Hi, I'm Radford Davis, and welcome to the discussion on rabies. Rabies is a disease that I consider to be a globally persistent one health problem, and I think no disease. Better, exemplifies the issue of one health than rabies, where we have to have the veterinary health professionals, the human health professionals, and public health all involved in tackling this disease.
Rabies is a disease of antiquity. It's been around a long time and hopefully it won't be around forever, but of all the diseases, zon diseases that I get questions on, rabies is the disease I get the most questions on. So before I get going too far, I want to talk about the objectives.
So hopefully by the end of this discussion, you should be able to name the major animal reservoirs of rabies and related list of viruses and their geographic occurrence. Describe the global burden of rabies on human health, economic impact, and the role of poverty. List the animals that pose the biggest risk for rabies, and the best approach is for control and or elimination of rabies in a geographic area.
Describe and give examples of how animal movements threaten incursion into regions of little or no rabies. And describe policies that can be put into place that can aid in reducing the burden of rabies and speed its elimination. So a little basics about rabies and related viruses.
They all belong to the Rhadovide family, and they are part of the genus Lissa Lissavirus. Long time ago, early in the 20th century, they were all considered to be really rabies. There was only really one virus, and that was rabies virus, but it wasn't until about the 1970s, 1950s to 1970s, that they started to recognise, experts started to recognise that we really have a number of rabies related viruses and so we start to discover more and more of these rabies related viruses.
And so today we now have within the genus Elyssavirus. 14 or more and it seems that every year we're we're discovering new listsaviruses. A little bit about the natural history.
So rabies can infect all mammals. All mammals are susceptible. Only a few of them, however, are good at being reservoirs.
We'll talk more about reservoirs here in just a moment. Rabies causes an acute progressive encephalomyelitis, and it is almost always fatal. So I'm talking about the classical rabies virus here in in in in this discussion, but much of this also applies to lysaviruses.
Lissavirus is also the the non-classical rabies virus lysiviruses also cause encephalomyelitis and can frequently be fatal. So when we talk about prevention, one of the things we're gonna talk about when we talk about the approach, to rabies will also apply to preventing, listsavirus infections as well, and the treatment, and prevention with the, the rabies vaccine, that's also effective against other lysaviruses. So our animal reservoirs for rabies, the most important animal reservoir across the globe is the dog.
The dog is by far the, the, the biggest culprit for human infections. But when we look at globally, the order Carnivora houses a number of animals that serve as reservoirs, terrestrial mammals, raccoons such as skunks, mammals such as skunks, raccoons, jackals, foxes, and the mongoose. Now, in the the new world, bats are also a reservoir for rabies.
In the United States, North America, South America, and in other parts of the world, Africa, Europe, Eurasia, Australia, they are, the bats are reservoirs for these other list of viruses. So we don't have any terrestrial reservoirs for the other list of viruses like we do for the classical rabies virus. Here's a chart showing the latest information that I could find on what we know about Lisa viruses and and and what are out there as of 2018.
When we look at this chart, we see across the top where these these viruses might occur, the continent geographical distribution, the species of Lyssavirus, the mammalian species most frequently infected, the phyloroup, and whether that phyloro is protected against by cross-protected by the rabies vaccine. And then human fatalities reported yes or no. We look at the phyloros here, we see yer groups 1 through 3, with classical rabies virus being phyloro 1.
And then we have groups 2 and 3 occurring throughout parts of Africa, Europe, and Eurasia and Australia as well. So we just look at rabies, we see rabies is occurring worldwide except for Australia, Antarctica, and several several small islands. And it is, predominantly the reservoir is predominantly the dog, and we do have approximately 59,000 human fatalities every year, from, from rabies.
And of course, the, the rabies vaccine does protect against rabies infections. When we jump over to the other, to the right half of this chart, we see in Europe, European bat list of viruses 1 and 2 in the Bola bat virus. All in final group one, and all having bats as a reservoir host, and they all are also cross-protected by the rabies vaccine.
So this means that a person who is exposed to these viruses, we can prevent them from developing disease if they're caught early enough, by administering the, the rabies vaccines. For, European batless virus one, we've had two human case fatalities documented, same for European batless virus 2. So far no case fatalities from the Bola bat virus, that, that I know of.
Incidentally, just a bit of information that when we talk about Lysaviruses, this is coming from Greek mythology, Greek, mythology. Lissa was a goddess or spirit of rage and fury and madness. So it kind of fits with what we know about about rabies.
