Rabies in the SAARC region: An epidemiological study of disease burden and challenges

Abstract

Our original study explored trends in rabies-related cases in the South Asian Association for Regional Cooperation region from 2017 to 2021. We analyzed population-level data from Global Health Observatory, World Animal Health Information Database and media reports using Microsoft Excel v.2016. Rabies prevalence varied with India experiencing the highest increase, while Bhutan reported a significant decrease. In contrast, Nepal and Pakistan observed fluctuations, emphasizing the need for ongoing intervention.

Keywords

Rabies SAARC region trends interventions multifaceted approach

Introduction

Rabies, one of the most lethal infectious diseases, is a significant public health concern in the South Asian Association for Regional Cooperation (SAARC) region, represented by the South-East Asia Region Office (SEARO) of the World Health Organization (WHO).¹ An estimated 22,000–28,000 human deaths are reported annually in South East Asia, accounting for 45% of the global total.² The SAARC region composes of eight member countries: Afghanistan, Bangladesh, Bhutan, India, Maldives, Nepal, Pakistan and Sri Lanka.³ WHO has declared rabies endemic in five of these: Bangladesh, Bhutan, India, Nepal and Sri Lanka,³ amongst which, Bangladesh and Afghanistan stand out, the former having the third-highest estimated number of human deaths from rabies worldwide, (c. 2000–2500 annually), and the latter with the highest estimated incidence, at 5.7 per 100,000 of population.⁴ From 2017 to 2019, Afghanistan reported 29 human deaths, 1789 recorded dog bites and 36,959 animal rabies cases, further underscoring the gravity of the situation.⁴

A total of 59,000 human rabies deaths occur annually over 150 countries, with 95% in Africa and Asia.⁵ This figure is likely a gross underestimate, as the burden of disease disproportionately affects rural, impoverished populations, with approximately half of the cases attributable to children under 15 years of age.⁵ Dogs are implicated in up to 99% of cases as the primary vectors.⁵ In 2019, India reported the highest number of deaths from rabies worldwide, reaching 5206.34.⁶ With rabies nearly always fatal once clinical symptoms appear, a high incidence rate suggests a significant future increase, in view of a growing population.

Important consequences have been observed as well in WHO-SEARO.⁷ It is crucial to remain cognizant that several countries are shared by these two regions, which emphasize the urgent need for integrated rabies control and preventive activities. This study aims to bridge this knowledge gap by providing an overview of the existing trends in rabies-related deaths and cases in the SAARC countries between 2017 and 2021, thereby informing targeted interventions for effective rabies control and elimination in the region.

Methods

We analyzed data from Global Health Observatory and World Animal Health Information Database, as well as media reports.^6,7 Data on dog bites, rabies-related deaths and policy recommendations were collected and analyzed using Microsoft Excel v. 2016 to calculate relevant statistics and identify trends. Summary charts were created to represent the data visually, supporting the narrative discussion. The crude death rate (CDR) was computed utilizing mortality and population data. The case fatality rate (CFR) was also calculated for each country, with obtainable data, providing an insight into the percentage of rabies cases resulting in death. This information is critical for understanding the severity of the disease in each country and can help guide public health interventions.

Results

The trends in rabies deaths within the SAARC region between 2017 and 2020 indicate varying patterns amongst its member states (Figure 1). Whilst Afghanistan's three deaths suggest potential underreporting, Bangladesh demonstrated a significant decline in rabies fatalities. Bhutan reported only one death in 2020, indicating the rarity of the disease in the country. The CDR for this particular disease was about 1.29 per 100,000 people. India showed a promising decline in the CDR from 2017 to 2020, suggesting that preventative measures may be having a positive effect. Nepal's figures fluctuated, which might reflect inconsistencies in reporting, changing environmental factors or changes in disease control measures. Pakistan's data were limited to 2018 making it difficult to assess trends accurately, but the available data suggest a significant burden of disease. Sri Lanka experienced a steady increase in fatalities. Overall, these trends highlight a varied incidence of rabies across the SAARC region (Table 1).

Figure 1.

Deaths reported in South Asian Association for Regional Cooperation (SAARC) due to rabies between 2017 and 2020.

