Ottorino Cosivi

Progress towards eliminating canine rabies: policies and perspectives from Latin America and the Caribbean

Human rabies transmitted by dogs is considered a neglected disease that can be eliminated in Latin America and the Caribbean (LAC) by 2015. The aim of this paper is to discuss canine rabies policies and projections for LAC regarding current strategies for achieving this target and to critically review the political, economic and geographical factors related to the successful elimination of this deadly disease in the context of the difficulties and challenges of the region. The strong political and technical commitment to control rabies in LAC in the 1980s, started with the regional programme coordinated by the Pan American Health Organization. National and subnational programmes involve a range of strategies including mass canine vaccination with more than 51 million doses of canine vaccine produced annually, pre- and post-exposure prophylaxis, improvements in disease diagnosis and intensive surveillance. Rabies incidence in LAC has dramatically declined over the last few decades, with laboratory confirmed dog rabies cases decreasing from approximately 25 000 in 1980 to less than 300 in 2010. Dog-transmitted human rabies cases also decreased from 350 to less than 10 during the same period. Several countries have been declared free of human cases of dog-transmitted rabies, and from the 35 countries in the Americas, there is now only notification of human rabies transmitted by dogs in seven countries (Bolivia, Peru, Honduras, Haiti, Dominican Republic, Guatemala and some states in north and northeast Brazil). Here, we emphasize the importance of the political commitment in the final progression towards disease elimination. The availability of strategies for rabies control, the experience of most countries in the region and the historical ties of solidarity between countries with the support of the scientific community are evidence to affirm that the elimination of dog-transmitted rabies can be achieved in the short term. The final efforts to confront the remaining obstacles, like achieving and sustaining high vaccination coverage in communities that are most impoverished or in remote locations, are faced by countries that struggle to allocate sufficient financial and human resources for rabies control. Continent-wide cooperation is therefore required in the final efforts to secure the free status of remaining countries in the Americas, which is key to the regional elimination of human rabies transmitted by dogs.

Rabies update for Latin America and the Caribbean.

