Introduction

KwaZulu-Natal (KZN), a province on the eastern seaboard of South Africa, has since 1976 had an ongoing battle with canine rabies. The province is ideally suited for the spread and maintenance of the disease, due to it being densely populated by people who like to keep dogs, but cannot afford to confine or provide most basic veterinary needs for the animals. This rabies problem has seemed irretraceable over the years, despite minor successes, mainly influenced by government control programs. Rabies control programs have experienced alternating successes and failures due to factors such as financial constraints, changes in management, political interferences and the lack of, or increased interest by other key role players.

This all changed in 2007 with the implementation of an international collaborative project, partly sponsored by the Bill and Melinda Gates foundation, also supported by various international scientific organizations such as the World Health Organization.

Key to the success of the project has been the establishment of a single point of reference for rabies control for the province; i.e., "the rabies project." This single point of reference for control activities, research and technological developments, has managed to steer control efforts in a practical applicable way, to find solutions within uniqueness of the province. This body of success has in turn attracted expertise, financial support by government and private organizations and most importantly improved public awareness and participation.

Animal rabies in KZN is now at a 31 year low, with only a single human death in 22 months (see Figure 1). It is believed that the lessons learnt from this project prove that rabies can be eliminated within a developing world "African" environment, and that solutions must come from Africa through innovation and understanding the uniqueness of the continent, its people and the systems that exist.

Figure 1. Rabies in KZN since its introduction in 1976, and the success of the project, which started in 2007

Discussion

Eliminating canine rabies in KwaZulu-Natal is no longer a question of how? (Other rabies-related viruses endemic to the bat family not included in this.) All the mechanisms exist, or have been tested, that prove elimination can be achieved. The only outstanding element remaining for the few last outbreak sites, is the political will and local infrastructure shortcomings needed to deal with these." Rabies control is not about brilliant scientific innovation, but simple, well-managed, focused vaccination campaigns."

The main factors that prevent success are three fold: Politics, Personalities and Bureaucracy.

 Politics - Politics obviously supports government structures and focus on the ground. Getting buy in at the political level will expedite any program. Showcasing local success has quickly garnered the necessary political buy in.

 Personalities - Strong individual leaders, for and against can quickly drive or stop successful efforts. Champions are essential to own and drive programs.

 Bureaucracy - Government systems have proved a major stumbling block to initiating and maintaining momentum in the KZN project.

Factors necessary for success in Africa:

1.  Champions - It has been very noticeable in KZN that having a single person or group completely dedicated to the success of the project is fundamental to success! This has been repeated in areas where the project has expanded on both a local, provincial and country-wide scale. Having a dedicated project or leader, which will take into consideration the uniqueness of that area, apply practical research, bring in the required expertise and keep pushing the processes, which is foundational to success.

2.  Research^1-8 - Not only does research answer important questions, but is an important vehicle to attract interest and resources, in the form of partnerships. KZN has many partners that contribute to the project both technically and financially. These partners in turn raise the profile of the project, which stimulates improved local government cooperation.

Some key topics of research conducted in KZN:

a.  Surveillance

i.  Forensic detection of rabies virus in decomposed exhumed dog carcasses¹

ii.  Regional surveillance and phylogeographical analyses⁴

iii.  Bayesian approach for inferring the dynamics of partially observed endemic infectious diseases from space-time-genetic data⁵

iv.  Evaluation of a rapid immunodiagnostic test kit for detection of African lyssaviruses from brain material⁷

b.  Economics

i.  Towards canine rabies elimination in KwaZulu-Natal, South Africa, assessment of health economic data⁴

c.  Control

i.  Dog behavior

ii.  Evaluation of bait vaccines

iii.  Evaluation of immunocontraceptives

iv.  Factors associated with the rabies vaccination status of dogs in KwaZulu-Natal, South Africa ecology (PhD)⁶

3.  Collaborative Partnerships - The Bill and Melinda Gates foundation, while contributing financially to the project, have a rather small part to play in terms of the resources needed to achieve success. However, the name of the organization and that of the World Health Organization, for example, has dramatically raised the profile of the project, which in turn increased the financial contributions by the South Africa Government, making success possible. This in turn has paved the way to a role our strategy, which works on the principal of starting small, and developing interest and support through success. Small contributions ("stimulus packages") in terms of equipment, vaccine and expertise are rolled out on border regions, which in turn stimulates central governments. This success can be seen on most border regions; a natural momentum has been borne from this project which is now reaching as far north as the northern francophone countries of Africa.

