Global Rabies Control

7/31/2019 Global Rabies Control

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The Historical Perspective 3000 BCE - Possible references in Vedic literature

2300 BCE Described in Babylonian texts

1885 Louis Pasteur successfully tests his rabies vaccine on a boy bitten by a

rabid dog .

2004 - Teenage girl in Wisconsin becomes first person to survive clinical

rabies due to treatment regimen that comes to be called the Milwaukee

Protocol.

(Kumar, 2009)


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Current Global Status Estimated 55,000 human deaths per year, acquired mostly from dog

bites

99% of human cases occur in the developing world, primarily South

Asia and Africa

In these two regions alone:

1.74 million disability-adjusted life years (DALYs) lost every year

$583.5 million US annually in post-exposure prophylaxis costs


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Current Global Status Approximately $300 million spent annually in the US on preventive

efforts

Annual global costs of prevention well over $1 billion US.

(WHO, 2004)


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Risk for International Travelers In 2009, a physician in Virginia developed clinical rabies shortly after

returning from a trip to India, where he was bitten by a dog. He died

despite treatment with the Milwaukee Protocol. (MMWR, 2010)

In 2011, a U.S. Army soldier developed rabies after a bite from a dog

while on tour in Afghanistan. He died despite treatment with the

Milwaukee Protocol. (MMWR, 2012)


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Vaccine Technology Nervous tissue vaccines largely phased out due to high rate of serious adverse

reactions, but are inexpensive and still in use in a few poor countries. (WHO,

2004)

Cell culture and recombinant vaccines are recommended by WHO and have

been shown to produce immunity with low dose intradermal vaccination

(humans only), reducing individual costs. (Verma, et al., 2011)

Oral vaccines are available for use in dog and wildlife populations, but are a

more labor-intensive option. (WHO, 2004)


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So why is rabies a neglected disease?

[S]adly, one of the oldest known diseases occurring primarilyin animals and being responsible, by far, for most of the

deaths in humans of any of the known zoonoses andexceeding, by far, the sum total of recorded human deathsfrom BSE, [Highly Pathogenic Avian Influenza] humanpandemic threats or the recent H1N1 influenza outbreak,

seems to be either forgotten or pushed backwards into thequeue of animal disease priorities. (Brckner, 2009)


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Barriers to Prevention/Control Lack of notifiability Health ministries do not have data on incidence

to identify problem areas

Lack of education Low literacy rates and lack of understanding of the

pathogenesis of disease

Cost of control measures Costs are often borne by individuals or

governments that cannot afford them

(WHO, 2004)


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Barriers to Prevention/Control Cultural factors

Differing concepts of pet ownership

Religious factors

Buddhist & Hindu proscriptions against killing

Muslims consider dogs to be unclean

Need 60 to 75% immunity in reservoir (canine) population Animal birth control preferable to mass euthanasia/poisoning

Vaccine programs require sustained effort

(WHO, 2004)


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Rabnet WHO Interactive Rabies

Mapping System

Unfortunately in the absence of regular (at least annual) data uploading from too many WHOMember States in order to avoid giving a wrong picture of how much and how widelydistributed rabies is in the world the Rabnet site has been closed until further notice. - Rabnet

website, 07 July 2012


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Case Study

Sri Lanka A large scale rabies control program has been in place since 1975

(Kumarapeli & Awerbuch-Friedlander, 2009)

Human deaths are greatly reduced, but dog vaccination campaigns have failed

to reach the necessary 60-75% coverage to eliminate the reservoir population.

The national government does not mandate notification and there is no

coordination between districts

Efforts to control the dog population, either through euthanasia or animal birth

control, have been insufficient to have adequate impact


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Case Study

Sri Lanka Matibag, et al. (2009), investigated knowledge, attitudes, and practice

in Nuwara Eliya district

Still scope for public education, despite 30 years of control efforts

Less than 2/3 of interviewees report favorable attitude toward animal birth

control, which may impact control of dog population


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Case Study - Tanzania Hampson, et al. (2009), looked at canine population factors and

transmission dynamics in two districts

The reproductive number of the disease, R0, was low (though adequate to

sustain disease presence) for both districts and did not appear to be

dependent upon dog population densities.

High rates of turnover in the canine population require sustained

vaccination efforts to maintain adequate population immunity.


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Case Study - Tanzania Lembo, et al. (2010), looked at Tanzania as a model for whether barriers to

rabies control are, in theory, surmountable.

Identified four major reasons for poor rabies control

Lack of prioritization of disease

Lack of epidemiological data

Operational constraints

Lack of resources

First two factors are a chicken-egg conundrum low priority because data is

lacking, but little data collection because disease isnt a priority


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Case Study - Tanzania Operational constraints are largely based around misconceptions of dog

ownership and misinterpretation of the status of at-large dogs.

