India has made significant progress in its battle against the disease, which kills an estimated 5,700 people annually. However, the critical shortage of rabies immunoglobulin threatens to undermine the country’s goal of eliminating human deaths from dog-mediated rabies by 2030.
Published Jun 16, 2025 | 7:00 AM ⚊ Updated Jun 16, 2025 | 7:00 AM
Rabies vaccination. (iStock)
Synopsis: Despite widespread availability of anti-rabies vaccines in India, over 80 percent of public health facilities lack rabies immunoglobulin (RIG), a vital part of treatment after a high-risk bite, a new ICMR study has found. The shortage is worst at the primary care level, where almost no centres stock RIG, putting patients at serious risk.
Even as anti-rabies vaccines are widely available across public health centres in India, over 80 percent of centres lack rabies immunoglobulin (RIG), a vital component of rabies post-exposure treatment, according to a new study by the Indian Council of Medical Research (ICMR).
The study, published in The Lancet journal, surveyed 534 health facilities across 60 districts in 15 states.
Anti-rabies vaccines (ARV) were found in nearly 80 percent of public sector health facilities, with availability exceeding 90 percent in secondary and tertiary care centres.
District hospitals showed the highest availability at 95 percent, while medical college hospitals maintained stocks at 92 percent of surveyed locations.
However, the picture becomes dramatically different when examining rabies immunoglobulin (RIG) availability. Four out of five public sector facilities – 80 percent – lacked this critical treatment, with only 20 percent maintaining stocks.
The shortage was most acute at the primary care level, where more than 19 out of 20 facilities – over 94 percent – lacked RIG supplies. Even more concerning, only 1.8 percent of urban primary health centres (PHCs) maintained RIG stocks.
India has made significant progress in its battle against the disease, which kills an estimated 5,700 people annually. However, the critical shortage of rabies immunoglobulin threatens to undermine the country’s goal of eliminating human deaths from dog-mediated rabies by 2030.
Rabies immunoglobulin is a critical component in treating patients exposed to the infection.
Category III bites – deep wounds, bites near the head and neck, or multiple bites – represent the most dangerous scenarios where the virus can spread rapidly to the brain. These severe cases require both ARV and RIG for effective prevention.
“Rabies immunoglobulins are crucial for managing category III animal bites. However, our study revealed that RIGs were available in only one in five public sector health facilities,” the study authors noted.
“NRCP guidelines recommend that any wound with bleeding should be treated with RIG in addition to ARV. In practice, over half of all animal bite wounds reported to health facilities are likely to be categorised as category III, requiring RIG as part of PEP.”
The researchers emphasised that this shortage creates a cascade of problems:
“The scarcity of RIG in primary care facilities can lead to bite cases being referred to higher centres, resulting in increased vaccination costs for individuals, higher case-loads at advanced centres, or even the omission of RIG in PEP.”
This system failure forces healthcare providers into an impossible choice: refer patients to distant tertiary care centres, potentially delaying critical treatment, or proceed with incomplete protection that may prove fatal.
The cost extends beyond individual patients, as families face increased expenses travelling to higher-level facilities, while tertiary care centres become overwhelmed with cases that could have been handled at the primary level.
Most concerningly, some patients may receive inadequate treatment or abandon care altogether due to accessibility barriers.
The study also reveals regional variations in treatment availability, with some regions showing dramatically better preparedness than others.
For anti-rabies vaccines, southern states led the country with 93 percent of facilities maintaining stocks, followed closely by western states at 90 percent.
Eastern states showed moderate availability at 81 percent, while northern states lagged at 76 percent.
Most concerning were the northeastern states, where only 60 percent of facilities had vaccines available – meaning two out of five facilities in this region could not provide even basic rabies prevention.
The study found that while secondary and tertiary care facilities maintained relatively consistent ARV availability across regions (above 90 percent), primary care centres showed dramatic variation.
This is particularly problematic since primary health centres serve as the first point of contact for most rural populations, who face the highest rabies exposure risk.
Even where vaccines were available during the survey, the system showed signs of stress.
One in four health facilities reported experiencing complete stockouts – days when they had zero vaccine vials available – at least once in the previous year.
This presents an unacceptable risk for any bite victim seeking treatment during these periods.
The study also highlighted gaps in healthcare worker training and patient follow-up systems. Only 45 percent of government facilities had at least one staff member recently trained in rabies management, despite the complexity of proper wound care and vaccination protocols.
Even more concerning, fewer than one-third of facilities actively followed up with patients to ensure completion of the full vaccine series – a critical step for preventing treatment failure.
Storage and distribution challenges further complicate the picture. While most facilities (92 percent) had appropriate refrigeration to maintain vaccines at the required 2–8°C temperature, the decentralised procurement system creates inconsistencies across states.
Each state follows its own process for funding, purchasing, and distributing rabies treatments, leading to variations in timeline efficiency and supply reliability.
The study revealed a contrast in the private healthcare sector, where more than half of facilities offering ARV also maintained RIG stocks.
However, this apparent advantage comes with a significant caveat – private care often remains financially inaccessible to the rural poor who face the highest rabies risk.
Private facilities also showed different treatment patterns, with 50 percent using human rabies immunoglobulin (HRIG) or newer rabies monoclonal antibodies, compared to public facilities that primarily relied on equine rabies immunoglobulin (ERIG).
While HRIG and monoclonal antibodies offer advantages in terms of safety and efficacy, their higher cost makes them impractical for large-scale public health implementation without significant investment.
The research highlighted rabies monoclonal antibodies (RmAb) as a promising solution to RIG shortages.
Unlike traditional RIG derived from horse serum or human donors, these laboratory-manufactured antibodies can be produced in large quantities with consistent quality and fewer side effects.
They are also more cost-effective than HRIG and do not require animal sources, making production more ethical and scalable.
(Edited by Dese Gowda)
