The role of non-governmental organisations in controlling rabies: the Global Alliance for Rabies Control, Partners for Rabies Prevention and the Blueprint for Rabies Prevention and Control.

Rabies control worldwide has been inadequate and neglected for many decades, and the disease continues to predominantly affect poor communities in Africa and Asia. As a zoonosis for which the main reservoir and vector, the domestic dog (Canis familiaris), is an economically non-viable species, the absence of cross-sectoral cooperation has been a major factor in the lack of effective control efforts. A shift in global focus is required to concentrate on the fact that rabies has the highest case fatality ratio of all infectious human diseases and that it still affects human health more significantly than many other infectious diseases that are perceived to pose more significant risks. Equally necessary is an acknowledgement that rabies control is complex and that the task of creating and executing a strategic plan for the disease can be overwhelming for those governments in the developing world where dog rabies is most problematic. Nonprofit organisations operate independently of governments and intergovernmental organisations and can play a dynamic role in inter-sectoral collaboration and the creation of approaches and strategies for the control of complex diseases such as rabies. In 2008, the Global Alliance for Rabies Control (GARC) established Partners for Rabies Prevention (PRP), a widely representative group of rabies stakeholders and experts, which endeavours to support public-private rabies control activities throughout the world. After a landscape analysis, the PRP proceeded to develop and launch the Blueprint for Rabies Prevention and Control (comprising the Blueprint for Canine Rabies Prevention and Control; the Blueprint for Fox Rabies Prevention and Control and the Rabies Surveillance Blueprint). Subsequently, the Stepwise Approach towards Rabies Elimination (SARE) was embedded into the Canine Rabies Blueprint. The SARE is a planning and self-assessment tool that countries can use to develop activities and monitor progress towards a national programme and strategy for sustainable rabies control and elimination. Each of the elements needed to execute the SARE-derived strategy is cross-linked to the Canine Rabies Blueprint, which provides the specific methods and tools required, supported by references and examples. Together, the Canine Rabies Blueprint and the SARE should be regarded as a novel and dynamic operational toolkit, and a resource that provides comprehensive information for the development and implementation of rabies control strategies, built entirely on the principles of 'One Health'.

Cela fait des dizaines d'années que la rage est une maladie négligée et que les efforts consacrés à la combattre à l'échelle mondiale sont insuffisants ; la maladie continue donc à sévir en plusieurs endroits de la planète en affectant surtout les communautés pauvres d'Afrique et d'Asie. La rage est une zoonose dont le principal réservoir et vecteur, le chien domestique (Canis familiaris), est une espèce ne présentant pas d'enjeu économique de sorte que c'est surtout l'absence de coopération intersectorielle qui est la principale cause du manque d'efficacité des activités de lutte. Il faut faire évoluer ces efforts à l'échelle mondiale à partir du constat que la rage est de toutes les maladies infectieuses humaines celle qui a le taux de létalité le plus élevé et que son impact sur la santé humaine reste supérieur à celui d'autres maladies infectieuses pourtant perçues comme présentant des risques plus significatifs. Il est tout aussi indispensable de prendre conscience du fait que la lutte contre la rage est une entreprise complexe et que la conception et l'exécution d'un plan stratégique contre cette maladie constituent des tâches écrasantes pour les gouvernements des pays en développement, où la rage canine pose le plus de problèmes. Les organisations à but non lucratif opérant indépendamment des gouvernements et des organisations intergouvernementales peuvent jouer un rôle pour dynamiser la collaboration intersectorielle et contribuer à la conception d'approches et de stratégies de lutte contre des maladies complexes telles que la rage. En 2008, l'Alliance mondiale contre la rage (GARC) a lancé l'initiative Partners for Rabies Prevention (PRP), un groupe formé d'un vaste éventail de parties prenantes et d'experts dans le domaine de la rage et ayant pour vocation de soutenir les activités relevant de partenariats public-privé pour lutter contre la rage partout dans le monde. Après une analyse globale de la situation, le partenariat a élaboré et mis en route le Plan directeur de prévention et de contrôle de la rage (doté de trois volets, à savoir les Plans directeurs pour la prévention et le contrôle de la rage canine et vulpine et le Plan directeur pour la surveillance de la rage). Par la suite, l'Approche raisonnée de l'élimination de la rage (SARE) a été intégrée au Plan directeur pour la prévention de la rage canine. SARE est un outil de planification et d'auto-évaluation mis à disposition des pays afin de les aider à concevoir leurs activités et à suivre les progrès enregistrés dans l'élaboration de leurs stratégies et programmes nationaux de lutte et d'élimination de la rage. Chaque élément opérationnel des stratégies élaborées sur la base de SARE est rattaché au Plan directeur pour la prévention et le contrôle de la rage canine, qui fournit les méthodes et les outils spécifiques nécessaires ainsi que des références et des exemples pertinents. Pris ensemble, le Plan directeur et SARE sont à envisager à la fois comme une boîte à outils opérationnelle innovante et dynamique et comme une base d'informations exhaustives pour l'élaboration et la mise en oeuvre de stratégies de lutte contre la rage, entièrement conçues dans une perspective « Une seule santé ¼.

