WHO's latest rabies recommendations and guidance save lives and reduce the cost of treatment

Rabies vaccination is a crucial part of rabies post-exposure prophylaxis (PEP), but it tends to consist of long and costly regimens of intramuscular (IM) injections. Most human rabies deaths are caused by delayed access, unaffordability or ineffective delivery of PEP. Reducing these barriers is crucial to ensure that this incurable yet preventable disease does not cost lives. In 2022, WHO published new guidance towards the introduction or expansion of rabies vaccination into national immunization programmes to systematically drive down human rabies deaths effectively and cost-efficiently. Such guidance grounds on the latest scientific recommendation provided by WHO’s Strategic Advisory Group of Experts in 2018. WHO recommends a shortened 1-week rabies vaccination schedule, with visits on days 0, 3 and 7. On each visit, a 2-site intradermal (ID) injection (using only 0.1 ml of vaccine in each site) is administered. ID administration allows for vials to be shared among several patients within a 6-8 hours timeline. Compared to IM administration, ID is cost- and dose-sparing, even in low-throughput clinics. Additionally, this regimen requires only 3 visits to the healthcare facility, improving patient compliance. However, the uptake of this shortened ID regimen remains limited. It should now be a matter of urgency for Health Ministries in rabies-endemic settings to adopt the WHO-recommended shortened ID vaccination schedule and ensure appropriate medical training to improve PEP delivery. This will enable countries to improve PEP delivery and allow underserved populations to access affordable, life-saving rabies vaccines

Avant-propos de l’OMS

Cet ouvrage rend hommage aux progrès réalisés dans le changement de paradigme pour aborder de façon efficace la santé et le bien-être des personnes et des animaux dans l’environnement qu’ils partagent. Il s’agit d’une ressource précieuse non seulement pour les médecins et les vétérinaires, mais aussi pour l’ensemble de la collectivité qui reconnaît de plus en plus les avantages à relier différentes disciplines et différents secteurs ..

Difficulties in estimating the human burden of canine rabies

Current passive surveillance data for canine rabies, particularly for the regions where the burden is highest, are inadequate for appropriate decision making on control efforts. Poor enforcement of existing legislation and poor implementation of international guidance reduce the effectiveness of surveillance systems, but another set of problems relates to the fact that canine rabies is an untreatable condition which affects very poor sectors of society. This results in an unknown, but potentially large proportion of rabies victims dying outside the health system, deaths that are unlikely to be recorded by surveillance systems based on health center records. This article critically evaluates the potential sources of information on the number of human deaths attributable to canine rabies, and how we might improve the estimates required to move towards the goal of global canine rabies elimination

Stepwise approach for the control and eventual elimination of Taenia solium as a public health problem

Background: Taenia solium taeniosis/cysticercosis is a public health and agricultural problem, especially in low-income countries, and has been ranked the top foodborne parasitic hazard globally. In 2012, the World Health Organization published a roadmap that called for a validated strategy for T. solium control and elimination by 2015. This goal has not been met, and validated evidence of effective control or elimination in endemic countries is still incomplete. Measuring and evaluating success of control programmes remains difficult, as locally acceptable targets have not been defined as part of the 2012 roadmap nor from other sources, and the performance of tools to measure effect are limited. Discussion: We believe that an international agreement supported by the tripartite World Health Organization, Food and Agriculture Organization of the United Nations, and World Organisation for Animal Health is needed to facilitate endemic countries in publicising SMART (Specific, Measurable, Achievable/attainable, Relevant, Time-bound) country-level control target goals. These goals should be achievable through locally acceptable adoption of options from within a standardised intervention tool-kit', and progress towards these goals should be monitored using standardised and consistent diagnostics. Several intervention tools are available which can contribute to control of T. solium, but the combination of these - the most effective control algorithm - still needs to be identified. In order to mount control efforts and ensure political commitment, stakeholder engagement and funding, we argue that a stepwise approach, as developed for Rabies control, is necessary if control efforts are to be successful and sustainable. Conclusions: The stepwise approach can provide the framework for the development of realistic control goals of endemic areas, the implementation of intervention algorithms, and the standardised monitoring of the evaluation of the progress towards obtaining the control target goals and eventually elimination

Modelling to inform prophylaxis regimens to prevent human rabies

International audienceBACKGROUND: The Strategic Advisory Group of Experts (SAGE) Working Group on rabies vaccines and immunoglobulins was established in 2016 to develop practical and feasible recommendations for prevention of human rabies. To support the SAGE agenda we developed models to compare the relative costs and potential benefits of rabies prevention strategies.METHODS: We examined Post-Exposure Prophylaxis (PEP) regimens, protocols for administration of Rabies Immunoglobulin (RIG) and inclusion of rabies Pre-Exposure Prophylaxis (PrEP) within the Expanded Programme on Immunization (EPI). For different PEP regimens, clinic throughputs and consumables for vaccine administration, we evaluated the cost per patient treated, costs to patients and potential to treat more patients given limited vaccine availability.RESULTS: We found that intradermal (ID) vaccination reduces the volume of vaccine used in all settings, is less costly and has potential to mitigate vaccine shortages. Specifically, the abridged 1-week 2-site ID regimen was the most cost-effective PEP regimen, even in settings with low numbers of bite patients presenting to clinics. We found advantages of administering RIG to the wound(s) only, using considerably less product than when the remaining dose is injected intramuscularly distant to the wound(s). We found that PrEP as part of the EPI programme would be substantially more expensive than use of PEP and dog vaccination in prevention of human rabies.CONCLUSIONS: These modeling insights inform WHO recommendations for use of human rabies vaccines and biologicals. Specifically, the 1-week 2-site ID regimen is recommended as it is less costly and treats many more patients when vaccine is in short supply. If available, RIG should be administered at the wound only. PrEP is highly unlikely to be an efficient use of resources and should therefore only be considered in extreme circumstances, where the incidence of rabies exposures is extremely high

One health for neglected tropical diseases

The forthcoming World Health Organization road map for neglected tropical diseases (NTDs) 2021–2030 recognises the complexity surrounding control and elimination of these 20 diseases of poverty. It emphasises the need for a paradigm shift from disease-specific interventions to holistic cross-cutting approaches coordinating with adjacent disciplines. The One Health approach exemplifies this shift, extending beyond a conventional model of zoonotic disease control to consider the interactions of human and animal health systems within their shared environment and the wider social and economic context. This approach can also promote sustainability and resilience within these systems. To achieve the global ambition on NTD elimination and control, political will, along with contextualised innovative scientific strategies, is required.http://trstmh.oxfordjournals.orghj2021Veterinary Tropical Disease

Assessing the practicalities of joint snakebite and dog rabies control programs:Commonalities and potential pitfalls

Both rabies and snakebite primarily affect underserved and impoverished communities globally, with an estimated 200,000 people dying from these diseases annually, and the greatest burden being in Africa and Asia. Both diseases have been neglected and have thus been denied appropriate prioritization, support, and interventions, and face many of the challenges common to all neglected tropical diseases (NTDs). In line with the call for integrated approaches between NTDs in the recent NTD Roadmap, we sought to build upon previous conceptualizations for an integrated approach by identifying the commonalities between snakebite and rabies to explore the feasibility of an integrated approach. While multiple areas for potential integration are identified, we highlight the potential pitfalls to integrating rabies and snakebite programs, considering the nuances that make each disease and its intervention program unique. We conclude that health system strengthening, and capacity building should be the focus of any integrated approach among NTDs, and that by strengthening overall health systems, both rabies and snakebite can advocate for further support from governments and stakeholders