Rabies Challenges

At the occasion of the Colloquium rabiesand Emerging Viral Diseases in North

Africa and Western Europe Hammamet,Tunisia 6-8 June 2009

by F.-X. Meslin and S. Cleaveland

Attributes of the rabies (dog)Attributes of the rabies (dog) Acute killer diseaseAcute killer disease Low to moderate incidenceLow to moderate incidence

(0.5-2.0 deaths/100000/year)(0.5-2.0 deaths/100000/year) Under and mis-diagnosedUnder and mis-diagnosed Under-reportedUnder-reported

Transmitted by a nonTransmitted by a nonproductive animal speciesproductive animal species

Affecting a component of theAffecting a component of thepopulation which is usuallypopulation which is usuallypoor and living away frompoor and living away fromurban centresurban centres

Falling in between sectors forFalling in between sectors forits effective controlits effective control

Rabies: "A neglecteddisease"

invisibleinvisible

controlcontrolunfeasibleunfeasible

disease ofdisease ofpoverty -poverty -stigmastigma

un-economicalun-economicalunhygienicunhygienic

First challenge: to break the "circle of neglect" by generatingFirst challenge: to break the "circle of neglect" by generatingthe evidence basethe evidence base

2 - Smallno. ofcases

3 - Lack ofincentive 1- Poor

surveillance

4 - Lackof

funding

Data-drivenData-drivenassessmentassessment

Estimate oftrue incidence

No effectivecontrol andelimination

Deaths/100 000Deaths/100 000

Nber of PEP/100 000Nber of PEP/100 000

Nber of bites/100 000Nber of bites/100 000

Assess the public health burden ofAssess the public health burden ofrabiesrabies

Evaluate the economic burden ofEvaluate the economic burden ofrabiesrabies

Redefine the best prevention andRedefine the best prevention andcontrol strategycontrol strategy

Develop an communicationDevelop an communicationstrategystrategy

Influence decision-makersInfluence decision-makers

Deaths/100 000Deaths/100 000Nber of PEP/100 000Nber of PEP/100 000

Nber of bites/100 000Nber of bites/100 000

Inform generalInform generalpublic (children)public (children)

Convince fundingConvince fundingagenciesagencies

Cost per averted DeathsCost per averted Deaths

Cost of PEP in $Cost of PEP in $

next challenges: inform,next challenges: inform,influence and convinceinfluence and convince

WHO sponsored studies to re-assess theWHO sponsored studies to re-assess theburden of rabiesburden of rabies

Cleaveland et al. (2002) Bull WHO 80 (4): 304-31

Active surveillance and modelling: article on Re-evaluating theActive surveillance and modelling: article on Re-evaluating theburden of rabies in Africa and Asia by D.L. Knobel burden of rabies in Africa and Asia by D.L. Knobel et al, in WHOet al, in WHObulletin, 2005,83:360-368bulletin, 2005,83:360-368

National cluster community surveys: Bangladesh, Myanmar andNational cluster community surveys: Bangladesh, Myanmar andPakistanPakistan

Surveillance data and modelling: CambodiaSurveillance data and modelling: Cambodia Multicentric studies: article on Assessing the burden of humanMulticentric studies: article on Assessing the burden of human

rabies in India: Results of a national multi-centre epidemiologicalrabies in India: Results of a national multi-centre epidemiologicalsurvey by M.K.Sudarshan survey by M.K.Sudarshan et al, IJID, 2007, 29-35.et al, IJID, 2007, 29-35.

23,700

31,500

Urban17%

Rural83%

Challenge: estimate the annual Human RabiesChallenge: estimate the annual Human RabiesDeaths in Africa and AsiaDeaths in Africa and Asia

Knobel et al., BulletinWHO, 83: 360-368,2005

India: ~ 19,000

China: ~ 2,500

We have data to show thatWe have data to show that……..

Rabies is an important diseaseRabies is an important diseasethat exerts a substantial burdenthat exerts a substantial burdenon human and animal health,on human and animal health,public health economies, wildlifepublic health economies, wildlifeconservation and animal welfareconservation and animal welfare

Rabies affects mainlyRabies affects mainlyimpoverished communitiesimpoverished communities

98% of human deaths comefrom bites of rabid dog;

mostly children who comeface to face with them

3.3 billion people at risk inAfrica and Asia

Challenge: place rabies on the DALY scaleChallenge: place rabies on the DALY scale5600

