Zero by 30: the global strategic plan to end human deaths from dog

ZERO BY 30

THE GLOBAL

STRATEGIC PLAN

HUMAN DEATHS

FROM DOG-MEDIATED

RABIES BY 2030

TO END

ISBN 978-92-4-151383-8

I8956EN/1/03.18

ISBN 978-92-5-130461-7

9 789251 304617

Cover_20180530.indd 1 01.06.18 20:00

ZERO BY 30

The Global Strategic Plan

to end human deaths from

dog-mediated rabies by 2030

World Health Organization

Food and Agriculture Organization of the United Nations

World Organisation for Animal Health

Global Alliance for Rabies Control

Geneva, 2018

Zero by 30: the global strategic plan to end human deaths from dog-mediated rabies by 2030

ISBN 978-92-4-151383-8 (WHO)

ISBN 978-92-5-130461-7 (FAO)

ISBN 978-92-95108-76-9 (OIE)

for Animal Health (OIE), 2018

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Acknowledgements .................................................................................................................................................... iv

Abbreviations ............................................................................................................................................................... v

Executive summary .................................................................................................................................................... vi

Rationale .....................................................................................................................................................................1

Why eliminate rabies? ............................................................................................................................................ 1

Why eliminate rabies now? .................................................................................................................................... 4

The United Against Rabies collaboration ..................................................................................................................7

United to end the neglect ....................................................................................................................................... 7

Vision to reach Zero by 30...................................................................................................................................... 8

The value proposition ......................................................................................................................................8

The theory of change ..................................................................................................................................... 10

Objective 1: to effectively use vaccines, medicines, tools and technologies .......................................................13

Outcome 1.1: rabies is prevented through increased awareness and improved education ................................ 13

Outcome 1.2: rabies is prevented through increased and effective dog vaccination .......................................... 14

Outcome 1.3: human deaths from rabies exposures are prevented by ensuring equitable, affordable and

timely access to health care, medicines and vaccines ........................................................................................15

Objective 2: to generate, innovate and measure impact ........................................................................................17

Objective 2.1: to provide effective policies, guidance and governance ............................................................... 17

Outcome 2.1: policies, guidelines, and governance to prevent human rabies deaths are created and

adopted at regional and national levels ...............................................................................................................17

Objective 2.2: to ensure reliable data to enable effective decision-making .........................................................19

Outcome 2.2: appropriate technology and information are made available ........................................................ 19

Outcome 2.3: progress towards the goal is constantly and consistently monitored and reported ..................... 20

Objective 3: to sustain commitment and resources ...............................................................................................21

Outcome 3.1: key stakeholders are consistently and comprehensively engaged ...............................................21

Outcome 3.2: nances and other resources are effectively and efciently used ................................................ 22

Outcome 3.3: results and impact of the United Against Rabies collaboration are regularly monitored

and reported ........................................................................................................................................................23

Budget and governance ........................................................................................................................................... 25

A phased approach to funding Zero by 30 ..........................................................................................................25

Budget requirements: phase 1 ............................................................................................................................. 26

Budget requirements: beyond 2020 .....................................................................................................................26

Governance .......................................................................................................................................................... 28

Monitoring our progress and managing risks .........................................................................................................29

Workplan delivery monitoring and evaluation ...................................................................................................... 29

Risk mitigation ..................................................................................................................................................... 29

Conclusion ................................................................................................................................................................31

References ................................................................................................................................................................33

Annex 1. What is rabies? ........................................................................................................................................... 34

Annex 2. Successful regional elimination in Latin America and the Caribbean, and proof-of-concept

programmes in Africa and Asia ..................................................................................................................36

Annex 3. The theory of change ................................................................................................................................. 39

Annex 4. The logic framework for the United Against Rabies collaboration .............................................................40

Annex 5. Human and animal rabies biological banks ............................................................................................... 43

Annex 6. Integrated bite case management ............................................................................................................. 46

Annex 7. The stepwise approach towards rabies elimination ...................................................................................47

CONTENTS

ACKNOWLEDGEMENTS

The four partners (FAO, WHO, OIE and GARC) of the United Against Rabies collaboration gratefully acknowledge the

contributions to developing this business plan of the following individuals and organizations, specically:

Steering Committee Members: Bernadette Abela-Ridder, Katinka de Balogh, Kim Doyle, April Johnson, Isabelle

Dieuzy-Labaye, Louis Nel, Henk Jan Ormel, Sean Shadomy, Matthew Stone, Gregorio Torres

Writing team: Annette Ives, Jocelyn Kessels, Anne-Marie Labouche, Jennifer Macleod, Louise Taylor

Consultants: PwC: Gill Sivyer, Saleh Khan, Gerard Coenen, Sakshi Uberoi, Krupa Varghese, WHO: Lea Knopf

Modelling work: Jesse Blanton, Katie Hampson, Caroline Trotter, Ryan Wallace

WHO interns: Mercedes Carballo, Dayna Schultz, Victoria Suslovitch

Monique Eloit (OIE), Dirk Engels (WHO), Ren Minghui (WHO), Ren Wang (FAO), Lord Alexander Trees (House of Lords

and University of Liverpool) and Joris Vandeputte (International Alliance for Biological Standardization) provided

valuable insights that helped to focus the business plan.

We thank the WHO staff Rabindra Abeyasinghe, Lamine Diawara, Elkhan Gasimov, Gyenendra Gongal, Aya Yajima

and Marco Vigilato, Stephen Martin, Martin Friede, Erin Sparrow, Naoko Obara, Tejinder Chowdhary, Alejandro

Javier Costa and WHO collaborating centres on rabies.

From FAO, we thank Angélique Angot, Juan Lubroth, Mia Rowan and Berhe G. Tekola. From OIE, we thank Catherine

Bertrand-Ferrandis, Yael Farhi and Stéphane Renaudin. From GARC, we thank Deepashree Balaram.

We acknowledge also the contributions of our in-country stakeholders; the Gavi learning agenda; the Partners for

Rabies Prevention; the Bill & Melinda Gates Foundation for studies that provided data; UBS Optimus Foundation;

and the assistance of Rabies Unit and the Global Immunization Division of the United States Centers for Disease

Control and Prevention.

FAO Food and Agriculture Organization of the United Nations

GARC Global Alliance for Rabies Control

GSG Global Steering Group

IBCM integrated bite case management

OCV oral cholera vaccine

OHZDP One Health Zoonotic Disease Prioritization

OIE World Organisation for Animal Health

PAHO Pan American Health Organization

PEP post-exposure prophylaxis

PrEP pre-exposure prophylaxis

REDIPRA Regional Meeting of Rabies Program Directors

RIG rabies immunoglobulin

SARE Stepwise Approach towards Rabies Elimination

SIRVERA Regional Information System for Epidemiological Surveillance of Rabies

WAHIS World Animal Health Information System

WHO World Health Organization

ABBREVIATIONS

WHY ELIMINATE RABIES?

An estimated 59 000 people die from rabies each year.

That’s one person every nine minutes of every day, 40%

of whom are children living in Asia and Africa. As dog

bites cause almost all human cases, we can prevent

rabies deaths by increasing awareness, vaccinating

dogs to prevent the disease at its source and admin-

istering life-saving treatment after people have been

bitten. We have the vaccines, medicines, tools and tech-

nologies to prevent people from dying from dog-medi-

ated rabies. For a relatively low cost it is possible to

break the disease cycle and save lives.

A country’s health system benets from the capac-

ity-building required for rabies surveillance. This core

activity strengthens the health system by improving

the mechanisms for surveillance of other disease and

expanding access to health care. Minimizing duplica-

tion and improving efciencies by pooling resources

and developing strong health service networks saves

money and makes the most of resources. Countries can

maximize the impact of each dollar invested.

Investing in rabies elimination saves lives and

strengthens both human and veterinary health systems.

A collaborative response, through rabies programmes,

contributes to disease prevention and preparedness.

This means integrated rabies elimination is a model for

One Health collaboration.

In the past, the global response has been fragmented

and uncoordinated. We need to break the status quo

and come together with a combined will, an achiev-

able goal and a common plan. That combined will was

evident in 2015, and the resulting global call to action

made it clear that now is the time to act.

A CALL FOR ACTION

In 2015, the world called for action by setting a goal

of zero human dog-mediated rabies deaths by 2030,

worldwide. Now, for the rst time, four organizations –

the World Health Organizaton (WHO), the World Organ-

isation for Animal Health (OIE), the Food and Agricul-

ture Organization of the United Nations (FAO) and the

Global Alliance for Rabies Control (GARC) – have joined

forces, as the United Against Rabies collaboration, and

are determined to reach this goal.

The United Against Rabies collaboration leverages

existing tools and expertise in a coordinated way to

empower, engage and enable countries to save human

lives from this preventable disease. The global strategic

plan puts countries at the centre with renewed interna-

tional support to act.

This country-centric engagement will be exible and

consider different contexts and capacities. Countries

will lead efforts, driving the changes needed to reach

Zero by 30, empowered by the United Against Rabies

collaboration, as they build sustainable institutional

capacity and end human deaths from dog-mediated

rabies.

EXECUTIVE SUMMARY

A PHASED APPROACH TO ELIMINATION

We propose a pragmatic, three-phase approach to achieve the shared goal of Zero by 30:

Phase 1: START UP

2018-2020

29 countries

Phase 2: SCALE UP

2021-2025

+52 countries

Phase 3: MOP UP

2026-2030

+19 countries

OBJECTIVE 1

to effectively use

vaccines, medicines,

tools and

technologies

Reduce human rabies risk

- improved awareness and

education

- increased access to healthcare,

medicines and vaccines

- dog vaccinations

OBJECTIVE 2

to generate,

innovate and

measure impact

Provide guidance and data

- effective policies, guidance

and governance

- ensuring reliable data to enable

effective decision-making

OBJECTIVE 3

to sustain

commitment

and resources

Harness multi-stakeholder

engagement

demonstrate the impact of

activities completed under

the United Against Rabies

collaboration

HOW WE WILL REACH ZERO BY 30

Our global strategic plan prioritizes the societal changes needed to reach Zero by 30 into three objectives:

Phase 2: SCALE UP

We will engage with and involve 52 more countries

in rabies elimination, to give a total of 81 out of 100

endemic countries. Using the strong foundation estab-

lished in Phase 1, rened and improved with learning

and experience, we will expand our efforts and truly go

global.

Phase 3: MOP UP

We will engage the remaining endemic countries in

the ght to eliminate rabies, and continue to support

country efforts as communities, nations and regions

advance to reach Zero by 30. Phase 3 is the last mile.

Phase 1: START UP

We will build a strong foundation for rabies elimination by

preparing and improving normative tools and structures

to catalyse action. Core activities include supporting

countries to prepare robust, budgeted, effective and

sustainable national rabies elimination plans following a

One Health approach; and facilitating the coalescence

of these plans into a coordinated regional effort.

vii

viii

NEXT STEPS

Reaching Zero by 30 will save the lives of children and

the livelihoods of adults. It will keep families together.

Investing in rabies elimination strengthens health

systems, improves equity and access to care, and

contributes to sustainable development. For the rst

time in history, we are united to coordinate capaci-

ty-building and leverage existing knowledge, tools and

technology.

We will not stop there. We will pursue breaking trans-

mission in dogs, thereby maintaining freedom from

disease. The United Against Rabies collaboration

is already working with countries to coordinate and

catalyse global change. Investing in rabies will accel-

erate progress, as the world works to make elimination

a reality.

Our One Health collaboration engages experts and

stakeholders from the public and private sectors to play

an active role in empowering, supporting and engaging

countries to prevent rabies and make zero human

deaths from rabies by 2030 a reality.

BUDGET AND MONITORING

Our global strategic plan details the funding require-

ments for the core activities of Phase 1 only (START

UP: 2017–2020, estimated at US$ 16.5 million). This will

allow us to stay agile and to exibly adapt our strategy

to accommodate changing environments, lessons

learned along the way and new technologies.

Financing and implementing national rabies elimination

plans at the country level is not included in our budget.

Countries will need to mobilize domestic and interna-

tional resources to sustainably nance and implement

control activities.

We will develop a detailed workplan to guide implemen-

tation, including a monitoring framework with dened,

aligned milestones to measure progress. Each country

will lead the drive towards Zero by 30.

RATIONALE

3. Mass dog vaccination is a proven, cost–effec-

tive way to save human lives by stopping trans-

mission of rabies at its source. While a variety of

animal species can host rabies, dogs are respon-

sible for 99% of human cases (3). Disease models

and real-world experience show that sustained

vaccination coverage of 70% of dog populations

is sufcient to stop transmission of the disease

between dogs, and from dogs to humans (3, 6).

Eliminating rabies in dogs is therefore key to

sustainably preventing human disease.

Because rabies affects the world’s

most vulnerable populations

Rabies is a neglected tropical disease. Most rabies

cases occur in Africa and Asia.

