Rabies Post-Exposure Prophylaxis in India: Clinical Strengths and Ground-Level Challenges

Rabies continues to remain one of the most fatal zoonotic diseases despite being entirely preventable. It is estimated that nearly 59,000 deaths occur globally each year, with India contributing approximately 20,000 deaths annually, accounting for a significant share of the global burden^1,2. This persistent mortality highlights a critical gap between the availability of preventive measures and their real-world implementation. For veterinarians, who often serve as the first point of contact in animal bite cases, understanding the practical realities of post-exposure prophylaxis (PEP) is essential. 

Rabies is unique in that timely intervention, even after exposure, can prevent disease progression. The virus typically travels from the site of the bite to the central nervous system, providing a window during which PEP can be life-saving. The standard protocol includes immediate and thorough wound washing with soap and water for at least 15 minutes, followed by administration of anti-rabies vaccine (ARV) and rabies immunoglobulin (RIG) wherever indicated. Globally, more than 29 million people receive PEP annually, preventing thousands of deaths^1,3. However, despite this, rabies continues to claim lives, indicating systemic gaps in implementation. 

Strengths in the Existing PEP Framework 

India’s PEP programme is supported by several strengths that provide a solid foundation for rabies control. One of the most important is the availability of effective biological products. Modern cell culture vaccines have replaced older nerve tissue vaccines, offering improved safety and efficacy. The introduction of intradermal vaccination in 2006 further improved affordability and accessibility, making large-scale use feasible. The two-site intradermal schedule has demonstrated advantages in terms of safety, immunogenicity, and cost-effectiveness^1,4. 

Another key strength is the efficient utilisation of available biologicals. The practice of administering rabies immunoglobulin directly into the wound site has significantly reduced wastage while maintaining effectiveness. Additionally, India has a strong indigenous production capacity, with vaccines and immunoglobulins being manufactured domestically^1,5,6. This ensures that supply can be scaled up when required. 

The inclusion of rabies biologicals in the national list of essential medicines further strengthens accessibility and prioritisation within the healthcare system. Policy-level initiatives such as the National Rabies Control Programme and the National Action Plan for Dog Mediated Rabies Elimination by 2030 reflect renewed political commitment toward rabies control. These programmes also emphasise a One Health approach, integrating human and animal health strategies¹. 

Persistent Gaps in Implementation 

Despite these strengths, several weaknesses continue to limit the effectiveness of PEP in India. One of the most critical issues is inadequate inventory management. Stock-outs of ARV and RIG are frequently reported, particularly in public healthcare facilities. Surveys have shown that up to 40.7% of facilities experience shortages of RIG, directly affecting timely treatment⁷. 

Another major challenge is the delayed dissemination and implementation of updated guidelines. Although guidelines are regularly updated, their adoption at peripheral healthcare centres is often inconsistent. This results in variability in treatment practices, duplication of records, and inefficiencies in service delivery. 

Misclassification of animal bites is also a significant concern. Minor scratches without bleeding may be incorrectly categorised, leading to either inadequate or unnecessary treatment¹. This reflects gaps in training and highlights the need for standardised protocols and continuous education of healthcare providers. 

Compliance and Infrastructure Barriers¹ 

Compliance with PEP remains suboptimal across the country. Studies have reported completion rates ranging from 52.3% to 78%, indicating that a large proportion of patients fail to complete the vaccination schedule. Several factors contribute to this, including distance to healthcare facilities, loss of wages, lack of awareness, and misconceptions about treatment. 

Infrastructure limitations further compound the problem. Proper wound washing is the first and most critical step in rabies prevention, yet more than half of healthcare facilities lack adequate wound washing infrastructure. This significantly reduces the effectiveness of PEP even when vaccines are administered correctly. 

Myths and misconceptions among patients also play a role. Practices such as applying irritants like chili, lime, or salt to wounds are still prevalent, delaying proper treatment and increasing the risk of rabies. 

Role of Veterinarians in Strengthening PEP 

Veterinarians play a crucial role in bridging the gap between clinical protocol and real-world practice. They are often the first professionals consulted after an animal bite and are uniquely positioned to guide immediate wound management, assess risk, and ensure timely referral for PEP. 

Beyond clinical care, veterinarians have a significant role in community education. By addressing misconceptions and promoting awareness about proper wound care and the importance of completing vaccination schedules, they can improve compliance and outcomes. 

Moving Toward Effective Rabies Control 

The continued burden of rabies in India is not due to lack of resources but rather gaps in implementation. Strengthening inventory management, improving dissemination of guidelines, enhancing infrastructure, and increasing awareness are critical steps. 

For veterinarians, integrating clinical expertise with public health awareness is essential. By actively participating in education, surveillance, and prevention strategies, they can contribute significantly to reducing rabies mortality and achieving the goal of elimination by 2030. 

Reference 

1. Pardeshi G, Sharma P, Ittiel A. Rabies post-exposure prophylaxis in India: a SWOT analysis. Therapeutic Advances in Vaccines and Immunotherapy. 2026 Jan;14:25151355251410780. https://journals.sagepub.com/doi/pdf/10.1177/25151355251410780 

2. World Health Organization. Rabies in India. World Health Organization. Geneva, Switzerland, https://www.who.int/india/health-topics/rabies. 

3. World Health Organization. Rabies. Geneva, Switzerland: World Health Organization. https:// www.who.int/news-room/fact-sheets/detail/rabies. 

4. Kessels J, Tarantola A, Salahuddin N, Blumberg L, Knopf L. Rabies post-exposure prophylaxis: A systematic review on abridged vaccination schedules and the effect of changing administration routes during a single course. Vaccine. 2019 Oct 3;37:A107-17. https://www.sciencedirect.com/science/article/pii/S0264410X19301057 

5. World Health Organization. Rabies vaccines: WHO position paper – April 2018. Weekly epidemiological record, No 16, 2018, 93, 201–220. World Health Organization. Geneva, Switzerland. April 19, 2018, https://www.who.int/ publications/i/item/who-wer9316. 

6. Hampson K, Abela-Ridder B, Bharti O, Knopf L, Léchenne M, Mindekem R, Tarantola A, Zinsstag J, Trotter C. Modelling to inform prophylaxis regimens to prevent human rabies. Vaccine. 2019 Oct 3;37:A166-73. https://www.sciencedirect.com/science/article/pii/S0264410X18315196 

7. Sudarshan MK, Haradanhalli RS. Facilities and services of postexposure prophylaxis in anti-rabies clinics: a national assessment in India. Indian Journal of Public Health. 2019 Sep 1;63(5):26-30. https://journals.lww.com/IJPH/_layouts/15/oaks.journals/downloadpdf.aspx?an=01586002-201963050-00007