Dog Population Rabies Immunity before a Mass Vaccination Campaign in Lima, Peru: Vulnerabilities for Virus Reestablishment.

Lima, Peru, has not had a case of canine rabies since 1999. However, Lima remains at risk of rabies reintroduction due to the free movement of dogs from nearby rabies-endemic areas. In Latin America, rabies vaccination campaigns must reach 80% of dogs to halt transmission, but estimates of vaccine coverage are often unavailable, unreliable, or inaccurate. Quantifying virus neutralizing antibodies (VNA) allows monitoring of the immunological status of the canine population, evaluation of the degree of humoral protection to the virus, and assessing, partially, the population response to vaccination. We evaluated the dog population's immunity level against the rabies virus before a mass vaccination campaign in Lima. We collected 141 canine blood samples in the district of Surquillo and quantified rabies virus neutralizing antibody titers using the fluorescent antibody virus neutralization test). We surveyed dogs owners to reconstruct canine vaccination histories. Among dogs previously vaccinated, 73.9% exceeded the seroconversion threshold of > 0.5 IU/mL. Among all dogs, only 58.2% reached the titer limit for seroconversion. Dogs ≤ 1 year old constituted 26.2% of the total canine population and had lower levels of VNA than dogs > 1 year old (χ2 = 9.071; P = 0.028). Importantly, dogs vaccinated with single-pathogen vaccines had higher levels of VNA than those who received combined-pathogen vaccines (χ2 = 7.721; P = 0.005). We provide an important and timely glimpse to the immunity status of the dog population in urban areas of Lima, a metropolis near a dog rabies-endemic region.

The Amazonian Tropical Bites Research Initiative, a hope for resolving zoonotic neglected tropical diseases in the One Health era.

BACKGROUND: Neglected tropical diseases (NTDs) disproportionately affect populations living in resource-limited settings. In the Amazon basin, substantial numbers of NTDs are zoonotic, transmitted by vertebrate (dogs, bats, snakes) and invertebrate species (sand flies and triatomine insects). However, no dedicated consortia exist to find commonalities in the risk factors for or mitigations against bite-associated NTDs such as rabies, snake envenoming, Chagas disease and leishmaniasis in the region. The rapid expansion of COVID-19 has further reduced resources for NTDs, exacerbated health inequality and reiterated the need to raise awareness of NTDs related to bites. METHODS: The nine countries that make up the Amazon basin have been considered (Bolivia, Brazil, Colombia, Ecuador, French Guiana, Guyana, Peru, Surinam and Venezuela) in the formation of a new network. RESULTS: The Amazonian Tropical Bites Research Initiative (ATBRI) has been created, with the aim of creating transdisciplinary solutions to the problem of animal bites leading to disease in Amazonian communities. The ATBRI seeks to unify the currently disjointed approach to the control of bite-related neglected zoonoses across Latin America. CONCLUSIONS: The coordination of different sectors and inclusion of all stakeholders will advance this field and generate evidence for policy-making, promoting governance and linkage across a One Health arena.

Sustaining communicable disease elimination efforts in the Americas in the wake of COVID-19.

The COVID-19 pandemic has disrupted implementation of health interventions and set back priority programs aiming to control and eliminate communicable diseases. At the same time, the pandemic has opened up opportunities to expedite innovations in health service delivery to increase effectiveness and position health on the development and political agendas of leaders and policy makers. In this context, we present an integrated, sustainable approach to accelerate elimination of more than 35 communicable diseases and related conditions in the region of the Americas. The Elimination Initiative promotes a life-course, person-centred approach based on four dimensions - preventing new infections, ending mortality and morbidity, and preventing disability - and four critical lines of action including strengthening health systems integration and service delivery, strengthening health surveillance and information systems, addressing environmental and social determinants of health, and furthering governance, stewardship, and finance. We present key actions and operational considerations according to each line of action that countries can take advantage of to further advance disease elimination in the region.

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

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

Bite Injuries among Vaccination Staff Participating in a Mass Canine Rabies Vaccination Campaign, Haiti 2016-2017.

