Implementation of an intersectoral program to eliminate human and canine rabies: the Bohol Rabies Prevention and Elimination Project

Prospects for dog rabies elimination in Nigeria by 2030

The attainment of the global target of zero dog-mediated human rabies by 2030 depends on functional rabies programmes. Nigeria, a rabies-endemic country, and the most populous country in Africa has a very poor rabies control strategy with a score of 1.5 out of 5 based on the Stepwise Approach towards Rabies Elimination (SARE). In this article, we report a scoping review that we conducted to highlight the strengths, weaknesses, opportunities and threats as well as situational analysis of rabies control in Nigeria and suggest a timeline for key activities that are needed to ensure zero by 30. Our findings reveal that rabies is grossly under-reported as only 998 human and 273 dog-suspected rabies cases were reported across Nigeria between 2017 and 2022. Our literature review also demonstrates a paucity of information on rabies in both human and animal health sectors. A total of 49 studies on dog rabies in Nigeria, with a predominance of reports from the North Central geopolitical region (48%, n = 23) were therefore included in this study. Currently, only 16.2% (n = 6/37) of Nigerian states have available data related to the estimated dog populations, the dog ownership rates, the vaccination status of dogs or the incidence of dog bites. Based on a dog-to-human ratio of 1:16.3, we estimated that the dog population in Nigeria was 12,969,368 (95% CI: 12,320,900-13,617,836). Thus, to attain herd immunity and dog rabies control in Nigeria, at least 9.1 million dogs must be vaccinated annually. Our review reveals that, despite the strengths and available opportunities to achieve rabies control in Nigeria by 2030, the weaknesses and challenges will make the attainment of zero by 30 very difficult or impossible. Nigeria's best-case scenario by the year 2030 is SARE stage 3-4 (control-elimination) out of 5. Otherwise, the rabies control programme might not surpass SARE stages 2-3. To attain zero by 30, Nigeria must re-strategize its current rabies control programme by funding and implementing the national strategic plan for rabies control, creating a rabies desk office in the 37 states (FCT inclusive), rigorously conducting mass vaccination campaigns, providing post-exposure prophylaxis, prioritizing mass enlightenment with a focus on responsible pet ownership and conduct baseline national rabies surveillance in the animal and human health sectors.

Analysis of human rabies deaths reported at two hospitals in Karachi, Pakistan: a call to save lives by reforming rabies prevention facilities

BACKGROUND

Rabies is endemic in low- and middle-income countries. It is caused mainly by the bite of a rabid dog and is fatal if not treated effectively and in a timely manner with quality post-exposure prophylaxis. Despite a profusion of private and public healthcare centres in Sindh province, most are ill-equipped to treat dog bites.

METHODS

We analysed 129 human deaths from rabies who presented at the emergency departments of two tertiary care hospitals in Karachi over 10 y. Demographic data, time, location of the bite and distance travelled to report symptoms of rabies were recorded.

RESULTS

Most victims were male, and children were more often affected; almost none had received post-exposure prophylaxis. A total of 12% of bites were on the face, head or neck. The mean incubation period was 56 d. Most (60%) of the rabies victims travelled long distances, hoping to receive treatment.

CONCLUSIONS

Rabies deaths were either due to a lack of awareness or the non-availability of rabies immunobiologicals within easy reach. Public health services must raise awareness, conduct surveillance and provide appropriately spaced centres for free treatment of dog bites. This lethal disease must be prevented at all costs.

Identifying high-risk areas for dog-mediated rabies using Bayesian spatial regression

Despite ongoing control efforts, rabies remains an endemic zoonotic disease in many countries. Determining high-risk areas and the space-time patterns of rabies spread, as it relates to epidemiologically important factors, can support policymakers and program managers alike to develop evidence-based targeted surveillance and control programs. In this One Health approach which selected Thailand as the example site, the location-based risk of contracting dog-mediated rabies by both human and animal populations was quantified using a Bayesian spatial regression model. Specifically, a conditional autoregressive (CAR) Bayesian zero-inflated Poisson (ZIP) regression was fitted to the reported human and animal rabies case counts of each district, from the 2012–2017 period. The human population was used as an offset. The epidemiologically important factors hypothesized as risk modifiers and therefore tested as predictors included: number of dog bites/attacks, the population of dogs and cats, number of Buddhist temples, garbage dumps, animal vaccination, post-exposure prophylaxis, poverty, and shared administrative borders. Disparate sources of data were used to improve the estimated associations and predictions. Model performance was assessed using cross-validation. Results suggested that accounting for the association between human and animal rabies with number of dog bites/attacks, number of owned and un-owned dogs; shared country borders, number of Buddhist temples, poverty levels, and accounting for spatial dependence between districts, may help to predict the risk districts for dog-mediated rabies in Thailand. The fitted values of the spatial regression were mapped to illustrate the risk of dog-mediated rabies. The cross-validation indicated an adequate performance of the spatial regression model (AUC = 0.81), suggesting that had this spatial regression approach been used to identify districts at risk in 2015, the cases reported in 2016/17 would have been predicted with model sensitivity and specificity of 0.71 and 0.80, respectively. While active surveillance is ideal, this approach of using multiple data sources to improve risk estimation may inform current rabies surveillance and control efforts including determining rabies-free zones, and the roll-out of human post-exposure prophylaxis and anti-rabies vaccines for animals in determining high-risk areas.

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Bayesian spatial regression was used to quantify location-based risk of dog-mediated rabies

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Available and publicly accessible data from disparate sources were gathered

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Risk was estimated using the association between

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Risk estimates were compared over time to determine the prediction ability

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Study suggests while active surveillance is ideal, using multiple data sources may improve risk estimation

Perception of canine rabies among pupils under 15 years in Kwara State, North Central Nigeria

Rabies is an endemic, highly fatal, and vaccine-preventable disease with severe socio-economic implications. Most (99%) human rabies cases are transmitted through dog bites. Children under 15 years account for 40% of all dog bite victims and 35–50% of all rabies deaths. Rabies awareness among this vulnerable group is critical to rabies prevention. However, there is a paucity of data on rabies awareness among pupils under 15. Hence, this study assessed the awareness and attitude of pupils under 15 years towards canine rabies in Kwara state in Nigeria. The study was conducted as a cross-sectional survey of 1,388 pupils across the state using a structured questionnaire that was administered as a one-on-one interview using the Open Data Kit on Android phones in December 2019. Of the 1388 pupils included in this study, only 21.7% (n = 301) of them were aware of rabies. The mean rabies score was 1.7±0.8 and only 29.2% (n = 88/301) of the pupils had adequate knowledge of canine rabies. The dog ownership rate was 18.7% (n = 259) with an average of 1.93 dogs per household. Approximately 5% (n = 66) of the pupils have been previously bitten by a dog. One-third of the dog bite victims (35%, n = 23/66) were managed and treated at home and only 12% (n = 8/66) were treated in a health facility. The result of the multivariable logistic regression showed that students aged between 13–15 years were more likely (OR: 1.93; 95% CI: 0.72–3.01; p < 0.001) to have adequate knowledge of rabies than the younger pupils. Similarly, pupils that have dogs in their households (OR: 2.09; 95%CI: 1.49–2.75; p < 0.001) and those that reside in Kwara South (OR:1.78 95% CI:1.29, 2.44; p < 0.001) were more likely to be aware and have adequate knowledge of canine rabies respectively. Finally, Pupils from non-dog-owning households were more likely (OR:2.2; 95% CI: 1.45, 4.42; p < 0.001) to have been bitten by dogs than those from dog-owning households. The awareness and attitude of pupils under 15 to canine rabies was poor. We advocate the introduction of rabies lessons into the school curriculum in Kwara State to reduce the incidence of dog bites and prevent dog-mediated human rabies.

Rabies is an endemic disease that kills approximately 59000 persons mostly in low- and middle-income countries. The disease is mostly transmitted through dog bites and children under 15 years account for 40% of all dog bite incidents and 35–50% of all rabies death. This study assessed the knowledge and perception of canine rabies among pupils under 15 years in Kwara State, Nigeria. Our findings showed a very low rabies awareness rate (21.7%) and equally low knowledge of rabies (29.2%) with a mean knowledge score of 1.7±0.8. The dog ownership rate was 18.7% with an average of 1.93 dogs per household. Approximately 5% of the pupils have been previously bitten by a dog. One-third of the dog bite victims were managed and treated at home and only 12% were treated in a health facility. The age of the pupil, their dog ownership status and their geopolitical location within Kwara State influenced the pupil’s knowledge of canine rabies. To control rabies, we must institute multi-sectoral collaborations of critical stakeholders and introduce rabies lessons into the school curriculum in Kwara State.

