Abstract
The World Health Organization, the World Organization for Animal Health, and the Food and Agriculture Organization have resolved to eliminate human rabies deaths due to dog bites by 2030, and the Vaccine Alliance (Gavi) has added human rabies vaccines to their investments for 2021–2025. Implementing these goals cost-effectively and sustainably requires understanding the complex connections between dog rabies vaccination and human risk and response. The objective of this paper is to estimate how dog rabies vaccinations affect human rabies deaths, mediated through dog rabies cases, dog bite reporting, and post-exposure human rabies vaccination. To approach this objective, we apply multivariate regression analysis over five rabies-related outcomes: (a) dog vaccinations, (b) dog rabies cases, (c) reported human exposures, (d) human post-exposure prophylaxis (PEP) use, and (e) human rabies cases. Analysis uses aggregate annual data over 1995–2005 for seven Latin American countries that experienced dramatic declines in canine and human rabies. Among other results, we estimate the following. (i) A 10% increase in dog vaccinations decreases dog rabies cases by 2.3%. (ii) Reported exposures decline as concurrent dog rabies cases decline, but these declines are more than offset by increases in reported exposures per dog rabies case, which may result from higher rabies awareness due to anti-rabies campaigns. (iii) A 10% increase in PEP use decreases human deaths by 7%, but a 10% increase in dog vaccination induces a 2.8% decrease in PEP use. The net effect is that a 10% increase in dog vaccination reduces human deaths by 12.4% overall, although marginal effectiveness declines as dog rabies incidence declines. (iv) Increases in income and public health expenditures increase PEP demand. The findings highlight the importance of mass dog vaccination, heightened awareness, treatment access, and clinical algorithms to reduce both false negatives leading to death and false positives leading to costly unnecessary PEP prescriptions.
Highlights
In November 2018, The Vaccine Alliance (Gavi) added human rabies vaccines to investments for 2021–2025 [1]
During 1995 through 2005, there was an increase in Dog Vaccinations in the seven countries, accompanied by a marked decrease in both Dog and Human Rabies Cases (Fig 2, thick top line; natural logarithmic scale), while Reported exposures and post-exposure prophylaxis (PEP) completions per dog case, and per human case increased substantially (Fig 3b, 3d and 3f, respectively)
The results show that a 10% increase in a year’s Dog Rabies Cases is associated with 5.6% more cases in the following year
Summary
In November 2018, The Vaccine Alliance (Gavi) added human rabies vaccines to investments for 2021–2025 [1]. This investment in human vaccine for post-exposure prophylaxis aligns Gavi with the tripartite goal of the World Health Organization, World Animal Health Organization, and Food and Agriculture Organization to eliminate rabies as a cause of human death [2]. While rabies was ranked high for its public health impact in Gavi’s analysis for vaccine prioritization, concern was raised regarding the operational complexity of human post-exposure prophylaxis (PEP) as cost effective control requires progressive reduction in the zoonotic transmission of rabies and decreased demand for PEP over time. Access to PEP is necessary following bites of unvaccinated dogs or dogs for which the vaccination and disease status is uncertain [9,10]
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