Reply to Kapur, V. Is Pre-Exposure Prophylaxis a Cost-Effective Intervention to Avert Rabies Deaths among School-Aged Children in India? Comment on “Royal et al. A Cost-Effectiveness Analysis of Pre-Exposure Prophylaxis to Avert Rabies Deaths in School-Aged Children in India. Vaccines 2023, 11, 88”

Thank you so much for forwarding the critical analysis the author (VK) conducted on our recently published modelling study ‘A Cost-Effectiveness Analysis of Pre-Exposure
Prophylaxis to Avert Rabies Deaths in School-Aged Children in India’ in your reputed journal [1]. We are thankful to the author for this analysis and for providing his input [2]. The current scenario of human rabies surveillance in the states and its reporting to the central government is poor in India [ 3]. The reported data are institution-based/passive surveillance, with inherent limitations of the iceberg phenomenon of a disease in a community/population. Moreover, a concordance of 43% on dog bite data was reported between the Integrated Disease Surveillance Programme (IDSP) and the Association for Prevention & Control of Rabies in India (APCRI) survey [ 3– 5]. The numbers on the animal bite incidence and burden of rabies in the literature and government data are highly under-reported [3]. There have been reports from various field-based studies on the exponential increase in animal bites, especially in hilly and forest areas. The state of Himachal Pradesh reports
an exponential rise (almost six times) in cases of dog bites from 11,412 in 2013 to 65,906 in 2021 through IDSP (as reported by IDSP, Himachal Pradesh). A recent publication reported a consistent rise in the cases of dog bites and rabies deaths in the state of Kerala, with more than 200,000 cases of dog bites and 21 rabies deaths (almost double the deaths reported in the previous year) in 2022 [6]. Moreover, six out of these 21 victims died despite of administration of rabies immunoglobulins and anti-rabies vaccination. The neighbouring state of Tamil Nadu also reported an alarming number of rabies deaths during the first eight months of 2022 [6].