The road to rabies elimination in India by 2030: a review on the functionality of anti-rabies clinics in India

INTRODUCTION

Rabies is a neglected tropical zoonotic disease transmitted through the rabid animal bite mostly by dogs. The disease is caused by the rabies virus (RABV), a member of the genus Lyssavirus belonging to Rhabdoviridae family.¹ It is a hundred percent fatal yet preventable disease if timely vaccination is undertaken.² Rabies is a societal zoonotic disease ravaging poor and remote human settlements disproportionately relative to urban rich communities.¹ In India it is mainly transmitted commonly by dogs and cats (97%), followed by wild animals (2%) such as mangoose, foxes, jackals and wild dogs and occasionally by horses, donkeys, monkeys, cows, goats, sheep’s and pigs, etc.³ It is characterized by encephalitis and generalized paresis and has a high case fatality rate, with deaths occurring within 7–10 days after the onset of symptoms, in the absence of supportive care.² Interventions for global rabies control are multidisciplinary, with initiatives aimed at both human and animal populations. The most significant challenges are remote healthcare access, particularly in rural settings, and low dog vaccination coverage. Madagascar reflects these challenges with high knowledge gaps and barriers to access, whereas Sri Lankas successful One- Health strategy of mass dog vaccination and free post-exposure prophylaxis has resulted in dramatic decline in human rabies deaths.^4,5 India has progressed considerably in controlling rabies.⁶ Goa's elimination program of rabies (2013-2019) illustrates the usefulness of an integrated "One Health" strategy, with mass dog vaccination (more than 426,000 doses given), public education, increased surveillance, and a hotline to report rabies.⁷

A third, large-scale study, estimating human rabies deaths and animal bites for the period 2022-2023, recorded 9.1 million animal bite cases (chiefly dog bites) and an estimated 5,726 human rabies deaths each year, a remarkable reduction from past decades, but still highlighting the persistent threat.⁸ These results highlight the utmost importance of enhanced infrastructure, regular supplies, public awareness, and compliance with post-exposure prophylaxis guidelines to work towards the target of eliminating dog-mediated human rabies by 2030.

ARCs are present in government sectors such as medical college hospitals, district hospitals, and other peripheral health institutions. These could be distinct separate entities with a board of “anti-rabies clinic” or merged with the OPD, injection rooms, casualty, etc. The set up varies in the private sector, where it is provided in an emergency room of a corporate hospital, nursing home, etc., or could be in the consulting room of a private medical practitioner. Preferably, ARCs must be easily accessible and should have all the requirements for Pre- and Post Exposure Prophylaxis with a standardized recording and reporting system. In addition to these facilities, the ARCs should have washing area, sufficient workforce, cold chain equipment and continuous power supply and generator backup.¹

As these anti-rabies clinics provide life-saving PEP against rabies, the present review is conducted to determine the extent of Anti-Rabies Clinic functionality in the country and to identify the prevailing gaps as to achieve the elimination of Rabies elimination by 2030.

METHODS

The review was conducted using the search engines Medline and Google scholar.

Medline: Fields used were- MeSH terms, Tittle/ Abstract. Boolean apparatus used were- OR, AND. The search strategy employed was (((("rabies"(MeSH Terms)) AND (anti rabies clinic (Title/Abstract))) OR (Model anti rabies clinic

(Title/Abstract).This was done to identify articles covered by Medline that had the term "rabies" in "anti-rabies clinics" or "model anti rabies clinics" in the title or abstract.

Google scholar: The search term used was "facility" evaluation of "anti-rabies clinic" for dog bite management. This wider search was used to try to catch more academic and grey literature on the subject.

Database searches were conducted between April 2025 to June 2025 (Figure 1).

Articles were included from 2010- 2025, in English language, full- text availability, and fulfilling any one of the domain in the Functionality at Ant rabies Clinic for minimum available facilities, i.e., minimum available facilities at ARC, Minimum staffing pattern at ARC, Minimum Infrastructure, Logistics.⁹ Article were gradient excluded if they did not include any one of the domain in the Functionality at Ant rabies Clinic for minimum available facilities. A total of 129 published papers were found by the search. 122 articles were excluded as they were not relevant to the direct objective of reviewing the management of dog bites at the anti-rabies clinic. Full- text of the remaining 7 studies was assessed for eligibility which further excluded 2 studies as the full text was unavailable. The data extraction was performed on 5 studies which included the observational studies. All studies included in the data extraction were published between 2010 and 2025.

Geographic focus

The studies including the functionality of the ARC involves data collection in the North, South, East, West and North- Eastern region, however the uniform data collection in all the regions is lacking. The studies included in the current research, along with the region is displayed in Table 1 and Figure 2.

Functionality of Anti rabies Clinic (ARC)

The functionality of ARC on the four domains as per NRCP, i.e., Minimum available facilities at ARC, Minimum staffing pattern, Minimum Infrastructure, Logistics, is outlined below in Table 2.

