“Official” Indian human rabies death toll of 20,000 ignored government’s own data & appears to have been based on 101-year-old research

From ANIMAL PEOPLE, July/August 2012:

DELHI, CHENNAI–Collecting current data about disease
incidence in India since 2003, the Indian Central Bureau of Health
Intelligence has known for nearly 10 years that the oft-claimed
Indian human rabies death toll of 20,000 per year is high by a factor
of nearly 100.
Often cited by politicians and media, the 20,000 figure has
repeatedly inflamed rabies panics, including street dog massacres
and mob attacks on humane societies that participate in the federally
sponsored Animal Birth Control program. Funded by the Animal Welfare
Board of India since2003, the ABC program seeks to replace lethal
dog population control with sterilization.

The purported 20,000 human rabies deaths per year have also
been used to rationalize spending upward of $25 million U.S. ($1.1
billion rupees) to provide free post-exposure vaccination to dog bite
victims, instead of funding a much less costly national dog
vaccination program which could eradicate canine rabies from India.
Dogs sterilized under ABC auspices must be vaccinated, but
the ABC program does not fund later revaccination or vaccination of
dogs who are not sterilized. Many Indian humane societies
nonetheless vaccinate or revaccinate all dogs presented to them as a
public service, as resources permit.
According to the Central Bureau of Health Intelligence,
rabies has killed an average of 238 Indians per year during the past
nine years, within a range of 162 to 361. But apart from posting
the data to a web site, the Central Bureau of Health Intelligence
has done little to correct the 20,000 figure, which appears to have
been projected from data collected 101 years ago, in 1911, but is
claimed as current in publications of the World Health Organization,
Alliance for Rabies Control, and other branches of the Indian
government.
Ironically, the Central Bureau of Health Intelligence
findings reinforce the thus far little noted finding of the 2003
WHO-sponsored National Multicentric Rabies Survey, led by M.K.
Sudarshan. This survey found that human rabies appeared to be
“endemic and stable” at 235 human deaths per year, based on data
collected from hospital isolation units. “From 1985, India reported
every year about 25,000 to 30,000 human rabies deaths,” Sudarshan
wrote in a 2005 summary of the survey. “However, these figures were
an estimate based on the projected statistics of isolation
hospitals,” which proved to be much too high, and which at that
time had not been traced to source.
Sudarshan in a June 18, 2012 e-mail affirmed to ANIMAL
PEOPLE his belief that the high “official figures coming from the
Government of India are erroneous,” and that “a scientific
reassessment of the burden of rabies in India” is overdue.
Providing the basis for such a scientific reassessment is
what the Central Bureau of Health Intelligence has been quietly
doing. The Central Bureau of Health Intelligence is an office within
the Directorate General of Health Services, under the Ministry of
Health & Family Welfare. Since 2005, the Central Bureau of Health
Intelligence has included current rabies statistics in National
Health Profile, an online annual report. From 2005 through 2011,
the Central Bureau of Health Intelligence found, India had 274,
361, 221, 244, 260, 162, and 223 human rabies deaths,
respectively: an annual average of 249.
But the National Health Profile numbers won little notice
until cited on April 29, 2012 in the Lok Sabha, the lower house of
the Indian parliament, by Indian health minister Gulam Nabi Azad.
Unaware of the source of the information, longtime Blue Cross of
India chief executive and Animal Welfare Board of India member Chinny
Krishna summarized Gulam Nabi Azad’s remarks in an e-mail published
as a letter-to-the-editor in the May 2012 edition of ANIMAL PEOPLE.
Krishna’s summary was then further distributed to more than 40,000
public health professionals worldwide by the International Society
for Infectious Diseases’ Program for Monitoring Emerging Diseases,
and to more than 1,000 heads of Indian humane societies by the
Federation of Indian Animal Welfare Organizations.
ANIMAL PEOPLE examined the matter further in the June 2012
front page article “New Indian data cuts worldwide human rabies death
toll by 40%.” Abstracted by ProMed, the article brought responses
which helped ANIMAL PEOPLE to find the Central Bureau of Health
Intelligence information and publicize it to ProMed, FIAPO, and the
Asian Animal Protection Network.
Human rabies deaths have at times been underreported in parts
of India due to local political considerations and defects in public
health data tracking systems. Both factors were involved when 15
rabies deaths were found to have gone unreported in Chennai suburbs
during the first four months of 2011.
Rabies in humans is not “notifiable” in India, meaning that
reporting deaths to the national epidemiological tracking system is
not mandatory for all institutions. The National Health Profile
“Health Status Indicators” tables open with a disclaimer
acknowledging that “Since the reported data is by and large from
government health facilities, it may have limitations in terms of
its completeness as private medical and health care institutions
still need to strengthen their reporting to their respective
government health units.”
However, the possible omission of data from “private
medical and health care institutions” means little as regards rabies,
since the government clinics that provide free post-exposure rabies
vaccination receive and treat most dogbite victims, and since active
human rabies cases are handled almost exclusively by government
hospitals.
Despite rare instances of officials suppressing awareness of
rabies outbreaks, as exposed in Chennai in 2011, most rabies
outbreaks in India receive intensive coverage from aggressively
competing media. Speculation that the National Health Profile
numbers might be low due to underreporting would appear to be negated
by an ANIMAL PEOPLE search of 535 articles published by Indian mass
media and medical journals, 2005-2012, which described 123, 73,
195, 29, 23, 103, and 69 human deaths for those years,
respectively–an average of 65% fewer deaths than were recorded by
the National Health Profile.
The articles reported rabies death totals for Andhra Pradesh,
Goa, Manipur, Tamil Nadu, and Uttar Pradesh states. If these
totals were projected to the whole of India by comparing deaths to
the human population, the number of rabies deaths per year for all
of India would be 415.
The National Health Profile, the media search totals
of human rabies deaths, and projections from reported complete state
data are all so low as to call into question how the figure of 20,000
originated, along with a figure of 35,000 often cited by Indian mass
media before the 20,000 number gained currency.
These claimed death tolls, especially when cited by
WHO, are more remarkable in view that WHO on June 15, 1975
distributed a media release asserting that “Rabies is on the rise
throughout the world with ever increasing danger to human life,” as
indicated by 430 total human rabies deaths worldwide in 1973, “most
of them in Latin America and Asia, especially Brazil and India.”
A review of rabies data conducted at a 2002 Association for
Prevention and Control of Rabies in India conference in
Bhubanesh-war, a year before the National Multicentric Rabies
Survey, lowered the then-Indian government estimate of human rabies
deaths to 17,000 diagnosed cases plus 3,000 undiagnosed deaths per
year, and projected the toll as 20,565 per year from 1992 through
2002.
The estimate of 20,565 rabies deaths per year has been
attributed to British epidemiologist Katie Hampson, but Hampson
herself has noted that “older published data was used,” expressing
hope of obtaining “updated information.” Other reports based on the
2002 findings halved the projection of undiagnosed human deaths, to
suggest a total of 18,500.
A 2005 WHO report appeared to reinforce the 2002 estimate
with a projection of 19,700 human rabies deaths per year, based on
the supposition that the human rabies death toll can be projected by
estimating the dog population and making the rather shaky assumption
that rabies occurs at a relatively constant rate among all
free-roaming dogs.

