1. Using surveillance to evaluate control efforts Sunny Townsend, Katie Hampson, Sarah Cleaveland, Tiziana Lembo, Zac Mtema Boyd Orr Centre for Population and Ecosystem Health University of Glasgow sunnytownsend@gmail.com

2. Acknowledgements University of Glasgow Katie Hampson, Sarah Cleaveland, Zac Mtema, Tiziana Lembo, Kirstyn Brunker, Elaine Ferguson, Dan Haydon University of Pretoria Darryn Knobel, Louis Nel, Nardus Mollentze Sokoine University of Agriculture Rudovick Kazwala, Gurdeep Jaswant, Khadija Said Ifakara Health Institute Lwitiko Sikana, Joel Chagalucha, Maganga Sambo, Kennedy Lushasi Serengeti Health Initiative Felix Lankester, Imam Mzimbiri, Anna Czupryna, Machunde Bigambo, Kaneja Ibrahim Mangaru, Paulo Charles, Israel Silaa WHO/Bill and Melinda Gates Project, Tanzania Matthew Maziku, Rufaro Chatora, Pelagia Muchuruza Ministry of Health and Social Welfare, Tanzania Geofrey Mchau, Mohammed Mohammed Serengeti rabies surveillance project Matthias Magoto, Cleophas Simon, Zilpah Kaare Department of Health, Philippines Raffy Deray, Joji Jimenez FAO Indonesia Eric Brum, Luuk Schoonman, Ayu PM Dewi Animal Welfare Coalition Mona Consunji, Marlon Pancipane, Ally Policarpio Balinese government and associates Agung, I Ketut Gunata, Helen Scott-Orr Bali Animal Welfare Association Janice Giradi, Gusti Ngurah Bagus,Corlevin Kalalo WHO/Bill and Melinda Gates Project, KZN Kevin Leroux, Daniel Stewart, Keith Perret WHO-BMGF project coordinators Francois Meslin, Anastasia Pantelias, Bernadette Abela- Ridder

3. Gates Foundation – WHO Rabies Elimination Demonstration Projects in Asia and Africa GOAL: To prevent human rabies through control and eventual elimination of canine rabies, creating a paradigm shift for human rabies prevention in Africa and Asia How? By demonstrating the feasibility, sustainability and cost- effectiveness of human rabies elimination through dog vaccination thereby catalysing similar initiatives in Africa and Asia

4. Progress towards rabies elimination

8. What impact has the Gates project made? How much more resources are needed to sustain health gains and progress towards elimination? Progress towards rabies elimination What surveillance data are essential to answer these questions?

9. What impact has the Gates project made? How much more resources are needed to sustain health gains and progress towards elimination? What surveillance data are essential to answer these questions? Progress towards rabies elimination

10. Laboratory based surveillance International standards for elimination Limitations – Case detection from routine surveillance in Tanzania is very low – But has improved in recent years

11. Laboratory based surveillance Even high intensity research only detects 5-10% of cases: During an epidemic in Serengeti district, most dog rabies cases were identified using contact tracing Confirmed ~5-10% of cases This means that for each detected case there are 9 undetected cases on average (95%CI 0-34 undetected cases) What other types of surveillance data can also be useful to assess impacts?

12. Possible indicators to determine impact Incidence – Laboratory confirmed rabies cases – Dog rabies cases based on clinical signs – Bite injuries Intervention – Coverage – Completeness N Tanzania SE Tanzania

13. Dog rabies cases based on clinical signs Not 100% sensitive but useful source of data Laboratory diagnosis +- Clinical diagnosis +5519 -033 Positive predictive value = 74% (95% CIs: 64 - 84%)

14. Bite injury records as indicators of dog rabies infection Limitations Animal bites are not only due to rabid animals Not all bite patients seek treatment However … Useful where it is difficult to diagnose rabid dogs Animal bite records are readily available data in Tanzania Can convert to suspect rabid dogs (Cleaveland et al. 2002)

15. Possible indicators to determine impact Incidence – Laboratory confirmed rabies cases – Dog rabies cases based on clinical signs – Bite injuries Intervention – Coverage – Completeness Need at least one indicator!

16. Possible indicators to determine impact Incidence – Laboratory confirmed rabies cases – Dog rabies cases based on clinical signs – Bite injuries Intervention – Coverage % of dogs vaccinated in a village – Completeness % of villages vaccinated in a district Need at least one indicator!

