How rabies control can help build the One Health systems we need.
By Professor Sarah Cleaveland and Professor the Lord Trees*
The coronavirus pandemic has opened the world’s eyes to zoonotic diseases – illnesses that are transmitted from animals to humans (and sometimes vice-versa). Covid-19, Ebola, MERS, avian flu and HIV all originated in animals. Most future pandemics will also start with cross-species “spillover”.
One of the oldest and most frightening zoonotic diseases is rabies. No longer a threat to people in the UK, rabies remains prevalent in over 150 countries, mainly in Africa and Asia, and costs an estimated $8.6 billion a year, mainly in lost productivity and treatment costs.
It’s estimated that around 60,000 people die every year from the disease. Almost half of those killed are children under the age of 15 and by far the main source of infection is a bite from a rabid dog. Once symptoms appear, the disease is almost always fatal.
Despite its gruesome pathology, rabies is an entirely preventable disease. Unlike many other zoonoses, the route to rabies control is clear: it requires effective surveillance and reporting, mass dog vaccination to prevent transmission to humans, speedy vaccination to treat people suspected of exposure to rabies, and public education. Latin America has significantly reduced rabies and Mexico was recently declared canine rabies-free by following this process. However control of the disease in Africa and Asia remains poor due to inadequate monitoring and reporting, few dogs being vaccinated and people in the most vulnerable communities rarely having reliable or affordable access to post-bite vaccinations.
While rabies and COVID-19 are very different diseases, the current pandemic clearly shows that we cannot afford to ignore the interconnections between the health of people and animals. However we lack the systems to respond effectively. We need to bridge the governmental divides and budget lines separating human and animal health, and share knowledge in real time to systematically detect dangerous pathogens and intervene swiftly to control them.
At present, human health systems dwarf the animal health sector, and institutional barriers constrain the ability of the two sectors to act in concert. But we do have a way forward in ‘One Health’, a globally-recognised framework for integrating human, animal and environmental health responses. The challenge is to implement it more widely.
There is no doubt that making One Health a reality is complicated. It adds new dimensions to interactions and processes for detecting, reporting and responding to disease outbreaks. Rather than building completely new systems, we should build on existing knowledge where we can. Rabies provides an excellent platform for One Health implementation, particularly in developing countries where resources are limited. We know a lot about the disease, we have cost-effective interventions for saving lives, and when implemented, the rapid and tangible impacts are clearly recognised by communities, building trust and confidence and reversing cycles of neglect.
At present the gap between human and animal health receives very little political attention or resources, especially in developing countries. Instigating a One Health approach for rabies therefore needs top-level political leadership to create formal ways for human and veterinary systems to link up. With most veterinary budgets focussed on controlling livestock diseases of economic value, governments and external funders need to recognise the value of veterinary interventions in supporting public health and ensure sufficient resources for mass dog vaccinations and surveillance. Community outreach and education programmes need to be in place to encourage people to have their dogs vaccinated and registered and to report incidents to relevant authorities. At the same time, treatment for people suspected of rabies exposure must be made accessible and affordable. But in a few short years, governments would be able to show demonstrable results in rabies reduction, creating new networks, building capabilities, and laying the foundations for tackling other zoonotic diseases.
There are already many measures in place to eliminate dog-mediated rabies and establish One Health in practice. A global strategy has been agreed by the World Health Organization (WHO), Food and Agriculture Organization (FAO) and the World Organization for Animal Health (OIE). Gavi, the global vaccines alliance, plans to add human post-exposure vaccine to its schedule in the next few years, making this costly medicine more widely available to the world’s poorest people. The OIE is working with endemic countries to create National Rabies Control Programmes. Kenya and Tanzania have established One Health and Zoonotic Disease Units, and technical experts from the East African region have been developing a coordinated regional rabies elimination plan. Numerous NGO-led dog vaccination and education projects are run every year and work is underway to create a One Health financial facility to support mass dog vaccination and enable the scaling-up of rabies elimination efforts.
The Covid-19 pandemic has focussed global attention on the need to build One Health systems and rabies control offers a practical way forward. It will take more money and political engagement, especially from national governments, but in the face of a pathogen like coronavirus, we need to make One Health a reality, and there is little time to lose.
*Professor Sarah Cleaveland OBE, MRCVS FMedSci FRSE FRS is Professor of Comparative Epidemiology, University of Glasgow.
Professor the Lord Alexander “Sandy” Trees MRCVS, FMedSci, HonFRSE is a Crossbench Member of the House of Lords, Emeritus Professor of Veterinary Parasitology and former Dean of the Faculty of Veterinary Science, University of Liverpool