Introduction

The global rabies conference in Geneva in December 2015 set the goal of eliminating canine-mediated human rabies by 2030 through the Global Framework for the Elimination of Dog-Mediated Human Rabies. Five pillars were identified to achieve rabies elimination: S-Socio-cultural; T-Technical; O-Organizational; P-Political; and R-Resources (STOP-R). Two of the key aspects highlighted were the following: importance of strengthening the intersectoral collaboration through the One Health approach (O-Organization); implementation of mass dog vaccination which is the most cost-effective intervention to achieve dog-mediated human rabies elimination (T-Technical). Rabies is a neglected tropical disease wherein 59,000 human lives each year are lost mainly in rural areas of Africa and Asia. It has been controlled in Latin America and Caribbean wherein only 10 deaths were reported due to dog-mediated rabies in 2016 (Haiti and Guatemala). Almost 60% of global human rabies deaths (35,172 human rabies deaths) occur in Asia with India accounting to almost 60% of the deaths in the region. Africa, on the other hand, record a high human rabies deaths of 21, 476 annually (36% global deaths).

Importance of Dog Vaccination in Rabies Control

The economic burden of rabies is immense with USD 8.6 billion loss per year, the majority of which is productivity loss due to premature deaths (54%). Although dog vaccination is the most effective way to control rabies, only 2% of the cost is allocated to dog vaccination and population control. It has been proven in Latin America that investing in dog vaccination to achieve 70% coverage for mass dog vaccination to maintain herd immunity against rabies is effective in decreasing dog-mediated human rabies.

Awareness about rabies, dog vaccination and prompt access to post-exposure prophylaxis for bite victims are the key in the control and prevention of dog-mediated human rabies. Although dog vaccination seems to be the most cost-effective and simple method to prevent rabies, the challenge of ensuring 70% vaccination coverage of the dog population in a country is complex. This presentation will focus on how the global community addresses the challenge on the issue of mass dog vaccination and how individual communities are gaining success in controlling dog-mediated human rabies through dog vaccination.

Challenges and Solutions

Lack of access to safe and efficacious dog vaccines is one of the factors that impact conduct of mass dog vaccination at a country level. Since 2012, the World Organization for Animal Health (OIE) established regional vaccine banks with the aim to support national governments with easier access to high-quality, affordable vaccines. By December 2017, 19 million dog rabies vaccines have been supplied to 28 countries in Asia and Africa through the vaccine bank.

Limited focus on strategic planning and allocation of financial resources hinders the implementation of mass dog vaccination in the field. Based on the successful elimination at the regional level of Latin America, a regional rabies elimination approach through the establishment of regional rabies elimination control networks in Africa, Asia and Middle East is underway. These regional meetings provide venue for conduct of workshops such as the Stepwise for Rabies Elimination (SARE) to develop work plans for rabies elimination as well as Global Dog Rabies Elimination Pathway (GDREP) to determine financial requirements to support mass dog vaccination.

At the field level, operational challenges include the lack of manpower to support MDV and proper estimation of dog population as well as dog vaccination coverage. The Global Education Platform (GEP) of Global Alliance for Rabies Control (GARC) provides free online courses to support training of vaccinators such as the Rabies Educators Certificate (REC) and the Animal Handling and Vaccination Course (AHVC). GARC as well as Humane Society International (HSI) and Mission Rabies have also developed computer-based tools to support dog population estimation and vaccination coverage. Oral rabies vaccination is now also being seen as a possible support to mass dog vaccination, specifically targeted for dogs that are free roaming and difficult to handle for parenteral administration of rabies vaccine.

Lack of knowledge about rabies and misconceptions on its prevention and control hinder the community to support local rabies programs. Innovative methods to mobilize the community have been implemented in different countries through community education and school-based intervention.

Success Stories

Countries in Latin America have shown that a regional approach focusing mainly on mass vaccinating dogs together with proper animal bite management and surveillance can decrease rabies human deaths and confirmed dog rabies cases significantly. A total of 50 million dogs are estimated to be vaccinated in the region annually.

In Bangladesh, thousands of dog catchers and vaccinators were trained as the result of a snow-ball technique capacity building mechanism. Through this mechanism, 70% mass dog vaccination coverage was achieved in 1 week wherein majority of the dogs are free roaming.

Focusing on mass dog vaccination together with other rabies control components such as information campaign, strengthened surveillance and better access to PEP were also key to reducing human rabies deaths (Sri Lanka) with some countries achieving zero human rabies deaths (Mexico). Strengthening mass dog vaccination campaigns have been also crucial in controlling rabies in Kwazulu Natal (South Africa), Visayas (Philippines) and Tanzania.

One Health Approach From the Global to the Local Level

One Health approach emphasized on the intersectoral approach to fight rabies. As a global response to the goal of eliminating dog-mediated rabies by 2030, a United Against Rabies collaboration composed of FAO, OIE, WHO and GARC has been established to support countries to achieve rabies elimination by sharing existing tools and expertise. Regional networks have also been established in Africa, Asia and Middle East to serve as a venue for national program managers from the animal health and medical sector together with regional partners to plan a regional approach for rabies elimination.

At the country-field level, Integrated Bite Case Management (IBCM) serves as a basis for animal health and medical personnel to collaborate to assess the risk of an animal bite and plan the best course for animal bite management strategy. The impact of IBCM is that it can reduce the cost of treatment of rabies in humans by determining rabies risk in biting animal (low risk if dog is regularly vaccinated; high if dog is free roaming, non-vaccinated and have signs of rabies).

Private practitioners and professional/civic organizations play a huge role in the rabies elimination efforts. This is seen through the cooperation between sectors during World Rabies Day celebration. In the Philippines, the bayanihan (cooperation and community) spirit has been the main driving force in the rabies elimination efforts such as the training of village health workers to support mass dog vaccination. In remote communities in Northern Tanzania, dog vaccination is scheduled in the community during the deworming of children.

The goal of global elimination of dog-mediated human rabies faces a lot of challenges but inspiring stories of cooperation and sharing of innovations at the global to the local level have shown that reaching the 2030 rabies elimination is feasible.

References

1.  World Health Organization (WHO), Food and Agriculture Organization of the United Nations (FAO) and World Organisation for Animal Health (OIE), Global Alliance for Rabies Control (GARC). 2018, Zero by 30: the global strategic plan to end human deaths from dog-mediated rabies by 2030. World Health Organization; 2018, WHO Expert Consultation on Rabies, Third report. Geneva: (WHO Technical Report Series, No. 1012).

2.  WHO and OIE. Report of the Rabies Global Conference: Global conference on the elimination of dog-mediated human rabies: the time is now! WHO Geneva. 2016.