When we look at the sort of a simplified map and layout of of listsaviruses and and rabies, on the left half we have the new world, and on the right half we have the old world. So in the new world, bats serve as a reservoir for the classical rabies virus. We find humans that that are infected, we find terrestrial mammals that are infected, and wildlife as well as domestic animals, livestock.
On the right half, we have the old world, and, and we have here the list of viruses, starting at the top European bat list of virus one, and with European bat list of virus one we have documented this to occur in Some wildlife, as well as domestic animals. There have been reports of cats. In fact, I think it was in France, the first cases of European batless virus one were reported in France in 2003 and 2007.
European batless virus one has also been reported in sheep, and then you see this icon, next to that, yellow box for European batless virus one of a human. And we have had a couple of human deaths from EDLV one. For European bat list virus 2, we haven't had any crossover into terrestrial mammals, wild or domestic, but we have had two human case fatalities.
And then as you go down the rest of this and you you get to the bottom of this right hand of the map, you see Mola virus, Moolalysavirus, that has been found in a number of wild and domestic, mammals as well as as in humans. This is just a map or a graph I should say, a chart showing the rabies virus variants that have been discovered in the United States in 2015. When we look at this, we can see that, yeah, there is a spillover of rabies virus, to from reservoir hosts into a number of different, other terrestrial mammals, and, and so for when we look on the left under domestic, animals, we see cats.
We found cats infected with the raccoon strain, the different types of skunk strains, and even bat strains. When we look over on the right to the wildlife, we see skunks and raccoons, fairly regularly a mingling of the different variants between these two species because they're both, both terrestrial mammals and frequently we'll we'll get in fights with each other. What we don't see on this, this, chart, this is just 2015.
What we don't see is that in years previous to this. We have documented bad strains in skunks that have circulated skunk to skunk. And this is a bit of a concern because what it means is that we're getting a bad variant now into a terrestrial species and having terrestrial mammal to terrestrial mammal circulation.
It's been very limited circulation, but the concern is that this could grow and then we could have now a new terrestrial mammal rabies variant become endemic. Which we don't want. When we look at Europe, European bat list of virus 1 and 2, this is a study that looked at the the number of reported cases from 1977 to 2010 of EVLV1N2 and one case of Bole bat virus as well.
So in the top in the the box A, this is all European bat list of virus one. Great distribution throughout Europe and in the bottom is European bat list of virus too. So what we see for the top, the top box is, well, there are two, I, I want to also point out that there are two strains of European batless virus, 11 A and one B.
So most of EVLV one is distributed, say, from, most frequently from the Netherlands, northern Germany, Denmark, Poland, France, and down into Spain. When we look at EBLV1A, that's distributed over northern Europe between Netherlands and Russia, and EVLV-1B is found mostly around Western Europe, from Spain to the Netherlands, and Netherlands is the only country that I'm aware of that has had EBLV1A and B, both reported. However, Rabies evolved and we'll come to the discussion a little bit later about the the movement of rabies and the concern, that movement can come from domestic animal transportation, or it can come from wildlife.
And in this case, we now have, just last fall in October. The United Kingdom documented its first case. Of European batless virus one, and this was discovered in a bat found a dead bat found in Dorset.
Now, this is, this is a bit of a concern because it could be a harbinger of of the fact that there probably is more EVLV one in the United Kingdom than than what people are aware. Surely there is more than just one bat in the UK with EVLV one, and I think time will tell and and it's very likely that more cases will be discovered with time. Incidentally, it's, it's estimated about 150 people each year, in, in, the United Kingdom, seek out, post-exposure prophylaxis for exposure to bats and that list of viruses.
So this is a map looking at the sort of a rudimentary distribution of the of the reservoirs. So rabies is enzootic and dogs in most developing countries and common in wildlife in many developed countries, and rabies is also growing to be more important in wildlife in developing countries as well. We'll look at that here in a minute, and that can be.
That can be a burden, very much of a concern to human health as well as, conservation and tourism. So about in the 1960s, somewhere in the 1960s, wild mammals started to replace the dogs, the dominant reservoir throughout many of the developed countries, and today when we look at Europe and and parts of Eurasia. And we look at Eastern Europe, the dog is still a a main reservoir for rabies in eastern Europe and in in areas where Europe borders with the Middle East.
The fox is more of a reservoir in central and eastern Europe and the raccoon dog in northeastern Europe and throughout Europe, as well as many parts of the the old world, we have the insectivs bat as a as a reservoir for many of the listed viruses. This is the type of dog you might see if you visited Africa. Otherwise, we, we like to call this the little brown dog, a dog that, you can see is, is not in terrific terrifically good health, and is intact.
