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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
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
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