EFFECTIVE SURVEILLANCE STRATEGIES FOR HUMAN AND CANINE RABIES ELIMINATION PROGRAMS

1. EFFECTIVE SURVEILLANCE STRATEGIES
FOR HUMAN AND CANINE RABIES ELIMINATION PROGRAMS
Mary Elizabeth Miranda,
Field Epidemiology Training Program Alumni Foundation,
Philippines
email: betsygmiranda@gmail.com, megmiranda@fetpafi.org
ABSTRACT
Global elimination of rabies has become a priority of major international organizations including WHO,
FAO and OIE. Although rabies control is often not among the disease priorities of the public health and
agriculture ministries, it is a disease that crosses different sectors of society and diverse fields of
discipline. Multisectoral disease control programs benefit from combined human and animal health
resources fromvaried sectors and levels of society.
Particularly for diseases in the elimination phase such as canine-mediated rabies, information on the
number and distribution of animal and human rabies cases and deaths is essential for successful disease
elimination. It is needed to determine which areas or population groups are most affected, so that
resources can be targeted to the populations most in need. Information on the incidence of disease is
needed to alert program about outbreaks, so that control measures can be intensified. Data trends in
disease incidence and mortality are also needed in order to judge the success of a program and to
determine whether it is performing as expected or whether adjustments in the scale or blend of
interventions are required. The outcomes of timely disease control and response strategies, the
probability of elimination,and the certainty of declaring freedomfromdisease depends on it.
Traditional and innovative approaches to detecting and understanding communicable disease
outbreaks have been attempted to overcome constraints such as high operational cost, wide coverage
areas, and labor intensity. Applying innovative surveillance tools complements traditional surveillance
methods. Community engagement through enhanced participatory surveillance such as mobile-phone
based reporting systems help shorten the time to disease detection. Innovative surveillance and the use of
non-traditional sources can provide a wealth of information about the public's health.
Surveillance is often poorly resourced but there are important institutional drivers and enablers to
sustain the system in both animal and public health. The overarching objective is to advocate for
continued better targeted funding to strengthen capacities for immediate and effective surveillance,
prevention, response and preparedness for infectious disease outbreaks and similar major threats.
Synergistic investment mechanisms and integrative efforts must be enabled by the government and
community partners. Global freedom from the threat of dog-mediated rabies is feasible given political
will, adequate resources and diligent program management.
Keywords: Rabies, Surveillance, Zoonoses, Emerging Infectious Diseases, Disease Control and
Elimination

