Rabies is a zoonotic disease of paradox and is a serious public health problem in 150 countries and territories, mainly in Asia and Africa. It is 100% fatal once clinical symptoms appear, yet it is 100% preventable. Despite having the preventive tools, this ancient neurotropic viral infection continues to haunt the modern world by killing one person every 9 min. Often viewed historically as a disease of the “third world,” rabies is recognized by the World Health Organization (WHO) as a neglected tropical disease (NTD), affecting developing nations where access to basic amenities remains a luxury. Eliminating dog-mediated rabies is inextricably linked to the United Nations’ Sustainable Development Goals (SDGs), specifically SDG 1 (No Poverty), SDG 3 (Good Health and Well-being), and SDG 17 (Partnership for Goals). “Zero by 30,” the global mandate of zero human deaths from dog-mediated rabies by 2030, was adopted in India as the National Action Plan for Dog Mediated Rabies Elimination by 2030. Despite the domestic translation, the gap between policy and operational reality remains wide. Rabies has manifestations to a febrile viral illness with neurological signs. It presents in two forms. Hyperactivity, lack of coordination, aerophobia, hydrophobia, and hallucinations are present in furious rabies. Paralytic rabies has a longer course and is less dramatic than furious one. It accounts for one-fifth of the total cases of rabies. Muscle paralysis begins gradually from the wound site. Coma sets in the patient, and death occurs. This form of rabies is often misdiagnosed. Rabies needs to be differentiated from acute encephalitis due to any other infectious or noninfectious causes, autoimmune encephalitis, brain tumor, cerebral malaria, cerebral vascular accidents, Creutzfeldt–Jakob disease, Guillain–Barré syndrome, hypoglycemia, meningitis, neurosyphilis, psychosis, poisoning in general and belladonna alkaloids, poliomyelitis, seizures, thiamine deficiency, and tetanus.1 THE EPIDEMIOLOGICAL BURDEN: A GLOBAL AND NATIONAL CRISIS Globally, rabies claims an estimated 59,000 (95% confidence interval: 25–159,000) lives annually, with 77% of these deaths occurring in the Southeast Asian region.2 Underreporting of cases can occur when subjects with an animal bite do not seek care, clinicians misdiagnose symptoms, nonuse of standard clinical definitions, severely fragmented surveillance systems, and nonavailability of diagnostics and state of art laboratories for true disease burden assessment. Prevailing myths and misconceptions also contribute to poor health-seeking behavior for rabies. India stands at the epicenter of this crisis, bearing roughly 36% of the global rabies burden. While conservative estimates place India’s annual rabies death toll between 18,000 and 20,000, the country remains a global hotspot for rabies. A systematic review estimated around 17.4 million dog bites in India, suggesting significant underreporting in official records.3 THE MAGNITUDE OF THE THREAT Rabies is a major global concern. The crisis is immediate. Urbanization and expanding waste management issues are accelerating dog–human interactions. While historically this has been an issue of rural fringes, it is increasingly infiltrating urban centers and diverse ecological zones across India. It is a disease that preys on the young; approximately half of all global rabies victims are children under 15, who are more likely to play with animals and less likely to report minor bites or scratches. In India, 40% of fatalities are in children under the age of 15. The Rabies Lyssavirus operates in two practical contexts. The “wild” (or street) virus circulates aggressively in nature, highly adapted to transmission via the saliva of hosts (primarily dogs in Asia). Conversely, the “fixed” virus is the attenuated strain used in laboratories to manufacture the very vaccines that save lives. In India, the disease is mainly transmitted by the bite of a rabid dog (dogs are responsible for about 97% of human rabies cases), followed by cats (2%), jackals, mongooses, and others (1%). Enhancing surveillance and sequencing technologies demonstrate that Lyssavirus is highly diverse. Fifteen species are known to cause Rabies. Ongoing genetic evolution and diversification of the rabies virus and related Lyssaviruses have raised concerns regarding the future effectiveness of currently available human rabies vaccines and human rabies immunoglobulin (RIG) in preventing rabies infection.4 WHY DOES RABIES PERSIST? THE HOST–ENVIRONMENT EQUATION The persistence of rabies is a classic failure of the One Health paradigm – a framework that recognizes the interconnectedness of human, animal, and environmental health. One Health is a collaborative, multisectoral and transdisciplinary approach. It works at local, regional, national, and global levels. The root of the problem lies in a staggering dog population ratio. India’s 2019 Livestock Census officially counted 15 million stray dogs. However, recent epidemiological studies suggest a massive undercounting problem; for instance, dog densities in areas like the National Capital Region point to populations nearly 15 times higher than official estimates. When a rapidly multiplying host population with an environment rich in open garbage (a food source) combines with dense human settlements, it creates a perfect storm for viral transmission. BOTTLENECKS TO ELIMINATION Achieving “Zero by 30” requires dismantling hurdles on two fronts. Dog-related strategies Multiple strategies will be required to reduce dog bites and other incidents, including dog aggression. There exists evidence that legislated dog control strategies reduce dog bite rates.5 Estimation of dog population Globally, there are approximately 8.3 billion humans and 700 million to 1 billion dogs. This translates to one dog for every 8–11 humans on the planet. The vast majority (75%) of dogs are free-roaming community or stray dogs. India is