Rabies: Making a dent in a deadly global problem

“Rabies? Is that really still a problem?”

My friend’s confusion is understandable. After all, rabies is entirely preventable. Louis Pasteur developed the first vaccine over 100 years ago, and the United States is one of several countries in which dogs are rabies free (although about $300 million is spent annually to keep it that way).¹

And yet, every year, rabies claims an estimated 59,000 human lives.¹ This translates to about 1 death every 9 minutes—not to mention the devastation it wreaks in wild and domesticated animal populations. The deadliest zoonotic disease, only a handful of people have ever developed symptoms and lived to tell the tale. By that point, it’s typically too late.

So, to answer the question above—yes, rabies really is still a problem, one that disproportionately affects the rural poor and children (about half of human rabies cases are in children under the age of 15).² It remains particularly deadly in Asia and Africa, where the numbers of human deaths from dog-mediated rabies each year are in the tens of thousands. A staggering 35% of global human rabies deaths occur in India alone.²

The World Health Organization (WHO) has classified rabies as a neglected tropical disease,³ a category made up of bacteria and viruses that affect more than a billion people and cost developing economies billions of dollars a year. As WHO puts it, these diseases “pose a devastating obstacle to health and remain a serious impediment to poverty reduction and socioeconomic development.”

But despite its neglected designation and the current worldwide focus on a certain other virus (namely, SARS-CoV-2), there are organizations that are keeping rabies at the forefront of their missions. dvm360 had the opportunity to speak with team members from two of them—Andy Gibson, BVetMed, MRCVS, director of strategic research with Mission Rabies, and Terence Scott, PhD, rabies technical lead with the Global Alliance for Rabies Control (GARC)—to learn more about how they’re working to end rabies, how the coronavirus pandemic is affecting their efforts, and how veterinary professionals can join the fight against this deadly zoonotic disease.

Mission Rabies: Boots on the ground in rabies-endemic areas

Rabies is a true One Health issue. Exposure to rabid dogs accounts for more than 90% percent of human rabies cases and 99% of human deaths from the disease.¹ Researchers have demonstrated that rabies can be controlled successfully in an area and human deaths can drop to zero if just 70% of dogs are vaccinated.¹ That’s where Mission Rabies comes in.

A 3-pronged approach

The nonprofit organization, originally an initiative of the Worldwide Veterinary Service, has a 3-pronged approach to eliminating rabies, says Dr. Gibson. Not surprisingly, dog vaccinations top the list. Second, Mission Rabies seeks to educate the communities in which it works, predominantly through teaching schoolchildren.

“Children are overrepresented in human deaths, and they’re more likely to take on the messages and adapt their behavior,” Dr. Gibson explains. “We teach them how to be safe around dogs, how to not provoke dogs, how to avoid getting bitten and, if they do get bitten, how to avoid rabies infection.” The third, final, and crucial prong is surveillance. “If we don’t have information on where the virus is circulating, we’re just working in the dark,” he notes. “How else can we know if we’re making improvements?”

Dr. Gibson with schoolchildren in Malawi. Teaching children about the disease is one approach takes Mission Rabies to mitigating it. (Image courtesy Richard Murgatroyd Photography)

Thanks to surveillance, Dr. Gibson knows that they are having an effect where they work. He originally started out as a volunteer with Mission Rabies, traveling to Goa, a state in western India, to vaccinate dogs in 2013. After that trip, Mission Rabies decided to focus on Goa as a way to develop a template for the South Asian region, and Dr. Gibson made rabies elimination his full-time job.

He returned to Goa with Mission Rabies in 2014 and started testing dogs. “We never thought we’d get as many positive tests as we did,” he notes. “We were getting 10 a month, 2 a week—and I was like, ‘Wow! How was no one tracking this?’ But unless rabies is centrally monitored, you won’t have a grasp on the problem.”

