Vaccinate-assess-move method of mass canine rabies vaccination utilising mobile technology data collection in Ranchi, India

Elimination of human rabies in Goa, India through an integrated One Health approach

Dog-mediated rabies kills tens of thousands of people each year in India, representing one third of the estimated global rabies burden. Whilst the World Health Organization (WHO), World Organization for Animal Health (OIE) and the Food and Agriculture Organization of the United Nations (FAO) have set a target for global dog-mediated human rabies elimination by 2030, examples of large-scale dog vaccination programs demonstrating elimination remain limited in Africa and Asia. We describe the development of a data-driven rabies elimination program from 2013 to 2019 in Goa State, India, culminating in human rabies elimination and a 92% reduction in monthly canine rabies cases. Smartphone technology enabled systematic spatial direction of remote teams to vaccinate over 95,000 dogs at 70% vaccination coverage, and rabies education teams to reach 150,000 children annually. An estimated 2249 disability-adjusted life years (DALYs) were averted over the program period at 526 USD per DALY, making the intervention 'very cost-effective' by WHO definitions. This One Health program demonstrates that human rabies elimination is achievable at the state level in India.

Scaling-up the delivery of dog vaccination campaigns against rabies in Tanzania

An increasing number of countries are committing to meet the global target to eliminate human deaths from dog-mediated rabies by 2030. Mass dog vaccination is central to this strategy. To interrupt rabies transmission from dogs to humans, the World Health Organization recommends that vaccination campaigns should be carried out every year in all dog-owning communities vaccinating 70% of their susceptible dogs. Monitoring and evaluation of dog vaccination campaigns are needed to measure progress towards elimination. In this study, we measured the delivery performance of large-scale vaccination campaigns implemented in 25 districts in south-east Tanzania from 2010 until 2017. We used regression modelling to infer the factors associated with, and potentially influencing the successful delivery of vaccination campaigns. During 2010–2017, five rounds of vaccination campaigns were carried out, vaccinating in total 349,513 dogs in 2,066 administrative vaccination units (rural villages or urban wards). Progressively more dogs were vaccinated over the successive campaigns. The campaigns did not reach all vaccination units each year, with only 16–28% of districts achieving 100% campaign completeness (where all units were vaccinated). During 2013–2017 when vaccination coverage was monitored, approximately 20% of vaccination units achieved the recommended 70% coverage, with average coverage around 50%. Campaigns were also not completed at annual intervals, with the longest interval between campaigns being 27 months. Our analysis revealed that districts with higher budgets generally achieved higher completeness, with a twofold difference in district budget increasing the odds of a vaccination unit being reached by a campaign by slightly more than twofold (OR: 2.29; 95% CI: 1.69–3.09). However, higher budgets did not necessarily result in higher coverage within vaccination units that were reached. We recommend national programs regularly monitor and evaluate the performance of their vaccination campaigns, so as to identify factors hindering their effective delivery and to guide remedial action.

Globally there are approximately 59,000 annual human rabies deaths, with more than 99% of these resulting from dog-mediated rabies. Mass dog vaccination is known to be the cornerstone of effective control of dog rabies. Empirical and theoretical evidence shows that annual vaccination campaigns need to achieve 70% coverage of the susceptible dog population to interrupt transmission and ensure the dog population is protected until the next campaign. Recently, international organizations announced their commitment to reaching the global target of zero human deaths from dog-mediated rabies by 2030. Scaling-up of vaccinations is now underway in more than 100 rabies-endemic countries. However, there are operational and logistical challenges associated with scaling-up these operations in different geographical and cultural settings. This study monitored and evaluated the performance large-scale vaccinations in Tanzania. We found that vaccinations were not implemented in all villages, which resulted in coverage gaps. Additionally, vaccinations were not implemented annually and, as a result, coverage dropped below the critical vaccination threshold. We conclude that there is a need to improve the delivery of dog vaccinations for achieving the global target of zero dog-mediated human rabies deaths by 2030.

Review of Oral Rabies Vaccination of Dogs and Its Application in India

Oral rabies vaccines (ORVs) have been in use to successfully control rabies in wildlife since 1978 across Europe and the USA. This review focuses on the potential and need for the use of ORVs in free-roaming dogs to control dog-transmitted rabies in India. Iterative work to improve ORVs over the past four decades has resulted in vaccines that have high safety profiles whilst generating a consistent protective immune response to the rabies virus. The available evidence for safety and efficacy of modern ORVs in dogs and the broad and outspoken support from prominent global public health institutions for their use provides confidence to national authorities considering their use in rabies-endemic regions. India is estimated to have the largest rabies burden of any country and, whilst considerable progress has been made to increase access to human rabies prophylaxis, examples of high-output mass dog vaccination campaigns to eliminate the virus at the source remain limited. Efficiently accessing a large proportion of the dog population through parenteral methods is a considerable challenge due to the large, evasive stray dog population in many settings. Existing parenteral approaches require large skilled dog-catching teams to reach these dogs, which present financial, operational and logistical limitations to achieve 70% dog vaccination coverage in urban settings in a short duration. ORV presents the potential to accelerate the development of approaches to eliminate rabies across large areas of the South Asia region. Here we review the use of ORVs in wildlife and dogs, with specific consideration of the India setting. We also present the results of a risk analysis for a hypothetical campaign using ORV for the vaccination of dogs in an Indian state.

Free-roaming dog population dynamics in Ranchi, India

Rabies causes approximately 20,000 human deaths in India each year. Nearly all of these occur following dog bites. Large-scale, high-coverage dog rabies vaccination campaigns are the cornerstone of rabies elimination strategies in both human and dog populations, although this is particularly challenging to achieve in India as a large proportion of the dog population are free-roaming and unowned. Further, little is known about free-roaming dog ecology in India which makes defining optimum vaccination strategies difficult. In this study, data collected using a mobile phone application during three annual mass vaccination and neutering (surgical sterilisation of both males and females) campaigns of free-roaming dogs in Ranchi, India (during which a total of 43,847 vaccinations, 26,213 neuter surgeries and 28,172 re-sight observations were made) were interrogated, using two novel approaches to estimate the proportion of neutered dogs that were lost from the city (assumed due to mortality or migration) between campaign years. Analysis revealed high losses of neutered dogs each year, ranging from 25.3% (28.2-22.8) to 55.8% (57.0-54.6). We also estimated that the total population declined by 12.58% (9.89-15.03) over the three-year period. This demonstrates that there is a high turnover of free-roaming dogs and that despite neutering a large number of dogs in an annual sterilisation campaign, the decline in population size was modest over a three-year time period. These findings have significant implications for the planning of rabies vaccination campaigns and population management programmes as well as highlighting the need for further research into the demographics of free-roaming, unowned dogs in India.

Investigation of protective level of rabies antibodies in vaccinated dogs in Chennai, India

BACKGROUND

Rabies is still endemic in India causing an estimated 20,000 human deaths a year. Free roaming dogs and unvaccinated owned dogs play a major role in the maintenance of the disease. Dog vaccination is the most crucial aspect of rabies prevention and control strategies; therefore vaccine immunogenicity and longevity are important determinants of the efficiency of rabies control efforts.

METHODS

In this study at Madras Veterinary College, India, a total of 297 serum samples were collected from owned dogs that were vaccinated against rabies. Data regarding age, gender, breed, neuter status and last date of vaccination were collected at the time of blood collection. The level of rabies virus neutralising antibodies in the sera of these dogs was measured through rapid focus fluorescence inhibition test. The factors associated with protective level of rabies antibodies in vaccinated dogs were investigated through multivariable regression analysis.

RESULTS

This cross-sectional investigation shows that only 40% (119/297) of the all the dogs in the study showed presence of protective level of anti-rabies antibodies, and 40% (72/180) of the dogs vaccinated within the last year showed presence of protective levels of antibodies causing concern about rabies vaccine quality and its impact on rabies control. The study also shows that older and neutered dogs are more likely to have protective titre among vaccinated dogs, while non-descript breed dogs are less likely to have a protective titre compared to pure breeds.

CONCLUSION

In this study 60% (108/180) of young prima dogs and adult dogs did not show protective levels of antibodies within the year of last rabies vaccination, although they had previous vaccination history. This high percentage of apparent non-responders is a cause of concern of administration, distribution, storage, potency and quality management of vaccines in India.