La lucha antirrábica a escala mundial lleva muchos decenios de inadaptación y de relegación a un segundo plano, mientras la enfermedad sigue afectando principalmente a las comunidades pobres de África y Asia. Tratándose de una zoonosis cuyo principal reservorio y vector, el perro doméstico (Canis familiaris), es una especie económicamente inviable, la falta de cooperación intersectorial es uno de los principales factores que explican la ausencia de medidas de control eficaces. Es imperativo imprimir un giro a las líneas de trabajo mundiales para empezar a tener en cuenta que la rabia presenta la tasa de letalidad más alta de todas las enfermedades infecciosas del ser humano y que sigue afectando a la salud humana en mayor medida que otras muchas infecciones consideradas en cambio más peligrosas. También hay que tomar conciencia de que la lucha contra la rabia es compleja y de que los gobiernos de los países en desarrollo, donde la rabia es más problemática, a veces se ven superados por la titánica empresa de elaborar y aplicar un plan estratégico en la materia. Las organizaciones sin ánimo de lucro, que trabajan independientemente de gobiernos y organizaciones intergubernamentales, pueden cumplir una función dinámica de cara a la colaboración intersectorial y la creación de métodos y procedimientos de lucha contra enfermedades complejas como la rabia. Así, en 2008, la Alianza Mundial de Lucha contra la Rabia (GARC) estableció «Partners for Rabies Prevention¼ (PRP), amplio grupo representativo de los círculos de especialistas y otros interlocutores relacionados con la rabia que se dedica a respaldar en todo el mundo actividades de lucha antirrábica que federan a los sectores público y privado. Tras un análisis de la situación general, PRP procedió a elaborar y poner en práctica el «Plan maestro [Blueprint] de prevención y control de la rabia¼ (que a su vez se declina en un plan maestro de prevención y control de la rabia canina; un plan maestro de prevención y control de la rabia vulpina; y un plan maestro de vigilancia antirrábica). Ulteriormente, al plan maestro contra la rabia canina se le incorporó el «método progresivo para la eliminación de la rabia¼ (SARE, por sus siglas en inglés). El SARE es una herramienta de planificación y autoevaluación que los países pueden emplear para definir actividades y seguir de cerca la progresión hacia un programa y una estrategia nacionales de control y eliminación sostenibles de la rabia. Cada uno de los elementos necesarios para ejecutar la estrategia que se deriva del SARE guarda vínculos cruzados con el plan maestro contra la rabia canina, en el que se facilitan los métodos e instrumentos específicos necesarios, acompañados de referencias y ejemplos. El plan maestro contra la rabia canina y el SARE deben ser vistos conjuntamente como una novedosa y dinámica «caja de herramientas prácticas¼ y una fuente de información completa para definir y aplicar estrategias de lucha antirrábica, asentadas ambas por entero en los principios de «Una sola salud¼.

United Against Rabies Forum: The first 2 years.

Rabies continues to kill an estimated 59,000 people annually, with up to 99% of human cases transmitted by domestic dogs. The elimination of human deaths from dog-mediated rabies is achievable by applying a One Health approach, and the framework to do this is outlined in Zero by 30: the Global Strategic Plan to end human deaths from dog-mediated rabies by 2030. To build on this global goal, and implement the approaches set out in Zero by 30, the United Against Rabies Forum was launched in 2020. This paper gives a review of the objectives, governance, activities and achievements of the United Against Rabies Forum to date. It also outlines ongoing work, and next steps as the United Against Rabies Forum reviews its first 2 years of activities and identifies priority areas for the coming 12 months.

