14.1.1 WHO headquarters
The WHO World Survey of Rabies, created in 1990, was subsequently enhanced by a computerized data management system to process data collected online at country level, known as ‘Rabnet’. The system was improved from 2000 onwards with the addition of new features, such as the production of interactive maps at global and country levels and customized charts, graphs and maps. The database was designed to analyse global trends in the disease as well as regional and national changes. The system was, however, closed down in 2010, as too few individual reports were entered annually into the system by designated national rabies focal points to make analysis of the data meaningful. WHO, the WHO regional offices and collaborating centres on rabies and GARC are studying alternative ways of collecting data and producing annual reports on human and animal rabies. Information on rabies in humans, domestic animals and wildlife should be shared across sectors.
The concept of ‘neglected zoonotic diseases’ emerged at a meeting held at WHO headquarters in September 2005 (2) and was reinforced at international conferences held in 2007 (3) and 2010 (4). The term ‘neglected’ for this group of diseases indicates that they are insufficiently addressed by governments and the international community, and that they are best defined by the people and communities they affect most: poor people living in remote rural areas or urban slums of the developing world. The term is now well accepted internationally. Rabies has unfortunately all the features of a neglected zoonotic disease. It is, however, the disease most amenable to control, as the tools are available. It is the first zoonosis on the list of neglected diseases targeted for regional and eventually global elimination. An interagency meeting proposed investment in a ‘priority neglected zoonotic diseases portfolio’, comprising regional elimination of human–dog transmitted rabies in Latin America and Asia (5). A first costing indicated that about US$ 10 million per annum in external funding for the next 5 years will be required to achieve the expected outcomes by 2016.
Rabies is discussed at length in the first and second WHO reports on neglected tropical diseases (6,7) and is included in the shorter list of targeted
W H O T ec hni ca l R ep or t S er ie s N o. 9 82 , 2 01 3
diseases for regional elimination in the executive summary of the ‘roadmap for implementation’ published in 2012 (8). Rabies is also one of the main viral zoonoses in the technical report of the Disease Reference Group on Zoonoses of the Special Programme for Research and Training in Tropical Diseases (TDR) published by WHO in 2012 (9,10).
Recommendations and a map are available and updated regularly on the risk for contracting rabies (see section 6.8) in the WHO publication International
travel and health, to inform international travellers about the necessity for pre-
exposure prophylaxis, depending on their destination (11).
Since the last Expert Consultation in 2004 and in accordance with its mandate to provide guidance to Member States on rabies prophylaxis, WHO has issued a position paper on rabies vaccines in a series of regularly updated position papers on vaccines and vaccine combinations against diseases of international public health importance (12). This position paper, issued in 2010, was based on the outcome of a WHO consultation on rabies prevention and control in humans and animals held in Annecy, France, in 2009 (13). The position paper, which replaced one issued in 2002, was reviewed and endorsed by WHO’s Strategic Advisory Group of Experts on vaccines and immunization (12). Position papers are designed for use mainly by national public health officials and immunization programme managers and are of interest to international funding agencies, the vaccine manufacturing industry, the medical community, the scientific media and the public.
Since 2002, WHO has maintained a website that provides information on rabies in humans and animals, human and animal vaccines and pre- and post- exposure prophylaxis. It also contains selected WHO reports and peer-reviewed articles. Since 2009, the site has provided information on progress made in implementation of the 5-year (2009–2013) pilot project for human and dog rabies elimination in selected developing countries (KwaZulu-Natal in South Africa, southwestern United Republic of Tanzania and the Visayas in the Philippines) funded by the Bill & Melinda Gates Foundation and managed by WHO (14,15).
