Rysava, Kristyna (2021) Canine rabies control and management in Southeast Asia : from data to models. PhD thesis, University of Warwick.

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Abstract

Canine rabies is a significant public health concern and economic burden in most low- and
middle-income countries across Africa and Asia. Global targets for elimination of dog-mediated rabies have been set for 2030. Though fatal once clinical symptoms appear, rabies is preventable through appropriate administration of human and dog vaccines. Postexposure prophylaxis (PEP) is highly effective in averting the onset of rabies if delivered promptly after a person is bitten by a rabid animal. However, its unequal distribution creates disparity between settings. Where access to PEP is limited and the personal costs prohibitive, many people die having been refused appropriate healthcare. On the other hand, indiscriminately administered PEP results in excessive expenditure on non-case patients, subsequent financial strains and vaccine shortages, whilst vulnerable communities remain untreated. The lack of formal surveillance leads to suboptimal detection of the disease, preceding unrestricted transmission and misleading representation of its magnitude, undermining advocacy for funding of control programmes. While mass dog vaccination can eliminate rabies from the source population, it requires extensive resources and is currently not conducted systematically and at scale in most rabies endemic countries.

The main objectives of this thesis were first to critically review and evaluate
accomplishments and failures of the existing rabies control and management strategies in
Southeast Asia (Chapters 1 and 2), and secondly to use these assessments to draw and test potential improvements to accelerate the elimination targets across the region (Chapters 3 and 4). We used a combination of long-term epidemiological datasets, experimental design and theoretical models to examine the theory and implementation of intersectoral, enhanced surveillance and dog quarantine in the context of canine rabies in domestic dogs.

Several key themes have emerged from this work. First and foremost, to eliminate rabies
will require time, resources and commitment as well as a combination of strategies
following the One Health concept. An effective One Health approach entails long-term
planning, intersectoral communication and collaboration, and sustained effort using tried
and tested methods.

Efforts should be directed towards well-coordinated high-coverage annual dog vaccinations
using high-quality vaccines and enhanced surveillance targeted through investigations of
biting animals. The logistics of vaccinating a very large, free-roaming dog population that is typical of most Southeast Asian countries may be challenging but certainly not impossible. Lessons can be drawn from Bali, Indonesia for other large and dense dog populations, where dog management and rabies control appear difficult. Well-trained teams with nets can rapidly catch and vaccinate large numbers of dogs where central-point vaccinations are insufficient, and post-vaccination surveys of collared dogs can be used to evaluate coverage and target supplementary vaccinations. However, careful planning is required to ensure all communities are reached during campaigns and sufficient vaccine is available over consecutive years. Effective communication strategies are needed to coordinate intersectoral activities, and to keep communities as well as rabies practitioners engaged.

Using detailed questionnaires on animal bite histories combined with phone follow-ups and
field investigations, we demonstrated the effectiveness of Integrated Bite Case
Management (IBCM) in detecting rabies in the dog population, offering a more sensitive
alternative to routine surveillance conducted at random. We noted that the reported
patient bite incidence reflects the availability of the vaccine and proximity of bite patients to clinics rather than the actual disease incidence in the dog population and should not be
taken as an indicator of rabies burden alone without further field investigations. In fact,
rabies transmission between dogs appears to take place mostly locally with cases from
neighbouring areas, and focal cases from the previous month having been most significantly predictive of future rabies occurrence both in Bali and the Philippines.

We advocate that joint investigations such as Integrated Bite Case Management have the
potential to foster intersectoral relationships, opening much needed space for collaborative
investments between public health and veterinary services. Triage of patients and
investigations of suspect dogs offer an effective tool for improved PEP recommendations
and reduction of potentially unnecessary expenditures and can provide real-time guidance
for tailored quarantine of high-risk contacts. Temporary exclusion of infected dogs appears
powerful in curtailing rabies transmission despite the low prevalence of the disease,
particularly in settings where optimal vaccination coverage is yet to be achieved, providing a critical stopgap to reduce the number of human deaths due to rabid bites.

We conclude that all of the control and prevention activities discussed in this thesis will be
necessary for complete interruption of transmission of the virus and sustained elimination
of rabies, especially given the enduring risk of re-introductions from neighbouring
populations.

Item Type:	Thesis (PhD)
Subjects:	R Medicine > RA Public aspects of medicine S Agriculture > SF Animal culture
Library of Congress Subject Headings (LCSH):	Rabies in dogs -- Southeast Asia, Rabies in dogs -- Vaccination -- Southeast Asia, Rabies in dogs| -- Prevention -- Southeast Asia, Rabies in dogs -- Treatment -- Southeast Asia, Animals as carriers of disease, Dogs -- Virus diseases
Official Date:	March 2021
Dates:	Date Event March 2021 UNSPECIFIED
Institution:	University of Warwick
Theses Department:	The Zeeman Institute for Systems Biology & Infectious Disease Epidemiology Research
Thesis Type:	PhD
Publication Status:	Unpublished
Supervisor(s)/Advisor:	Tildesley, Mike
Sponsors:	Engineering and Physical Sciences Research Council ; University of Warwick
Extent:	112 leaves
Language:	eng

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