SPEEDIER - Surveillance integrating Phylogenetics and Epidemiology for Elimination of Disease: Evaluation of Rabies Control in the Philippines

Rabies, a horrific but preventable disease, kills over 200 people annually in the Philippines. The National Rabies Prevention and Control Program in the Philippines has catalysed rabies control efforts with some provinces now aiming to declare freedom from disease. However, incursions and outbreaks continue and human deaths still occur. While improved postexposure prophylaxis (PEP) access has reduced mortality, it has proven expensive. Indeed rising PEP use has put a strain on local and national budgets, even as rabies circulation has declined, raising the question of how these efforts can be sustained. Meanwhile, routine rabies surveillance in the Philippines has major shortcomings and is not sufficiently sensitive for international agencies to recognize rabies free areas or to rapidly respond to incursions which remain a risk while rabies circulates in other provinces. As a result, surveillance measures need strengthening and use of PEP needs rationalizing for the Philippines to fully benefit from rabies control measures that are currently underway.

Our overarching aim is to deliver a cost-effective, epidemiologically robust surveillance package that can be rolled out across the Philippines to guide and sustain the elimination of canine rabies. Through implementation research we will develop best practice for an enhanced surveillance approach using Integrated Bite Case Management (IBCM) as a strategy to detect rabid animals, with risk assessment of bite patients triggering epidemiological investigations. IBCM has been identified as a potential strategy that can sufficiently enhance surveillance to enable verification of rabies freedom by international organizations and rapid detection of incursions for effective outbreak responses to maintain rabies freedom. Operationalizing IBCM as a key component of enhanced surveillance will have immediately beneficial applications within the Philippines and is of critical importance for the global campaign to eliminate human rabies deaths by 2030.

IBCM has also been demonstrated as an effective way to improve PEP administration, ensuring at risk persons are treated and unnecessary PEP use is reduced. Within our implementation study, we will conduct a pragmatic stepped-wedge cluster randomized controlled trial to evaluate the potential for cost savings and improved patient care through rationalized PEP. We estimate that if implemented effectively, rationalized PEP could save over $9 million every year in the Philippines.

Focusing on the low socio-economic class provinces of Romblon, Occidental Mindoro, and Oriental Mindoro, that include geographically isolated and disadvantaged communities, SPEEDIER will provide learning opportunities to local health and veterinary professionals and support communities to attain disease freedom, contributing to the Philippines developmental goals (2014 Kalusugang Pangkalahatan ('Universal Health') Road Map). Integrated, intersectoral, surveillance and response systems are advocated by international agencies, but rarely operationalized in resource-poor settings. Using our detailed epidemiological understanding of rabies and experience of deploying new technologies, we will develop an integrated surveillance and response system that enables effective working between sectors at multiple scales of governance. This is important; international agencies like the World Health Organisation and the World Organisation for Animal Health recognize the essential need to develop effective surveillance and sustainable approaches to guide rabies elimination programmes. The tools and best practice produced by SPEEDIER will therefore be invaluable for the global target to achieve zero human rabies deaths by 2030.

SPEEDIER's aim is to deliver a cost-effective, epidemiologically robust, enhanced surveillance and response package to guide and sustain the elimination of rabies from the Philippines. The package includes integration of surveillance and response activities by the human and animal health sectors ('One Health') through a program of Integrated Bite Case Management to improve patient care and trigger early detection of animal rabies cases. As part of the package we will develop a genomic surveillance platform as a decision support tool to inform control activities and assess incursions risks, and undertake epidemiological modeling to inform contingency planning for managing re-emergence and maintaining disease freedom.

We will specifically develop protocols, integrated training and surveillance tools with comprising: 1) risk assessments of bite victims as part of Integrated Bite Case Management; 2) the latest WHO recommended PEP protocols; 2) Epidemiological investigations including animal observation, sample collection and rapid diagnostic testing and 3) use of a mobile phone application for reporting by human and animal health workers and 4) real-time whole genome sequencing of viruses using a multiplex/MinION approach incorporated into genomic surveillance platform for communicating risks of rabies spread and progress towards elimination. This enhanced surveillance will be implemented over across 3 provinces: Romblon, Mindoro Occidental and Mindoro Oriental to generate comprehensive data on dog bite incidence, associated rabies risk, PEP use and circulating viruses. Within this implementation study, a pragmatic stepped-wedge cluster-randomised trial of rationalized use of PEP will assess potential for cost savings and improved patient care.

The tools and best practice produced by SPEEDIER will enable sustainable national roll out and provide a model for the global target to achieve zero human rabies deaths by 2030.

Rabies causes an estimated 60,000 human deaths every year, with at least 15 million people needing costly life-saving post-exposure prophylaxis (PEP). Rabies disproportionately affects developing countries like the Philippines, an ODA compliant country, where it kills 200-250 people annually, mainly children. While empirical evidence supports the feasibility of rabies elimination, there is little research to underpin the formulation of efficient cost-effective strategies for managing the final stages of elimination programs. This project will build the scientific knowledge to support national, regional and global policy frameworks for the progressive elimination of rabies.

The immediate beneficiary of SPEEDIER is the people in the provinces of Romblon, Occidental Mindoro and Oriental Mindoro, especially children. Successful implementation will result in a) annual cost savings of at least $30,000 per province; b) treatment of rabies exposed bite victims who would otherwise be missed; and c) increased case detection. As a result, after 24 months without detection, these provinces can be internationally recognized as Rabies-free. Tailored guidance will also be developed for how to imminently achieve freedom for provinces encountering challenges. Disease freedom will enhance their economies, including emerging tourism industries. SPEEDIER will enable a cost-effective and epidemiologically robust surveillance package to be rolled out across the Philippines to guide and sustain the elimination of rabies contributing to the Philippines' developmental goals (2014 Kalusugang Pangkalahatan ('Universal Health') Road Map). In the long-term, this approach is expected to save more than $9 million per year in the Philippines.

SPEEDIER will improve inter-sectoral collaboration in the Philippines by building effective working relationships between human and animal health workers at local and national levels, informing and empowering them to act more effectively. SPEEDIER will demonstrate the effectiveness of a One Health approach that explicitly recognises interconnected challenges rooted in socio-cultural, economic, policy and technical areas. We will enhance technical skills, surveillance and analytical methods to evaluate and manage rabies outbreaks and to improve public health policy. As a result, the human and animal health sectors as well as policy makers in the Philippines will benefit from programmatic success towards rabies elimination that will act as a template for successfully addressing other development and health challenges. This will be particularly important for other zoonoses and emerging infections that require a One Health Approach.

Through SPEEDIER, the Philippines will contribute to the WHO Global Business Plan for the elimination of human deaths from dog-mediated rabies by 2030. SPEEDIER will operationalise the latest WHO guidelines for rabies surveillance, prevention and elimination and provide a practical model for implementation in similar settings elsewhere. This will be particularly important for GAVI-eligible countries (low- and lower-middle income countries), in anticipation of the 2018 Vaccine Investment Strategy including human rabies vaccine. Knowledge exchange of the Philippines' experience in operationalising guidelines and their successful implementation of enhanced surveillance to verify freedom from rabies can ultimately inform global health policy and practice, supported by WHO, the World Organisation for Animal Health, the Global Alliance for Rabies Control, GAVI, the Vaccine Alliance, the FAO, and global pharmaceuticals.