Mission Rabies started vaccinating in Goa in a big way, and after just 3 years, they saw a 90% decrease in rabies cases. Human rabies deaths in Goa have been at 0 for the past 2 years (the state previously averaged 17 deaths per year). “Every year Goa doesn’t have a human death is an amazing feeling,” says Dr. Gibson. “You’ll never know the people who are still alive because of your work.”

Animal handlers from Mission Rabies vaccinate and place reflective collar on dog in Goa, India. (Image courtesy Richard Murgatroyd Photography)

Balancing care for 2 viruses

Dr. Gibson and his team now vaccinate about 100,000 dogs a year in Goa—that is, when there isn’t a worldwide pandemic going on.

“The lockdowns have affected our ability to run our vaccination camps,” he explains. “We can’t send teams street by street like we usually would, but we’ve been adapting and following government guidance to try to get our teams working in a way that’s safe, and we’ve largely been able to keep vaccinating dogs in most of the places we work in some way or another.”

At the moment, that looks like focusing on stray populations and social distancing as much as possible. In Malawi, where Mission Rabies typically vaccinates another 100,000 dogs each year, teams have been working in more rural, less densely populated areas instead of running city campaigns from a central point.

A young dog owner in Blantyre, Malawi carries his newly vaccinated pet. Dogs that have been vaccinated are marked on top of the head with animal-friendly paint. (Image courtesy Richard Murgatroyd Photography)

Still, Dr. Gibson is concerned about increases in dog rabies cases at some of the project sites. “I wonder if this might be due to the big government lockdown in India,” he says. “India has a huge stray dog population, and there are a lot of people who go out and feed these strays. But with the lockdown, no one could go out and feed them. This could lead to an increase in dog aggression and dogs roaming farther distances to find food, and that is the perfect environment for rabies to spread.”

Stray dogs being fed in Goa, India. The coronavirus lockdown may lead dogs to roam farther distances to find food, potentially increasing their likelihood of encountering and spreading rabies. (Image courtesy Richard Murgatroyd Photography)

While the travel ban has prevented Dr. Gibson from supporting teams in person, it hasn’t dimmed his passion (or lightened his workload). In addition to helping further the initiatives of both Mission Rabies and the World Veterinary Service, he’s also working toward his PhD at the Roslin Institute at the University of Edinburgh in Scotland and is hoping to publish research on methods of rabies control in India soon.

“Rabies is a real problem for so many people, and for so little, a lot can be done to change it,” he says. “We’re really trying to come at it with solutions we’ve developed from experience in the field and replicate them in new areas. We want to make people aware that they shouldn’t have to live with this problem. At the same time, we want to provide support for governments as well—writing proposals and plans for vaccination campaigns, providing them with methods and monitoring tools.”

GARC: Remote capacity building

GARC was established in 2007, and while its goal is similar to that of Mission Rabies—to prevent human deaths from dog-mediated rabies and to relieve the burden of rabies in other animal populations—it takes a slightly different approach.

“We’re trying to help governments with rabies elimination any way we can,” Dr. Scott explains. “We help them assess the rabies situation in their countries, determine priorities and build their capacity to fight rabies themselves through training, support and surveillance resources. All of these things are designed to be run remotely because it’s physically impossible to have teams in every country where we work.”

And GARC works in a lot of different countries. It’s divided into 3 networks: ARACON (Asian Rabies Control Network), MERACON (Middle East, Eastern Europe, Central Asia, and North Africa Rabies Control Network) and PARACON (Pan-African Rabies Control Network).

GARC mass dog vaccination team volunteers administers rabies vaccinations in Zanzibar. Note the GARC Data Logger worn around the neck of some volunteers. This tool works on GPS triangulation rather than mobile data to track mass dog vaccination programs. (Images courtesy of GARC)

Innovation in isolation

Despite being largely remote, the GARC team hasn’t been unaffected by this new pandemic paradigm. “We typically do face-to-face training and workshops where we help governments develop national strategies,” Dr. Scott explains. “Obviously, that’s been heavily affected, so we’re creating new ways to do these things remotely. While travel will eventually resume at some point, this situation has challenged our perceptions on the need for in-person interactions. We want to adapt as best as possible now while we have the opportunity to develop these workshops as being feasible in an online situation.”

