Social and Economic Factors of Rabies

Rabies is a viral, neurotropic disease that, upon the development of symptoms, has a 100% fatality rate.  This neglected tropical disease (NTD) is transmitted by human exposure to unvaccinated dogs and is responsible for approximately 59,000 deaths worldwide (Hampson et al., 2015).  Rabies cases are endemic in poor, rural communities of underdeveloped countries, primarily Asia and Africa (Taylor & Nel, 2015).  Although rabies is 100% preventable, it is a disease that is still rampant in Cambodia.  The purpose of this discussion is to examine the social and economic factors surrounding rabies in Cambodia and global resources allocated to aid in the management of rabies.

Social Factors

Cambodia has a population of 500,000 dogs, the majority of which are domesticated.  It is estimated that each year 600,000 Cambodians suffer from a severe dog bite each year, with 800 resulting in death (Fontenille, 2017).  Of the countries endemic to rabies, Cambodia accounts for 1.3% of global deaths (Fontenille, 2017).  With the population estimated to be about 14 million, that translates to a yearly incidence of six deaths per 100,000 people (Tarantola et al., 2015). Children under 17 account for sixty percent of those bites.  Of those 600,000 people, less than 5% of them receive post-exposure prophylaxis (PEP) due to the inability to access treatment (Fontenille, 2017). 

Economic Factors

The economic burden of rabies encompasses direct and indirect costs.  It has been calculated that the global cost of rabies cases is $8.6 billion per year.  The cost components include premature death (55%), canine vaccination (1.5%), PEP cost (20%), lost income during PEP therapy (15.5%), and livestock losses (6%).  The annual cost of the canine vaccination, which represents 1.5% of the global cost, is estimated to be $130 million (Lavan, King, Sutton, & Tunceli, 2017).  The Institute Pasteur in Cambodia, a research and public utility that is partnered with the Cambodian Ministry of Health, provides rabies vaccination to approximately 21,000 people per year, which consists of four separate intradermal injections over the span of 21 days (Fontenille, Didier, 2017).  The average cost of rabies PEP is $49, which can provide a significant financial burden on families whose daily income ranges from one to two dollars per person (WHO, 2018). 

U.S. Global Health Policies and Initiatives

The “One Health” approach was developed by the World Health Organization (WHO), the World Organization for Animal Health (OIE), and the Food and Agriculture Organization (FAO) of the United Nations which advocates for mass canine rabies vaccination programs in endemic areas.  The general consensus is that mass vaccination is not only is more cost-effective than PEP, it eliminates the canine reservoir which is the primary source of transmission.  Statistical studies show that vaccinating 70% of the canine population with be sufficient enough to induce herd immunity, which will reduce canine rabies, thereby, reducing human exposure (Lavan, King, Sutton, & Tunceli, 2017).  The OIE developed a Regional Vaccine Bank in 2012 which has enabled them to donate 50,000 rabies vaccines to Asia (OIE, 2012).  This milestone was the first attempt to help combat rabies at the source.  Since then, they have donated 15.9 million rabies vaccines to over 26 high-risk countries (OIE, 2012).   

The World Health Organization, with the help of it partners, are currently working to develop a global projection of the need of human and canine vaccines as well as rabies immunoglobulin (RIG).  In addition, they are working on understanding global manufacturing capacity and looking into the bulk purchasing of vaccines and RIG for high risk countries

Resource Allocation

The Association of Southeast Asia Nations (ASEAN) is a group of ten countries that have collaborated to develop a framework to reduce and eliminate rabies (Global Alliance for Rabies Control, 2015).  The strategy builds on the “One Health” approach of STOP pillars which focuses on the sociocultural, technical, organizational, policy, and legislative aspects of rabies control.  It highlights the importance of stakeholders, legislation, and public health interventions as well as disseminates information to increase education and community engagement.

Progress

 In December 2015, The World Health Organization, the World Organization for Animal Health (OIE) formed a collaboration with the Global Alliance for Rabies Control and the Food and Agriculture Organization of the United Nations (FAO) to launch a global initiative of zero human rabies deaths by 2030 (WHO, 2017).  This initiative celebrates September 28 as World Rabies Day and helps to raise awareness about rabies and prevention methods.  It also provides updates on current progress being made to defeat rabies as well as future initiatives.

