Improving Rabies Detection and Control in Latin America and the Caribbean through Enhanced FETP Training in New Technologies

Rabies is vaccine-preventable yet kills nearly 59,000 people annually, with 99 percent of human deaths caused by bites or exposure to saliva from infected dogs. In Latin America and the Caribbean, the areas at highest risk of human rabies transmitted by dogs include the Dominican Republic, Haiti, Bolivia, Guatemala, and parts of Brazil and Peru.

TEPHINET consultant Dr. David Moran has been leading efforts to strengthen rabies detection and control in the Dominican Republic and Guatemala by training local field epidemiology training program (FETP) fellows and Ministry of Health staff in techniques and tools to improve understanding of rabies vaccine coverage, rabies surveillance system evaluation, and response to rabid dogs.

According to Moran, the most cost-effective strategy to control and eradicate human rabies transmitted by dogs is immunization of the susceptible canine population to achieve herd immunity, requiring at least 70 percent of dogs to be vaccinated. In countries where rabies still remains a problem, evaluation of vaccination coverage, dog bite investigations, surveillance of rabid suspected animals, and surveys of rabies awareness and medical-seeking behavior amongst the population are needed to improve rabies elimination efforts.

“The best way to implement these strategies is through the use of modern technological tools,” says Moran. “FETP students are the best stakeholders to apply these tools in their countries to obtain science-based data to improve mass vaccination campaigns and rabies surveillance.”

Since July 2018, three cases of human rabies have been reported and confirmed in the town of Pedernales, Dominican Republic, which sits across the border from Anse-a-Pitre, Haiti. An investigation by the CDC found that the rabies virus in these three patients was the same virus circulating in dogs roaming across eastern and southern Haiti.

In response, Pedernales held a massive dog vaccination campaign in August 2018. The Ministry of Health of the Dominican Republic and the Ministry of Agriculture of Haiti (the entity responsible for canine rabies control activities in Haiti) requested assistance in controlling the outbreak. This bi-national request included assistance in improving rabies surveillance systems, evaluating dog vaccination practices, and enhancing post-exposure rabies treatment practices.

Together with his CDC collaborators, Moran traveled to the Dominican Republic to respond to this request. Moran, who is a veterinarian and researcher with the arbovirus and zoonosis program at the Center for Health Studies at the Universidad del Valle de Guatemala, has been highly involved in collaborative research projects regarding zoonotic pathogens in Guatemala. His team’s objectives in responding to the request from the Dominican Republic and Haiti included holding coordination meetings with health authorities, improving local understanding of rabies vaccination coverage and barriers to increasing coverage, and conducting training to build local capacity to manage and respond to dog bites and suspected rabid dogs.

In February 2019, they conducted a training for Dominican Republic FETP fellows on techniques to conduct rabies field investigations using a custom-built Android and iOS app (WVS Data Collection developed by Mission Rabies) to record, report and schedule activities related to Integrated Bite Case Management (IBCM), a system developed to improve treatment for bite victims. The fellows conducted surveys to determine the need for post-exposure prophylaxis (PEP) among people exposed to dog bites, surveying 180 households and interviewing community leaders to identify historic rabies cases. As a result, five dog bite victims were identified and referred for PEP.

“We trained the Dominican Republic FETP students and Ministry of Health staff with a hands-on strategy, collecting and analyzing data in real time using the WVS app,” says Moran. “This makes them feel confident about the results and the use of these results for planning interventions in the area.”

Preliminary results from the surveys showed that 35-40 percent of the dogs in Pedernales are free-roaming and have been observed crossing the border with Haiti. This movement of free-roaming dogs creates a high risk of rabies virus transmission between the two countries.

Moran and his collaborators held a similar workshop for Ministry of Health staff in Guatemala in March 2019 with support from the local Pan-American Health Organization (PAHO) office. In this workshop, 29 epidemiologists, including one FETP graduate, and 29 environmental health officers were trained in the use of sampling methods and the design of surveys to be conducted amongst selected households in different communities in their area to estimate the canine population in their health districts.

The training included exercises in calculating sample size of households in areas where the surveys will be conducted. Trainees will coordinate the surveys used to estimate the canine population nationwide over the next four months.

“This estimation will be used for the planning and evaluation of the next mass vaccination campaign,” says Moran. “This is one strong step toward the elimination of human rabies transmitted by dogs in Guatemala.”