An atypical zoonosis
Rabies, in many ways, is an atypical zoonosis. It continues to feature as a priority disease by multiple national as well as international agencies. There is substantial research evidence regarding its burden, transmission dynamics as well as intervention efficacy.
In addition, rabies is one of the few diseases for which well-structured and scientifically sound templates for developing national control programmes have been created. However, despite all this effort the disconnect between rabies research and policy remains real.
Rabies continues to be classified as a neglected disease by the WHO. The global estimates of rabies incidence have remained constant in the last ten years hovering around 50,000 human cases. Why is it that despite the availability of highly efficacious intervention strategies and sustained research and advocacy, decision makers in Africa and Asia continue to be hesitant of mounting national rabies control programmes?
Given the lack of movement in policy discussions despite the sheer amount of rabies research (relative to other ‘neglected’ diseases), I suggest that those of us working on rabies research and advocacy use the occasion of the World Rabies Day to sit back and reflect upon the reasons we have not been able to convey our insights to decision makers in large parts of the world.
How is it that the researchers and decision makers appear to be talking across each other? Might this be because we are asking the wrong questions? Key messages around rabies control in the recent past have pushed for setting rabies elimination as a goal that is best achieved through canine vaccination. The popular scientific consensus, best encapsulated by WHO is that national mass dog vaccination campaigns are the most cost-effective strategy for preventing rabies.
Statements such as these make several generalisations and, if we are to make any headway, these need to be critically examined.
Framing the problem: Need for a rethink
Rabies elimination is a worthy goal indeed. But given its limited traction, it is worth asking if this target reflects the priorities only of the rabies community or is shared by national governments and affected population groups as well.
While rabies remains a sensitive disease to report, public health officers are often more exercised by dog bite numbers than rabies incidence alone. It is therefore quite likely that interventions advocating for dog bite reduction will find more policy traction than those focussing on rabies elimination alone.
Obviously, if the attention moves from prevention of rabies alone to dog bites control as well, then we will have to start talking about Animal Birth Control programmes that are even more expensive than the canine vaccination programmes (both of which have to be funded in addition to the human vaccination programmes).
Choosing interventions: Making decisions
Another example of the research policy disconnect plaguing rabies discussions relates to the economic evaluations conducted around the disease. Resource allocation is often a zero-sum game for policy makers. Asking them to fund resource-intensive canine vaccination for rabies control might mean taking away funds from a competing social (and political) priority.
Therefore, in order to convince decision makers to go for a particular intervention it will be important to go beyond examining allocative efficiencies using incremental cost effectiveness analysis. We will instead need to develop standards for choosing comparator strategies and study time horizon so that the Incremental Cost Effectiveness Ratio (ICER) values can start to be compared across studies.
Developing standardised composition of intervention packages and incorporating insights from decision analysis will all be required to develop more policy-responsive research around rabies control. Given the recent calls to use rabies as a test case for one health approach, even more important perhaps, is to develop analytic techniques that facilitate analysis and presentation of the costs and benefits of rabies control strategies across multiple sectors and species.
The big picture: Putting values, functions and sectors together
Based upon the above ideas, a group of us thought to ourselves, what would happen when we put together costs and benefits of rabies interventions across human, canine and livestock populations in one matrix? Will such an analysis aid decision making if researchers and decision makers from all these sectors sit together in one room? We got a preview of the exciting possibilities of an integrative approach to research and policy at a recently-concluded meeting in Delhi.
Supported by a Grand Challenge award for bringing animal and human health sectors together, and working with partners across RCZI, PHFI, LSHTM & Yale, we have tried to combine disease transmission and economic evaluation models with decision analytic techniques to present a series of cost and impact results from the perspectives of different sectors drawn from a single integrative database.
We started out our exercise by mapping existing information needs of key rabies stakeholders in India in early 2015. We presented our approach and preliminary findings of a generalized cost effectiveness of rabies control in Tamil Nadu at a stakeholder meeting organized on 7-8 September 2015 in Delhi. The meeting participants consisted of researchers as well as policy makers from animal and human health sectors. Participants included officers from WHO, AWBI, GALVmed, NIVEDI, FIAPO as well as the Departments of Public Health and Animal Husbandry from Government of Tamil Nadu.
We analysed the costs and impacts of different combinations of rabies interventions across human, canine and livestock sectors across a 20-year time horizon. From our analysis, it seems that rabies transmission can be controlled relatively quickly with moderate coverage of canine vaccination. A modified ABC-AR strategy consisting of female-only sterilisation also yielded promising results.
Political economy of rabies
While the precise findings from our study will make for a separate post, even the approach of conducting and presenting our findings received interesting reactions from the group. The complexity of political economy of rabies was highlighted when we polled for the preferred outcome indicators among different sector-specific groups. Dog bite emerged as an equally significant indicator of interest as rabies transmission across most sectors. As mentioned above, this has important implications for rethinking existing rabies control strategies.
Another key finding was that the participants valued different time horizons for the study. The program managers, in particular, were interested in shorter time horizons that could demonstrate quick returns for their investments. The state program officers, in particular, were excited by the possibility of demonstrating benefits of interventions across multiple sectors as it would be helpful to them in making a case for increased budgetary allocation.
While there was some scepticism from the group with regards to sourcing the data from different contexts and for the reductionist nature of mathematical models, there was widespread interest in the utility of such an approach for decision-making in rabies.
It is heartening that the tagline for World Rabies Day emphasises on doing so ‘together’. As I have mentioned elsewhere, the rabies community needs to recognize the complexity of rabies landscape where stakeholders might have different expectations from a rabies control strategy. Instead of chasing silver bullet solutions emerging out of simplistic assumptions of rabies control, we need to engage with the diverse constituency of rabies more closely and co-develop solutions with broader appeal.