This may be a stray dog, but very likely if you searched around and found somebody to ask and and said, you know, who's whose dog is this? You might be able to figure out that this dog actually, these dogs, both these dogs have owners. So these are the these are the risks to people, right?
Dogs. Account, sorry about that. Dogs account for over 99% of human infections.
And as we'll see a little bit later, vaccination rates for dogs in many parts of Africa are not very good, and, post-exposure prophylaxis in many parts of of Africa for treating humans is not always available. So dogs are very important reservoir, very important vector for rabies and humans. Within the United States, we have 8 terrestrial strains that I just wanted to quickly mention.
We have our raccoon strain on the eastern seaboard. We have the, in the blue, the north central, and in the yellow, the south central skunk strain in the on the west in California, we have our California skunk strain. We have 3 different fox strains.
The grey foxes and in the in Alaska, the Arctic fox, and in Puerto Rico we have the mongoose as a reservoir as well. In addition to having lots of bats. This is a map showing in red all the positive bat isolates that we had in 2015.
In the grey, these are all areas that submitted bats for testing. So the darker the grey, the more bats that were submitted, and lighter grey, fewer bats were submitted. So you can see the throughout the United States we're finding bats in almost every state of the United States with rabies.
More, more bats are being found on the west coast in Texas and in the New England states. But essentially we consider bats to be a a nationwide reservoir for rabies in the United States. I want to turn my attention now to looking at the global burden and role of rabies, the role of, of poverty and rabies.
So rabies, when we look at The ultimate burden of rabies. It has a human and animal health burden. It causes morbidity and mortality.
It has an economic burden from the individual to the local community economic burden up to a national burden. And then it has also a burden on the, the issue of wildlife conservation. As rabies has moved into wildlife, this now threatens conservation efforts, endangered species, biodiversity, and it can threaten local economies that depend on, wildlife conservation, local economies as well as national economies.
So an example of of how rabies is a significant burden can be seen when we look at Peru. So in Peru, vampire bats transmit rabies. They are a reservoir for rabies in Peru, Ecuador, parts of Bolivia as well.
And livestock are very important to about 750 million people worldwide. Who rely on livestock, for a livelihood, so livestock can be used for transportation, for manure, for fertilisation, for fuel, for keeping warm and cooking. Cattle can also be used for dowries, for, bank accounts, emergency funds.
The family faces a crisis, they can sell an animal, get money to meet that that immediate need. Each cow lost can be roughly improve the equivalent to a month's wages, a month's income for a farmer. So, it's estimated about 70% of farmers report nightly attacks of vampire bats on on their cattle.
And more than 700 cattle died in 2014 in Peru, with an estimated value of $170,000. So you can see that can be a significant drain if you own just 4 or 5 cattle, losing 1 can be a very significant burden to you. On average, it's costing in Peru about $12 to vaccinate 10 head of cattle, and amazingly, about 80% of the farmers are reporting that they are vaccinating their cattle.
But cattle aren't the only culprits that are that are bitten by vampire bats. Vampire bats will also, feed on pigs, also feed on sheep, goats, alpacas, and also people. This is a map looking at the endemicity of dog rabies and the human impact, and I want to draw your attention really to the the red areas.
So Africa and many parts of Asia where they have endemic dog rabies and endemic, yearly human fatalities as a result. So a little bit now about the human toll, it's estimated there are 59,000 deaths each year. Sometimes you see this, this figure written as 55,000, 60,000.
The premise behind these is that that they are estimates that there's a lot of underreporting and undocumented death and rabies, so nobody really knows exactly how many people are dying every year, but this is the best guess coming from the World Health organisation. In most of these cases, most of these deaths are occurring in Asia and Africa. 40% of the deaths.
Are occurring in those under 15 years of age. I think this is mostly because these are in children they are less aware of how to approach dogs, how to handle dogs, how to behave around dogs, signs to look for when dogs are aggressive, kids are less likely to Know how to touch or handle a dog or to stay away from dogs, or to recognise signs that the dog might have rabies. 99% of these deaths, again, are due to dog bites.
Most of these deaths are occurring in rural areas and I think much of this can be attributed to the fact that many folks living in rural areas are living in poverty, but also that getting treatment, getting to a facility to get the proper treatment and affording that treatment is very difficult. The, the nearest clinic could be hours away by walk. So those who are poor have the greatest toll, the most difficulty in getting access to care and paying for that care.
Globally, it's estimated that rabies carries an economic burden of $8.6 billion a year, and again, most of this is borne by those who are poor and disadvantaged. When we talk about burden, I feel the need that we need to talk about what's known as the disability adjusted life here.
