Implementation of a mass canine rabies vaccination campaign in both rural and urban regions in southern Malawi

Current status and molecular epidemiology of rabies virus from different hosts and regions in Malawi

Although rabies is endemic in Malawi, there have been no studies in which rabies virus was systematically investigated and characterized in multiple animal hosts in that country. In order to provide molecular epidemiological data on rabies virus in Malawi, 683 suspected rabies case reports from 2008 to 2021 were examined, and 46 (dog = 40, cow = 5, and cat = 1) viable rabies-positive brain samples archived at the Central Veterinary Laboratory (CVL), Lilongwe, Malawi, were analyzed genetically. The results showed an increase in the submission of brain samples from 2008 to 2010, with the highest number of submissions observed in 2020. Of the 683 case reports analyzed for the period under review, 38.1% (260/683) (CI: 34.44 - 41.84) were confirmed by direct fluorescent antibody test. Among the confirmed cases, 65.4% (170/260) (CI: 59.23 - 71.09) were canine rabies. Further, phylogenetic analysis revealed that sequences from different animal hosts clustered together within the Africa 1b lineage, suggesting that the strains circulating in livestock are similar to those in domestic dogs. This finding supports the hypothesis that canine rabies is spilling over to livestock and emphasizes the need for further studies to provide data for effective control of rabies in Malawi.

Implementing a One Health Approach to Rabies Surveillance: Lessons From Integrated Bite Case Management

As part of the 'Zero by 30' strategy to end human deaths from dog-mediated rabies by 2030, international organizations recommend a One Health framework that includes Integrated Bite Case Management (IBCM). However, little is understood about the implementation of IBCM in practice. This study aims to understand how IBCM is conceptualized, exploring how IBCM has been operationalized in different contexts, as well as barriers and facilitators to implementation. Semi-structured interviews were conducted with seventeen practitioners and researchers with international, national, and local expertise across Africa, Asia, and the Americas. Thematic analysis was undertaken using both inductive and deductive approaches. Four main themes were identified: 1) stakeholders' and practitioners' conceptualization of IBCM and its role in rabies elimination; 2) variation in how IBCM operates across different contexts; 3) barriers and facilitators of IBCM implementation in relation to risk assessment, PEP provisioning, animal investigation, One Health collaboration, and data reporting; and 4) the impact of the COVID-19 pandemic on IBCM programs. This study highlights the diversity within experts' conceptualization of IBCM, and its operationalization. The range of perspectives revealed that there are different ways of organizing IBCM within health systems and it is not a one-size-fits-all approach. The issue of sustainability remains the greatest challenge to implementation. Contextual features of each location influenced the delivery and the potential impact of IBCM. Programs spanned from highly endemic settings with limited access to PEP charged to the patient, to low endemicity settings with a large patient load associated with free PEP policies and sensitization. In practice, IBCM was tailored to meet the demands of the local context and level of rabies control. Thus, experts' experiences did not necessarily translate across contexts, affecting perceptions about the function, motivation for, and implementation of IBCM. To design and implement future and current programs, guidance should be provided for health workers receiving patients on assessing the history and signs of rabies in the biting animal. The study findings provide insights in relation to implementation of IBCM and how it can support programs aiming to reach the Zero by 30 goal.

Development of Dog Vaccination Strategies to Maintain Herd Immunity against Rabies

Human rabies can be prevented through mass dog vaccination campaigns; however, in rabies endemic countries, pulsed central point campaigns do not always achieve the recommended coverage of 70%. This study describes the development of a novel approach to sustain high coverage based on decentralized and continuous vaccination delivery. A rabies vaccination campaign was conducted across 12 wards in the Mara region, Tanzania to test this approach. Household surveys were used to obtain data on vaccination coverage as well as factors influencing dog vaccination. A total 17,571 dogs were vaccinated, 2654 using routine central point delivery and 14,917 dogs using one of three strategies of decentralized continuous vaccination. One month after the first vaccination campaign, coverage in areas receiving decentralized vaccinations was higher (64.1, 95% Confidence Intervals (CIs) 62.1-66%) than in areas receiving pulsed vaccinations (35.9%, 95% CIs 32.6-39.5%). Follow-up surveys 10 months later showed that vaccination coverage in areas receiving decentralized vaccinations remained on average over 60% (60.7%, 95% CIs 58.5-62.8%) and much higher than in villages receiving pulsed vaccinations where coverage was on average 32.1% (95% CIs 28.8-35.6%). We conclude that decentralized continuous dog vaccination strategies have the potential to improve vaccination coverage and maintain herd immunity against rabies.