Elimination of dog-transmitted human rabies worldwide will require large-scale dog vaccination campaigns. However, this places participating vaccinators at increased risk. Data from the 2016-2017 Haitian mass rabies vaccination campaign was analyzed to determine dog bite incidence among vaccinators. A survey was then developed for completion by all identifiable bitten vaccinators covering demographics; experience and training; bite episode details; attitudes toward dogs and rabies; and medical care. A parallel group of unbitten vaccinators was also surveyed. Dog bite incidence was 0.03% (43/127,000) of all dogs vaccinated. The capture, vaccinate, and release method of vaccination carried a significantly higher risk of dog bite (0.35%, 6/1,739 vaccinations) than other methods (P < 0.001). Twenty-seven bitten vaccinators, and 54 control vaccinators were included in the survey analysis. No differences were found between groups in demographics, experience, or training. However, bitten vaccinators were significantly more likely than the control group to have experienced a dog bite before the study period (P < 0.001). This may be associated with a lesser appreciation of dogs, and/or a poorer ability to interpret dog behavioral signals within this group. Although 98% of the control group indicated they would seek medical care for a dog bite, only 35% of bitten vaccinators sought such care. On a yearly basis, for the Haitian campaign, a full series of postexposure rabies vaccinations for all bite victims would prove more cost-effective than preexposure vaccination of all vaccinators. These findings may prove useful for the planning and safety of future mass dog vaccination campaigns.

One Health for neglected tropical diseases.

The forthcoming World Health Organization road map for neglected tropical diseases (NTDs) 2021-2030 recognises the complexity surrounding control and elimination of these 20 diseases of poverty. It emphasises the need for a paradigm shift from disease-specific interventions to holistic cross-cutting approaches coordinating with adjacent disciplines. The One Health approach exemplifies this shift, extending beyond a conventional model of zoonotic disease control to consider the interactions of human and animal health systems within their shared environment and the wider social and economic context. This approach can also promote sustainability and resilience within these systems. To achieve the global ambition on NTD elimination and control, political will, along with contextualised innovative scientific strategies, is required.

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

Domestic dogs are responsible for nearly all the ¼59,000 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.

Towards the elimination of dog-mediated rabies: development and application of an evidence-based management tool.

BACKGROUND: International organizations advocate for the elimination of dog-mediated rabies, but there is only limited guidance on interpreting surveillance data for managing elimination programmes. With the regional programme in Latin America approaching elimination of dog-mediated rabies, we aimed to develop a tool to evaluate the programme's performance and generate locally-tailored rabies control programme management guidance to overcome remaining obstacles. METHODS: We developed and validated a robust algorithm to classify progress towards rabies elimination within sub-national administrative units, which we applied to surveillance data from Brazil and Mexico. The method combines criteria that are easy to understand, including logistic regression analysis of case detection time series, assessment of rabies virus variants, and of incursion risk. Subjecting the algorithm to robustness testing, we further employed simulated data sub-sampled at differing levels of case detection to assess the algorithm's performance and sensitivity to surveillance quality. RESULTS: Our tool demonstrated clear epidemiological transitions in Mexico and Brazil: most states progressed rapidly towards elimination, but a few regressed due to incursions and control lapses. In 2015, dog-mediated rabies continued to circulate in the poorest states, with foci remaining in only 1 of 32 states in Mexico, and 2 of 27 in Brazil, posing incursion risks to the wider region. The classification tool was robust in determining epidemiological status irrespective of most levels of surveillance quality. In endemic settings, surveillance would need to detect less than 2.5% of all circulating cases to result in misclassification, whereas in settings where incursions become the main source of cases the threshold detection level for correct classification should not be less than 5%. CONCLUSION: Our tool provides guidance on how to progress effectively towards elimination targets and tailor strategies to local epidemiological situations, while revealing insights into rabies dynamics. Post-campaign assessments of dog vaccination coverage in endemic states, and enhanced surveillance to verify and maintain freedom in states threatened by incursions were identified as priorities to catalyze progress towards elimination. Our finding suggests genomic surveillance should become increasingly valuable during the endgame for discriminating circulating variants and pinpointing sources of incursions.

Defining New Pathways to Manage the Ongoing Emergence of Bat Rabies in Latin America.

Rabies transmitted by common vampire bats (Desmodus rotundus) has been known since the early 1900s but continues to expand geographically and in the range of species and environments affected. In this review, we present current knowledge of the epidemiology and management of rabies in D. rotundus and argue that it can be reasonably considered an emerging public health threat. We identify knowledge gaps related to the landscape determinants of the bat reservoir, reduction in bites on humans and livestock, and social barriers to prevention. We discuss how new technologies including autonomously-spreading vaccines and reproductive suppressants targeting bats might manage both rabies and undesirable growth of D. rotundus populations. Finally, we highlight widespread under-reporting of human and animal mortality and the scarcity of studies that quantify the efficacy of control measures such as bat culling. Collaborations between researchers and managers will be crucial to implement the next generation of rabies management in Latin America.

Integration of animal health and public health surveillance sources to exhaustively inform the risk of zoonosis: An application to echinococcosis in Rio Negro, Argentina.