Every Dog Has Its Data: Evaluation of a Technology-Aided Canine Rabies Vaccination Campaign to Implement a Microplanning Approach

Background: Robust dog vaccination coverage is the primary way to eliminate canine rabies. Haiti conducts annual canine mass vaccination campaigns, but still has the most human deaths in the Latin American and Caribbean region. We conducted an evaluation of dog vaccination methods in Haiti to determine if more intensive, data-driven vaccination methods, using smartphones for data reporting and geo-communication, could increase vaccination coverage to a level capable of disrupting rabies virus transmission. Methods: Two cities were designated into "Traditional" and "Technology-aided" vaccination areas. Traditional areas utilized historical methods of vaccination staff management, whereas Technology-aided areas used smartphone-supported spatial coordination and management of vaccination teams. Smartphones enabled real time two-way geo-communication between campaign managers and vaccinators. Campaign managers provided geographic instruction to vaccinators by assigning mapped daily vaccination boundaries displayed on phone handsets, whilst vaccinators uploaded spatial data of dogs vaccinated for review by the campaign manager to inform assignment of subsequent vaccination zones. The methods were evaluated for vaccination effort, coverage, and cost. Results: A total of 11,420 dogs were vaccinated during the 14-day campaign. The technology-aided approach achieved 80% estimated vaccination coverage as compared to 44% in traditional areas. Daily vaccination rate was higher in Traditional areas (41.7 vaccinations per team-day) compared to in technology-aided areas (26.8) but resulted in significantly lower vaccination coverages. The cost per dog vaccinated increased exponentially with the associated vaccination coverage, with a cost of $1.86 to achieve 25%, $2.51 for 50% coverage, and $3.19 for 70% coverage. Conclusions: Traditional vaccination methods failed to achieve sufficiently high vaccination coverages needed to interrupt sustained rabies virus transmission, whilst the technology-aided approach increased coverage above this critical threshold. Over successive campaigns, this difference is likely to represent the success or failure of the intervention in eliminating the rabies virus. Technology-aided vaccination should be considered in resource limited settings where rabies has not been controlled by Traditional vaccination methods. The use of technology to direct health care workers based on near-real-time spatial data from the field has myriad potential applications in other vaccination and public health initiatives.

Human rabies: prospects for elimination

Almost half of all countries in the world are effectively free of human deaths from dog-mediated rabies. But the disease still affects people in low- and middle-income countries, especially the rural poor, and children. Successful regional elimination of human rabies is attributable to advances in significant and sustained investment in dog vaccination, post-exposure vaccination and surveillance, illustrated by productive efforts to reduce human rabies in Latin America over the last 35 years. Nonetheless, countries still facing endemic rabies face significant barriers to elimination. Using the 2017 Global Strategic Plan to end human rabies deaths from dog-mediated rabies by 2030 as a reference point and an organizing framework, we assess progress toward global rabies elimination by examining the characteristics of successful regional control efforts and barriers to elimination. Although substantive barriers exist for countries where rabies remains endemic, advances in knowledge, technology, institutions, and economics provide a basis for optimism.

Using data-driven approaches to improve delivery of animal health care interventions for public health

Rabies is arguably the exemplar of the One Health Agenda in which preventative health care in one species can improve health of other species. Interrogation of large epidemiology datasets offers the potential to deliver health care initiatives in a more efficient and cost-effective manner. However, real-life examples demonstrating this potential are limited. Here, we report a real-time, data-driven approach to improve cost effectiveness of dog vaccination campaigns in urban sub-Saharan African settings, which eliminates the need of expensive door-to-door vaccination by replacing them with strategically positioned fixed and roaming static points (SPs). This approach has the potential to act as a template for future successful and sustainable urban SP-only dog vaccination campaigns.

Rabies kills ∼60,000 people per year. Annual vaccination of at least 70% of dogs has been shown to eliminate rabies in both human and canine populations. However, delivery of large-scale mass dog vaccination campaigns remains a challenge in many rabies-endemic countries. In sub-Saharan Africa, where the vast majority of dogs are owned, mass vaccination campaigns have typically depended on a combination of static point (SP) and door-to-door (D2D) approaches since SP-only campaigns often fail to achieve 70% vaccination coverage. However, D2D approaches are expensive, labor-intensive, and logistically challenging, raising the need to develop approaches that increase attendance at SPs. Here, we report a real-time, data-driven approach to improve efficiency of an urban dog vaccination campaign. Historically, we vaccinated ∼35,000 dogs in Blantyre city, Malawi, every year over a 20-d period each year using combined fixed SP (FSP) and D2D approaches. To enhance cost effectiveness, we used our historical vaccination dataset to define the barriers to FSP attendance. Guided by these insights, we redesigned our vaccination campaign by increasing the number of FSPs and eliminating the expensive and labor-intensive D2D component. Combined with roaming SPs, whose locations were defined through the real-time analysis of vaccination coverage data, this approach resulted in the vaccination of near-identical numbers of dogs in only 11 d. This approach has the potential to act as a template for successful and sustainable future urban SP-only dog vaccination campaigns.

Role of Oral Rabies Vaccines in the Elimination of Dog-Mediated Human Rabies Deaths

Domestic dogs are responsible for nearly all the »59,000 global human rabies deaths that occur annually. Numerous control measures have been successful at eliminating dog-mediated human rabies deaths in upper-income countries, including dog population management, parenteral dog vaccination programs, access to human rabies vaccines, and education programs for bite prevention and wound treatment. Implementing these techniques in resource-poor settings can be challenging; perhaps the greatest challenge is maintaining adequate herd immunity in free-roaming dog populations. Oral rabies vaccines have been a cornerstone in rabies virus elimination from wildlife populations; however, oral vaccines have never been effectively used to control dog-mediated rabies. Here, we convey the perspectives of the World Organisation for Animal Health Rabies Reference Laboratory Directors, the World Organisation for Animal Health expert committee on dog rabies control, and World Health Organization regarding the role of oral vaccines for dogs. We also issue recommendations for overcoming hesitations to expedited field use of appropriate oral vaccines.

Lessons Learned and Paths Forward for Rabies Dog Vaccination in Madagascar: A Case Study of Pilot Vaccination Campaigns in Moramanga District

Canine rabies causes an estimated 60,000 human deaths per year, but these deaths are preventable through post-exposure prophylaxis of people and vaccination of domestic dogs. Dog vaccination campaigns targeting 70% of the population are effective at interrupting transmission. Here, we report on lessons learned during pilot dog vaccination campaigns in the Moramanga District of Madagascar. We compare two different vaccination strategies: a volunteer-driven effort to vaccinate dogs in two communes using static point vaccination and continuous vaccination as part of routine veterinary services. We used dog age data from the campaigns to estimate key demographic parameters and to simulate different vaccination strategies. Overall, we found that dog vaccination was feasible and that most dogs were accessible to vaccination. The static-point campaign achieved higher coverage but required more resources and had a limited geographic scope compared to the continuous delivery campaign. Our modeling results suggest that targeting puppies through community-based vaccination efforts could improve coverage. We found that mass dog vaccination is feasible and can achieve high coverage in Madagascar; however, context-specific strategies and an investment in dog vaccination as a public good will be required to move the country towards elimination.

Feasibility and Effectiveness Studies with Oral Vaccination of Free-Roaming Dogs against Rabies in Thailand

(1) Background: Thailand has made significant progress in reducing the number of human and animal rabies cases. However, control and elimination of the last remaining pockets of dog-mediated rabies have shown to be burdensome, predominantly as a result of the large numbers of free-roaming dogs without an owner that cannot be restrained without special efforts and therefore remain unvaccinated. To reach these dogs, the feasibility, and benefits of oral rabies vaccination (ORV) as a complementary tool has been examined under field conditions. (2) Methods: ORV of dogs was tested in five study areas of four provinces in Thailand. In these areas, sites with free-roaming dogs were identified with the support of local municipal workers and dog caretakers. ORV teams visited each of five study areas and distributed rabies vaccine (SPBN GASGAS) in three bait formats that were offered to the dogs using a hand-out and retrieval model. The three bait types tested included: egg-flavored baits, egg-flavored baits pasted with commercially available cat liquid snack, and boiled-intestine baits. A dog offered a vaccine bait was considered vaccinated when the discarded sachet was perforated or if a dog chewed vaccine bait at least 5 times before it swallowed the bait, including the sachet. (3) Results: A total of 2444 free-roaming dogs considered inaccessible for parenteral vaccination were identified at 338 sites. As not all dogs were approachable, 79.0% were offered a bait; of these dogs, 91.6% accepted the bait and subsequently 83.0% were considered successfully vaccinated. (4) Conclusion: Overall, 65.6% of the free-roaming dogs at these sites were successfully vaccinated by the oral route. Such a significant increase of the vaccination coverage of the free-roaming dog population could interrupt the rabies transmission cycle and offers a unique opportunity to reach the goal to eliminate dog-mediated human rabies in Thailand by 2030.