4700

2400

1800

1600

1000

700 600

200

0

1000

2000

3000

4000

5000

6000

Lymphat

ic fi

laria

sis

Inte

stin

al n

emat

ode in

fect

ions

Leish

man

iasi

s

Schis

toso

mia

sis

Trypan

osom

iasi

s

Onch

ocerc

iasi

s

Den

gue

Chag

as

lepro

sy

5600

4700

2400

19401800

1600

1000

700600

200

0

1000

2000

3000

4000

5000

6000

Lymphat

ic fi

laria

sis

Inte

stin

al n

emat

ode in

fect

ions

Leish

man

iasi

s

Rab

ies

Schis

toso

mia

sis

Trypan

osom

iasi

s

Onch

ocerc

iasi

s

Den

gue

Chag

as

lepro

sy

Knobel et al.,Bulletin WHO, 83:360-368,2005

Challenge: telling how much rabies costsChallenge: telling how much rabies coststo societyto society

US$ burden Asia & Africa: $580 millions

Total Asia: 560 (96,5%)

Total Africa : 20 (3.5%)

–– from reduction of number of PET ( 50, 33 and 25% of initial numberfrom reduction of number of PET ( 50, 33 and 25% of initial numberdelivered at year 3, 4 and 5 respectively );delivered at year 3, 4 and 5 respectively );

–– from applying PET selectively after year 5 ( delivering not more thanfrom applying PET selectively after year 5 ( delivering not more than5% of initial number of treatments );5% of initial number of treatments );

–– from abandoning current low level dog vaccination and dog removalfrom abandoning current low level dog vaccination and dog removalactivities;activities;

Challenge: demonstrate costs andChallenge: demonstrate costs andbenefits of dog rabies eliminationbenefits of dog rabies elimination

scenario 2scenario 1

-50000

0

50000

100000

150000

1 3 5 7 9

Year

Net benefits

-100000

-50000

0

50000

100000

1 3 5 7 9

Year

Net benefits

flows of net benefitsflows of net benefits

Rabies control: dog vaccination in Tanzania

Cost perDALY

avertedUS$ 10

Cost of vaccinationprogrammeUS$ 620 000

=

_ Costs saved on PETsUS$ 400 000

22 000DALY’s averted

Adding figures for Serengeti and Mara districts:

Extending the analysis to the whole of Tanzania, the cost per DALYaverted is $ 11 including the research costs.

Challenge: harvest the benefits of dog rabiesChallenge: harvest the benefits of dog rabieseliminationelimination

0

0.5

1

1.5

2

2.5

3

3.5

4

4.5

Jan-93 Jun-94 Oct-95 Mar-97 Jul-98 Dec-99 Apr-01

Mon

thly

inc

iden

ce (

bite

s fr

om s

uspe

cted

rab

id d

ogs/

100,

000

peop

le)

Vaccinated zone

Non-vaccinated zone

Dog vaccination can have rapid impacts ondemand for PEP

Cleaveland et al., (2003) Vaccine, Cleaveland et al., (2003) Vaccine, 2121: 1965-1973: 1965-1973

Hampson et al., unpublished dataHampson et al., unpublished data

7.17.5

9.1 9.39.7

10.610.9 11.1

12.6

13.313.7

14.9

15.916.2

14.5

10

103

7

20

15

22

45

29

60

20

19

00

2

4

6

8

10

12

14

16

18

1990 1991 1992 1993 1994 1995 1996 1997 1998 1999 2000 2001 2002 2003 2004

0

10

20

30

40

50

60

70

Challenge: demonstrate the feasibility of humanChallenge: demonstrate the feasibility of humanrabies eliminationrabies elimination

Cases of rabies in humans

Vaccinated dogs(Millions)

In northern Tanzania: From 2003-2007, between 30,000and 50,000 dogs vaccinated each year in 160 villages

Central-point vaccinationKaare et al., Vaccine, in press

High coverageHigh coverageirrespective ofirrespective ofsocioeconomicsocioeconomicstatusstatus

0

20

40

60

80

100

Baria

di

Bund

aMag

uMea

tu

Sereng

eti

Tarim

e

District

Pe

rce

nta

ge

co

vera

ge

High Low

0

20

40

60

80

100

Sishan

i

Matong

o

Kihumbu

Tamau

Mwakilo

ba

Kijirish

i

Tindab

uligi

Linge

ka

Nyambu

ri

Mereng

aItir

yo

Kitawas

i

Village

Per

cent

age

vacc

inat

ion

cove

rage

Challenge: ensure sustainability of theChallenge: ensure sustainability of thecontrol strategy!control strategy!

What if you don't?What if you don't?

Re-emergence of human rabiesRe-emergence of human rabiesin Tunisia (in Tunisia (1982-1997)1982-1997)

0

50

100

150

200

250

300

350

400

19

60-

82

84 86 88 90 92 94 96

25

10

5

Human rabiescases

Dog rabies cases

0

50000

100000

150000

200000

250000

300000

350000

400000

450000

1961-

82

84 86 88 90 92 94 96

Dogs vaccinated

1997

2003

2004

Rabies spreading in Indonesia

20042008

Rabies Post-Exposure Prophylaxis, Thailand,Rabies Post-Exposure Prophylaxis, Thailand,years 1995-2004years 1995-2004..

