Substantial reductions in rabies, but still a lot to be done
Authors: Maria Cristina Schneider, Lucia R Montebello Pereira
Journal: The Lancet Global Health (2017)

The Global Burden of Disease Study1Murray CJ Barber RM Foreman KJ et al.Global, regional, and national disability-adjusted life years (DALYs) for 306 diseases and injuries and healthy life expectancy (HALE) for 188 countries, 1990–2013: quantifying the epidemiological transition.Lancet. 2015; 386: 2145-2191Summary Full Text Full Text PDF PubMed Scopus (1333) Google Scholar shows that incidence of human rabies has fallen by around 40% worldwide since 1990. Despite substantial gains in tackling this neglected disease, more than 20 000 people still die from rabies every year, mostly in Asia and Africa.2Herricks JR Hotez PJ Wanga V et al.The Global Burden of Disease Study 2013: what does it mean for the NTDs?.PLoS Negl Trop Dis. 2017; 11: e0005424Crossref Scopus (151) Google Scholar Many European countries and North America have already eliminated rabies as a public health problem through mandatory vaccination of dogs and good access to postexposure prophylaxis for human beings.3Rupprecht CE Barrett J Briggs D et al.Can rabies be eradicated?.Dev Biol. 2008; 131: 95-122Google Scholar In Latin American countries, where poverty remains widespread, 90% reductions in the incidence of human and canine rabies have been seen,4Schneider MC Belotto A Adé MP et al.Current status of human rabies transmitted by dogs in Latin America.Cad Saude Publica. 2007; 23: 2049-2063Crossref PubMed Scopus (91) Google Scholar achieved by strong government commitment and support from international organisations since the 1980s. The approach is based on four main pillars: decentralised access to postexposure prophylaxis free of charge, annual mass dog vaccinations provided by governments, surveillance, and education and communication.4Schneider MC Belotto A Adé MP et al.Current status of human rabies transmitted by dogs in Latin America.Cad Saude Publica. 2007; 23: 2049-2063Crossref PubMed Scopus (91) Google Scholar, 5Vigilato MAN Clavijo A Knobl T et al.Progress towards eliminating canine rabies: policies and perspectives from Latin America and the Caribbean.Philos Trans R Soc Lond B Biol Sci. 2013; 368: 20120143Crossref PubMed Scopus (136) Google Scholar In The Lancet Global Health, Melissa Etheart and colleagues6Etheart MD Kligerman M Augustin PD et al.Effect of counselling on health-care-seeking behaviours and rabies vaccination adherence after dog bites in Haiti, 2014–15: a retrospective follow-up survey.Lancet. 2017; 5: e1017-e1025PubMed Scopus (36) Google Scholar illustrate the strong commitment of a Latin American country to fighting rabies despite economic challenges and frequent natural-disaster events. This well designed study assessed the effects on seeking health care of an integrated bite case management (IBCM) programme as a component of rabies control. The programme provides reporting linkages to the Haiti Animal Rabies Surveillance Program and counselling on risk of rabies and appropriate treatment to animal-bite victims. Etheart and colleagues did a retrospective follow-up survey of randomly selected dog-bite victims who were assessed by Haiti's IBCM programme over 16 months up to September, 2015. 1478 dog bites were reported, and 115 victims were randomly followed up. IBCM was associated with a 1·2 times increase in frequency of bite victims seeking medical care and a 2·4 times increase in frequency of vaccination uptake. The data also helped to identify best practices for use of postexposure prophylaxis for rabies in low-income settings, which could be used to guide development of IBCM programmes in other countries around the world. Another notable aspect of this paper is the decision-tree method used to estimate the number of human rabies deaths predicted in the absence of an IBCM programme (four with vs 11 without among 1478 people bitten; 65% decrease). Since Pasteur's vaccine discovery in 1885, human deaths from rabies, a disease with almost a 100% fatality rate, have been avoidable. The key elements to prevention include knowing the risk, having information available about what needs to be done after exposure and where to obtain postexposure prophylaxis, and, most importantly, having the vaccine and rabies immunoglobulin available. For many countries worldwide, especially those with large populations and high poverty, access to postexposure prophylaxis is still a dream, particularly in rural communities. After the nerve-tissue-derived rabies vaccine was no longer recommended for human use by WHO,7WHOWHO