# Disparities in Global Rabies Burden from GBD 2021: Children, older adults, and low-SDI countries at continued risk

## TL;DR

Rabies remains a deadly disease in low-income countries, especially for children and the elderly, despite global declines in cases and deaths since 1990.

## Contribution

The study uses GBD 2021 data to reveal persistent disparities in rabies burden and highlights the need for targeted interventions in high-risk groups and regions.

## Key findings

- Global rabies incidence and DALYs declined significantly from 1990 to 2021, with the highest rates in low-SDI countries like Nepal, Ethiopia, and Malawi.
- Children aged 5–9 and adults over 70 remain at highest risk, showing a U-shaped age distribution of rabies burden.
- Epidemiological improvements drove most of the decline, but population growth and aging partially offset gains in some regions.

## Abstract

Rabies is a fatal yet preventable viral infection of the central nervous system zoonotic disease, with an almost 100% case fatality rate once symptoms appear. Despite the availability of effective vaccines and post-exposure prophylaxis, rabies continues to cause substantial mortality, particularly in parts of Asia and across the African continent where access to post-exposure prophylaxis (PEP), timely diagnosis, and dog vaccination programs remain limited.

Rabies is a nearly invariably fatal zoonotic encephalitis caused by lyssaviruses, with an estimated 59 000 human deaths annually, predominantly in Asia and cross the African continent where access to PEP and dog vaccination is limited. Due to historical underreporting and fragmented surveillance, the true burden remains unclear. Using Global Burden of Diseases (GBD) 2021 data, we systematically assess the global, regional, and national burden of rabies from 1990 to 2021 to identify key drivers of change and persistent disparities.

We extracted rabies incidence and disability-adjusted life-year (DALY) data from the GBD 2021 via the Global Health Data Exchange. Countries were stratified into five sociodemographic index (SDI) categories. Age-standardized rates per 100 000 population were computed using the GBD world standard. We applied Bayesian age-period-cohort (APC) modeling to characterize temporal trends and project future age-standardized incidence rate (ASIR) and age-standardized DALY rates (ASDR), decomposition analysis to partition burden changes into epidemiological, population growth, and aging components, and frontier benchmarking to assess each country’s performance relative to its SDI.

From 1990 to 2021, global rabies ASIR fell by 69.4% (0.42 to 0.13/100 000) and annual cases by 54% (22 035–10 181). Over the same period, DALYs declined 58.4% (1 368 780–569 550) and ASDR dropped from 24.48 to 7.51/100 000. In 2021, the highest ASIRs were in Nepal (1.71), Ethiopia (1.05) and Malawi (0.77/100 000). Age-period-cohort analysis showed net drifts of -3.96%/year for incidence and -3.90%/year for DALYs. Decomposition attributed ~170% of incidence decline to epidemiological gains, offset by ~60% from population growth and ~52% from aging.

Scale up mass dog vaccination, ensure affordable PEP and strategic Pre-exposure prophylaxis, focus on high-risk age cohorts, bolster surveillance and data-driven governance, and sustain multisectoral investment through the phased “Zero by 30” framework. By aligning programmatic efforts with the demonstrated successes in high-performing countries and addressing the implementation deficits in lagging regions, the global community can accelerate progress toward the World Health Organization (WHO) goal of zero dog-mediated human rabies deaths by 2030.

Rabies is a fatal yet preventable viral infection of the central nervous system, with an almost 100% case fatality rate once symptoms appear. Using data from the Global Burden of Disease Study 2021, this study presents a comprehensive assessment of global, regional, and national rabies trends from 1990 to 2021. We estimated incidence and disability-adjusted life-years (DALYs) and applied age-period-cohort (APC) modeling, decomposition analysis, and frontier benchmarking to evaluate temporal patterns, demographic drivers, and inequalities across 204 countries and five sociodemographic index (SDI) levels. Results revealed a substantial global decline in incidence and DALYs over the study period. However, the burden remains disproportionately concentrated in low-SDI regions such as the African continent and South Asia. APC analysis revealed a persistent U-shaped distribution in incidence and burden, with peaks in children aged 5–9 years and adults over 70 years. Decomposition analysis showed that epidemiological improvements, rather than population aging or growth, accounted for most of the reductions in burden. Nonetheless, in regions like Eastern Sub-Saharan Africa and South Asia, demographic pressure partially offset gains. Frontier analysis further exposed persistent inequalities, with countries like Nepal, Ethiopia, and Malawi falling significantly behind their expected performance levels, while high-SDI countries and parts of Latin America sustained near-zero burden since 1990. These findings underscore the urgent need for intensified One Health strategies, equitable post-exposure prophylaxis (PEP) access, and targeted interventions for high-risk groups, especially children and the elderly, to close the remaining gaps and achieve the World Health Organization (WHO) goal of zero human deaths from dog-mediated rabies by 2030.