 In 2016, the WHO Strategic Advisory Group of Experts on Immunization (SAGE) created a group to work on rabies vaccines and immunoglobins.  Currently, this group is reviewing and analyzing scientific evidence and relevant considerations to determine the most efficient vaccine regimens as well as any potential new biologicals (WHO, 2017).  This will help with the development and implementation of the most effective policies, procedures, and programs to aid in rabies elimination.

Additional Resources Needed

 A study by Hampson et al. (2015) showed that dog vaccination is the single, most cost-effective way to reduce the burden of rabies.  Therefore, a collaborative investment between veterinary and medical sectors could help reduce rabies through mass dog vaccination, which would ultimately reduce the need and cost for PEP.  In addition, if PEP is needed, developing a research team to find a way to change the administration route and decreasing the number of doses will help increase compliance to the treatment regimen, thereby, reducing the number of rabies-related deaths.

 One issue experienced in Cambodia and other tropical regions is vaccine thermostability. If not stored at 2-7 ⁰C (35-45 ⁰F), the potency of the vaccine is lost, leading to loss of efficacy, wasted funding, and additional costs to replace the supply (Lavan, King, Sutton, & Tunceli, 2017).  Therefore, having a team of individuals that are dedicated to developing a vaccine that is stable at ambient temp, even for just a small period of time, would be advantageous.  It would lead to decreased costs, avoidance of loss of potency, and decrease dependence on cold-chain storage.  

Conclusion

Rabies is a disease viral disease that is vaccine-preventable but still devastates the Cambodian population.  Mass canine vaccination is a prevention method that attempts to decrease rabies transmission at the source.  United States agencies have formed domestic and global partnerships to find ways to eliminate rabies through education dissemination and community outreach, vaccine donations, developing ways increase vaccine availability, and improving access to PEP.  Further research is needed find additional cost-effective measures to eliminate the economic burden of rabies.

References

• Fontenille, Didier, 2017.  Rabies in Cambodia.  Retrieved from: https://www.pasteur.fr/en/research-journal/news/rabies-cambodia
• Global Alliance for Rabies Control.  (2015).  ASEAN rabies elimination strategy: Ending rabies together by 2020.  Retrieved from: https://rabiesalliance.org/resource/asean-rabies-elimination-strategy-ending-rabies-together-2020
• Hampson, K., Coudeville, L., Lembo, T., Sambo, M., Kieffer, A.,  Attlan, M., . . .  Dushoff, J.  (2015).  Estimating the global burden of endemic canine rabies.  PLOS Neglected Topical Diseases, 9(5), 1-20.  doi:10.1371/journal.pntd.0003709
• Lavan, R. P., King, A. I. M., Sutton, D. J., & Tunceli.  (2017).  Rationale and support for a one health program for canine vaccination as the most cost-effective means of controlling zoonotic rabies in endemic settings.  Vaccine, 35(13), 1668-1674
• Tarantola, A., Ly, S., In, S., Ong, S., Peng, Y., Heng, N., & Buchy, P.  (2015).  Rabies vaccine and rabies immunoglobin in cambodia: Use and obstacles to use.  Journal of travel Medicine, 22(5), 348-352.  doi: 10.1111/jtm.12228
• Taylor, L. H., & Nel, L. H.  (2015).  Global epidemiology of canine rabies: Past, present, and future prospects.  Veterinary Medicine 6, 361-371.  doi: 10.2147/VMRR.S51147
• World Health Organization.  (2017).  Rabies.  Retrieved from:  http://afro.who.int/health-topics/rabies
• World Health Organization.  (2018).  Rabies.  Retrieved from: http://www.who.int/en/news-room/fact-sheets/detail/rabies

• World Organization for Animal Health.  (2012).  OIE regional vaccine bank for asia provides 50,000 rabies vacines to lao pdr.  Retrieved from: http://www.oie.int/en/for-the-media/press-releases/detail/article/oie-regional-vaccine-bank-for-asia-provides-50000-rabies-vaccines-to-lao-pdr/