Global Rabies Control
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Transcript of 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.