Necessity is the mother of invention, and a lack of travel has provided time for it. Dr. Scott created the Rabies Epidemiological Bulletin (REB), a surveillance tool that’s designed to be a “one-stop-shop for rabies surveillance data reporting and analysis,” long before the coronavirus pandemic. But with more time in his home office and less time on the road, he’s been working on improving user experience and, importantly, how training is done. “We’ve developed detailed protocols (with step-by-step screenshots) that enable us to begin implementation without face-to-face training,” Dr. Scott explains.

“Because of this,” he continues, “We’ve actually managed to work with a couple of governments in Africa to get REB up and running using our remote training and implementation. They may not be able to go out into the field to vaccinate or to collect samples or anything, but they can start adding their retroactive data into the system to make sure it’s up to date and can see trends over time. So, when things kick off again, they can continue from present and monitor the impact of their work.”

Another GARC tool that’s gotten some attention in the midst of travel bans is the Stepwise Approach towards Rabies Elimination (SARE), which helps governments assess their country’s current rabies situation and develop a national strategy and work plan to eliminate it. The assessment aspect of the tool is composed entirely of yes/no questions, and Dr. Scott says that once it’s filled out, the tool generates a clear work plan with key performance indicators, timelines, responsible authorities, objectives, and other outputs that help government rabies personnel find a way forward. “We’re currently working with some of our partners to create a way to undertake an entirely remote workshop for implementing SARE—something that’s never been done before,” he explains.

Despite these accomplishments, Dr. Scott is concerned about the long-term effects of COVID-19 on rabies. “Rabies is labeled as a neglected disease, and it’s exactly that,” he laments. “And as soon as something else comes along that’s perceived to have a greater public health impact or greater impact on livestock and animals that have a market value (as opposed to dogs, which aren’t seen as valuable), it becomes even more neglected.”

Join the global fight

It would be cruel to outline the horrific suffering rabies is causing without offering ways to get involved, and with World Rabies Day coming up on September 28, it’s a particularly prudent time to join the cause at a global level.

While Goa and Malawi are year-round sites for Mission Rabies, the organization also has pilot projects in places like Sri Lanka, Uganda, Cambodia, and Tanzania, where they run short-term vaccination programs in a particular community to reach about 5000 dogs. Both the year-round and pilot sites take volunteers of all backgrounds. Fair warning: Like Dr. Gibson, you might get hooked. Visit missionrabies.com/volunteer/ to learn about future trips.

If you’d rather battle rabies from your home office, you have options. GARC has several free online educational courses, including one that’s specifically designed for those who work in animal health. Scott encourages anyone who handles and vaccinates animals to go through the course. There’s also an introductory course that empowers people of all backgrounds to become rabies educators. “I’m horribly biased, but I think [education is] especially important in countries like the U.S. that are dog rabies free,” he says. “People forget that rabies is still a possibility, and it can be missed.”

In addition to these courses, GARC has a wealth of free resources, including a World Rabies Day social media toolkit and posters, videos, and factsheets aimed at increasing rabies awareness at the community level. You can even check out what people around the world are doing on World Rabies Day and register an event of your own.

And finally, because pandemics can be particularly hard on nonprofit finances, you can also join the fight by donating to Mission Rabies and GARC.

Sarah Mouton Dowdy, a former associate content specialist for dvm360.com, is a freelance writer and editor in Kansas City, Missouri.

References

1. Rabies around the world. Centers for Disease Control and Prevention. Reviewed July 29, 2020. Accessed August 18, 2020. https://www.cdc.gov/rabies/location/world/index.html
2. Rabies. World Health Organization. Accessed August 18, 2020. https://www.who.int/health-topics/rabies#tab=tab_1
3. Neglected tropical diseases. World Health Organization. Accessed August 18, 2020. https://www.who.int/neglected_diseases/diseases/en/