Proof of concept for elimination
From concept to completion: the rabies control pilot project supported by the Bill & Melinda Gates Foundation
Background
From 2009 to 2013, the World Health Organization (WHO) led a pilot project funded by the Bill & Melinda Gates Foundation in three candidate territories known to have a high prevalence of canine rabies: KwaZulu-Natal province in South Africa; the south-eastern part of the United Republic of Tanzania and the Visayas archipelago in the Philippines.
Objective
The objectives of the project were:
- to demonstrate that human rabies can be prevented through the control of rabies in dogs using a One Health approach combining global public and veterinary health; and
- to collect valuable evidence for the efficacy and feasibility of this strategy for use worldwide.
Strategy
The strategy was to make existing control measures sustainable in the three territories and to demonstrate the feasibility, cost–effectiveness and benefits to human health from elimination of canine rabies.
The tactical choice of project regions – in East Africa, South Africa and an Asian archipelago – was intended to compare data by various geographical, demographic, cultural and organizational factors.
The five objectives underpinning the rabies control strategy in each area were:
- to collect baseline data
- to improve the delivery of post-exposure prophylaxis (PEP) and pre-PEP according to WHO guidelines
- to evaluate domestic dog rabies control plans
- to improve surveillance and diagnostics; and,
- to ensure long-term sustainable rabies control.
Key outcomes
Data gathered during the pilot project demonstrated that rabies control policies are effective and feasible. The key outcomes of each project area are as follows:
- The Philippines
- Increased coverage of dog vaccination with associated decreases in the numbers of positive canine rabies cases and human rabies deaths (comparing 2008 and 2013 data);
- KwaZulu-Natal
- Elimination of human rabies (the last human cases were recorded in 2013), improved rabies information databases and extension of control strategies to some neighbouring regions.
- United Republic of Tanzania
- Elimination of human and dog rabies in Pemba Island (zero cases reported since 2014); improved data availability through mobile phone-based surveillance; demand for human PEP in most areas reduced as dog vaccination campaigns improved.
Key lessons learned
- Success breeds success. Rabies “champions” enhance participation in campaigns at local and national levels.
- Projects must be kick-started. Funding catalyses implementation of national rabies control strategies. The “Just Start!” motto encourages action and the belief that any action, no matter how small, is better than no action.
- Data collection is essential. Data are used to determine strategies for resource allocation and funding as well as to monitor project progression or new outbreaks. The processes of data collection were improved and refined as the project progressed.
- International support is important. WHO and the Bill & Melinda Gates Foundation gave weight to the campaign and helped to drive action on the ground.
- Political support directly affects project success. Committed, enthusiastic local leadership in the United Republic of Tanzania was key to mobilizing resources and achieving vaccination targets.
- Organizational structure contributes to the success of project implementation. Staff training and effective planning and budgeting are essential to the success of a project.
- External factors can significantly impact a project’s success. Adverse weather conditions (such as Typhoon Haiyan in the Philippines in 2013), disease outbreaks and events (such as the Philippines’ local government elections during March–May 2013) can impact implementation by halting projects or diverting financial and human resources from rabies control projects to other areas. Planning should include a disaster preparedness plan, or alternative strategies in response to potential external factors.
Looking ahead
- At national level
- Maintain the rabies control policies and successes when the funding from the Bill & Melinda Gates foundation ends.
- At local and national levels
- Sustain the rabies elimination gains through strong financial and political support and ownership of programmes.
- Use the WHO Rationale for investing in the global elimination of dog-mediated rabies as evidence for the feasibility of implementation of rabies control worldwide.
Meeting reports
Report of the sixth meeting of the International Coordinating Group of the World Health Organization and the Bill & Melinda Gates Foundation project on eliminating human and dog rabies
Report of the fifth meeting of the International Coordinating Group of the World Health Organization and the Bill & Melinda Gates Foundation project on eliminating human and dog rabies
Report of the fourth meeting of the International Coordinating Group of the Bill & Melinda Gates Foundation–World Health Organization project on eliminating human and dog rabies
Project details
The WHO Department of Control of Neglected Tropical Diseases has received a project grant of nearly US$ 10 million to demonstrate the feasibility of, and promote an evidence-based strategy for, controlling and eliminating human rabies in low-income countries through control and elimination of the disease in the domestic dog.
The project, phased over a five-year period (2008–2013), will be implemented in regions of three countries where dog rabies is endemic: the United Republic of Tanzania (East Africa), Kwa-Zulu Natal (South Africa) and the Visayas archipelago (Philippines). Its aims are to achieve a “paradigm shift” in strategic planning and implementation of activities in these regions and to generate additional information on the rate of success based on geographical, demographical, cultural, organizational, tactical and other heterogeneities of the three project areas.
Background
Rabies, a viral disease that is nearly always fatal, contains a large animal reservoir. More than 99% of all human rabies cases are transmitted by the bites of infected dogs. Every year, 55 000 humans and countless dogs die from rabies, mostly in Africa and Asia. Most cases occur in children aged below 15 years. Dog rabies continues to escalate across much of Asia and Africa as a result of the low priority given to its control, arising from lack of awareness of the true scale and magnitude of the disease burden.