Evaluation of country infrastructure as an indirect measure of dog-mediated human rabies deaths.

Background: Rabies is a neglected disease, primarily due to poor detection stemming from limited surveillance and diagnostic capabilities in most countries. As a result, there is limited ability to monitor and evaluate country, regional, and global progress towards the WHO goal of eliminating human rabies deaths by 2030. There is a need for a low-cost, readily reproducible method of estimating rabies burden and elimination capacity in endemic countries. Methods: Publicly available economic, environmental, political, social, public health, and One Health indicators were evaluated to identify variables with strong correlation to country-level rabies burden estimates. A novel index was developed to estimate infrastructural rabies elimination capacity and annual case-burden for dog-mediated rabies virus variant (DMRVV) endemic countries. Findings: Five country-level indicators with superior explanatory value represent the novel "STOP-R index:" (1) literacy rate, (2) infant mortality rate, (3) electricity access, (4) political stability, and (5) presence/severity of natural hazards. Based on the STOP-R index, 40,111 (95% CI 25,854-74,344) global human rabies deaths are estimated to occur in 2022 among DMRVV-endemic countries and are projected to decrease to 32,349 (95% CI 21,110-57,019) in 2030. Interpretation: The STOP-R index offers a unique means of addressing the data gap and monitoring progress towards eliminating dog-mediated human rabies deaths. Results presented here suggest that factors external to rabies programs influence the successes of rabies elimination, and it is now possible to identify countries exceeding or lagging in expected rabies control and elimination progress based on country infrastructure.

The New Face of Human Rabies in Mexico, What's Next After Eradicating Rabies in Dogs.

In pre-Hispanic Mexico, dogs were not identified as an important source of rabies. We know from codexes and chronicles of the conquerors that at that time, rabies cases in humans and domestic animals were caused by local wildlife species such as bats. Canine-rabies virus variant seems to have arrived with Europeans. The first documented case of canine rabies in the Americas is found in Mexico in the Annals of the Holy Inquisition (16th century). During Mexico's independence, cases were frequently reported. In the 19th century the first attempts to control human rabies were made through sanitary measures such as elimination of rabid dogs and applying postexposure vaccination. During the first half of the 20th century, the efficacy of canine vaccination to prevent human rabies was established. However, in Mexico, despite reports of numerous human cases (>70/year), canine vaccination did not have enough coverage. It was only during the 1990s that Mexico made a serious commitment to eliminate dog-transmitted human rabies. Since the beginning, vaccination campaigns have been free and massive. Coverage increased from 7,100,000 doses in 1990 to more than 18,000,000 since 2017. This culminated in the elimination of dog-mediated human rabies cases since 2006. Subsequently, the epidemiology of rabies had changed. Nowadays, it is wildlife species (mainly bats and skunks) that are the source of human rabies. As a mega-biodiverse country Mexico has numerous wildlife species with potential to transmit rabies virus. Thus it is paramount to remain vigilant with respect to canine vaccination campaigns and to promote rabies research in wildlife.

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.

Rabies and the pandemic: lessons for One Health.

This article examines the impact of coronavirus disease 2019 (COVID-19) on dog-mediated rabies, a neglected tropical disease that remains endemic in >65 countries. A globally agreed strategy for rabies elimination is underpinned by a One Health approach, coordinating human and animal health sectors and engaging communities. We present data on the scale and nature of COVID-19 disruption to rabies control programmes and the wider learning for One Health implementation. We argue that the global shift in health priorities caused by the pandemic, and consequent side-lining of animal health, will have broader ramifications for One Health implementation and preparedness for future emergent zoonoses.

United Against Rabies Forum: The One Health Concept at Work.

