World Rabies Day: Challenges and Opportunities to Get to Zero by 30
Rabies – A global Public Health Problem
September 28th is World Rabies Day, and the theme this year is “breaking rabies boundaries,” highlighting the need to address what’s standing in the way of achieving the Zero by 30 target of eliminating human rabies transmitted by dogs by 2030.
Rabies is a vaccine-preventable zoonotic virus that is 100% fatal without prompt treatment. This virus can affect many different types of mammals, and can be found all over the world. As a zoonotic disease – one that can be passed onto multiple species, vaccination among domestic animals has helped control the spread of this disease within animal populations, and is a critical strategy to prevent rabies in humans. Nevertheless, rabies still persists as a public health problem in many countries, resulting in 59,000 human deaths per year, 97% of which are dog-mediated transmission with the highest number of cases in Africa (36.4%) and Asia (59.6%). The populations most affected are those living in close proximity to unvaccinated animal populations carrying the disease and limited access to health care, with 40% of rabies deaths occurring in children under 15 years of age.
The 1st rabies vaccine was developed in 1885 by Louis Pasteur before the cause of rabies – Rabies lyssavirus was identified. Nearly a century and a half later, we now have a much better understanding of the rabies virus with improved vaccines to treat it. Prompt Post Exposure Prophylaxis (PEP), which consists of thorough wound washing, administration of a course of quality human rabies vaccine, and immunoglobulins when indicated, are very effective in treating this disease. However, no therapy has consistently demonstrated efficacy in treating the disease once the virus reaches the central nervous system and clinical symptoms develop. At this stage, rabies infection is 100% fatal.
Human Rabies in Canada – A Rare but Real Threat
Unlike most other neglected tropical diseases that people in Canada might experience, Rabies is a nationally reportable, treatable disease in Canada. Earlier this month the 1st human rabies case in 50 years was confirmed in Ontario. While we do not know a lot about the status of this particular case, the individual affected was admitted to the hospital for treatment. Typically, it takes days to weeks before any clinical symptoms appear. Since reporting on human rabies cases began in 1924, there have only been 27 reported cases, and all reported cases in Canada have been fatal. This is likely due to delays in seeking treatment rather than a lack of treatment available.
While in most other places in the world where rabies infected dog bites are the cause of rabies infections in humans, in Canada nearly all human cases have been due to interaction with rabid bats or exposure to the virus outside of Canada. Rabies is also found in racoons and skunks that can be found in both rural and urban areas in several provinces, and in northern Canada, foxes are the main animal host of the rabies virus.
An Act to establish a National Rabies Awareness Day in Canada
Yukon Member of Parliament Brendan Hanley, a physician prior to becoming a politician, sponsored a private members Bill C-349 in June, 2023: An act to establish a National Rabies Awareness Day, and to provide for the development of a national strategy for combating rabies in Canada.
With limited access to routine veterinary services including of rabies vaccinations for companion and domesticated animals, and an overall lack of access to health care for remote, northern communities, a lack of systematic surveillance and control of rabies in Northern Canada can pose a public health risk. This bill proposes working within a One Health approach to combat rabies; and working with Indigenous governing bodies and veterinarian and public health experts to build strategies to manage barriers in access to routine rabies vaccines for animals, and their availability for people living in northern communities.
Photo by: Ciewe Ciake Serge Alain, Cameroon
Global Action to End Rabies
The Global Strategic Plan for the eradication of human rabies deaths caused by dogs worldwide by 2030 was introduced in 2018 by the World Health Organization (WHO), in partnership with the World Organization for Animal Health (WOAH), the Food and Agriculture Organization of the United Nations (FAO), and the Global Alliance for Rabies Control (GARC). It places a strong emphasis on the prevention of canine rabies through yearly mass vaccination that reaches at least 70% of dog populations.
However, this year, following decades of advocacy and delays in implementation due to Covid 19, Gavi, the Vaccine Alliance, has now begun its rollout of the human rabies vaccine as part of routine immunization to eliminate human rabies cases in over 50 high burden countries. Through it’s Vaccine Investment Strategy (VIS), GAVI is co-financing countries’ access to the rabies vaccine to meet a gap in having the treatment available for people who need access to PEP in rural and remote communities. While it does not include Rabies immunoglobulins (RIG), which many cases will need for effective treatment, it will nevertheless support countries in making treatment more widely available.
In response to Gavi’s roll out of rabies PEP, Dr. Bernadette Abela, Team Lead, Neglected Zoonotic Diseases, WHO. has shared that:
“Gavi’s investment in human rabies vaccines for PEP is very exciting. We are already seeing a number of countries with a high rabies burden using this opportunity to develop comprehensive national plans, bringing together the essential elements of effective rabies programs including prompt access to post exposure vaccines, mass dog vaccination, and public education about the importance of seeking medical attention, and how to avoid dog bites and stay safe.”
While this investment by GAVI alone will not be enough to eliminate dog-mediated human rabies deaths, it is a huge boost to the zero by 30 rabies deaths campaign. Rabies deaths continue to occur because access to health care is generally inequitable, particularly for people living in rural and remote areas, and people that get bitten may not know to seek health care even when easily accessed, as clinical symptoms only appear in the days and weeks (and in some cases, months) following a bite from an infected animal.
Conclusion – Keeping Rabies on the Radar
The progress that has been made in controlling rabies rates in Canada and in other countries is testament to the critical role played by One Health strategies, and how very closely linked our own health is to animal health. It also highlights the need for multi-disciplinary strategies in managing infectious diseases. Rabies, like many other diseases, requires careful and disciplined surveillance, reporting and action to prevent and control.
That’s why Bill C-349 is also significant. Having our own national rabies day would prompt our federal and provincial governments to do a pulse check on rabies, to see where the blind spots are and where we may have opportunities to change the trajectory of its epidemiological spread to people, and among animals in our urban and rural environments.
I will leave the last words to Dr. Bernadette Abela:
“The important thing to remember is that rabies is a disease we know how to beat – we have proven strategies and very effective vaccines. We really can prevent many more people dying from rabies, if we work together.”
Links to share
WHO Rabies Post-Exposure Prophylaxis Decision Tree: Decide with Confidence
Dr. Bogoch on Rabies case in Ontario
Latest episode of Rabies Today: “World Rabies Day – Working with Communities”
July 2021 CNNTD blog post by Katrina Bouzanis interviewing Agathe Allibert on her research on rabies in the Canadian arctic (en Français)