Major Harvey

The mysterious original source of the claims that there were
ever either circa 35,000 or 20,000 human rabies deaths per year in
India may have been revealed by The Statesman, a leading Indian
newspaper, on July 11, 2011. According to an article reprinted on
that date from 100 years earlier, in July 1911 a Major Harvey who
was the director of the Pasteur Institute at Kasauli reported that
through “personal inquiries” he had learned “that out of 3,289
Indians bitten by rabid dogs or dogs suspected of being rabid, only
1,636 came for treatment.”
Harvey also projected that only three out of every 17 bites
by a rabid dog actually transmitted rabies to the human victim.
Founded in 1904 by Sir David Semple, inventor of the Semple
nerve tissue culture anti-rabies vaccine, the Pasteur Institute at
Kasauli is now called the Central Research Institute. Harvey was
Semple’s colleague and successor William F. Harvey. His findings,
as reported by The Statesman, appear to have been in re-circulation
ever since, in three different garbled forms.
Harvey’s estimate that only about half of rabid dog bite
victims seek post-exposure treatment has become an oft-repeated claim
that only about half of all victims of bites by any dogs seek
post-exposure rabies vaccination–and that therefore any numbers
reported for human rabies deaths are low.
Harvey’s estimate that three out of 17 bites from a rabid dog
transmit rabies appears to have been mingled with a guesstimate that
about one dog bite in 10 is inflicted by a rabid dog. Multiplied by
two million dog bites per year, another long-circulating
guesstimate, this produces the figure of about 35,000 human rabies
deaths per year.
Harvey’s total of “3,289 Indians bitten by rabid dogs or dogs
suspected of being rabid,” multiplied by the five-fold increase in
Indian human population between 1911 and 2002, plus the 3,000 deaths
that the Association for Prevention and Control of Rabies in India
suggested occur without diagnosis, comes to very nearly 20,565.
There are other possible reasons for the discrepancy between
the claims of 35,000 and 20,000 human rabies deaths in India per
year, and the much lower Central Bureau of Health Intelligence
figures. Chinny Krishna has suggested to ANIMAL PEOPLE and FIAPO
that the post-2000 turn away from use of the Semple vaccine, which
required multiple painful injections into the abdomen, has
encouraged more dog bite victims to seek post-exposure anti-rabies
vaccination.
It is also likely that deaths from many other febrile
diseases may have been misdiagnosed as rabies. Japanese
encephalitis, for example, only recently recognized in India, can
produce lookalike superficial symptoms, but according to the
National Health Profile is now known to have killed between 600 and
1,600 Indians per year during the first decade of the 21st century.
A persistent belief among many Indians that some people and animals
recover from rabies adds to the likelihood that some “rabies” cases
are misdiagnosed, and are reported without being confirmed by
post-mortem brain tissue examination.