17. Vaccination coverage Coverage needs to be 70% to interrupt transmission AND make sure the dog population is protected until the next vaccination campaign

18. Estimating vaccination coverage What data do we need, and what is available? Coverage = Count of vaccinated dogs Dog population size We have village level data for numbers of dogs vaccinated from mobile phone surveillance We have district level human:dog ratios (HDRs) extrapolated from a subset of villages from a single household survey in 2011 We have the human population census However….

19. Human population projections Annual growth rates vary from -0.001% - 11.4% per annum Difficulties in estimating dog population sizes and coverage

20. Vaccination coverage (%) Vaccination coverage differs by > 20% using different human population projections

21. Estimating coverage – other ways 1. Household surveys – Lots of effort and therefore expensive – Problems with extrapolation due to community differences Coverage at time of survey = Count of vaccinated dogs in households Total count of dogs in households 2. Mark-resight surveys immediately after vaccination – Effective and cheap if become routine part of campaigns Coverage = Count of marked dogs marked + unmarked dogs Dog population size = Count of vaccinated dogs Coverage

22. Impact of Gates project in SE Tanzania Dog vaccinations have been implemented in every district but not every year High coverage was possible, but many districts only achieved low coverage

23. Impact of Gates project in SE Tanzania Previous incidence in focal area  Incidence in neighbouring areas  Urban areas  Mainland  % coverage  Bite injuries in district ~ BUT THE VACCINATIONS REDUCED BITE INCIDENCE!

24. The importance of completeness

25. Monthly reported rabies cases Serengeti District Elimination prospects depend on completeness of vaccination coverage and rate of re-introductions

26. Monthly reported rabies cases Serengeti District Low vaccination coverage in just 6 out of 75 villages led to resurgence of cases

27. 1978 (17,202 cases) Freuling et al. 2013 Phil Trans B 2010 (7,581 cases) Control: 90% reduction in disease incidence # Campaigns SUCCESS: Rabies free in Finland, Netherlands, Switzerland, Belgium, Luxembourg, Czech republic, Germany, Austria, France, Italy*, Slovakia** (+ Hungary, Lithuania, Estonia) Effort for control = effort for control to elimination Completeness speeded up elimination Elimination: 100% reduction for 2+yrs # Campaigns Control: 90% reduction in disease incidence

28. Unvaccinated villages jeopardize control and elimination Reached all villages 100% success 3 villages missing 99% success 3 clustered villages missing: <90% success 

29. Urgent need to increase campaigns in some districts Measuring completeness % of villages vaccinated Complete vaccination in some districts

30. Essential! Possible indicators to determine impact of interventions Incidence – Laboratory confirmed rabies cases – Dog rabies cases based on clinical signs – Bite injuries Intervention – Coverage – Completeness Need at least one indicator!

31. Progress towards rabies elimination What impact have the Gates projects made so far? How much more resources are needed to sustain health gains and progress towards elimination? What surveillance data are essential to answer these questions?

32. Incidence – Laboratory confirmed rabies cases – Dog rabies cases based on clinical signs – Bite injuries Intervention – Coverage at time of vaccination – Completeness at time of vaccination Sustainability – Costs – PEP demand – Reintroduction risk from outside Gates zone Possible indicators to determine impact and sustainability of interventions

33. Costs Allowances for field staff consistently comprise ~75% dog vaccination delivery costs

34. PEP demand Eventually more judicious administration is required Goes down as disease comes under control ID should reduce costs Goes up initially with awareness

35. Reintroduction risk from infected neighbours Vaccination strategies need to be in place to maintain freedom in landlocked areas Surveillance is critical to detect any incursions and prevent their further spread

36. Surveillance AFFECTS impact Reactive vaccination in response to outbreaks is common in most of rabies-endemic Africa but not effective – Whereas routine mass vaccination (i.e. annual campaigns) is fast and reliable at controlling rabies Most laboratory surveillance in Africa is very poor (i.e. <2% case detection) and cannot determine impact – However 5-10% detection rate is good enough and achievable! – Suspect and bite cases are important indicators and can be made readily available With good surveillance, 6 months with no cases indicates elimination, but 2 more years with continued vaccination almost guarantees elimination  

37. Asante sana!