title: An intersectoral approach to enhance surveillance and guide rabies control and elimination programs
Creators: name: Swedberg, Catherine
Publisher: name: University of Glasgow
Year: 2023

description: Rabies is a viral zoonotic disease causing horrific neurological symptoms inevitably leading to death without prompt administration of post-exposure prophylaxis (PEP) to prevent infection. While any mammal can be infected by and transmit rabies, almost 99% of the estimated 59,000 human deaths per year are due to bites from rabid dogs, with the vast majority occurring in Asia and Africa. Through mass dog vaccinations starting in the 1920s, rabies has been successfully eliminated from domestic dog populations in practically all high-income countries. Yet, many lowand middle-income countries (LMICs) are still endemic and face extensive challenges controlling rabies and achieving elimination. Strengthening surveillance through integrated intersectoral methods has been an important component of the Zero by 30 global strategy to eliminate human deaths from dog-mediated rabies by 2030. Similar to other neglected tropical diseases, only a small percentage of human and animal rabies cases are captured in surveillance at the local level, then go on to be reported in official national and international statistics. This lack of detection and underreporting has resulted in suboptimal data quality that conceals the true magnitude of the burden of rabies, leading to a cycle of neglect by reducing advocacy, funding, and stakeholder engagement. Hence, surveillance must be sufficiently enhanced to monitor, evaluate, and inform rabies control efforts to support LMICs to achieve elimination. This thesis aims to critically review and evaluate the One Health approach, Integrated Bite Case Management (IBCM), as a cost-effective method to enhance rabies surveillance and guide control and elimination programs in LMICs, with a particular focus on a case study of IBCM implementation in the Philippines. The thesis is presented in a series of five chapters, starting with a general introduction (Chapter 1), followed by three standalone data chapters (Chapters 2, 3 &amp; 4), and concluding with a general discussion (Chapter 5). IBCM is a current gold standard surveillance method advocated by WHO and other international organizations. Yet, as a relatively novel One Health approach, there is still little understood about the implementation of IBCM in practice. In Chapter 2, I examined how IBCM is conceptualized by experts in the field, exploring variation in its operationalization in different epidemiological and geographical contexts. Findings from this study highlighted the diversity of how IBCM can be organized within existing government systems/sectors and demonstrated it is not a one-sizefits-all approach. Contextual features of each location influenced the success of delivery and the potential impact of IBCM, with the issue of sustainability identified as one of the greatest challenges. For successful development and implementation of IBCM programs, this study recommends that more guidance is provided for health workers receiving bite patients on assessing rabies-risk, and for stakeholders and practitioners on how to tailor IBCM to fit the local context. In Chapter 3, I explored this topic in more depth through the evaluation of a threeyear (January 2020 to December 2022) implementation study of IBCM in Oriental Mindoro province, Philippines. Using a mixed methods process evaluation, I assessed the feasibility and fidelity of effective delivery of IBCM, and how protocols were adapted to the context over the course of the study. The evaluation showed that the initial protocols envisioning trained government staff would uptake IBCM activities were not feasible due to implementation barriers. However, following adaptations made by the project team and participants, including adjustments for the COVID-19 pandemic, IBCM was delivering more effectively in 2021 and 2022. The findings concluded that, if implemented effectively, IBCM showed great promise as a strategy to enhance rabies surveillance in the Philippines, with evidence from the study providing key lessons for the adaptation and scale-up of IBCM to additional provinces in the Philippines. In Chapter 4, I used data collected from enhanced IBCM surveillance in Oriental Mindoro province from the implementation study discussed in Chapter 3. This quantitative data was used to develop an adapted probabilistic decision tree model used to estimate the burden of rabies, evaluate surveillance performance, and assess the impact of current rabies prevention practices. Results from this study estimated a high incidence of bite patient presentations to health facilities (1,160/100,000 persons/year), with &lt;2% deemed high-risk for rabies exposures (&lt;25/100,000 persons/year) and an average of 71.4% of probable rabies-exposed patients seeking PEP. Routine surveillance confirmed &lt;1% of circulating animal cases, whereas IBCM resulted in a fivefold increase in detection. The model estimated that between 275 to 838 dogs developed rabies; 18 to 28 deaths were averted by PEP; and total costs of over $535,385 USD per year, i.e. $16,730-38,240 USD per death averted, in Oriental Mindoro province. These findings highlight that current PEP practices in the Philippines are not cost-effective without concurrent strengthened risk-based surveillance to reduce the indiscriminate use of PEP. The study concludes that integrating IBCM into national policy has the potential to guide PEP administration to reduce unnecessary expenditure on PEP and inform rabies control measures. Overall, this thesis exemplifies the value of enhancing rabies surveillance using a One Health approach to achieve Zero by 30 rabies elimination goals. Yet, the development and implementation of IBCM must be carefully considered and planned to ensure the effective delivery of IBCM activities leading to desired outputs and outcomes. With more guidance provided by international organizations to streamline protocols and procedures, the IBCM approach has the potential to be a key component of national strategies to monitor and evaluate the progress of rabies control efforts, verify elimination, and promptly detect incursion events.