Timing of reproduction and association with environmental factors in female free-roaming dogs in southern India

Annual peaks in reproductive activity have been identified in multiple domestic dog populations. However, there is little evidence to describe how these peaks may be associated with environmental factors such as daylength, which plays a well-established role in breeding patterns of seasonally-reproductive species. Data were collected 2016-2020 during 7,743 and 4,681 neuter surgeries on adult female unowned free-roaming dogs in veterinary clinics in Goa and Tamil Nadu respectively. Temperature, precipitation, relative humidity, and daylength data were gathered for time periods preceding the neuter surgery that may have influenced the likelihood of pregnancy (potential influence periods). A multivariable generalised additive model was used to assess the relationship between these factors and pregnancy. The prevalence of pregnancy varied by month in both locations indicating seasonality of reproduction in these groups. The annual pattern was more distinct in Goa with a peak in pregnancies between September and December. In Goa, decreasing daylength was associated with a higher probability of pregnancy (p = 0.040). Decreasing temperature was associated with decreasing probability of pregnancy in the Nilgiris (p = 0.034). Bitches had a median of 6 foetuses, with no evidence of seasonal variation. Environmental factors were associated with patterns of pregnancy in free-roaming dogs, however statistically-significant factors varied by geographical location. Establishing local seasonal patterns of breeding in free-roaming dogs and assessing their relationship with environmental influences is recommended to facilitate effective and efficient population management strategies, which aim to reduce conflict between human and free-roaming dog populations.

Application of the GARC Data Logger-a custom-developed data collection device-to capture and monitor mass dog vaccination campaigns in Namibia

Domestic dogs are responsible for 99% of all cases of human rabies and thus, mass dog vaccination has been demonstrated to be the most effective approach towards the elimination of dog-mediated human rabies. Namibia demonstrated the feasibility of this approach by applying government-led strategic rabies vaccination campaigns to reduce both human and dog rabies incidences in the Northern Communal Areas of Namibia since 2016. The lessons learnt using paper-based form for data capturing and management of mass dog vaccination campaign during the pilot and roll out phase of the project (2016–2018) led to the implementation of a simple and accurate data collection tool in the second phase (2019–2022) of the rabies elimination program. In this paper, we describe the implementation of such custom-developed vaccination tracking device, i.e. the Global Alliance for Rabies Control (GARC) Data Logger (GDL), and the integration of the collected data into a website-based rabies surveillance system (Rabies Epidemiological Bulletin—REB) during 2019 and 2020 campaigns. A total of 10,037 dogs and 520 cats were vaccinated during the 2019 campaign and 13,219 dogs and 1,044 cats during the 2020 campaign. The vaccination data were recorded with the GDL and visualized via REB. Subsequent GIS-analysis using gridded population data revealed a suboptimal vaccination coverage in the great majority of grid cells (82%) with a vaccination coverage below 50%. Spatial regression analysis identified the number of schools, estimated human density, and adult dog population were associated with the vaccination performance. However, there was an inverse correlation to human densities. Nonetheless, the use of the GDL improved data capturing and monitoring capacity of the campaign, enabling the Namibian government to improve strategies for the vaccination of at-risk areas towards achieving adequate vaccination coverage which would effectively break the transmission of rabies.

We used a custom-developed vaccination tracking device—the Global Alliance for Rabies Control (GARC) Data Logger—to capture dog rabies vaccination data during the 2019 and 2020 mass vaccination campaign in the Northern Communal Areas of Namibia, and then integrated the collected data into the web-based Rabies Epidemiological Bulletin, a rabies-specific disease surveillance platform for rabies-endemic countries. This approach allowed automatic collation, analysis and, visualization of data and drastically improved the data capturing and monitoring capacity of the Namibian government led campaign. Additionally, subsequent GIS analysis enabled a better estimation of vaccination coverage at a much higher spatial resolution, thus identifying areas where improvements in the vaccination strategy are needed to ensure long-term success of the project.

Multisectoral approach to achieve canine rabies controlled zone using Intervention Mapping: Preliminary results

BACKGROUND

Annually, in India, millions of dog bite cases occur; most of them are inflicted by a stray dog. There are over 25 million dogs in the country. The rate of stray dog vaccination is suboptimal in India. This study aims to develop an intervention strategy, using Intervention Mapping framework, tailored for the target community to achieve canine rabies controlled zone.

METHODOLOGY

This is an exploratory, cross-sectional study conducted at a tertiary care Medical Institute at Jodhpur, Rajasthan, India, from 2018-2019. The semi-structured, In-Depth Discussion was conducted with a multidisciplinary planning group comprising of members from veterinary, health, and administrative sectors. The In-Depth Discussion focused on knowledge regarding complete stray dog vaccination schedule, self-efficacy (to prevent dog bites), challenges, and barriers faced by residents to achieve canine rabies controlled zone. Further, discussion with veterinary stakeholders focused on challenges faced for rigorous implementation of stray dog vaccination and sterilization.

RESULTS

In-Depth Discussion revealed the following challenges: Lack of participation by the study population for canine vaccination, incomplete knowledge about annual canine vaccination schedule, lack of understanding of dog gestures, lack of infrastructure and resources at veterinary hospitals. The majority of the dogs in the study area were stray dogs that were partially or non-vaccinated and non-sterilized. An intersectoral collaboration was achieved between the community members, veterinary stakeholders both private and Non-Governmental organisations, and heath sector. Following which 35 (76.0%) stray dogs were vaccinated, and 17 (35.4%) were sterilized with community support. Burden of dog bite cases also decreased. The stray dog density map was prepared, and community engagement activity on dog gestures was conducted.

CONCLUSION

The present study demonstrates the feasibility of achieving canine rabies controlled zone. When implemented in a phase-wise manner across all Medical and Residential complex, this strategy would ensure achieving canine rabies controlled zone through multi-stakeholder engagement.

Portable Rabies Virus Sequencing in Canine Rabies Endemic Countries Using the Oxford Nanopore MinION

As countries with endemic canine rabies progress towards elimination by 2030, it will become necessary to employ techniques to help plan, monitor, and confirm canine rabies elimination. Sequencing can provide critical information to inform control and vaccination strategies by identifying genetically distinct virus variants that may have different host reservoir species or geographic distributions. However, many rabies testing laboratories lack the resources or expertise for sequencing, especially in remote or rural areas where human rabies deaths are highest. We developed a low-cost, high throughput rabies virus sequencing method using the Oxford Nanopore MinION portable sequencer. A total of 259 sequences were generated from diverse rabies virus isolates in public health laboratories lacking rabies virus sequencing capacity in Guatemala, India, Kenya, and Vietnam. Phylogenetic analysis provided valuable insight into rabies virus diversity and distribution in these countries and identified a new rabies virus lineage in Kenya, the first published canine rabies virus sequence from Guatemala, evidence of rabies spread across an international border in Vietnam, and importation of a rabid dog into a state working to become rabies-free in India. Taken together, our evaluation highlights the MinION's potential for low-cost, high volume sequencing of pathogens in locations with limited resources.

Modelling the challenges of managing free-ranging dog populations

Free-ranging domestic dogs (FRD) are not only vectors of zoonoses of public health concern, but also pose direct threats to humans, livestock, and endangered wildlife. Many developing countries have struggled to control FRD, despite using both lethal and non-lethal methods. India has amongst the highest FRD populations globally and the highest incidences of dog-mediated human rabies, but only deploys Catch-Neuter-Vaccinate-Release (CNVR) for FRD control as a humane alternative to lethal methods, without evidence of it working successfully. Here, we use an agent-based dog population dynamics model to examine the time, effort, financial resources, and conditions needed to successfully control FRD in a typical urban setting. We simulate several scenarios, from an "ideal world" closed population with easily accessible dogs, to a more realistic open population with heterogeneity in catchability of dogs. In only one "best-case" scenario, CNVR resulted in a significant and lasting reduction in FRD, but with vaccination rates peaking only at 35%, which is half the WHO-recommended coverage. The customisable and portable modelling tool that we have developed allows managers to simulate real world processes and understand the expected effort needed to reduce regional dog populations, and assess methods for achieving effective anti-rabies vaccination coverage.