Resource issues:

Lack of diagnostic capacity and surveillance infrastructure

Dog rabies control programs often seen as a strictly veterinary concern, rather

than as a broader public health issue, so cross-agency funding and cooperation

are rare


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Developing a Global Focus Global Alliance for Rabies Control (GARC) is an NGO based in the US

and Scotland to advocate for better global governance to tackle the

problem of human rabies. (http://www.rabiescontrol.net)

GARC is a founding partner organization of the Partners for Rabies

Prevention (PRP), which is an informal network of stakeholders

including WHO, FAO, World Organisation for Animal Health (OIE),

private foundations such as the Bill & Melinda Gates Foundation, and

industry representatives.
http://www.rabiescontrol.net/http://www.rabiescontrol.net/


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Developing a Global Focus GARC initiated World Rabies Day (http://www.worldrabiesday.org/) on

28 September 2007, the anniversary of Louis Pasteurs death, to raise

global awareness. GARC also works with regional rabies control networks and

management plans.

PRP has developed the Blueprint for Rabies Prevention and Control

(http://rabiesblueprint.com) and is working to expand availability in

multiple languages.
http://www.worldrabiesday.org/http://rabiesblueprint.com/http://rabiesblueprint.com/http://www.worldrabiesday.org/


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Developing a Global Focus The Bill & Melinda Gates Foundation has provided $10 million to

WHO for a proof-of-concept study to establish the feasibility of

elimination of human rabies by controlling the disease in dog

populations.

The study, started in 2008, has three project areas Tanzania,

South Africa, & the Philippines and will run through 2013.

http://www.who.int/rabies/bmgf_who_project/en/index.html
http://www.who.int/rabies/bmgf_who_project/en/index.htmlhttp://www.who.int/rabies/bmgf_who_project/en/index.html


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So can the global community fix this?

The short answer is yes

BUT

It will require a willingness to address identified shortfalls, to be

innovative, and to commit to long-term management efforts.

(Lembo, et al., 2011)


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References Brckner, G. (2009). Rabies - The role of the World Organisation for Animal Health in

mobilising control. Vaccine, 27, 71397140. doi:10.1016/j.vaccine.2009.09.038

Centers for Disease Control and Prevention. (2010, October 1). Human Rabies - Virginia,

2009. MMWR, 59(38), 1236-1238.

Centers for Disease Control and Prevention. (2012, May 4). Imported Human Rabies in a

U.S. Army Soldier - New York, 2011. MMWR, 61(17), 302-305.

Hampson, K., Dushoff, J., Cleaveland, S., Haydon, D., Kaare, M., Packer, C., & Dobson, A.

(2009). Transmission dynamics and prospects for the elimination of canine rabies. PLoS

Biology, 7(3), 462-471. doi:10.1371/journal.pbio.1000053


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References Kumar, P. D. (2009). Rabies. Westport, CT: Greenwood Press.

Kumarapeli, V., & Awerbuch-Friedlander, T. (2009). Human rabies focusing on dog

ecology - A challenge to public health in Sri Lanka. Acta Tropica, 112, 33-37.

doi:10.1016/j.actatropica.2009.06.009

Lembo, T., Attlan, M., Bourhy, H., Cleaveland, S., Costa, P., deBalogh, K., . . . Wandeler,

A. B. (2011). Renewed global partnerships and redesigned roadmaps for rabies prevention

and control. Veterinary Medicine International. doi:10.4061/2011/923149


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References Lembo, T., Hampson, K., Kaare, M., Ernest, E., Knobel, D., Kazwala, R., . . . Cleaveland, S.

(2010). The feasibility of canine rabies elimination in Africa: Dispelling doubts with data.

PLoS Neglected Tropical Diseases, 4(2), e626. doi:10.1371/journal.pntd.0000626

Matibag, G., Ohbayashi, Y., Kanda, K., Yamashina, H., Kumara W.R., B., Perera, I., . . .

Tamashiro, H. (2009). A pilot study on the usefulness of information and education

campaign materials in enhancing the knowledge, attitude and practice of rabies in rural

Sri Lanka. Journal of Infections in Developing Countries, 3(1), 55-64.


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References Verma, R., Khanna, P., Prinja, S., & Rajput, M. (2011). Intra-dermal administration of

rabies vaccines in developing countries. Human Vaccines, 7(7), 792-794.

doi:10.4161/hv.7.7.15410

World Health Organization. (2004). WHO Expert Consultation on Rabies. Geneva:

World Health Organization.

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Global Rabies Control