The major objectives of the project in each area are: (i) to improve targeted delivery of post-exposure prophylaxis to exposed patients; (ii) to control and eliminate rabies in domestic dogs while respecting the natural world; (iii) to improve surveillance and diagnostics; (iv) to build a strategy ensuring sustainability of the rabies-free status.
Massive dog killing is not an effective method of controlling rabies. It is even hypothesized that such mass culling will lead to a rapid compensation through better survival of the fittest (more healthy dogs) and the immigration of new dogs. This project therefore focuses on the control and eventual elimination of human and dog rabies using humane and ethical methods.
Objectives
The measurable objectives of the project will be accomplished through several key activities:
- data collection on human and dog populations and cases of animal rabies;
- mass dog vaccination;
- education and training to foster community awareness;
- improved diagnosis and surveillance in human and animal populations;
- improved access to human rabies biologicals (post-exposure prophylaxis);
- design of a long-term sustainable strategy for maintaining freedom from canine rabies, including dog movement and border controls and improved management of dog populations;
- coordination, implementation, monitoring and evaluation, closely coordinated between the three project areas.
Bill & Melinda Gates Foundation project
WHO will work in close collaboration with responsible agencies in the three countries. In the United Republic of Tanzania, the Ministry of Livestock Development and Fisheries will have a prominent role in obtaining the objectives, while in South Africa, the Department of Agriculture Veterinary Services has the responsibility of coordinating the project with other sectors. In the Philippines, the Department of Health, the Department of Agriculture and the local government units will work in collaboration.
The project areas were selected at the occasion of a meeting of the "Rabies Consultative Group" held in WHO, to contribute towards refined strategies for canine rabies elimination, to elicit expert advice and to facilitate achievements of the given objectives, thereby limiting expenses related to preventing the disease in humans and animals in future years, with the assistance of the Foundation. The three projects have the potential to successfully control human and dog rabies within five years. The eventual elimination of rabies in these areas will ensure that more than 50 million people do not live in fear of rabies.
Countries involved in the project
United Republic of Tanzania project area
The project site in the south-east of the country includes the Dar es Salaam, Lindi, Morogoro, Mtwara and Pwani regions. It comprises 24 districts and 459 wards, with a population of 6 200 000 humans (based on projections from the 2002 census data) and 400 000 dogs (estimated from specific demographic and geographic dog:human ratios).
As much as possible, the project zone will exploit natural boundaries to facilitate establishment and maintenance of a rabies-free area, including the coastline to the east, the Udzungwa mountains to the west and the Ruvuma river to the south. The Dar-es-Salaam–Mbeya highway to Morogoro and the railway line to Kilosa will define the northern boundary of the project zone. The area comprises a range of cultural settings (coastal, urban, agro-pastoral and pastoral), allowing data to be generated on dog vaccination and rabies surveillance measures in different communities.
The Tanzanian site is distinct from the other project sites because it includes a large wildlife-protected area (the Selous Game Reserve). This will allow hypotheses to be examined in relation to the role of biodiverse wildlife areas as buffers against infection, and/or the potential of wildlife as constraints to eliminating canine rabies (considered less likely). The site will also include Mafia Island and Pemba Island, or both, for comparison of the dynamics of canine rabies elimination in island and inland settings.
Country reports
South Africa project area
Kwa-Zulu Natal, located on the eastern seaboard of the South Africa, is one of the smallest (92 100 km2) but most populous (ca. 9 500 000) of South Africa’s nine provinces. It extends from the international borders with Swaziland and Mozambique in the north, to the province of the eastern Cape in the south, while inland it is bound by the Free State and Mpumalanga provinces and by Lesotho. The human:dog ratio has been recorded as 6.5:1 in the tribal and informal land areas, and these areas have therefore been targeted for the implementation of activities to control dog rabies.
This project is designed to be rolled out to neighbouring regions and countries in order to open up the southern African subcontinent in a massive effort to eliminate canine rabies. Stronger commitments from provincial authorities have alleviated many of the logistic, financial and managerial difficulties in implementing and maintaining successful dog vaccination strategies. External support will help Kwa-Zulu Natal to exert the final push towards the elimination of rabies in the province.
Country reports
Philippines project area
The project site will cover three out of the country’s 17 administrative regions, 16 out of 82 provinces and 31 out of 117 cities and serve almost 19% of the country’s human population (17 million inhabitants) and an estimated 9 million dogs. Implementation of the project will be divided into two phases. Phase I (year 1) will cover the entire western Visayas and two provinces of central Visayas (human population, 8.7 million). Phase II (year 2 onwards) will cover the remaining provinces of central Visayas (Cebu and Bohol) and the entire eastern Visayas region (human population, 8.3 million).
Priority will be given to western Visayas, since this region has been consistently highly endemic for human and canine rabies and has the highest number of patients with animal bites. As a result of logistic restrictions, the Philippine National Rabies Prevention Control Program is still between phases I and II. At the end of the project, it would move into Phase III of animal rabies control, with all the islands of Visayas declared rabies-free zones.
Country reports
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