Clinical, epidemiological, and spatial features of human rabies cases in Metro Manila, the Philippines from 2006 to 2015

Rabies remains a public health problem in the Philippines despite the widespread provision of rabies vaccines and rabies immunoglobulin (RIG) as post-exposure prophylaxis (PEP). Detailed descriptions of recent human rabies cases in the Philippines are scarce. This study aimed to describe the clinical, epidemiological, and spatial features of human rabies cases between January 1, 2006, and December 31, 2015. We conducted a retrospective hospital-based case record review of all patients admitted to one referral hospital in Manila who received a clinical diagnosis of rabies. During the 10-year study period there were 575 patients (average 57.5 cases per year, range 57 to 119) with a final diagnosis of rabies. Most patients were male (n = 404, 70.3%) and aged ≥ 20 years (n = 433, 75.3%). Patients mostly came from the National Capital Region (n = 160, 28.0%) and the adjacent Regions III (n = 197, 34.4%) and IV-A (n = 168, 29.4%). Case mapping and heatmaps showed that human rabies cases were continuously observed in similar areas throughout the study period. Most patients had hydrophobia (n = 444, 95.5%) and/or aerophobia (n = 432, 93.3%). The leading causative animals were dogs (n = 421, 96.3%) and cats (n = 16, 3.7%). Among 437 patients with animal exposure history, only 42 (9.6%) had been administered at least one rabies vaccine. Two patients (0.5%), young children bitten on their face, had received and a full course of rabies vaccine. Human rabies patients were continuously admitted to the hospital, with no notable decline over the study period. The geographical area in which human rabies cases commonly occurred also did not change. Few patients received PEP and there were two suspected cases of PEP failure. The retrospective design of this study was a limitation; thus, prospective studies are required.

Rabies remains a public health problem in the Philippines despite improvements in the availability of rabies vaccines and rabies immunoglobulin (RIG) as post-exposure prophylaxis (PEP). The incidence of rabies is highest in Metro Manila and surrounding areas. We reviewed the records of all human rabies patients admitted to the national infectious disease hospital in Manila between 2006 and 2015. This hospital treats most cases in this area. During the 10-year study period, human rabies cases were continuously admitted to the hospital, with no notable decline in numbers by year. Most patients were adult men bitten by domestic dogs. The geographical areas in which cases commonly occurred during the 10-year period also did not change over time. Only 9.6% of patients had received at least one dose of a rabies vaccine as PEP. Although the risk of PEP failure is reported to be almost zero, we identified two suspected cases of PEP failure. The retrospective design of this study was a limitation, and the exact details of PEP were not reliably available. As human rabies death is a significant public health concern, the circumstances of each case should be prospectively investigated. Further research is required to understand how to reduce the number of rabies cases.

Implementing a One Health Approach to Rabies Surveillance: Lessons From Integrated Bite Case Management

As part of the 'Zero by 30' strategy to end human deaths from dog-mediated rabies by 2030, international organizations recommend a One Health framework that includes Integrated Bite Case Management (IBCM). However, little is understood about the implementation of IBCM in practice. This study aims to understand how IBCM is conceptualized, exploring how IBCM has been operationalized in different contexts, as well as barriers and facilitators to implementation. Semi-structured interviews were conducted with seventeen practitioners and researchers with international, national, and local expertise across Africa, Asia, and the Americas. Thematic analysis was undertaken using both inductive and deductive approaches. Four main themes were identified: 1) stakeholders' and practitioners' conceptualization of IBCM and its role in rabies elimination; 2) variation in how IBCM operates across different contexts; 3) barriers and facilitators of IBCM implementation in relation to risk assessment, PEP provisioning, animal investigation, One Health collaboration, and data reporting; and 4) the impact of the COVID-19 pandemic on IBCM programs. This study highlights the diversity within experts' conceptualization of IBCM, and its operationalization. The range of perspectives revealed that there are different ways of organizing IBCM within health systems and it is not a one-size-fits-all approach. The issue of sustainability remains the greatest challenge to implementation. Contextual features of each location influenced the delivery and the potential impact of IBCM. Programs spanned from highly endemic settings with limited access to PEP charged to the patient, to low endemicity settings with a large patient load associated with free PEP policies and sensitization. In practice, IBCM was tailored to meet the demands of the local context and level of rabies control. Thus, experts' experiences did not necessarily translate across contexts, affecting perceptions about the function, motivation for, and implementation of IBCM. To design and implement future and current programs, guidance should be provided for health workers receiving patients on assessing the history and signs of rabies in the biting animal. The study findings provide insights in relation to implementation of IBCM and how it can support programs aiming to reach the Zero by 30 goal.

A generalizable one health framework for the control of zoonotic diseases

Effectively preventing and controlling zoonotic diseases requires a One Health approach that involves collaboration across sectors responsible for human health, animal health (both domestic and wildlife), and the environment, as well as other partners. Here we describe the Generalizable One Health Framework (GOHF), a five-step framework that provides structure for using a One Health approach in zoonotic disease programs being implemented at the local, sub-national, national, regional, or international level. Part of the framework is a toolkit that compiles existing resources and presents them following a stepwise schematic, allowing users to identify relevant resources as they are required. Coupled with recommendations for implementing a One Health approach for zoonotic disease prevention and control in technical domains including laboratory, surveillance, preparedness and response, this framework can mobilize One Health and thereby enhance and guide capacity building to combat zoonotic disease threats at the human-animal-environment interface.

How are large-scale One Health initiatives targeting infectious diseases and antimicrobial resistance evaluated? A scoping review

While One Health initiatives are gaining in popularity, it is unclear if and how they are evaluated when implementation at scale is intended. The main purpose of this scoping review was to describe how One Health initiatives targeting infectious diseases and antimicrobial resistance at a large scale are evaluated. Secondary objectives included identifying the main facilitators and barriers to the implementation and success of these initiatives, and how their impacts were assessed. Twenty-three studies evaluating One Health initiatives were eligible. Most studies included the human (n = 22) and animal (n = 15) sectors; only four included the environment sector. The types of evaluated initiative (non-exclusive) included governance (n = 5), knowledge (n = 6), protection (n = 17), promotion (n = 16), prevention (n = 9), care (n = 8), advocacy (n = 10) and capacity (n = 10). Studies used normative (n = 4) and evaluative (n = 20) approaches to assess the One Health initiatives, the latter including impact (n = 19), implementation (n = 8), and performance (n = 7) analyses. Structural and economic, social, political, communication and coordination-related factors, as well as ontological factors, were identified as both facilitators and barriers for successful One Health initiatives. These results identified a wide range of evaluation methods and indicators used to demonstrate One Health's added values, strengths, and limitations: the inherent complexity of the One Health approach leads to the use of multiple types of evaluation. The strengths and remaining gaps in the evaluation of such initiative highlight the relevance of comprehensive, mixed-method, context-sensitive evaluation frameworks to inform and support the implementation of One Health initiatives by stakeholders in different governance settings.

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Studies evaluating One Health initiatives were scarce.

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Only One Health initiatives related to infectious diseases were evaluated.

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Evaluations were mainly conducted using quantitative approaches.

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Involvement of the community was identified as a major facilitator.

Aligning healthcare, public health and social services: A scoping review of the role of purpose, governance, finance and data

Organisations spanning social services, public health and healthcare have increasingly experimented with collaboration as a tool for improving population health and reducing health disparities. While there has been progress, the results have fallen short of expectations. Reflecting on these shortcomings, the Robert Wood Johnson Foundation (RWJF) recently proposed a new framework for cross-sector alignment intended to move the field towards improved outcomes. A central idea in this framework is that collaboratives will be more effective and sustainable if they develop collaborative systems in four core areas: shared purpose, governance, finance and shared data. The goal of this paper is to provide a foundation for research on the four core areas of the cross-sector alignment framework. Accordingly, this study is based on two guiding questions: (1) how are collaboratives currently implementing systems in the four core areas identified in the framework, and (2) what strategies does the literature offer for creating sustainable systems in these four areas? Given the emergent nature of research on health-oriented cross-sector collaboration and the broad research questions, we conducted a systematic scoping review including 179 relevant research papers and reports published internationally from the years 2010-2020. We identified the main contributions and coded each based on its relevance to the cross-sector alignment framework. We found that most papers focused on programme evaluations rather than theory testing, and while many strategies were offered, they tended to reflect a focus on short-term collaboration. The results also demonstrate that starting points and resource levels vary widely across individuals and organisations involved in collaborations. Accordingly, identifying and comparing distinct pathways by which different parties might pursue cross-sector alignment is an imperative for future work. More broadly, the literature is ripe with observations that could be assessed systematically to produce a firm foundation for research and practice.