Human deaths from rabies are preventable and can be eliminated by applying a systematic One Health approach. However, this ancient disease still threatens the lives of millions of people in up to 150 countries and kills an estimated 59, 000 people every year. Rabies today is largely a disease of poverty, almost always linked to dog bites, with most deaths occurring in neglected communities in Africa and Asia. The disease places an immense economic burden on its victims, a cost that far outweighs the investment needed to control it. A global framework for rabies elimination in humans is set out in Zero by 30: The Global Strategic Plan to end human deaths from dog-mediated rabies by 2030. Despite the existence of proven control strategies and agreement on the path to eliminating human rabies deaths, mortality numbers from rabies remain high, and COVID-19 has set back efforts even further. But COVID-19 has also highlighted the value of a One Health approach to zoonotic disease and pandemic prevention. Rabies control programs offer a practical route to building One Health capacities that can also address other zoonotic threats, including those with pandemic potential. The United Against Rabies Forum aims to accelerate progress on rabies elimination while applying a One Health approach. The Forum promotes cross-sector collaboration among stakeholders and supports countries in their rabies elimination efforts. Increased political engagement and resource mobilization, both internationally and nationally, will be needed to achieve global rabies goals and can also make One Health implementation a reality.

Rabies research in Ethiopia: A systematic review.

Rabies is an important zoonosis in Ethiopia, where lack of research is cited as a constraint to implementation of the national rabies control strategy. We conducted a systematic review of publications and theses on rabies in Ethiopia, to document research gaps and areas of knowledge saturation in relation to geographic and species focus, methods and findings. We also examined funding sources and extent of local researcher participation. After screening titles and abstracts, the full text of 119 publications was included in data extraction. More than 40% of publications involved data collection in one region (Oromia); no publications reported findings from Benishangul-Gumuz, Dire Dawa or Gambella. Dogs and wildlife (especially Canis simensis) were the focus of research in 45% and 24% publications, respectively. Descriptive epidemiology (N = 39 publications), ethno-medicine/-pharmacology (N = 17) and knowledge, attitude, and practice surveys (KAP, N = 15) were amongst the most common study designs, while studies involving economic methods (N = 3) and experimental epidemiology to test interventions (N = 3) were under-represented. Incidence surveys (N = 9) commonly used post-exposure prophylaxis administration in humans as a proxy for exposure without laboratory confirmation of the rabies status of the animal. KAP surveys tended to highlight reasonable levels of knowledge of rabies and poor practices, including overreliance on medicinal plants. International researchers were the first or last (senior) author on 42% and 58% of publications, respectively, most of which were funded by international organizations (45/72 publications reporting funding source). Based on this systematic review, we suggest more applied research is needed to address gaps in laboratory surveillance (including in humans, domestic and wild animals); identify effective ways to overcome socio-cultural and other barriers to accessing effective rabies treatments; inform best approaches to incentivizing mass dog vaccination programs; and generate local estimates of the cost-benefit and cost-effectiveness of different control strategies to improve financing and political buy-in for rabies control in Ethiopia.

Capacity Building Efforts for Rabies Diagnosis in Resource-Limited Countries in Sub-Saharan Africa: A Case Report of the Central Veterinary Laboratory in Benin (Parakou).

Rabies has been listed as a priority zoonotic disease in many African countries and the countdown to reach the goal of eliminating dog-mediated human rabies deaths by 2030 means that disease control measures need to be applied fast. In this context, an essential pillar of any national plan to control rabies is the implementation of reliable diagnostic techniques to ensure the success of field surveillance systems. Although many African countries have received international support for the control of rabies-some countries, like Benin, have not received a similar level of support. Indeed, until 2018, Benin was not able to diagnose rabies and rabies diagnosis in animals as well as humans relied solely on observed clinical symptoms. Although the Central Veterinary Laboratory (CVL) of Parakou had the equipment to implement two recommended tests, the lack of specific reagents and skills prevented the implementation of a rabies diagnostic service. Here we present the joint efforts of the national authorities in Benin, intergovernmental agencies, and non-governmental organizations to assess the strengths and weaknesses of the government's rabies control efforts. We have applied the Stepwise Approach toward Rabies Elimination (SARE) analysis, implemented rabies diagnostic capacities at the CVL of Parakou, characterized strains of rabies virus circulating in Benin, and finally integrated an inter-laboratory comparison program.

ORAL RABIES VACCINATION STRATEGIES TOWARD RACCOON (PROCYON LOTOR) RABIES ELIMINATION ON SUBURBAN LONG ISLAND, NEW YORK, USA.

