Rabies Case for Global Elimination

RABIES CASE FOR GLOBAL ELIMINATION

Dr Bernadette ABELA-RIDDER Team Leader, Neglected Zoonotic Diseases Department of the Control of Neglected Tropical Diseases 17 Neglected Tropical Diseases Protozoan Infections ¾ Leishmaniasis Helminth Infections ¾ Human African trypanosomiasis ¾ Chagas disease ¾ Soil-transmitted helminth infections ¾ Ascariasis-Trichuriasis-Hookworm ¾ Lymphatic filariasis ¾ Onchocerciasis ¾ Schistosomiasis ¾ Dracunculiasis (guinea-worm disease) ¾ Cysticercosis ¾ Echinococcosis ¾ Foodborne trematodes infections

Bacterial Infections ¾ Leprosy ¾ Trachoma Viral Infections ¾ Buruli ulcer ¾ Dengue ¾ Endemic treponematoses ¾ RABIES

Dr Bernadette ABELA-RIDDER [email protected] - Webinar on Rabies Prevention and Control Tools in Asia - 30 June 2015 WHO Roadmap for rabies…. Can we commit to go further?

Dr Bernadette ABELA-RIDDER [email protected] - Webinar on Rabies Prevention and Control Tools in Asia - 30 June 2015 Rationale for investment: Freedom from dog- mediated human rabies is a global public good WHO, FAO, OIE, GARC unite to eliminate human rabies and control the disease in animals

1. Rabies disproportionately burdens poor rural communities

2. Dog-mediated human rabies can be eliminated by vaccinating dogs

3. Rabies is preventable yet continues to kill

4. Rabies elimination is feasible

Dr Bernadette ABELA-RIDDER [email protected] - Webinar on Rabies Prevention and Control Tools in Asia - 30 June 2015 Start small: Make the case

KZN Project Success 2007-2014 7 500 2010 473 450 2013 6 BMGF 400 BMGF 23% 4% 5 350 335 4 300 270 Human250 220 KZN KZN 3 Animal200 183 185 77% 96% 2 150 100 1 80 37 50 0 0 7 8 9 1011121314 Philippines, 2007-2015 450 400 410 350 300 250

200 202 150 118 100

50 75 75 80 60 72 21 0 2007 2008 2009 2010 2011 2012 2013 2014 2015

Dr Bernadette ABELA-RIDDER [email protected] - Webinar on Rabies Prevention and Control Tools in Asia - 30 June 2015 Catalysing expansion 3. 4. 1.

1. Swaziland 5. 2. Eastern Cape 3. Mozambique 4. Mpumalanga 5. Orange Free State 6. 6. Lesotho 7. Other Countries –Kenya –Congo –Senegal 2.

Dr Bernadette ABELA-RIDDER [email protected] - Webinar on Rabies Prevention and Control Tools in Asia - 30 June 2015 Rabies Free Zones 9 of the 15 Visayas group of islands declared jointly by DA and DOH rabies free

Region 6: 1. Guimaras 2. Boracay

Region 7: Region 8: 1. Siquijor 1. Biliran 2. Apo Island 2. Limasawa 3. Camotes 4. Malapascua Island 5. Olympia

Dr Bernadette ABELA-RIDDER [email protected] - Webinar on Rabies Prevention and Control Tools in Asia - 30 June 2015 Demonstrate Decrease in bites, decrease in PEP use, decrease in rabies (Tanzania)

Dr Bernadette ABELA-RIDDER [email protected] - Webinar on Rabies Prevention and Control Tools in Asia - 30 June 2015 Surveillance data for planning, monitoring and evaluation • Knowing the extent of the problem and where

• Breaking the transmission in high risk communities and corridors

• Forecasting of vaccine needs (animal and human)

• Monitoring and evaluation of interventions & their impact • ….