Minimum available facilities at ARC

Majority of the studies (n=3) talked about the availability of rabies biologicals for post- exposure prophylaxis, i.e., Anti-rabies vaccine and ERIG. (Figure 3). Studies conducted in 15 states across the North, East, South, West, Central and North- Eastern regions reported that only one- third of the public facilities had 7- 20 days/year stock out, whereas, the 95 % tertiary hospitals had uninterrupted ARV supply. However, RIG availability was observed in only 20% of the public health facilities and stock duration was 30-60 days/ year. RIG was unavailable in over 75% of PHCs, whereas, ARV and RIG together were available in only 11.6% of facilities. Animal bite registers were present in 62.1% of ARCs²; and stock registers in 69.9%².¹ Study talked about the record keeping in ARC and revealed that only 17.1% of the ARCs had PEP case forms showing an inconsistent implementation of the bite registers and reporting. One study reveals that only 58.2% facilities had a separate wound washing area.²

*E=East, W=West, N=North, S=South, C=Central, NE=North East

Minimum staffing pattern at ARC

The review of the studies reveals that many ARCs lack formally trained personnel, and most rely on the informal training. In the study conducted in Southern region, 88 Medical Officers were assessed on Rabies Knowledge, Attitude and Practice, which revealed a score of <75%.⁴

Another study in Western region revealed that 68% of the staff lacked formal training.² In terms of animal bite wound categorization, as revealed by the study only 54.4% could correctly categorize the wound.⁴ These studies depict a low knowledge- practice linkage in the PEP delivery.

Minimum infrastructure

All the ARCs had cold chain facilities, out of which 97% used domestic refrigerators. 54.3% had separate are for wound washing facilities.² (Figure 4).

Logistics

One study talked about the tissue culture anti- rabies vaccine approved by the DGCI for ID/IM route and revealed that 60.2% of the ARCs used Intra- dermal route of vaccine administration in the public sector and 54.3% use Intra- muscular route in the ARC.²

DISCUSSION

India is on a mission to eliminate human rabies by 2030, the current state of research in support of this goal has not been comprehensively analysed. With the inclusion of ARV into the essential drug list, it reaffirms Government's commitment to deal with the deadly disease.^3-10 Here, we provide a literature review on the research on the functionality of Anti rabies clinics in India. We found significant gaps in the geographic coverage of research as well on the domains of the minimum available facilities that should be present in the Anti- rabies clinic, as per the NRCP.⁹ Since the invention of Neural tissue anti- rabies vaccine manufactured in India in 1907, to identifying rabies as a priority disease in 2007, and the release of national guidelines on rabies prophylaxis by the Government of India and revised from time to time, Rabies control in the country has reaffirmed its efforts by the launch of NAPRE IN 2021.³

The call for action in 2015, set a goal of "zero human dog- mediated rabies deaths by 2030", worldwide. The joining of the forces of four organisations- the World Health Organization (WHO), the World Organization for Animal Health (OIE), the Food and Agriculture Organization of the United Nations (FAO) and the Global Alliance for Rabies Control (GARC), as the United Against Rabies collaboration, and are determined to reach the global target of “Zero human deaths due to dog-mediated Rabies by 2030”. Worldwide, harmonized processes are required to acknowledge and measure country progress towards this goal.³ Globally, Mexico is the only country that has been validated by the WHO for eliminating rabies as a public health problem.¹¹ The reasons attributed to it include mass dog vaccination coverage, political will, sustained program implementation, application of timely, proven strategies and surveillance, and gradually shifting responsibility and leadership for rabies control from the national to state level.¹² The experience from the Western hemisphere also outlines these strategies.¹³

In India, the experience from the state measures implemented in Goa, i.e., the One Health Approach has resulted in the elimination of canine rabies in the region. The implementation of mass dog vaccination, education of the community, strengthened dog surveillance were few of the measures undertaken in the state.³ Under NRCP, maintenance of a regular uninterrupted supply of Anti Rabies Vaccine (ARV) and Anti Rabies Serum (ARS) up to PHC level for timely Anti Rabies PEP for all Animal bite victims, establishment of Model Anti Rabies Clinics at District Level are the mainstay for the elimination of the disease in the country.⁹

CONCLUSION

Research into rabies in India is limited considering the long-standing impact of the disease on human health in the country. In order to achieve the goal of eliminating all human rabies deaths by 2030, more applied research is needed to address the gaps in the Anti rabies clinics across the country. The integration of Human health, Animal health and Environment, the key concepts in One-Health is need of the hour.

Recommendations

Developing strong legislation and regulations for dog management is essential, including estimating dog population numbers in each municipal area, town, and village committees under city administration. It is also important to initiate and maintain mass dog vaccination programs for the next three consecutive years while ensuring a sufficient supply of vaccines. In addition, region-wise public awareness campaigns and information-sharing activities should be strengthened at different levels. The extension and capacity-building of rabies diagnostic laboratories, along with joint surveillance activities, are also necessary. Finally, strong political commitment and adequate resource allocation are required to ensure effective implementation of these measures.

Funding: No funding sources

Conflict of interest: None declared

Ethical approval: Not required

REFERENCES

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