Prior to about the mid 1980s, when we talked about the burden of disease, much was talked about. The mortality rate of a disease, or maybe the morbidity. But they weren't really combined.
So if you look to disease such as rabies, people always just talked about the mortality rate of of the disease, but it can carry another type of burden. So in the 1980s, World Health organisation created what's known as the disability adjusted life year. This incorporates one lost year of healthy life and is a measure of the gap between current health and ideal health.
And what makes up ad is they, they, they calculate out. Years of a person's life lost prematurely, plus the years lost due to disability. So for example, we can look at a child who might contract rabies at 1010 years of age.
And they die at 10 years of age. They've lost, let's say, 60 years of life. So that carries a significant dally because they they they died so early in life.
If we look at another disease where they they might suffer from disability at the same time, let's say tuberculosis. Well, a person may die, let's say 5 years or 10 years early with tuberculosis, let's say 10 years. But during that entire 10 years that or or or the time that they were sick with tuberculosis.
They weren't able to work, they weren't able to contribute to the family income, and maybe they had to, have long term care in the home or at a clinic. Let's say they lived with 10 for 10 years with this disability of tuberculosis and they died 10 years early. So we had those two together to come up with a dally.
So when we look at the burden in in the context of Glas. We look at Latin America and the Caribbean, they've done, quite a bit in the last few decades to combat rabies at a higher, vaccination rates among dogs. In 2016 they reported 10 deaths in humans due to dog bites, 23 deaths due to, other animals.
In Asia, in 2016, they reported 35, a little over 35,000 deaths, and that represents 60% of all global deaths from rabies, and it's estimated Asia has 2.2 million galleys per year. India accounts for 60% of the deaths that are occurring in Asia, and 35% of the world deaths that are occurring.
Again, there's a lot of underreporting and this is a significant burden for the rural poor in in Asia. It's estimated about In Asia, about 1.5 billion is spent on, on just post-exposure prophylaxis of humans in Asia.
In Africa, they reported a little over 21,000, almost 21,500 deaths, representing 36% of the global death rate, or 1.34 million ds per year. In Central Asia, and Middle East, 1875 and 229 deaths respectively in those two areas, and then you can see the the dleys there about 12,400 in Central Asia and almost 2000 ds per year in the Middle East.
When we look at rabies and compare it to other zonac diseases of public health importance, the top graph we can see deaths per year, rabies does carry a significant mortality rate. Among these diseases listed, it's the highest. It, this chart shows 55,000, but the latest figures from WHO 59,000 for human deaths.
But when you look at Day's, rabies spar exceeds all of the other zoonotic diseases because going back to who's who's a big the, the, a big portion of the deaths, and that is, is in kids. So children who are dying young contribute significantly to these dies because rabies really isn't carrying a disability. You might have a disability from a dog bite, but not from rabies.
You're really either going to survive rabies or you're going to die from that. The valleys really are coming from premature, fatalities. So of that $8.6 billion in economic burden, where is that going?
Well, you can see 54% is lost due to premature death, productivity lost due to premature death. 0.01% is due to collecting data for rabies surveillance, 2% for dog vaccination and population control.
Now this varies. So Latin America. This is 17% in many parts of Asia or Africa, this may be less than 2%.
Livestock losses, again, livestock is very important, you know, to the, to the, to the rural poor, especially, and even though we talk about the economic burden of livestock laws, there's also this burden of, of being able to, have freedom, economic freedom to be able to to make have your own sovereign choices that that having livestock and having that that that wealth derived from livestock offers. Also, there is this, this. This dignity issue that having a burden from rabies or any disease can create the sense of being dependent upon others and and not being able to support yourself.
On the left is the burden coming from medical care, medical treatment, 2% coming from travel costs, 20% direct costs, this is paying for vaccines, paying for the office visit to see the healthcare provider, paying for any necessary drugs, and then 15% lost income seeking treatment, so taking time off of work. So it's estimated for individuals, this life-saving post-exposure prophylaxis or PEP can be hugely expensive, the equivalent of about a month's wages for the average Asian and almost 2 months' wages for, somebody in Africa. And I will also, I should also mention here the the economic burden regarding wildlife conservation and tourism.
So there are certain parts of the world that depend upon tourism for visiting these national parks. And as rabies has moved from dog into wildlife that threatens that tourism, those tourism dollars. For example, the, the, wild African dogs in South African national parks are estimated to be worth about $9000 per year, in tourism draw.