2. INTRODUCTION
Effective surveillance provides information on the number and distribution of rabies cases and deaths. It
contributes to early detection of new outbreaks, tracking spread of disease and gives early warning to
human and animal health officials nationally and internationally for follow up and timely response
(WHO, Keusch). It is critical for the design and implementation of rabies control and elimination
programs. Globally, the capacity of rabies surveillance systems to provide information on the disease
distribution and trends in rabies varies widely, and unfortunately many disease surveillance systems
operating around the world are not very effective in alerting officials to emerging diseases particularly
those that are transmitted between humans and animals (Keusch, Lembo). Methodologies for disease
surveillance include the traditional surveillance, innovative surveillance that utilize tools that facilitate
communication regarding potential disease outbreaks among human and animals, and participatory
disease surveillance. Once interventions are implemented, surveillance is also essential to generate data
on the progress and cost-effectiveness of such programs, which are essential for their sustainable
implementation.
Active and passive surveillance
Rabies surveillance, both passive and active should be backed up by laboratory diagnosis as much as
possible to be effective (WHO TRS 2013, Banyard, Rupprecht). It is recommended that countries that
lack or have inadequate diagnostic facilities improve their capacity through OIE laboratory twinning
projects and links with WHO Collaborating Centers (WHO TRS 2013). Passive surveillance is useful
because it provides continuous monitoring and requires lesser resources. In contrast, active surveillance
particularly for international reference, national, and subnational laboratories disseminate information
about notifiable diseases like rabies. While the active surveillance is more costly and labor intensive, it
provides a more complete trend of disease occurrence. Since rabies is zoonotic, human and animal rabies
surveillance systems should be unified through a One Health approach among surveillance professionals
on the ground (Zinstagg, Lechenne). The reporting of disease data from different sectors need to be
multisectoral, integrated and interdisciplinary in approach. Such strategies must involve the collation of
animal disease data that must be shared with public health authorities, to enable them to develop and
implement effective policies. The OIE World Animal Health Information System (WAHID) reporting
system depend on consistent disease reporting, backed up by confirmatory laboratory diagnosis by
participating countries. Reliable systematic surveillance of human rabies deaths and animal prevalence at
the national level is an urgent issue.
Field implementers and partner communities may face constraints such as high operational cost, wide
regions of coverage and labor intensity. Many innovative approaches have been attempted to overcome
these problems. There are numerous lessons of good practices learnt from experience. Community-led
disease reporting was maximized in implementing a bottom-up intersectoral program to eliminate human
and canine rabies in Bohol, Philippines (Lapiz et al., 2013). Another example is the mobile phone-based
surveillance system that was used to support the rabies control program across southern Tanzania (Mtema
et al 2016).
Outbreak detection and response
Effective surveillance systems allow early detection and reporting of cases, vital for initiating timely
responses and enabling informed decisions about when and where to intensify control efforts. Increased
speed of early detection of outbreaks leads to more efficient resource mobilization and disease control
measures. Weak surveillance may therefore result in delayed control interventions and complacency and

3. can jeopardize chances of disease elimination. The work of Townsend et al. in 2013 estimated that
detection probabilities of <0.1 are broadly typical of rabies surveillance in endemic countries and areas
without a history of rabies. Using outbreak simulation techniques the probability of detection affects
outbreak spread, and outcomes of response strategies such as time to control an outbreak, probability of
elimination, and the certainty of declaring freedom from disease was investigated. Assuming realistically
poor surveillance (probability of detection <0.1), it was shown that proactive mass dog vaccination is
much more effective at controlling rabies and no more costly than campaigns that vaccinate in response to
case detection. Control through proactive vaccination followed by two years of continuous monitoring
and vaccination should be sufficient to guarantee elimination from an isolated area not subject to repeat
introductions. It was recommended that rabies control programmes should be able to maintain
surveillance levels that detect at least 5% (and ideally 10%) of all cases to improve their prospects of
eliminating rabies, and this can be achieved through greater intersectoral collaboration. The approach
illustrated how surveillance is critical for the early outbreak detection, control and elimination of diseases
such as canine rabies and can provide minimum surveillance requirements and technical guidance for
elimination programmes under a broad-range of circumstances.
Maintenance ofrabies-free status
Surveillance is a critical element in the control and elimination of infectious diseases. Exhaustive
epidemiologic investigations have to show that rabies has been eliminated in an area. Surveillance should
be maintained even in countries that have successfully eliminated canine rabies because of the risk of re-
emergence. Successful control, ultimate disease elimination, and maintenance of disease-free status,
depends highly on effective surveillance.
CONCLUSION
Eliminating rabies can progress once concerted efforts are made. This is despite perceptions that poor
accessibility of dogs and low community compliance might compromise success. The impetus for control
is hampered by a lack of awareness of its true impact. Effective rabies surveillance is critical to
quantifying the disease impact relative to other diseases to set priorities for public health interventions
(Coleman). As control efforts progress towards elimination, surveillance becomes even more critical in
order to detect new incursions. It is critical to advocate for continued better targeted funding to strengthen
capacities for immediate and effective surveillance, prevention, response and preparedness for infectious
disease outbreaks and similar major threats. There must be synergistic investment mechanisms and
integrative efforts by the government and community partners. Global freedom from the threat of dog-
mediated rabies is feasible given political will, adequate resources and diligent program management.
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