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Published Date: 2012-06-10 15:22:39
Subject: PRO/AH/EDR> Rabies - India (04): mortality estimates
Archive Number: 20120610.1163188

RABIES - INDIA (04): MORTALITY ESTIMATES
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Date: Sat 9 Jun 2012
From: Merritt Clifton <anmlpepl@whidbey.com>

Comment on human rabies death toll in India
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[Merritt Clifton has forwarded the following commentary in response to ProMED-mail post Rabies - India: WHO travel alert 20120609.1162367, in which the moderator stated that: "The human death toll in India has been estimated as 35 000 per annum, but may now be declining".]

Some history and discussion of the Indian estimates of human rabies deaths appears to be in order, not least because the figure of 35 000 per year has been used by Indian mass media since 1976, at least, and though it is often cited with various different attributions, I have yet to find anyone who really knows where it came from, or how it was calculated. The following is pared down from my cover article in the current edition of ANIMAL PEOPLE.

On 29 Apr 2012, as ProMed noted on 1 May 2012 [Rabies - India: (WB) 20120501.1119730], Indian national health minister Gulam Nabi Azad presented the most recent Indian government statistics on mortality from all causes to the Lok Sabha, the Indian parliament. After discussing heart disease, diabetes, and cancer, Gulam Nabi Azad mentioned that only 223 human rabies deaths were recorded in India in 2011. This was barely 1% of the 2002 government estimate (20 000), which was a projection meant to be an average over 10 years, 1992-2002.

As rabies is not a notifiable disease in India, reports of human rabies deaths are not routinely forwarded to the federal health ministry. Therefore, the figure that Gulam Nabi Azad used on 29 Apr 2012 may have been low -- but how low? The Animal Welfare Board of India, Federation of Indian Animal Protection Organizations, and Animal Birth Control India all track canine rabies outbreaks, albeit relatively informally, and do collect and share human mortality information as part of their work. Longtime Blue Cross of India chief executive and Animal Welfare Board of India member Chinny Krishna e-mailed to me shortly after Gulam Nabi Azad spoke that 'the figure given by Gulam Nabi Azad is in the opinion of many of us working on the ground much closer to reality" than the previous figures of 20 000.

Introducing the use of street dog vaccination and sterilization to combat canine rabies in 1966, Krishna was already skeptical of the WHO and Indian government estimates of human rabies fatalities by 1976, when he first criticized the figure of 35 000. "For at least 25 years, I fought the claim of 35 000 rabies deaths in India yearly," Krishna posted recently to FIAPO. "I spoke at the Association for Prevention and Control of Rabies in India conference at Bhubaneshwar when the decennial figures for 1992-2002 were released," lowering the estimated toll to 17 000 diagnosed human deaths and 3000 deaths that went undiagnosed. Krishna suspected that the high figures were produced by the combination of inadequate case tracking, faulty diagnostic work, and official projections based on obsolescent and inaccurate presumptions about how rabies spreads.

Eventually Krishna persuaded People for Animals founder Maneka Gandhi, who for more than five years was the Indian federal minister for animal welfare, and was also for a time minister for statistics, but Mrs Gandhi lost her cabinet position before she could organise an official reappraisal of the rabies numbers. Likewise convinced was Animal Welfare Board of India chair Rammehar Kharb, a retired military veterinarian who on appointment in May 2006 pledged to "eradicate rabies from India by mass vaccination of stray dogs." WHO-South East Asia Regional Organization technical officer for veterinary public health Gyanendra Gongal also came to question the official numbers. Journalist Hiranmay Karlekar in a 2008 book entitled 'Savage Humans & Stray Dogs' attributed the inflated human rabies death estimates to the desire of makers of post-exposure vaccines to sell more of their product to dog bite victims and to their biggest customers, the government clinics that are mandated to treat dog bite victims free of charge.

ANIMAL PEOPLE pointed out repeatedly, beginning in 1997, that several mosquito-borne and tick-borne diseases, common to India but not widely recognized until relatively recently, also produce high fever and other rabies symptoms, and are likewise frequently fatal if left untreated. Undetected insect-carried febrile illnesses could easily have accounted for most of the unconfirmed "rabies" death toll. Chinny Krishna sought unsuccessfully on several occasions to enlist FIAPO members to participate in an unfunded national rabies data collection effort. At the June 2011 Asia for Animals conference in Chengdu, China, Krishna assembled representatives of the AWBI, ABC India, ANIMAL PEOPLE (including myself), and Humane Society International for an informal brainstorming session which concluded that available information on clinically confirmed rabies cases suggested that the annual human rabies death toll in India could not be more than 2000 to 3000. Data from Andhra Pradesh and Goa states, released after rabies outbreaks in 2011, later projected a range of 2000 to 3150 human rabies deaths per year, if all states were afflicted to the same extent."I would not necessarily go so far as to say that the number of human rabies cases a year in India is around 2000," Humane Society International president Andrew Rowan said at the time, "but I certainly suspect it is well below 20 000."

--
communicated by:
Merritt Clifton
Editor, ANIMAL PEOPLE
PO Box 960
Clinton, WA 98236
USA

[It is apparent from the above that the figure for the extent of human rabies mortality in India is in urgent need of revision. It would help if human rabies was ranked as a notifiable disease in India.

The HealthMap interactive map of India can be accessed t: http://healthmap.org/r/1pSH. - Mod.CP]

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