Dog rabies control in West and Central Africa: A review

Rabies is a neglected but preventable zoonotic disease that predominantly affects the most vulnerable populations living in remote rural areas of resource-limited countries. To date, every country on the African mainland is considered endemic for dog-mediated rabies with an estimated 21'500 human rabies deaths occurring each year. In 2018, the United Against Rabies collaboration launched the Global Strategic Plan to end human deaths from dog-mediated rabies by 2030. The epidemiology of rabies from most Western and Central African countries remains poorly defined, making it difficult to assess the overall rabies situation and progress towards the 2030 goal. In this review, we attempt to provide an overview of the current rabies situation in 22 West and Central African countries based on published scientific literature and information obtained from rabies focal points. To this end, information was collected on i) established surveillance, ii) diagnostic capacity, iii) post-exposure prophylaxis (PEP) availability and coverage, iv) dog population estimates, v) dog vaccination campaigns, vi) animal and human health communication (One Health), vii) molecular studies, viii) Knowledge, Attitude and Practices (KAP), ix) cost estimates and x) national control strategies. Although rabies is a notifiable disease in the majority of the studied countries, national surveillance systems do not adequately capture the disease. A general lack of rabies diagnostic capacity has an additional negative impact on rabies surveillance and attempts to estimate rabies burden. Recurrent shortages of human rabies vaccine are reported by all of the countries, with vaccine availability usually limited to major urban centers but no country has yet adopted the new WHO-recommended 1-week intradermal vaccination regimen. Most countries carry out subsidized mass dog vaccination campaigns on World Rabies Day. Such activities are indispensable to keep rabies in the public consciousness but are not of the scale and intensity that is required to eliminate rabies from the dog population. Countries will need to scale up the intensity of their campaigns, if they are to progress towards the 2030 goal. But more than half of the countries do not yet have reliable figures on their dog populations. Only two countries reached stage 2 on the Stepwise Approach towards Rabies Elimination ladder - indicating that their national governments have truly prioritized rabies elimination and are thus providing the necessary support and political buy-in required to achieve success. In summary, the sub-region of West and Central Africa seems to be divided into countries which have accepted the challenge to eliminate rabies with governments committed to pushing forward rabies elimination, while other countries have achieved some progress, but elimination efforts remain stuck due to lacking government commitment and financial constraints. The possibility to meet the 2030 goal without international solidarity is low, because more than two-thirds of the countries rank in the low human development group (HDI ≤ 152). Leading countries should act as role models, sharing their experiences and capacities so that no country is left behind. Unified and with international support it is possible to reach the common goal of zero human rabies deaths by 2030.

11 years of regular access to subsidized veterinary services is associated with improved dog health and welfare in remote northern communities

Access to veterinary services can have positive impacts on animal health and welfare, and on human mental and physical health and well-being; however, many communities worldwide lack access to such services. At their request, the 5 communities of the Sahtu Settlement Area, Northwest Territories, Canada, have received annual access to preventive veterinary services through the University of Calgary's Northern Community Health Rotation since 2008. To determine the reach of the program, we conducted a dog census in 2017. We then conducted a chart review of 11 years of dog medical records from 2008 to 2018 to evaluate how the reach of the program, the uptake of veterinary services, and dog population demographics, health and welfare measures changed over the duration of the program. In the chart review, we used either multi-level logistic regression or generalized linear models, to determine how seven variables, including age, sex, breed, body condition, deworming, vaccination, and sterilization status upon clinic entry, changed over the course of program delivery. Our results suggest that program reach, veterinary service uptake, and dog demographic, health and welfare measures improved over time. We observed high rabies vaccination coverage in some communities (48 %-83 % of the dog population) and moderate overall sterilization status (25 %-56 % of the dog population) with female dog sterilization more common than male (75 % of dogs leaving the 2017 clinics, compared to 43 %). Several dog demographic, health, and welfare measures, including age, body condition, and vaccination, deworming, and sterilization status, were significantly better in later years of the program (all p < 0.001). Differences among communities, both in dog population numbers from the 2017 census (40-89 dogs) and in the uptake of veterinary services in 2017 (48 %-83 % of the dog population), were notable. Vaccination uptake was directly related to clinic attendance, but sterilization was impacted by additional factors, including community members' acceptance of the procedure. Some unintended consequences were noted, however, including the potential effect of sterilization on the availability of traditional dog breeds in the communities. Overall, our study findings demonstrate that subsidized veterinary services provided over a regular and extended period of time benefit animal population demographics, health and welfare, and could have positive impacts on human well-being. The framework of community collaboration and long-term commitment developed through this program serves as a model for achieving common health goals among communities in need and veterinary service providers.

Challenges to improved animal rabies surveillance: Experiences from pilot implementation of decentralized diagnostic units in Chad

Better surveillance is desperately needed to guide rabies prevention and control to achieve the goal of zero dog-mediated human rabies by 2030, defined by the World Health Organization (WHO) and partners in 2015. With the help of funding from the Vaccine Alliance (GAVI) learning agenda, we implemented animal rabies surveillance based on One Health communication, improved accessibility of diagnostic testing and facilitated sample transport to increase case detection in three regions of Chad. Through the project, rabies surveillance, previously only available in N'Djaména, was extended to selected provincial rural and urban areas. Nine decentralized diagnostic units (DDU) were established, hosted by veterinary district agencies (VDA) in four different administrative regions. Four additional VDAs in the study area were reinforced with facilitation of sample collection and transport. Staff from all these 13 veterinary facilities were trained in sample collection and diagnostics. DDUs performed Rapid Immunodiagnostic Tests (RIDT) providing a preliminary result before samples were sent to the central laboratory in N'Djamena for confirmation with the standard Florescent Antibody Test (FAT). Within the project period from June 2016 to March 2018, 115 samples were reported by veterinary facilities in the study areas compared to 63 samples received from outside the study area, the vast majority of them originating from the capital city N'Djaména (N=61). Eighty nine percent of all 178 samples reported to IRED during the project period tested positive. Most of the samples originated from dogs (92%). Other confirmed rabies positive animals observed were cats, a donkey and a pig. Although surveillance of animal rabies was the focus, four human saliva samples were also submitted for diagnosis. We observed high differences in reporting rates between the four study regions. This could be attributable to differences in rabies epidemiology but are also influenced by the distance to the central laboratory in N'Djaména, the cultural background and the level of public awareness. The possibility for local testing through RIDT was very welcomed by local veterinary staff and preliminary insights suggest a positive influence on One Health communication and PEP initiation. However, these aspects as well as the relative impact of local testing on sample collection in comparison to reinforcement of sample collection and transport alone, need to be further investigated. Challenges encountered related to poor infrastructure (buildings, appliances, materials) and low logistic capacity (lacking means and material for transport and communication) of veterinary services in Chad. In addition, veterinary personnel lack experience in data management. Together with staff turnover, this leads to a need for repeated training. Major shortcoming of the approach was the high cost per sample and limited sustainability beyond the project timeframe.

A shorter post-exposure prophylaxis regimen for rabies, Pakistan

OBJECTIVE

To assess the cost and effectiveness of the two-site, 1-week, intradermal rabies post-exposure prophylaxis regimen recommended by the World Health Organization (WHO) in 2018.

METHODS

We compared the number of rabies vaccine and rabies immunoglobulin ampoules consumed at The Indus Hospital in Karachi, Pakistan and their cost before and after implementing WHO's 2018 recommendations. In 2017, patients with suspected rabies-infected bites were treated using the two-site, 4-week, Thai Red Cross regimen, which involved administering four rabies vaccine doses intradermally over 4 weeks and infiltrating immunoglobulin into serious wounds, with the remainder injected into a distant muscle. In 2018, patients received three vaccine doses intradermally over 1 week, with a calculated amount of immunoglobulin infiltrated into wounds only. Remaining immunoglobulin was saved for other patients. The survival of patients bitten by apparently rabid dogs was used as a surrogate for effectiveness.

FINDINGS

Despite treating 8.5% more patients in 2018 (5370 patients) than 2017 (4948 patients), 140 fewer ampoules of rabies vaccine and 436 fewer ampoules of rabies immunoglobulin were used, at a cost saving of 4202 United States dollars. Of 56 patients bitten by apparently rabid dogs, 50 were alive at 6-month follow-up. The remaining six patients could not be contacted but did not present to any hospital with rabies.

CONCLUSION

The new regimen was more economical than the two-site, 4-week regimen and was equally effective. This regimen is recommended for preventing rabies in countries where the disease is endemic and rabies vaccine and immunoglobulin are in short supply.

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.

Barriers and opportunities for canine rabies vaccination campaigns in Addis Ababa, Ethiopia

BACKGROUND

Canine rabies is endemic in Ethiopia and presents a significant burden for both animal and human health. We investigate barriers to dog vaccination in Addis Ababa, Ethiopia. These results can be utilized to improve and target future rabies control efforts.

METHODOLOGY/PRINCIPLE FINDINGS

During May of 2017, dog owners were surveyed during a free canine rabies vaccination programs that utilized both door-to-door (DtD) and central point (CP) vaccination methods. Surveys collected information on preferences for rabies vaccine delivery and were administered in Amharic. A total of 1057 surveys were completed. Of those surveyed, 62.4 % indicated that their dogs had been vaccinated against rabies within the last year. Commonly reported barriers to vaccination were a lack of awareness that dogs required rabies vaccines (18.1 %) and lack of knowledge about where to find vaccine (15.0 %). The median price owners were willing to pay for vaccination was 25 birr ($0.91 USD) and the median distance willing to travel was 1.0 km; however, 48.9 % of those surveyed during DtD were unwilling to travel at all. We identified 3 classes of respondents who were grouped due to their responses by latent class analysis: 'the Unaware', 'the Vaccinators', and 'the Multiple Barriers'.

