP coverage, respectively, and q represents the model estimate for the dog to human bite rate. From h y , the annual human rabies deaths predicted by the model for the year y, λ = 0.8h 2014 to account for the underreporting of the typically misdiagnosed "nonfurious" human rabies cases (2,14), and P = 0.8h 2004 /d, where d = 495,378, the overall annual mortality in Tamil Nadu. In 2005, the state government of Tamil Nadu committed to making PEP available for all dog bite victims at health clinics.…”

“…mathematical modeling | cost-effectiveness | rabies | sterilization | vaccination R abies claims the lives of an estimated 59,000 people each year, over 20,000 of which are in India (1) primarily among children in rural or marginalized populations (2). Rabies is a classic "One Health" challenge (3): more than 99% of these deaths arise from exposure to a rabid dog (4).…”

“…Nonetheless, 65 human rabies fatalities were reported in 2014 (12,13). This reported mortality likely corresponds to an actual burden of about 80 deaths, given that only 80% of human rabies cases present with the characteristic "furious" symptoms and that the other 20% presenting as febrile and paralytic are generally misdiagnosed (2,14), often as malaria (15). Despite the high prioritization of rabies control by zoonotic disease experts in India (16), policymakers have been reluctant to implement widespread canine rabies interventions without assessments of the balance between expenditure and effectiveness (17).…”

Effectiveness of oral immunization of free-living foxes in the reduction of rabies in Poland in 2011-2015

“…W rejonach tych z reguły występuje ograniczony dostęp do opieki zdrowotnej, a śmiertelność u ludzi sięga nawet do 96%. W wielu krajach świata stanowi ona poważny problem również w ujęciu ekonomicznym, gdyż ogólne koszty związane z profilaktyką, leczeniem oraz stratami gospodarczymi w skali globu sięgają około 8,6 mld dolarów (7,8,19,20,22).…”