Dr Bernadette ABELA-RIDDER [email protected] - Webinar on Rabies Prevention and Control Tools in Asia - 30 June 2015 Lessons learnt: Think big, start small, scale up

• Vaccinate the dogs and break the cycle

• Cross sectorial collaboration - One health • Surveillance (also to show absence of disease) • Awareness and education • Wound cleaning and post-exposure prophylaxis

Dr Bernadette ABELA-RIDDER [email protected] - Webinar on Rabies Prevention and Control Tools in Asia - 30 June 2015

Global conference Global elimination of dog-mediated human rabies - The Time Is Now 10-11 December 2015, WHO Headquarters, Geneva, Switzerland

1. Disseminate results of the proof of concept for the elimination of dog-transmitted rabies in different settings and explore expansion and sustainability in other endemic areas;

2. Build support and case for investment to progress towards rabies elimination from national, regional, global and other stakeholders including the private sector;

3. Promote a One Health inter-sectoral collaboration approach between the human and animal health and other sectors;

4. Shape the forward vision agenda with shared purpose including with donors and stakeholders for the elimination of dog-transmitted human rabies.

1. Rabies disproportionately burdens poor rural communities

2. Dog-mediated human rabies can be eliminated by vaccinating dogs

3. Rabies is preventable yet continues to kill

4. Rabies elimination is feasible

Dr Bernadette ABELA-RIDDER [email protected] - Webinar on Rabies Prevention and Control Tools in Asia - 30 June 2015

The Blueprint for Rabies Control

Per capita human death rates from canine rabies

Hampson et al., 2015

Rabies • Ancient! • Most Fatal Disease! • Completely Preventable Why Neglected?

Rural communities: -Poverty -Remote location -Poor infrastructure -Negligible health care Who is responsible? 1. Dogs not economically vital 2. Public health impact not appreciated Underreporting: Veterinary neglect Laboratory diagnosis of free roaming non-existent and dogs. misdiagnosis common

Global health agenda: Dog rabies in developing world Less newsworthy than novel strains of influenza or coronaviruses etc. Rabies: - Most Fatal Disease -Completely Preventable Why Neglected?

Who is responsible? Rural communities: -Poverty 1. Dogs not economically vital -Remote location 2. Public health impact not Veterinary appreciated -Poor infrastructure neglect of -Negligiblegg health care free roaminging dogs. Underreporting: Global health agenda: Laboratory Dog rabies in developing diagnosis non- world existent and Less newsworthy than misdiagnosis novel strains of influenza common or coronaviruses etc.

Global Alliance for Rabies Control

2007 World Rabies Day

2008 Partners for Rabies Prevention

2010 2011-2015 2013-2015

Rabiesblueprint.com Burden of rabies HE of rabies www.RabiesBlueprint.org

CanineRabiesBlueprint.org

Very collaborative effort

Online, freely available

Third version completed Sept 2014

Promoted through the networks

Google analytics suggest that usage is increasing Overview of the Site CANINE RABIES BLUEPRINT PAGES 1. Introduction 9 2. Roles and Responsibilities 2 3. Infrastructure, legislative framework, costs and funding 3.1. Infrastructure 11 3.2. Legislation 15 3.3. Costs and Funding 7 4. Communications plan 4.1. Importance of an effective communication plan 1 4.2. Developing a communication plan 8 4.3. Evaluating the campaign and its impact 4 5. Operational activities 5.1. What do we need to know before we start planning a programme? 17 5.2. What do we need to buy? 6 5.3. Who do we need to train and in what? 4 5.4. What are we going to do – dog component? 20 5.5. What are we going to do – human component? 6 5.6 Evaluation 5 5.7. How do we ensure sustainability of the programme? 1 6. A stepwise approach to planning and evaluation 10 LINKS Case studies 22 Documents 112 Navigation Searching and by component Example of a regular page From the Communications section Example of a documents page A Case Study Another Case Study Tools for Advocacy Rabies Educator certificate

South Africa Philippines Rabies Educator Certificate

The Rabies Educator Certificate (REC) program is a free online course for community educators, public health workers and anyone interested in learning how to prevent rabies in their communities.

Pan African Rabies Control Network

We need to stand together

Developing a Stepwise Approach towards (Dog- Transmitted) Rabies Elimination (SARE)

Katinka de Balogh Senior Officer – Veterinary Public Health Animal Health Service Food and Agriculture Organization of the United Nations 48 Global Rabies Burden: A Public Health Concern

• Neglected and re-emerging zoonotic disease • 50-70,000 estimated human rabies cases per year • Rabies is closely linked to poverty

• Over 95% of all human rabies deaths are observed in Asia and Africa

• Over 99% of the human rabies cases reported are due to dog- bites

One Health

• Rabies control best to follow the One Health approach The One Health – Rabies requires coordinated response concept addresses by veterinary and public health health risks at the services animal, human and – It is a human health problem which environmental has social and economic dimensions interface in order to as well as costs in the animal health enhance human and animal sector wellbeing and welfare, and sustainable Human rabies transmitted by dogs management of the can be eliminated! environment.

