Introduction
Rabies remains one of the most preventable yet neglected zoonotic diseases in India. Despite the availability of effective vaccines, rabies continues to claim an estimated 18,000–20,000 human lives annually in India, accounting for nearly 36% of the global burden [1]. The majority of cases are associated with dog bites, with children being disproportionately affected [2]. Although post-exposure prophylaxis (PEP) is widely available, gaps in timely access, awareness, and affordability persist. A strong public health argument can be made for the inclusion of rabies vaccination, particularly pre-exposure prophylaxis (PrEP), in the National Immunisation Schedule (NIS).
Burden of Rabies in India
- India contributes the highest rabies mortality worldwide.
- Rabies is 100% fatal once symptoms appear, but 100% preventable with timely vaccination.
- The majority of deaths occur in rural and semi-urban populations with poor access to PEP.
- Children under 15 years account for almost 40% of bite victims [3].
Current Status of Vaccine Production and Availability
India is self-reliant in rabies vaccine production. Multiple public and private manufacturers produce both cell culture vaccines (CCVs) and rabies immunoglobulins (RIGs) [4]. Intradermal (ID) regimens, endorsed by WHO, reduce vaccine use by 60–80% compared to intramuscular (IM) regimens, making them more cost-effective and feasible for mass adoption [5]. However, despite sufficient production capacity, gaps remain in distribution, rural access, and affordability.
Cost Comparison: Prophylaxis vs. Post-Exposure Therapy
| Intervention | Estimated Cost per Person (INR) | Notes |
| Intradermal Pre-Exposure Prophylaxis (PrEP) | ₹300–350 | 3-dose ID schedule; requires minimal vaccine volume [6] |
| Post-Exposure Prophylaxis (PEP, ID schedule) | ₹1,000–1,200 | Includes multiple visits; excludes immunoglobulin cost [6,7] |
| PEP with Rabies Immunoglobulin (RIGs) | ₹3,500–7,000 | Essential in severe category III bites; high cost and limited availability [7] |
| Treatment of Clinical Rabies | >₹50,000 | Includes hospitalization, ICU care; invariably fatal despite costs [8] |
Interpretation:
- PrEP via intradermal vaccination costs less than one-third of PEP.
- Avoiding severe rabies cases saves not only healthcare expenditure but also prevents catastrophic household costs and premature mortality.
Why Include Rabies Vaccine in the National Immunisation Schedule?
Justification
- High Burden and Preventable Mortality: Rabies is entirely vaccine-preventable. Inclusion in NIS would directly address a long-standing public health gap.
- Equity and Access: NIS ensures free and universal coverage, reaching rural and marginalized populations where rabies mortality is highest.
- Cost-Effectiveness: ID PrEP is cheaper than PEP or RIGs, and far less costly than treatment of symptomatic rabies.
- Child Protection: Children are at greatest risk, and school-entry vaccination could provide durable protection.
- Global Precedent: Countries like the Philippines and Sri Lanka have successfully integrated rabies PrEP in high-risk groups [9].
Pros and Cons of NIS Inclusion
Pros (for masses):
- Free and universal access to vaccines.
- Reduced need for costly PEP and RIGs.
- Prevents mortality and financial hardship for poor families.
- Builds herd-level immunity in high-bite settings.
Pros (for public health experts):
- Long-term cost savings for the healthcare system.
- Simplifies rabies control strategies by combining with dog vaccination.
- Strengthens India’s commitment towards “Zero by 2030” global rabies elimination goals [10].
Cons / Challenges:
- Additional budgetary burden on NIS.
- Need for cold chain expansion and logistics.
- Risk of low compliance without community education.
- Requires integration with veterinary interventions (dog vaccination, stray dog management).
Policy Perspective
Including rabies vaccine in NIS—at least for high-risk groups such as children and communities in rabies-endemic areas—can dramatically reduce human rabies mortality. Cost analyses clearly demonstrate that preventive intradermal vaccination is far cheaper than post-exposure or terminal care. Given India’s domestic vaccine manufacturing capacity, implementation is technically and economically feasible.
Conclusion
Rabies remains an avoidable tragedy in India. Universal access to intradermal rabies vaccination through the National Immunisation Schedule would represent a landmark public health intervention. It would not only prevent thousands of deaths annually but also reduce economic burden on households and the health system. Policymakers must seize this opportunity to integrate rabies vaccination into routine immunisation as a step towards eliminating rabies deaths by 2030.
References
- World Health Organization. Rabies Fact Sheet. Geneva: WHO; 2023.
- Sudarshan MK, Madhusudana SN, Mahendra BJ, Rao NSN, Ashwath Narayana DH, Abdul Rahman S, et al. Assessing the burden of human rabies in India: results of a national multi-center epidemiological survey. Int J Infect Dis. 2007;11(1):29–35.
- Hampson K, Coudeville L, Lembo T, Sambo M, Kieffer A, Attlan M, et al. Estimating the global burden of endemic canine rabies. PLoS Negl Trop Dis. 2015;9(4):e0003709.
- National Centre for Disease Control (NCDC). National Rabies Control Programme: Operational Guidelines. Delhi: MoHFW; 2021.
- World Health Organization. WHO Expert Consultation on Rabies: Third Report. WHO TRS 1012. Geneva: WHO; 2018.
- Wilde H, Hemachudha T, Shantavasinkul P, Lumlertdacha B. Rabies 2020: perspectives on intradermal vaccination. Clin Exp Vaccine Res. 2019;8(2):103–10.
- Gogtay NJ, Nagpal A, Mallad A, Patel K, Stimpson SJ, Belur A, et al. Demystifying the cost-effectiveness of intradermal rabies vaccination in India. Vaccine. 2017;35(48 Pt B):6480–7.
- Mohanty S, Patel P, Kamath S, Satapathy A, Anand A. Economic burden of rabies in India: a cost-of-illness study. Trop Med Int Health. 2022;27(6):508–16.
- Quiambao BP, Dytioco HZ, Dizon RM, Crisostomo ME, Laot TM, Teuwen DE. Rabies post-exposure prophylaxis in the Philippines: health status and economic analysis. Vaccine. 2005;23(13):1709–14.
- World Health Organization & OIE. Zero by 30: The Global Strategic Plan to End Human Deaths from Dog-Mediated Rabies by 2030. Geneva: WHO; 2018.
