Dog vaccination could save more lives than routine child PrEP in Keralam, says study

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Intensifying vaccination of dogs and ensuring that people bitten by dogs receive timely and complete rabies post-exposure prophylaxis (PEP) could save far more lives in Keralam than routine pre-exposure prophylaxis (PrEP) vaccination of children, according to a new modelling study on the cost-effectiveness of rabies interventions.

The study, published in The Lancet Regional Health – Southeast Asia, estimates that routine childhood PrEP—vaccinating children against rabies before any animal exposure — would prevent only about 10 additional deaths over 10 years, while adding an estimated $10.5 million to $36.5 million to healthcare costs.

In contrast, comprehensive vaccination of dogs, combined with improved post-bite treatment and efforts to close gaps in PEP, could reduce rabies deaths by 83% compared to the current strategy, the study says. Scaling up vaccination of both owned and free-roaming dogs to 70% coverage could potentially bring human rabies deaths down to zero in Keralam within three years, according to the model.

The research was led by the University of Glasgow in collaboration with researchers from the Directorate of Medical Education, Kerala University of Health Sciences, the School of Public Health, the Directorates of Health and Animal Husbandry in Keralam, and the London School of Economics and Political Science.

Rabies prevention is already one of Keralam’s most intensive public health interventions, with more than 9,00,000 people receiving free treatment every year following animal bites. The State also has a PEP completion rate of over 90%. Yet human rabies deaths continue to occur, with 33 deaths reported in 2025, including among children.

The findings add a new dimension to the ongoing debate over whether Keralam should introduce routine PrEP for children as a rabies prevention strategy. Paediatricians and several public health experts have advocated childhood PrEP because children are particularly vulnerable to severe bites, including injuries to the face and hands, which could become fatal, despite post-exposure treatment.

The study does not rule out PrEP. Instead, it argues that PrEP may be more appropriate for specific high-risk populations who face difficulties in reaching healthcare facilities quickly after exposure, including some geographically dispersed tribal communities.

It argues that given Keralam’s relatively strong access to PEP, universal childhood PrEP may produce relatively little additional mortality reduction for the huge resources required, whereas improved dog vaccination and better wound management and timely PEP may produce greater population-level gains.

“The study is a comparison of the cost effectiveness of PrEP against other interventions as a population-level strategy to reduce rabies. It points out that, as a public health strategy, investing in dog vaccination is more cost effective because it stops virus transmission in the community, and takes us closer to rabies elimination,” said Zinia T. Nujum of the School of Public Health, KUHS, who led the research in Kerala.

According to Martha Luka, researcher at the University of Glasgow’s School of Biodiversity, One Health & Veterinary Medicine and lead author, PrEP for children is unlikely to be the best use of public health resources in Keralam, where access to post-bite vaccination and completion of the regimen are already high.

Canines are the reservoir of the rabies virus and accounts for 70% of the rabies cases. Vaccinating the dog population interrupts transmission before people are exposed, whereas PrEP mainly protects vaccinated individuals while the wider risk remains.

The researchers modelled 12 different combinations of dog vaccination, post-bite treatment and PrEP over a 10-year period from 2026-2035. The study’s sensitivity analysis underlines the importance of improving access to PEP. Raising the proportion of bite victims who seek medical care from 70% to 95% could prevent more than 1,100 additional deaths—over 20 times the mortality reduction achievable even with maximum PrEP coverage in the model.

The researchers also found that increasing vaccination coverage among domestic dogs alone could produce substantial health gains. “About 70-80% of dog-bite cases in the State are due to domestic dogs. Mandatory licensing and vaccination of domestic dogs, can help improve coverage. We could focus on completing domestic dog vaccination and then move on to vaccinating strays,” said Dr. Nujum.

However, she pointed out that the population of free-roaming dogs in Keralam could be at least five times the official estimate, highlighting the need for better data to plan vaccination programmes. The researchers argue that the State’s priority should therefore be a sustained One Health-based dog vaccination programme targeting at least 70% coverage, involving local bodies, Animal Husbandry and Health departments, veterinary teams, NGOs and communities.

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