Approximately 80% of human cases occur in rural areas,

and over 40% of rabies deaths occur in children aged

under 15 years (3, 7) (Figure 1). Globally, the economic

burden of rabies is estimated at US$ 8.6 billion per

annum (1) (Figure 2). This cost is disproportionately

borne by the world’s poorest and most disadvantaged

communities. People continue to die of rabies because

it is neglected, because their awareness of the disease

is limited, because the disease remains uncontrolled in

dogs, and because they lack access to basic medical

care, such as PEP, following an exposure.

Our global strategic plan prioritizes the societal

changes needed to reach Zero by 30 into three

Pre-exposure prophylaxis (PrEP) consists of a series of rabies

vaccines administered prior to a potential exposure, followed

by booster vaccinations in the case of a bite. PrEP is costly,

and only recommended for people at constant risk of rabies

exposure, such as veterinarians, and laboratory workers

handling live virus.

WHY ELIMINATE RABIES?

Because rabies kills

Every year, an estimated 59 000 people die of one of

the oldest and most terrifying diseases known to man:

rabies (1) (Annex 1). Rabies is caused by infection with a

lyssavirus. The disease is named after Lyssa, the Greek

spirit of madness, frenzy and rage, vividly evoking the

horror of a rabid death (2).

Rabies is spread via bites and scratches from infected

animals. Dogs are responsible for 99% of human

cases (3). Clinically, rabies is characterized by tful

consciousness, hyperactivity, hallucinations and hydro-

phobia (furious rabies), or paralysis and coma (para-

lytic rabies), progressing rapidly and inevitably towards

death (3).

Because rabies is preventable

Although fatal once clinical signs appear, rabies is

preventable through three proven, effective interven-

tions.

1. Awareness of rabies disease engages commu-

nities and empowers people to save themselves

by seeking the care they need (4). This includes an

understanding of how to prevent rabies in animals,

when to suspect rabies, and what to do in case of

a bite.

2. Post-exposure prophylaxis (PEP) consists of

a series of rabies vaccines and, in some cases,

rabies immunoglobulin (RIG), administered after a

suspected exposure to rabies. Appropriate wound

management and prompt access to quality-as-

sured PEP is almost 100% effective in preventing

human rabies deaths (5).

+ +

+ 0

+/- +/-

+/- 0

0 0

Rabies

Endemic dog and human rabies

No information

No dog rabies nor human rabies

Controlled dog rabies

Sporadic dog-transmitted rabies

Endemic dog rabies

Endemicity of dog and human rabies, 2016

Figure 1. Endemicity of dog and human rabies, 2016. Rabies affects poor and rural populations

Figure 2. Rabies imposes a heavy economic burden

54%

0.01%

15%

20%

2%Travel costs

Direct costs

Lost income

seeking treatment

Livestock

losses

Productivity losses due

to premature death

Rabies surveillance

(data)

Dog vaccination &

population control

Treatment

costs (37%)

US$ 8.6 billion

per year

Because eliminating rabies

strengthens health systems

Investing in rabies maximizes the impact of eachdollar.

Providing life-saving PEP to the people at highest risk

of rabies relies on health systems capable of reaching

the world’s most underserved populations (8). The same

basic infrastructure required to build rabies aware-

ness and improve access to PEP in communities is

required to provide essential medicines, vaccines and

health care; strengthening human and veterinary health

systems, improving health outcomes and maximizing

the impact of each invested dollar. That means that

every dollar invested in well integrated rabies elimina-

tion programmes not only quickly makes a signicant

impact on eradicating human rabies deaths but also

improves access to health care for the world’s most

vulnerable people (Figure 3).

Because eliminating rabies is a model

for One Health collaboration

Engaging communities to build awareness of rabies,

and vaccinate dogs to prevent human disease, requires

close One Health collaboration between, at a minimum,

the human and veterinary health sectors (9). The cooper-

ative mechanisms required to prevent rabies are a model

for One Health collaboration, and establish a basis for

response to other existing or emerging zoonoses that

may pose a pandemic threat. A One Health model is

within reach for even low- and middle-income coun-

tries, and rabies disproportionately affects the world’s

most vulnerable people. The economic burden resulting

from lost livestock and working animals directly affects

resource-poor communities. A coordinated response

between animal and human health systems not only

has a positive impact on the livelihood of communities

but also strengthens surveillance of rabies and other

diseases in the human health system.

Because the world wants to end

neglect and inequality

In February 2015, the World Health Organization (WHO),

the Food and Agriculture Organization of the United

Nations (FAO), the World Organisation for Animal Health

(OIE) and the Global Alliance for Rabies Control (GARC)

united to launch the End Rabies Now campaign, which

proposed a goal of zero human rabies deaths by 2030,

worldwide. In December 2015, a global conference of

international stakeholders endorsed the vision of zero

human rabies deaths by 2030, or Zero by 30 (10).

The goal is perfectly aligned with the United Nations

Sustainable Development Goal (SDG) 3 to “ensure

healthy lives and promote well-being for all at all ages”,

and specically targets 3.3, to “by 2030, end the

epidemics of … neglected tropical diseases”; and 3.8,

to “achieve universal health coverage … and access to

safe, effective, quality and affordable essential medi-

cines and vaccines for all” (11).

As rabies disproportionately affects poor and rural

communities, eliminating human deaths from rabies is

also consistent with SDG 1 to “end poverty in all its

forms” and the commitment of Member States to “leave

no one behind” (11). The conviction to eliminate rabies

is supported by WHO’s leadership priorities to increase

access to essential medicines and focus on universal

health coverage; the adoption in 2016 by the World

Assembly of Delegates of OIE Resolution No. 26 on

global elimination of dog-mediated rabies, mandating

Member countries to collaborate and endorse Zero

by 30 (12); and by FAO’s commitment to reduce rural

poverty (13).

Figure 3. Investment breaks the cycle of neglect

WHY ELIMINATE RABIES NOW?

Because we have come so far

For more than 4000 years, rabies has plagued human-

kind. For centuries, the disease has inspired remedies

dark and magical, from poultices made from the skulls

of hanged men, to branding with Saint Hubert’s Key (a

metal nail, cross or cone) and cutting the attachment of

the tongue, where the disease was thought to reside (2).

In the 1500s, it was suggested that human rabies was

transmitted through broken skin via animal bites, and,

in 1885, Louis Pasteur created the rst effective human

vaccine (14). This marked a turning point in rabies

prevention and, with the advent of modern vaccines,

the world has made enormous progress in ghting

the disease. Successful interventions have eliminated

dog-mediated human rabies in Western Europe, North

America, Japan, South Korea and parts of Latin America

and, recently, in smaller scale pilot programmes in Africa

and Asia, saving thousands of lives (3, 15, 16) (Figure 4).

In Latin America and the Caribbean, the Pan Amer-

ican Health Organization (PAHO) has coordinated the

regional programme to eliminate dog-mediated human

rabies in urban (since 1983) and rural (since 1991)

areas. By expanding access to post-exposure prophy-

laxis, completing mass dog vaccination campaigns,

improving rabies diagnosis and surveillance, and

increasing rabies awareness through educational

campaigns and community involvement, the region

saw an impressive and consistent decline in the number

of human rabies cases. Between 1980 and 2010 the

number of laboratory-conrmed dog rabies cases was

reduced by 98% and that of human rabies deaths by

97% (Annex 2). These are children who lived, and who

were spared a horric death from a preventable disease.

Because the mechanisms to eliminate

rabies are now in place

During the past decade, the evidence base for rabies

elimination has been put in place. Regional networks

are active in engaging countries to support each other,

exchange knowledge and build capacity; from neigh-

bour to neighbour, as part of the global movement to

eliminate rabies (3). These networks enable countries to

access existing tools, share local expertise and report

data through regional platforms, providing a supportive

structure and basis for expansion to achieve global

success.

The knowledge, tools and technology to eliminate

human rabies deaths are available and have proven

effective (Figure 4). Proof-of-concept programmes have

demonstrated that rabies elimination is feasible using

existing tools, even in poor, endemic settings (Annex 2).

These programmes demonstrate feasibility in different

country contexts. In Mexico, media and commu-

nity engagement, mass dog vaccination campaigns,

national rabies notication and a decentralized surveil-

lance system have resulted in zero human rabies deaths.

In KwaZula-Natal, South Africa, training and awareness

materials, dog vaccine banks, and free access to PEP

have led to the elimination of human rabies. In Sri Lanka,

mass dog-vaccination and sterilization campaigns, free

PEP and a system of national notication of human and

animal rabies cases implemented in 1990–2014 have

reduced the number of human rabies cases by 85%.

Because for the rst time in history we

are united to succeed

For the rst time in history, the world has a goal to elim-

inate human rabies deaths by 2030.

For the rst time in history, the world is united to coor-

dinate and leverage the wealth of existing knowledge,

tools and technology to achieve what we know is

possible.

For the rst time in history, we have a tangible opportu-

nity to eliminate the pain, suffering and death inicted

by rabies on humanity since the beginning of written

memory.

Together, for the rst time, international health organi-

zations are united against rabies, with the knowledge,

tools and strategy to end the suffering inicted by the

disease. WHO, FAO, OIE and GARC are committed and

are collaborating to empower, support and catalyse

countries to own and implement rabies elimination

programmes as we march towards the shared goal of

Zero by 30.

This global strategic plan presents a coordinated,

country-centric strategy to eliminate human deaths

from dog-mediated rabies by 2030. It integrates rabies

prevention with other healthcare interventions to

strengthen health systems and engage stakeholders

throughout the world in the ght to end rabies.

Figure 4. The knowledge, tools and technology to eliminate human rabies deaths are available and proven to work

Mexico

Vaccination

of dogs

100,000

200,000

300,000

400,000

Rabies cases

per year in

human & dogs

(x50)

1980 1990 2000 2010

100

200

300

400

100,000

200,000

300,000

400,000

500,000

Sri Lanka

Rabies cases

per year

Vaccination

of dogs

+ PEP

10 100 1000 10,000 100,000

0.1

100

1000

99% of human rabies is transmitted by bites of rabid dogs:

dog & human rabies cases are closely linked

Dog vaccination stops rabies transmission from dogs to humans

Preventing human deaths

by post-exposure prophylaxis (PEP) and dog vaccination

2008 2009 2010 2011 2012 2013

Cases of rabies

per year in

human & dogs

Kwa-Zulu Natal

(South Africa)

(x70)

20142007

Dog rabies cases

Human

rabies

cases

Incidences of human & dog rabies worldwide

(1990-2017

R=0.78

1992 1996 2000 2004 2008 2012 2016

WHO, OIE and FAO already coordinate efforts to

advance the One Health approach for several priority

diseases, including rabies, within the Tripartite collab-

oration (9).

The World Health Organization, established in

1946, is tasked to build a better, healthier world for all.

• Global leadership for public health develop-

ment to meet needs of disadvantaged popu-

lations.

• Nexus for governments, international organi-

zations, NGOs, private sector and civil society.

• Provides technical support to countries and

catalyses capacity-building.

The Food and Agriculture Organization of the

United Nations, established in 1945, aims to elimi-

nate hunger and food insecurity worldwide.

• Advocates for improved social and economic

status of all people worldwide.

• Engages partners and stakeholders including

governments, civil society and the private

sector.

• Links what happens in local communities to

regional and global initiatives.

The World Organisation for Animal Health,

established in 1924, aims to improve animal health and

welfare.

• Develops evidence-based international stan-

dards, guidelines and recommendations for

disease control and animal welfare.

• Manages the OIE World Animal Health Infor-

mation System (WAHIS) for animal disease

notication.

• Promotes strengthening of Veterinary Services

worldwide.

The Global Alliance for Rabies Control, estab-

lished in 2007, is dedicated to eliminating deaths from

rabies.

• Develops information, surveillance and

training tools to increase country capacity for

rabies control.

• Provides training and capacity building to

countries and coordinates regional intersec-

toral rabies networks.

• Undertakes advocacy, education and commu-

nication campaigns (World Rabies Day, End

Rabies Now).

The four organizations United Against Rabies

BOX

UNITED TO END THE NEGLECT

Until now, efforts to eliminate rabies have been frag-

mented across sectors and regions. In affected coun-

tries, elimination of the disease has been championed

by few. National responses, where implemented,

are often uncoordinated between the human and

animal health sectors. Examples of best practice have

emerged, but their hard-learned lessons have not been

broadly shared.

We need to break the status quo: the time is now.

The rumblings for change began in 2015, when the

world called for action by setting a global goal of zero

human dog-mediated rabies deaths by 2030, world-

wide.

The United Against Rabies collaboration is our unied

response to this global call.