expert consultation on rabies: second report.World Health Organ Tech Rep Ser. 2013; 982: 1-139Google Scholar high-quality cell culture and embryonated-egg-based vaccines were available from only a few producers. In 2012, only three rabies vaccines worldwide were approved by WHO for intramuscular use.7WHOWHO expert consultation on rabies: second report.World Health Organ Tech Rep Ser. 2013; 982: 1-139Google Scholar For severe cases, use of rabies immunoglobulin is recommended, but it is rare and expensive. The sustainable production of rabies vaccine and the costs of postexposure prophylaxis need to be addressed to reduce the inequality in rabies-associated mortality. Haiti's joint effort between the health and agriculture authorities is an example of the One Health approach, which was established to make rabies control a priority, and is supported by other countries in the Americas and by international organisations. Since the early 2000s, Brazil has made several donations of human and dog rabies vaccines to Haiti, providing the tools for national authorities to launch mass dog vaccination campaigns and give bit victims easier access to timely postexposure prophylaxis. Many other initiatives and technical cooperation between various countries and Haiti exist.8Schneider MC Pereira LR Bittencourt dos Anjos C Vigilato MA Contribuição de Médicos Veterinários brasileiros no controle da raiva no Haiti e na República Dominicana.Rev CFMV. 2012; 18: 8-15Google Scholar, 9Millien MF Pierre-Louis JB Wallace R et al.Control of dog mediated human rabies in Haiti: no time to spare.PLoS Negl Trop Dis. 2015; 9: e0003806Crossref Scopus (17) Google Scholar Excellent results have already been seen, as Etheart and colleagues report,6Etheart MD Kligerman M Augustin PD et al.Effect of counselling on health-care-seeking behaviours and rabies vaccination adherence after dog bites in Haiti, 2014–15: a retrospective follow-up survey.Lancet. 2017; 5: e1017-e1025PubMed Scopus (36) Google Scholar and show that even countries facing challenges can save lives from rabies. Since the creation of the Global Alliance for Rabies Control in 2007, rabies was given increased opportunity for advocacy at the global, national, and local levels. In the past 15 years, many initiatives have been developed for rabies control in Africa, some in partnership with the UK, leading to rapid advances in disease control.10Lushasi K Cleaveland S Changalucha J et al.Progress towards rabies elimination from Pemba Island, Southern Tanzania.Online J Public Health Informatics. 2017; 9: e118Crossref Google Scholar The experiences in Haiti6Etheart MD Kligerman M Augustin PD et al.Effect of counselling on health-care-seeking behaviours and rabies vaccination adherence after dog bites in Haiti, 2014–15: a retrospective follow-up survey.Lancet. 2017; 5: e1017-e1025PubMed Scopus (36) Google Scholar and other Latin America countries5Vigilato MAN Clavijo A Knobl T et al.Progress towards eliminating canine rabies: policies and perspectives from Latin America and the Caribbean.Philos Trans R Soc Lond B Biol Sci. 2013; 368: 20120143Crossref PubMed Scopus (136) Google Scholar will be useful to other regions. Dog vaccination is necessary to reduce the transmission and risk to humans, but the availability of postexposure prophylaxis is essential to avoid cases of disease, especially since rabies virus is present in many other animal species worldwide. To fight against this ancient but neglected disease, more resources are need to advance research and development of new types of vaccines and immunoglobulin that will lower costs and improve regimes, and to encourage technological innovations to improve testing and diagnosis and provide other new tools.11Fooks AR Banyard ZC Horton DL Johnson N McElhinney LM Jackson AC Current status of rabies and prospects for elimination.Lancet. 2014; 384: 1389-1399Summary Full Text Full Text PDF PubMed Scopus (290) Google Scholar The global community needs to continue its efforts to help nations to eliminate dog-mediated human rabies and save lives, especially in vulnerable communities. We declare no competing interests. The authors alone are responsible for the views expressed in this publication, and they do not necessary represent the decisions or policies of the Pan American Health Organization. Effect of counselling on health-care-seeking behaviours and rabies vaccination adherence after dog bites in Haiti, 2014–15: a retrospective follow-up surveyAdherence to medical providers' recommendations might be improved through counselling provided by IBCM programmes. Full-Text PDF Open Access