Table 1.

Deaths per population reported in SAARC due to rabies between 2017 and 2020.

Country	Deaths in 2020/N	CDR in 2020	Deaths in 2019/N	CDR in 2019	Deaths in 2018	CDR in 2018	Deaths in 2017	CDR in 2017
Afghanistan	0/ 38,972,230	0	0/ 37,769,499	0	0/ 36,686,784	0	3/ 35,643,418	0.01
Bangladesh	24/ 167,420,951	0.14	57/ 165,516,222	0.34	57/ 163,683,958	0.35	80/ 161,793,964	0.49
Bhutan	1/ 772,506	1.29	0/ 767,459	0	0/ 762,096	0	0/ 756,121	0
India	268/ 1,396,387,127	0.02	521/ 1,383,112,050	0.04	364/ 1,369,003,306	0.03	994/ 1,354,195,680	0.07
Nepal	NR	NR	18/ 28,832,496	0.06	32/ 28,506,712	0.11	8/ 28,183,426	0.03
Pakistan	NR	NR	NR	NR	448/ 219,731,479	0.2	NR	NR
Sri Lanka	31/ 21,715,079	0.14	26/ 21,649,664	0.12	25/ 21,580,710	0.12	23/ 21,506,813	0.11

NR: not reported; N: total population size; SAARC: South Asian Association for Regional Cooperation; CDR: crude death rate.

No trends were reported in Maldives.

Case fatality rates were calculated for each country. These varied significantly (Table 2). India had a CFR of 1.18% in 2021. In the same year, Pakistan and Nepal exhibited CFRs of 5.15% and 1.84%, respectively.

Table 2.

Reported rabies cases, total population and case fatality rate (CFR) in 2021.

Country	Reported rabies cases (2021)	Population (2021)	Case fatality rate (2021)
Bhutan	13	777,486	Data Not Available
India	1,701,133	1.4 billion	1.18%
Nepal	56,619	29.2 million	1.84%
Pakistan	97,000	222.6 million	5.15%

Owing to data limitations, no trends could be established for Afghanistan, Bangladesh, Maldives and Sri Lanka. Whereas for Bhutan, due to the absence of mortality data, the CFR could not be calculated.

Discussion

Rabies mortality and prevalence statistics for the SAARC region reveal disparate trends. The COVID-19 pandemic introduced further challenges to global health structures, potentially influencing the documentation and handling of other diseases, including rabies, between 2020 and 2021.⁸

Recent scientific developments, such as oral rabies vaccines for wildlife and stray animal populations, may a significant impact rabies control⁹ within the SAARC context, where stray dogs represent the primary reservoir of the virus.¹⁰ The economic implications of such interventions should be supported by richer countries.¹¹

Challenges faced by the constituent countries require comprehensive vaccination programmes to be implemented, public awareness campaigns strengthened, surveillance and reporting systems enhanced, resources mobilized, capacity-building efforts increased and multisectoral collaboration fostered through the adoption of the One Health Initiative and adherence to regional strategies such as the SAARC Regional Rabies Control Strategy^4,12 (Table 3).

Table 3.

Key challenges and recommendations to eradicate rabies in the SAARC region.

Challenges	Recommendations	Policy citations
Insufficient vaccination coverage	Implement comprehensive vaccination programs	One Health Initiative, SAARC Regional Rabies Control Strategy
Lack of public awareness	Strengthen public awareness campaigns	WHO, World Rabies Day campaigns
Inadequate surveillance and reporting	Enhance surveillance and reporting systems	OIE, Rabies Bulletin Europe
Resource constraints	Mobilize resources and capacity building	FAO, Rabies Blueprint
Fragmented and uncoordinated efforts	Foster multisectoral collaboration and coordination	One Health Initiative, Global Alliance for Rabies Control

SAARC: South Asian Association for Regional Cooperation; WHO: World Health Organization.

Footnotes

Declaration of conflicting interests

The author(s) declared no potential conflicts of interest with respect to the research, authorship, and/or publication of this article.

Funding

The author(s) received no financial support for the research, authorship, and/or publication of this article.

ORCID iD

Zouina Sarfraz

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