160,443

176,118207,808

234,394 239,698

340,394

401,181

24,193

390,408

24,863

344,321

22,218

351,535

30,678

0

50,000

100,000

150,000

200,000

250,000

300,000

350,000

400,000

450,000

1995 1996 1997 1998 1999 2000 2001 2002 2003 2004

Source : Bureau of General Communicable Diseases, Department of Disease Control,Source : Bureau of General Communicable Diseases, Department of Disease Control,Ministry of Public Health, Bangkok, Thailand.Ministry of Public Health, Bangkok, Thailand.

: P.E.T :RIG.T.

68

19

74

Human rabies deathsHuman rabies deaths

Challenge: demonstrating success when implementing theChallenge: demonstrating success when implementing theGates foundation/WHO coordinated projects for human andGates foundation/WHO coordinated projects for human and

dog rabies eliminationdog rabies elimination

Demonstrate in today's context in Asia and Africa:Demonstrate in today's context in Asia and Africa: the feasibility and sustainability of human rabies elimination through the feasibility and sustainability of human rabies elimination through

dog rabies eliminationdog rabies elimination

the cost-effectiveness of dog rabies elimination through reducedthe cost-effectiveness of dog rabies elimination through reducednumber of PEP following dog rabies control and eliminationnumber of PEP following dog rabies control and elimination

The validity of a "paradigm shift in dealing with human-dog mediatedThe validity of a "paradigm shift in dealing with human-dog mediatedrabies"rabies"

The project aims to catalyse similar initiatives for the control andThe project aims to catalyse similar initiatives for the control andelimination of rabies in Africa and Asia within the next decade.elimination of rabies in Africa and Asia within the next decade.

South-east TanzaniaSouth-east Tanzania 6.5 million people and6.5 million people and ~ 432,000 dogs~ 432,000 dogs

Exploits natural boundariesExploits natural boundaries

Large enough to investigate Large enough to investigate dynamicsdynamicsand and economics economics of canine rabiesof canine rabieselimination elimination and sustainability ofand sustainability ofmaintainingmaintaining rabies-free areas rabies-free areas

Demonstration Project in TanzaniaDemonstration Project in Tanzania

Province of Kwa Zulu NatalProvince of Kwa Zulu Natal 92 100 km292 100 km2 population 9,500,000) of thepopulation 9,500,000) of the

nine RSA provinces.nine RSA provinces. international borders withinternational borders with

Swaziland and MozambiqueSwaziland and Mozambiquein the North, province of thein the North, province of theEastern Cape in the South,Eastern Cape in the South,while inland it is bound bywhile inland it is bound bythe provinces of the Freethe provinces of the FreeState and Mpumalanga, andState and Mpumalanga, andby the Kingdom of Lesotho.by the Kingdom of Lesotho.

Demonstration Project in South AfricaDemonstration Project in South Africa

Project area inProject area inthe Philippinesthe Philippines

Visayas group of islandscovering 25% of the totalnumber of animal rabiescases, 28% of the totalhuman rabies and 27% of theanimal bites in the entirecountry.The project will serve almost19 % of the country’s humanpopulation (with 17 millioninhabitants in the area) andan estimated 9 million dogs.

Rabies is considered a low priority for public health andRabies is considered a low priority for public health andveterinary servicesveterinary services

There are too many free-roaming/stray dogs that cannot beThere are too many free-roaming/stray dogs that cannot bevaccinated. Turn-out at vaccination points would be too low tovaccinated. Turn-out at vaccination points would be too low tovaccinate sufficient dogs to control rabies. There are too manyvaccinate sufficient dogs to control rabies. There are too manyfree-roaming/stray dogs that cannot be vaccinated.free-roaming/stray dogs that cannot be vaccinated.

We donWe don’’t have enough information on dog ecology and dogt have enough information on dog ecology and dogpopulation sizespopulation sizes

There are many different wild animal species that can beThere are many different wild animal species that can besources of infection.sources of infection.

We donWe don’’t have sufficient resources to vaccinate enough dogs.t have sufficient resources to vaccinate enough dogs.

We canWe can’’t control rabies becauset control rabies because……..(or the 5 major challenges to be(or the 5 major challenges to be

overcome)overcome)

Challenges and opportunities: RoadChallenges and opportunities: Roadmapmap

Generating the evidence baseGenerating the evidence base Developing a control strategyDeveloping a control strategy Defining the best advocacy messagesDefining the best advocacy messages

"human rabies: invariably fatal, eminently preventable""human rabies: invariably fatal, eminently preventable"

Eliciting political support and commitmentEliciting political support and commitment Involving civil society:Involving civil society:

Involving NGOs (case of India) Involving NGOs (case of India) –– Identifying ChampionsIdentifying Champions

Mobilizing resources (GF) andMobilizing resources (GF) and (re)Demonstrating the efficacy of the chosen strategy(re)Demonstrating the efficacy of the chosen strategy