For the rst time, four international partners – WHO, OIE,

FAO and GARC – have united to break the status quo

(Box 1). By leveraging the unique strengths and exper-

tise of each organization in the eld of rabies control,

World Rabies Day 2016 in Bhutan, 2016 (Photo credit: Yoenten Phuentshok)

THE UNITED AGAINST

RABIES COLLABORATION

our cross-cutting collaboration provides coordinated,

global leadership to catalyse and empower countries to

prevent human rabies deaths.

The world has the knowledge, tools and technologies

needed to eliminate rabies: countries need a plan to put

them into action, a strategy to mobilize resources and

political will to get the job done. Through a coherent

global strategy and harmonized, practical guidance

and training, the United Against Rabies collaboration

provides a structure and support for elimination. We will

use our joint strengths to advocate for rabies prioriti-

zation, to engage stakeholders in the global ght and

to build capacity to create an enabling environment for

countries to succeed.

Rabies elimination is no longer a dream.

Now, for the rst time, it is a goal with a strategy, and a

global force united to see it through. Combined, we can

leverage existing capacity in a new way: to empower,

to engage and to enable countries to save human lives

from this horric but preventable disease.

VISION TO REACH ZERO BY 30

Our global strategic plan provides a harmonized,

coherent foundation for rabies elimination that coun-

tries can adapt and own, as we support them to reach

Zero by 30.

This plan puts countries at the centre through coordi-

nated, global support to create national and regional

rabies elimination plans, build capacity, integrate rabies

control with other health initiatives, and strengthen

health systems to reach the world’s most underserved

populations.

The value proposition

Our collaboration engages stakeholders across coun-

tries and sectors, brings together public and private

development partners, and catalyses communities,

nations and regions to implement and own their rabies

elimination plans (Figure 5).

Countries take control of and lead efforts to ensure

ownership and accountability (Box 2). National and

regional elimination plans will increase preparedness

and surveillance and mobilize domestic resources. By

fostering collaboration across ministries and enhancing

national capacity at all levels, these plans will promote

inclusion of dog bite treatments into health systems

and increase access to dog and human vaccines, while

developing a One Health approach. By maximizing

resources and impact, countries can move towards

their SDG targets while building a healthier future. The

United Against Rabies collaboration will support these

efforts by promoting rabies awareness and prevention

and advocating for support and prioritization of rabies

elimination. By establishing global norms and standards,

coordinating global rabies elimination efforts and moni-

toring progress and results, the collaboration will drive

elimination by maximizing the use of resources. For the

rst time, we are marching together, with synergy and

structure, to coordinate our interventions and maximize

the impact of investment in rabies elimination.

Figure 5. United Against Rabies is a country-centric, multi-stakeholder collaboration

Countries lead elimination efforts

Countries are at the centre of the global strategic plan to reach Zero by 30 because coun-

try-led national rabies elimination plans are the cornerstone of our approach. Developing

and implementing their own national plans puts countries in the driver’s seat, with global

tools, structures and support at the ready to kick-start, fuel and accelerate progress

towards national goals.

Rabies is already a priority disease in many endemic countries. Since 2014, of the 18

countries involved in One Health zoonotic disease prioritization workshops conducted

across Africa, Asia, Eurasia and the Americas, 17 have prioritized rabies: rabies is the

most commonly prioritized zoonosis worldwide (17).

Our phased approach builds on existing political will by starting with countries that already

prioritize rabies and are active in its control (see section 7.1). Catalytic global structures

will support these countries to own and implement pragmatic, sustainable national plans;

providing impetus and means for country successes to inspire and drive regional and

global elimination efforts.

Proven mechanisms are already in place to engage countries in rabies elimination. Rabies

stimulus packages are helping to build local capacity by providing tailored support to

kick-start community projects (18). Successful pilot projects have demonstrated that elim-

ination is feasible, generating momentum for action and promoting investment for sustain-

ability and growth.

The outputs of the Stepwise Approach towards Rabies Elimination, or SARE, provide prac-

tical guidance to countries and assist with the prioritization of national activities. Stimulus

packages are tailored to respond to these priorities. Through the logical steps proposed

to develop and implement national rabies control programmes, this approach responds

to existing national control and elimination efforts by supporting countries to advance

from stage zero (where no data are available) to stage ve (where rabies elimination is

maintained). Since 2015, 76 workshops involving 26 countries, including four in-country

workshops, have been conducted using this stepwise approach (Annex 7).

The global strategic plan will bolster these existing initiatives as we catalyse countries to

take ownership, use national elimination plans to meet country goals and, ultimately, reach

Zero by 30.

2BOX

Objective 1:

to effectively use vaccines, medicines, tools and tech-

nologies to reduce the risk of human rabies through

expanded dog vaccinations, improved awareness and

education, and increased access to health care, medi-

cines and vaccines for populations at risk.

Objective 2:

to generate, innovate and measure impact through (i)

effective policies, guidance and governance by harmo-

nizing international recommendations, frameworks and

strategies and by building capacity in countries; and (ii)

ensuring the availability of reliable data to enable effec-

tive decision-making by encouraging the use of tech-

nology and health innovations, and by rening tools

for countries to monitor and report data, strengthen

surveillance capacity and integrate reporting systems.

Objective 3:

to sustain commitment and resources through

multi-stakeholder engagement and by demonstrating

the impact of activities completed under the United

Against Rabies collaboration in national, regional and

global rabies elimination programmes.

These objectives will help to ensure that dog vaccina-

tion programmes are effective and comprehensive, that

vaccines and information reach populations at high risk

of rabies, and that dog bite prevention strategies are

widely implemented. A secondary aim of these objec-

tives is to make available trained professionals in human

and animal health and education alongside accurate

and comprehensive rabies surveillance and programme

monitoring. The following sections describe each of

these objectives and how we intend to meet them.

The theory of change

Although societal changes are needed to reach Zero

by 30, achieving zero human rabies deaths worldwide

is technically feasible. Our theory of change outlines

what is required to make these changes and save lives,

reduce expenditures, and validate rabies elimination in

countries and regions.

The theory of change (Annex 3) is built upon three pillars:

(i) operational capacity-building to strengthen health

systems; (ii) education and advocacy to prevent human

rabies deaths; and (iii) monitoring and evaluation to

enable this global work. The logic framework (Annex 4)

translates the steps of the theory of change into a blue-

print for action by describing the key outcomes, outputs

and major activities required to realize Zero by 30.

The value proposition and the theory of change outline

how the United Against Rabies collaboration can act

to drive elimination through effective use of vaccines,

medicines, tools and technologies; reliable data to

enable effective decision-making; sustained commit-

ment to drive progress; and effective policies, guid-

ance, governance and support (Figure 6).

OBJECTIVE 1

to effectively use

vaccines, medicines,

tools and

technologies

OBJECTIVE 2

to generate,

innovate and

measure impact

OBJECTIVE 3

to sustain

commitment

and resources

Reduce human rabies risk

- improved awareness and

education

- increased access to healthcare,

medicines and vaccines

- dog vaccinations

Provide guidance and data

- effective policies, guidance

and governance

- ensuring reliable data to enable

effective decision-making

Harness multi-stakeholder

engagement

demonstrate the impact of

activities completed under

the United Against Rabies

collaboration

ZERO HUMAN DEATHS FROM DOG-MEDIATED RABIES BY 2030

OBJECTIVES

less expenditure

on rabies

fewer rabies

exposures

validated rabies

elimination in individual

countries/regions

* World Health Organization (WHO), Food and Argriculture Organization of the United Nations (FAO),

World Organisation for Animal Health (OIE), and Global Alliance for Rabies Control (GARC)

monitoring &

evaluation

effectiveness

& sustainability

operational

capacity-building

preparedness

educational &

advocacy programmes

awareness

& commitment

collaboration was formed by four partners:

WHO, FAO, OIE, GARC*

The

UNITED AGAINST RABIES

PROBLEM STATEMENT

Although 100% preventable, rabies kills more than 59,000 people in over 150 countries

every year. The disease is nearly always fatal once symptoms appear.

Figure 6. Our global strategic plan prioritizes the objectives dened in the theory of change

Dog vaccination and education

campaign in Tanzania

(Photo credit: Sarah Cleaveland)

The fundamentals of rabies control are well estab-

lished. We need wide-scale access to this knowledge,

and capacity-building to allow countries to access and

implement these tools in their communities.

Outcome 1.1: rabies is prevented

through increased awareness and

improved education

People need to know about rabies to vaccinate dogs and

seek care if they are exposed. Engaging communities

to improve rabies education and awareness is essential

to prevent human deaths (4). Global campaigns such as

World Rabies Day and End Rabies Now already actively

involve community leaders, and bring rabies to the fore-

front through innovative local activities and events (19).

Moving forward, we will focus on education and aware-

ness campaigns that leverage national best prac-

tices into relevant, locally appropriate communication

OBJECTIVE 1

TO EFFECTIVELY USE VACCINES,

MEDICINES, TOOLS AND TECHNOLOGIES

messages. We will provide tools, templates and guid-

ance for countries to adapt for national campaigns and

save lives by educating people at risk of rabies on the

need to vaccinate dogs, when to suspect rabies in a

dog or person and what to do in case of a bite.

Promoting bite prevention strategies and responsible

dog ownership will further build awareness of the need

to vaccinate dogs to prevent disease and limit potential

exposure (20). Responsible dog ownership and rabies

education will provide countries with adaptable, One

Health strategies to build awareness and sustainably

prevent rabies in animals and humans.

Outcome 1.1: Rabies is prevented through increased awareness and improved education

ACTIVITIES 2017–2020 EXPECTED OUTCOMES 2020

Coordinate communication campaigns for

World Rabies Day, in priority endemic countries

Effective, locally adaptable communication and

awareness tools and strategies

Develop coherent strategies for responsible

dog ownership and bite prevention education

Sustainable responsible dog ownership and

bite prevention education programmes

Engage partners, communities, and national

and international media to build rabies aware-

ness

Outcome 1.2: rabies is prevented

through increased and effective dog

vaccination

Dog vaccination is key to stopping rabies transmission

between dogs, and from dogs to humans. By preventing

transmission of rabies at its source, vaccinating dogs is

a cost–effective and sustainable way to save lives (3, 21,

22) (Figure 7). We will build on existing tools and exper-

tise to develop locally adaptable, best-practice guid-

ance for implementing dog vaccination in countries and

their communities. This will catalyse national strategies

that improve dog vaccination capacity, and allow for

streamlined integration of dog vaccination with other

disease control initiatives.

Regional capacity-building workshops will enable

countries to engage with and help their neighbours

by sharing training, operational knowledge and novel

strategies to address local challenges. These will help

to strengthen regional networks as we help to coalesce

local and national rabies interventions into unied and

effective regional elimination strategies.

We will further support countries to conduct effec-

tive dog vaccination campaigns through (i) dog rabies

biological banks to ensure consistent availability of

affordable, safe and effective vaccines (Annex 5); (ii)

strengthening health and veterinary services to deliver

effective dog vaccination campaigns, and enhance

monitoring and reporting of dog rabies cases and dog

vaccination coverage; and (iii) promoting innovative

mechanisms to reach free-roaming dogs and increase

dog vaccination coverage.

Access to rabies vaccines and biologicals is a key

component of our global strategic plan, and triggers

national programmes. For both human and animal

diseases, biological banks have successfully improved

access to affordable, safe and high-quality vaccines.

We encourage countries to forecast their own vaccina-

tion and supply chain needs as they initiate, implement

and complete mass dog vaccination campaigns. Local,

regional and global reporting structures will enable

countries to share and learn from the data generated

during campaigns. Countries can use these data to

rene and improve implementation and thereby ensure

that campaigns achieve sufcient vaccination coverage

to prevent transmission of rabies disease to people.

Outcome 1.2: Rabies is prevented through increased and effective dog vaccination

ACTIVITIES 2017–2020 EXPECTED OUTCOMES 2020

Leverage existing tools to support effective

SOPs for dog vaccination at the country level

Coherent, standardized, evidence-based tools

and strategies for effective dog vaccination

Organize regional workshops for coordinators

to train in best practices and share lessons

learned

Strengthened, vitalized and supportive regional

networks

Establish a biological bank to increase access

for affordable dog rabies vaccines

Improved availability and access to dog rabies

vaccines (see Annex 4)

Support effective use of monitoring and surveil-

lance data to validate vaccination coverage

Local, regional and global reporting structures

established to facilitate data collection and

sharing

Promote innovative approaches to enhance

dog vaccination campaign coverage

Cost of rabies post-exposure prophylaxis and dog vaccination

Indicative rabies treatment costs per

patient in rabies endemic countries

a) Full vaccine course at a medical centre consisting of four consultations

and four vaccine vials administered through intramuscular injection (IM);

41 rabies endemic countries where data are available were used.

