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Introduction: In Madagascar, rabies is endemic and a notifiable disease. The objective of this mixed study was to understand the challenges faced by the Veterinary Health Officers (VHOs) in the current rabies surveillance system in Madagascar. Methods: A survey was conducted from mid-April to the end of July 2021 during which all officially-listed VHOs (N = 150) were contacted by phone at least twice. Participants, representative of the 22 regions of Madagascar, were interviewed by phone based on a semi-structured questionnaire on (1) their knowledge of rabies epidemiology in their area of activities, (2) the occurrence of human and animal rabies and the species affected in the region where they work, (3) the factors that might influence rabies surveillance depending on (a) their activities and area of operation, (b) the socio-cultural aspects of local communities, and (c) the general organization of animal rabies surveillance. Results: The majority (80/90) of VHOs declared having been informed of at least one suspected or confirmed case of human and/or animal rabies in their area of activity during their work as VHOs: at least once a month for 11 of them, at least once a year for 40 and with undetermined frequency for 29. Several obstacles hinder the surveillance of rabies resulting in under-reporting. The lack of funds to access suspect animals, collect, pack and ship samples in compliance with biosecurity measures and the cold chain, was mentioned as a major obstacle to surveillance. The second barrier is socio-cultural: in many large coastal regions, dogs are taboo and VHOs fear rejection by the community if they treat dogs. Discussion and conclusion: While the general population requires information on the rabies situation in Madagascar and on how to proceed in the event of a bite, veterinarians and decision-makers need to be fully aware of an evidence-based approach to rabies surveillance, prevention and control. Communication between the human and animal health sectors should be improved. Politicians need to be persuaded of the importance of funding to eliminate rabies in Madagascar. The adoption, in early 2023, of a national strategic plan for rabies control is a first step in this direction.
RESUMEN
Rabies is endemic in Madagascar and a neglected disease. The aim of this study was to summarize human and animal rabies surveillance activities in Madagascar from 2011 to 2021. Samples from terrestrial mammals and humans were tested for rabies virus infection using direct fluorescent antibody, RT-PCR and virus isolation by the National Reference Laboratory (NRL) for rabies at the Institut Pasteur de Madagascar. Among 964 animal and 47 human samples tested, 66.7 and 70.2% were positive, respectively. The NRL received these suspect rabies samples from 48 of 114 districts of Madagascar. Most of them were submitted from the district of the capital city Antananarivo (26.3%) and mainly from its region Analamanga (68.9%). Animal samples were mainly from dogs (83%), cats (9.5%) and cattle (5.8%). Pigs, lemurs, goats accounted for less than 1%. During the 11 years of surveillance, 48 human skin and/or brain biopsy samples were received from 20 districts, mainly from Antananarivo and its surroundings (N = 13), Toamasina and its surroundings (N = 8) and Moramanga (N = 6). The high positivity rate for all species and the non-homogeneous spatial distribution of samples suggests substantial underreporting of rabies cases. There is a clear need to better understand the reasons for underreporting and prioritize rabies surveillance, prevention and control in Madagascar, with improvements in budget, education and infrastructure. A joint animal and human health rabies control program including vaccination of at least 70% of the dog population, is needed to achieve the goal of eliminating dog-transmitted human rabies by 2030 from Madagascar.
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Canine rabies causes an estimated 60,000 human deaths per year, but these deaths are preventable through post-exposure prophylaxis of people and vaccination of domestic dogs. Dog vaccination campaigns targeting 70% of the population are effective at interrupting transmission. Here, we report on lessons learned during pilot dog vaccination campaigns in the Moramanga District of Madagascar. We compare two different vaccination strategies: a volunteer-driven effort to vaccinate dogs in two communes using static point vaccination and continuous vaccination as part of routine veterinary services. We used dog age data from the campaigns to estimate key demographic parameters and to simulate different vaccination strategies. Overall, we found that dog vaccination was feasible and that most dogs were accessible to vaccination. The static-point campaign achieved higher coverage but required more resources and had a limited geographic scope compared to the continuous delivery campaign. Our modeling results suggest that targeting puppies through community-based vaccination efforts could improve coverage. We found that mass dog vaccination is feasible and can achieve high coverage in Madagascar; however, context-specific strategies and an investment in dog vaccination as a public good will be required to move the country towards elimination.
RESUMEN
In Madagascar, dog-mediated rabies has been endemic for over a century, however there is little data on its incidence or impact. We collected data over a 16-month period on provisioning of post-exposure prophylaxis (PEP) at a focal clinic in the Moramanga District and determined the rabies status of biting animals using clinical and laboratory diagnosis. We find that animal rabies cases are widespread, and clinic-based triage and investigation are effective ways to increase detection of rabies exposures and to rule out non-cases. A high proportion of rabies-exposed persons from Moramanga sought (84%) and completed PEP (90% of those that initiated PEP), likely reflecting the access and free provisioning of PEP in the district. Current clinic vial sharing practices demonstrate the potential for intradermal administration of PEP in endemic African settings, reducing vaccine use by 50% in comparison to intramuscular administration. A high proportion of PEP demand was attributed to rabies cases, with approximately 20% of PEP administered to probable rabies exposures and an additional 20% to low-to-no risk contacts with confirmed/probable animal or human cases. Using a simplified decision tree and our data on rabies exposure status and health-seeking behavior, we estimated an annual incidence of 42-110 rabies exposures and 1-3 deaths per 100,000 persons annually. Extrapolating to Madagascar, we estimate an annual burden of 282-745 human rabies deaths with current PEP provisioning averting 1499-3958 deaths each year. Data from other clinics and districts are needed to improve these estimates, particularly given that PEP availability is currently limited to only 31 clinics in the country. A combined strategy of mass dog vaccination, enhanced surveillance, and expanded access to PEP along with more judicious guidelines for administration could effectively reduce and eventually eliminate the burden of rabies in Madagascar.