50 Surveillance and Human laboratory Health diagnostics Post exposure Sector Public prophylaxis awareness LEGISLATION, Animal bite POLITICAL reporting and wound Animal SUPPORT treatment vaccination AND FUNDING Municipal & community Dog engagement population Surveillance control Animal and laboratory Health diagnostics Sector 51 Rabies is a vaccine preventable disease

Challenges: • Making Post-exposure prophylaxis accessible and affordable

• Increasing vaccination of dogs against rabies

• Importance of animal bite clinics

52 Question for you …

In your country are people more at risk of dying of rabies?

1. In urban areas 2. In rural areas 3. Don’t know

53 Countries/municipalities are often overwhelmed when dealing with (human) rabies outbreaks….

• Fear • Political/social pressure, • Lack of resources • Lack of available and accessible Post-exposure prophlaxis (PEP) • Low vaccination rate of dogs…..

Why develop a stepwise approach?

Goal of SARE: I. Provide a structured approach II. Enable countries to define the “Stage” of rabies control they are in III. Provide defined “keys” to move to a next stage (measure progress) IV. Indicated links to relevant sections of the rabiesblueprint

Role of FAO: I. To assist countries in getting started and implement SARE

Rabies Stakeholder Consultations Kick-starting integrated rabies control

DRC Kenya Republic of Congo

Cameroun Gabon Cameroun Georgia Regional Meetings Vietnam 56 Stepwise Approach: How does it work?

6 stages to move from endemic to free from human rabies transmitted by dogs

Endemic FREE

List of achievements (keys) essential to move to the next stage

57 FAO-GARC SARE-TOOL (version July 2014) 58 59

COUNTRY ENDEMIC FOR DOG TRANSMITTED RABIES Stage 0

No information on rabies available but rabies 0 suspected to be present

Key to move from Stage 0 to Stage 1: Rabies occurrence in any species is reported to international agencies

Stage 1

Assessment of the local rabies epidemiology, elaboration of a short term rabies action plan 1

Key to move from Stage 1 to Stage 2: Functional intersectoral rabies task force in place, rabies is a notifiable disease (in humans and animals)

Direct links to the rabies Stage 1 blueprint

Assessment of the local rabies epidemiology, elaboration of a short term rabies action plan 1

Key to move from Stage 1 to Stage 2: Functional intersectoral rabies task force in place, rabies is a notifiable disease (in humans and animals)

Stage 2

Development of the national rabies prevention and control strategy 2

Key to move from Stage 2 to Stage 3: National rabies prevention and control strategy endorsed and funded

65 FAO-GARC SARE-TOOL (version July 2014) 66 Determining the SARE Stage and need

67 WHANT TO LEARN MORE ABOUT SARE? 68 Access SARE Online

http://caninerabiesblueprint.org/The- Stepwise-Approach-towards http://caninerabiesblueprint.org/IMG/pdf /canine_rabies_blueprint_v3_- =_stepwise_approach_to_planning_and _evaluation.pdf

Thank You

Questions?

Contact: [email protected] 70 RABIES The International Standards

Dr Gregorio Torres - [email protected]

LinkTADs webinar on rabies prevention and control tools in Asia

71 World Organisation for Animal Health

Established in 1924 5 regions 180 countries http://www.oie.int

Mandate of the OIE “to improve animal health and animal welfare world-wide”

72 Our mandate

• Transparency (WAHIS)

• Veterinary scientific information (disease control)

• Safe Trade (WTO)

73 Outline

• Standard setting procedures

• Terrestrial animal health code • Rabies • Stray dog population control

• Manual of diagnostics and vaccines

• One Health and vaccine banks

74 OIE terrestrial animals standards

• Terrestrial Code: Standards for disease control and safe international trade

• Terrestrial Manual: Standards for laboratory diagnostic methods and requirements for the production and control of vaccines

http://www.oie.int/en/international-standard-setting/overview/ 75 OIE standard setting procedure

Member participation

Democratic Transparent

Science based Rapid & flexible

International collaboration

Well-established

76 Commissions, Request OIE delegates, stakeholders Specialist Commissions (Scientific & Code)

Development of Support (Expert Advice: international Ad hoc Groups) standards Specialist Commissions (Scientific & Code)