Consultation

costs

Mass dog vaccination cost

per dog

Average costs: US$ 4.03

n=10 published studies

25%

75%

(min: US$ 7.48 – max: US$ 597.36)

Vaccines costs

Average costs: US$ 108.07

Up to 99% of bite victims survive

with prompt wound washing

& vaccine without RIG

Up to 80% savings with

intradermal PEP regimens ª

RIG is recommended for

severe category III exposures

b) Single or multiple transdermal bites or scratches, licks on broken skin,

contamination of mucous membrane with saliva from licks and exposure

to bats.

(min: US$ 1.56 – max: US$ 11.33 )

Logistics &

consumables

17%

57%

Vaccinator

costs

Awareness

18%

Vaccines

costs

Dog vaccination is key to stopping

rabies transmission between dogs, and from dogs to humans

Figure 7. Dog vaccination is key to stopping rabies transmission between dogs, and from dogs to humans

Outcome 1.3: human deaths from

rabies exposures are prevented

by ensuring equitable, affordable

and timely access to health care,

medicines and vaccines

Timely, appropriate prophylaxis is almost 100% effec-

tive in preventing death from rabies. However, this

basic care is not available in many endemic areas (3,

5). Expanding access to high-quality, affordable PEP for

populations at risk of rabies relies on health systems

capable of reaching the world’s most underserved

populations. In this way, supporting national plans

that promote treating dog bites and rabies exposures

in people contributes to achieving universal health

coverage.

We will facilitate prudent use of rabies biologicals

through standardized, pragmatic, evidence-based

guidance for PEP, PrEP and RIG. Practical courses

for health professionals on PEP administration, bite

management and palliative care for clinical rabies cases

(where prophylaxis was not applied) will build capacity

and further improve delivery of life-saving rabies PEP.

Through high-quality, safe, rabies biological banks, we

will catalyse increased access to competitively priced,

safe and efcacious vaccines and immunoglobulins for

those who need them (Annex 5). We encourage coun-

tries to use their own PEP and rabies surveillance data

to forecast vaccination needs and budget for biolog-

ical purchases. Globally, we are advocating for inclu-

sion of rabies PEP into the 2018 GAVI vaccine invest-

ment strategy (23). If successful, this would ensure free

access to PEP in lower income, GAVI-eligible countries.

Countries also need a mechanism to prevent over-use

of PEP, especially when successful control activities

cause the incidence of rabies to decline. Bite prevention

education (see outcome 1.1) and integrated bite case

management (IBCM) are proposed as parallel strategies

to reduce unnecessary costs and use of rabies biologi-

cals (24). Bite prevention education aims to prevent dog

bites in the rst instance, while IBCM engages medical

and veterinary sectors to assess the risk of genuine

exposure to rabies and the subsequent need for PEP

(Annex 6). This provides a means for countries to reduce

human treatment costs for rabies, as they concurrently

reduce transmission risk through controlling rabies in

dogs.

We will integrate last mile strategies to increase access

of poor and rural populations to PEP into the global

movement towards achieving universal health coverage,

and support countries to evaluate and amend current

practices for PEP procurement to ensure availability

and access for all.

Outcome 1.3: Human deaths from rabies exposures are prevented by ensuring equitable,

affordable and timely access to healthcare, medicines and vaccines

ACTIVITIES 2017–2020 EXPECTED OUTCOMES 2020

Support national plans that expand access to

basic healthcare for all

Increased access to basic healthcare, espe-

cially for underserved populations

Leverage existing tools to support prudent use

of PEP, PrEP and RIG by health services

Coherent, standardized, evidence-based tools

and strategies for use of PEP, PrEP and RIG

Regional workshops to build capacity in

best-practice rabies prevention and care

Improved availability and access to human

rabies biologicals (see Annex 4–Banks)

Establish a biological bank to increase access

to affordable human rabies biologicals

Mechanism to reduce rabies biological usage

where rabies incidence is low (e.g. IBCM)

Promote the use of surveillance data for fore-

casting of vaccine needs

Investigate bite prevention education and

IBCM as strategies to reduce biological usage

OBJECTIVE 2.1 TO PROVIDE

EFFECTIVE POLICIES, GUIDANCE AND

GOVERNANCE

Coherent international standards and guidance reect

best practice in rabies control. We need to support

countries to access and adapt this guidance to their

local situation, and to monitor, assess and rene strate-

gies with the greatest impact.

Outcome 2.1: policies, guidelines, and

governance to prevent human rabies

deaths are created and adopted at

regional and national levels

Clear guidance, strategies and frameworks to prevent

human rabies deaths provide a standardized struc-

ture for countries to adapt, own and implement. We

will adapt existing knowledge, policies and tools into

a coherent framework of standardized methods, oper-

ating procedures, guidance and governance, and incor-

porate them into universally available tools. This will

ensure a consistent global approach to the surveillance,

diagnosis and prevention of human and dog rabies.

Capacity-building and training to provide coordinated,

comprehensive and complementary guidance to coun-

tries to support the development and delivery of national

rabies control strategies. Training of human and animal

health professionals will strengthen the effective use of

vaccines, medicines and tools.

Harmonized international recommendations for rabies

prevention in people and animals will streamline a

One Health approach into policy development. We will

update existing tools such as SARE (Annex 7) to provide

coordinated, comprehensive guidance to countries (25).

Our global approach will advocate for prioritization of

rabies elimination, and provide a mechanism to tackle

inequality in healthcare.

Efcient and effective governance of rabies elimination

programmes will enable transparency at the national

and regional levels, and encourage accountability.

Based on global best practices and lessons learned

from countries that have successfully combated rabies,

we will provide guidance documents on how to clearly

dene the roles, responsibilities and accountabilities of

persons and organizations involved in elimination activ-

ities to maximize the impact of investment.

Established reporting structures with dened linkages

between departments will ensure continuity and prog-

ress of elimination activities in the context of changing

political environments and personnel. We will support

countries to set realistic and attainable goals, and to

establish cross-sectoral working groups to advocate

for and prioritize rabies elimination.

OBJECTIVE 2

TO GENERATE, INNOVATE AND

MEASURE IMPACT

Outcome 2.1: Policies, guidelines and governance to prevent human rabies deaths are

created and adopted at regional and national levels

ACTIVITIES 2017–2020 EXPECTED OUTCOMES 2020

Review existing rabies guidelines and manuals

to identify conicts and gaps

Coherent, standardized tools and strategies to

prevent human rabies deaths

Engage countries and stakeholders to adapt

existing tools for rabies prevention

Harmonized international recommendations for

rabies prevention in humans and animals

Develop and validate guidance for countries on

roles, responsibilities and accountability

Established reporting structures and cross-sec-

toral working groups within countries

OBJECTIVE 2.2 TO ENSURE RELIABLE

DATA TO ENABLE EFFECTIVE DECISION

MAKING

Outcome 2.2: appropriate technology

and information are made available

Technology and health innovations will improve existing

tools and programmes to produce practical, afford-

able technologies that simplify rabies case reporting,

management, cost–effectiveness and reach. We will

build on existing online resources such as the Rabies

Blueprint and SARE (Annex 7), and develop appropriate

additional technology for policy-makers, scientists,

medical professionals, teachers and the public.

We will explore opportunities to improve rabies clin-

ical diagnosis through e-learning courses and IT-based

assessment tools, and how leveraging existing

programmes such as toll-free numbers and village

reporters can enhance decentralized rabies surveil-

lance.

We will encourage countries to engage with national

stakeholders to identify their own research needs, eval-

uate the potential for new innovations to be incorpo-

rated into health systems, and to nd and share practical

solutions, e.g. through cross-sectoral working groups

and regional workshops. Overall, we aim to stimulate

innovation in vaccination strategies, diagnostics and

supply chains, to meet current needs, with a focus on

tools and technologies that can be applied universally

and practically in resource-poor settings.

Improving rabies diagnostics will improve disease

surveillance in humans and animals. Developing a reli-

able, safe, sensitive point-of-care diagnostic tool to

detect viral infection in humans and animals after a bite

exposure would overcome current diagnostic limita-

tions (i.e. laboratory-based tests requiring sophisti-

cated training, equipment and sample transportation).

Through expert stakeholder consultations, we will seek

support from the community of practice, and engage

with countries, academia and industry to establish clear

research priorities for rabies diagnostic tests.

We will update existing laboratory manuals to provide

harmonized, current guidance for human and animal

rabies diagnosis (using established WHO and OIE

processes), and conduct practical regional workshops

for programmatic training in rabies surveillance and

diagnosis.

Outcome 2.2: Appropriate technology and information are made available

ACTIVITIES 2017–2020 EXPECTED OUTCOMES 2020

Review current vaccine and diagnostic tech-

nologies to identify research gaps and needs

Innovative technological solutions in vaccines,

diagnostics and supply chain

Review and update online tools for rabies

education and elimination

Online tools for policy-makers, scientists,

medical professionals, teachers and public

Engage stakeholders to promote innovation in

rabies diagnosis and vaccine delivery

Cohernet, standardized tools and strategies for

robust rabies surveillance

Promote development of a reliable, safe, sensi-

tive point-of-care diagnostic tool

Update existing laboratory manuals to provide

harmonized, evidence-based guidance

Regional workshops to train technical staff in

sampling, transport and laboratory diagnosis

Outcome 2.3: progress towards the

goal is constantly and consistently

monitored and reported

Accurate and comprehensive monitoring for new rabies

cases allows us to assess progress, validate rabies-free

status, and target interventions and resources to areas

where rabies is present. We will clarify best-practice

surveillance systems for both human and animal rabies,

and rene tools for countries to monitor and report data.

Through regional workshops, we will build surveillance

capacity, share successes and lessons learned from

proof-of-concept projects conducted by countries, and

support the development of locally appropriate surveil-

lance systems. Globally, we are promoting integrated

reporting systems for human and animal surveillance

data with a view to building a coordinated and compre-

hensive understanding of the rabies disease burden

and the impact of interventions.

Reporting results and programme impacts allows us to

identify interventions that work, demonstrate return on

investment and assess progress towards our goals. We

will support countries to collect and report programme

data, and to use their own data to forecast vaccine

needs, assess performance and target elimination

approaches. We will establish processes to validate

and verify progress towards zero human rabies deaths,

and develop guidance for last mile strategies and how

to maintain elimination once achieved.

Outcome 2.3: Progress towards the goal is constantly and consistently monitored and

reported

ACTIVITIES 2017–2020 EXPECTED OUTCOMES 2020

Design and disseminate information on surveil-

lance and data collection tools

Improved tools for rabies surveillance, data

collection and analysis

Organize regional workshops to train technical

staff in best-practice rabies surveillance

Integrated regional and global reporting

systems for human and animal rabies data

Support establishment of clear reporting chains

within human and veterinary health services

Regular programmatic monitoring at national

and regional levels

Use surveillance data to demonstrate impact of

investment in rabies elimination

Established process for validation and verica-

tion of reaching zero human rabies deaths

Engage countries to highlight importance of

data reporting, and support them to improve

Supporting the theory of change element: “sustained

commitment drives progress”

By providing a coherent foundation for rabies control,

our global strategic plan builds condence in the feasi-

bility of global elimination, and engages countries,

stakeholders and development partners in the ght to

end rabies. We will sustain commitment and drive prog-

ress through achieving the following outcomes:

Outcome 3.1: key stakeholders are

consistently and comprehensively

engaged

Engaging stakeholders through effective advocacy

encourages investment in elimination and creates an

enabling policy environment. We will engage devel-

opment partners from public and private sectors by

demonstrating the value of investing in rabies elimina-

tion programmes. To prioritize areas where the burden of

disease is highest, we will develop a regional advocacy

strategy for Africa and Asia, and involve local leaders

and international personalities to champion Zero by 30.

Advocacy to highlight the feasibility of rabies elimination

promotes rabies prioritization within countries. We will

develop advocacy materials and strategies that demon-

strate why rabies elimination is a global public good (8).

These will promote a One Health approach, including

community engagement to build rabies awareness,

dog vaccination to interrupt rabies transmission and

increased access to life-saving PEP for people.

We will support countries to synergize rabies elimina-

tion programmes with other healthcare interventions

to strengthen health systems and improve outcomes

for other diseases. We will provide guidance to coun-

tries on how to approach development partners for

nancing, enabling them to own and implement local

programmes to achieve their elimination goals.

OBJECTIVE 3

TO SUSTAIN COMMITMENT AND

RESOURCES

Outcome 3.1: Key stakeholders are consistently and comprehensively engaged

ACTIVITIES 2017–2020 EXPECTED OUTCOMES 2020

Design and implement partnership strategies

with the public and sectors

Investment in rabies elimination by countries,

and regional and international partners

Roll out communication campaigns to endemic

countries

Regional advocacy strategies, including for

Africa and Asia

Support development of robust, integrated

national rabies elimination plans

National rabies elimination plans integrated to

strengthen health systems

Outcome 3.2: nances and other

resources are effectively and

efciently used

Ensuring funding to reach Zero by 30 is essential to

plan, implement and maintain rabies elimination activ-

ities. Existing models for vaccine forecasting and

investments have been adapted to identify and predict

resource needs. We will use programme outcomes to

advocate for investment and establish clear resource

mobilization strategies. We will support countries to

obtain and invest their own funds in rabies elimination

activities to ensure ownership and success.

