Neglected tropical diseases

Human dog-mediated-rabies: strengthening capacity and raising awareness are crucial for elimination

24 September 2012 | Geneva

A World Health Organization (WHO) International Expert Consultation on rabies has urged countries endemic for canine rabies to initiate and strengthen their rabies prevention and control activities, and to increase the level of awareness about the disease, particularly among children.

“A re-assessment of the burden of rabies made during the meeting showed that 50 000 people, mostly in Africa and Asia, still die in spite of 20 million others receiving post-exposure prophylaxis (PEP) worldwide,” said Dr François Meslin, Team Leader for Neglected Zoonotic Diseases at WHO’s Department of Control of Neglected Tropical Diseases. “Data show that the majority of fatal cases involve people from poor, rural communities without access to dog bite management centres and rabies biologicals. Also, too many PEP delivered in the world today are not administered to the right people.”

Rabies is a neglected disease of poor and vulnerable populations. Once an individual is infected with the virus – usually through the bite of a rabid dog – and the symptoms develop, rabies is nearly always fatal.

The main obstacle to assessing the incidence of the disease is under reporting and misdiagnosis of human rabies cases. The disease occurs mainly in remote rural communities where PEP is not accessible and where effective measures to prevent the disease in its major animal host – the dog – are not implemented. Under-reporting prevents mobilization of resources and undermines implementation of control and prevention measures, such as dog vaccination.

“Endemic countries should strengthen their capacity to implement control and elimination programmes,” said Dr Lorenzo Savioli, Director of the Department of Control of Neglected Tropical Diseases. “During the past decade, although progress has been made at the international and national levels in breaking the cycle of rabies neglect through assertive advocacy, much remains to be done in promoting the use of existing tools and strategies to eliminate this disease from entire WHO regions. Raising disease awareness among populations mostly at risk, particularly children, is crucial to eliminating this vaccine-preventable disease.”

Around 70 participants attended the WHO Expert Consultation on rabies held at WHO’s headquarters in Geneva, Switzerland, on 18–20 September 2012. Other important issues discussed included:

  • new recommendations for pre- and post-exposure prophylaxis (the need for local treatment of a suspected dog-induced wound immediately after exposure and the application of a course of potent and effective WHO-recommended rabies vaccine);
  • design of comprehensive dog and wildlife rabies control programmes;
  • classification of rabies and other lyssavirusses;
  • laboratory diagnosis of rabies in humans and animals;
  • review of the rabies situation in domestic and wild animals in endemic countries, and the estimated health and economic burden of the disease;
  • management of rabid patients;
  • rabies biological products for humans and animals.

The meeting discussed novel approaches for applied research on the health economics of dog vaccination for human rabies prevention, and the sustainability and cost-effectiveness of such programmes in various cultural, ecological and economic settings. Such research could also include an analysis of the socioeconomic challenges to implementing programmes as well as the potential for integrating dog rabies control with other dog-borne zoonoses such as echinococcosis and leishmaniasis.

It also recommended that national rabies control programmes involve the animal and public health sectors as well as other sectors such as education, local government, police and civil society, particularly animal welfare and conservation associations.

In recent years, a number of rabies control and elimination pilot programmes carried out in Africa, Asia and Latin America have achieved a sustained reduction in human rabies cases through mass vaccination of dogs. In a number of urban areas, particularly in India, vaccination coupled with sterilization of dogs has resulted in local elimination of rabies in both humans and animals.

The Consultation also urged WHO to continue to advocate human rabies prevention through the elimination of rabies in dogs and to promote a wider use of the intradermal route for PEP, which reduces volume and the cost of cell-cultured vaccine by 60% to 80%.

WHO’s target, as outlined in its NTD roadmap (published in January 2012) is to eliminate human and dog rabies in all Latin American countries by 2015 and human rabies transmitted by dogs in South-East Asia by 2020.