Rabies

Executive summary: Driving progress towards rabies elimination

14 January 2019 | Geneva −− Two high level meetings were held in 2018 on “Driving progress towards rabies elimination”. The first, held in Kathmandu, Nepal in May, hosted representatives of 18 countries from the Asian region and the second, held jointly with the 2nd Pan-African Rabies Control Network (PARACON), was held in Johannesburg, South Africa in May, with 24 rabies-endemic African countries in attendance. The meetings included representatives and stakeholders from civil society, nongovernmental organizations, academia and pharmaceutical industries and aimed to share lessons learnt and identify next steps for improving country and regional strategies to achieve rabies elimination.

The meetings focused on:

  • Discussing results of the recent multi-country studies under the Gavi Learning Agenda on rabies
  • Disseminating the new WHO position on rabies immunization, published in April 2018
  • Building advocacy for rabies elimination and supporting networking between countries
  • Determining the needs and next steps to eliminate dog mediated rabies, in line with the United Against Rabies “Zero by 30: The Global Strategic Plan to end human deaths from dog-mediated rabies by 2030”, published in June 2018

The Asian and African regions are overrepresented with their burden of human rabies, accounting for more than 95% of global rabies deaths. Elimination of dog mediated rabies is feasible with available tools and technical knowledge. Disease awareness, responsible dog ownership, mass dog vaccination, cross-sectoral collaboration, appropriate wound management and access to post-bite treatment (post-exposure prophylaxis) are critical factors in of rabies control and elimination.

Although feasible strategies for rabies eliminations vary between countries and regions, the following points were identified as key factors for success.

  • Implementation of the updated WHO position, uptake of dose and cost saving intradermal vaccination schedules, including support to regulatory authorities, and scaling up of PEP access;
  • The need for market shaping to assure high quality and safe human and dog vaccines and immunoglobulins;
  • Use of innovative, low-cost strategies to improve reach of remote, rural populations by involving traditional healers, community health workers and others;
  • Engagement of multiple sectors and One Health collaboration across all levels is critical and should include community education and awareness programmes and dog bite prevention and vaccination campaigns;
  • Improved surveillance and data at both the national and global level are critical for advocacy;
  • targeted interventions, evidence-based forecasting of biologicals and resource prioritization;
  • Various platforms and tools are available to countries for developing and implementing national strategies, community awareness programmes, dog vaccination campaigns and technical training.

Political commitment remains a crucial factor for sustaining and driving progress which requires that government authorities provide the leadership and coordination.

Countries were invited to participate in break out and plenary sessions where they could share their experiences, identify country needs and refine plans on accelerating rabies elimination. Both regions identified the need for:

  • Country ownership with government leadership and a budgeted rabies national plan;
  • Standardized data collection including separation of dog bites from other animal bites like snakebites and consistent reporting, and linking of national data to global reporting systems;
  • Learning from and integrating rabies programmes within health systems and other disease platforms;
  • Improvement of communication and collaboration between sectors and adoption of One Health principles into rabies programmes, such as integrated bite case management (IBCM);
  • Engagement of manufacturers to transition from IM to ID vaccination schedules and encourage them to apply for WHO pre-qualification. Ethiopia was urged to phase out the use of Nerve Tissue Vaccines (NTVs).

Other issues discussed at the Nepal meeting included:

  • Attending to non-rabid bites from healthy or vaccinated dogs and potential for overuse of PEP. The implementation of IBCM could reduce unnecessary use of PEP.
  • Vaccine hesitancy for PEP among pregnant and breastfeeding women due to the fear of harm to the foetus or breastfeeding child. PEP is safe to administer to pregnant and breastfeeding women.
  • Mass dog vaccination should focus on achieving high coverage in high burden areas, rather than focus on low risk animal populations.
  • The importance of making rabies notifiable to improve reporting and surveillance.
  • Innovative methods to involve and engage communities including training of traditional healers and the involvement of other NTDs like snakebite envenoming.
  • The review of ASEAN countries regional elimination timeline, in line with the global 2030 target.

Other issues discussed at the South Africa meeting meeting included:

  • Access and stock out of vaccines is a major concern for many countries. Implementation of ID vaccination schedules could help address this;
  • There is a need to improve training in the healthcare sector on appropriate palliative care in rabies patients. Guidelines for palliative care are available in the WHO Expert Consultation on Rabies;
  • Immunocompromised patients, such as HIV positive patients, should receive PEP following possible rabies virus exposure, including wound washing, rabies vaccination and RIG.
  • Surveillance of human rabies cases can be difficult due to cultural barriers to post mortem sampling. Raising awareness in communities of rabies and the importance of diagnosis can help overcome this.
  • Dog culling programmes are not sustainable nor acceptable from a welfare perspective. The implementation of more sustainable, locally adapted DPM tools are needed;
  • Oral rabies vaccines for dogs are a promising supplementary tool with which to improve dog vaccination coverage. WHO & OIE plan to develop guidance based on evidence of safety, efficacy and use settings in 2019;

The meetings showcased successful rabies elimination strategies and innovations. The meetings highlighted the needs of countries with different settings. Moving forward, WHO, OIE, FAO and GARC in close coordination with the global community has dedicated their support to countries endeavouring to eliminate dog-mediated rabies. Countries are encouraged to identify a national rabies focal point with WHO and commit to reporting national data on an annual basis to improve global rabies surveillance and trend analysis. Countries are also encouraged to implement new WHO recommendations and will be supported in developing or revising national strategic plans for rabies elimination.

Commitment across all sectors, built on a platform of One Health collaboration, will ensure that the global health community continues to drive progress towards the elimination of dog-mediated rabies by 2030.