Outcome 3.2: Finances and other resources are effectively and efciently used

ACTIVITIES 2017–2020 EXPECTED OUTCOMES 2020

Review mechanisms for resource allocation,

cost-sharing mechanisms and fundraising

Detailed budget formulated including estab-

lished models, supply landscapes and resource

projections

Organize regional workshops to engage coun-

tries in developing resource mobilization strat-

egies

Sustainable resource mobilization strategies

available for countries to nance national plans

Map existing and innovative funding mecha-

nisms

Synergize rabies elimination with other

programmes, and engage new partners

Outcome 3.3: results and impact of the

United Against Rabies collaboration

are regularly monitored and reported

to key stakeholders

Regular monitoring and reporting of our impact to key

stakeholders will showcase programme achievements

and key milestones, and demonstrate progress towards

our three objectives and Zero by 30 (see section 8.1:

Workplan delivery monitoring and evaluation). Evalu-

ating our activities will allow us to rene and improve

implementation in subsequent countries and phases.

Financing strategies for the activities described within

the logic framework are contained in our detailed

budget (see Chapter 7: Budget and governance).

We will collaborate with experienced external fund-

raisers to generate investment in elimination and seek

additional nancing for the purchase of initial stock for

the rabies biological banks. We will foster synergies

with other programmes and explore innovative funding

mechanisms.

Outcome 3.3: Results and impact of the United Against Rabies collaboration are regularly

monitored and reported to key stakeholders

ACTIVITIES 2017–2020 EXPECTED OUTCOMES 2020

Advocate globally, regionally and at the country

level for investment in elimination

Regular reporting of the activities and impact of

the United Against Rabies collaboration

Deliver a resource mobilization campaign Sustained nancing of rabies elimination efforts

to achieve Zero by 30

Review implementation and lessons learned in

Phase 1 to inform and rene Phases 2 and 3

Rabies vaccination in Indonesia

(Photo credit: WHO / SEARO / Budi Chandra)

Phase 1: START UP

2018-2020

29 countries

Phase 2: SCALE UP

2021-2025

+52 countries

Phase 3: MOP UP

2026-2030

+19 countries

BUDGET AND

GOVERNANCE

A PHASED APPROACH TO FUNDING

ZERO BY 30

At present, 100 countries are endemic for dog-medi-

ated rabies: we cannot go from zero to full elimination in

one go, and neither can we start work in all countries at

the same time. We need to take a pragmatic approach

and break down our ambitious global goal of Zero by 30

into small, achievable targets. To do this, we propose a

three-phased approach to elimination:

Phase 1: START UP

Phase 1 is where we will build a strong foundation for

rabies elimination by preparing normative tools and

structures to catalyse action. We will start by engaging

countries that have the greatest chance of success:

countries where rabies is a priority disease; countries

already active in rabies control; countries where pilot

projects are already running; and countries we can

learn from to improve future implementation.

Developing national and regional rabies elimination

plans are core phase 1 activities. Anchoring rabies

control within a national programme is critical to

ensure country ownership and a budgeted, sustainable

approach that is adapted to local conditions. Our work

is to support and catalyse countries to prepare their

own national plans and facilitate their coalescence into

a coordinated regional effort to reach our global goal of

Zero by 30.

Our global strategic plan details the funding require-

ments for the core activities of Phase 1 only. This will

allow us to stay agile, and exibly adapt our strategy

to accommodate new opportunities, changing envi-

ronments and lessons learned along the way (see 7.2

Budget requirements: phase 1).

Phase 2: SCALE UP

Phase 2 is where we expand to engage and involve

most endemic countries in rabies elimination. Using the

strong foundation established in Phase 1, rened and

improved with learning and experience, we will expand

our efforts and truly go global.

During this phase we will continue to support countries

engaged in Phase 1, promoting the steady continua-

tion of budgeted, sustainable national programmes as

we begin the same process with many new countries.

Promoting successes will maintain momentum and

further inspire new countries to engage. Our focus will

sharpen on regional elimination plans, by mobilizing

countries to come together, build and implement a

strategy for their region as we move towards Zero by

30.

Phase 3: MOP UP

Phase 3 is where we engage remaining countries in the

ght to eliminate rabies, and continue to support country

efforts as communities, nations and regions advance to

nish the job. This phase is the last mile. The lessons

learned in phases 1 and 2 will be vital to ensuring the

success of this nal phase as the remaining 19 coun-

tries push towards rabies elimination. We will need to

capitalize on all of the achievements from the rst two

phases and make Zero by 30 a reality.

BUDGET REQUIREMENTS: PHASE 1

Our United Against Rabies collaboration is building a

foundation for rabies elimination through normative,

catalytic work to provide countries with the required

support, tools and structures for success.

We estimate a total nancial requirement for Phase

1 (start up: 2017–2020) of US$ 16.5 million (see info-

graphic: Budget overview for phase 1). This includes

capacity-building to support countries to develop

robust elimination strategies (36% of total budget);

advocacy to prioritize rabies elimination (28% of total

budget); and establishing coherent, harmonized global

norms and standards (12% of total budget).

Our role is to catalyse change; to streamline invest-

ment between and across sectors, and support coun-

tries to develop and implement national plans that are

pragmatic and evidence-based. Financing and imple-

menting national rabies elimination plans at the country

level is not included in our budget. Countries will be

able to use their plans to mobilize domestic and inter-

national resources to nance and implement control

activities.

Investing in rabies means health systems capable of

reaching underserved populations. We will support

countries to develop robust nancing strategies for

rabies elimination that are effective, sustainable and

integrated into national programmes to strengthen

health systems overall. International organizations are

mandated to work to end rabies. “Zero human rabies

deaths by 2030” is the target that together, we are

working to achieve.

BUDGET REQUIREMENTS:

BEYOND2020

In the long term, we estimate a total cost of US$ 49.7

million (including the US$ 16.5 million for phase 1) to

implement the three phases of our global strategic plan

and reach Zero by 30. This estimate takes into consid-

eration various scenarios and modelling estimates,

and assumes no evolution of the disease or change

in proposed activities and that associated costs will

remain constant over time. Twenty-nine countries are

budgeted for inclusion in phase 1, however country

selection will be made in the work planning based on

the criteria outlined in section 7.1.

Most importantly, this estimate does not include

nancing for implementation of national rabies elimina-

tion plans at the country level. As part of our strategy,

each country will be supported to devise the most

disease appropriate action to reach zero human deaths

by or before 2030. This will be done through the national

rabies elimination plans. Countries will have to identify

the resources and means, both domestic and interna-

tional, to reach their own elimination goals. Our role is

to support the countries to prepare and deliver on their

national elimination plans.

We will review the projected budget towards the end of

Phase 1, using the experience and data generated to

revise estimates for Phase 2 (scale up: 2021–2025) and

Phase 3 (mop up: 2026–2030) (see Figure 8). Phase 1 will

establish the groundwork to streamline implementation

of phases 2 and 3.

Reaching zero will have a huge impact on the lives and

livelihoods of children and families around the world,

but we cannot stop there. We will need to break trans-

mission between dogs altogether, and maintain freedom

from the disease. This is the beginning: the partners in

the United Against Rabies collaboration are already

working together, and with countries, to coordinate

and catalyse global change. Investment in our global

strategic plan will accelerate growth in and delivery of

our united approach, as we make rabies elimination a

reality.

2018

–2020

2030

$ 16.5 million

Total:

$ 49.7 million

2021

−2025

2026−2030

Start up Scale up Mop up

$ 21.1 million

$ 12.1 million

Zero

human

deaths

29 countries +52 countries +19 countries

Figure 8. Three-phased approach to elimination

12 %

36 %

5 %

28 %

3 %

12 %

4 %

Support national plan

preparation

& capacity

building

Monitor progress

& report results

Advocate for support &

prioritize rabies elimination

Coordinate global

rabies elimination

efforts

Establish global

norms &

standards

Establish global

biological bank(s)

Promote rabies awareness,

prevention & responsible

dog ownership

Phase 1 budget

(US$ 16.5 million)

per input activity

$ 1.96

$ 1.33

$ 3.48

$ 3.00

$ 2.30

$ 1.79

$ 1.68

$ 0.67

$ 0.29

Policies & guidelines are created & adopted at

regional & national levels

Appropriate technology & innovation are

made available

Progress is constantly & comprehen

sively monitored & reported

Key stakeholders are consistently

& comprehensively engaged

Finances & other resources are

effectively & efﬁciently used

United Against Rabies’ activities are

transparently reported to key stakeholders

Increased & effective dog

vaccination

Ensure equitable, affordable & timely access to healthcare,

medicines & vaccines

Increased awareness & improved

education

Million

US$ 6.77

million

2.64

US$ 7.09

million

Budget overview for Phase 1

Total cost for Phase 1: US$ 16.5 million

US$

12 %

36 %

5 %

28 %

3 %

12 %

4 %

Support national plan

preparation

& capacity

building

Monitor progress

& report results

Advocate for support &

prioritize rabies elimination

Coordinate global

rabies elimination

efforts

Establish global

norms &

standards

Establish global

biological bank(s)

Promote rabies awareness,

prevention & responsible

dog ownership

Phase 1 budget

(US$ 16.5 million)

per input activity

$ 1.96

$ 1.33

$ 3.48

$ 3.00

$ 2.30

$ 1.79

$ 1.68

$ 0.67

$ 0.29

Policies & guidelines are created & adopted at

regional & national levels

Appropriate technology & innovation are

made available

Progress is constantly & comprehen

sively monitored & reported

Key stakeholders are consistently

& comprehensively engaged

Finances & other resources are

effectively & efﬁciently used

United Against Rabies’ activities are

transparently reported to key stakeholders

Increased & effective dog

vaccination

Ensure equitable, affordable & timely access to healthcare,

medicines & vaccines

Increased awareness & improved

education

Million

US$ 6.77

million

2.64

US$ 7.09

million

Budget overview for Phase 1

Total cost for Phase 1: US$ 16.5 million

US$

GOVERNANCE

The United Against Rabies collaboration proposes to

establish a Global Steering Group (GSG) comprised of

one representative from each of the partner organiza-

tions WHO, OIE, FAO and GARC. This will be an agile

core unit capable of responding to changing environ-

ments and needs.

The nominated representative will be knowledgeable

and sufciently senior to take programmatic and gover-

nance decisions on behalf of their institution. The GSG

will elect a Chairperson from one of the four partner

organizations for a two-year term either automatically,

sequentially or by vote.

Where possible and required, the GSG will engage

external working groups of experts, key stakeholders,

development partners, country representatives and

academics. This exible, needs-based approach will

allow for effective, evidence-based decision-making

without large and unwieldy governance mechanisms.

The decisions taken by GSG members are not legally

binding to their respective institutions, but rather, bind

the partners in consensus towards a common goal. A

key responsibility of the GSG will be to link the global

strategic plan to a workplan with clear roles and respon-

sibilities among partners. In this regard, the GSG will

take all programmatic, nancial and resource decisions

related to delivering the global work plans for the United

Against Rabies collaboration.

Mass dog rabies vaccination Payatas Manila

(Photo credit: Geloy Conception / GARC)

WORKPLAN DELIVERY MONITORING

AND EVALUATION

Countries are at the core of our global strategic plan.

They have primary responsibility for implementing the

activities detailed in their national rabies elimination

plans. National plans should be referred to for details

of national responsibilities, targets and progress indi-

cators.

Using the objectives described in the global strategic

plan as a basis, we will develop a detailed workplan

to guide implementation. This will include a monitoring

framework with dened, aligned, milestones to measure

progress. The United Against Rabies collaboration will

implement activities according to this workplan and

assess progress against the major objectives outlined

in our global strategic plan.

We will provide yearly reports on quantitative and qual-

itative outputs, and review our shared tools, templates

and guidance at regular intervals. We will publish a

summary of lessons learned at the end of each phase,

and use this knowledge to inform and adjust activi-

ties and budget for the subsequent phase. Each year,

partners in the United Against Rabies collaboration will

invite stakeholders from countries, regions, academia

and the public and private sectors to share progress

and contribute expertise as we advance towards Zero

by 30.

RISK MITIGATION

Our biggest risk is a slow start

We, as the four organizations forming the United

Against Rabies collaboration, are working together,

and will continue to work together, to reach Zero by 30,

irrespective of funding. Zero by 30 provides a mid-term

horizon that requires immediate action. Recent model-

ling work shows that this goal is attainable if the

supportive mechanisms critical to its success are put

into place right now (26).

The world has lived with rabies for too long. We need to

harness the momentum of the present global landscape

and seize this opportunity to end human rabies deaths.

Successful elimination efforts in countries supported in

Phase 1 will ensure rapid progress towards the global

goal and generate momentum to drive further country

engagement.