To the Editor: Rabies incidence in Latin America and the Caribbean has decreased and several countries (Uruguay, Chile, Costa Rica, Mexico, and Panama) and areas of Peru, Brazil, and Argentina are free of human rabies transmitted by dogs, although there are certain areas to which this disease is still endemic (1). Coordinated actions for regional elimination of human rabies transmitted by dogs began in 1983 in Latin America and the Caribbean with the assistance of the Pan American Health Organization (PAHO). This effort has led to an ≈90% reduction of human and canine rabies (2). In this region, rabies is associated with poverty and considered a neglected disease (3). Resolution 19 of the 49th Directing Council of PAHO in 2009 regarding neglected diseases and other infections related to poverty set a target for eliminating human rabies transmitted by dogs by 2015. PAHO is currently developing strategies to assist countries during this period (4). Since 2010, a total of 111 human rabies cases transmitted by bats, dogs, and other animal species were reported from Latin America and the Caribbean: 40 transmitted by dogs and 63 by bats (Table). Although a major reduction in human rabies transmitted by dogs was observed in 2010 (only 6 cases), the total number of cases increased to 24 in 2011; most were confirmed by laboratory testing. Table Cases of human rabies in 10 countries in Latin America and the Caribbean, 2010–2012* The higher risk areas for human rabies transmitted by dogs, for which more collaboration and financial support are urgently needed, are Haiti, Bolivia, Guatemala, Dominican Republic, and parts of Brazil (Maranhao State) and Peru (Puno Region). Unfavorable conditions in which persons in these areas are living limit control strategies and maintain rabies transmission (3). According to the PAHO Epidemiologic Surveillance System for Rabies, during 2010–2012, Bolivia and Haiti had the highest incidence of human rabies transmitted by dogs in the Western Hemisphere: 15% (6/40) and 40% (16/40) of all cases, respectively (5). Many factors, including national disasters and social, cultural, and economic factors, have interfered with canine rabies control programs in these countries. Bolivia has a population of 10 million, and 60.0% of the population is considered below the national poverty line. This country has poor suburbs on the outskirts of large cities, with large populations of unowned dogs and limited resources to implement dog mass vaccination campaigns and animal birth control programs. Haiti has a population of >10 million, and 77% of the population is considered below the national poverty line. In 2010, Haiti was devastated by a major earthquake that affected all sectors, including laboratory diagnosis for rabies (6). After the earthquake, the country was struck by a cholera epidemic. Financial resources have been diverted to control such priorities and to provide humanitarian aid. Haiti and Bolivia heavily depend on technical cooperation and donations from other governments or institutions, and are a high priority for elimination of human rabies transmitted by dogs (7). Another challenge for Latin America and the Caribbean is development of a common strategy for preventing human rabies transmitted by bats, especially in remote areas in the Amazon region (Peru, Ecuador, and Brazil) and Mexico (7), from which 97% of human rabies cases were reported during this period. Since 2000, vampire bats have been the leading cause of human rabies in Latin America and the Caribbean (8). Comparison of data for 2010–2012 with data for the previous 3 years shows a 5.2% increase in bat-transmitted human rabies, especially during 2011, which accounted for ≈53% of reports during the past 3 years (5). Bats have been identified as a reservoir for many Lyssavirus spp. genotypes, and the geographic distribution of variants has been associated with climate changes and ecologic imbalances. Spread of bats has been facilitated by human-made shelters near human dwellings (9). Although rabies control in Latin America and the Caribbean has been successful, certain approaches currently used, such as mass vaccination campaigns for dogs, postexposure prophylaxis, and epidemiologic surveillance, require improvement in some countries. In addition, allocation of resources is needed to enhance national programs to eliminate human rabies transmitted by dogs. PAHO is responsible for coordination and technical cooperation of the Rabies Elimination Program and Operation of the Epidemiologic Surveillance System for Rabies. For the past 60 years, the Pan American Center for Foot-and-Mouth Disease/PAHO has accumulated capabilities to develop national programs for zoonoses prevention and control, particularly for rabies elimination in Latin America and the Caribbean. Strengthening regional, national, and subnational rabies control programs must be a priority. The decision in Latin America and the Caribbean to eliminate dog-transmitted rabies began in 1983 and involved strong political commitment with multinational efforts, as well as support and coordination of other international organizations, nongovernmental organizations, and the private sector. This interinstitutional collaboration is needed to promote prevention and control activities to achieve the elimination of human rabies transmitted by dogs in the Western Hemisphere by 2015.

Zoonotic tuberculosis in human beings caused by Mycobacterium bovis—a call for action

Mycobacterium tuberculosis is recognised as the primary cause of human tuberculosis worldwide. However, substantial evidence suggests that the burden of Mycobacterium bovis, the cause of bovine tuberculosis, might be underestimated in human beings as the cause of zoonotic tuberculosis. In 2013, results from a systematic review and meta-analysis of global zoonotic tuberculosis showed that the same challenges and concerns expressed 15 years ago remain valid. These challenges faced by people with zoonotic tuberculosis might not be proportional to the scientific attention and resources allocated in recent years to other diseases. The burden of zoonotic tuberculosis in people needs important reassessment, especially in areas where bovine tuberculosis is endemic and where people live in conditions that favour direct contact with infected animals or animal products. As countries move towards detecting the 3 million tuberculosis cases estimated to be missed annually, and in view of WHOs end TB strategy endorsed by the health authorities of WHO Member States in 2014 to achieve a world free of tuberculosis by 2035, we call on all tuberculosis stakeholders to act to accurately diagnose and treat tuberculosis caused by M bovis in human beings.