Scaling-up the delivery of dog vaccination campaigns against rabies in Tanzania

An increasing number of countries are committing to meet the global target to eliminate human deaths from dog-mediated rabies by 2030. Mass dog vaccination is central to this strategy. To interrupt rabies transmission from dogs to humans, the World Health Organization recommends that vaccination campaigns should be carried out every year in all dog-owning communities vaccinating 70% of their susceptible dogs. Monitoring and evaluation of dog vaccination campaigns are needed to measure progress towards elimination. In this study, we measured the delivery performance of large-scale vaccination campaigns implemented in 25 districts in south-east Tanzania from 2010 until 2017. We used regression modelling to infer the factors associated with, and potentially influencing the successful delivery of vaccination campaigns. During 2010–2017, five rounds of vaccination campaigns were carried out, vaccinating in total 349,513 dogs in 2,066 administrative vaccination units (rural villages or urban wards). Progressively more dogs were vaccinated over the successive campaigns. The campaigns did not reach all vaccination units each year, with only 16–28% of districts achieving 100% campaign completeness (where all units were vaccinated). During 2013–2017 when vaccination coverage was monitored, approximately 20% of vaccination units achieved the recommended 70% coverage, with average coverage around 50%. Campaigns were also not completed at annual intervals, with the longest interval between campaigns being 27 months. Our analysis revealed that districts with higher budgets generally achieved higher completeness, with a twofold difference in district budget increasing the odds of a vaccination unit being reached by a campaign by slightly more than twofold (OR: 2.29; 95% CI: 1.69–3.09). However, higher budgets did not necessarily result in higher coverage within vaccination units that were reached. We recommend national programs regularly monitor and evaluate the performance of their vaccination campaigns, so as to identify factors hindering their effective delivery and to guide remedial action.

Globally there are approximately 59,000 annual human rabies deaths, with more than 99% of these resulting from dog-mediated rabies. Mass dog vaccination is known to be the cornerstone of effective control of dog rabies. Empirical and theoretical evidence shows that annual vaccination campaigns need to achieve 70% coverage of the susceptible dog population to interrupt transmission and ensure the dog population is protected until the next campaign. Recently, international organizations announced their commitment to reaching the global target of zero human deaths from dog-mediated rabies by 2030. Scaling-up of vaccinations is now underway in more than 100 rabies-endemic countries. However, there are operational and logistical challenges associated with scaling-up these operations in different geographical and cultural settings. This study monitored and evaluated the performance large-scale vaccinations in Tanzania. We found that vaccinations were not implemented in all villages, which resulted in coverage gaps. Additionally, vaccinations were not implemented annually and, as a result, coverage dropped below the critical vaccination threshold. We conclude that there is a need to improve the delivery of dog vaccinations for achieving the global target of zero dog-mediated human rabies deaths by 2030.

Spatial Distribution and Population Estimation of Dogs in Thailand: Implications for Rabies Prevention and Control

Poor management of dog populations causes many problems in different countries, including rabies. To strategically design a dog population management, certain sets of data are required, such as the population size and spatial distribution of dogs. However, these data are rarely available or incomplete. Hence, this study aimed to describe the characteristics of dog populations in Thailand, explore their spatial distribution and relevant factors, and estimate the number of dogs in the whole country. First, four districts were selected as representatives of each region. Each district was partitioned into grids with a 300-m resolution. The selected grids were then surveyed, and the number of dogs and related data were collected. Random forest models with a two-part approach were used to quantify the association between the surveyed dog population and predictor variables. The spatial distribution of dog populations was then predicted. A total of 1,750 grids were surveyed (945 grids with dog presence and 805 grids with dog absence). Among the surveyed dogs, 86.6% (12,027/13,895) were owned. Of these, 51% were classified as independent, followed by confined (25%), semi-independent (21%), and unidentified dogs (3%). Seventy-two percent (1,348/1,868) of the ownerless dogs were feral, and the rest were community dogs. The spatial pattern of the dog populations was highly distributed in big cities such as Bangkok and its suburbs. In owned dogs, it was linked to household demographics, whereas it was related to community factors in ownerless dogs. The number of estimated dogs in the entire country was 12.8 million heads including 11.2 million owned dogs (21.7 heads/km²) and 1.6 million ownerless dogs (3.2 heads/km²). The methods developed here are extrapolatable to a larger area and use much less budget and manpower compared to the present practices. Our results are helpful for canine rabies prevention and control programs, such as dog population management and control and rabies vaccine allocation.