Draft text Member Countries OIE Comments ASSEMBLY INTERNATIONAL STANDARD Adoption 77 OIE international standards on rabies

• Terrestrial Animal Health Code

• Manual of Diagnostic tests and Vaccines for Terrestrial Animals

78 OIE international standards on rabies

Vertical Horizontal

Chapter 7.7 Chapter 8.12 Stray dogs Infection with population Rabies virus control

Chapter 5.11 Chapter 1.1 Certificate Notification

Chapter 2.1.13 Chapter 1.4 Rabies (Manual) Surveillance

79 Cap. 8.12. Infection with Rabies virus

• General provisions • Case definition, hosts, incubation period • Control rabies in dogs • Notifiable, surveillance, diagnostic, stray dog management • Rabies Free Country (self-declaration) • Surveillance, notification, preventive measures • No indigenous case in the last 2 years • Recommendation for importation • Certification Chapter 5.11 • Dogs, cats, ferrets, ruminants, equids, camelids, suids, rodents, wildlife

AIM: Mitigate the risk of rabies transmision to human and to prevent the international spread of the disease

80 Cap. 7.7 Stray dog population control

• Within the OIE animal welfare section

• It addresses humane methods for the control of dog populations and the prevention of zoonotic diseases

• It is not exclusively for rabies

• Outline: Dog ecology, programme components, control measures

Responsible Ownership it is key in rabies control 81 Cap. 2.1.13. Rabies

• Summary

• Section A. Introduction (aetiology)

• Section B. Diagnostic techniques • Sample Collection and shipment • Identification of the agent • Serological test

• Section C. Requirement for vaccines • For injectable use • For oral use

82 Rabies - One Health Concept

… rabies control is a Public Good to “ be considered a priority model to apply the One Health concept...” The OIE is committed to supporting the efforts of the international community to achieve worldwide elimination of dog mediated rabies in humans

83 Vaccine banks

• Benefits : quality (OIE Manual), costs vs benefits, speed and logistics, better coordination

• Asia. Afghanistan, Bangladesh, Bhutan, Indonesia, Lao PDR, Myanmar, Nepal, Philippines*, Singapore, Sri Lanka and Vietnam.

• Africa. Mali, South Africa*, Togo

• Cooperation (*) WHO Global Procurement and Logistics

84 Conclusions

• International Standards agreed by Member Countries

• Technical texts for international trade (WTO)

• Provide guidance and support on disease control measures and surveillance

• Dynamic and adjusting to new circumstances

85 Thank you for your attention!

86 Principles and Practices for Rapid Rabies Control

30 June, 2015

Eric Brum, DVM, MSc Team Leader – FAO ECTAD Bangladesh

FAO Bangladesh Principles and Practices for Rapid Rabies Control

FAO Bangladesh Epidemiological foundation of disease control • To control an infectious disease, must decrease the rate of new infections • R0 = basic reproductive number = the expected number of secondary infections resulting from one single infection in a completely susceptible population • Example: 1 person with measles spreads the disease to 10 other people Æ R0 = 10

• R0 > 1 Æ number of new infections will increase over time • R0 = 1 Æ number of new infections will remain stable over time • R0 < 1 Æ number of new infections will decrease over time

FAO Bangladesh What’s the Ro of rabies in humans?

Zero. Humans are a dead-end host! -

Thus, the R0 of rabies cannot be decreased by dealing only with humans /

Dogs are the virus reservoir and source of 99% of the infections to humans and other “non-flying” mammals.

FAO Bangladesh Why is the rabies virus different in dogs? Why is the rabies Ro > 1 in dogs?

1. Dogs are social animals.

FAO Bangladesh FAO Bangladesh FAO Bangladesh FAO Bangladesh FAO Bangladesh FAO Bangladesh Why is the rabies virus different in dogs? Why is the rabies Ro > 1 in dogs?

1. Dogs are social animals.

2. Dogs interact with the world through their teeth.

FAO Bangladesh What are ways to decrease R0?

• R0 is directly proportional to 3 factors:

transmissibility contact rate duration of infection Tools

no change no change Stamping out

no change Vaccination

no change no change Sterilization

Rapid response to no change no change suspect dogs (if you’re fast!) *from J.H. Jones 2007 FAO Bangladesh Why is it so challenging to rely on case detection to control rabies in dogs?