Approximately 1.86 million baits containing a vaccinia-rabies glycoprotein recombinant vaccine were distributed with helicopters, vehicles, and bait stations during 2006-10. A bait density of 250 baits/km2 effectively controlled rabies cases in enzootic and preepizootic areas. However, a cluster of 11 rabid raccoons at the eastern edge of infection resulted in the initiation of semiannual, high-density (500 baits/km2) vaccination campaigns in approximately 20% of the oral rabies vaccination zone during July and September (2007-09). Bait success (i.e., chewed sachets or removed baits) at bait stations was negatively associated with station distances from water. Conversely, bait success improved with increasing distances from roads. Bait stations deployed significantly more baits in developed open space when compared to low- and medium- to high-intensity developed areas. However, a difference was not detected between developed open space and forest habitats. Rabies was confined to 86 raccoons within 317 km2 (10%) of a 3,133 km2 suburban landscape, with a disproportionate number of rabid raccoons (n=74) in developed areas, when compared to 10 cases in forest-wetland habitats. Two rabid raccoons did not fall within either general land-use classification. Rabies advanced 15.1 km eastward at a rate of 6.4 km/yr during a 28-mo interval (2004-06).

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.

The Formation of the Eastern Africa Rabies Network: A Sub-Regional Approach to Rabies Elimination.

International rabies networks have been formed in many of the canine-rabies endemic regions around the world to create unified and directed regional approaches towards elimination. The aim of the first sub-regional Eastern Africa rabies network meeting, which included Kenya, Ethiopia, Tanzania, Rwanda, and Uganda, was to discuss how individual country strategies could be coordinated to address the unique challenges that are faced within the network. The Stepwise Approach towards Rabies Elimination and the Global Dog Rabies Elimination Pathway tool were used to stimulate discussion and planning to achieve the elimination of canine-mediated human rabies by 2030. Our analysis estimated a total dog population of 18.3 million dogs in the Eastern Africa region. The current dog vaccination coverage was estimated to be approximately 5% (915,000 dogs), with an estimated 4910 vaccinators available. Assuming that every vaccinator performs rabies vaccination, this equated to each vaccinator currently vaccinating 186 dogs per year, whilst the target would be to vaccinate 2609 dogs every year for the community to reach 70% coverage. In order to achieve the World Health Organization-recommended 70% vaccination coverage, an additional 11 million dogs need to be vaccinated each year, pointing to an average annual shortfall of $ 23 million USD in current spending to achieve elimination by 2030 across the region. Improved vaccination efficiency within the region could be achieved by improving logistics and/or incorporating multiple vaccination methods to increase vaccinator efficiency, and could serve to reduce the financial burden associated with rabies elimination. Regional approaches to rabies control are of value, as neighboring countries can share their unique challenges while, at the same time, common approaches can be developed and resource-saving strategies can be implemented.

Toward Elimination of Dog-Mediated Human Rabies: Experiences from Implementing a Large-scale Demonstration Project in Southern Tanzania.

A Rabies Elimination Demonstration Project was implemented in Tanzania from 2010 through to 2015, bringing together government ministries from the health and veterinary sectors, the World Health Organization, and national and international research institutions. Detailed data on mass dog vaccination campaigns, bite exposures, use of post-exposure prophylaxis (PEP), and human rabies deaths were collected throughout the project duration and project areas. Despite no previous experience in dog vaccination within the project areas, district veterinary officers were able to implement district-wide vaccination campaigns that, for most part, progressively increased the numbers of dogs vaccinated with each phase of the project. Bite exposures declined, particularly in the southernmost districts with the smallest dog populations, and health workers successfully transitioned from primarily intramuscular administration of PEP to intradermal administration, resulting in major cost savings. However, even with improved PEP provision, vaccine shortages still occurred in some districts. In laboratory diagnosis, there were several logistical challenges in sample handling and submission but compared to the situation before the project started, there was a moderate increase in the number of laboratory samples submitted and tested for rabies in the project areas with a decrease in the proportion of rabies-positive samples over time. The project had a major impact on public health policy and practice with the formation of a One Health Coordination Unit at the Prime Minister's Office and development of the Tanzania National Rabies Control Strategy, which lays a roadmap for elimination of rabies in Tanzania by 2030 by following the Stepwise Approach towards Rabies Elimination (SARE). Overall, the project generated many important lessons relevant to rabies prevention and control in particular and disease surveillance in general. Lessons include the need for (1) a specific unit in the government for managing disease surveillance; (2) application of innovative data collection and management approaches such as the use of mobile phones; (3) close cooperation and effective communication among all key sectors and stakeholders; and (4) flexible and adaptive programs that can incorporate new information to improve their delivery, and overcome challenges of logistics and procurement.

