Mass vaccination of dogs, control of canine populations and post‐exposure vaccination – necessary but not sufficient for achieving childhood rabies elimination

Rabies is an unmitigated tragedy, particularly affecting children in some of the world’s poorest tropical nations. The vast majority of the estimated 61 000 deaths caused by rabies each year occur in rural areas of Africa and Asia, with children younger than 15 years significantly overrepresented [1]. Between 40% and 50% of rabies deaths occur in children younger than 15 years [2]. Surveillance limitations and prevailing cultural beliefs may contribute to underreporting, particularly in children, so the burden is likely to be considerably greater [3]. The rabies virus belongs to the genus Lyssavirus in the family Rhabdoviridae. Transmission to humans usually occurs following a transdermal bite or scratch by an infected animal, predominantly dogs in Africa and Asia, although all mammal species are susceptible to infection. Bat species not only play an important role in transmitting other lyssaviruses globally, but also transmit rabies virus in the rural Amazon area of South America. Infection less commonly occurs when saliva from an infected mammal comes into direct contact with a person’s mucosa or with open skin wounds. Currently, there is a three-pronged approach to preventing rabies deaths in humans. Firstly, if dog rabies could be totally prevented, there would be almost no human cases. Thus, there has been a significant global drive to control canine rabies through dog vaccination and control of stray animals. Where this One Health strategy is fully implemented, particularly in industrialised countries with effective public health systems including a sophisticated veterinary health infrastructure, it can be extraordinarily effective [4]. However, in many environments, particularly in poorer rabies-endemic countries, it is confounded by weak and inadequately funded veterinary public health programmes and occasionally by wild animal species serving as reservoirs, for example vampire bats in South America. Secondly, safe rabies prevention strategies exist that effectively protect people who have been exposed to bites, scratches or saliva in open wounds from an infectious animal, if they are applied without delay. These include vigorous washing of the wound, post-exposure vaccination with cell-culture vaccines and administration of equine or human rabies immunoglobulin. This important strategy is hampered by the tentative availability of vaccine and particularly rabies immunoglobulin in health services serving endemic areas and lack of awareness amongst some affected communities of the need to seek care immediately [5]. The third effective measure is vaccinating people who are likely to be exposed to rabid animals prior to their exposure. This method has particularly been embraced by travellers from developed countries visiting canine rabiesendemic areas, or by individuals, including veterinarians, wildlife professionals and laboratory staff, whose employment places them at risk of exposure. Both the traditional intramuscular administration of vaccine and the less expensive intradermal route, requiring much lower quantities of vaccine, are highly effective in preventing rabies [6]. Although booster doses of post-exposure vaccine are still required following a high-risk exposure, the number of doses is reduced and no rabies immunoglobulin is necessary. This is particularly attractive in endemic areas where the availability of rabies immunoglobulin is often severely limited [7]. However, these three strategies have not prevented the ongoing estimated 61,000 deaths due to rabies each year [8]. In India, the country with the highest *Free full access from www.tmih.com