1. Effective Surveillance Strategies
for Human and Canine Rabies
Elimination Programs
Mary Elizabeth Miranda
Field Epidemiology Training Program Foundation
and Research Institute for Tropical Medicine
Philippines

2. Endemicity of canine rabies in Asia
• Canine RABV - zoonotic
infection that invariably spill
over into non-reservoir hosts
(humans, cats , bovines etc)
• Onward transmission within
these dead-end hosts is not
sustained
• estimated 96% of documented
human cases are from an
infected dog bite

3. Table 1. Regional human and animal rabies occurrence and status of certain animal disease control
measures, 2011 (Data sources: Ministries of Health, WHO SEARO, OIE WAHID)
Country
Reported
Number of
Human Cases
Rate Per
Million
Population
Per Year
Presence
of Dog
Rabies
Rabies Notifiable to the OIE
General
Surveillance
and Monitoring
Dog
Vaccination
Programme
Dog Cat Wildlife
Brunei 0 0 No Yes Yes Yes Yes No
Cambodia 800* 56 Yes No No No No No
Indonesia 116 0.48 Yes Yes No Yes Yes Yes
Lao PDR 1 0.16 Yes Yes Yes No Yes Yes
Malaysia 0 0 No Yes Yes Yes Yes Yes
Myanmar 1000* 21 Yes Yes Yes No Yes Yes
The Philippines 208 2 Yes No No No Yes Yes
Singapore 0 0 No Yes Yes Yes Yes ** Yes
Thailand 8 0.12 Yes Yes Yes Yes Yes Yes
Vietnam 89 1 Yes Yes No No Yes Yes
*estimate only
**targeted surveillance only
Burden on human and animal health

4. Molecular epidemiology
Analysis of phylogeographic structure of canid RABV revealed
only limited viral movement among geographical localities
- Philippine samples are distinct and divergent from other Southeast Asian
countries (export cases could be readily identified from the Philippines)
- Laos - three viral lineages are currently circulating in the country; related to
those of neighboring countries, indicating shared ancestry but no recent
viral invasion
- China being a big country, some samples cluster with those from the
Mekong River Subregion (Malaysia, Laos, Vietnam and Thailand)
- Indian isolates – dog rabies variants major circulating viruses and are
related geographically
- Korean isolates form a monophyletic group closely related to the Arctic
strains but distant from other Asian strains
Most Asian strains are within genotype 1 therefore
current vaccine works for strains circulating in the region

5. Spread across mainland Asia
- widespread RABV infection in
dog populations
- movement of animals across
borders thru formal and
informal entry points
- role of illegal dog trade
- Illegal dog trade for food
sensitive issue although no
one can deny that it exists

6. Spread among island countries
Indonesia and Philippines
- archipelagos with islands
endemic and sporadic
cases
- numerous islands rabies-
free
- Incursion of cases in
rabies-free areas

7. Spread to rabies-free areas
• Only Malaysia, Singapore and Brunei free
• Constant risk of reintroduction or re-
emergence of animal rabies cases
• Incursions of dog rabies cases in some
Indonesian territories historically disease free
– Bali, Nias, Flores, Maluku

8. Rabies incidence and spread in Bali prior to
island-wide mass vaccination.
Townsend SE, Sumantra IP, Pudjiatmoko, Bagus GN, Brum E, et al. (2013) Designing Programs for Eliminating Canine Rabies from Islands: Bali,
Indonesia as a Case Study. PLoS Negl Trop Dis 7(8): e2372. doi:10.1371/journal.pntd.0002372
http://127.0.0.1:8081/plosntds/article?id=info:doi/10.1371/journal.pntd.0002372
Incursion in mid- 2008
Rapid spread across the island
>150 human rabies deaths
$ 2M / yr postexposure
vaccinations
Example of Bali

9. Disease Surveillance
• critical component of disease control and elimination
programmes but is often poorly resourced, particularly in
developing countries lacking good infrastructure
• especially for zoonoses which require combined
veterinary and medical capacity and collaboration
• allows early detection and reporting of cases, initiating
timely responses and enabling informed decisions about
when and where to intensify control efforts
• once interventions implemented – also essential to
generate data on the progress and cost-effectiveness of
such sustainable implementation of programmes

10. As human or animal health professionals –
an improved understanding of the history,
techniques and contemporary tools of disease
surveillance important to surveillance efforts in
your own country and community, leading to
improved prevention, control
and eventual elimination of rabies

11. Traditional disease surveillance
• The purpose is to understand the ongoing patterns of
disease in a population so that control and prevention
measures can be applied efficiently and effectively.
• accomplished through the systematic collection,
evaluation and analysis of health information
• Traditional sources
Official Ministry reports
Hospital records
Veterinary surveillance records
Laboratory results – public & private