So if those dogs succumb to rabies, or maybe if they even pose a threat, to, to, to human health, that can be a a loss in tourism dollars. Also the rabies post-exposure prophylaxis and dog vaccination. On the left is the average cost of PEP is listed here as $108.
And of course this varies drastically depending upon what part of the world we're talking about. In a country like Sierra Leone, it could be simple, you know, 5 to $8. In the United States, I know, I know my students that we vaccinate, they're paying close to $300 per vaccine.
Up to 80% of savings can be recognised if we use the intramuscular vaccine in humans as an intradermal route. This has been done before in times of shortages and is done in in various parts of the world as well already. But taking a 1 millilitre intramuscular vaccination.
Vaccine and dividing that into 0.1 aliquats, 0.1 mL aliquats and using that to vaccinate.
That has been successful, but I've also experienced, with vaccinating students that way, vaccine failures, so it can be sometimes a hit and miss. In many parts of the world, The PEP does not involve the use, the use of human ras immunoglobulin. In many developed parts of the world where that's available, that can be, that could be offered and used, but in many poor areas of the world that is not available.
So the protocol really is the vaccines, washing of the wound. I can't emphasise enough that the importance of washing the wound, that's probably the most important step, washing a bite wound immediately for 15 minutes with soap and water. And then follow that up with medical care and the vaccines.
So up to 99% of white victims will survive with that prompt wound washing and the vaccine without the rabies immunoglobulin. On the right, mask dog vaccination costs. Average costs of about $4 globally, but again that varies depending upon where you live.
When you look at what are the costs of vaccinating a dog, you see in the orange, the vaccinator costs 57%, so getting people out there with the vaccine to to do the vaccinations, the vaccine cost itself represents only 18% of the cost. So why do people still die of rabies? Well, that's A good question.
A big reason is that it is a neglected tropical disease of the 20. Tropical diseases, the neglected tropical diseases the World Health organisation recognised, rabies is still considered one of them. It's, it's still a fairly rare event compared to many diseases, out there, but the, the problem is is it's highly fatal, so it carries a significant fatality rate.
Low awareness among people and sometimes healthcare providers as to the occurrence of rabies in their their country or their locale, and low awareness as to the the importance of the disease, how to be, how to treat it, or what to do if you're bitten by a dog, for example. When I've worked in Sierra Leone, the first time I was there, we were there to work on the issue of rabies, the national approach to rabies, and how to combat and prevent human cases. And we visited the World Health organisation office.
And we were stunned to learn that at the World Health organisation country office in Sierra Leone, they did not know that rabies occurred in Sierra Leone. They were not aware of that. Why do people still die of rabies?
Well, uncontrolled rabies still occurs in dogs. We, we don't have great vaccination rates all over the world. Lack of access to basic medical care and vaccines by people, especially those who are poor.
And and this includes the PEP and not not necessarily the rabies immunoglobulin, but I think all this combined demonstrates the importance of veterinary involvement and the involvement of of coordinated efforts between veterinarians, health and public health, and this one health, approach to to addressing rabies. This is a chart, a map showing the deaths from rabies. So on the top we see pure numbers of rabies, deaths occurring.
You see that India highlights, that really stands out and it's, with, with over 8100 deaths occurring in rabies, in India. And in the we have death rates. So even though India by gross numbers accounts for the most human case fatalities every year on a per per 100,000 person rate.
Many African countries surpass that. So you look at places like Ethiopia, Somalia, Central African Republic, ***. These are countries that have very high case fatality rates.
In this case fatality rate, prevalence, this, this, this case fatality rate, is, is overlaps nicely, and obviously with the, the poverty rate. You're seen as the extreme poverty rate of 2014, people who are getting by on $1.90 or less per day.
And this, you can see in Central African Republic, where 80 to 100% of the population of that country are extremely poor, but also afflicted with rabies. So on top of the burden of poverty, they're faced with the burden of rabies as well. So health and poverty go hand in hand.
Poor health can impoverish and poverty can lead to poor health. So it follows that by improving one, we can, to some degree, improve the other. So this is why it's so important to understand how these are linked and how we can intervene and improve both.
Cost is a barrier to health. When we look at the burden of rabies, rabies costs money and health care costs money. To see a physician, see a health aide or nurse, to get a test done, to purchase a medical care, or, or a test or to purchase medication, that requires money.
It requires taking time off of work. It requires, maybe travelling, so you have to find transportation, pay for that transportation. You might have to stay in the city, you might have to find lodging and food and all that requires money.