As mentioned above, partnerships/collaborations are critical to success, as they heighten the profile of the project, bring resources and political clout on a local level. Examples of partners/collaborators in the KZN project (Only key role players are mentioned):

a.  Welfare

i.  World Society for the Protection of Animals (WSPA)

ii.  Society for the Prevention of Cruelty to Animals (SPCA)

iii.  International Companion Animal Management (ICAM) Coalition

iv.  Animal Anti-Cruelty League

b.  Government

i.  Veterinary services

ii.  Health

iii.  Education

iv.  Local government

c.  c. International

i.  World Health Organization

ii.  World Animal Health Organization (OIE)

iii.  FAO

iv.  Bill and Melinda Gates foundation v. USDA

v.  CDC (US)

4.  Pilot projects - KZN success has grown out of a small demonstration project stimulating greater buy in. In the same way, the project has sought to expand its influence by initiating projects on border regions. This has been an effective strategy, as wherever the project has influenced a neighbor, through vaccine donations campaign support or primary health care clinics, etc., the mantle has been taken up by that group and moved forward. It is common for the world to arrive in an African country and throw money at the central government, which either disappears, or there is a lack of drive to accomplish the objectives. The KZN project aims to inspire, equip and train local technical staff on its borders, the success of which will inspire expansion in that country or province. KZN has now been involved in various ways with all its neighboring countries and provinces and has been part of training programs that have extended across the whole continent.

Conclusion

Although canine rabies has been eliminated in many parts of the world, Africa is still a continent that faces major challenges, in initiating sustainable, effective control strategies. Each country is unique and the factors needed for success will be different. The KZN model is not a "how to vaccinate in your country model," but is a model of the processes of evaluation, research and innovation that can be universally applied in developing the necessary strategies for each unique situation. The expansion and natural momentum of this project across Africa has been unprecedented, and expanding from central points of success could well be the solution in Africa, as "success inspires expansion."

References

1.  Markotter W, Coertse J, le Roux K, et al. Utility of forensic detection of rabies virus in decomposed exhumed dog carcasses. BMC Vet Res. 2013.

2.  Nel L, le Roux K, Atlas R. Meeting the rabies control challenge in South Africa. Microbe. 2009;4(2).

3.  Le Roux K. Role and influence of government control programs on rabies in KwaZulu-Natal. In: Southern and Eastern African Rabies Group meeting; 2012.

4.  Shwiff S, Hatch B, Anderson A, et al. Towards canine rabies elimination in KwaZulu-Natal, South Africa: Assessment of health economic data. USDA. 2014. Pending publication.

5.  Mollentze N, Nel L, Townsend S, et al. A Bayesian approach for inferring the dynamics of partially observed endemic infectious diseases from space-time-genetic data. 4INRA, UR546 Biostatistics and Spatial Processes, 84914 Avignon CEDEX 9, France. 2013.

6.  Hergert M, le Roux K, Nel L. Factors associated with the rabies vaccination status of dogs in KwaZulu-Natal, South Africa. Zoonosis Public Health. 2014.

7.  Markotter W, York D, Sabeta C, et al. Evaluation of a rapid immunodiagnostic test kit for detection of African lyssaviruses from brain material. Onderstepoort J Vet Res. 2009.

8.  Mollentze N, Weyer J, Markotter W, le Roux K, Nel L. Dog rabies in southern Africa: regional surveillance and phylogeographical analyses are an important component of control and elimination strategies. New York, NY: Springer Science+Business Media; 2013.