Rabies deaths in Kerala despite vaccinations raises concerns – Down To Earth Magazine

State data shows 14 deaths, of which 5 had taken shots; Expert says several factors while treating dog bites 

Stray dog bites leading to rabies deaths despite vaccination in Kerala have raised several eyebrows, with questions on the efficacy of shots and whether proper protocol is being followed while treating bites.
Over 95,000 people have been bitten this year, leading to 14 deaths. Of these, five had taken the rabies vaccine, showed the state’s health ministry data. 
Media reports have alleged the fatality figure stands at 21, while 11 deaths were reported last year. Moreover, there has been a two-fold increase in rabid dogs in the past five years, according to Kerala Animal Husbandry department. 
The Supreme Court September 9, 2022, in an oral observation, said those who feed stray dogs could also be held responsible for vaccinating them and bearing costs of any person who has been bitten. It was hearing a public interest litigation over the issue. 
The apex court also sought a report from the Justice Sri Jagan Commission formed in 2016 to address issues of dog attacks in the state and provide compensation to victims. 
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The statistics point to a myriad of questions. Has the virus changed such the vaccine is no longer effective? Or are dog bites not being treated efficiently, following the appropriate protocol?
Failure on the part of state authorities to take swift measures by administering anti-rabies vaccines to stray dogs is also a possibility. 
The blood and cerebrospinal fluid samples from a 12-year-old who was bit by a stray have confirmed the presence of virus-neutralising antibodies. The tests were conducted at the National Institute of Virology in Pune and the child later died. But the antibodies are evidence that vaccines continue to work.
It is possible this happened due to the concentration, placement and time at which the antibodies were administered, according to experts.  
Nevertheless, the state government has set up an expert committee to look into the five deaths of those vaccinated. The Kerala Medical Services Corporation has withdrawn a batch of the anti-rabies vaccine from hospitals and warehouses. 
While pre-exposure rabies vaccine is an option for international travellers to endemic regions, the same cannot be said for locals at risk. Pre-exposure vaccines are more cost-effective than post-exposure vaccines, followed by immunoglobulin, if the bite rate is greater than three per cent, according to a February 2021 study published in the journal BMJ Global Health.
India is an endemic country for rabies, where 17.4 million dog bites occur annually, resulting in 18,000-20,000 cases of human rabies, found a 2014 study published in the Indian Journal of Medical Research.
Post-exposure vaccine (PEP) without pre-exposure vaccine (PrEP) “is slower-acting, time-sensitive and time-consuming, while PrEP increases the likelihood of survival in bitten individuals,” the BMJ study’s authors argued. “PrEP might provide sufficient protection if exposure goes unrecognised or when PEP is delayed, incomplete or unavailable.”
While vaccination is critical, several other factors in the treatment of a dog bite play a key role in the patient outcome. Some of the factors were listed by Dr Rajeev Jayadevan — co-chairman of IMA’s National task force on COVID-19. 
These include: Bites in rich nerve-supply areas require immediate attention and multiple wounds allow the virus to attack the brain from several fronts. A bite on the neck or head vastly reduces the distance the virus has to travel to reach the brain and failure to wash thoroughly and promptly increases the virus’ chances of survival. 
Read more: Coping with COVID-19 need not derail progress against rabies

The wrong site of injection and incorrect administration of the vaccine are some other factors in the treatment of a dog bite. 
Administering anti-rabies vaccine to stray dogs is another avenue to bring down rabies cases and deaths. This is especially critical given the increase in rabid dogs in Kerala. Inefficiency in implementing the animal birth control programme is among the key reasons for the surge in cases.
“The state government’s mismanagement and unscientific approach are the reasons for the growing stray dog incidents in Kerala,” MN Jayachandran, animal rights activist and former member of Kerala State Animal Welfare Board, was quoted by English daily The New Indian Express.
Animal welfare organisations had been doing vaccination of stray dogs earlier. But the government didn’t want the NGOs to get involved. Now, the crisis has peaked and the government should engage NGOs to undertake vaccination of community dogs, Jayachandran said. 
(This story has been updated to reflect that some of the Supreme Court comments were oral observations) 
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