And if you're poor, that keeps people from from seeking care, and that contributes to the death rate and the toll of of rabies. Also, in countries where rabies occurs and many other diseases that are of significant public health importance, when the government is spending money on these diseases, it's diverting money from other important things that that could be spent on to improve life prosperity and health. So as the government spends money on rabies or other diseases like let's say tuberculosis or malaria or TB.
As money goes to those efforts, less money is going to establish more robust health care for the general population, maternal health care, child health care, less money is going to vaccination vaccination campaigns, less money is going to disease surveillance, less money is going to education and gender issues. I'll give you a real life example that that I found in Sierra Leone in 2010 when I was there was this boy, his brother, well, his family lived in a very remote area of Sierra Leone, several hours from the capital. They're very poor family.
This this is a seven year old boy, his brother, 10 year old brother, was bitten by a rabbit dog. And his brother died. This boy was also bitten by the same dog.
This is 2 months post-bite. We, the some of the people we were travelling with learned about this family and brought them to the capital. And the sole reason that this family did not pursue medical intervention and and post-exposure prophylaxis for their children was that they had no car, no means of transportation, no money.
So to get this family into the capital, we brought them in, we paid for the post-exposure treatment of this child, and we put the the family up and provided them the the meals and the housing while they were getting care for their child. But this represents a real, real hurdle for many people around the globe, that poverty can keep people in poor health and lead to a significant burden of rabies. So I want to now focus on the movement of rabies and how this disease can continue to evolve and continue to be a problem.
So movement of rabies, as I've already mentioned, can occur through the movement of wildlife, either wildlife moving on its own or humans interceding and and propelling that along by moving animals for whatever reason. The movement of domestic animals. As well as tourists and citizens going to areas and getting infected and coming back and bringing with them rabies.
So in Europe, Europe eliminated dog rabies in the early 20th century, and they tackled rabies and foxes in the 1980s through the use of the oral vaccine. So the, the threat from rabies in Europe has decreased dramatically from these oral rabies vaccine campaigns. But fox rabies still does exist and and does tend to pose a risk in eastern and southern European areas to some degree.
But the EU has been the driving force since 1989 in in in supporting and advocating for the use of the oral rabies vaccine. So this has led the the use of of oral rabies vaccine really has led to the elimination of terrestrial rabies in much of Europe. When we look at how things have progressed, we see from 1990 to 2012, the number of documented cases of rabies in animals has has decreased dramatically where in by 2012 of the 6000 cases, about a third of those 6000 were coming from, the countries of Ukraine and Russia.
So today many European countries are free of rabies, but rabies is a transboundary disease and can easily cross borders. So in 2008 that happened in Italy, that was, they, they had a reintroduction of rabies in Italy, in Greece in 2012 and Slovakia in 2013. So these border areas are still kind of fragile to the reintroduction of rabies.
So in that that time period that we talked about from 1990 to 2012 of those, we, we talked about having a great reduction in animal rabies cases. During that time period, there were 210 human case fatalities, 31 of these coming from people visiting Europe or sorry, people from Europe visiting Africa or Asia. And then we did have some indigenous cases reported in Eastern Europe, coming from exposure to dogs and, and foxes as well.
So I think this is why it's important that we have an approach to the movement of animals across borders because they can still carry a, a threat of the reintroduction of rabies, to a, a rabies free area. From 200 to 2013, there were 22 cases of importing dogs and cats, into, Europe that were incubating rabies. The threat of incubating, of a dog incubating or a cat incubating rabies, bringing that animal from the United States into the United Kingdom.
Is estimated to be very, very tiny, 7.2 times 10-6. So, and the reason this is so is because the United Kingdom now has significant protocols and policies in place for the importation of of pets from the from the United States.
So this is, this is why it's important to have these, these regulations and policies regarding importation as well as animal movement across borders. And I think I'll just briefly highlight that movement is is evident in in in Europe. When we look at the example here, France.
France had 7 cases of human rabies from 1995 to 2016, and this can come, the, the exposures to rabies are not so really and it's not an indigenous problem anymore because France eliminated rabies back around 2001 in terrestrial mammals. But it's coming from A lot of the post-exposure treatment are is being applied to individuals who had indigenous exposure within France, but really didn't need the PEP so much. But when we look at their other exposures, it's, exposures in other areas, so other territories of France, or overseas territories or are being going outside of France and returning to France.
So you can see in the orange, during that 95 to 2016 time period, over 87,000 cases were treated for PEP for exposure on mainland France. Outside of France, a little over 14,000, almost 15,000 people sought PEP for exposure outside, and then within the French territories, about 4000 people. So some of this is coming from dogs, the exposure to dogs, the administration of PEP from dog exposure.
