Rabies is a devastating disease that causes around 60,000 human deaths globally each year with over 99% of human rabies deaths resulting from dog-mediated transmission. Whilst rabies has been eliminated from domestic dog populations in most high-income countries, the disease remains a serious public health concern and economic burden in low- and middle-income countries.

It is often the poorest communities that are affected most heavily, largely due to prohibitive and/or limited access to post-exposure prophylaxis (PEP), low vaccine coverage in dogs and misunderstanding of rabies risk.

Threats to public health

Despite initiatives by the government in the Philippines to prevent a wide range of infectious diseases, rabies remains endemic, killing over 200 people every year. PEP provides an extremely effective solution for prevention of human deaths, but its repeated shortages, high costs and the generally inadequate awareness of rabies risk in the general public leaves many people without access to appropriate treatment. Mass dog vaccination can eliminate rabies from the dog population, preventing further transmission to humans, but a rapid demographic turnover, coupled with the nature of dog management in the country pose significant challenges to reach the required levels of vaccination coverage at the scale necessary to eliminate the disease. Ultimately, a lack of integration between human health and veterinary sectors impedes rabies surveillance and further leads to potentially inappropriate PEP recommendations and inadequate control.

A major obstacle to reducing rabies is the minimal detection of the disease amongst free roaming dogs. Early detection of rabid dogs, improving community awareness of rabies and the need for appropriate treatment after a dog bite can help reduce the risk of further human exposure, and ultimately reduce deaths. Dr Michael Tildesley, in collaboration with PhD student, Kristyna Rysava, undertook a project to improve surveillance through bite-case management and timely identification of rabies-infected dogs.

Canine rabies causes around 200 human deaths in the Philippines annually.

Developing a surveillance scheme

Tildesley and Rysava have designed a surveillance scheme in three Animal Bite Treatment Centres (ABTCs) in the province of Albay in the Philippines. Together with the Warwick IT team, Rysava and Tildesley developed a mobile phone-based application, called the Bite Incidence Tool for Enhanced Rabies Surveillance (BITERS) that facilitates direct communication between ABTCs, veterinary services and local government, leading to quick and efficient information sharing about suspect dogs.

Members of the BITERS team interviewing a patient's mother.

"We have a local team at all three ABTCs to interview animal bite patients using our BITERS application when they present at clinics for their post-exposure vaccination. The BITERS team interviews patients about dog-bite histories and advises them to quarantine suspect dogs for 14 days to monitor any rabies-related symptoms and other health and behavioural changes.

The BITERS team follows up with the patient after 14 days to determine the status of the biting animal, and if change in the dog's status occurs earlier, the local veterinary office is prompt to carry out a field investigation. All data are documented and uploaded to our server” Dr Tildesley explains.

The data have been used by the Warwick team to determine the effectiveness of this integrated surveillance protocol and results were presented to the Bureau of Animal Industry (BAI) and the Department of Health (DoH) to illustrate the benefits of using the application to improve rabies surveillance.

“The use of this technology at ABTCs provides valuable evidence to support the need for enhanced surveillance and ultimately reduce the human health risk of canine rabies,” adds Dr Tildesley. “Our surveillance protocol aids field investigations in ensuring that rabid dogs are investigated and managed in a timely manner, which helps reduce human health risks.”

Detecting rapid dogs

Through this project, the team have worked closely with partners at the Albay Veterinary Office (AVO) and the Bicol Regional Teaching and Training Hospital (BRTTH) to integrate human and animal health sectors in the province. The BITERS team communicates directly with the nursing staff treating bite patients at the ABTCs and the AVO epidemiology team, who investigates rabid dogs in the community.

Dr Tildesley continues: “Since our surveillance project began, we have seen an increase in the number of rabid dogs detected in Albay province. Removing these dogs from the local community has had a positive impact upon human health, by reducing the chances of rabid bites.”

A local child receives a post exposure vaccination.

A dog is caught in a catching net to receive a rabies vaccination as part of the mass dog vaccination campaign in Albay province.

The team worked closely with the Bureau of Animal Industry and the Department of Health throughout this project, and at the time of writing are liaising with the local government in Albay to secure funding to continue the work. “We have also presented our findings to potential collaborators in Thailand, with the hope that our research can be translated to other settings that are affected by rabies. We aim to extend the impact of our work beyond the Philippines so that we can ultimately help reduce rabies throughoutin South East Asia” concludes Dr Tildesley.

This project links to the UN Sustainable Development Goal of Good Health and Well-Being.

Principal Investigator: Dr Mike Tildesley

Co-Investigators:

Kristyna Rysava

Dr Rona Bernales (Philippines Dept. of Agriculture)

Dr Florencio Adonay (AVO)

Dr Emelinda Lopez (BAI)

BITERS team:

Jason Espineda

Angelica Villafane Silo

Sarah Carino

Country: The Philippines

UN Goals addressed: