ZERO BY 30 THE GLOBAL STRATEGIC PLAN TO END HUMAN DEATHS FROM DOG-MEDIATED RABIES BY 2030Cover_20180530.indd 1 11.06.18 16:36
ZERO BY 30The Global Strategic Planto end human deaths fromdog-mediated rabies by 2030World Health OrganizationFood and Agriculture Organization of the United NationsWorld Organisation for Animal HealthGlobal Alliance for Rabies ControlGeneva, 2018
Zero by 30: the global strategic plan to end human deaths from dog-mediated rabies by 2030ISBN 978-92-4-151383-8 (WHO)ISBN 978-92-5-130461-7 (FAO)ISBN 978-92-95108-76-9 (OIE)© World Health Organization (WHO), Food and Agriculture Organization of the United Nations (FAO) and World Organisation forAnimal Health (OIE), 2018All rights reserved. WHO, FAO and OIE encourage the reproduction and dissemination of material in this information product. Anyproposed reproduction or dissemination for non-commercial purposes will be authorized free of charge upon request, providedthe source is fully acknowledged. Any proposed reproduction or dissemination for resale or other commercial purposes, includingeducational purposes, is prohibited without the prior written permission of the copyright holders, and may incur fees.Requests for permission to reproduce or translate WHO publications – whether for sale or for non-commercial distribution –should be addressed to WHO Press through the WHO web site (http://www.who.int/about/licensing/copyright_form/en/index.html).“The designations employed and the presentation of material in this publication do not imply the expression of any opinion what-soever on the part of the World Health Organization (WHO), the Food and Agriculture Organization of the United Nations (FAO) orof the World Organisation for Animal Health (OIE) concerning the legal status of any country, territory, city or area or of its authori-ties, or concerning the delimitation of its frontiers or boundaries. Dotted and dashed lines on maps represent approximate borderlines for which there may not yet be full agreement. The mention of specific companies or products of manufacturers, whether ornot these have been patented, does not imply that these are or have been endorsed or recommended by WHO, FAO and OIE inpreference to others of a similar nature that are not mentioned. The published material is being distributed without warranty of anykind either expressed or implied. The responsibility for the interpretation and use of the material lies with the reader. In no eventshall WHO, FAO and OIE be liable for damages arising from its use. The views expressed herein are those of the authors and donot necessarily represent those of WHO, FAO, OIE .”
CONTENTSAcknowledgements..................................................................................................................................................... ivAbbreviations................................................................................................................................................................ vExecutive summary..................................................................................................................................................... viRationale...................................................................................................................................................................... 1 Why eliminate rabies?............................................................................................................................................. 1 Why eliminate rabies now?..................................................................................................................................... 4The United Against Rabies collaboration................................................................................................................... 7 United to end the neglect........................................................................................................................................ 7 Vision to reach Zero by 30...................................................................................................................................... 8 The value proposition....................................................................................................................................... 8 The theory of change...................................................................................................................................... 10Objective 1: to effectively use vaccines, medicines, tools and technologies........................................................ 13 Outcome 1.1: rabies is prevented through increased awareness and improved education................................. 13 Outcome 1.2: rabies is prevented through increased and effective dog vaccination........................................... 14 Outcome 1.3: human deaths from rabies exposures are prevented by ensuring equitable, affordable and timely access to health care, medicines and vaccines......................................................................................... 15Objective 2: to generate, innovate and measure impact......................................................................................... 17 Objective 2.1: to provide effective policies, guidance and governance................................................................ 17 Outcome 2.1: policies, guidelines, and governance to prevent human rabies deaths are created and adopted at regional and national levels................................................................................................................ 17 Objective 2.2: to ensure reliable data to enable effective decision-making.......................................................... 19 Outcome 2.2: appropriate technology and information are made available......................................................... 19 Outcome 2.3: progress towards the goal is constantly and consistently monitored and reported...................... 20Objective 3: to sustain commitment and resources................................................................................................ 21 Outcome 3.1: key stakeholders are consistently and comprehensively engaged................................................ 21 Outcome 3.2: finances and other resources are effectively and efficiently used................................................. 22 Outcome 3.3: results and impact of the United Against Rabies collaboration are regularly monitored and reported......................................................................................................................................................... 23Budget and governance............................................................................................................................................ 25 A phased approach to funding Zero by 30........................................................................................................... 25 Budget requirements: phase 1.............................................................................................................................. 26 Budget requirements: beyond 2020...................................................................................................................... 26 Governance........................................................................................................................................................... 28Monitoring our progress and managing risks.......................................................................................................... 29 Workplan delivery monitoring and evaluation....................................................................................................... 29 Risk mitigation...................................................................................................................................................... 29Conclusion................................................................................................................................................................. 31References................................................................................................................................................................. 33Annex 1. What is rabies?............................................................................................................................................ 34Annex 2. Successful regional elimination in Latin America and the Caribbean, and proof-of-concept programmes in Africa and Asia................................................................................................................... 36Annex 3. The theory of change.................................................................................................................................. 39Annex 4. The logic framework for the United Against Rabies collaboration.............................................................. 40Annex 5. Human and animal rabies biological banks................................................................................................ 43Annex 6. Integrated bite case management.............................................................................................................. 46Annex 7. The stepwise approach towards rabies elimination.................................................................................... 47
ACKNOWLEDGEMENTS The four partners (FAO, WHO, OIE and GARC) of the United Against Rabies collaboration gratefully acknowledge the contributions to developing this business plan of the following individuals and organizations, specifically: Steering Committee Members: Bernadette Abela-Ridder, Katinka de Balogh, Kim Doyle, April Johnson, Isabelle Dieuzy-Labaye, Louis Nel, Henk Jan Ormel, Sean Shadomy, Matthew Stone, Gregorio Torres Writing team: Annette Ives, Jocelyn Kessels, Anne-Marie Labouche, Jennifer Macleod, Louise Taylor Consultants: PwC: Gill Sivyer, Saleh Khan, Gerard Coenen, Sakshi Uberoi, Krupa Varghese, WHO: Lea Knopf Modelling work: Jesse Blanton, Katie Hampson, Caroline Trotter, Ryan Wallace WHO interns: Mercedes Carballo, Dayna Schultz, Victoria Suslovitch Monique Eloit (OIE), Dirk Engels (WHO), Ren Minghui (WHO), Ren Wang (FAO), Lord Alexander Trees (House of Lords and University of Liverpool) and Joris Vandeputte (International Alliance for Biological Standardization) provided valuable insights that helped to focus the business plan. We thank the WHO staff Rabindra Abeyasinghe, Lamine Diawara, Elkhan Gasimov, Gyenendra Gongal, Aya Yajima and Marco Vigilato, Stephen Martin, Martin Friede, Erin Sparrow, Naoko Obara, Tejinder Chowdhary, Alejandro Javier Costa and WHO collaborating centres on rabies. From FAO, we thank Angélique Angot, Juan Lubroth, Mia Rowan and Berhe G. Tekola. From OIE, we thank Catherine Bertrand-Ferrandis, Yael Farhi and Stéphane Renaudin. From GARC, we thank Deepashree Balaram. We acknowledge also the contributions of our in-country stakeholders; the Gavi learning agenda; the Partners for Rabies Prevention; the Bill & Melinda Gates Foundation for studies that provided data; UBS Optimus Foundation; and the assistance of Rabies Unit and the Global Immunization Division of the United States Centers for Disease Control and Prevention.iv
ABBREVIATIONSFAO Food and Agriculture Organization of the United NationsGARC Global Alliance for Rabies ControlGSG Global Steering GroupIBCM integrated bite case managementOCV oral cholera vaccineOHZDP One Health Zoonotic Disease PrioritizationOIE World Organisation for Animal HealthPAHO Pan American Health OrganizationPEP post-exposure prophylaxisPrEP pre-exposure prophylaxisREDIPRA Regional Meeting of Rabies Program DirectorsRIG rabies immunoglobulinSARE Stepwise Approach towards Rabies EliminationSIRVERA Regional Information System for Epidemiological Surveillance of RabiesWAHIS World Animal Health Information SystemWHO World Health Organization v
EXECUTIVE SUMMARY WHY ELIMINATE RABIES? A CALL FOR ACTION An estimated 59 000 people die from rabies each year. In 2015, the world called for action by setting a goal That’s one person every nine minutes of every day, 40% of zero human dog-mediated rabies deaths by 2030, of whom are children living in Asia and Africa. As dog worldwide. Now, for the first time, four organizations – bites cause almost all human cases, we can prevent the World Health Organizaton (WHO), the World Organ- rabies deaths by increasing awareness, vaccinating isation for Animal Health (OIE), the Food and Agricul- dogs to prevent the disease at its source and admin- ture Organization of the United Nations (FAO) and the istering life-saving treatment after people have been Global Alliance for Rabies Control (GARC) – have joined bitten. We have the vaccines, medicines, tools and tech- forces, as the United Against Rabies collaboration, and nologies to prevent people from dying from dog-medi- are determined to reach this goal. ated rabies. For a relatively low cost it is possible to break the disease cycle and save lives. The United Against Rabies collaboration leverages existing tools and expertise in a coordinated way to A country’s health system benefits from the capac- empower, engage and enable countries to save human ity-building required for rabies surveillance. This core lives from this preventable disease. The global strategic activity strengthens the health system by improving plan puts countries at the centre with renewed interna- the mechanisms for surveillance of other disease and tional support to act. expanding access to health care. Minimizing duplica- tion and improving efficiencies by pooling resources This country-centric engagement will be flexible and and developing strong health service networks saves consider different contexts and capacities. Countries money and makes the most of resources. Countries can will lead efforts, driving the changes needed to reach maximize the impact of each dollar invested. Zero by 30, empowered by the United Against Rabies collaboration, as they build sustainable institutional Investing in rabies elimination saves lives and capacity and end human deaths from dog-mediated strengthens both human and veterinary health systems. rabies. A collaborative response, through rabies programmes, contributes to disease prevention and preparedness. This means integrated rabies elimination is a model for One Health collaboration. In the past, the global response has been fragmented and uncoordinated. We need to break the status quo and come together with a combined will, an achiev- able goal and a common plan. That combined will was evident in 2015, and the resulting global call to action made it clear that now is the time to act.vi
HOW WE WILL REACH ZERO BY 30Our global strategic plan prioritizes the societal changes needed to reach Zero by 30 into three objectives: OBJECTIVE 1 OBJECTIVE 2 OBJECTIVE 3 to effectively use to generate, to sustain vaccines, medicines, innovate and commitment tools and measure impact and resources technologies Reduce human rabies risk Provide guidance and data Harness multi-stakeholder - improved awareness and - effective policies, guidance engagement education and governance - demonstrate the impact of - increased access to healthcare, - ensuring reliable data to enable activities completed under medicines and vaccines effective decision-making the United Against Rabies - dog vaccinations collaborationA PHASED APPROACH TO ELIMINATIONWe propose a pragmatic, three-phase approach to achieve the shared goal of Zero by 30: Phase 1: START UP Phase 2: SCALE UP Phase 3: MOP UP 2018-2020 2021-2025 2026-2030 29 countries +52 countries +19 countriesPhase 1: START UP Phase 2: SCALE UPWe will build a strong foundation for rabies elimination by We will engage with and involve 52 more countriespreparing and improving normative tools and structures in rabies elimination, to give a total of 81 out of 100to catalyse action. Core activities include supporting endemic countries. Using the strong foundation estab-countries to prepare robust, budgeted, effective and lished in Phase 1, refined and improved with learningsustainable national rabies elimination plans following a and experience, we will expand our efforts and truly goOne Health approach; and facilitating the coalescence global.of these plans into a coordinated regional effort. Phase 3: MOP UP We will engage the remaining endemic countries in the fight to eliminate rabies, and continue to support country efforts as communities, nations and regions advance to reach Zero by 30. Phase 3 is the last mile. vii
BUDGET AND MONITORING NEXT STEPS Our global strategic plan details the funding require- Reaching Zero by 30 will save the lives of children and ments for the core activities of Phase 1 only (START the livelihoods of adults. It will keep families together. UP: 2017–2020, estimated at US$ 16.5 million). This will Investing in rabies elimination strengthens health allow us to stay agile and to flexibly adapt our strategy systems, improves equity and access to care, and to accommodate changing environments, lessons contributes to sustainable development. For the first learned along the way and new technologies. time in history, we are united to coordinate capaci- ty-building and leverage existing knowledge, tools and Financing and implementing national rabies elimination technology. plans at the country level is not included in our budget. Countries will need to mobilize domestic and interna- We will not stop there. We will pursue breaking trans- tional resources to sustainably finance and implement mission in dogs, thereby maintaining freedom from control activities. disease. The United Against Rabies collaboration is already working with countries to coordinate and We will develop a detailed workplan to guide implemen- catalyse global change. Investing in rabies will accel- tation, including a monitoring framework with defined, erate progress, as the world works to make elimination aligned milestones to measure progress. Each country a reality. will lead the drive towards Zero by 30. Our One Health collaboration engages experts and stakeholders from the public and private sectors to play an active role in empowering, supporting and engaging countries to prevent rabies and make zero human deaths from rabies by 2030 a reality.viii
RATIONALEWHY ELIMINATE RABIES? 3. Mass dog vaccination is a proven, cost–effec- tive way to save human lives by stopping trans- mission of rabies at its source. While a variety ofBecause rabies kills animal species can host rabies, dogs are respon- sible for 99% of human cases (3). Disease models and real-world experience show that sustainedEvery year, an estimated 59 000 people die of one of vaccination coverage of 70% of dog populationsthe oldest and most terrifying diseases known to man: is sufficient to stop transmission of the diseaserabies (1) (Annex 1). Rabies is caused by infection with a between dogs, and from dogs to humans (3, 6).lyssavirus. The disease is named after Lyssa, the Greek Eliminating rabies in dogs is therefore key tospirit of madness, frenzy and rage, vividly evoking the sustainably preventing human disease.horror of a rabid death (2).Rabies is spread via bites and scratches from infected Because rabies affects the world’sanimals. Dogs are responsible for 99% of human most vulnerable populationscases (3). Clinically, rabies is characterized by fitfulconsciousness, hyperactivity, hallucinations and hydro-phobia (furious rabies), or paralysis and coma (para- Rabies is a neglected tropical disease. Most rabieslytic rabies), progressing rapidly and inevitably towards cases occur in Africa and Asia.death (3). Approximately 80% of human cases occur in rural areas, and over 40% of rabies deaths occur in children agedBecause rabies is preventable under 15 years (3, 7) (Figure 1). Globally, the economic burden of rabies is estimated at US$ 8.6 billion per annum (1) (Figure 2). This cost is disproportionatelyAlthough fatal once clinical signs appear, rabies is borne by the world’s poorest and most disadvantagedpreventable through three proven, effective interven- communities. People continue to die of rabies becausetions. it is neglected, because their awareness of the disease is limited, because the disease remains uncontrolled in 1. Awareness of rabies disease engages commu- dogs, and because they lack access to basic medical nities and empowers people to save themselves care, such as PEP, following an exposure. by seeking the care they need (4). This includes an understanding of how to prevent rabies in animals, Our global strategic plan prioritizes the societal when to suspect rabies, and what to do in case of changes needed to reach Zero by 30 into three a bite. 2. Post-exposure prophylaxis (PEP) consists of a series of rabies vaccines and, in some cases, rabies immunoglobulin (RIG), administered after a suspected exposure to rabies. Appropriate wound management and prompt access to quality-as- sured PEP is almost 100% effective in preventing human rabies deaths (5).11 Pre-exposure prophylaxis (PrEP) consists of a series of rabiesvaccines administered prior to a potential exposure, followedby booster vaccinations in the case of a bite. PrEP is costly,and only recommended for people at constant risk of rabiesexposure, such as veterinarians, and laboratory workershandling live virus. 1
Endemicity of dog and human rabies, 2016 Rabies + + Endemic dog and human rabies + 0 Endemic dog rabies +/- +/- Sporadic dog-transmitted rabies +/- 0 Controlled dog rabies 0 0 No dog rabies nor human rabies No information Figure 1. Endemicity of dog and human rabies, 2016. Rabies affects poor and rural populations 54% Productivity losses due Travel costs 2% to premature death 0.01% Rabies surveillance US$ 8.6 billion (data) Direct costs 20% per year 2% Dog vaccination & Lost income population controlseeking treatment 15% Treatment 6% Livestock costs (37%) losses Figure 2. Rabies imposes a heavy economic burden2
Because eliminating rabiesstrengthens health systemsInvesting in rabies maximizes the impact of each dollar.Providing life-saving PEP to the people at highest riskof rabies relies on health systems capable of reachingthe world’s most underserved populations (8). The samebasic infrastructure required to build rabies aware-ness and improve access to PEP in communities isrequired to provide essential medicines, vaccines andhealth care; strengthening human and veterinary healthsystems, improving health outcomes and maximizingthe impact of each invested dollar. That means thatevery dollar invested in well integrated rabies elimina-tion programmes not only quickly makes a significantimpact on eradicating human rabies deaths but alsoimproves access to health care for the world’s mostvulnerable people (Figure 3). Figure 3. Investment breaks the cycle of neglectBecause eliminating rabies is a modelfor One Health collaborationEngaging communities to build awareness of rabies,and vaccinate dogs to prevent human disease, requiresclose One Health collaboration between, at a minimum, and specifically targets 3.3, to “by 2030, end thethe human and veterinary health sectors (9). The cooper- epidemics of … neglected tropical diseases”; and 3.8,ative mechanisms required to prevent rabies are a model to “achieve universal health coverage … and access tofor One Health collaboration, and establish a basis for safe, effective, quality and affordable essential medi-response to other existing or emerging zoonoses that cines and vaccines for all” (11).may pose a pandemic threat. A One Health model iswithin reach for even low- and middle-income coun- As rabies disproportionately affects poor and ruraltries, and rabies disproportionately affects the world’s communities, eliminating human deaths from rabies ismost vulnerable people. The economic burden resulting also consistent with SDG 1 to “end poverty in all itsfrom lost livestock and working animals directly affects forms” and the commitment of Member States to “leaveresource-poor communities. A coordinated response no one behind” (11). The conviction to eliminate rabiesbetween animal and human health systems not only is supported by WHO’s leadership priorities to increasehas a positive impact on the livelihood of communities access to essential medicines and focus on universalbut also strengthens surveillance of rabies and other health coverage; the adoption in 2016 by the Worlddiseases in the human health system. Assembly of Delegates of OIE Resolution No. 26 on global elimination of dog-mediated rabies, mandating Member countries to collaborate and endorse ZeroBecause the world wants to end by 30 (12); and by FAO’s commitment to reduce ruralneglect and inequality poverty (13).In February 2015, the World Health Organization (WHO),the Food and Agriculture Organization of the UnitedNations (FAO), the World Organisation for Animal Health(OIE) and the Global Alliance for Rabies Control (GARC)united to launch the End Rabies Now campaign, whichproposed a goal of zero human rabies deaths by 2030,worldwide. In December 2015, a global conference ofinternational stakeholders endorsed the vision of zerohuman rabies deaths by 2030, or Zero by 30 (10).The goal is perfectly aligned with the United NationsSustainable Development Goal (SDG) 3 to “ensurehealthy lives and promote well-being for all at all ages”, 3
WHY ELIMINATE RABIES NOW? existing tools, even in poor, endemic settings (Annex 2). These programmes demonstrate feasibility in different Because we have come so far country contexts. In Mexico, media and commu- nity engagement, mass dog vaccination campaigns, national rabies notification and a decentralized surveil- For more than 4000 years, rabies has plagued human- lance system have resulted in zero human rabies deaths. kind. For centuries, the disease has inspired remedies In KwaZulu-Natal, South Africa, training and awareness dark and magical, from poultices made from the skulls materials, dog vaccine banks, and free access to PEP of hanged men, to branding with Saint Hubert’s Key (a have led to the elimination of human rabies. In Sri Lanka, metal nail, cross or cone) and cutting the attachment of mass dog-vaccination and sterilization campaigns, free the tongue, where the disease was thought to reside (2). PEP and a system of national notification of human and animal rabies cases implemented in 1990–2014 have In the 1500s, it was suggested that human rabies was reduced the number of human rabies cases by 85%. transmitted through broken skin via animal bites, and, in 1885, Louis Pasteur created the first effective human vaccine (14). This marked a turning point in rabies Because for the first time in history we prevention and, with the advent of modern vaccines, are united to succeed the world has made enormous progress in fighting the disease. Successful interventions have eliminated dog-mediated human rabies in Western Europe, North For the first time in history, the world has a goal to elim- America, Japan, South Korea and parts of Latin America inate human rabies deaths by 2030. and, recently, in smaller scale pilot programmes in Africa and Asia, saving thousands of lives (3, 15, 16) (Figure 4). For the first time in history, the world is united to coor- dinate and leverage the wealth of existing knowledge, In Latin America and the Caribbean, the Pan Amer- tools and technology to achieve what we know is ican Health Organization (PAHO) has coordinated the possible. regional programme to eliminate dog-mediated human rabies in urban (since 1983) and rural (since 1991) For the first time in history, we have a tangible opportu- areas. By expanding access to post-exposure prophy- nity to eliminate the pain, suffering and death inflicted laxis, completing mass dog vaccination campaigns, by rabies on humanity since the beginning of written improving rabies diagnosis and surveillance, and memory. increasing rabies awareness through educational campaigns and community involvement, the region Together, for the first time, international health organi- saw an impressive and consistent decline in the number zations are united against rabies, with the knowledge, of human rabies cases. Between 1980 and 2010 the tools and strategy to end the suffering inflicted by the number of laboratory-confirmed dog rabies cases was disease. WHO, FAO, OIE and GARC are committed and reduced by 98% and that of human rabies deaths by are collaborating to empower, support and catalyse 97% (Annex 2). These are children who lived, and who countries to own and implement rabies elimination were spared a horrific death from a preventable disease. programmes as we march towards the shared goal of Zero by 30. Because the mechanisms to eliminate This global strategic plan presents a coordinated, rabies are now in place country-centric strategy to eliminate human deaths from dog-mediated rabies by 2030. It integrates rabies prevention with other healthcare interventions to During the past decade, the evidence base for rabies strengthen health systems and engage stakeholders elimination has been put in place. Regional networks throughout the world in the fight to end rabies. are active in engaging countries to support each other, exchange knowledge and build capacity; from neigh- bour to neighbour, as part of the global movement to eliminate rabies (3). These networks enable countries to access existing tools, share local expertise and report data through regional platforms, providing a supportive structure and basis for expansion to achieve global success. The knowledge, tools and technology to eliminate human rabies deaths are available and have proven effective (Figure 4). Proof-of-concept programmes have demonstrated that rabies elimination is feasible using4
Preventing human deaths by post-exposure prophylaxis (PEP) and dog vaccination 99% of human rabies is transmitted by bites of rabid dogs: dog & human rabies cases are closely linkedCases of rabies Kwa-Zulu Natal per year in Incidences of human & dog rabies worldwide (South Africa) 1000 (1990-2017)human & dogs 10 100 R=0.78 8 Human 6 rabies 10 cases 4 (x70) 1 2 Dog rabies cases 0 0.1 2007 2008 2009 2010 2011 2012 2013 2014 10 100 1000 10,000 100,000 Dog vaccination stops rabies transmission from dogs to humans Rabies cases Vaccination per year in Mexico of dogs Rabies cases Sri Lanka Vaccinationhuman & dogs per year of dogs + PEP 80 400,000 400 500,000 400,000 60 300,000 300 300,000 40 200,000 200 200,000 (x50) 20 100,000 100 100,000 0 0 0 0 1992 1996 2000 2004 2008 2012 2016 1980 1990 2000 2010Figure 4. The knowledge, tools and technology to eliminate human rabies deaths are available and proven to work 5
1 BOX The four organizations United Against Rabies WHO, OIE and FAO already coordinate efforts to advance the One Health approach for several priority diseases, including rabies, within the Tripartite collab- oration (9). The World Health Organization, established in 1946, is tasked to build a better, healthier world for all. • Global leadership for public health develop- ment to meet needs of disadvantaged popu- lations. • Nexus for governments, international organi- zations, NGOs, private sector and civil society. • Provides technical support to countries and catalyses capacity-building. The Food and Agriculture Organization of the United Nations, established in 1945, aims to elimi- nate hunger and food insecurity worldwide. • Advocates for improved social and economic status of all people worldwide. • Engages partners and stakeholders including governments, civil society and the private sector. • Links what happens in local communities to regional and global initiatives. The World Organisation for Animal Health, established in 1924, aims to improve animal health and welfare. • Develops evidence-based international stan- dards, guidelines and recommendations for disease control and animal welfare. • Manages the OIE World Animal Health Infor- mation System (WAHIS) for animal disease notification. • Promotes strengthening of Veterinary Services worldwide. The Global Alliance for Rabies Control, estab- lished in 2007, is dedicated to eliminating deaths from rabies. • Develops information, surveillance and training tools to increase country capacity for rabies control. • Provides training and capacity building to countries and coordinates regional intersec- toral rabies networks. • Undertakes advocacy, education and commu- nication campaigns (World Rabies Day, End Rabies Now).6
THE UNITED AGAINSTRABIES COLLABORATION our cross-cutting collaboration provides coordinated,UNITED TO END THE NEGLECT global leadership to catalyse and empower countries to prevent human rabies deaths.Until now, efforts to eliminate rabies have been frag- The world has the knowledge, tools and technologiesmented across sectors and regions. In affected coun- needed to eliminate rabies: countries need a plan to puttries, elimination of the disease has been championed them into action, a strategy to mobilize resources andby few. National responses, where implemented, political will to get the job done. Through a coherentare often uncoordinated between the human and global strategy and harmonized, practical guidanceanimal health sectors. Examples of best practice have and training, the United Against Rabies collaborationemerged, but their hard-learned lessons have not been provides a structure and support for elimination. We willbroadly shared. use our joint strengths to advocate for rabies prioriti-We need to break the status quo: the time is now. zation, to engage stakeholders in the global fight and to build capacity to create an enabling environment forThe rumblings for change began in 2015, when the countries to succeed.world called for action by setting a global goal of zerohuman dog-mediated rabies deaths by 2030, world- Rabies elimination is no longer a dream.wide. Now, for the first time, it is a goal with a strategy, and aThe United Against Rabies collaboration is our unified global force united to see it through. Combined, we canresponse to this global call. leverage existing capacity in a new way: to empower, to engage and to enable countries to save human livesFor the first time, four international partners – WHO, OIE, from this horrific but preventable disease.FAO and GARC – have united to break the status quo(Box 1). By leveraging the unique strengths and exper-tise of each organization in the field of rabies control,World Rabies Day 2016 in Bhutan, 2016 (Photo credit: Yoenten Phuentshok) 7
VISION TO REACH ZERO BY 30 Countries take control of and lead efforts to ensure ownership and accountability (Box 2). National and regional elimination plans will increase preparedness Our global strategic plan provides a harmonized, and surveillance and mobilize domestic resources. By coherent foundation for rabies elimination that coun- fostering collaboration across ministries and enhancing tries can adapt and own, as we support them to reach national capacity at all levels, these plans will promote Zero by 30. inclusion of dog bite treatments into health systems and increase access to dog and human vaccines, while This plan puts countries at the centre through coordi- developing a One Health approach. By maximizing nated, global support to create national and regional resources and impact, countries can move towards rabies elimination plans, build capacity, integrate rabies their SDG targets while building a healthier future. The control with other health initiatives, and strengthen United Against Rabies collaboration will support these health systems to reach the world’s most underserved efforts by promoting rabies awareness and prevention populations. and advocating for support and prioritization of rabies elimination. By establishing global norms and standards, coordinating global rabies elimination efforts and moni- The value proposition toring progress and results, the collaboration will drive elimination by maximizing the use of resources. For the first time, we are marching together, with synergy and Our collaboration engages stakeholders across coun- structure, to coordinate our interventions and maximize tries and sectors, brings together public and private the impact of investment in rabies elimination. development partners, and catalyses communities, nations and regions to implement and own their rabies elimination plans (Figure 5). Figure 5. United Against Rabies is a country-centric, multi-stakeholder collaboration8
2BOX Countries lead elimination efforts Countries are at the centre of the global strategic plan to reach Zero by 30 because coun- try-led national rabies elimination plans are the cornerstone of our approach. Developing and implementing their own national plans puts countries in the driver’s seat, with global tools, structures and support at the ready to kick-start, fuel and accelerate progress towards national goals. Rabies is already a priority disease in many endemic countries. Since 2014, of the 18 countries involved in One Health zoonotic disease prioritization workshops conducted across Africa, Asia, Eurasia and the Americas, 17 have prioritized rabies: rabies is the most commonly prioritized zoonosis worldwide (17). Our phased approach builds on existing political will by starting with countries that already prioritize rabies and are active in its control (see section 7.1). Catalytic global structures will support these countries to own and implement pragmatic, sustainable national plans; providing impetus and means for country successes to inspire and drive regional and global elimination efforts. Proven mechanisms are already in place to engage countries in rabies elimination. Rabies stimulus packages are helping to build local capacity by providing tailored support to kick-start community projects (18). Successful pilot projects have demonstrated that elim- ination is feasible, generating momentum for action and promoting investment for sustain- ability and growth. The outputs of the Stepwise Approach towards Rabies Elimination, or SARE, provide prac- tical guidance to countries and assist with the prioritization of national activities. Stimulus packages are tailored to respond to these priorities. Through the logical steps proposed to develop and implement national rabies control programmes, this approach responds to existing national control and elimination efforts by supporting countries to advance from stage zero (where no data are available) to stage five (where rabies elimination is maintained). Since 2015, 76 workshops involving 26 countries, including four in-country workshops, have been conducted using this stepwise approach (Annex 7). The global strategic plan will bolster these existing initiatives as we catalyse countries to take ownership, use national elimination plans to meet country goals and, ultimately, reach Zero by 30. 9
The theory of change Objective 1: to effectively use vaccines, medicines, tools and tech- Although societal changes are needed to reach Zero nologies to reduce the risk of human rabies through by 30, achieving zero human rabies deaths worldwide expanded dog vaccinations, improved awareness and is technically feasible. Our theory of change outlines education, and increased access to health care, medi- what is required to make these changes and save lives, cines and vaccines for populations at risk. reduce expenditures, and validate rabies elimination in countries and regions. The theory of change (Annex 3) is built upon three pillars: Objective 2: (i) operational capacity-building to strengthen health systems; (ii) education and advocacy to prevent human to generate, innovate and measure impact through (i) rabies deaths; and (iii) monitoring and evaluation to effective policies, guidance and governance by harmo- enable this global work. The logic framework (Annex 4) nizing international recommendations, frameworks and translates the steps of the theory of change into a blue- strategies and by building capacity in countries; and (ii) print for action by describing the key outcomes, outputs ensuring the availability of reliable data to enable effec- and major activities required to realize Zero by 30. tive decision-making by encouraging the use of tech- nology and health innovations, and by refining tools The value proposition and the theory of change outline for countries to monitor and report data, strengthen how the United Against Rabies collaboration can act surveillance capacity and integrate reporting systems. to drive elimination through effective use of vaccines, medicines, tools and technologies; reliable data to enable effective decision-making; sustained commit- ment to drive progress; and effective policies, guid- Objective 3: ance, governance and support (Figure 6). to sustain commitment and resources through multi-stakeholder engagement and by demonstrating the impact of activities completed under the United Against Rabies collaboration in national, regional and global rabies elimination programmes. These objectives will help to ensure that dog vaccina- tion programmes are effective and comprehensive, that vaccines and information reach populations at high risk of rabies, and that dog bite prevention strategies are widely implemented. A secondary aim of these objec- tives is to make available trained professionals in human and animal health and education alongside accurate and comprehensive rabies surveillance and programme monitoring. The following sections describe each of these objectives and how we intend to meet them.10