Development and Evaluation of a Mobile App for Guiding Rabies Prophylaxis among Health-Care Professionals in India

Background:

The majority of dog-mediated human rabies as well as rabies-related human deaths are reported from low-income countries of Asia and Africa where access to appropriate postexposure prophylaxis is limited or nonexistent. At present, India is second in position after China in terms of having the highest number of mobile phone users surpassing the United States.

Objective:

In this context, we decided to develop a user-friendly, technically less demanding, mobile App for health-care professionals, which is accessible even without Internet facility.

Methodology:

The current study was conducted in four phases, namely assemblage of informational contents on rabies, development of the software, assessment of the reliability of the questionnaire tool and evaluation of the mobile App. The evaluation of App was conducted among physicians and nursing staffs in a tertiary care referral hospital.

Results:

The information content was prepared referring national and international guidelines. The App was designed with Hypertext Markup Language 5 for presentation on the World Wide Web and was coined the name of “RabiApp.” This is a hybrid App of the native App and web App, allowing the information to be stored in the local server. The mobile App was assessed using a validated and reliable questionnaire after confirming the internal consistency by means of Cronbach's alpha. The overall Cronbach's alpha for the main scale was 0.788, which was a respectable score.

Conclusion:

The developed App is a user-friendly, easily accessible platform, which can help health-care professionals in making decisions regarding rabies wound management, treatment, and prophylaxis.

Evaluating the role of surgical sterilisation in canine rabies control: A systematic review of impact and outcomes

Current recommendations for the elimination of canine-mediated human rabies focus on mass dog vaccination as the most feasible and cost-effective strategy. However, attempts to control rabies are often combined with canine surgical sterilisation programmes. The added value of sterilisation is widely debated. A systematic review was undertaken to compare the outcomes and impact of vaccination and sterilisation programmes with vaccination only programmes. A systematic search of three electronic databases (CAB Abstracts, Medline and Global Health) and grey literature was performed. From 8696 abstracts found, 5554 unique studies were identified, and 16 studies met the inclusion criteria. Eight described vaccination only programmes and eight described vaccination and sterilisation programmes. Indicators of impact measured were dog bites and/or doses of post-exposure prophylaxis administered; numbers of dog and/or human rabies cases; dog population demographic changes; changes in health and welfare of dogs, and indicators related to human behaviour change. The studies were contextually very diverse, programmes being implemented were complex, and there was variation in measurement and reporting of key indicators. Therefore, it was difficult to compare the two types of intervention, and impossible to make an evaluation of the role of sterilisation, using this evidence. Given the large number of vaccination and sterilisation programmes conducted globally, the lack of studies available for review highlights a gap in data collection or reporting, essential for impact assessment. There are several knowledge gaps concerning the impact of the sterilisation component alone, as well as subsequent effects on rabies transmission and control. Prospective studies comparing the outcomes and impact of the two interventions would be required in order to establish any additional contribution of sterilisation, as well as the underlying mechanisms driving any changes. In the absence of such evidence, the priority for rabies control objectives should be implementation of mass vaccination, as currently recommended by the World Health Organisation.

Zero human deaths from dog-mediated rabies by 2030: perspectives from quantitative and mathematical modelling

Dog-mediated rabies continues to kill tens of thousands of people every year in low- and middle-income countries despite being an entirely vaccine-preventable disease. WHO and partners have launched a global campaign to reach zero human deaths from dog-mediated rabies by 2030. The primary tools for reaching this target are mass dog vaccination to interrupt transmission in domestic dog populations that maintain infection, appropriate post-exposure prophylaxis (PEP) for rabies-exposed persons to prevent the fatal onset of disease, together with education to support their effective uptake. Models have been developed to assess the feasibility, impact and cost-effectiveness of these measures. From these models, we argue that the 2030 target of zero human rabies deaths is achievable, but will require concerted effort, engagement and investment. A proposed Gavi investment in human rabies vaccines has potential to drive progress towards the 2030 target; however, concomitant investment is needed to scale up mass dog vaccination or this target will be missed. Predicted economic benefits of mass dog vaccination vary according to national PEP provisioning and healthcare access. Integrated Bite Case Management can enhance surveillance and rationalize PEP use, but needs adapting to and integrating within local health systems and international reporting systems to improve PEP accountability, monitor impacts and support verification of disease freedom. Modelling approaches need refining to project realistic and geographically specific timelines for achieving targets. Model iterations informed by data on the implementation of interventions can be used to evaluate progress and guide future strategies. Critically such models are needed to advocate for investment, since the greatest risk to the ‘Zero by 30’ strategy is the limited long-term cross-sectoral or targeted financing to support countries to deliver and sustain mass dog vaccination.

Costs and effectiveness of alternative dog vaccination strategies to improve dog population coverage in rural and urban settings during a rabies outbreak

Dog-rabies elimination programs have typically relied upon parenteral vaccination at central-point locations; however, dog-ownership practices, accessibility to hard-to-reach sub-populations, resource limitations, and logistics may impact a country's ability to reach the 70% coverage goal recommended by the World Organization for Animal Health (OIE) and World Health Organization (WHO). Here we report the cost-effectiveness of different dog-vaccination strategies during a dog-rabies outbreak in urban and peri-urban sections of Croix-des-Bouquets commune of the West Department, Haiti, in 2016. Three strategies, mobile static point (MSP), mobile static point with capture-vaccinate-release (MSP + CVR), and door-to-door vaccination with oral vaccination (DDV + ORV), were applied at five randomly assigned sites and assessed for free-roaming dog vaccination coverage and total population coverage. A total of 7065 dogs were vaccinated against rabies during the vaccination campaign. Overall, free-roaming dog vaccination coverage was estimated at 52% (47%-56%) for MSP, 53% (47%-60%) for DDV + ORV, and 65% (61%-69%) for MSP + CVR (differences with MSP and DDV + ORV significant at p < 0.01). Total dog vaccination coverage was 33% (95% CI: 26%-43%) for MSP, 49% (95% CI: 40%-61%) for MSP + CVR and 78% (77%-80%) for DDV + ORV (differences significant at p < 0.001). Overall, the least expensive campaign was MSP, with an estimated cost of about $2039 per day ($4078 total), and the most expensive was DDV + ORV with a cost of $3246 per day ($6492 total). Despite the relative high cost of an ORV bait, combining DDV and ORV was the most cost-effective strategy in our study ($1.97 per vaccinated dog), largely due to increased efficiency of the vaccinators to target less accessible dogs. Costs per vaccinated dog were $2.20 for MSP and $2.28 for MSP + CVR. We hope the results from this study will support the design and implementation of effective dog vaccination campaigns to achieve the goal of eliminating dog-mediated human rabies deaths by 2030.

Reviewing Solutions of Scale for Canine Rabies Elimination in India

Canine rabies elimination can be achieved through mass vaccination of the dog population, as advocated by the WHO, OIE and FAO under the 'United Against Rabies' initiative. Many countries in which canine rabies is endemic are exploring methods to access dogs for vaccination, campaign structures and approaches to resource mobilization. Reviewing aspects that fostered success in rabies elimination campaigns elsewhere, as well as examples of largescale resource mobilization, such as that seen in the global initiative to eliminate poliomyelitis, may help to guide the planning of sustainable, scalable methods for mass dog vaccination. Elimination of rabies from the majority of Latin America took over 30 years, with years of operational trial and error before a particular approach gained the broad support of decision makers, governments and funders to enable widespread implementation. The endeavour to eliminate polio now enters its final stages; however, there are many transferrable lessons to adopt from the past 32 years of global scale-up. Additionally, there is a need to support operational research, which explores the practicalities of mass dog vaccination roll-out and what are likely to be feasible solutions at scale. This article reviews the processes that supported the scale-up of these interventions, discusses pragmatic considerations of campaign duration and work-force size and finally provides an examples hypothetical resource requirements for implementing mass dog vaccination at scale in Indian cities, with a view to supporting the planning of pilot campaigns from which expanded efforts can grow.

