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150 THIRD WHO REPORT ON NEGLECTED TROPICAL DISEASES *** Investment case The high cost of rabies is attributed to mortality and lost productivity, both direct and indirect costs of post-exposure prophylaxis and dog vaccination, surveillance and livestock losses. Fortunately, government-led strategies to eliminate canine rabies have succeeded in many countries worldwide. In the long term, dog vaccination is more costeffective than human post-exposure treatment. 1 Dog vaccination will drive down not only the deaths attributable to rabies but also the need for post-exposure prophylaxis as a part of dog-bite patient care. While human deaths are entirely preventable through post-exposure prophylaxis and pre-exposure vaccination, these interventions will not eliminate the disease and costs will therefore continue to escalate over time if rabies is not controlled at its canine source. 2,3 Unfortunately, investment in dog vaccination to eliminate rabies from endemic countries in Africa and most of Asia has been minimal to date. Three large-scale projects are under way in the Philippines, South Africa and the United Republic of Tanzania. The project in KwaZulu-Natal has reduced the prevalence of rabies, facilitating a shift towards rapid outbreak response. As a result, it is being expanded within South Africa to the Eastern Cape and across the country’s borders to Lesotho, Mozambique and Swaziland. Vaccination costs across the three sites are between US$ 1.18 and US$ 11.27 per dog. In these endemic regions, the substantial costs associated with human intervention could be avoided if elimination was achieved. In areas where the cost per dog vaccinated is very high, however, efforts will be needed to reduce costs to levels that are more affordable in order to maintain and sustain high coverage vaccination campaigns needed to eliminate the disease. For example, integration with existing platforms for control of other NTDs and access to health is being considered as a way of increasing the reach, cost-effectiveness and sustainability of rabies control programmes in Africa. As work continues on the third edition of the Disease Control Priorities Project, WHO is analysing the cost-effectiveness of elimination of dog-mediated human rabies. _____________________ 1 People, pathogens and our planet: the economics of one health. Washington (DC): The World Bank (Report number 69145-GLB; http://documents.worldbank.org/curated/en/2012/06/16360943/people-pathogens-planet-economics-onehealth; accessed October 2014). 2 Kasempimolporn S, Jitapunkul S, Sitprija V. Moving towards the elimination of rabies in Thailand. J Med Assoc Thail. 2008;91:433–7. 3 Zinsstag J, Durr S, Penny MA, Mindekem R, Roth F, Gonzalez SM et al. Transmission dynamics and economics of rabies control in dogs and humans in an African city. Proc Natl Acad Sci. 2009;106:14996–5001.
*** THE DISEASES − CHAPTER 4 151 Burden and distribution Rabies causes tens of thousands of deaths annually worldwide. Its global distribution has changed little since 2011, with more than 90% of rabies deaths occurring in Africa and Asia (Fig. 4.13.1). Fig. 4.13.1 Distribution of risk to humans of contracting rabies, worldwide, 2013 High risk Moderate risk Low risk No risk No data available Not applicable Official reporting of rabies incidence in animals and of human exposure to the virus remains inadequate, making it difficult to accurately determine the global burden of the disease. It is increasingly accepted that the available data underestimate the true incidence (4,5). Methods have been developed to improve estimates of mortality attributable to rabies. A predictive approach that uses a probability decision-tree method has been introduced to establish the likelihood of developing rabies following a bite from a dog suspected of being rabid. This approach has been used to estimate mortality in Africa and Asia, and to determine countryspecific mortality estimates in Bhutan and Cambodia. Most recently, it has been adapted to estimate the global burden of endemic canine rabies (6). As with the other dog-transmitted NTDs, management of waste has a direct impact on roaming dog populations. The involvement of other sectors – including the veterinary but also water, sanitation and hygiene sectors – is therefore critical.
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