Human rabies elimination through One Health in action at the Indian state scale

Will ours be the generation to end human death from dog-mediated rabies? Goa state in India has taken a huge leap towards this ambition, leveraging modern technologies to achieve human rabies elimination through an integrated One Health approach.
Human rabies elimination through One Health in action at the Indian state scale
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Dog-mediated rabies is at the core of a tragic paradox; effective elimination methods have been known for a century, and yet thousands of geographically and socioeconomically isolated children still die in abject suffering from the disease every year1. Countries across Latin America eliminated the dog rabies virus through mass vaccination of the dog population, but large-scale control efforts have failed to progress in much of Africa and Asia2. The status quo will result in an estimated one million human deaths from dog-mediated rabies between 2020 and 2035, emphasising the need for urgent expansion of control efforts in rabies endemic countries.

A pioneering initiative in Goa state, India has demonstrated that rabies control in the world’s worst affected country is within reach3. The project brought together government, non-government organisations and academic partners to develop an effective One Health approach to tackling rabies elimination from the ground up, through an iterative process of implementation and refinement. Seven years after inception, the programme can now showcase methods for cost-effective human rabies elimination at the state-scale in India.

Year-wise graphs of intervention outputs and indicators of rabies control from 2012 - 2019
Year-wise graphs of intervention outputs and indicators of rabies control from 2012 - 2019

The international charity Mission Rabies implemented the project under the leadership of the Government of Goa with the objective of making Goa the first rabies free state of India. However, the nature of free-roaming dog populations in South Asia presents major challenges to high-coverage dog vaccination programmes4. A high proportion of dogs in India cannot be readily handled, resulting in the need for more innovative vaccination methods. We demonstrated that a combination of door-to-door vaccination, targeting dogs that could be manually restrained, followed by the capture-vaccinate-release approach, where skilled teams use dog nets to catch difficult-to-handle dogs, achieved high enough vaccination coverages to eliminate the virus from most parts of Goa. Viral perpetuation was identified at the northern border, where Goan dogs interact with rabies endemic dog populations in the neighbouring state, highlighting the challenge of rabies control at state boundaries.

Year-wise maps of Goa state showing canine rabies cases and the extent of dog vaccination

Innovation in smartphone technology to enhance programme coordination, monitoring and reporting was fundamental to success. Project managers spatially directed remote vaccination teams through assignment of mapped ‘Working Zones’ displayed within a smartphone app. The GPS location and details of each vaccination event were recorded offline in the field and subsequently uploaded for review by the project manager in a web-interface5. This two-way flow of data enabled a step change in operational efficiency, supported timely analysis of data to foster refinement of methods, and facilitated transparent reporting to garner continued political support6.

Broad public awareness of the zoonotic risk of rabies was generated through school and community education initiatives. Rabies classes were delivered to 170,000 children per year in an education campaign conducted in schools throughout the state. These fun and interactive sessions communicated simple rabies educational messages such as ‘what is rabies’, ‘how to avoid dog bites’ and ‘what to do if you are bitten by a dog’ through a combination of presentation, theatre and quizzes7. Additional engagements at community groups, health centres and local authorities ensured that a broad awareness of the risk of rabies and how communities could support control efforts was achieved.

Collaboration between government and non-governmental stakeholders supported the state-wide intensification of rabies surveillance through improved reporting, investigation, and diagnosis of suspect rabid dogs. Through analysis of dog rabies incidence, we found that areas of high dog density experienced the greatest rabies burden. This would support the prioritization of such areas during the scale-up of nascent dog vaccination campaigns in other Indian states.

We additionally demonstrated the application of modern technologies for viral sequencing in low-resource settings, conducting rabies virus sequencing in the Goa government veterinary diagnostic laboratory for the first time8. Three distinct rabies virus lineages were identified, with the most recent common ancestor estimated to be in 2003. Continued monitoring of rabies phylogeny will support effective rabies control strategy and will enable demonstration of successful elimination.

Finally, we used a previously published model to estimate the cost-effectiveness of the intervention9,10. According to WHO criteria of health intervention cost-effectiveness, the project was determined to be ‘very cost-effective’11 and the death of an estimated 121 people from rabies would be prevented over a ten year period from 2013 to 2023. With momentum building towards the global goal of dog transmitted human rabies elimination by 2030, this example from Goa presents governments across India and South Asia with the clear opportunities to benefit their societies through the active pursuit of rabies control.

 

References

  1. World Health Organization & WHO. WHO Expert Consultation on rabies.Third report. World Health Organization technical report series. vol. 1012 (2018).
  2. Kakkar, M., Venkataramanan, V., Krishnan, S., Chauhan, R. S. & Abbas, S. S. Moving from rabies research to rabies control: lessons from India. PLoS Negl. Trop. Dis. 6, e1748 (2012).
  3. Gibson, A. D. et al. Elimination of human rabies in Goa , India through an integrated One Health approach. 1–13 (2022) doi:10.1038/s41467-022-30371-y.
  4. Tiwari, H. K., Robertson, I. D., O’Dea, M. & Vanak, A. T. Demographic characteristics of free-roaming dogs (FRD) in rural and urban India following a photographic sight-resight survey. Sci. Rep. 9, 1–10 (2019).
  5. Gibson, A. D. et al. One million dog vaccinations recorded on mHealth innovation used to direct teams in numerous rabies control campaigns. PLoS One 13, e0200942 (2018).
  6. Monroe, B. et al. Every dog has its data : evaluation of a technology-aided canine rabies vaccination campaign to implement a microplanning approach. Front. Public Heal. 9, (2021).
  7. Burdon Bailey, J. L. et al. A rabies lesson improves rabies knowledge amongst primary school children in Zomba, Malawi. PLoS Negl. Trop. Dis. 12, e0006293 (2018).
  8. Gigante, C. M. et al. Portable Rabies Virus Sequencing in Canine Rabies Endemic Countries Using the Oxford Nanopore MinION. Viruses 12, 1255 (2020).
  9. Kunkel, A. et al. The urgency of resuming disrupted dog rabies vaccination campaigns: a modeling and cost-effectiveness analysis. Sci. Rep. 11, 1–8 (2021).
  10. Borse, R. H. et al. Cost-effectiveness of dog rabies vaccination programs in East Africa. PLoS Negl. Trop. Dis. 12, e0006490 (2018).
  11. World Health Organisation. Making choices in health: WHO guide to cost-effectiveness analysis. vol. 1 (World Health Organisation, 2003).

 

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