1. The incubation period can be very long.

FAO Bangladesh FAO Bangladesh FAO Bangladesh FAO Bangladesh FAO Bangladesh Why is it so challenging to rely on case detection to control rabies in dogs?

1. The incubation period can be very long.

2. Clinical rabies is actually quite difficult to detect. Biting may be the only obvious sign.

FAO Bangladesh Ok, so why not just cull dogs to control rabies?

1. Only temporary decrease in contact rate achieved (e.g. only temporary decease in R0). 2. Dogs are social animals so contact rate does not decrease in direct proportion to decreased density. 3. Decreases community support for rabies control activities, making disease eradication difficult.

FAO Bangladesh So how can we decrease the R0?

• R0 is directly proportional to 3 factors:

transmissibility contact rate duration of infection Tools

no change no change Stamping out

no change Vaccination

no change no change Sterilization

Rapid response to no change no change suspect dogs (if you’re fast!) *from J.H. Jones 2007 FAO Bangladesh Effective dog vaccination

1. Efficacious vaccine

2. Long-lasting immunity

4. Access to target population

FAO Bangladesh So what’s the R0 of rabies in dogs?

The R0 is between 1 – 2 in dogs.

FAO Bangladesh What percentage of the herd needs to be immune to decrease R0 < 1?

% immune = 1 – (1/R0)

If R0 = 1.5, then % of immune dogs = 1 – (1/1.5) = 33%

The lower the R0, the lower the herd immunity required.

FAO Bangladesh Rabies in comparison to other diseases

Measles R = 10-15 Measles R00 = 10-15

Smallpox FMD R0= ~10 R0= 3-5 Polio R0= 5-7 Rinderpest R0= ~5

Canine Rabies

R0=1-2

FAO Bangladesh If the R0 of rabies is so low, why has it not been eliminated yet like the other diseases?

Good question! -

Simply not enough focus on dog vaccination

FAO Bangladesh So once the vaccination coverage is high, what else can be done?

Keep the vaccinated dogs alive!

The lower the population turnover, the slower the decline in vaccination coverage over time.

FAO Bangladesh And how do we decrease population turnover?

•Decrease death rate •Provide better care (e.g. food, water) •Do not intentionally kill dogs •Decrease birth rate •Surgical sterilization (permanent) •Chemical sterilization (temporary)

FAO Bangladesh Effective vaccination

1. Efficacious vaccine

2. Long-lasting immunity

4. Access to target population

FAO Bangladesh Which dogs are the most important to vaccinate in order to have the greatest impact on R0?

Dogs with the highest likelihood of encountering the rabies virus.

FAO Bangladesh Which dogs have the highest likelihood of encountering the rabies virus?

Dogs that are not kept in enclosed areas. •Roaming owned dogs •Stray dogs

FAO Bangladesh FAO Bangladesh What’s the best way to vaccinate these outside dogs?

1. Vaccinate them when they’re still puppies! 2. Use collars

FAO Bangladesh FAO Bangladesh FAO Bangladesh What’s the best way to vaccinate these dogs?

1. Vaccinate them when they’re still puppies! 2. Use collars 3. Use nets 4. Work hard and work together!

FAO Bangladesh The power of teamwork

AnjingDogs vaccinateddi vaksinasi

350 300 250 200 DayHari 1 150 100 50 0 Jayo Satri Elang Singa Lapar Gudig Gebar Agam Kincing Garuda Kuning Harimau Nyo-dog Lancang Mabuhai OK Team Klampitan

Day 1: 50 dogs per team

FAO Bangladesh The power of teamwork

AnjingDogs vaccinateddi vaksinasi

350 300 250 200 DayHari 1 150 DayHari 2 100 50 0 Satri Jayo Elang Singa Lapar Gudig Gebar Agam Kincing Garuda Kuning Nyo-dog Harimau Lancang Mabuhai OK Team OK Klampitan

Day 1: 50 dogs per team

FAO Bangladesh The power of teamwork

AnjingDogs vaccinateddi vaksinasi

350 300 250 Hari 1 200 Day 1 DayHari 2 150 DayHari 3 100 50 0 Satri Jayo Elang Singa Lapar Gudig Gebar Agam Kincing Garuda Kuning Nyo-dog Harimau Lancang Mabuhai OK Team OK Klampitan

Day 1: 50 dogs per team Last day: 210 dogs per team

FAO Bangladesh Effective vaccination

1. Efficacious vaccine

2. Long-lasting immunity

3. Herd immunity • = vaccination threshold • Sufficient immune animals within the target population to protect even those individuals that are not immune (e.g. maintain R0 < 1) • Percentage of immunity required to achieve herd immunity is based on the R0 • Reduce population turnover via sterilization and no dog culling to maintain herd immunity as long as possible.