Ranging patterns and factors associated with movement in free-roaming domestic dogs in urban Malawi

Rabies is a neglected zoonotic disease that causes around 59,000 deaths per year globally. In Africa, rabies virus is mostly maintained in populations of free-roaming domestic dogs (FRDD) that are predominantly owned. Characterizing the roaming behavior of FRDD can provide relevant information to understand disease spread and inform prevention and control interventions. To estimate the home range (HR) of FRDD and identify predictors of HR size, we studied 168 dogs in seven different areas of Blantyre city, Malawi, tracking them with GPS collars for 1-4 days. The median core HR (HR50) of FRDD in Blantyre city was 0.2 ha (range: 0.08-3.95), while the median extended HR (HR95) was 2.14 ha (range: 0.52-23.19). Multivariable linear regression models were built to identify predictors of HR size. Males presented larger HR95 than females. Dogs living in houses with a higher number of adults had smaller HR95, while those living in houses with higher number of children had larger HR95. Animals that received products of animal origin in their diets had larger HR95, and only in the case of females, animals living in low-income areas had larger HR50 and HR95. In contrast, whether male dogs were castrated or not was not found to be associated with HR size. The results of this study may help inform rabies control and prevention interventions in Blantyre city, such as designing risk-based surveillance activities or rabies vaccination campaigns targeting certain FRDD subpopulations. Our findings can also be used in rabies awareness campaigns, particularly to illustrate the close relationship between children and their dogs.

Characteristic and outcomes of human and animal bites in Malawi

INTRODUCTION

Bites are an important contributor to traumatic injury worldwide. In low- and middle-income countries, data regarding bite injuries outside of rabies is limited. Therefore, we sought to describe the injury characteristics and outcomes of bites in Lilongwe, Malawi, and determine risk factors for animals and human bites.

METHODS

We performed a retrospective analysis of the Kamuzu Central Hospital trauma registry from 2008-2018. We performed Bivariate analyses comparing bite to non-bite trauma and human to animal bites. Multivariable Poisson regression modeling then estimated risk factors for bites.

RESULTS

A total of 124,394 patients were captured by the registry, of which 3,680 (3%) had a bite injury mechanism. Human bites accounted for 14.5% of bite injuries, and animals represented the remaining 85.5%. In rare cases, animal bite victims had serious complications, such as amputation (n = 6, 0.2%), orthopedic procedures (n = 5, 0.2%), and death (n = 7, 0.2%). Risk factors for an animal bite included being on a farm, field, or lake and being at home, whereas risk factors for a human bite included alcohol use and being at home.

CONCLUSION

Animal bite injuries in Malawi can confer a risk of serious complications, such as amputation and, in rare cases, death. Alcohol-associated, in-home interpersonal violence is a significant risk factor for human bite injuries. Further studies are needed to identify risk factors for complications and mortality.

Human rabies: prospects for elimination

Almost half of all countries in the world are effectively free of human deaths from dog-mediated rabies. But the disease still affects people in low- and middle-income countries, especially the rural poor, and children. Successful regional elimination of human rabies is attributable to advances in significant and sustained investment in dog vaccination, post-exposure vaccination and surveillance, illustrated by productive efforts to reduce human rabies in Latin America over the last 35 years. Nonetheless, countries still facing endemic rabies face significant barriers to elimination. Using the 2017 Global Strategic Plan to end human rabies deaths from dog-mediated rabies by 2030 as a reference point and an organizing framework, we assess progress toward global rabies elimination by examining the characteristics of successful regional control efforts and barriers to elimination. Although substantive barriers exist for countries where rabies remains endemic, advances in knowledge, technology, institutions, and economics provide a basis for optimism.

Lessons Learned and Paths Forward for Rabies Dog Vaccination in Madagascar: A Case Study of Pilot Vaccination Campaigns in Moramanga District

Canine rabies causes an estimated 60,000 human deaths per year, but these deaths are preventable through post-exposure prophylaxis of people and vaccination of domestic dogs. Dog vaccination campaigns targeting 70% of the population are effective at interrupting transmission. Here, we report on lessons learned during pilot dog vaccination campaigns in the Moramanga District of Madagascar. We compare two different vaccination strategies: a volunteer-driven effort to vaccinate dogs in two communes using static point vaccination and continuous vaccination as part of routine veterinary services. We used dog age data from the campaigns to estimate key demographic parameters and to simulate different vaccination strategies. Overall, we found that dog vaccination was feasible and that most dogs were accessible to vaccination. The static-point campaign achieved higher coverage but required more resources and had a limited geographic scope compared to the continuous delivery campaign. Our modeling results suggest that targeting puppies through community-based vaccination efforts could improve coverage. We found that mass dog vaccination is feasible and can achieve high coverage in Madagascar; however, context-specific strategies and an investment in dog vaccination as a public good will be required to move the country towards elimination.

