As India faces one of the world’s highest rabies burdens, experts weigh the benefits of extending pre-exposure rabies vaccination to children at high risk, amid ongoing discussions on its practical implementation and the importance of dog control measures.
Rabies remains one of the most feared infections in medicine because, once symptoms begin, it is almost always fatal. Yet it is also one of the most preventable, provided exposure is handled quickly and correctly. That tension is driving a renewed debate in India over whether children should receive rabies vaccination before any bite occurs, particularly in a country that still carries a heavy share of the world’s rabies burden.
India continues to record the largest number of rabies deaths globally, and children account for a troubling share of victims. The Indian Academy of Paediatrics recommended pre-exposure prophylaxis, or PrEP, for all children in 2022, but the guidance has been framed cautiously and has not been widely publicised. At the same time, Indian Council of Medical Research-National Institute of Epidemiology estimates suggest there are about 9.1 million animal bites in the country each year, with dogs responsible for more than three-quarters of them and an estimated 5,726 human rabies deaths annually.
Even so, many specialists argue that a universal childhood approach may go too far. Dr Khan Amir Maroof, a community medicine specialist and rabies researcher at University College of Medical Sciences and GTB Hospital, told India Today that he does not think every child needs vaccination before exposure. He said any additional vaccine in the routine immunisation schedule should be justified by strong scientific evidence, especially in a country where children already receive multiple injections under the government programme. National guidelines also describe PrEP as an option for high-risk groups, while the paediatric recommendation can be considered on a voluntary basis.
The practical question, then, is which children benefit most. Doctors say the strongest case is for children who live with animals, spend time around stray dogs or are otherwise more likely to be bitten or scratched. Maroof said the World Health Organisation’s approach is to consider PrEP where exposure risk is especially high, and he pointed to Indian data suggesting that in many places the proportion of people who experience dog bites is lower than the level usually used to justify routine population-wide vaccination. A separate Indian study is also examining simpler intradermal schedules in children, reflecting an effort to make preventive vaccination easier to deliver in endemic areas.
The concern is not academic. Children are more vulnerable because they are smaller, more likely to suffer bites to the face or hands and less likely to report a scratch or minor wound to an adult. Dr Sanjay Wazir, director of paediatrics at Motherland Hospital in Gurugram, said that this combination makes severe exposure more likely in children. The World Health Organisation likewise says children make up a large share of dog-bite victims and are at greater risk of serious injury because bites to the head and neck occur more often in them than in adults.
Still, experts stress that vaccination before exposure is not a substitute for controlling rabies in dogs, which are the main source of human infection. The World Health Organisation says dogs are responsible for 99 per cent of human rabies cases worldwide, and mass dog vaccination remains one of the key public health tools for interrupting transmission. Maroof argued that the priority should remain dog vaccination, a point reinforced by research published in The Lancet Regional Health, which drew on a project in Kerala.
For parents, the most important message is that PrEP does not remove the need for urgent action after a bite or suspicious scratch. Dr Ashu Khajuria, a paediatrician with Kailash Hospital & Neuro Institute, said a vaccinated child still needs medical assessment after exposure. The reason is that PrEP mainly primes the immune system; if an exposure occurs later, treatment is simpler, but the wound still has to be cleaned and the child still needs proper clinical review. For someone without prior vaccination, post-exposure prophylaxis can involve wound care, rabies vaccine and, in more serious cases, rabies immunoglobulin.
That is why immediate first aid remains essential. The wound should be washed thoroughly with soap and running water for at least 15 minutes, then assessed without delay. WHO guidance says Category II exposures need wound cleansing and vaccination, while Category III exposures require vaccine plus rabies immunoglobulin or a suitable monoclonal antibody where indicated. The health agency says that correct wound care and timely, quality-assured post-exposure prophylaxis are almost 100 per cent effective at preventing human rabies deaths.
Evidence from India also supports the safety and usefulness of pre-exposure vaccination in children who are at risk. A study in Bangalore involving children aged five to ten years found that intradermal rabies vaccination was generally well tolerated, with only minor reactions such as local pain and mild fever. Taken together, the research and expert guidance point towards a careful, case-by-case approach: broader protection for children most likely to encounter dogs, but continued emphasis on prompt treatment, dog vaccination and stronger public health measures to reduce exposure in the first place.
Disclaimer: This content is for informational purposes only and is not intended to be a substitute for professional medical judgment, advice, diagnosis, or treatment.