The analysis of zoonotic disease risk requires the consideration of both human and animal geo-referenced disease incidence data. Here we show an application of joint Bayesian analyses to the study of echinococcosis granulosus (EG) in the province of Rio Negro, Argentina. We focus on merging passive and active surveillance data sources of animal and human EG cases using joint Bayesian spatial and spatio-temporal models. While similar spatial clustering and temporal trending was apparent, there appears to be limited lagged dependence between animal and human outcomes. Beyond the data quality issues relating to missingness at different times, we were able to identify relations between dog and human data and the highest 'at risk' areas for echinococcosis within the province.

[Situation of public laboratories manufacturing antivenoms in Latin AmericaA situação dos laboratórios públicos produtores de soros antivenenos na América Latina]. / Situación de los laboratorios públicos productores de antivenenos en América Latina.

The situation of public laboratories manufacturing antivenoms in Latin America was analyzed, based on the results of a workshop coordinated by the Pan American Foot-and-Mouth Disease Center (PANAFTOSA) of the Pan American Health Organization (PAHO). Nine countries in the region have 12 public laboratories that produce and distribute antivenoms for use against different venomous animals. The situation of each laboratory was discussed, and an analysis was conducted of the current scenario, which is characterized by increasing regulatory requirements that vary in terms of infrastructure and production capacity. The authors identified a need to organize regional cooperation processes to improve the availability of antivenoms, including: research and development projects to improve processes and technologies; studies of the capacity of antivenoms to neutralize different poisons; and technical training programs for professionals and technical personnel. In the current context, in which the World Health Organization has prepared a global strategy for the prevention and control of snakebite envenoming, PANAFTOSA has taken on coordination of this initiative in the Americas. Improving the availability of antivenoms is the priority. As a result of the workshop, the RELAPA network was created, bringing together public laboratories that manufacture antivenoms in Latin America, in order to strengthen these laboratories and increase the availability of, and access to effective and safe antivenoms throughout Latin America.

A situação dos laboratórios públicos produtores de soros antivenenos na América Latina foi analisada com base nas conclusões de um seminário coordenado pelo Centro Pan-Americano de Febre Aftosa (PANAFTOSA) da Organização Pan-Americana da Saúde (OPAS). Em nove países da Região, encontram-se 12 laboratórios públicos que produzem e distribuem soros contra venenos de diferentes animais peçonhentos. Examinou-se a situação de cada laboratório, analisou-se o panorama atual marcado por crescentes demandas de regulação e pela heterogeneidade da infraestrutura e capacidade produtiva dos laboratórios e destacou-se a necessidade de um esforço concertado de cooperação regional com vistas a aumentar a disponibilidade de soros antivenenos, englobando projetos de pesquisa e desenvolvimento para o avanço dos processos e tecnologias, estudos do perfil da capacidade de neutralização dos soros contra diversos venenos e programas de capacitação técnica de profissionais e pessoal técnico. No contexto atual, em que uma estratégia mundial de prevenção e controle de acidentes ofídicos foi elaborada pela Organização Mundial da Saúde e que a coordenação das ações relacionadas na Região das Américas foi assumida pelo PANAFTOSA, melhorar a disponibilidade de soros antivenenos é prioridade. Como resultado deste seminário, a Rede de Laboratórios Públicos Produtores de Soros Antivenenos da América Latina (RELAPA) foi formada com o objetivo de fortalecer os laboratórios e aumentar a disponibilidade e a acessibilidade de soros antivenenos eficazes e seguros em toda América Latina.

An evaluation of Brazil's surveillance and prophylaxis of canine rabies between 2008 and 2017.

An effective surveillance system is critical for the elimination of canine rabies in Latin America. Brazil has made substantial progress towards canine rabies elimination, but outbreaks still occurred in the last decade in two states. Brazil uses a health information system (SINAN) to record patients seeking post-exposure prophylaxis (PEP) following contact with an animal suspected of having rabies. This study evaluated: (i) whether SINAN can be reliably used for rabies surveillance; (ii) if patients in Brazil are receiving appropriate PEP and (iii) the benefits of implementing the latest World Health Organization (WHO) recommendations on PEP. Analysing SINAN records from 2008 to 2017 reveals an average of 506,148 bite-injury patients/year [range: 437k-545k] in the country, equivalent to an incidence of 255 bite-injuries/100,000 people/year [range: 231-280]. The number of reports of bites from suspect rabid dogs generally increased over time. In most states, records from SINAN indicating a suspect rabid dog do not correlate with confirmed dog rabies cases reported to the Regional Information System for Epidemiological Surveillance of Rabies (SIRVERA) maintained by the Pan American Health Organization (PAHO). Analyses showed that in 2017, only 45% of patients received appropriate PEP as indicated by the Brazilian Ministry of Health guidance. Implementation of the latest WHO guidance using an abridged intradermal post-exposure vaccination regimen including one precautionary dose for dog bites prior to observation would reduce the volume of vaccine required by up to 64%, with potential for annual savings of over USD 6 million from reduced vaccine use. Our results highlight the need to improve the implementation of SINAN, including training of health workers responsible for delivering PEP using an Integrated Bite Case Management approach so that SINAN can serve as a reliable surveillance tool for canine rabies elimination.

