Bill & Melinda Gates Foundation fund WHO-coordinated project to control and eventually eliminate rabies in low-income countries
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.
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.
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.
The project will include only the Visayas group of islands, which contain 25% of the total number of animal rabies cases, 28% of the total cases of human rabies and 27% of animal bites for the entire country (based on the 2006 annual rabies report).
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.
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.
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.
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.