Sometimes cats and, and wildlife as well. And if I recall, I think some of the concern is, French individuals, going to Morocco and, and, and coming back with, exposures, and concerns, and this is, an image, a news capture that I found late last year of, a Britain who did just that. They visited Morocco, and this was a news report in November.
They were bitten by a dog. And they died of of rabies, unfortunately. So I think again this comes back to the issue of awareness, people being aware of rabies, it's a rare disease, deaths are rare, especially in, in Europe, and the United Kingdom, but being aware of of the risks, while travelling is, is important.
A survey of veterinarians in the United Kingdom, it was a small survey, a small sample size of 44 vets. When they were asked, what do they think about the, the threat of the possibility of rabies reentering Western Europe, 56% thought it was either high or very high. Right, let's look at control and elimination.
So we have today the United Nations countries have really agreed on. Some goals called sustainable development goals in 2015, and these are goals to reach by mostly 2030 to improve health and prosperity, alleviate poverty around the world. We have one sustainable development goal, goal number 3, which really addresses health and in particular would be applicable to rabies.
So by 2030, this target. Is recommending the and advocating for the end of the epidemic of AIDS, TB, malaria, and neglecting tropical diseases, including this would include also rabies since it's a neglected tropical disease. Right, let's talk about prevention of rabies.
So we can prevent rabies by increasing awareness. Through, drawing awareness to how to prevent rabies. So, the, the fact that it's transmitted through, through dogs, dog bites, people could be aware of, that, that, how to avoid dog bites, how to avoid, aggressive dogs while travelling, not to pet dogs.
Being aware of dogs that may be acting suspicious and when to seek care. So if they've been bitten by a dog or been bitten by by a bad or or some other type of exposure that they know to seek care. We can prevent rabies through the use of post-exposure prophylaxis and the widespread use of this.
Through Better, supply, better meeting the needs of poor countries and supplying the poor countries with the vaccines and with immunoglobulin. And through more vaccination of dogs, greater vaccination of dogs, we need to vaccinate 70% of the dog population in order to stop dog to dog transmission. But that is the key right there.
Dog vaccination is the key to stopping rabies and and and reining in the epidemics of rabies and the mortality of, of rabies. So in a, a one mind health, one health mindset, sorry, one health mindset. To, to tackle rabies, we, we build up this infrastructure and awareness, PEP access that can utilise not only the veterinary infrastructure and that, but also the healthcare infrastructure, so there's this, this idea, this thought that we could use the same resources, maybe the same logistics, the same transportation.
The same refrigerators or the same laboratories, the same buildings, maybe even sometimes the same people to bring about this awareness and PEP access for those who need it. So strengthening the human and veterinary health care systems, this will improve our outcomes, this will improve awareness, this will reduce the burden and will maximise the dollars that we're spending on combating and treating rabies. So vaccination is the key in dogs.
We are going to advocate for the use of a vaccine that's at least 2 years in duration. And we never want to turn dogs away from a a vaccine campaign, even if they were just vaccinated one year ago, because we don't want to send the message that that they're not wanted. We want to include everybody and over vaccinating is better than under vaccinating.
And it's OK, even though most of the vaccines are only licenced for vaccinating dogs at 12 months of age or older. If we see a dog under 12 months of age, go ahead and vaccinate the dog with the understanding that that dog should be boostered off as soon as possible. Charging for vaccines in poor areas of the world is not advocated because we have less compliance that way.
There have been programmes that have tried to recoup some of the costs for the vaccine clinics, and it it just never works out very well. So it's best if those vaccines can be paid for ahead of time and administered freely. What about combining vaccination sterilisation programmes?
Well, these really should be funded separately. The prioritisation should be on vaccination, fund the vaccine side of things. And when you have that solidified and established.
Well, then you can bring in the sterilisation, but when we divided up and tried to combine the two, that divides efforts, time, and money. So it's best to try and when we're just focusing on rabies, just focus on the the vaccination. Throw in sterilisation when we can identify money separately for that, and when we already have high vaccination rates.
There has been some thinking in the past that when rabies has made it into wildlife that we need to call wildlife to thin herds to thin populations, and culling in dogs, stray dog populations and in wildlife is never the answer. It's never successful and never really reduces the transmission of rabies. It's it gets a bad image, and from a humane and and public welfare perspective.
It's not effective in an economic perspective and ecologically it, it doesn't make sense either. It's not successful. So, we're not gonna advocate for that.