Comparing Methods of Assessing Dog Rabies Vaccination Coverage in Rural and Urban Communities in Tanzania.

Rabies can be eliminated by achieving comprehensive coverage of 70% of domestic dogs during annual mass vaccination campaigns. Estimates of vaccination coverage are, therefore, required to evaluate and manage mass dog vaccination programs; however, there is no specific guidance for the most accurate and efficient methods for estimating coverage in different settings. Here, we compare post-vaccination transects, school-based surveys, and household surveys across 28 districts in southeast Tanzania and Pemba island covering rural, urban, coastal and inland settings, and a range of different livelihoods and religious backgrounds. These approaches were explored in detail in a single district in northwest Tanzania (Serengeti), where their performance was compared with a complete dog population census that also recorded dog vaccination status. Post-vaccination transects involved counting marked (vaccinated) and unmarked (unvaccinated) dogs immediately after campaigns in 2,155 villages (24,721 dogs counted). School-based surveys were administered to 8,587 primary school pupils each representing a unique household, in 119 randomly selected schools approximately 2 months after campaigns. Household surveys were conducted in 160 randomly selected villages (4,488 households) in July/August 2011. Costs to implement these coverage assessments were $12.01, $66.12, and $155.70 per village for post-vaccination transects, school-based, and household surveys, respectively. Simulations were performed to assess the effect of sampling on the precision of coverage estimation. The sampling effort required to obtain reasonably precise estimates of coverage from household surveys is generally very high and probably prohibitively expensive for routine monitoring across large areas, particularly in communities with high human to dog ratios. School-based surveys partially overcame sampling constraints, however, were also costly to obtain reasonably precise estimates of coverage. Post-vaccination transects provided precise and timely estimates of community-level coverage that could be used to troubleshoot the performance of campaigns across large areas. However, transects typically overestimated coverage by around 10%, which therefore needs consideration when evaluating the impacts of campaigns. We discuss the advantages and disadvantages of these different methods and make recommendations for how vaccination campaigns can be better monitored and managed at different stages of rabies control and elimination programs.

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.

Enhanced Rabies Surveillance to Support Effective Oral Rabies Vaccination of Raccoons in the Eastern United States.

Enhanced rabies surveillance (ERS) is essential for sound oral rabies vaccination (ORV) decisions to prevent the spread of specific rabies virus variants in meso-carnivores and to achieve disease elimination. Use of a direct rapid immunohistochemistry test (dRIT) in North America for timely, accurate rabies diagnosis in the field has facilitated greater ERS emphasis since 2005. ERS used in tandem with exposure-based public health surveillance provides a comprehensive understanding of the geographic distribution of rabies as an aid to formulate effective management strategies for raccoons and other meso-carnivores. In 2015, best management practices were implemented for improving, reinvigorating, and standardizing ERS. A point system for weighing ERS sample categories was evaluated, to determine whether sampling emphasis should be focused upon ill or strange-acting animals, the highest quality category. During 2016, 70.7% of rabid animals detected through ERS in raccoon rabies management states were obtained from strange-acting animals, followed by animals found dead (14.1%), road kills (9.1%), and nuisance-collected specimens (6.1%). Sample category weights may be adjusted based on additional evaluation to ensure continued emphasis on the highest value samples. High quality ERS, in conjunction with serologic evidence of population-based immunity, form the backbone for ORV decisions in the elimination of raccoon rabies.

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.

Elimination of Dog-Mediated Human Rabies Deaths by 2030: Needs Assessment and Alternatives for Progress Based on Dog Vaccination.