14.1.2 WHO regional offices
Asia
The WHO Regional Office for South-East Asia has been proactive in preparing standards and guidelines, issuing recommendations and providing technical support to Member States for the prevention and control of human and animal rabies in the region. It advocates use of cost–effective intradermal vaccination to improve the availability and affordability of modern rabies vaccines, and phasing out of the production and use of nerve tissue vaccine. The production and use of this vaccine has been abandoned since 2005 in Bangladesh, Cambodia, India, the Lao People’s Democratic Republic, Nepal and Viet Nam. The WHO Collaborating
101 Centre for Rabies Diagnostics in Bangalore, India, has introduced direct rapid immunohistochemistry tests into the region in collaboration with the WHO Collaborating Centre for Reference and Research on Rabies at the Centers for Disease Control and Prevention in Atlanta, Georgia, USA, and regional hands-on training in rabies diagnosis was organized in Bangalore in 2010 to train laboratory professionals in the use of these tests.
To consolidate achievements in the control of zoonoses, particularly rabies, in Member States, the regional office has organized meetings (16,17) and prepared a regional strategy for elimination of human rabies transmitted by dogs. The aim is to eliminate human rabies by progressive control of dog rabies and human prophylaxis in rabies-endemic countries and to maintain the status of rabies-free areas in the region by 2020 (17).
Latin America
The programme for elimination of humans rabies transmitted by dogs is led by the Veterinary Public Health unit of the Pan American Health Organization/WHO Regional Office for the Americas in Rio de Janeiro, Brazil. The objectives of the plan for eliminating rabies from the principal cities of Latin America, initiated in 1983, were extended in 1992 to elimination of dog-transmitted rabies in small conglomerates and rural areas. Since 1983, the occurrence of dog-transmitted rabies has diminished steadily, with a reduction of approximately 90% in human and canine cases.
A series of inter-American meetings on health and agriculture at ministerial level is organized by the Veterinary Public Health unit to discuss intersectoral policies and include the regional rabies elimination programme. Every 2 years, the unit also convenes a meeting of the directors of national rabies programmes, at which the epidemiological situation and strategies for prevention of rabies are discussed and updated. The conclusions and recommendations are submitted to ministers of health and agriculture during the interministerial meetings for their consideration and endorsement. The eleventh meeting of the directors of national programmes, held in Brasilia in 2006, recommended elimination of human rabies transmitted by dogs from the hemisphere by 2012, and the fifteenth interministerial meeting, held in Rio de Janeiro in 2008, committed the ministers of health and of agriculture to this goal (18). In 2009, the forty-ninth Directing Council of the Pan American Health Organization in Resolution CD49.R9 proposed 2015 as the target date for regional elimination of all neglected diseases and other poverty-related infections, including rabies (19).
The Regional Information System for Epidemiologic Surveillance of Rabies in the Americas (http://siepi.panaftosa.org.br/) produces reports on human and animal rabies based on official data entered into the system by health and agriculture ministries in Member States. Data from 1970 onwards are available for on-line consultation.
W H O T ec hni ca l R ep or t S er ie s N o. 9 82 , 2 01 3
14.1.3 WHO network of collaborating centres on rabies
A network of collaborating centres on rabies was established almost at the inception of WHO to support WHO activities at country, intercountry, regional, interregional and global levels. The collaborating centres also participate in strengthening the institutional capacity of Member States in terms of information, services, research and training for rabies-related activities such as diagnosis, surveillance, research and monitoring and evaluation of projects and programme for elimination of rabies in humans and animals.
The centres are officially designated by WHO on the basis of a jointly agreed plan of work, usually for 4 years, renewable after annual evaluation of their performance by WHO. The plan of work depends on the expertise or specificity of the centre but usually covers:
■ collection, collation and dissemination of information on rabies;
■ standardization of rabies diagnostic reagents, prophylactic and thera-
peutic substances, as well as methods and procedures for their ap- plication;
■ design and application of appropriate techniques;
■ provision of reference substances and other services;
■ participation in collaborative research under the Organization’s lead-
ership;
■ training, including research training; and
■ coordination of activities carried out by several institutions.
There are 12 designated WHO collaborating centres, most for reference and research on rabies. Five are in Asia, four in Europe and three in the USA (see Annex 8). The WHO Collaborating Centre for Rabies Surveillance and Research hosted by the Friedrich-Loeffler-Institute in Germany produces the WHO Rabies
Bulletin Europe (see section 14.2.2).