home to roughly 1.45 billion people. The estimated number of dog population is 36.9 million pet dogs and 60–80 million stray dogs. Thus, there is roughly one dog for 18–23 people, varying from state to state.6 Identification of rabies-risk zones These are the places where the dog–human population ratio is higher, and this results in competition between dogs for food and increased aggressive behavior, sometimes provoked by human beings as well. These usually include places with higher density of humans such as hostels, markets, picnic spots, and also slums. Sterilization and dog–population control Effective Animal Birth Control (ABC) programs do more than just reduce numbers. Sterilization significantly decreases aggression in dogs, reducing the urge to fight for territory or mates, which in turn leads to a drastic reduction in biting incidents. However, ABC implementation remains patchy and resource-starved. Due to the massive population of street dogs in India and varying enforcement across states, there is a paucity of information at the national and state levels. As per localized surveys, sterilization rates range widely (35%–85%). Sterilization rates in India for pet dogs are generally lower than those of Western countries. In the US, 85% of dogs are sterilised. At least 70% of dogs should be sterilised for optimum dividend. Mass dog vaccination To break the chain of transmission, 70% of the dog population must be vaccinated to achieve herd immunity.7 While smaller nations like Bhutan recently achieved 100% sterilization and 90% vaccination, scaling this across South Asia and African countries requires monumental logistical effort and sustained funding. Human-related strategies Postexposure prophylaxis access The mismatch between skyrocketing dog bites and localized rabies deaths points to a severe disparity in access to life-saving postexposure prophylaxis (PEP) and RIG. Cost, distance to clinics, and vaccine stockouts frequently turn a survivable bite into a death sentence. In the event of any bite, a country-specific schedule should be followed, giving due cognizance to WHO and other international guidelines. Preexposure prophylaxis High-risk groups – such as animal handlers, waste management workers, and children in hyperendemic zones – are rarely prioritized for preexposure prophylaxis (PrEP), leaving the most vulnerable exposed. PrEP should also be given to travelers at risk due to extended stay in endemic countries. POPULATION AWARENESS AND EDUCATION Prevention of dog bites, awareness of doggie language,8 dog training, engineering measures, and availability of PEP should be the key activities for population awareness and education. Myths, traditional remedies, application of chilli powder or herbs to wounds, and delayed hospital visits are fatal errors born of poor mass education. Comprehensive risk mitigation requires communities to be aware of the absolute necessity of immediate wound washing (with soap and water for 15 min) and urgent medical care. All prevailing myths and misconceptions should be eliminated for promoting positive health-seeking behavior of the population.9 OPERATIONALIZING ELIMINATION: FROM CONCEPT TO PRACTICE One Health approach is the key approach for elimination of rabies. At the recent One Health Summit in May 2026, global partners (WHO, WOAH, FAO, and UNEP) launched a renewed push to integrate veterinary services into national public health responses. For this purpose, the key action points are: (A) Shift from reactive human treatment to proactive animal management. Investing in mass dog vaccination is ultimately more cost-effective than infinite human PEP distribution. (B) We cannot manage what we cannot measure. Robust surveillance and accurate dog population censuses are nonnegotiable. Notification of rabies cases and capturing all dog bite cases through different surveillance systems, including community-based approaches and linking them to the health system for wound care and PEP, should receive top priority. (C) Municipalities (waste management), veterinary services (animal health), and health ministries (human health) must stop working in silos. The elimination of dog-mediated rabies is not a scientific mystery waiting to be solved; it is a logistical and political test waiting to be passed. The judiciary can exercise its power to accelerate the preventive strategy of Rabies control. This is amply highlighted by the judgment of the Supreme Court of India on May 19, 2026.10 A discernible absence of sustained, systematic, and incremental efforts to expand and strengthen infrastructure to manage steadily the stray dog population has been observed, and the court directed to take necessary action in this regard. We possess the fixed virus to create the vaccines, the epidemiological knowledge to target the wild virus, and the One Health framework to balance the human–animal environment. What we need now is the unwavering political will to fund, scale, and sustain these efforts. For the thousands of children who remain at risk in our streets every day, the time to act is not tomorrow – it is right now. The greatest burden of rabies falls on the poorest people relying on livestock for food and animals. The urban menace of rabies can be addressed through a rabies-free city initiative. Globally, rabies costs 8.6 billion USD annually; it has the highest burden per capita among all NTDs (32.8 disability-adjusted life years per lakh population).2 This disease is a classic example of a zoonotic disease that does not fit into the domain of any single department having the responsibility of controlling rabies. Encouraging partnership with the United Against Rabies Multisectorial forum, World Health Organization and various countries to build capacity of their One Health work force may provide immense opportunities for rabies elimination. Research and development should receive top priorities in this regard.
C. P. Mishra (Wed,) studied this question.