ZERO HUMAN DEATHS FROM DOG-MEDIATED RABIES BY 2030 less expenditure fewer rabies validated rabies on rabies exposures elimination in individual countries/regions Reduce human rabies risk Provide guidance and data Harness multi-stakeholder - improved awareness and - effective policies, guidance engagement education and governance - demonstrate the impact of - increased access to healthcare, - ensuring reliable data to enable activities completed under medicines and vaccines effective decision-making the United Against Rabies - dog vaccinations collaboration OBJECTIVE 1 OBJECTIVE 2 OBJECTIVE 3 to effectively use to generate, to sustain vaccines, medicines, innovate and commitment tools and measure impact and resources technologies OBJECTIVES educational & monitoring & operational evaluation advocacy programmes capacity-building effectiveness awareness preparedness & sustainability & commitment collaboration was formed by four partners: The UNITED AGAINST RABIES WHO, FAO, OIE, GARC* PROBLEM STATEMENT Although 100% preventable, rabies kills more than 59,000 people in over 150 countries every year. The disease is nearly always fatal once symptoms appear. * World Health Organization (WHO), Food and Agriculture Organization of the United Nations (FAO), World Organisation for Animal Health (OIE), and Global Alliance for Rabies Control (GARC)Figure 6. Our global strategic plan prioritizes the objectives defined in the theory of change 11
Dog vaccination and education campaign in Tanzania (Photo credit: Sarah Cleaveland)12
OBJECTIVE 1 TO EFFECTIVELY USE VACCINES, MEDICINES, TOOLS AND TECHNOLOGIESThe fundamentals of rabies control are well estab- messages. We will provide tools, templates and guid-lished. We need wide-scale access to this knowledge, ance for countries to adapt for national campaigns andand capacity-building to allow countries to access and save lives by educating people at risk of rabies on theimplement these tools in their communities. need to vaccinate dogs, when to suspect rabies in a dog or person and what to do in case of a bite.Outcome 1.1: rabies is prevented Promoting bite prevention strategies and responsiblethrough increased awareness and dog ownership will further build awareness of the needimproved education to vaccinate dogs to prevent disease and limit potential exposure (20). Responsible dog ownership and rabies education will provide countries with adaptable, OnePeople need to know about rabies to vaccinate dogs and Health strategies to build awareness and sustainablyseek care if they are exposed. Engaging communities prevent rabies in animals and humans.to improve rabies education and awareness is essentialto prevent human deaths (4). Global campaigns such asWorld Rabies Day and End Rabies Now already activelyinvolve community leaders, and bring rabies to the fore-front through innovative local activities and events (19).Moving forward, we will focus on education and aware-ness campaigns that leverage national best prac-tices into relevant, locally appropriate communicationOutcome 1.1: Rabies is prevented through increased awareness and improved education ACTIVITIES 2017–2020 EXPECTED OUTCOMES 2020 Coordinate communication campaigns for Effective, locally adaptable communication and World Rabies Day, in priority endemic countries awareness tools and strategies Develop coherent strategies for responsible Sustainable responsible dog ownership and dog ownership and bite prevention education bite prevention education programmes Engage partners, communities, and national and international media to build rabies aware- ness 13
Outcome 1.2: rabies is prevented affordable, safe and effective vaccines (Annex 5); (ii) through increased and effective dog strengthening health and veterinary services to deliver vaccination effective dog vaccination campaigns, and enhance monitoring and reporting of dog rabies cases and dog vaccination coverage; and (iii) promoting innovative Dog vaccination is key to stopping rabies transmission mechanisms to reach free-roaming dogs and increase between dogs, and from dogs to humans. By preventing dog vaccination coverage. transmission of rabies at its source, vaccinating dogs is a cost–effective and sustainable way to save lives (3, 21, Access to rabies vaccines and biologicals is a key 22) (Figure 7). We will build on existing tools and exper- component of our global strategic plan, and triggers tise to develop locally adaptable, best-practice guid- national programmes. For both human and animal ance for implementing dog vaccination in countries and diseases, biological banks have successfully improved their communities. This will catalyse national strategies access to affordable, safe and high-quality vaccines. that improve dog vaccination capacity, and allow for streamlined integration of dog vaccination with other We encourage countries to forecast their own vaccina- disease control initiatives. tion and supply chain needs as they initiate, implement and complete mass dog vaccination campaigns. Local, Regional capacity-building workshops will enable regional and global reporting structures will enable countries to engage with and help their neighbours countries to share and learn from the data generated by sharing training, operational knowledge and novel during campaigns. Countries can use these data to strategies to address local challenges. These will help refine and improve implementation and thereby ensure to strengthen regional networks as we help to coalesce that campaigns achieve sufficient vaccination coverage local and national rabies interventions into unified and to prevent transmission of rabies disease to people. effective regional elimination strategies. We will further support countries to conduct effec- tive dog vaccination campaigns through (i) dog rabies biological banks to ensure consistent availability of Outcome 1.2: Rabies is prevented through increased and effective dog vaccination ACTIVITIES 2017–2020 EXPECTED OUTCOMES 2020 Leverage existing tools to support effective Coherent, standardized, evidence-based tools SOPs for dog vaccination at the country level and strategies for effective dog vaccination Organize regional workshops for coordinators Strengthened, vitalized and supportive regional to train in best practices and share lessons networks learned Establish a biological bank to increase access Improved availability and access to dog rabies for affordable dog rabies vaccines vaccines (see Annex 4) Support effective use of monitoring and surveil- Local, regional and global reporting structures lance data to validate vaccination coverage established to facilitate data collection and sharing Promote innovative approaches to enhance dog vaccination campaign coverage14