The global strategic plan is a catalytic proposal: invest-

ment in this plan will accelerate the growth, delivery and

impact of our activities. We advocate for investment in

rabies to strengthen health systems and save lives,

and are working with countries to develop sustainable

resource mobilization strategies to implement national

plans.

Strong systems are sentinels

Disease outbreaks can divert attention and resources

from core disease prevention programmes. Our cross-

sector approach promotes national elimination plans

and puts health systems’ strengthening at their core. By

building country capacity and integrating rabies control

with other measures to strengthen health systems,

we will demonstrate the value of country ownership

of disease control and encourage countries to invest

further in successful disease control programmes.

Health and surveillance systems with the capacity to

detect and prevent endemic diseases, especially in

underserved rural areas, are sentinels for detecting

and responding to emerging diseases. Robust national

rabies control programmes can integrate with epidemic

response mechanisms to increase access and reach to

populations at risk.

MONITORING OUR

PROGRESS AND

MANAGING RISKS

Chinese child with her dog

(Photo credit: World Animal Protection

Reaching Zero by 30 will save the lives of children and

the livelihoods of adults. Vulnerable rural communities

will not carry the heavy economic burden imposed by

the disease, from lost income or livestock. Most impor-

tantly, no one will ever suffer in pain and die from this

preventable disease.

Investing in rabies strengthens health systems,

improves equity and access to healthcare and contrib-

utes to sustainable development. The capacity-building

required for rabies elimination is an investment not only

in the elimination of at fatal but preventable disease but

also in building capacity in the world’s most neglected

regions and improving access to health services within

these communities.

CONCLUSION

For the rst time in history, we are united to leverage

existing knowledge, tools and technology in a new way.

Now is the time to act, when we can gather the polit-

ical will to engage and empower and make the societal

changes we need to reach Zero by 30.

The United Against Rabies collaboration is already

working with countries to coordinate and catalyse

global change. Investing in the elimination of rabies will

accelerate progress, as the world works to make this

goal a reality by 2030.

Rabies elimination is feasible: the time to act is now.

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M et al. Estimating the global burden of endemic canine rabies. PLoS

Negl Trop Dis. 2015;9:e0003709. doi:10.1371/journal.pntd.0003709.

2. Baer GM. The natural history of rabies, 2nd edition. Boca Raton

(FL): CRC press; 1991.

3. WHO Expert Consultation on Rabies: third report. Geneva: World

Health Organization; 2018 .

4. Hampson K, Dobson A, Dushoff J, Magoto M, Sindoya E, Cleave-

land S. Rabies exposures, post-exposure prophylaxis and deaths in

a region of endemic canine rabies. PLoS Negl Trop Dis. 2008;2:e339.

doi:10.1371/journal.pntd.0000339.

5. Wilde H. Failures of post-exposure rabies prophylaxis. Vaccine.

2007;25:7605–9. doi:10.1016/j.vaccine.2007.08.054.

6. Coleman PG, Dye C. Immunization coverage required to prevent

outbreaks of dog rabies. Vaccine. 1996;14:185–6. PMID:8920697.

7. Knobel DL, Cleaveland S, Coleman PG, Fèvre EM, Meltzer MI,

Miranda MEG et al. Re-evaluating the burden of rabies in Africa and

Asia. Bull World Health Organ. 2005;83:360–8.

8. Rationale for investing in elimination of dog-mediated human

rabies. Geneva: World Health Organization; 2015 (http://apps.who.

int/iris/bitstream/10665/185195/1/9789241509558_eng.pdf).

9. Rabies is a tripartite (WHO–FAO–OIE) priority. Paris: World Organ-

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10. Global elimination of dog-mediated rabies: report of a global rabies

conference, 10–11 December 2015. Geneva: World Health Organiza-

tion; 2016 (http://apps.who.int/iris/bitstream/10665/204621/1/WHO_

HTM_NTD_NZD_2016.02_eng.pdf).

11. United Nations Sustainable DevelopmentGoals.In: Sustainable

Development Knowledge Platform[website]. New York (NY): United

Nations; 2015 (https://sustainabledevelopment.un.org/).

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OIE durings its 84th General Session (22–27 May 2016). Paris: World

Organisation for Animal Health; 2016 (http://www.oie.int/leadmin/

Home/eng/About_us/docs/pdf/Session/2016/A_RESO_2016_public.

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Agriculture Organization of the United Nations; 2017 (http://www.fao.

org/3/a-i6835e.pdf).

14. Rupprecht CE, Hanlon CA, Hemachudha T. Rabies re-examined.

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rican rabies control network (PARACON): a unied approach to

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doi:10.1016/j.antiviral.2015.10.002.

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ease-prioritization-workshop-508.pdf).

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a concept. Geneva: World Health Organization; 2016 (http://apps.

who.int/iris/bitstream/10665/254044/1/WHO-HTM-NTD-NZD-

2016.6-eng.pdf).

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Vaccines. 2016;2:19. doi:10.1186/s40794-016-0035-8.

20. Fahrion AS, Taylor LH, Torres G, Müller T, Dürr S, Knopf L et

al. The road to dog rabies control and elimination–What keeps us

from moving faster? Front Public Health. 2017;5:103. doi:10.3389/

fpubh.2017.00103.

21. Fitzpatrick MC, Hampson K, Cleaveland S, Mzimbiri I, Lankester

DVM, Lembo T et al. Cost–effectiveness of canine vaccination to

prevent human rabies in rural Tanzania. Ann Intern Med. 2014;160:91–

100. doi:10.7326/M13-0542.

22. Meslin FX, Briggs D. Eliminating canine rabies, the principal source

of human infection: what will it take? Antiviral Res. 2013;98:291–6.

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23. Kallenberg, J. Gavi’s vaccine investment strategy. In: WHO

Product Development for Vaccines Advisory Committee (PDVAC)

meeting -2017 [presentation]. Geneva: World Health Organization;

2017 (http://www.who.int/immunization/research/meetings_work-

shops/PDVAC_2017_GAVI_VIS_Kallenberg_GAVI.pdf).

24. Undurraga EA, Meltzer MI, Tran CH, Atkins CY, Elheart MD,

Millien MF et al. Cost–effectiveness evaluation of a novel integrated

bite case management program for the control of human rabies, Haiti

2014–2015. Am J Trop Med Hyg. 2017;96:1307–17. doi:10.4269/

ajtmh.16-0785.

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control. FAO/GARC Workshop, Rome, 6–8 November 2012 [FAO

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Organization of the United Nations; 2012 (http://www.fao.org/3/a-

i3467e.pdf).

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Elimination of dog-mediated human rabies deaths by 2030: needs

assessment and alternatives for progress based on dog vaccination.

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EPIDEMIOLOGY

Rabies is present on all continents, except for Antarc-

tica, where it is estimated to cause more than 59 000

deaths each year (1) (Figure A1.1). Global mortality esti-

mates are highest in Asia and Africa. Dogs are respon-

sible for 99% of human cases; however, bats are

thought to be the original animal reservoir (2, 3). Rabies

transmission via wildlife other than bats is considered

rare.

PATHOGENESIS AND CLINICAL DISEASE

Rabies is an acute encephalitis or meningoencephalitis

caused by infection with a lyssavirus (2). The virus is

present in the saliva of infected animals, and is trans-

mitted through contact between the virus and wounds

or other mucosal surfaces.

Infection establishes within the peripheral nervous

system, spinal cord and brain. Clinical signs relate to

inammation and brain damage, and include hyperac-

tivity, hallucinations and hydrophobia (furious rabies), or

paralysis and coma (paralytic rabies), followed by death.

In most cases, the incubation period is 2–3 months but

can vary from 5 days to more than 1 year.

Rabies is fatal once clinical signs appear. It differs

from many other infections in that clinical disease can

be prevented through timely immunization, even after

exposure to the infectious agent.

DIAGNOSIS

Clinical diagnosis of rabies is informed by patient

presentation and history of exposure to a suspected

rabid animal (2). Laboratory conrmation of human

rabies can be performed ante-mortem or post-mortem

on saliva, spinal uid or tissue biopsies to detect intact

virions, viral genomic RNA and antibody or antigen.

PREVENTION

Prompt administration of post-exposure prophylaxis,

consisting of thorough wound washing, rabies immu-

noglobulin in severe cases, and a series of human

rabies vaccines, is highly effective in preventing death

in persons exposed to the rabies virus (2). Vaccinating

dogs in parallel to PEP provision is an effective, low-cost

strategy to prevent transmission of rabies virus from

dogs to humans. Education and awareness are key to

prevent bites from rabid animals, promote dog vaccina-

tion and encourage people to seek timely treatment if

exposed to rabies.

REFERENCES

1. Hampson K, Coudeville L, Lembo T, Sambo M,

Kieffer A, Attlan M et al. Estimating the global burden

of endemic canine rabies. PLoS Negl Trop Dis.

2015;9:e0003709. doi:10.1371/journal.pntd.0003709.

2. WHO Expert Consultation on Rabies: third report.

Geneva: World Health Organization; 2018.

3. Knobel DL, Cleaveland S, Coleman PG, Fèvre EM,

Meltzer MI, Miranda MEG et al. Re-evaluating the

burden of rabies in Africa and Asia. Bull World Health

Organ. 2005;83:360–8.

ANNEX 1

What is rabies?

+ +

+ 0

+/- +/-

+/- 0

0 0

Rabies

Endemic dog and human rabies

No information

No dog rabies nor human rabies

Controlled dog rabies

Sporadic dog-transmitted rabies

Endemic dog rabies

Endemicity of dog and human rabies, 2016

Figure A1.1. Endemicity of dog-mediated human rabies (2)

Successful rabies control programmes have been

implemented throughout the world, demonstrating that

elimination is technically feasible in different country

contexts.

In Latin America and the Caribbean, the Pan American

Health Organization (PAHO) has coordinated a regional

programme to eliminate dog-mediated human rabies in

urban areas (since 1983) and rural areas (since 1991).

Concerted efforts across the region have focused

on expanding access to post-exposure prophy-

laxis (assisted by a revolving regional vaccine fund)

(1), completing mass dog vaccination campaigns,

improving rabies diagnosis and surveillance, and

increasing rabies awareness through educational

campaigns and community involvement (2). These

activities led to an impressive and consistent decline in

ANNEX 2

Successful regional elimination in Latin

America and the Caribbean, and proof-of-

concept programmes in Africa and Asia

Figure A2.1. Numbers of human and dog rabies cases reported in Latin

America and the Caribbean (1982–2012) Data courtesy of PANAFTOSA,

Veterinary Public Health – PAHO/WHO

the number of human rabies cases reported across the

region between 1980 and 2010:

• > 98% reduction in laboratory-conrmed dog

rabies cases (from 25 000 to < 300)

• > 97% reduction in human rabies deaths (from

350 to < 10) (2) (Figure A2.1).

In 2016, only eight dog-mediated human rabies cases

were reported in the region, all in Haiti (3).

At the heart of this region-wide success is the political

commitment, dedicated vaccine budget and mass dog

vaccination programmes enacted in all countries, and

technical support from PAHO.

Biennial Regional Meetings of Rabies Program Direc-

tors (REDIPRAs) were crucial for strategic gover-

nance, collaboration and support between countries

and to ensure robust regional surveillance (through

the Regional Information System for Epidemiological

Surveillance of Rabies, or SIRVERA) (3).

Table A2.1. Examples of successful rabies elimination programmes

Location

(reference) Activities Outcomes

Latin America and the

Caribbean

1980–2013

(2, 4)

• Development of regional programmes for

rabies control involving mass dog vaccinations,

PEP provision, surveillance and education

programmes

• Regional surveillance system (SIRVERA)

• Centralized operational strategy

• > 97% reduction in human

rabies cases region-wide

• Zero dog-mediated human

rabies reported in 28 of 35

countrie

Bangladesh

2010–present

(5)

• Over 5-fold increase in government investment

to sustain and expand rabies control activities

in 2017-2022

• Capacity building: training dog vaccinators and

dog catchers

• Switch from dog population control to mass

dog vaccination campaigns

• Free PEP for bite victims

• >90% reduction in human

rabies cases

Mexico

1990–2000

(2)

• Media and community engagement

• Mass dog vaccination campaigns

• National rabies notication Decentralized

surveillance system

• Zero human rabies deaths

Philippines (Visayas)

2010–present

(6, 7)

• Rabies prevention, education and awareness

activities

• Establishment of a national rabies database

• Mass dog vaccination campaigns

• Use of dog vaccine banks

• Free PEP for bite victims

• > 80% decrease in human

rabies cases from 2008 to

2013; >40% reduction from

2008 to 2015

• Two provinces, ve island

municipalities and ve smaller

islands declared rabies-free

South Africa (KwaZu-

lu-Natal)

2007–2014

(7)

• Training and awareness materials for medical

staff and the public

• Dog vaccine banks and strategic dog vaccina-

tion in high-risk “corridors”

• Free PEP for bite victims

• Rabies stimulus packages to support expan-

sion of control activities

• Elimination of human rabies in

KwaZulu-Natal

• Expansion of control activities

to neighbouring areas such as

Eastern Cape, Lesotho and

Swaziland

Sri Lanka

1990–2014

(8)

• National notication of human and animal

rabies cases

• Mass dog vaccination and sterilization

campaigns

• Free PEP for bite victims

• > 85% reduction in human

rabies cases

United Republic of

Tanzania (south-east)

2010–2015

(9)

• Novel mobile phone surveillance system

• Mass dog vaccination campaigns

• Cost-saving switch from intramuscular to intra-

dermal PEP

• >75% reduction in animal bite

cases (proxy for rabies expo-

sure) across project sites

• Local elimination of human

cases on Pemba Island by

2014

REFERENCES

1. PAHO revolving fund. In: PAHO/WHO [website]; 2016

(www.paho.org/revolvingfund).