12. Can be passive or routine surveillance
• Key sources of data in passive surveillance are
monthly/annual disease surveillance reports
• Primary healthcare facilities and laboratories
required to notify health authorities about any
patient presenting with a notifiable disease
• Veterinary services, facilities and laboratories
required to submit reports to national authorities
Traditional disease surveillance

13. Zoonotic Disease Dynamics
To effectively put zoonoses surveillance data
into action for disease control, need
information on:
• Context (environment)
– available prevention and treatment resources;
urban, rural and remote areas affected; general
perceptions of people around this disease
• Dynamics of disease transmission
(including host, agent and vectors)
– infectious period; clinical signs and symptoms;
antimicrobial resistance patterns; disease
vector like an animal or insect; role of wildlife

14. Surveillance in Animal Populations:
The One Health Concept
• The one health concept recognizes
the important links between human,
animal and environmental health
• It is estimated that 75 percent of
emerging infectious diseases in
humans are zoonoses, and that more
than 70 percent of these zoonoses
come from wildlife. Surveillance of
diseases in domestic animals and
wildlife is vital.
Image Source: Thompson, A. R. C. (2013) Parasite zoonoses and
wildlife: One health, spillover and human activity. International
Journal for Parasitology, 43:1079-1088.

15. Pros and Cons of Traditional Surveillance
PROS CONS
Accurate information from
credible sources
Slow detection
Opportunity to provide
incentives to overcome non-
reporting
May miss novel diseases or
those with vague case
definitions
Able to access detailed,
protected information from
government and healthcare
facilities
Uses only confirmed
information, from a limited
number of sources
Source: Tephinet Epicore lecture

16. Improving Disease Surveillance
Gaps that need to be addressed:
– Delays in official reporting
– Capturing unusual disease events
– Limited reach of traditional systems
Innovative surveillance efforts that leverage non-traditional
information sources can help address some of these gaps in
order to find outbreaks faster

17. Innovative surveillance platforms
• Despite these challenges, innovative surveillance
approaches continue to demonstrate an ever-
increasing potential to help us detect outbreaks
faster and with greater sensitivity.
• Innovative platforms need the participation of
human and animal health professionals on the
ground to validate informal surveillance data and
to harness the full potential of innovative
surveillance systems

18. Pros and Cons of Innovative Surveillance
PROS CONS
Fast detection and reporting Information captured might not
be accurate or significant*
Not constrained to certain
events
Sources may present biased
information
Multiple sources of information
(e.g., clinicians, labs, media
reports, internet blogs)
Uses broad case definitions
Leverages publicly available
information, increasing
transparency
No standard data format, takes
additional time to synthesize
Source: Tephinet Epicore lecture

19. Challenges in Using Non-Traditional Sources
of Disease Information
Innovative surveillance and the use of non-traditional
sources can provide additional disease surveillance
information. However this requires
– Basic IT skills and Internet access
– Data management skills
– Planning of human resources
– Adequate knowledge of source and its quality
– Transdiscplinary expertise

20. Relevant applications for rabies
• One Health approach among surveillance professionals
sharing disease data from public health and veterinary
services at sub-national, national & regional level
• Improving laboratory-based surveillance by increasing
diagnostics with support of OIE and WHO reference labs
• Community-led reporting / participatory surveillance
– Examples of mobile phone-based reporting that support rabies
control programs
• Joint investigations of unusual occurrence of animal
cases or any report of suspect human case

21. Fig. 2 Simulation scenario indicating the critical time points from an incursion to the declaration of freedom from rabies. An example
simulation illustrated as a time series and as the spatial occurrence of cases on an island grid (circular, 500 km loc="p...
Sunny E. Townsend , Tiziana Lembo , Sarah Cleaveland , François X. Meslin , Mary Elizabeth Miranda , Anak Agung Gde...
Surveillance guidelines for disease elimination: A case study of canine rabies
Comparative Immunology, Microbiology and Infectious Diseases, Volume 36, Issue 3, 2013, 249 - 261
http://dx.doi.org/10.1016/j.cimid.2012.10.008
Surveillance guidelines for disease elimination – case study for rabies

23. Regional Rabies Elimination
Crossborder Strategies
• challenge of implementing dog rabies elimination
program in contiguous and cross border areas -
constant risk of re-introduction of cases from
neighboring endemic areas
• mutually agreed strategies must be in place to have a
harmonized institutional operational framework
• cross border rabies control once successful will
geographically expand rabies-free areas

24. Regional Rabies Elimination
• Obvious benefits of regional efforts
– reduce cross border transmission
– control canine rabies introduction to rabies-free areas
– prevent further exporting human cases
• Regional responsibilities to be shared to achieve the
common goals of rabies freedom across Asia
• Each country expected to systematically implement
rabies control and elimination programme in
accordance with set international standards

25. “Unless an effective reporting and
surveillance programme is
developed, there is no prospect
whatsoever for a successful
eradication programme”
D.A. Henderson
Epidemiologist who led the international effort during the
1960s to eradicate smallpox