Zero human deaths from dog-mediated rabies by 2030: perspectives from quantitative and mathematical modelling

Dog-mediated rabies continues to kill tens of thousands of people every year in low- and middle-income countries despite being an entirely vaccine-preventable disease. WHO and partners have launched a global campaign to reach zero human deaths from dog-mediated rabies by 2030. The primary tools for reaching this target are mass dog vaccination to interrupt transmission in domestic dog populations that maintain infection, appropriate post-exposure prophylaxis (PEP) for rabies-exposed persons to prevent the fatal onset of disease, together with education to support their effective uptake. Models have been developed to assess the feasibility, impact and cost-effectiveness of these measures. From these models, we argue that the 2030 target of zero human rabies deaths is achievable, but will require concerted effort, engagement and investment. A proposed Gavi investment in human rabies vaccines has potential to drive progress towards the 2030 target; however, concomitant investment is needed to scale up mass dog vaccination or this target will be missed. Predicted economic benefits of mass dog vaccination vary according to national PEP provisioning and healthcare access. Integrated Bite Case Management can enhance surveillance and rationalize PEP use, but needs adapting to and integrating within local health systems and international reporting systems to improve PEP accountability, monitor impacts and support verification of disease freedom. Modelling approaches need refining to project realistic and geographically specific timelines for achieving targets. Model iterations informed by data on the implementation of interventions can be used to evaluate progress and guide future strategies. Critically such models are needed to advocate for investment, since the greatest risk to the 'Zero by 30' strategy is the limited long-term cross-sectoral or targeted financing to support countries to deliver and sustain mass dog vaccination.

Fighting Dog-Mediated Rabies in Namibia-Implementation of a Rabies Elimination Program in the Northern Communal Areas

The major part of the global burden of dog-mediated rabies falls on Africa and Asia, where still an estimated 60,000 people die of the disease annually. Like in many African countries, dog-mediated rabies is a major public health concern in Namibia, costing the country an estimated 242 human deaths during the past two decades, in particular in the Northern Communal Areas (NCAs). Consequently, under the “One Health” concept, the Namibian government adopted a National Rabies Control Strategy in 2015, which strives to contribute to the global goal of ending dog-mediated human rabies deaths by 2030. A key component of this strategy was the implementation a dog rabies elimination program in the NCAs in 2016, being designed as a stepwise regional rollout strategy by building on experience gained in a pilot project area. The area of implementation covers approximately 263,376 km² and 64 constituencies, with around 1.2 million inhabitants and estimated 93,000 dogs.

Development of a high number, high coverage dog rabies vaccination programme in Sri Lanka

BACKGROUND

Rabies is estimated to cause 59,000 deaths and economic losses of US$8.6 billion every year. Despite several years of rabies surveillance and awareness programmes, increased availability of post-exposure prophylaxis vaccinations and dog population control, the disease still remains prevalent in Sri Lanka. This study reports the roll-out of a high number, high coverage canine rabies vaccination campaign in Sri Lanka, providing estimates for the vaccination coverage achieved, analysing the local dog demographics, and identifying barriers of attendance to static vaccination clinics.

METHODS

A mass dog vaccination campaign was undertaken in Negombo, Sri Lanka. The campaign was composed of static point and door-to-door vaccination stages, with a final survey of vaccination coverage. A large volume of data on the distribution, health, and signalment of vaccinated dogs was collected through a mobile phone application. A logistic regression model was developed to investigate which socio-spatial and dog-related factors influenced attendance of owners to static vaccination points.

RESULTS

The campaign vaccinated over 7800 dogs achieving a vaccination coverage of 75.8%. A dog:human ratio of 1:17 was estimated. Most dogs were owned, and the dog population was mostly male, adult, and non-sterilized. Unawareness, unavailability and handling problems were the most common reasons given by owners to explain failure to attend a static vaccination point. The regression analysis showed that increasing distance to a static point, in addition to young age and poor health of the dog, were associated with a decrease in the likelihood of attendance to a static vaccination points.

CONCLUSION

This study demonstrates the feasibility of high number, high coverage vaccination campaigns in Sri Lanka. The information on dog ecology and barriers of attendance to static point vaccination clinics will facilitate development of future vaccination campaigns.

Utilising Group-Size and Home-Range Characteristics of Free-Roaming Dogs (FRD) to Guide Mass Vaccination Campaigns against Rabies in India

Adequate vaccination coverage of free roaming dogs (FRD) against canine rabies is not achieved primarily due to difficulties in administering parenteral vaccinations to this population. One factor associated with this difficulty is the tendency of FRD to form groups, which increases their aggressive behavior, resulting in a significant risk of dog-bites for the vaccinators. This study investigated factors that influenced FRD forming groups and their home-ranges, using data obtained from photographic capture-recapture/sight-resight surveys conducted in rural Shirsuphal (584 sightings) and urban Panchkula (3208 sightings), India. In the rural site, older dogs (OR 0.5, 95% CI 0.2-0.9, p = 0.03) and FRD sighted within 20 m of garbage sites (OR 0.6, 95% CI 0.4-0.9, p = 0.02) were less likely to be in groups. The number of dogs sighted with an FRD decreased with increased resight-probability of that dog (β= -1.0, p < 0.001). The rural FRD with smaller home-ranges were more likely to be sighted alone (OR 2.3, 95% CI 1.0-95, p = 0.04) than those with larger home-ranges. In the urban site, females (OR 1.3, 95% CI 1.1-1.5, p = 0.002) and older dogs (OR 1.5, 95% CI 1.1-2.1, p = 0.07) were more likely to be found in groups, and groups of dogs were more likely to be seen within 20 meters of garbage sites (OR 1.7, 95% CI 1.5-2.0, p < 0.001). The distribution of urban FRD sighted alone, in pairs, triads, and in packs of ≥4 dogs were not random in the administrative (p = 0.02), and the two industrial (p = 0.03 & 0.01) survey tracks of the urban site, implying stable groups. The resighting probability of a dog (β = 0.3, p < 0.0001) and presence of garbage within 20 m (β = 0.2, p < 0.0001) in the urban site increased the likelihood of sighting a FRD with other dogs. It is concluded that data on the resighting probability, presence of garbage points, and home-ranges can be utilised to guide the selection of parenteral or oral rabies vaccination to achieve a population vaccination coverage of 70% to break the transmission cycle of rabies virus in FRD in India.

A Novel Integrated and Labile eHealth System for Monitoring Dog Rabies Vaccination Campaigns

The elimination of canine rabies through the implementation of high coverage mass dog vaccination campaigns is a complex task, particularly in the resource-limited countries of the rabies endemic world. Here we demonstrated the feasibility of applying targeted rabies vaccination campaigns to deliver more impactful intervention campaigns in resource-limited settings using evidence and lessons learnt from other diseases. With the use of strategic rabies intervention programs, we demonstrate the noteworthy reduction of rabies cases in two very different African settings. The strategic intervention was most significantly aided by the use of a custom-developed vaccination tracking device (the Global Alliance for Rabies Control (GARC) Data Logger) and an integrated rabies surveillance system (the Rabies Epidemiological Bulletin). Our first case study, an island-wide strategic dog vaccination on Tanzania's Unguja island, reduced the incidence of rabies by 71% in the first 16 months of implementation. In the second case study, a similar approach was applied in the metropolitan capital city of Zimbabwe and the incidence of rabies declined by 13% during the first 13 months of implementation. The methodologies and results presented here suggest that, in resource-limited settings, an optimal approach towards the elimination of dog rabies would revolve around strategic interventions, subject to the use of appropriate planning, surveillance, and vaccination tools.