Application of the GARC Data Logger-a custom-developed data collection device-to capture and monitor mass dog vaccination campaigns in Namibia

Domestic dogs are responsible for 99% of all cases of human rabies and thus, mass dog vaccination has been demonstrated to be the most effective approach towards the elimination of dog-mediated human rabies. Namibia demonstrated the feasibility of this approach by applying government-led strategic rabies vaccination campaigns to reduce both human and dog rabies incidences in the Northern Communal Areas of Namibia since 2016. The lessons learnt using paper-based form for data capturing and management of mass dog vaccination campaign during the pilot and roll out phase of the project (2016–2018) led to the implementation of a simple and accurate data collection tool in the second phase (2019–2022) of the rabies elimination program. In this paper, we describe the implementation of such custom-developed vaccination tracking device, i.e. the Global Alliance for Rabies Control (GARC) Data Logger (GDL), and the integration of the collected data into a website-based rabies surveillance system (Rabies Epidemiological Bulletin—REB) during 2019 and 2020 campaigns. A total of 10,037 dogs and 520 cats were vaccinated during the 2019 campaign and 13,219 dogs and 1,044 cats during the 2020 campaign. The vaccination data were recorded with the GDL and visualized via REB. Subsequent GIS-analysis using gridded population data revealed a suboptimal vaccination coverage in the great majority of grid cells (82%) with a vaccination coverage below 50%. Spatial regression analysis identified the number of schools, estimated human density, and adult dog population were associated with the vaccination performance. However, there was an inverse correlation to human densities. Nonetheless, the use of the GDL improved data capturing and monitoring capacity of the campaign, enabling the Namibian government to improve strategies for the vaccination of at-risk areas towards achieving adequate vaccination coverage which would effectively break the transmission of rabies.

We used a custom-developed vaccination tracking device—the Global Alliance for Rabies Control (GARC) Data Logger—to capture dog rabies vaccination data during the 2019 and 2020 mass vaccination campaign in the Northern Communal Areas of Namibia, and then integrated the collected data into the web-based Rabies Epidemiological Bulletin, a rabies-specific disease surveillance platform for rabies-endemic countries. This approach allowed automatic collation, analysis and, visualization of data and drastically improved the data capturing and monitoring capacity of the Namibian government led campaign. Additionally, subsequent GIS analysis enabled a better estimation of vaccination coverage at a much higher spatial resolution, thus identifying areas where improvements in the vaccination strategy are needed to ensure long-term success of the project.

Factors associated with mobile phone ownership and potential use for rabies vaccination campaigns in southern Malawi

BACKGROUND

Rabies is a fatal but preventable viral disease, which causes an estimated 59 000 human deaths globally every year. The vast majority of human rabies cases are attributable to bites from infected domestic dogs and consequently control of rabies in the dog population through mass vaccination campaigns is considered the most effective method of eliminating the disease. Achieving the WHO target of 70% vaccination coverage has proven challenging in low-resource settings such as Sub Saharan Africa, and lack of public awareness about rabies vaccination campaigns is a major barrier to their success. In this study we surveyed communities in three districts in Southern Malawi to assess the extent of and socio-economic factors associated with mobile phone ownership and explore the attitudes of communities towards the use of short message service (SMS) to inform them of upcoming rabies vaccination clinics.

METHODS

This study was carried out between 1 October-3 December 2018 during the post-vaccination assessment of the annual dog rabies campaign in Blantyre, Zomba and Chiradzulu districts, Malawi. 1882 questionnaires were administered to households in 90 vaccination zones. The surveys gathered data on mobile phone ownership and use, and barriers to mobile phone access. A multivariable regression model was used to understand factors related to mobile phone ownership.

RESULTS

Most survey respondents owned or had use of a mobile phone, however there was evidence of an inequality of access, with higher education level, living in Blantyre district and being male positively associated with mobile phone ownership. The principal barrier to mobile phone ownership was the cost of the phone itself. Basic feature phones were most common and few owned smartphones. SMS was commonly used and the main reason for not using SMS was illiteracy. Attitudes to receiving SMS reminders about future rabies vaccination campaigns were positive.

CONCLUSIONS

The study showed a majority of those surveyed have the use of a mobile phone and most mobile phone owners indicated they would like to receive SMS messages about future rabies vaccination campaigns. This study provides insight into the feasibility of distributing information about rabies vaccination campaigns using mobile phones in Malawi.