Heterogeneity in the spread and control of infectious disease: consequences for the elimination of canine rabies

Understanding the factors influencing vaccination campaign effectiveness is vital in designing efficient disease elimination programmes. We investigated the importance of spatial heterogeneity in vaccination coverage and human-mediated dog movements for the elimination of endemic canine rabies by mass dog vaccination in Region VI of the Philippines (Western Visayas). Household survey data was used to parameterise a spatially-explicit rabies transmission model with realistic dog movement and vaccination coverage scenarios, assuming a basic reproduction number for rabies drawn from the literature. This showed that heterogeneous vaccination reduces elimination prospects relative to homogeneous vaccination at the same overall level. Had the three vaccination campaigns completed in Region VI in 2010–2012 been homogeneous, they would have eliminated rabies with high probability. However, given the observed heterogeneity, three further campaigns may be required to achieve elimination with probability 0.95. We recommend that heterogeneity be reduced in future campaigns through targeted efforts in low coverage areas, even at the expense of reduced coverage in previously high coverage areas. Reported human-mediated dog movements did not reduce elimination probability, so expending limited resources on restricting dog movements is unnecessary in this endemic setting. Enhanced surveillance will be necessary post-elimination, however, given the reintroduction risk from long-distance dog movements

Quantifying primaquine effectiveness and improving adherence: a round table discussion of the APMEN Vivax Working Group.

The goal to eliminate malaria from the Asia-Pacific by 2030 will require the safe and widespread delivery of effective radical cure of malaria. In October 2017, the Asia Pacific Malaria Elimination Network Vivax Working Group met to discuss the impediments to primaquine (PQ) radical cure, how these can be overcome and the methodological difficulties in assessing clinical effectiveness of radical cure. The salient discussions of this meeting which involved 110 representatives from 18 partner countries and 21 institutional partner organizations are reported. Context specific strategies to improve adherence are needed to increase understanding and awareness of PQ within affected communities; these must include education and health promotion programs. Lessons learned from other disease programs highlight that a package of approaches has the greatest potential to change patient and prescriber habits, however optimizing the components of this approach and quantifying their effectiveness is challenging. In a trial setting, the reactivity of participants results in patients altering their behaviour and creates inherent bias. Although bias can be reduced by integrating data collection into the routine health care and surveillance systems, this comes at a cost of decreasing the detection of clinical outcomes. Measuring adherence and the factors that relate to it, also requires an in-depth understanding of the context and the underlying sociocultural logic that supports it. Reaching the elimination goal will require innovative approaches to improve radical cure for vivax malaria, as well as the methods to evaluate its effectiveness

Pre-exposure rabies prophylaxis: A systematic review

To review the safety and immunogenicity of pre-exposure rabies prophylaxis (including accelerated schedules, co-administration with other vaccines and booster doses), its cost-effectiveness and recommendations for use, particularly in high-risk settings.We searched the PubMed, Centre for Agriculture and Biosciences International, Cochrane Library and Web of Science databases for papers on pre-exposure rabies prophylaxis published between 2007 and 29 January 2016. We reviewed field data from pre-exposure prophylaxis campaigns in Peru and the Philippines.Pre-exposure rabies prophylaxis was safe and immunogenic in children and adults, also when co-administered with routine childhood vaccinations and the Japanese encephalitis vaccine. The evidence available indicates that shorter regimens and regimens involving fewer doses are safe and immunogenic and that booster intervals could be extended up to 10\ua0years. The few studies on cost suggest that, at current vaccine and delivery costs, pre-exposure prophylaxis campaigns would not be cost-effective in most situations. Although pre-exposure prophylaxis has been advocated for high-risk populations, only Peru and the Philippines have implemented appropriate national programmes. In the future, accelerated regimens and novel vaccines could simplify delivery and increase affordability.Pre-exposure rabies prophylaxis is safe and immunogenic and should be considered: (i)\ua0where access to postexposure prophylaxis is limited or delayed; (ii)\ua0where the risk of exposure is high and may go unrecognized; and (iii)\ua0where controlling rabies in the animal reservoir is difficult. Pre-exposure prophylaxis should not distract from canine vaccination efforts, provision of postexposure prophylaxis or education to increase rabies awareness in local communities

Incidence of Category II and III Dog Bites among 5-14 year old children in El Nido estimated from passive and active surveillance, 2011 to 2012

<p><u>Active surveillance</u></p> <p> At enrollment, a questionnaire was completed in order to collect the history of potential rabies exposures (animal bites and scratches) over the past 6 months in the cohort children. Information about a child’s possible rabies exposures was collected retrospectively through home visits, mobile phone contact, and through consultations with midwives and village health workers, teachers and neighbors. During the 18 months of follow-up beginning July 2011, active detection of rabies exposures was conducted every three months until December 2012 and included the interview of the exposed patient’s parent regarding incidents of contact with a suspected rabid animal. Parents were contacted and asked whether their child had experienced contact with a suspect rabid animal since the previous interview and follow-up forms were completed. All patients that had experienced a potential exposure during the previous three months were visited at home and standardized rabies exposure forms (REF) were completed. All follow-up questionnaires administered during the study were similar except the questionnaire provided in March 2012, in which questions regarding the PrEP were added. Also in 2012, a small survey was carried out of the parents of 328 randomly chosen children who were not vaccinated, to determine the reasons for this.</p> <p> During the follow-up period, the ABTC data were collected on all children with a reported contact with a suspect rabid animal. Every three months thereafter, an ABTC data retrieval form was completed for every rabies exposure consultation for a child included in the study cohort. </p> <p> </p> <p><u>Passive surveillance</u></p> Data on animal bite consultations of children in the same age group as the study cohort at the ABTC were collected retrospectively for the period from January 2011 to December 2012 in order to establish a temporal trend of exposures. Bite incidence was calculated from the number of bites amongst children divided by the total number of children aged 5-14 years old based on the 2007 Population Census

Percentages of students who knew about rabies based on pre and post-tests of students in El Nido elementary schools, school year 2012–13.

<p>Percentages of students who knew about rabies based on pre and post-tests of students in El Nido elementary schools, school year 2012–13.</p

Costs of PEP according to PrEP status over 1 year.

<p>Costs of PEP according to PrEP status over 1 year.</p

Timeline of study activities.

<p>Timeline of study activities.</p

Estimated dog bite incidence among 5–14 year old children in El Nido using passive and active surveillance, 2011 and 2012.

<p>Estimated dog bite incidence among 5–14 year old children in El Nido using passive and active surveillance, 2011 and 2012.</p

Number of pre-exposure vaccination doses received by students in El Nido elementary schools based on municipal health office records, January to February 2012.

<p>Number of pre-exposure vaccination doses received by students in El Nido elementary schools based on municipal health office records, January to February 2012.</p

Percentages of Students who knew about Rabies based on pre and post-tests of students in El Nido Elementary Schools, School Year 2012-13

The rabies education manual was used during the 2012 to 13 school year. It contains modules on rabies which teachers could integrate into Science and Health, Makabayan (Civics, Social Studies, Geography, and History), Filipino, English and Mathematics subjects for the different grade levels throughout the year. An assessment of the impact of the education program was conducted among students in 12 randomly selected elementary schools in the municipality. Pre- and post-intervention tests were conducted among a sample of the students to assess the impact of the education materials, testing the students’ knowledge of rabies, its transmission, dog bite prevention, dog bite management, and responsible pet ownership. The pre-tests were conducted in July 2012 while the post-tests were conducted in March 2013