Human Rabies Survivors in India: An Emerging Paradox?

Citation: Subramaniam (Mani) R (2016) Human Rabies Survivors in India: An Emerging Paradox? PLoS Negl Trop Dis 10(7): e0004774. doi:10.1371/journal.pntd.0004774
Published: July 28, 2016

On a particularly hot afternoon early last year, a couple—barefoot and in tattered clothes—walked into the emergency services at the National Institute of Mental Health and Neurosciences (NIMHANS), a public neurocare hospital in Bangalore, India. The woman held a sick child in her arms and her male companion followed with two more children in tow.

Rabid_dogThe child was diagnosed to have rabies encephalitis—apparently acquired through a stray dog bite a month prior, for which medical care was not sought. The grim prognosis was conveyed to the parents, who were migrant labourers in the city. The child died within two hours of admission. However, there was nobody to claim the mortal remains of the young child; the parents had discreetly left the hospital premises and they could not be traced. The body lay in the mortuary, unclaimed for several weeks before it was cremated by the police.

The cost of cremating a dead child could be better utilized to feed other hungry mouths—this is the harsh reality faced by many mothers in India, their grief numbed by poverty.

Rabies, a fatal disease, yet almost 100% preventable by timely and appropriate postexposure prophylaxis (PEP), continues to kill about 20,000 people every year in India, accounting for almost a third of the 61,000 global human deaths due to rabies [1,2]. This figure may be an underestimate because rabies is not a notifiable disease in India, and systematic surveillance for animal and human rabies is not done.

These tragic deaths continue to happen primarily because a majority of victims do not receive rabies vaccination, and a few of those who do do not complete the full course. Moreover, the use of rabies immunoglobulins (RIG)is abysmally low [2]. This serious lapse in PEP can be attributed to the lack of awareness about the potential seriousness of animal bites and the need for prompt PEP in the community as well as among medical professionals and an irregular supply of antirabies vaccines and RIG, particularly in primary health care facilities. In addition, some dog bite victims cannot afford the cost of PEP or may resort to indigenous treatment practices [2].

At the other end of the dismal spectrum of the rabies scenario in India, an incredibly paradoxical finding has emerged in the recent past. Survival from human rabies (albeit with severe residual deficits) has been reported in 6 patients in the last 6 years from India [3–8], almost unheard of until 2010 except for a single case of partial recovery from rabies reported in 2002 [9]. It is a well-known fact that survival from rabies is extremely rare, and only about 15 human survivors from rabies have been reported globally [3,6,8]. In fact, we imbibed the tenets of rabies diagnosis as students of medicine decades ago: “If a patient has rabies, he will die in the next few days; if he does not die, he does not have rabies!”

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