4. Access to target population • Roaming and stray dogs are most important population to target • Dog catching with nets • Permanent collars for vaccinated dogs • Puppy vaccination • Teamwork!

FAO Bangladesh Principles and Practices for Rapid Rabies Control

FAO Bangladesh Impact indicator

Human cases on Bali, 2008-2013

90 80 70 60 50 40 30 20 Human rabies cases rabies Human 10 0 2008 2009 2010 2011 2012 2013 Year

Human cases in 2013 decreased by 98% compared to 2010.

FAO Bangladesh Dog vaccination and human cases

Dogs Vaccinated and Human Rabies Cases

140000 10 120000 100000 8 80000 6 60000 4 40000

number of dogs number of 2 20000 cases number of 0 0 Jul-10 Jul-11 Jul-12 Jul-13 Oct-10 Oct-11 Oct-12 Jan-10 Jan-11 Jan-12 Jan-13 Feb-10 Apr-10 Jun-10 Nov-10 Dec-10 Feb-11 Apr-11 Jun-11 Nov-11 Dec-11 Feb-12 Apr-12 Jun-12 Nov-12 Dec-12 Feb-13 Apr-13 Jun-13 Mar-10 Sep-10 Mar-11 Sep-11 Mar-12 Sep-12 Mar-13 May-10 Aug-10 May-11 Aug-11 May-12 Aug-12 May-13

Total Dog Vax Human Cases

FAO Bangladesh FAO Bangladesh Impact of systematic mass dog vaccination

MexicoMexico

Mexico cases 30 years g Number of do Number of Number of dog cases dog Number of Number of human caseshuman cases Number of Number of

Human and Animal Rabies Cases, Bali

1122 80

7700 1100 Bali 60 8 50 6 3 years! - 4400 30 4 2200

numbernumber of of human human cases cases 2 numbernumber of of animal animal cases cases 1100

0 0 1 1 1 1 3 1 3 1 1 3 3 1 1 3 1 1 3 1 3 -10 -1 -12 -10 -1 -12 -1 -10 -1 -12 r-10 r-1 r-12 r-1 y y y y g g g p p p ar-10 ar-1 ar-12 ar-1 p ec-10 p ec-1 p ec-12 p a a a a Jul-13 Jul-12 Jul-11 Jul-10 Jul-10 Jul-1 Jul-12 Jul-1 Oct-12 Oct-11 Oct-10 Oct-10 Oct-1 Oct-12 Jan-13 Jan-12 Jan-11 Jan-10Jan-10 Jan-1 Jan-12 Jan-1 Feb-10 A Jun-10 Nov-10 D Feb-1 A Jun-1 Nov-1 D Feb-12 A Jun-12 Nov-12 D Feb-1 A Jun-1 Apr-13 Jun-13 Feb-13 Nov-12 Dec-12 Apr-12 Jun-12 Feb-12 Nov-11 Dec-11 Apr-11 Jun-11 Feb-11 Nov-10 Dec-10 Apr-10 Jun-10 Feb-10 M Se M Se M Se M Mar-13 Sep-12 Mar-12 Sep-11 Mar-11 Sep-10 Mar-10 M Au M Au M Au M Aug-12 Aug-11 Aug-10 May-13 May-12 May-11 May-10 The “bitter pill” of One Health

Animal health Human health services services

Projected cost to $3,139,221 0 eliminate rabies from Bali

Projected 5-year $-2,899,785 / $11,180,796 - savings as a result of successful elimination

• Internal rate of return = 98%

FAO Bangladesh And what do we do globally?

Of the US$ 583.5 million spent annually: •83% is spent on post-exposure treatment •10% is spent on dog vaccination

Source: Knobel et al. 2005 FAO Bangladesh The persistence of rabies is not due to our neglect. It’s due to our collective ignorance, an ignorance now entrenched within our separated health systems.