CONCLUSIONS/SIGNIFICANCE

Although many respondents were willing to pay for rabies vaccine (94.0 %); the preferred cost (median) was less than the actual cost of providing the vaccine. This supports the need for reduced-cost or free vaccine to achieve and sustain the 70 % vaccine coverage target threshold for canine rabies elimination. Additionally, a significant portion (41.5 %) of those surveyed indicated that they were unwilling to travel in order to have their dog vaccinated. The latent class analysis provides useful guidance on how to reach target vaccination. Owners from 'the Unaware' group made up 18.1 % of respondents and their high rate of allowing their dogs to roam identifies them as a prime target for canine health and behavior education. 'The Multiple Barriers' owners reported lower degrees of dog roaming and were substantially more likely to be found by DtD campaigns, possibly because they have limited ability/interest in handling their dogs. These results demonstrate the importance of incorporating DtD vaccination as well as subsidies to maximize vaccine coverage in Addis Ababa.

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.

Policy Perspectives of Dog-Mediated Rabies Control in Resource-Limited Countries: The Ethiopian Situation

One Health disease-control programs are believed to be most effective when implemented within the population transmitting the disease. The World Health Organization (WHO) and partners have targeted the elimination of dog-mediated human rabies by 2030 primarily through mass dog vaccination. Mass vaccination, however, has been constrained by financial resource limitations. The current owner-charged dog vaccination strategy, used in most resource-limited countries like Ethiopia, has not reached the minimum coverage required to build population immunity. Dog vaccination is non-existing in most rural areas of Ethiopia, and coverage is <20% in urban areas. Although the health and economic benefits of rabies elimination outweigh the costs, the direct beneficiaries (public in general) and those who bear the costs (dog owners) are not necessarily the same. In this perspective paper, we aggregate evidence on the socioeconomic burden of rabies in Ethiopia as well as the implications for potential opportunities to control the disease and possibilities to obtain the required funding sources for evidence-based interventions in the control of rabies in Ethiopia.

Identification of risk factors for rabies exposure and access to post-exposure prophylaxis in Chad

Rabies remains a global public health problem, with Africa as one of the most affected continents. Endemic transmission in the unvaccinated domestic dog population of developing countries leads to many exposures with subsequent death in humans due to lack of access to existing effective prevention tools. The presented study identifies factors of exposure and rabies risk in Chad on the household and health facility levels and highlights the challenges of access to Post Exposure Prophylaxis (PEP). Data on bite exposure and prevention was collected through a representative cross-sectional survey in rural and urban households and through a continuous bite reporting survey in public health facilities. During the household survey 8000 homes were visited, including 3241 (41%) in urban areas and 4759 (59%) in rural areas. The frequency of dog ownership was similar in both rural and urban areas, with around 24% households owning at least one dog. Knowledge of rabies as a disease transmitted mainly from dogs to humans was generally good, but higher in urban (86%) compared to rural areas (73%). The need for early prevention and medical care after a bite was less well known with 35% of respondents believing that rabies is curable after onset of symptoms and only one in three bite victims seeking help in a health facility. Exposure risk based on bite incidence on the population level was increased for Christian compared to Muslim predominant religious context. During the health facility study, 1540 bite cases were registered, of which 58% originated from urban areas and 42% from rural areas. Demographic characteristics of the health facility data subset matched the household survey data subset for the majority of parameters. Only bites from known animals (same household or from neighbourhood) and bites from animals known to be alive were underrepresented, suggesting that such bites are regarded as less dangerous than bites from unknown animals and animals that died, were killed or disappeared. Since human vaccine was provided free of charge during the study, most victims received PEP (84%). However, not all patients completed treatment, with a higher risk of non-compliance observed in rural areas. Access to vaccine before the study was alarmingly low, with only 8.5% accessing PEP. Despite facilitated collaboration between human health and veterinary services through the project, consultation with veterinary services remained generally low. The observed challenges can inform future rabies control programmes on the national level to effectively increase access to PEP exceeding the expected improved availability of human vaccine through the upcoming GAVI investment.

Volunteer based approach to dog vaccination campaigns to eliminate human rabies: Lessons from Laikipia County, Kenya

BACKGROUND

An estimated 59,000 people die from rabies annually, with 99% of those deaths attributable to bites from domestic dogs (Canis lupus familiaris). This preventable Neglected Tropical Disease has a large impact across continental Africa, especially for rural populations living in close contact with livestock and wildlife. Mass vaccinations of domestic dogs are effective at eliminating rabies but require large amounts of resources, planning, and political will to implement. Grassroots campaigns provide an alternative method to successful implementation of rabies control but remain understudied in their effectiveness to eliminate the disease from larger regions.

METHODOLOGY/PRINCIPAL FINDINGS

We report on the development, implementation, and effectiveness of a grassroots mass dog rabies vaccination campaign in Kenya, the Laikipia Rabies Vaccination Campaign. During 2015-2017, a total of 13,155 domestic dogs were vaccinated against rabies in 17 communities covering approximately 1500 km2. Based on an estimated population size of 34,275 domestic dogs, percent coverages increased across years, from 2% in 2015 to 24% in 2017, with only 3 of 38 community-years of vaccination exceeding the 70% target. The average cost of vaccinating an animal was $3.44 USD with in-kind contributions and $7.44 USD without in-kind contributions.

CONCLUSIONS/SIGNIFICANCE

The evolution of the Laikipia Rabies Vaccination Campaign from a localized volunteer-effort to a large-scale program attempting to eliminate rabies at the landscape scale provides a unique opportunity to examine successes, failures, and challenges facing grassroots campaigns. Success, in the form of vaccinating more dogs across the study area, was relatively straightforward to achieve. However, lack of effective post-vaccination monitoring and education programs, limited funding, and working in diverse community types appeared to hinder achievement of 70% coverage levels. These results indicate that grassroots campaigns will inevitably be faced with a philosophical question regarding the value of local impacts versus their contributions to a larger effort to eliminate rabies at the regional, country, or global scale.

Rabies Prevention in Asia: Institutionalizing Implementation Capacities

Rabies in Asia and Africa contributes to over 99% of human rabies deaths that occur in the world today. The vast majority or 60% of these deaths are in Asia. Practically, more than four billion people in Asia or about 60% of the world’s population are at risk of getting rabies where an estimated 96% of documented human cases are from an infected dog bite. Canine-mediated rabies is one of the few communicable diseases that can possibly be eliminated by currently available vaccines and tools for veterinary and public health interventions. With a more comprehensive and integrated approach, it is expected that dog rabies will be eliminated in target areas, and there will be an eventual decline and disappearance of human rabies cases. The burden of rabies is primarily on human health but the disease control has to be focused on the animal source. The ultimate goal of a truly regional disease program is to control and eliminate dog-mediated rabies and protect and maintain rabies-free areas in Asia. Current regional efforts aim to strengthen the intercountry coordination, and technical and institutional capacities to manage dog rabies elimination programs. The regional and national implementation efforts provide strategic direction and cooperation to ensure successful implementation of rabies control measures and eventual elimination. The focus areas include human rabies prevention through pre- and postexposure prophylaxis, mass dog vaccination, surveillance and epidemiology, laboratory diagnostic capability, public awareness and risk communication, legislation, dog population management, and establishment and protection of rabies-free zones/areas. Existing mechanisms for implementation, when applied, give emphasis on One Health collaborations.

Estimating the effectiveness of vaccine programs in dog populations

Dogs harbor numerous zoonotic pathogens, many of which are controlled through vaccination programs. The delivery of these programs can be difficult where resources are limited. We developed a dynamic model to estimate vaccination coverage and cost-per-dog vaccinated. The model considers the main factors that affect vaccination programs: dog demographics, effectiveness of strategies, efficacy of interventions and cost. The model was evaluated on data from 18 vaccination programs representing eight countries. Sensitivity analysis was performed for dog confinement and vaccination strategies. The average difference between modelled vaccination coverage and field data was 3.8% (2.3%–5.3%). Central point vaccination was the most cost-effective vaccination strategy when >88% of the dog population was confined. More active methods of vaccination, such as door-to-door or capture-vaccinate-release, achieved higher vaccination coverage in free-roaming dog populations but were more costly. This open-access tool can aid in planning more efficient vaccination campaigns in countries with limited resources.