Elimination of foot-and-mouth disease in South America: lessons and challenges

Foot-and-mouth disease (FMD) is a highly transmissible and economically devastating disease of cloven-hoofed livestock. Although vaccines are available and have been instrumental in eliminating the disease from most of the South American animal population, viral circulation still persists in some countries and areas, posing a threat to the advances of the last 60 years by the official veterinary services with considerable support of the livestock sectors. The importance of the disease for the social and economic development of the American continent led to the establishment in 1951 of the Pan American Centre for Foot-and-Mouth Disease (PANAFTOSA), which has been providing technical cooperation to countries for the elimination of the disease. The first FMD national elimination programmes were established in South America around the 1960s and 1970s. To advance the regional elimination efforts in the 1980s, countries agreed on a Plan of Action 1988–2009 of the Hemispheric Program for the Eradication of Foot-and-Mouth Disease. The Plan of Action 1988–2009 did not reach the goal of elimination from the continent; and a new Plan of Action 2011–2020 was developed in 2010 based on the experience acquired by the countries and PANAFTOSA during the past 60 years. This plan is now being implemented; several challenges are still to be overcome to ensure the elimination of FMD from the Americas by 2020, however, the goal is achievable.

Control of Dog Mediated Human Rabies in Haiti: No Time to Spare

The American region has pledged to eliminate dog-mediated human rabies by 2015. As part of these efforts, we describe the findings of a desk and field mission review of Haiti’s rabies situation by the end of 2013. While government officials recognize the importance of dog-mediated rabies control, and the national rabies plan adequately contemplates the basic capacities to that effect, regular and sufficient implementation, for example, of dog vaccination, is hampered by limited funding. Compounding insufficient funding and human resources, official surveillance figures do not accurately reflect the risk to the population, as evidenced by the large number of rabid dogs detected by focalized and enhanced surveillance activities conducted by the Ministry of Agriculture, Natural Resources and Rural Development (MARNDR) and the Health and Population Ministry (MSPP) with the technical assistance of the United States Centers for Disease Control and Prevention. Although international support is common, either in the form of on-the-ground technical support or donations of immunobiologicals, it is not comprehensive. In addition, there is limited coordination with MARNDR/MSPP and with other actors at the strategic or operational level due to human resources limitations. Given these findings, the 2015 elimination goal in the region is compromised by the situation in Haiti where control of the disease is not yet in sight despite the best efforts of the resolute national officials. More importantly, dog-mediated rabies is still a threat to the Haitian population.

Gains and Future Road Map for the Elimination of Dog-Transmitted Rabies in the Americas

In 1983 the countries of the Americas, with the technical cooperation of the Pan American Health Organization (PAHO), pledged to eliminate human rabies transmitted by dogs.1 Since then, countries have made great efforts to eliminate this disease, with notable success, within the framework of the Regional Program of Elimination of Human Rabies. The success achieved during the last 30 years and the historical solidarity between countries in the region support the goal of elimination of dog-transmitted rabies in the American continent by 2015. As this date approaches, there is a need to reflect and reassess the current plan of rabies elimination. This work briefly describes the achievements of the Regional Program and the proposed new Regional Action Plan for the elimination of dog-transmitted rabies.

Visceral leishmaniasis: a One Health approach

LEISHMANIASIS is a vectorborne, protozoan disease caused by infection with Leishmania species transmitted by infected phlebotomine sandflies. This article focuses on visceral leishmaniasis, which results in the most severe clinical forms of the disease. It also focuses on Latin American and the Caribbean and Europe, where the zoonotic form of visceral leishmaniasis is prevalent. In the case of zoonotic visceral leishmaniasis, the role of the dog as the main vertebrate reservoir is well established (Dantas-Torres and others 2012), making visceral leishmaniasis a good example of the importance of embracing a One Health approach for efficient disease surveillance and control. In people, visceral leishmaniasis infections can be asymptomatic or develop into clinical forms comprising fever, weight loss, splenomegaly and hepatomegaly. If left untreated, visceral leishmaniasis results in death in 90 per cent of human cases. When treated, the fatality rate drops considerably, ranging from 1.5 to 8.4 per cent depending on the region. However, immunocompromised individuals are more prone to developing clinical disease and have higher case fatality rates (up to 20 per cent when treated) (WHO 2007, PAHO/WHO 2013, Alvar and others 2012). Clinical features of visceral leishmaniasis infection frequently reported in dogs include skin lesions, ocular inflammation or injury, weight loss, lethargy, inappetence and lymphadenomegaly. Leishmaniasis has been reported in 98 countries on five continents (WHO 2010). More than 90 per cent of the estimated 300,000 new cases per year of visceral leishmaniasis in humans occur in just six countries: India, Bangladesh, Sudan, South Sudan, Ethiopia and Brazil (WHO 2014a). In Europe, visceral leishmaniasis is caused by Leishmania infantum and transmitted by Phlebothomus perniciosus (WHO 2014b). Visceral leishmaniasis is endemic to 14 countries in southeastern and western Europe, with around 500 autochthonous new human cases reported annually; 73 per cent of these are in Albania, Italy …