Development of a Non-Meat-Based, Mass Producible and Effective Bait for Oral Vaccination of Dogs against Rabies in Goa State, India

Introduction: To achieve the global goal of canine-mediated human rabies elimination by 2030 there is an urgent need to scale-up mass dog vaccination activities in regions with large dog populations that are difficult to access; a common situation in much of India. Oral rabies vaccination may enable the vaccination of free-roaming dogs that are inaccessible to parenteral vaccination, and is considered a promising complementary measure to parenteral mass dog vaccination campaigns. WHO and OIE have published detailed minimum requirements for rabies vaccines and baits to be used for this purpose, requiring that baits must not only be well-accepted by the target population but must also efficiently release the vaccine in the oral cavity. For oral rabies vaccination approaches to be successful, it is necessary to develop baits which have a high uptake by the target population, are culturally accepted and amenable to mass production. The aim of this study was to compare the interest and uptake rates of meat-based and an egg-based prototype bait constructs by free roaming dogs in Goa, India. Methods: Three teams randomly distributed two prototype baits; an egg-flavoured bait and a commercial meat dog food (gravy) flavoured bait. The outcomes of consumption were recorded and compared between baits and dog variables. Results: A total of 209 egg-bait and 195 gravy-bait distributions were recorded and analysed. No difference (p = 0.99) was found in the percentage of dogs interested in the baits when offered. However, significantly more dogs consumed the egg-bait than the gravy-bait; 77.5% versus 68.7% (p = 0.04). The release of the blue-dyed water inside the sachet in the oral cavity of the animals was significant higher in the dogs consuming an egg-bait compared to the gravy-bait (73.4% versus 56.7%, p = 0.001). Conclusions: The egg-based bait had a high uptake amongst free roaming dogs and also enabled efficient release of the vaccine in the oral cavity, whilst also avoiding culturally relevant materials of bovine or porcine meat products.

A comparison of population estimation techniques for individually unidentifiable free-roaming dogs

Background

Measuring the size of free roaming dog populations quickly and accurately is critical in the implementation of numerous preventive health and population control interventions. However, few studies have investigated the relative performance of population size assessment tools when applied to dogs. The aim of this study was to compare the commonly used mark-resight methodology with distance sampling methods, which are less resource intensive, to estimate free-roaming dog abundance in Goa, India.

Twenty-six working zones were surveyed along all roads twice by the same surveyor at the same time of day, following a vaccination campaign which included marking of vaccinated dogs with a coloured paint. The Chapman estimate was then used to evaluate the mark-resight abundance. Additionally, the number of dogs and perpendicular distance from the road for all dogs sighted was recorded. This was used to estimate dog density and abundance using distance sampling methods. The detection function was fitted based on goodness-of-fit and AIC.

Results

The Chapman abundance estimate for the entire study area was 5202 dogs (95%CI 4733.8–5671.0), and the distance sampling method abundance estimate was 5067 dogs (95%CI 4454.3–5764.2). For individual working zones, after taking other factors into account in a mixed effects model, the average distance sampling estimate was 35% higher (95%CI 20–53%) than the Chapman estimate. There was also evidence of a difference in estimates between surveyors of 21% (95%CI 7–37%) and between days (22% lower on day 2, 95%CI 8–38%) for individual working zones.

Conclusion

Our study demonstrated that the distance sampling estimates were comparable overall to the Chapman method of abundance estimation of free roaming dogs across the entire study region but there was noticeable variation between the two methods when individual zones were compared. Consequently, distance sampling methods may be suitable to enumerate dogs over large areas in a more time efficient manner than the widely used mark-resight approach.

Electronic supplementary material

The online version of this article (10.1186/s12917-019-1938-1) contains supplementary material, which is available to authorized users.

Implementation of high coverage mass rabies vaccination in rural Uganda using predominantly static point methodology

Despite successful eradication programmes in many regions, rabies remains responsible for approximately 60,000 human deaths annually, and no country in Africa is rabies-free. Dogs are the principal reservoir of the virus in Africa and the World Health Organisation recommends that at least 70% of the dog population be vaccinated in order to break the transmission cycle. Most attempts at mass rabies vaccinations in Africa have failed to vaccinate high numbers of dogs at a high coverage. Successful studies have often used a door-to-door (DTD) approach, which is logistically challenging and expensive compared to a static point (SP) approach. Mission Rabies has successfully implemented a combined SP and DTD method in cities in India and Malawi. This campaign used a combined methodology in rural Uganda, starting with a SP campaign, followed by a DTD campaign, and then subsequent transect surveys to assess vaccination coverage. This was facilitated by the use of a smartphone application which recorded all vaccinations and survey responses along with their Global Positioning System location. A total of 4172 dogs were vaccinated in 7 days, attaining an estimated 88.4% coverage. This campaign is of particular note as 95.9% of the vaccinations were performed at SPs. The human-to-dog ratio was 4.9 with a mean dogs per house of 1.2. Most dogs were owned (93.7%). This demonstrates that high-number, high-coverage vaccination is achievable in rural Uganda and provides data that may refine future campaign approaches.

Oral bait handout as a method to access roaming dogs for rabies vaccination in Goa, India: A proof of principle study

Rabies has profound public health, social and economic impacts on developing countries, with an estimated 59,000 annual human rabies deaths globally. Mass dog vaccination is effective at eliminating the disease but remains challenging to achieve in India due to the high proportion of roaming dogs that cannot be readily handled for parenteral vaccination. Two methods for the vaccination of dogs that could not be handled for injection were compared in Goa, India; the oral bait handout (OBH) method, where teams of two travelled by scooter offering dogs an empty oral bait construct, and the catch-vaccinate-release (CVR) method, where teams of seven travel by supply vehicle and use nets to catch dogs for parenteral vaccination. Both groups parenterally vaccinated any dogs that could be held for vaccination. The OBH method was more efficient on human resources, accessing 35 dogs per person per day, compared to 9 dogs per person per day through CVR. OBH accessed 80% of sighted dogs, compared to 63% by CVR teams, with OBH accessing a significantly higher proportion of inaccessible dogs in all land types. All staff reported that they believed OBH would be more successful in accessing dogs for vaccination. Fixed operational team cost of CVR was four times higher than OBH, at 127 USD per day, compared to 34 USD per day. Mean per dog vaccination cost of CVR was 2.53 USD, whilst OBH was 2.29 USD. Extrapolation to a two week India national campaign estimated that 1.1 million staff would be required using CVR, but 293,000 staff would be needed for OBH. OBH was operationally feasible, economical and effective at accessing the free roaming dog population. This study provides evidence for the continued expansion of research into the use of OBH as a supplementary activity to parenteral mass dog vaccination activities in India.

Risk assessment on rabies entry through hunting dog movement with semi-quantitative approach to Sumatera Island, Indonesia

Objective:

The objective of this study was to assess the risk of rabies entry through the movement of hunting dog from Garut District to Sumatera Island with a semi-quantitative approach.

Materials and Methods:

Rabies entry assessment used the standard risk analysis according to the World Organization for Animal Health, with a semi-quantitative approach referring to Australian Biosecurity. Risk estimation calculation used Microsoft Excel and probabilities were estimated using Monte Carlo stochastic simulation modeling with @Risk (Palisade Corporation).

Results:

Risk estimation were considered as “very low” with a 0.02 (90%; 0.01–0.03) probability. The probability of undetected rabies-infected dog during Veterinary Certificate issuance [node probability (NP4)] was considered as the highest, with “moderate” likelihood and 0.63 (90%; 0.51–0.75) of probability value. The number of dog movement to Sumatera reached 27,000 heads per year which 5,050 heads of them come from Garut District. There were 2 of 100 dogs from Garut District entered to Sumatera possibly infected by rabies. The five highest parameters most determinant of the risk were dog vaccination before transported (0.66), dog obtained from other District (0.41), vaccination program (0.32), serologically test (0.27), and history of vaccination (0.23).

Conclusion:

Risk estimation from assessing on rabies entry to Sumatera through hunting dogs movement from Garut District was considered “very low.” Risk mitigation is focused on the highest parameters that contribute the most to risk based on the results of the sensitivity analysis. Semi-quantitative likelihood evaluations can consider the volume of dog traffic which is an important issue in risk analysis which is not easy to get with a simpler qualitative approach.

Cost Savings of Using Updated Thai Red Cross Intradermal Regimen in a High-Throughput Anti-Rabies Clinic in New Delhi, India

Replacement of the Essen intramuscular (EIM) by the updated Thai Red Cross intradermal (UTRCID) regimen for rabies post-exposure prophylaxis (PEP), in high-throughput hospitals of India, has been advocated since 2006 thanks to its cost-effectiveness. However, several anti-rabies clinics in India and other parts of the world have not initiated this switchover of regimens because of the paucity of financial literature, generated in realistic settings, regarding the same. We calculated the procurement costs of various items required for providing rabies vaccinations via the EIM regimen and UTRCID regimen, on an annual basis, a year before and after the switchover. From a healthcare provider’s perspective, the cost of vaccination per patient was calculated to be 5.60 USD for the EIM regimen and 2.40 USD for the UTRCID regimen. The switchover to the UTRCID regimen from the EIM regimen reduced the financial burden of the rabies vaccination by almost 60%. Procurement of vaccine vials contributed to the majority of the cost (>94%) in both of the regimens. Procurement of syringes with fixed needles contributed negligibly (<6%) to the financial burden in both the regimens. A policy to progressively switch over to the UTRCID regimen from the EIM in all high-throughput anti-rabies centers of India would dramatically reduce the economic burden of running a successful anti-rabies program.