BACKGROUND: Rabies imposes a substantial burden to about half of the world population. The World Health Organization (WHO), World Organization for Animal Health, and the Food and Agriculture Organization have set the goal of eliminating dog-mediated human rabies deaths by 2030. This could be achieved largely by massive administration of post-exposure prophylaxis-in perpetuity-, through elimination of dog rabies, or combining both. Here, we focused on the resources needed for the elimination of dog rabies virus by 2030. MATERIALS AND METHODS: Drawing from multiple datasets, including national dog vaccination campaigns, rabies literature, and expert opinion, we developed a model considering country-specific current dog vaccination capacity to estimate the years and resources required to achieve dog rabies elimination by 2030. Resources were determined based on four factors: (a) country development status, (b) dog vaccination costs, (c) dog rabies vaccine availability, and (d) existing animal health workers. Our calculations were based on the WHO's estimate that vaccinating 70% of the dog population for seven consecutive years would eliminate rabies. FINDINGS: If dog rabies vaccine production remains at 2015 levels, we estimate that there will be a cumulative shortage of about 7.5 billion doses to meet expected demand to achieve dog rabies elimination. We estimated a present cost of $6,300 million to eliminate dog rabies in all endemic countries, equivalent to a $3,900 million gap compared to current spending. To eliminate dog rabies, the vaccination workforce may suffice if all public health veterinarians in endemic countries were to dedicate 3 months each year to dog rabies vaccination. We discuss implications of potential technology improvements, including population management, vaccine price reduction, and increases in dog-vaccinating capacities. CONCLUSION: Our results highlight the resources needed to achieve elimination of dog-mediated human rabies deaths by 2030. As exemplified by multiple successful disease elimination efforts, one size does not fit all. We suggest pragmatic and feasible options toward global dog rabies elimination by 2030, while identifying several benefits and drawbacks of specific approaches. We hope that these results help stimulate and inform a necessary discussion on global and regional strategic planning, resource mobilization, and continuous execution of rabies virus elimination.

World Rabies Day - a decade of raising awareness.

World Rabies Day was set up in 2007 to raise global awareness about rabies, to provide information on how to prevent the disease in at-risk communities and support advocacy for increased efforts in rabies control. It is held annually on September 28th, with events, media outreach and other initiatives carried out by individuals, professionals, organisations and governments from the local to the international level. The Global Alliance for Rabies Control coordinates World Rabies Day, amplifying the campaign's reach through the provision of a central event platform and resources to support events across the world, the promotion of messages through key rabies stakeholders, and the implementation of specific activities to highlight particular issues. Over the last decade, more than 1,700 registered events have been held across the world and shared with others in the global rabies community. Events in canine rabies endemic countries, particularly in Africa and Asia, have increased over time. Beyond the individual events, World Rabies Day has gained the support of governments and international agencies that recognise its value in supporting existing rabies control initiatives and advocating for improvements. As the rabies landscape has changed, World Rabies Day remains a general day of awareness but has also become an integral part of national, regional and global rabies elimination strategies. The global adoption of 2030 as the goal for the elimination of rabies as a public health threat has led to even greater opportunities for World Rabies Day to make a sustainable impact on rabies, by bringing the attention of policy makers and donors to the ongoing situation and elimination efforts in rabies-endemic countries.

The Pan-African Rabies Control Network (PARACON): A unified approach to eliminating canine rabies in Africa.

Even though Africa has the highest per capita death rate from rabies of any continent, and the disease is almost entirely transmitted by the bites of rabid dogs, there has been no coordinated pan-African approach to controlling canine rabies. In order to attain an inclusive and unified network, the Pan-African Rabies Control Network (PARACON) was established in 2014. By following the 'One Health' concept, which involves close coordination between animal and human health sectors across national, regional and continental levels, PARACON will provide a platform to facilitate and promote coordinated and sustainable control strategies and programmes. Meetings will take place at regular intervals and will be centred on the involvement by key focal persons from the medical and veterinary sectors. The inaugural meeting was held in South Africa in June, 2015 and was focused around interactive discussions and workshops, whilst updating country representatives on the tools available to aid them in developing and implementing sustainable rabies intervention strategies. Experts from various global organizations, institutions and industry participated in the discussions and shared their experience and expertise. The workshops focused on the latest format of the Rabies Blueprint platform (www.rabiesblueprint.com), which in the broadest sense assists with control and elimination campaigns, including educational and advocacy drives, improvement of surveillance and diagnosis and the systematic monitoring of progress. Together with the Stepwise Approach towards Rabies Elimination, the Blueprint is a planning tool to help countries free themselves from canine-transmitted rabies.