Prioritization of capacities for the elimination of dog-mediated human rabies in the Americas: building the framework

Abstract The region of the Americas pledged to eliminate dog-transmitted human rabies by 2015. After 30 years of sustained efforts, regional elimination appears possible as dog-mediated human rabies cases are at an all-time low, and a number of countries and territories have already eliminated the disease. In this setting, there is an opportunity to generate a framework to support countries strategies in the achievement and maintenance of rabies-free status (RFS). To this end, we describe the development of a multi-criteria decision analysis (MCDA) model to help the evaluation of rabies programmes and the identification of the best investment strategy for countries and territories to improve and efficiently maintain their rabies status. The model contemplates human and animal related capacities, six in each area, to comprehensively assess the wide scope of rabies programmes. An initial elicitation of expert opinion of values and weights for the MCDA model was performed via a web-based questionnaire. Even at this pilot stage, the model produces comparable capacity-scores, and overall (combined for public and animal health areas) as well as area-specific investment strategies. The model is being developed by the Pan American Health Organization (PAHO) as part of the regional efforts towards dog-mediated human rabies elimination and will be presented to the countries for review, refinement, contextualization, and testing. The aspiration is that countries use the model to identify the best allocation of resources towards the elimination of dog-mediated human rabies.

Rabies in the Americas: 1998-2014

Through national efforts and regional cooperation under the umbrella of the Regional Program for the Elimination of Rabies, dog and human rabies have decreased significantly in Latin America and Caribbean (LAC) countries over the last three decades. To achieve this decline, LAC countries had to develop national plans, and consolidate capabilities such as regular mass dog vaccination, opportune post-exposure prophylaxis and sensitive surveillance. This paper presents longitudinal data for 21 LAC countries on dog vaccination, PEP and rabies surveillance collected from the biannual regional meeting for rabies directors from 1998–2014 and from the Regional Epidemiologic Surveillance System for Rabies (SIRVERA). Differences in human and dog rabies incidence rates and dog vaccination rates were shown between low, middle and high-income countries. At the peak, over 50 million dogs were vaccinated annually in national campaigns in the countries represented. The reported number of animal exposures remained fairly stable during the study period with an incidence rate ranging from 123 to 191 reported exposures per 100,000 people. On average, over 2 million doses of human vaccine were applied annually. In the most recent survey, only 37% of countries reported that they had sufficient financial resources to meet the program objectives. The data show a sufficient and sustained effort of the LAC countries in the area of dog vaccination and provide understanding of the baseline effort required to reduce dog-mediated rabies incidence.

Tribulations of the Last Mile: Sides from a Regional Program

In Latin American and Caribbean (LAC) countries, the number of cases of dog-mediated human rabies is at its lowest since the onset of the Regional Program for Rabies Elimination in 1983, a commitment from LAC countries to eliminate dog-mediated rabies coordinated by the Pan American Health Organization. Despite minor setbacks, the decline in the number of human cases has been constant since 1983. While many LAC countries have significantly reduced rabies to a level where it is no longer significant public health concern, elimination has proven elusive and pockets of the disease remain across the region. In the 33-year period since 1983, the region has set and committed to four dates for elimination (1990, 2000, 2012, and 2015). In this paper, we ponder on the multiple causes behind the elusive goal of rabies elimination, such as blanket regional goals oblivious to the large heterogeneity in national rabies capacities. Looking ahead to the elimination of dog-mediated rabies in the region, now established for 2022, we also review the many challenges and questions that the region faces in the last mile of the epidemic. Given the advanced position of the Americas in the race toward elimination, our considerations could provide valuable knowledge to other regions pursuing elimination goals.