2. Vigilato MAN, Clavijo A, Knobl T, Silva HMT, Cosivi O,

Schneider MC et al. Progress towards eliminating canine

rabies: policies and perspectives from Latin America

and the Caribbean. Philos Trans R Soc Lond B Biol Sci.

2013;368:20120143. doi: 10.1098/rstb.2012.0143.

3. Del Rio Vilas VJ, Freire de Carvalho MJ, Vigilato

MAN, Rocha F, Vokaty A, Pompei JA, Molina Flores

B et al. Tribulations of the last mile: sides from a

regional program. Front Vet Sci. 2017;4:4. doi:10.3389/

fvets.2017.00004.

4. Vigilato MAN, Cosivi O, Knöbl T, Clavijo A, Silva

HMT. Rabies update for Latin America and the Carib-

bean. Emerg Infect Dis. 2013;19:678–9. doi:10.3201/

eid1904.121482.

5. The Rabies Elimination Program of Bangladesh. In:

WHO/Neglected tropical diseases [website]. Geneva:

World Health Organization; 2017 (http://www.who.int/

neglected_diseases/news/Bangladesh-rabies-elimina-

tion-program/en/).

6. Lapiz SMD, Miranda MEG, Garcia RG, Daguro LI,

Paman MD, Madrinan FP et al. Implementation of an

intersectoral program to eliminate human and canine

rabies: the Bohol Rabies Prevention and Elimination

Project. PLoS Negl Trop Dis. 2012;6:e1891. doi:10.1371/

journal.pntd.0001891.

7. Rationale for investing in elimination of dog-me-

diated human rabies. Geneva: World Health Orga-

nization; 2015 (http://apps.who.int/iris/bitst

ream/10665/185195/1/9789241509558_eng.pdf).

8. Harischandra PL, Gunesekera A, Janakan N, Gongal

G, Abela-Ridder B. Sri Lanka takes action towards a

target of zero rabies death by 2020. WHO South East

Asia J Public Health. 2016;5:113.

9. Mpolya EA, Lembo T, Lushasi K, Mancy R, Mbunda

EM, Makungu S et al. Toward elimination of dog-medi-

ated human rabies: experiences from implementing a

large-scale demonstration project in southern Tanzania.

Front Vet Sci. 2017;4:21. doi:10.3389/fvets.2017.00021.

Furthermore, this experience highlighted the following:

• Different countries have different capabilities

to implement rabies elimination plans. Setting

short-term goals is easier to reconcile with

country budgets, and prevents donor fatigue.

• Data gaps and inconsistent indicators of prog-

ress hamper control efforts. A robust regional

database, such as SIRVERA, helps to ensure

consistent monitoring across countries, and

renew commitment to elimination.

• There is no room for inefciency in the last

mile of elimination. Operational research into

maximizing the cost–effectiveness of last mile

strategies is under way.

Moving forward, an understanding of capacity strength-

ening priorities, and integration of canine rabies control

into the regional action plan, should deliver the impetus

and the resources required to eliminate rabies in the

region by 2022.

Table A2.1 highlights key activities and outcomes of a

selection of rabies elimination programmes in Africa,

Asia, and Latin America and the Caribbean.

ANNEX 3

The theory of change

Objective 1: Elimination driven by effective utilization of vaccines,

medicines, tools and technologies

Outcomes Outputs Major activities

1.1 Rabies is prevented

through increased

awareness and improved

education

1.1.1 Strategies put in place

to educate and create aware-

ness for rabies prevention

Establish awareness and educational campaigns

Implement dog bite prevention strategies

1.1.2 Localized tools and

strategies created to promote

responsible dog ownership

Encourage and educate about responsible dog ownership

Conceptualize cultural differences that impact the societal

role and value of dogs (e.g. ecology, human interaction)

1.2 Rabies is prevented

through increased and

effective dog vaccination

1.2.1 National strate-

gies created and capacity

improved for dog vaccination

programmes

Optimize vaccination strategies

Initiate capacity-building for dog vaccination

Ensure rabies control strategies reach both conned and

free-roaming dog populations

Ensure ≥ 70% “at-risk” population coverage

1.2.2 High-quality dog

vaccine banks established

and vaccines delivered to

countries

Complete design, modelling and validation for stocks and

vaccine banks

Complete safety and quality checks for vaccine stocks and

banks, where relevant

Complete inspection of vaccine stocks and banks along

supply chain, where relevant

1.2.3 Countries supported to

conduct effective dog vacci-

nation campaigns

Identify and reach previously undetected or hard-to-reach

dog populations

Ensure appropriate structures and technologies are utilized

Ensure efciency of supply chain

Ensure trained personnel are available to respond

Implement programmes to match vaccine need with vaccine

demand

Promote guidelines for effective dog population management

1.3 Human deaths from

rabies exposures are

prevented by ensuring

equitable, affordable and

timely access to health-

care, medicines and

vaccines

1.3.1 Improved treatment,

and effective prevention,

of potential and conrmed

rabies exposures in humans

Promote the most safe, efcacious and efcient PEP tech-

niques and IBCM

Ensure PEP availability in primary point of care

Train staff to assess and manage animal bite cases

Employ accurate demand vaccine forecasting techniques

Increase access to and affordability of RIG

Promote less and fewer out-of-pocket expenditures for individuals

Increase palliative care availability for end-stage patients

1.3.2 High-quality and safe

biological banks and stocks

for humans established

Complete design, modelling and validation for stocks

Establish communications, advocacy and engagement for

bank(s)

Dene bank(s) relationship to supply chain

Complete safety and quality checks for stocks

Complete systematic inspection of vaccine stocks along

supply chain

1.3.3 Last mile strategy imple-

mented to reach high-risk

human populations

Identify and reach underserved human populations

Ensure appropriate structures and technologies are utilized

Ensure efciency of supply chain

Ensure trained personnel are available to respond

Ensure vaccine need matches vaccine demand

ANNEX 4

The logic framework for the United Against Rabies collaboration

ANNEX 4

The logic framework for the United Against Rabies collaboration

Objective 2.1: Policies, guidance and governance provide support

Outcomes Outputs Major activities

2.1 Policies and guidelines,

and governance to prevent

human deaths from rabies

exposure are created and

adopted at regional and

national levels

2.1.1 Clear guidance, strat-

egies, priorities and legal

frameworks at global, regional

and national levels provided to

prevent human deaths

Complete WHO and OIE recommendations and FAO guide-

lines

Dene guidelines for regulatory framework

Update and embed stepwise approach to national rabies

elimination policies and plans in line with the global frame-

work

Implementation of One Health approach embedded within

strong human and animal health services

2.1.2 Efcient and effective

governance of regional and

national rabies elimination

programmes established

Establish cross-sectoral working group

Establish roles, responsibilities and accountability

2.2 Appropriate technology

and information are made

available

2.1.3 Technology and health

innovations to eliminate human

deaths from rabies fostered

Incorporate existing tools and leverage existing programmes

Promote ICT-based enablers including surveillance tools

Promote supply chain innovations

Promote innovation into new vaccines and vaccine strategies

Promote innovative rapid and sensitive diagnostics

Promote dog population management tools (e.g. movement

control, contraceptive technology, identication)

Objective 2.2: Reliable data enables effective decision-making

Outcomes Outputs Major activities

2.3 Progress towards the

goal is constantly and

consistently monitored and

reported

2.3.1 Robust disease surveil-

lance in human and animals

established, supported by

improved diagnostics proce-

dures

Initiate capacity-building for laboratory diagnostics

Train staff in surveillance and diagnostic methods

Promote innovative strategies for surveillance and diagnostic

methods

2.3.2 Accurate and comprehen-

sive monitoring for new rabies

cases

Identify, dene and monitor indicators

(e.g. bites, deaths, PEP usages, and clinical and laboratory

data)

Conduct constant and consistent surveillance of cases

Ensure documentation of bite cases

Monitor dog populations (e.g. numbers, geography, demo-

graphics, vaccination status)

Establish and enhance reporting framework and reporting

chain

Assess baselines to evaluate progress and target responses

Conceptualize social factors that negatively affect reporting

Identify and reach areas in need of additional support

Identify and use shortcomings as teaching and learning oppor-

tunities

2.3.3 Regular and high-quality

results reporting on programme

impacts

Conduct frequent performance measurements

Measure progress towards rabies elimination

Showcase proof-of-concept programmes

Demonstrate connections between programme and saving

human lives

Demonstrate cost–effectiveness and return on investment

Create and utilize verication dossier for reaching zero human

rabies cases

Establish “nal inch” strategies

Generate plans for maintenance of rabies elimination once

achieved

Objective 3: To sustain commitment and resources

Outcomes Outputs Major activities

3.1 Key stakeholders are

consistently and compre-

hensively engaged

3.1.1 Increased stakeholder

commitment through effective

advocacy

Implement advocacy materials, roadmaps and strategies

for all stakeholders

Expand the range of and engage unique stakeholders

within all sectors

3.1.2 Sustained advocacy

to highlight importance and

feasibility of rabies elimination

Establish communications and engagement programmes

Promote recognition of rabies as a global public threat and

foster goodwill for elimination

Generate recognition of dog vaccination as the most effec-

tive way to achieve rabies elimination

3.2 Financial and other

resources are effective

and used efciently

3.2.1 Funding commitments

to reach zero human deaths

from rabies ensured and

sustained

Complete and utilize vaccine demand modelling, supply

landscapes and market economic projections

Establish clear resource mobilization strategies

Encourage countries to invest their own funds

Utilize rabies and programme impacts to leverage success

3.2.2 Sustainable programme

nancing strategies created,

resources mobilized and use

monitored

Generate an adequate supplementary budget and complete

costings based on available data

Promote and facilitate cost-sharing mechanisms (e.g.

PPPs)

Identify innovative funding mechanisms

Foster synergies with other programmes

Identify innovative funding mechanisms

3.3. Activities of the

United Against Rabies

collaboration are trans-

parently reported to key

stakeholders

3.3.1 Results and impact of

United Against Rabies collab-

oration regularly monitored

and reported to key stake-

holders

Review of United Against Rabies activities in countries and

regions using programme indicators

Annual review and publication of all activities and budget of

the United Against Rabies collaboration

ANNEX 5

Human and animal rabies

biological banks

CATALYSING ACCESS TO LIFE-SAVING RABIES BIOLOGICALS

Access to rabies vaccines and biologicals is a key component of the global strategic plan, and triggers national

programmes. For both human and animal diseases, biological banks have improved access to affordable, safe

and quality-assured vaccines, stimulated programme activities at all levels for all stakeholders and helped to

convert a vicious cycle of vaccine use to a virtuous cycle (1) (Figure A5.1).

We propose a similar mechanism to increase timely access to affordable human and dog vaccines and rabies immu-

noglobulins to prevent human rabies deaths.

Figure A5.1. Vaccine banks convert a vicious cycle of vaccine use to a virtuous cycle

HOW THE RABIES BIOLOGICAL BANKS

WILLWORK

Biological banks provide a procurement and distribu-

tion mechanism for underutilized biologicals, giving a

catalytic push to help countries improve access to life-

saving vaccines and rabies immunoglobulins. Central-

ized procurement and distribution reduces transac-

tion costs, simplies delivery, ensures a stable supply

of quality-assured vaccine, increases production and

brings pressure on price in exchange for volume.

Our proposal draws on mechanisms and lessons

learned from previous stockpiles for human diseases

such as cholera, meningitis and yellow fever, and the

existing dog rabies vaccine bank of OIE (see Vaccine

banks in action for examples).

We propose the following:

• Tenders to supply vaccines or rabies immuno-

globulin will be issued to suppliers with high-

quality products, who can manufacture suf-

cient biological quantities and ensure timely

delivery.

• Rabies biologicals will be dispatched directly

to countries through organizations and agen-

cies purchasing biologicals for in-country

activities, following existing, dened WHO

and OIE processes when appropriate.