Priorities in applied research to ensure programmatic success in the global elimination of canine rabies

The elimination of human rabies mediated by dogs is attainable in concept, based upon current sensitive and specific diagnostic methods, existing safe and effective human and veterinary vaccines and a sound virological, pathological and epidemiological understanding of the disease. Globally, all developed countries achieved this goal. Regionally, major progress occurred throughout the Americas. However, less advancement is evident in Africa and Asia. Our objective was to concentrate upon those salient improvements to extant tools and methods over the next five years which could assist and simplify the task for both those developing countries that have already begun the process, as well as other localities in the earlier stages of consideration. We considered several categories of applied research which could be accomplished in the short term, based upon the available scientific evidence and recent recommendations from subject matter experts and key opinion leaders, focused upon perceived major limitations to prior program success. Areas of concentration included: laboratory-based surveillance, pathogen detection and characterization; human rabies prophylaxis; veterinary biologics; implementation of canine vaccination; and oral vaccination of free-ranging community dogs. Further real-time application in these core areas with proven techniques and technology would simplify attaining not only the global goal focused subtly upon human mortality, but the actual elimination of canine rabies as well.

Development of non-governmental organisation-academic partnership to tackle rabies in Africa and Asia

Rabies kills approximately 60,000 people each year, mainly in sub-Saharan Africa and Asia, of which 40% of victims are less than 15 years old. Once clinical signs develop, the disease is almost invariably fatal. Globally, rabies has been estimated to cause 3∙7 million disability-adjusted life years and $8∙6B in economic losses annually. The vast majority of human rabies cases are caused by bites from rabies-infected dogs. Despite this loss of human life and resultant economic and societal costs, rabies can be prevented in both humans and dogs by vaccination. This has been demonstrated in many countries, notably in Central and South America, where large-scale, high coverage mass dog vaccination programmes have dramatically reduced the incidence of rabies. Even in parts of Africa and Asia, projects have shown that rabies can be eliminated locally. Nevertheless, rabies remains an important cause of mortality in many sub-Saharan and Asian countries. The reasons why some countries have been able to effectively eliminate rabies whereas others have not are complex and often impossible to definitively identify; commonly cited explanations include political, economic, logistical and societal barriers.

One million dog vaccinations recorded on mHealth innovation used to direct teams in numerous rabies control campaigns

Background

Canine transmitted rabies kills an estimated 59,000 people annually, despite proven methods for elimination through mass dog vaccination. Challenges in directing and monitoring numerous remote vaccination teams across large geographic areas remain a significant barrier to the up-scaling of focal vaccination programmes to sub-national and national level. Smartphone technology (mHealth) is increasingly being used to enhance the coordination and efficiency of public health initiatives in developing countries, however examples of successful scaling beyond pilot implementation are rare. This study describes a smartphone app and website platform, “Mission Rabies App”, used to co-ordinate rabies control activities at project sites in four continents to vaccinate over one million dogs.

Methods

Mission Rabies App made it possible to not only gather relevant campaign data from the field, but also to direct vaccination teams systematically in near real-time. The display of user-allocated boundaries on Google maps within data collection forms enabled a project manager to define each team’s region of work, assess their output and assign subsequent areas to progressively vaccinate across a geographic area. This ability to monitor work and react to a rapidly changing situation has the potential to improve efficiency and coverage achieved, compared to regular project management structures, as well as enhancing capacity for data review and analysis from remote areas. The ability to plot the location of every vaccine administered facilitated engagement with stakeholders through transparent reporting, and has the potential to motivate politicians to support such activities.

Results

Since the system launched in September 2014, over 1.5 million data entries have been made to record dog vaccinations, rabies education classes and field surveys in 16 countries. Use of the system has increased year-on-year with adoption for mass dog vaccination campaigns at the India state level in Goa and national level in Haiti.

Conclusions

Innovative approaches to rapidly scale mass dog vaccination programmes in a sustained and systematic fashion are urgently needed to achieve the WHO, OIE and FAO goal to eliminate canine-transmitted human deaths by 2030. The Mission Rabies App is an mHealth innovation which greatly reduces the logistical and managerial barriers to implementing large scale rabies control activities. Free access to the platform aims to support pilot campaigns to better structure and report on proof-of-concept initiatives, clearly presenting outcomes and opportunities for expansion. The functionalities of the Mission Rabies App may also be beneficial to other infectious disease interventions.

Rabies elimination research: juxtaposing optimism, pragmatism and realism

More than 100 years of research has now been conducted into the prevention, control and elimination of rabies with safe and highly efficacious vaccines developed for use in human and animal populations. Domestic dogs are a major reservoir for rabies, and although considerable advances have been made towards the elimination and control of canine rabies in many parts of the world, the disease continues to kill tens of thousands of people every year in Africa and Asia. Policy efforts are now being directed towards a global target of zero human deaths from dog-mediated rabies by 2030 and the global elimination of canine rabies. Here we demonstrate how research provides a cause for optimism as to the feasibility of these goals through strategies based around mass dog vaccination. We summarize some of the pragmatic insights generated from rabies epidemiology and dog ecology research that can improve the design of dog vaccination strategies in low- and middle-income countries and which should encourage implementation without further delay. We also highlight the need for realism in reaching the feasible, although technically more difficult and longer-term goal of global elimination of canine rabies. Finally, we discuss how research on rabies has broader relevance to the control and elimination of a suite of diseases of current concern to human and animal health, providing an exemplar of the value of a ‘One Health’ approach.

Impact of community-delivered SMS alerts on dog-owner participation during a mass rabies vaccination campaign, Haiti 2017

Haiti has historically vaccinated between 100,000 and 300,000 dogs annually against rabies, however national authorities have not been able to reach and maintain the 70% coverage required to eliminate the canine rabies virus variant. Haiti conducts massive dog vaccination campaigns on an annual basis and utilizes both central point and door-to-door methods. These methods require that dog owners are aware of the dates and locations of the campaign. To improve this awareness among dog owners, 600,000 text messages were sent to phones in two Haitian communes (Gonaives and Saint-Marc) to remind dog owners to attend the campaign. Text messages were delivered on the second day and at the mid-point of the campaign. A post-campaign household survey was conducted to assess dog owner’s perception of the text messages and the impact on their participation in the vaccination campaign. Overall, 147 of 160 (91.9%) text-receiving dog owners indicated the text was helpful, and 162 of 187 (86.6%) responding dog owners said they would like to receive text reminders during future rabies vaccination campaigns. In areas hosting one-day central point campaigns, dog owners who received the text were 2.0 (95% CI 1.1, 3.6) times more likely to have participated in the campaign (73.1% attendance among those who received the text vs 36.4% among those who did not). In areas incorporating door-to-door vaccination over multiple days there was no significant difference in participation between dog owners who did and did not receive a text. Text message reminders were well-received and significantly improved campaign attendance, indicating that short message service (SMS) alerts may be a successful strategy in low resource areas with large free roaming dog populations.

Exploring animal rabies endemicity to inform control programmes in Punjab, India

Previous studies estimate that one-third of the annual global burden of rabies (~20,000 cases) occurs in India. Elimination of canine rabies is essential to reduce this burden. Surveillance of animal cases can assess both the risk to humans and the efficacy of control strategies. The objective of this study was to describe the spatial and temporal occurrence of reported confirmed cases of rabies in animals in Punjab, India, from 2004 to 2014. We analysed passive surveillance data on 556 samples submitted from 2004 to 2014 to GADVASU, Ludhiana, Punjab, India. Regression and time series analyses were conducted to understand seasonal and long-term variation of cases and identify cross-correlation of monthly cases between species. Spatio-temporal analyses assessed spatial autocorrelation of date of reporting, mean geographic centres of disease occurrence and clustering of cases using Kulldorff's space-time permutation statistic. The annual number of submissions and proportion of confirmed cases were consistent throughout 2004-2014. Most submissions (320; 57.6%) were confirmed rabies cases, including dogs (40.6%), buffalo (29.7%) and cattle (23.1%). Regression analysis of monthly cases in dogs showed seasonal variation with significant increases in cases in March and August. Monthly case numbers in buffalo decreased over time. Long-term temporal trend was not detected in dog and cattle cases. Time-series models identified significant cross-correlation between dog and buffalo cases, suggesting that buffalo cases were spillover events from dogs. Significant spatio-temporal variation or clusters of cases were not detected. These results indicate that rabies cases in animals-and therefore, the potential for exposure to humans-were temporally and spatially stable during 2004-2014 in Punjab, India. The endemic nature of rabies transmission in this region demands a coordinated, sustained control programme. This study provides baseline information for assessing the efficacy of rabies control measures and developing seasonally targeted dog vaccination and rabies awareness strategies.