Quantifying the risk of rabies in biting dogs in Haiti

Rabies is a fatal viral disease typically transmitted through the bite of rabid animal. Domestic dogs cause over 99% of human rabies deaths. Over half of the world's population lives in a country where the canine rabies virus variant is endemic and dog bites are common. An estimated 29 million people worldwide receive post-bite vaccination after being exposed to animals suspected of rabies. Accurate and timely risk assessment of rabies in biting dogs is critical to ensure that rabies PEP is administered to all persons with a suspected rabies exposure, while avoiding PEP administration in situations where rabies can be definitively ruled out. In this study, a logistic regression model was developed to quantify the risk of rabies in biting dogs, using data from Haiti's animal rabies surveillance program. Significant risk factors identified in the model were used to quantify the probability of rabies in biting dogs. The risk of rabies in a biting dog as assessed through Haiti's rabies surveillance program was highly elevated when the dog displayed hypersalivation (OR = 34.6, 95% CI 11.3-106.5) or paralysis (OR = 19.0, 95% CI 4.8-74.8) and when the dog was dead at the time of the assessment (OR = 20.7, 95% CI 6.7-63.7). Lack of prior rabies vaccination, biting 2 or more people, and if the dog was a puppy also increased the probability that a biting dog would have rabies. The model showed high sensitivity (100%) and specificity (97%) when examined using validation data. This model enables us to project the risk of rabies in biting dogs in Haiti shortly after the bite event and make provisional PEP recommendations prior to laboratory testing or dog quarantine results. Application of this model may improve adherence to PEP for bite victims who can be educated on the quantitative risk of the exposure event. This model can also be used to reduce unnecessary PEP costs when the risk of rabies is determined as sufficiently low and the animal is available for observation.

Socio-spatial heterogeneity in participation in mass dog rabies vaccination campaigns, Arequipa, Peru

To control and prevent rabies in Latin America, mass dog vaccination campaigns (MDVC) are implemented mainly through fixed-location vaccination points: owners have to bring their dogs to the vaccination points where they receive the vaccination free of charge. Dog rabies is still endemic in some Latin-American countries and high overall dog vaccination coverage and even distribution of vaccinated dogs are desired attributes of MDVC to halt rabies virus transmission. In Arequipa, Peru, we conducted a door-to-door post-campaign survey on >6,000 houses to assess the placement of vaccination points on these two attributes. We found that the odds of participating in the campaign decreased by 16% for every 100 m from the owner’s house to the nearest vaccination point (p = 0.041) after controlling for potential covariates. We found social determinants associated with participating in the MDVC: for each child under 5 in the household, the odds of participating in the MDVC decreased by 13% (p = 0.032), and for each decade less lived in the area, the odds of participating in the MDVC decreased by 8% (p<0.001), after controlling for distance and other covariates. We also found significant spatial clustering of unvaccinated dogs over 500 m from the vaccination points, which created pockets of unvaccinated dogs that may sustain rabies virus transmission. Understanding the barriers to dog owners’ participation in community-based dog-vaccination programs will be crucial to implementing effective zoonotic disease preventive activities. Spatial and social elements of urbanization play an important role in coverage of MDVC and should be considered during their planning and evaluation.

In Peru and other dog rabies-affected countries, mass dog vaccination campaigns (MDVC) are implemented primarily through fixed-location vaccination points: owners have to bring their dogs to the vaccination points where they receive the vaccination. To stop rabies virus transmission, a high and even dog vaccination coverage is desired. In Arequipa, Peru, following a MDVC, we conducted a door-to-door survey of >6,000 houses to assess how the placement of vaccination points affected coverage of the campaign. When comparing dog owners with similar characteristics, we found that the odds of participating in the MDVC was reduced by 16% for every 100 m distance from the nearest vaccination point. Some social conditions were also associated with participating in the MDVC: for each child under 5 in the household, odds of participating in the MDVC decreased by 13%, and for each decade less lived in the area, the odds of participating in the MDVC decreased by 8%. Distance to the vaccination point and variation in social conditions across the city play important roles in achieving coverage of MDVC and should be considered during campaign planning and evaluation.

Impact of Integrating Rabies Education Into the Curriculum of Public Elementary Schools in Ilocos Norte, Philippines on Rabies Knowledge, and Animal Bite Incidence

As part of a province wide rabies elimination program, rabies specific information was integrated into the curriculum of all public elementary schools in Ilocos Norte, Philippines using a specifically developed teachers' manual. The rabies educational messages included rabies, animal bite prevention, bite management and responsible pet ownership and were integrated into lessons in several subjects. Four elementary schools were randomly selected and an assessment of the change in student's rabies knowledge and animal bite incidence were conducted. The study tested all students in grades 1-5 before the curriculum integration was implemented and retested these cohorts 1 year later, after implementation. Awareness of rabies was high before the implementation, likely due to the province-wide elimination campaign. However, awareness still increased significantly across all schools, and detailed knowledge of rabies increased significantly in all but one school and age cohort. Bite incidence in the 6 months prior to each survey was also recorded and the percentage of students suffering animal bites fell significantly between the two tests. The data suggested that knowledge increase correlated with decreased bite incidence in some groups but not all, suggesting a more complex relationship between knowledge acquisition and behavioral change which warrants further investigation.

A community-based knowledge, attitude, and practice survey on rabies among cattle owners in selected areas of Bhutan

Rabies remains a disease of significant zoonotic and economic concern in rabies endemic areas of Bhutan. Rabies outbreaks in livestock threaten the livelihoods of subsistence farming communities and pose a potential public health threat. As a part of identifying approaches to prevent rabies in cattle, a Knowledge, Attitude, and Practice (KAP) survey was conducted among cattle owners in selected rural areas of the southern rabies high-risk zone and low-risk zone in eastern Bhutan. Between March and April 2017, 562 cattle owners (281 in the east and 281 in the south) were interviewed using a questionnaire. Eighty-eight percent of the participants had heard of rabies but only 39% of the participants who had heard of rabies had adequate knowledge about rabies. Multivariable logistic regression analysis showed that residing in the south [OR = 9.25 (95% CI: 6.01-14.53)] and having seen a rabies case [OR = 2.46 (95% CI: 1.6-3.82)] were significantly associated with having adequate knowledge about rabies. Based on our scoring criteria, 65% of the total participants who had heard of rabies had a favorable attitude towards rabies control and prevention programs. The participants residing in the east were two times more likely to have a favourable attitude than their counterparts in the south [OR = 2.08 (95% CI: 1.43-3.05)]. More than 70% of the participants reported engaging in farm activities such as examining the oral cavity of sick cattle and assisting cattle during parturition. Only 25% of the participants reported using personal protective equipment while undertaking these activities. Despite a high level of rabies awareness, we observed that there is a lack of comprehensive knowledge about rabies regarding susceptible hosts, transmission routes, the health outcome of rabies infection in humans, and appropriate health-seeking behaviours. This study highlights the need to strengthen rabies education programs in rural communities to address the knowledge gaps that have been identified.

On the path to rabies elimination: The need for risk assessments to improve administration of post-exposure prophylaxis

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Incidence of bite-injury patients and costs of PEP are high in Bohol Province, Philippines.

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Dog vaccination has controlled rabies so few patients (<2%) are bitten by rabid dogs.

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Risk assessments with bite patients can identify potential rabid dog bites.

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Investigations triggered by patient risk assessments enable early detection of rabies.

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This One health approach to surveillance could guide judicious PEP provision and improve PEP access.

Background

Costs of rabies post-exposure prophylaxis (PEP) often remain high in regions where rabies has been controlled in dogs, presenting a challenge for sustaining rabies elimination programmes. We investigated the potential for bite patient risk assessments to improve PEP provision and surveillance in settings approaching elimination of dog-mediated rabies.

Methods

We conducted a longitudinal study of patients presenting to animal bite treatment centres (ABTCs) on the island province of Bohol in the Philippines to investigate the health status of biting dogs and to quantify current expenditure on PEP.

Results

Incidence of bite patients presenting to ABTCs was high (>300/100,000 persons/year) and increasing, resulting in substantial health provider costs. Over $142,000 was spent on PEP in 2013 for a population of 1.3 million. From follow up of 3820 bite patients we found that  >92% were bitten by healthy dogs (alive 14 days after the bite) and just 1.4% were bitten by probable or confirmed rabid dogs. The status of dogs that bit 6% of patients could not be determined. During the course of investigations of bites by suspect dogs, we were able to obtain samples for case confirmation, identify exposed persons who had not sought PEP as well as in-contact dogs at risk of developing rabies. We calculate that expenditure on PEP could at least be halved through more judicious approaches to provision of PEP, based on the histories of biting animals determined through risk assessments with bite patients.

Conclusions

We conclude that a One Health approach to surveillance based on Integrated Bite Case Management could improve the sustainability and effectiveness of rabies elimination programmes while also improving patient care by identifying those genuinely in need of lifesaving PEP.

