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Published Date: 2012-10-07 18:17:01
Subject: PRO/AH/EDR> Rabies - India (10): verbal autopsy mortality estimate
Archive Number: 20121007.1329262

RABIES - INDIA (10): VERBAL AUTOPSY MORTALITY ESTIMATE
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Date: Thu 4 Oct 2012
Source: PLoS Negl Trop Dis [summarised & edited]
http://www.plosntds.org/article/info%3Adoi%2F10.1371%2Fjournal.pntd.0001847

[Citation: Wilson Suraweera, Shaun K. Morris, Rajesh Kumar, David A. Warrell, Mary J. Warrell, Prabhat Jha, for the Million Death Study Collaborators. Editor: Jakob Zinsstag, Swiss Tropical and Public Health Institute, Switzerland]

Abstract
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Background: It 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 Findings: We 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 percent, CI 10 000 to 15 500) symptomatically identifiable furious rabies deaths in India. Most rabies deaths were in males (62 percent), in rural areas (91 percent), and in children below the age of 15 years (50 percent). The overall rabies mortality rate was 1.1 deaths per 100 000 population (99 percent, CI 0.9 to 1.4). 1/3rd of the national rabies deaths were found in Uttar Pradesh (4300) and nearly 3/4th (8900) were in 7 central and south-eastern states: Chhattisgarh, Uttar Pradesh, Odisha, Andhra Pradesh, Bihar, Assam, and Madhya Pradesh.

Conclusions and Significance: Rabies 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.

Author Summary
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Rabies, a disease of antiquity, has been partially controlled in many countries and eliminated in a few. However, according to the World Health Organization, rabies continues to kill thousands of people in India each year, more than in any other country. We used an enhanced type of verbal autopsy (a structured interview of the relatives or close associates of the dead by non-medical staff with central medical coding by at least 2 doctors) to identify the causes of over 122 000 deaths in a large scale, representative sample in India in 2001-03. Using these data, we estimate that in 2005, approximately 12 700 people died from symptomatically identifiable furious rabies. Because verbal autopsy is not able to identify atypical presentations of rabies, our figure underestimates the actual number of rabies deaths in India. The majority of rabies deaths occurred in males, in rural areas, in children below the age of 15 years, and in a few states. The concentrated geographic distribution of rabies in India suggests that targeting with preventive campaigns including vaccination of animals and post exposure vaccination of humans might achieve a significant reduction in the number of deaths or potentially even elimination of deaths from this disease.

Authors' conclusion: We estimate that there were 12 700 deaths due to symptomatically identifiable furious rabies in India in 2005. It is very important to note that this figure underestimates the total number of deaths due to rabies since paralytic and atypical cases would not have been detected by verbal autopsy.

This study is the 1st to estimate rabies mortality based upon a nationally representative sample of deaths rather than modeling or from extrapolation from selected focal surveillance. Thus, we provide previously unavailable regional and demographic information about human rabies deaths that can help to focus both human and canine rabies control programmes in the country and act as a baseline that can be used as comparison for future estimates of rabies mortality. Elimination of the canine reservoir of rabies is not likely in India at anytime in the near future. However, the concentrated geographic distribution of rabies in India suggests that a significant reduction in the number of human deaths or potentially even elimination of rabies deaths is possible, and this study serves as a baseline against which future gains may be measured.

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Communicated by:
Ronan Kelly <ronankelly@comcast.net>

[There has been an ongoing controversy in ProMED-mail (on-line and off-line) in the recent past concerning the veracity of the often repeated estimate that 5 000 of the 50 000 annual deaths from rabies virus infection occurs in India (see: Rabies - India (04): mortality estimates, archive no. 20120610.1163188, et seq.). Now, The Million Deaths Study Collaborators, using a verbal autopsy procedure, have arrived at an estimate of 12 700 symptomatically identifiable furious rabies cases in 2005. The overall rabies mortality rate was estimated by this methodology to be 1.1 deaths per 100 000 population. 1/3rd of the national rabies deaths were found in Uttar Pradesh (4 300), and nearly 3/4ths (8 900) were in 7 central and south-eastern states: Chhattisgarh, Uttar Pradesh, Odisha, Andhra Pradesh, Bihar, Assam, and Madhya Pradesh. This localisation of rabies virus infection suggests that reduction or even elimination of rabies deaths in India is an achievable goal in the long term.

A map of the states of India can be accessed at: http://www.mapsofindia.com/maps/india/india-political-map.htm. - Mod.CP

A HealthMap/ProMED-mail map can be accessed at: http://healthmap.org/r/1pSH.]

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