We're going to tackle rabies, at its source at the dog by achieving 70% plus vaccination rates. Just quickly, here's what an oral vaccine bait looks like in the United States in the top, the traditional bait inside is a packet of vaccine with a tetracycline marker. The packet below is a less costly vaccine packet, just spray coated with a fish meal, and these are distributed in remote areas.
Select remote areas, in the United States by plane, sometimes by hand if these rural areas border more communities or urban areas. So let's talk now about policies to reduce the burden of rabies and eliminate it. WHO, OIE, FAO, and Global Global Alliance for rabies Control have come up with what's called the zero by 30 campaign.
So we want to achieve zero human dog mediated rabies by 2030. To do this, they aim to empower countries and enable countries to achieve the goals that they have set. One of them is 70% plus dog vaccination rate, and as I've already mentioned, mass culling is ineffective.
So what are these ingredients for these the 0 by 30? Well, coming up with a national strategy and committees to support that national strategy, and the idea is that we're going to focus on preparing and implementing, monitoring long term elimination plans. This is gonna be based on local epidemiology of rabies.
That's important local because a rabies is not uniform in a country. It's going to stress awareness campaigns, mass dog vaccinations, and post-exposure prophylaxis and awareness and access. A second component is going to be enhancing the cooperation between veterinarians, veterinary services, public health, and wildlife, and coming together to help design approaches for, elimination in, in humans and animals.
Another component is is supporting the integrating integrated rabies control activities on all levels. So combining what's known and, and what is being done in animal health and in public health and in human health, so that the messages are the same and that the control programmes dovetail nicely with with each other. The idea is we're going to build collaboration, we're gonna build trust among the amongst these these agencies and these entities.
So some other ingredients are developing cooperation and trust between pharmaceutical industry and institutions so that we can get the vaccines into the country, out to the local areas where they're needed, both the human side and the animal side, find storage, find delivery mechanisms, keep the vaccines cold, get them into the hands of people who know how to use them and deliver them to the right people. Seeking funding is is a component both at national and international level, conducting education campaigns for dog about dog ownership responsibility, being aware of of the the threats dog pose, caring for bites, if you're a recent bite victim, what to do if somebody was bitten, and how to avoid dog, rabies and exposures, of rabies. Strengthening surveillance and diagnostic capacity on the human and animal side, and instituting cross-border collaboration with universities, with other institutes, other governments.
So here are their objectives. They have 3. Objective 1, to effectively use medicines, tools, and technologies.
So here they're reducing the human risk by improving awareness and education, increasing access to healthcare and dog vaccines. Objective 2, generate, innovate and measure impact. Again, creating effective policies, guidance, and making decisions based on evidence.
And then objective 3 sustaining the commitment and resources. This is about also finding money to, we're we're making these connections between agencies, between institutions, between governments, but it's also finding money to sustain those collaborations and also finding money to sustain the the campaigns within the country. Funding for these campaigns you can see here, we are in the midst globally of funding a startup in 29 countries for $16.5 million.
Phase two will be the scale of adding 52 more countries from 2021 to 2025 at the cost of $21 million and then a mop up this will occur with the addition of 19 countries, hopefully by 2030 we will end up with zero deaths of rabies, with a cost of about $50 million and you'll notice this is, this is occurring in 100 countries. Rabies is estimated to be in about 154 countries, but this will be quite quite a bit of, of the dog mediated rabies will be addressed by by these, by these objectives in these countries. So where's the money going for phase one?
You can see most of it is going to support national preparation capacity building. 28% is going for, advocating support and prioritising rabies elimination. And then, 12% it's going for establishing establishing global norms and standards and promoting rabies awareness and responsibility.
One of the things that is not supported by these budgets. Is the the activities within the country, the sustainable plans within the country to carry out the rabies initiatives, rabies vaccination awareness campaigns, building diagnostic capability. Right now, much of that, seems to be, on the shoulders of the country themselves.
So we'll see. I think that may be an area where, There may be some, some some fall in in achievement that in poor countries where they have to fund some of these, these programmes and initiatives on their own. Yes, they'll get help from WHOO FAO and GARC in setting up.
And establishing these these protocols, but carrying them out will come to the country to, to be funded by that that country. So I think that that could be an area that will be difficult for many countries to make that final push and achieve 00 rabies transmission. Just a couple of websites that I wanted to throw out, Global Global Alliance for rabies Control and the canine rabiesblueprint.org.
Both good websites were looking at the global elimination of rabies. And that concludes my discussion on global issue of rabies, the burden of rabies, and a a one health burden still, and I hope that has been, educational and enlightening. Thank you.