Characteristics of One Health surveillance systems: A systematic literature review

The concept of One Health (OH) promotes the decompartmentalisation of human, animal, and ecosystem health for the more efficient and sustainable governance of complex health issues. This means that traditional boundaries between disciplines and sectors must be transgressed and that all relevant stakeholders must be involved in the definition and management of health problems. International efforts have been made to strengthen collaboration across sectors and disciplines and OH surveillance is strongly encouraged at global, national and local-level to efficiently manage hazards involving humans, animals and ecosystems. This concept is intuitively appealing and would suggest the enhanced performance and cost-effectiveness of surveillance systems, as compared to more conventional approaches. Nevertheless, confusion and uncertainty regarding the practical application, outcomes and impacts prevail. We believe that this is due to the lack of a conceptual and methodological framework which would (i) define the characteristics of OH surveillance, and (ii) identify the appropriate mechanisms for inter-sectoral and multi-disciplinary collaboration, to ensure that the surveillance system performs well, with regard to the objective, the context and the health hazard under surveillance. The objective of the study is to define the organisational and functional characteristics of OH surveillance systems, the context in which they are implemented, as well as the influential factors which may obstruct or support their implementation and performance. To achieve this, a systematic literature review of existing OH surveillance systems was conducted using the Prisma guidelines. The selected systems were assessed according to 38 predetermined variables. These allowed the characterisation of their objectives, organisation, functioning, performance and benefits. Data extraction was conducted using a spreadsheet and a database was built using an electronic multiple-choice questionnaire. The literature search identified a total of 1635 records. After the screening phase, 31 references were kept and 22 additional references retrieved from bibliographies were added. From these 53 selected documents, we retrieved 41 different surveillance systems in line with the definition proposed in this study. The analysis of this database enabled the identification of different dimensions and areas of collaboration. Barriers and levers for the implementation of OH surveillance systems were also identified and discussed. Based on our results, we propose a framework to characterise the organisation of collaboration for the governance and operation of an effective OH surveillance system.

Improving systematic rabies surveillance in Cameroon: A pilot initiative and results for 2014-2016

Canine rabies is endemic in Cameroon, but human rabies exposures and cases are likely underreported because of inadequate surveillance. In 2014, the surveillance network in the West region of Cameroon was reinforced by introducing a new anti-rabies center, a framework for data collection and evaluation, provisions for sample collecting and laboratory confirmation, and training for health professionals. The objective of this observational cohort study was to describe the incidence and characteristics of reported exposures and human and animal rabies cases following this reinforcement of the existing rabies surveillance system. The surveillance network consisted of local, regional, and national health and veterinary authorities in 11 of the 20 West region districts, and was completely integrated within the existing national rabies surveillance network. Animal exposures and suspected rabies exposures, the suspected rabid animals involved, and laboratory confirmation of human and animal rabies cases were recorded in a centralized information database. Between January 2014 and June 2016, the network recorded 1340 animal exposure cases for an overall incidence rate of 38.2 animal exposures per 100,000 people, four confirmed rabies-positive animals, and one confirmed human rabies case out of four clinically suspected cases. In contrast, 62 animal exposures and an overall incidence rate of 6.1 exposures per 100,000 people were reported for the West region districts not participating in the reinforced surveillance. Of the 925 animal exposure victims for whom a detailed case report form was completed, 703 were considered to be at risk of rabies and only 428 (61%) of these received any post-exposure prophylaxis in the form of rabies vaccine. Obstacles encountered within the network included low rates of animal sample submission and animal follow-up by veterinarians. Reinforced rabies surveillance in the West region of Cameroon has provided the most accurate estimate of the region's disease and exposure burdens to date, and indicates that animal exposures are substantially underreported. The reinforced network also signaled that greater access to post-exposure prophylaxis is needed. Integration of regions not covered by the surveillance network and efforts to improve engagement of veterinary services will be needed to reveal the true burden of rabies in Cameroon.

An exploratory study on rabies exposure through contact tracing in a rural area near Bengaluru, Karnataka, India

NEED FOR STUDY

Rabies is a neglected zoonotic disease. Given the low incidence, apart from the existing reporting syst, there is a need to look for other means of case detection strategies for rabies. Contact tracing is one such method to efficiently capture information.

OBJECTIVES

To find out the rabid status of biting animal through contact tracing and to determine health seeking behavior of the bite victims.

MATERIALS AND METHODS

An exploratory study using contact tracing was conducted during the first quarter of 2017 in villages coming under three Public Health Centers. The households of the bite victims were visited and details of rabies exposure obtained from the bite victim/ adult responsible respondent using a standardized questionnaire.

RESULTS

A total of 69 dog/cat bite cases were identified. 69.5% of bites were by stray dogs. 97.1% bite victims had Category III bites. Only 4.5% bite victims had taken PEP. 70.1% of animal bite cases were administered ARV. Only 7.2% bite victims had exposure to probable rabid animals. All dog bite victims were alive after 3 months of follow up.

CONCLUSION

Contact tracing was successful in case detection of probable rabid animal exposures and suitable for a period of one year.

The epidemiology of dog rabies in Algeria: Retrospective national study of dog rabies cases, determination of vaccination coverage and immune response evaluation of three commercial used vaccines

Rabies is a neglected zoonotic disease. Several animal species can transmit rabies, but domestic dogs are the main reservoir implicated in rabies transmission to human and other susceptible animals. There is a scarcity of data regarding canine rabies in Algeria. Hence, this report is the first study that attempts to understand the epidemiology of dog rabies through a retrospective national study of rabies cases between 2010 and 2016, determination of canine vaccination coverage and evaluation of immune response of three rabies commercial vaccines used in Algeria. Our results revealed the persistent nature of dog rabies in Algeria; with a mean of 131 positive cases per year. The vaccination coverage findings indicated that 30.81% (126/409) of the reported vaccinated dog and 47.98% (261/544) of all studied dogs presented low level of rabies antibodies titres (less than 0.5 IU), and were therefore considered not immune to rabies. Additionally, our vaccine evaluation findigs showed a weak immune response of inactivated vaccine without adjuvant. Even with adjuvanted inactivated and attenuated live vaccines, several vaccinated dogs did not develop vaccine protection. Therefore, our results recommend further studies to test the efficiency of adding a booster vaccine shot, especially in primo-vaccinated dogs to optimize the vaccination protocol; rabies is potentially fatal zoonosis, tolerating no vaccine failure. Moreover, the present study establish the necessity to re-examine the national rabies control program, implemented in 1996, particularly concerning population education, vaccination strategy, surveillance and campaigns monitoring.

Understanding Factors Influencing Dog Owners' Intention to Vaccinate Against Rabies Evaluated Using Health Belief Model Constructs

Ethiopia has one of the highest incidence levels of human rabies in Africa, with 3-7 deaths per 100,000 people annually. The country has no official rabies control programme, despite the availability of an effective canine vaccine to control rabies. To support effective rabies control, an understanding of the factors affecting dog owners' voluntary intentions to vaccinate their dogs is important. As such, this study examined factors influencing dog owners' intentions to vaccinate their dogs using the constructs of health belief theory. In this cross-sectional study, a questionnaire, designed based on the Health Belief Model constructs was completed by 249 dog owners in 9 randomly selected wards of Bishoftu town in central Ethiopia between October and December 2016. An ordinal regression model was then fitted to explore factors which best predict the likelihood of a dog owner's intention. A classification and regression tree (CART) model was then used for recursive partitioning of the Likert scale in the significant variables to distinctively classify ordinal categories of vaccination intention. Participants' preventive intention was associated with the six constructs of the Health Belief Model: perceived susceptibility, readiness to action, self-efficacy, perceived threat, benefits, and barriers. Dog owner's knowledge about rabies was found to be positively associated with intention to vaccinate, whereas distance from vaccination centers and difficulty of dog transportation were found to be negatively associated to intention to vaccinate. Distance from vaccination center was found to be the best predictor for the intention to vaccinate. The results of this study have policy implications for controlling rabies including increasing dog owners' knowledge about rabies, locating vaccination centers at shorter distances from dog populations and providing suitable means to transport dogs to vaccination centers.

Meeting the urgent need for rabies education in Haiti

The highest rate of human rabies deaths reported in the Americas is in Haiti, and most of these deaths result from rabies virus infections that occur after individuals are bitten by infected dogs and do not receive rabies post-exposure prophylaxis. One barrier to rabies prevention in Haiti is a lack of knowledge about this disease among healthcare professionals and community members. During the past 4 years, The US Centers for Disease Control and Prevention has collaborated with public health officials and partners to develop, test and refine educational materials aimed at filling this need for rabies education. This report summarizes the use of feedback from knowledge, attitudes and practises surveys; key informant interviews; and focus groups to develop culturally appropriate rabies prevention materials for community members, health officials, clinicians, laboratory professionals, veterinary professionals, government officials and national and local district leaders about ways to prevent rabies. These formative research methods were critically important in ensuring that the materials would be culturally appropriate and would stand the greatest likelihood of motivating Haitians to protect themselves from rabies. Centers for Disease Control and Prevention is using lessons learned in Haiti to develop and test materials in other countries with high rates of canine rabies.