Human rabies biologicals will follow existing best prac-

tices established by WHO, including:

• clearly established criteria for release of

vaccine to countries;

• standardized request forms;

• assured product quality through WHO

prequalication processes;

• effective monitoring and evaluation of biolog-

ical usage; and

• guidance on data required for reporting and

evaluation of biological usage.

Dog rabies vaccines banks established according to

international standards will benet from guidelines,

recommendations and best practices established by

OIE (2). Countries may use the banks to procure quali-

ty-assured dog rabies vaccines at a preferential rate for

use in mass vaccination campaigns.

Existing rabies models will inform initial estimates of

biological needs to supply the banks (3, 4).

BIOLOGICAL BANK’S BUDGET

We anticipate the biological banks to be a self-sus-

taining revolving fund.

Establishing the global human and dog rabies biolog-

ical banks will require an initial investment to support

activities related to supply chain, safety checks for

human biologicals, modelling global rabies biological

requirements, and establishing communications, advo-

cacy and engagement.

To counterbalance currently poor vaccine forecasting

and assure manufacturers of vaccine uptake and

delivery, nancing for the initial purchase of human

and dog rabies biologicals to supply the banks will be

independent of the nancing call for the global strategic

plan.

VACCINE BANKS IN ACTION

Existing vaccine stockpiles such as the global cholera

stockpile and the OIE dog rabies vaccine bank have

created impetus for stakeholders to address neglected

diseases by incentivizing ownership and realization of

effective disease control programmes.

AN EXAMPLE OF A GLOBAL STOCKPILE

Cholera, a disease of vulnerable populations, is respon-

sible for global pandemics and explosive outbreaks.

It is endemic in 50 countries, and poses a risk to an

estimated 1.5 billion people worldwide. In 2013, WHO

established the oral cholera vaccine (OCV) stockpile

to improve outbreak preparedness and response, and

expand vaccine coverage in high-risk areas and popu-

lations (5).

During the rst three years of operation, the stockpile

procured and distributed more cholera vaccine than in

the previous 15 years combined (Figure A5.2). Through

careful management, production of cholera vaccine has

since increased in step with demand. An anticipated

17million doses of OCV were produced and consumed

in 2017, with the potential for production to increase to

25 million doses per annum and an ensuing reduction

in cost per dose in exchange for volume.

The outcomes of creating the OCV stockpile are

greater than simply a procurement and distribution

mechanism for vaccine. The stockpile stimulated GAVI

investment of US$ 150 million, brought an additional

vaccine manufacturer to market, generated programme

activity in-country, and catalysed the formation of the

Global Task Force for Cholera Control. Together, these

outcomes have contributed to a fundamental shift from

disease response, to active prevention and control.

WORLD ORGANISATION FOR ANIMAL

HEALTH (OIE) VACCINE BANKS

In 2012, OIE established a regional vaccine bank

to increase access to quality-assured, affordable

dog rabies vaccines for use in planned vaccination

campaigns. The OIE bank is operational in Asia and

Africa and, as of December 2017, has supplied more

than 19 million dog rabies vaccines to 28 countries (7).

This includes 5 million doses purchased by OIE (with

donor funds), 0.3 million doses purchased directly by

countries and 13.8 million doses purchased by WHO

for country operations.

The OIE Rabies Vaccine Bank can be compared to

a supply agreement. It is managed as a combination

between a rolling stock (held by the vaccine manu-

facturers) and production on demand: vaccines are

produced and delivered, in response to ofcial country

(or WHO) requests approved by OIE, by vaccine

suppliers pre-selected through an international call for

tender.

Access to the OIE Rabies Vaccine Bank by OIE Member

countries is subject to the existence of a national rabies

disease control strategy and supported by a justica-

tory rationale for the use of the vaccines (e.g. to address

an emergency outbreak, as a stimulus to launch a

national strategy). Access should be temporary, and

thus a sustainability plan is also required. Upon receipt

and use of the vaccines, the beneciary must provide

a detailed report on the use of the vaccines, including

impact and lessons learned.

Figure A5.2. Doses of oral cholera vaccines used worldwide (1997–2017)

WC-BS: whole cell/recombinant-B-unit oral cholera vaccine

Source: reference (6)

REFERENCES

1. Abela-Ridder B, Martin S, Gongal G, Engels D.

Rabies vaccine stockpile: xing the supply chain. Bull

World Health Organ. 2016;94:635.

2. Vaccine banks. In: OIE terrestrial manual 2016. Paris:

International Organisation for Animal Health; 2016

[version adopted by the World Assembly of Delegates

of the OIE in May 2016]:1.1.10 (http://www.oie.int/

leadmin/Home/eng/Health_standards/tahm/1.01.10_

VACCINE_BANKS.pdf).

3. Hampson K, Coudeville L, Lembo T, Sambo M, Kieffer

A, Attlan M et al. Estimating the global burden of endemic

canine rabies. PLoS Negl Trop Dis. 2015;9:e0003709.

doi:10.1371/journal.pntd.0003709.

4. Wallace RM, Undurraga EA, Blanton JD, Cleaton J,

Franka R. Elimination of dog-mediated human rabies

deaths by 2030: needs assessment and alternatives

for progress based on dog vaccination. Front Vet Sci.

2017;4:9. doi:10.3389/fvets.2017.00009.

5. Oral cholera vaccine stockpile for cholera emergency

response. Geneva: World Health Organization; 2013

(http://www.who.int/cholera/vaccines/Briefing_OCV_

stockpile.pdf).

6. Pezzoli L. Deployments of the oral cholera

vaccine stockpile, 2013–2017. Wkly Epidemiol Rec.

2017;32:437–52.

7. Vaccine Banks. In: OIE: protecting animals, preserving

our future [website]. Paris: World Organisation for

Animal Health; 2016 (http://www.oie.int/support-to-oie-

members/vaccine-bank).

WHAT IS IBCM?

Dog bites, licks and scratches are extremely common,

but not all dogs are rabid. Even in areas where canine

rabies is endemic, most of these exposures are not

from rabid animals. Integrated bite case management,

or IBCM, offers a means to determine whether a dog

bite is likely to constitute exposure to rabies, and there-

fore if post-exposure prophylaxis is, or is not, indicated

(1).

Providing PEP for suspected or possible rabies expo-

sures, as opposed to providing PEP for all dog bite

victims regardless of risk, has huge potential to reduce

unnecessary use of rabies biologicals. This is partic-

ularly important in situations where the incidence

of rabies in dog populations is low (e.g. following

successful control interventions), but rabies awareness,

treatment-seeking behaviour and therefore treatment

costs for people bitten by dogs remain high.

IBCM provides a strategy for countries to reduce human

treatment costs for rabies, as they concurrently reduce

transmission risk through control of rabies in dog popu-

lations.

HOW DOES IBCM WORK?

IBCM requires clear communication between human

and animal health sectors to (i) determine the risk of

rabies in the biting animal; and (ii) use this information

to assess the risk of rabies exposure in the bite victim,

and provide treatment accordingly. Animals involved in

human exposure that are not available for assessment

are considered rabies-suspect.

Determining whether rabies exposure is suspected

considers risk factors such as:

• Rabies epidemiology in the country – is rabies

present where the bite occurred?

• Severity of exposure – multiple, deep bites,

and bites to the head or neck are higher risk

• Clinical features of the biting animal – does it

appear rabid?

• Vaccination status of the biting animal – vacci-

nated animals are unlikely to have rabies

• Laboratory testing results – to conrm or rule

out rabies in the biting animal

Timely medical and veterinary responses improve case

detection rates and ensure appropriate case manage-

ment. Investigating suspect rabid animals further helps

to prevent human rabies deaths by actively identifying

rabies exposures, and can improve surveillance quality

overall.

IBCM IN ACTION

In a pilot programme conducted in Haiti, IBCM was

more cost–effective (i.e. lower cost per death averted)

and associated with better health outcomes (i.e. more

lives saved) than no IBCM. Further research is needed

to assess the feasibility and impact of IBCM in a variety

of settings and its potential for up-scaling.

REFERENCES

1. Undurraga EA, Meltzer MI, Tran CH, Atkins CY, Elheart

MD, Millien MF et al. Cost–effectiveness evaluation of a

novel integrated bite case management program for the

control of human rabies, Haiti 2014–2015. Am J Trop

Med Hyg. 2017;96:1307–17. doi:10.4269/ajtmh.16-

0785.

ANNEX 6

Integrated bite case management (IBCM)

The stepwise approach to rabies elimination, or SARE,

is a tool to assist countries to develop national plans,

enhance intersectoral collaboration and measure prog-

ress towards rabies elimination (1) . We can adapt SARE

to reect the coherent, best practice approach to rabies

elimination integral to our global strategic plan.

Linked to practical guidance provided by the Blueprint

for Rabies Prevention and Control

(http://rabiesblue-

print.org/), SARE guides countries through the stages

of increased control of dog-mediated rabies. It denes

the criteria for moving from one stage to the next: coun-

tries progress from Stage 0 (endemic with little data or

control capacity) to Stage 5 (zero human rabies deaths)

(Figure A7.1).

Four activities are key across all stages:

• dog vaccination;

• rabies awareness and communication;

• making PEP available and accessible; and

• capacity to diagnose rabies and monitor

incidence

SARE is a self-assessment tool that enables countries

to evaluate what stage they are at, prioritize next steps

to guide policy-makers and objectively assess prog-

ress. It has proven value as a planning tool for individual

countries, and for the development of common regional

elimination strategies.

Created by GARC and FAO, all partner organizations of

the United Against Rabies collaboration were involved

in its conception, and support its use by providing

SARE training in more than 40 countries.

ANNEX 7

The stepwise approach towards

rabies elimination

Figure A7.1 The ve stages of SARE

SARE IN ACTION: A CASE STUDY

FROMETHIOPIA

Ethiopia is estimated to have the second largest number

of rabies deaths of all African countries. In 2016, the

Ethiopian government hosted an intersectoral meeting

to assess progress towards elimination of dog-medi-

ated rabies at national and regional levels.

Participants undertook a self-assessment using the

SARE scoresheet, which allowed activities within

several categories to be marked as accomplished or

pending (2). Categories included: legislation; surveil-

lance; education and communication; prevention

and control; and cross-cutting issues. This exercised

enabled overall assessment of capacity for rabies

control, and analysis of how control measures were

being applied across the country.

The assessment identied several critical gaps,

including poor inter-sectoral collaboration and limited

availability of and access to dog vaccine. Strengths

included the existence of a surveillance system for

rabies, and legislation for outbreak declaration and

response. Overall analysis showed that Ethiopia is

still in the early stages of rabies control (Stage 0.5/5).

SARE enabled key gaps in capacity to be identied and

prioritized. This will allow the national rabies elimination

plan to be accelerated, and Ethiopia to progress more

rapidly towards zero human rabies deaths by 2030.

REFERENCES

1. Developing a stepwise approach for rabies prevention and

control. FAO/GARC Workshop, Rome, 6–8 November 2012

[FAO Animal and Health Proceedings, No. 18]. Rome: Food

and Agriculture Organization of the United Nations; 2012

(http://www.fao.org/3/a-i3467e.pdf).

2. Coetzer A, Kidane AH, Bekele M, Hundera AD, Pieracci

EG, Shiferaw ML et al. The SARE tool for rabies control:

current experience in Ethiopia. Antiviral Res. 2016;135:74–80.

doi:10.1016/j.antiviral.2016.09.011.

References: WHO second Expert Report, WHO fact sheet 99,

Rabies: rationale for investing in the global elimination of

dog-mediated human rabies

To prevent dog bites

To ensure prompt medical help

To increase responsible dog

ownership

Human rabies is 100%

vaccine-preventable

Dog vaccination can

eliminate human rabies

Elimination is feasible

and cost effective

RABIES IS A MAJOR

PUBLIC HEALTH PROBLEM

99 %

of human cases

result from dog

bites

4 out of 10 deaths

are in children

Fatal

once

symptoms

appear

Thorough washing of

the wound with soap,

and vaccine injection

save lives

Vaccinating

of dogs in high-risk

areas breaks rabies

transmission cycle

70%

Raising awareness is essential

•

Tools and technical knowledge exist

•

Proof-of-concept programmes demonstrate

feasibility in different country contexts

•

Throughout the world, most domestic

dogs are accessible for mass vaccination

campaigns

•

All communities should beneﬁt from our

ability to eliminate rabies

deaths / year

59 000

One death

every

worldwide

9 mins

ZERO BY 30

THE GLOBAL

STRATEGIC PLAN

HUMAN DEATHS

FROM DOG-MEDIATED

RABIES BY 2030

TO END

ISBN 978-92-4-151383-8

I8956EN/1/03.18

ISBN 978-92-5-130461-7

9 789251 304617

Cover_20180530.indd 1 01.06.18 20:18