Dog vaccination is key to stopping rabies transmission between dogs, and from dogs to humans Cost of rabies post-exposure prophylaxis and dog vaccination Indicative rabies treatment costs per Mass dog vaccination cost patient in rabies endemic countries per dog Average costs: US$ 108.07 Average costs: US$ 4.03 (min: US$ 7.48 – max: US$ 597.36) (min: US$ 1.56 – max: US$ 11.33 ) n=10 published studies Consultation Up to 80% savings with costs intradermal PEP regimens ª Vaccines costs Awareness 25% 18% 7% RIG is recommended for severe category III exposures b 75% 17% Logistics & consumables Vaccinator Vaccines costs Up to 99% of bite victims survive costs 57% with prompt wound washing & vaccine without RIG a) Full vaccine course at a medical centre consisting of four consultations and four vaccine vials administered through intramuscular injection (IM); 41 rabies endemic countries where data are available were used. b) Single or multiple transdermal bites or scratches, licks on broken skin, contamination of mucous membrane with saliva from licks and exposure to bats.Figure 7. Dog vaccination is key to stopping rabies transmission between dogs, and from dogs to humansOutcome 1.3: human deaths from (where prophylaxis was not applied) will build capacityrabies exposures are prevented and further improve delivery of life-saving rabies PEP.by ensuring equitable, affordableand timely access to health care, Through high-quality, safe, rabies biological banks, wemedicines and vaccines will catalyse increased access to competitively priced, safe and efficacious vaccines and immunoglobulins for those who need them (Annex 5). We encourage coun-Timely, appropriate prophylaxis is almost 100% effec- tries to use their own PEP and rabies surveillance datative in preventing death from rabies. However, this to forecast vaccination needs and budget for biolog-basic care is not available in many endemic areas (3, ical purchases. Globally, we are advocating for inclu-5). Expanding access to high-quality, affordable PEP for sion of rabies PEP into the 2018 GAVI vaccine invest-populations at risk of rabies relies on health systems ment strategy (23). If successful, this would ensure freecapable of reaching the world’s most underserved access to PEP in lower income, GAVI-eligible countries.populations. In this way, supporting national plansthat promote treating dog bites and rabies exposures Countries also need a mechanism to prevent over-usein people contributes to achieving universal health of PEP, especially when successful control activitiescoverage. cause the incidence of rabies to decline. Bite prevention education (see outcome 1.1) and integrated bite caseWe will facilitate prudent use of rabies biologicals management (IBCM) are proposed as parallel strategiesthrough standardized, pragmatic, evidence-based to reduce unnecessary costs and use of rabies biologi-guidance for PEP, PrEP and RIG. Practical courses cals (24). Bite prevention education aims to prevent dogfor health professionals on PEP administration, bite bites in the first instance, while IBCM engages medicalmanagement and palliative care for clinical rabies cases and veterinary sectors to assess the risk of genuine 15
exposure to rabies and the subsequent need for PEP (Annex 6). This provides a means for countries to reduce human treatment costs for rabies, as they concurrently reduce transmission risk through controlling rabies in dogs. We will integrate last mile strategies to increase access of poor and rural populations to PEP into the global movement towards achieving universal health coverage, and support countries to evaluate and amend current practices for PEP procurement to ensure availability and access for all. Outcome 1.3: Human deaths from rabies exposures are prevented by ensuring equitable, affordable and timely access to healthcare, medicines and vaccines ACTIVITIES 2017–2020 EXPECTED OUTCOMES 2020 Support national plans that expand access to Increased access to basic healthcare, espe- basic healthcare for all cially for underserved populations Leverage existing tools to support prudent use Coherent, standardized, evidence-based tools of PEP, PrEP and RIG by health services and strategies for use of PEP, PrEP and RIG Regional workshops to build capacity in Improved availability and access to human best-practice rabies prevention and care rabies biologicals (see Annex 4–Banks) Establish a biological bank to increase access Mechanism to reduce rabies biological usage to affordable human rabies biologicals where rabies incidence is low (e.g. IBCM) Promote the use of surveillance data for fore- casting of vaccine needs Investigate bite prevention education and IBCM as strategies to reduce biological usage16
OBJECTIVE 2 TO GENERATE, INNOVATE AND MEASURE IMPACTOBJECTIVE 2.1 TO PROVIDE Efficient and effective governance of rabies eliminationEFFECTIVE POLICIES, GUIDANCE AND programmes will enable transparency at the national and regional levels, and encourage accountability.GOVERNANCE Based on global best practices and lessons learned from countries that have successfully combated rabies, we will provide guidance documents on how to clearlyCoherent international standards and guidance reflect define the roles, responsibilities and accountabilities ofbest practice in rabies control. We need to support persons and organizations involved in elimination activ-countries to access and adapt this guidance to their ities to maximize the impact of investment.local situation, and to monitor, assess and refine strate-gies with the greatest impact. Established reporting structures with defined linkages between departments will ensure continuity and prog- ress of elimination activities in the context of changingOutcome 2.1: policies, guidelines, and political environments and personnel. We will supportgovernance to prevent human rabies countries to set realistic and attainable goals, and todeaths are created and adopted at establish cross-sectoral working groups to advocateregional and national levels for and prioritize rabies elimination.Clear guidance, strategies and frameworks to preventhuman rabies deaths provide a standardized struc-ture for countries to adapt, own and implement. Wewill adapt existing knowledge, policies and tools intoa coherent framework of standardized methods, oper-ating procedures, guidance and governance, and incor-porate them into universally available tools. This willensure a consistent global approach to the surveillance,diagnosis and prevention of human and dog rabies.Capacity-building and training to provide coordinated,comprehensive and complementary guidance to coun-tries to support the development and delivery of nationalrabies control strategies. Training of human and animalhealth professionals will strengthen the effective use ofvaccines, medicines and tools.Harmonized international recommendations for rabiesprevention in people and animals will streamline aOne Health approach into policy development. We willupdate existing tools such as SARE (Annex 7) to providecoordinated, comprehensive guidance to countries (25).Our global approach will advocate for prioritization ofrabies elimination, and provide a mechanism to tackleinequality in healthcare. 17