Effect of counselling on health-care-seeking behaviours and rabies vaccination adherence after dog bites in Haiti, 2014-15: a retrospective follow-up survey

BACKGROUND

Haiti has an integrated bite case management (IBCM) programme to counsel animal-bite victims on the risk of rabies and appropriate treatment, as well as the Haiti Animal Rabies Surveillance Program (HARSP) to examine the animals. We assessed the usefulness of the IBCM programme to promote best practices for rabies prophylaxis after exposure in a low-income rabies-endemic setting.

METHODS

We did a retrospective follow-up survey of randomly selected bite victims who were counselled by Haiti's IBCM programme between May 15, 2014, and Sept 15, 2015. We classified participants by HARSP decisions of confirmed, probable, suspected, or non-rabies exposures. We compared health-care outcomes in people who sought medical care before IBCM counselling with those in people who sought care after counselling. We used decision trees to estimate the probability of actions taken in the health-care system, and thereby human deaths.

FINDINGS

During the study period, 1478 dog bites were reported to HARSP for assessment. 37 (3%) were confirmed exposures, 76 (5%) probable exposures, 189 (13%) suspected exposures, and 1176 (80%) non-rabies exposures. 115 of these cases were followed up in the survey. IBCM counselling was associated with a 1·2 times increase in frequency of bite victims seeking medical care and of 2·4 times increase in vaccination uptake. We estimated that there would be four human rabies deaths among the 1478 people assessed by IBCM during the survey period, and 11 in the absence of this programme, which would equate to a 65% decrease in rabies deaths. Among three people dead at the time of the follow-up survey, one was deemed to be due to rabies after a probable rabies exposure.

INTERPRETATION

Adherence to medical providers' recommendations might be improved through counselling provided by IBCM programmes.

FUNDING

None.

Protecting children from rabies with education and pre-exposure prophylaxis: A school-based campaign in El Nido, Palawan, Philippines

BACKGROUND

Rabies remains endemic in the Philippines. A study was conducted in El Nido, Palawan, Philippines to: (i) detect the true incidence of animal bites in school children aged 5-14 years using active surveillance and compare these data to estimates from the existing passive surveillance system, (ii) evaluate the impact of rabies prevention education and pre-exposure prophylaxis (PrEP) on animal bite incidence, and (iii) assess the health economic impact of the interventions.

METHODOLOGY AND PRINCIPAL FINDINGS

A cohort of 4,700 school children was followed-up for any suspect rabies exposures between January 2011 and December 2012. Data on animal bite incidence from the study cohort were compared to that obtained from a review of consultation records at the Animal Bite Treatment Center (ABTC). PrEP was offered to children in all 27 public elementary schools in El Nido (in January to February 2012). Teachers were given a manual for integrating rabies in the public elementary school curriculum during the school year 2012-13. Active surveillance of the cohort revealed a higher incidence of suspect rabies exposures than that from passive surveillance. Despite a decrease in the number of Category III bites, there was no significant decrease in overall bite incidence as a result of the interventions. However, there was an increase in rabies awareness among school children in all grade levels. There was also a high level of acceptability of PrEP. Children who received PrEP and subsequently were bitten only needed two booster doses for post-exposure prophylaxis, resulting in substantial cost-savings.

CONCLUSIONS/SIGNIFICANCE

The true burden of animal bites remains underestimated in ABTC records. PrEP is advantageous in selected population groups, i.e. school-aged children in rabies endemic areas with limited access to animal and human rabies prevention services. Educating school children is beneficial. Strengthening veterinary interventions to target the disease at source is important.

Assessing the impact of public education on a preventable zoonotic disease: rabies

Effective methods to increase awareness of preventable infectious diseases are key components of successful control programmes. Rabies is an example of a disease with significant impact, where public awareness is variable. A recent awareness campaign in a rabies endemic region of Azerbaijan provided a unique opportunity to assess the efficacy of such campaigns. A cluster cross-sectional survey concerning rabies was undertaken following the awareness campaign in 600 households in 38 randomly selected towns, in districts covered by the campaign and matched control regions. This survey demonstrated that the relatively simple awareness campaign was effective at improving knowledge of rabies symptoms and vaccination schedules. Crucially, those in the awareness campaign group were also 1·4 times more likely to report that they had vaccinated their pets, an essential component of human rabies prevention. In addition, low knowledge of appropriate post-exposure treatment and animal sources of rabies provide information useful for future public awareness campaigns in the region and other similar areas.

Rabies

Rabies is a life-threatening neglected tropical disease: tens of thousands of cases are reported annually in endemic countries (mainly in Africa and Asia), although the actual numbers are most likely underestimated. Rabies is a zoonotic disease that is caused by infection with viruses of the Lyssavirus genus, which are transmitted via the saliva of an infected animal. Dogs are the most important reservoir for rabies viruses, and dog bites account for >99% of human cases. The virus first infects peripheral motor neurons, and symptoms occur after the virus reaches the central nervous system. Once clinical disease develops, it is almost certainly fatal. Primary prevention involves dog vaccination campaigns to reduce the virus reservoir. If exposure occurs, timely post-exposure prophylaxis can prevent the progression to clinical disease and involves appropriate wound care, the administration of rabies immunoglobulin and vaccination. A multifaceted approach for human rabies eradication that involves government support, disease awareness, vaccination of at-risk human populations and, most importantly, dog rabies control is necessary to achieve the WHO goal of reducing the number of cases of dog-mediated human rabies to zero by 2030.

The Health Impact of Rabies in Haiti and Recent Developments on the Path Toward Elimination, 2010-2015

Haiti, a Caribbean country of 10.5 million people, is estimated to have the highest burden of canine-mediated human rabies deaths in the Western Hemisphere, and one of the highest rates of human rabies deaths in the world. Haiti is also the poorest country in the Western Hemisphere and has numerous economic and health priorities that compete for rabies-control resources. As a result, primary rabies-control actions, including canine vaccination programs, surveillance systems for human and animal rabies, and appropriate postbite treatment, have not been fully implemented at a national scale. After the 2010 earthquake that further hindered the development of public health program infrastructure and services, the U.S. Centers for Disease Control and Prevention worked with the Ministry of Public Health and Population and key health development partners (including the Pan-American Health Organization) to provide technical expertise and funding for general disease surveillance systems, laboratory capacity, and selected disease control programs; including rabies. In 2011, a cross-ministerial rabies consortium was convened with participation from multiple international rabies experts to develop a strategy for successful rabies control in Haiti. The consortium focused on seven pillars: 1) enhancement of laboratory diagnostic capacity, 2) development of comprehensive animal surveillance system, 3) development of comprehensive human rabies surveillance system, 4) educational outreach, 5) sustainable human rabies biologics supply, 6) achievement of sustained canine vaccination rates of ≥ 70%, and 7) finalization of a national rabies control strategy. From 2010 until 2015, Haiti has seen improvements in the program infrastructure for canine rabies control. The greatest improvements were seen in the area of animal rabies surveillance, in support of which an internationally recognized rabies laboratory was developed thereby leading to an 18-fold increase in the detection of rabid animals. Canine rabies vaccination practices also improved, from a 2010 level of approximately 12% to a 2015 dog population coverage level estimated to be 45%. Rabies vaccine coverage is still below the goal of 70%, however, the positive trend is encouraging. Gaps exist in the capacity to conduct national surveillance for human rabies cases and access to human rabies vaccine is lacking in many parts of the country. However, control has improved over the past 5 years as a result of the efforts of Haiti’s health and agriculture sectors with assistance from multiple international organizations. Haiti is well situated to eliminate canine-mediated human rabies deaths in the near future and should serve as a great example to many developing countries struggling with similar barriers and limitations.

Systematic Review: Interventions to Educate Children About Dog Safety and Prevent Pediatric Dog-Bite Injuries: A Meta-Analytic Review

Objective

Dog-bite injury posits a significant threat to children globally. This review evaluated efficacy of cognitive/behavioral interventions for improving children's knowledge and behaviors around dogs.

Methods

Manuscripts published before January 3, 2014 evaluating cognitive/behavioral interventions for dog-bite prevention among children <18 years of age were eligible for inclusion. Among 2,270 abstracts screened, 123 full texts were retrieved. Twelve studies were included in the qualitative synthesis; nine were included in the meta-analysis. Risk of bias and quality of evidence were evaluated.

Results

Cognitive/behavioral interventions had a moderate effect in improving children's knowledge and a larger effect in improving children's behavior with dogs. The most effective intervention strategies were video for knowledge and instruction with live dogs for behaviors. Quality of evidence was poor.

Conclusions

Cognitive/behavioral interventions have potential to improve both children's knowledge and behaviors around dogs. Future interventions should include multiple follow-ups on dog-bite rates from an international perspective using rigorous randomized controlled trials.