First inter-laboratory comparison of Echinococcus granulosus sensu lato diagnosis in Latin America.

OBJECTIVE: To compare the performance of polymerase chain reaction (PCR) and enzyme-linked immunosorbent assay (ELISA) tests for diagnosing Echinococcus granulosus in dog feces among national reference laboratories in Argentina, Chile, Peru, and Uruguay. METHODS: National laboratories affiliated with the Ministry of Health/Agriculture of each country exchanged panels of 10 positive/negative samples obtained from their regular national surveillance programs in November 2015 - November 2016. All laboratories applied PCR; two also applied ELISA techniques. Sensitivity and specificity were determined for each laboratory and concordance of results among the laboratories was evaluated by Cohen Kappa coefficient. RESULTS: Poor concordance (3 of 10 paired comparisons had values of Kappa > 0.4), low sensitivity and specificity across all laboratories, and poor performance of both techniques in detecting E. granulosus in canine feces was demonstrated in this study. An ex-post comparison of the laboratories' test protocols showed substantial heterogeneity that could partially explain poor concordance of results. CONCLUSION: The results underscore the heterogeneity of canine echinococcosis diagnosis across the region and indicate possible sources of variability. Efforts to standardize canine echinococcosis testing must be included in the plan of action for the Regional Initiative for the Control of Cystic Echinococcosis. Future comparisons with fecal samples of known parasite load are needed.

Rabies in the Caribbean: A Situational Analysis and Historic Review.

Rabies virus is the only Lyssavirus species found in the Americas. In discussions about rabies, Latin America and the Caribbean are often grouped together. Our study aimed to independently analyse the rabies situation in the Caribbean and examine changes in rabies spatiotemporal epidemiology. A questionnaire was administered to the 33 member countries and territories of the Caribbean Animal Health Network (CaribVET) to collect current data, which was collated with a literature review. Rabies was endemic in ten Caribbean localities, with the dog, mongoose, and vampire bat identified as enzootic reservoirs. The majority of animal cases occurred in Puerto Rico, the Dominican Republic, and Haiti, while human cases only consistently occurred in the latter two areas. Rabies vaccination was conducted for high-risk animal populations with variable coverage, and rabies diagnostic capacities varied widely throughout the region. Illegal importation and natural migration of animals may facilitate the introduction of rabies virus variants into virus-naïve areas. Passive surveillance, together with enhanced methods and serological screening techniques, can therefore be of value. The insularity of the Caribbean makes it ideal for conducting pilot studies on reservoir host population management. Best practice guidelines developed for these reservoir hosts can be individually modified to the epidemiological status and available resources within each locality.

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

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

Rabies in the Americas: 1998-2014.

Through national efforts and regional cooperation under the umbrella of the Regional Program for the Elimination of Rabies, dog and human rabies have decreased significantly in Latin America and Caribbean (LAC) countries over the last three decades. To achieve this decline, LAC countries had to develop national plans, and consolidate capabilities such as regular mass dog vaccination, opportune post-exposure prophylaxis and sensitive surveillance. This paper presents longitudinal data for 21 LAC countries on dog vaccination, PEP and rabies surveillance collected from the biannual regional meeting for rabies directors from 1998-2014 and from the Regional Epidemiologic Surveillance System for Rabies (SIRVERA). Differences in human and dog rabies incidence rates and dog vaccination rates were shown between low, middle and high-income countries. At the peak, over 50 million dogs were vaccinated annually in national campaigns in the countries represented. The reported number of animal exposures remained fairly stable during the study period with an incidence rate ranging from 123 to 191 reported exposures per 100,000 people. On average, over 2 million doses of human vaccine were applied annually. In the most recent survey, only 37% of countries reported that they had sufficient financial resources to meet the program objectives. The data show a sufficient and sustained effort of the LAC countries in the area of dog vaccination and provide understanding of the baseline effort required to reduce dog-mediated rabies incidence.

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.