A Century Spent Combating Rabies in Morocco (1911-2015): How Much Longer?

Rabies has no known beginning in Morocco and to date, government control efforts and plans fail to eradicate the disease. A review and analysis of available epidemiological data are crucial to learn lessons from the past and to propose effective actions. Legally, animal rabies is a notifiable disease since 1913 and legislation has been updated periodically since. Dogs have always been considered as both the disease's vector and reservoir, while cattle, other herbivores, and humans are victims. Animal rabies cases evolution from 1942 to 2015 is characterized by ascending phase then decreasing one following structured rabies control plan implementation in 1980s. Indeed, from 1986 to 2010, three rabies control plans have been conducted based on free of charge rabies vaccination of owned dogs through mass campaigns. The geographical distribution of rabies is stable over the years with highest cases number in rich rural areas and around cities. Human rabies cases are decreasing over the time (1976-2015) thanks to the opening of new antirabic treatment centers in the last decade which permit the administration of more PEPs. After a century of rabies control, Morocco registered an average of 301 animal cases and 21 human cases annually for the last decade (2005-2015). Few reasons led to those limited results. The lack in law enforcement and, moreover, the fact that the law do not take into account responsible dog ownership aspect are of importance. Lack of dog population knowledge and management and intersectoral coordination deficiency are additional failure reasons. The gathered data will help to build a new strategy with a focus on a "One Health" approach. Dog population ecology parameters' study is of primary importance. We estimated dog population to be 2.8 million dogs based on human:dog ratio. Enhancing vaccination coverage of dog population is feasible by combining parenteral vaccination and complementary oral vaccination. Updating legislation by inclusion of responsible dog ownership and law enforcement are crucial. Over the last century, Morocco registered a slow decreasing tendency in the number of animal and human rabies cases. Urgent strategy need to be implemented because rabies elimination is an achievable goal in Morocco.

The Ilocos Norte Communities against Rabies Exposure Elimination Project in the Philippines: Epidemiological and Economic Aspects

As canine rabies control in Africa and Asia transitions from research-led proof-of-concept studies to government-led programs for elimination, experience and evidence of their impact and costs must be shared for the benefit of future programs. The Ilocos Norte Communities against Rabies Exposure project was implemented in April 2012 by the provincial veterinary and health offices and supported by many other partners. It delivered a comprehensive dog vaccination program and increased awareness of the need for postexposure prophylaxis (PEP), aiming to eliminate human and animal rabies cases from Ilocos Norte by 2015. Prior to the intervention, confirmed rabies cases in dogs were between 19 and 50 per year (2008-2011). The primary outcome of the project was a reduction in rabies cases in both dogs and humans to 0 in 2014 and 2015, which has subsequently been maintained. Animal bite consultations increased significantly during the project. Economic data for the dog vaccination and PEP components of the project were collated for two sites: Laoag City (an urban setting) and Dingras Municipality (a rural setting) between 2012 and 2014. The average programmatic cost of vaccinating each dog was $4.54 in Laoag City and $8.65 in Dingras, and costs fell as the project reached more dogs. The average costs of providing PEP were $69.72 per patient and $49.02 per patient for the two sites, respectively, again falling as the project reached more people. External donor contributions contributed less than 20% of dog vaccination costs and less than 1% of PEP costs. The project demonstrated that rabies elimination can be achieved in a short period of time, with concerted effort across multiple sectors. A lack of clear dog population estimates hampered interpretation of some aspects of the programme. From 2016, the provincial government has assumed complete responsibility for the programme and must now continue the vaccination and surveillance efforts. Although safeguards are in place, reintroduction from surrounding areas remains a threat, and vigilance must be maintained.

Eliminating Dog-Mediated Rabies in Sikkim, India: A 10-Year Pathway to Success for the SARAH Program

A third of the world rabies burden is in India. The Sikkim Anti-Rabies and Animal Health (SARAH) program is the first state-wide rabies program in India and demonstrates a successful One Health model of dog-mediated rabies elimination. The SARAH program was created in 2006 as a collaboration between the Government of Sikkim and international non-government organizations-Vets Beyond Borders and Fondation Brigitte Bardot. Activities are directed to canine rabies vaccination, humane dog population control, community education, and treatment of sick and injured animals. In 2005, there were 0.74 human rabies deaths per 100,000 (4 deaths) within Sikkim, and from 2006 to 2015, there were no human rabies deaths. In 2016, two human rabies deaths were reported near the West Bengal border region. From 2005 to 2010, the incidence of animal rabies is unknown; from 2010 to 2016, eight cases of animal rabies were reported. Major challenges for the program are continued commitment to rabies control in the face of 0 to low human rabies incidence and the risk of rabies incursions. Effective intersectoral communication between Health, Veterinary, Forestry, and Police officers is essential to enable rapid response to animal bite incidents and possible rabies incursions. An integrated One Health approach needs to be maintained with enhanced active rabies surveillance. Other states must establish similar programs if India is ever to achieve a goal of eliminating dog-mediated human rabies.

The Vaccination of 35,000 Dogs in 20 Working Days Using Combined Static Point and Door-to-Door Methods in Blantyre, Malawi

An estimated 60,000 people die of rabies annually. The vast majority of cases of human rabies develop following a bite from an infected dog. Rabies can be controlled in both human and canine populations through widespread vaccination of dogs. Rabies is particularly problematic in Malawi, costing the country an estimated 13 million USD and 484 human deaths annually, with an increasing paediatric incidence in Blantyre City. Consequently, the aim of this study was to vaccinate a minimum of 75% of all the dogs within Blantyre city during a one month period. Blantyre’s 25 administrative wards were divided into 204 working zones. For initial planning, a mean human:dog ratio from the literature enabled estimation of dog population size and dog surveys were then performed in 29 working zones in order to assess dog distribution by land type. Vaccination was conducted at static point stations at weekends, at a total of 44 sites, with each operating for an average of 1.3 days. On Monday to Wednesday, door-to-door vaccination sessions were undertaken in the areas surrounding the preceding static point stations. 23,442 dogs were vaccinated at static point stations and 11,774 dogs were vaccinated during door-to-door vaccinations. At the end of the 20 day vaccination programme, an assessment of vaccination coverage through door-to-door surveys found that of 10,919 dogs observed, 8,661 were vaccinated resulting in a vaccination coverage of 79.3% (95%CI 78.6–80.1%). The estimated human:dog ratio for Blantyre city was 18.1:1. Mobile technology facilitated the collection of data as well as efficient direction and coordination of vaccination teams in near real time. This study demonstrates the feasibility of vaccinating large numbers of dogs at a high vaccination coverage, over a short time period in a large African city.

Rabies is a devastating disease that is estimated to result in the death of approximately 60,000 people every year. Most humans contract rabies following a bite from an infected dog and it has been demonstrated that provided a large enough proportion of the dog population is vaccinated; rabies incidence can be markedly reduced in both humans and dogs. However, few studies have described the vaccination of large numbers of dogs in a short period. An increasing incidence of childhood rabies has been reported in Blantyre, Malawi’s second largest city, over the past decade. This study reports the development and implementation of a mass canine rabies vaccination campaign which used a combined approach of static point and door-to-door vaccination strategies. 23,442 dogs were vaccinated at static point stations and 11,774 dogs were vaccinated during door-to-door vaccination during 20 working days of vaccination. Post vaccination surveys revealed vaccine coverage of 79.3% (95% CI 78.6–80.1). This study, through the unique approach of using novel mobile technology and two vaccination strategies, demonstrates the feasibility of vaccinating over 35,000 dogs within a one month period in an African city where rabies has a high prevalence in the human population.