The Role of Dog Population Management in Rabies Elimination-A Review of Current Approaches and Future Opportunities

Free-roaming dogs and rabies transmission are integrally linked across many low-income countries, and large unmanaged dog populations can be daunting to rabies control program planners. Dog population management (DPM) is a multifaceted concept that aims to improve the health and well-being of free-roaming dogs, reduce problems they may cause, and may also aim to reduce dog population size. In theory, DPM can facilitate more effective rabies control. Community engagement focused on promoting responsible dog ownership and better veterinary care could improve the health of individual animals and dog vaccination coverage, thus reducing rabies transmission. Humane DPM tools, such as sterilization, could theoretically reduce dog population turnover and size, allowing rabies vaccination coverage to be maintained more easily. However, it is important to understand local dog populations and community attitudes toward them in order to determine whether and how DPM might contribute to rabies control and which DPM tools would be most successful. In practice, there is very limited evidence of DPM tools achieving reductions in the size or turnover of dog populations in canine rabies-endemic areas. Different DPM tools are frequently used together and combined with rabies vaccinations, but full impact assessments of DPM programs are not usually available, and therefore, evaluation of tools is difficult. Surgical sterilization is the most frequently documented tool and has successfully reduced dog population size and turnover in a few low-income settings. However, DPM programs are mostly conducted in urban settings and are usually not government funded, raising concerns about their applicability in rural settings and sustainability over time. Technical demands, costs, and the time necessary to achieve population-level impacts are major barriers. Given their potential value, we urgently need more evidence of the effectiveness of DPM tools in the context of canine rabies control. Cheaper, less labor-intensive tools for dog sterilization will be extremely valuable in realizing the potential benefits of reduced population turnover and size. No one DPM tool will fit all situations, but if DPM objectives are achieved dog populations may be stabilized or even reduced, facilitating higher dog vaccination coverages that will benefit rabies elimination efforts.

The Road to Dog Rabies Control and Elimination-What Keeps Us from Moving Faster?

Rabies, a vaccine preventable neglected tropical disease, still claims an estimated 35,000-60,000 human lives annually. The international community, with more than 100 endemic countries, has set a global target of 0 human deaths from dog-transmitted rabies by 2030. While it has been proven in several countries and regions that elimination of rabies as a public health problem is feasible and tools are available, rabies deaths globally have not yet been prevented effectively. While there has been extensive rabies research, specific areas of implementation for control and elimination have not been sufficiently addressed. This article highlights some of the commonest perceived barriers for countries to implementing rabies control and elimination programs and discusses possible solutions for sociopolitical, organizational, technical, and resource-linked requirements, following the pillars of the global framework for the elimination of dog-mediated human rabies adopted at the global rabies meeting in December 2015.

Estimating the intra-cluster correlation coefficient for evaluating an educational intervention program to improve rabies awareness and dog bite prevention among children in Sikkim, India: A pilot study

BACKGROUND

Educational initiatives targeting at-risk populations have long been recognized as a mainstay of ongoing rabies control efforts. Cluster-based studies are often utilized to assess levels of knowledge, attitudes and practices of a population in response to education campaigns. The design of cluster-based studies requires estimates of intra-cluster correlation coefficients obtained from previous studies. This study estimates the school-level intra-cluster correlation coefficient (ICC) for rabies knowledge change following an educational intervention program.

METHODS

A cross-sectional survey was conducted with 226 students from 7 schools in Sikkim, India, using cluster sampling. In order to assess knowledge uptake, rabies education sessions with pre- and post-session questionnaires were administered. Paired differences of proportions were estimated for questions answered correctly. A mixed effects logistic regression model was developed to estimate school-level and student-level ICCs and to test for associations between gender, age, school location and educational level.

RESULTS

The school- and student-level ICCs for rabies knowledge and awareness were 0.04 (95% CI: 0.01, 0.19) and 0.05 (95% CI: 0.2, 0.09), respectively. These ICCs suggest design effect multipliers of 5.45 schools and 1.05 students per school, will be required when estimating sample sizes and designing future cluster randomized trials. There was a good baseline level of rabies knowledge (mean pre-session score 71%), however, key knowledge gaps were identified in understanding appropriate behavior around scared dogs, potential sources of rabies and how to correctly order post rabies exposure precaution steps. After adjusting for the effect of gender, age, school location and education level, school and individual post-session test scores improved by 19%, with similar performance amongst boys and girls attending schools in urban and rural regions. The proportion of participants that were able to correctly order post-exposure precautionary steps following educational intervention increased by 87%.

CONCLUSION

The ICC estimates presented in this study will aid in designing cluster-based studies evaluating educational interventions as part of disease control programs. This study demonstrates the likely benefits of educational intervention incorporating bite prevention and rabies education.

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.

Barriers to dog rabies vaccination during an urban rabies outbreak: Qualitative findings from Arequipa, Peru

Background

Canine rabies was reintroduced to the city of Arequipa, Peru in March 2015. The Ministry of Health has conducted a series of mass dog vaccination campaigns to contain the outbreak, but canine rabies virus transmission continues in Arequipa’s complex urban environment, putting the city’s 1 million inhabitants at risk of infection. The proximate driver of canine rabies in Arequipa is low dog vaccination coverage. Our objectives were to qualitatively assess barriers to and facilitators of rabies vaccination during mass campaigns, and to explore strategies to increase participation in future efforts.

Methodology/Principal findings

We conducted 8 focus groups (FG) in urban and peri-urban communities of Mariano Melgar district; each FG included both sexes, and campaign participants and non-participants. All FG were transcribed and then coded independently by two coders. Results were summarized using the Social Ecological Model. At the individual level, participants described not knowing enough about rabies and vaccination campaigns, mistrusting the campaign, and being unable to handle their dogs, particularly in peri-urban vs. urban areas. At the interpersonal level, we detected some social pressure to vaccinate dogs, as well as some disparaging of those who invest time and money in pet dogs. At the organizational level, participants found the campaign information to be insufficient and ill-timed, and campaign locations and personnel inadequate. At the community level, the influence of landscape and topography on accessibility to vaccination points was reported differently between participants from the urban and peri-urban areas. Poor security and impermanent housing materials in the peri-urban areas also drives higher prevalence of guard dog ownership for home protection; these dogs usually roam freely on the streets and are more difficult to handle and bring to the vaccination points.

Conclusions

A well-designed communication campaign could improve knowledge about canine rabies. Timely messages on where and when vaccination is occurring could increase dog owners’ perception of their own ability to bring their dogs to the vaccination points and be part of the campaign. Small changes in the implementation of the campaign at the vaccination points could increase the public’s trust and motivation. Location of vaccination points should take into account landscape and community concerns.

Canine rabies was reintroduced in Arequipa, Peru in March 2015, a rare event in an area previously declared free of transmission. In Arequipa, annual mass dog vaccination is practiced as a preventive strategy, with additional campaigns being implemented since the recent detection of the virus. However, these additional efforts have not quelled the outbreak and low dog vaccination coverage is driving ongoing transmission. We conducted focus groups in urban and peri-urban areas of Arequipa to identify barriers to and facilitators of canine vaccination during mass campaigns. Based on our findings, communication campaigns should seek to increase knowledge about canine rabies and the vaccination campaign, and provide timely messages on where and when vaccination is occurring. Small changes at the campaign’s vaccination points could increase public’s trust. Finally, there are differences between urban and peri-urban areas, such as landscape and topography that affect participation in mass vaccination campaigns and that should be considered when selecting locations for vaccination points.

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.

Rabies Control: Could Innovative Financing Break the Deadlock?

The neglected zoonotic diseases (NZDs) have been all but eradicated in wealthier countries but remain major causes of ill-health and mortality in over 80 countries across Africa, Asia, and Latin America. The nature of neglect for the NZDs has been ascribed, in part, to underreporting resulting in an underestimation of their global burden that, together with a lack of advocacy, downgrades their relevance to policy-makers and funding agencies. While this may be the case for many NZDs, for rabies this is not the case. The global burden estimates for rabies (931,600 DALYs) more than justify prioritizing rabies control building on the strong advocacy platforms, functioning at local, regional, and global levels (including the Global Alliance for Rabies Control), and commitments from WHO, OIE, and FAO. Simple effective tools for rabies control exist together with blueprints for operationalizing control, yet, despite elimination targets being set, no global affirmative action has been taken. Rabies control demands activities both in the short term and over a long period of time to achieve the desired cumulative gains. Despite the availability of effective vaccines and messaging tools, rabies will not be sustainably controlled in the near future without long-term financial commitment, particularly as disease incidence decreases and other health priorities take hold. While rabies control is usually perceived as a public good, public private partnerships could prove equally effective in addressing endemic rabies through harnessing social investment and demonstrating the cost-effectiveness of control. It is acknowledged that greater attention to navigating local realities in planning and implementation is essential to ensuring that rabies, and other neglected diseases, are controlled sustainably. In the shadows of resource and institutional limitations in the veterinary sector in low- and middle-income countries, sufficient funding is required so that top-down interventions for rabies can more explicitly engage with local project organization capacity and affected communities in the long term. Development Impact Bonds have the potential to secure the financing required to deliver effective rabies control.