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Implementation of Intersectoral program to eliminate human and canine rabies.

Harare Metropolitan Province Rabies Prevention and Elimination Program
(HMPRPEP)

Proposal compiled by Lambert F Gwenhure
Assistance provided by the Global Alliance for Rabies Control
Email gwenhure@me.com : mobile +263773375128

Introduction and background
Rabies is a neglected zoonotic disease that accounts for the death of upwards of 59 000 people per
year, with Africa having the highest per capita death rate from rabies as well as an incredible high
burden (Figure 1) (Hampson et al. 2015). The same study not only looked at the global number of
deaths, but also estimated the number of deaths for each individual country and found that
Zimbabwe has approximately 410 people that die due to the preventable disease every year. This
might not seem significant, but the needless loss of life should be considered unacceptable as the
control and elimination of rabies has been show to be both practically and economically feasible
in many locations around the globe.

Figure 1. Annual cost of rabies for the African continent
The control and elimination of rabies relies on four key priorities, viz: i) enhanced laboratory
capabilities, ii) improved access to vaccines, iii) enforcement of responsible pet ownership, and
iv) enhanced public education (Banyard et al. 2013). Although these four key priorities appear to
be easily addressed, a successful rabies control and prevention program must be built around the
strengthening of inter-sectoral collaboration and cooperation between several public health
components in order to adequately address the requirements. Based on the aforementioned fact, a
truly comprehensive inter-sectoral program, relying on the One Health approach, disaggregates
the key priorities into more detailed and specific roles and requirements, with two activities being
considered crucial: Enhanced laboratory capabilities (and surveillance) and improved access to
vaccines.

Enhanced laboratory capabilities
The burden of rabies is demonstrated by surveillance and diagnostic capabilities. If either of
these two activities are lacking, the true burden of the disease cannot be demonstrated and the
cycle of neglect will continue.

Improved access to vaccines
The only feasible, and economical, way to eliminate human rabies is to control and eliminate the
disease in the dog population residing in the same geographical areas as the human population. It
has been shown that a vaccination coverage of 70% provides sufficient coverage to ensure herd
immunity, resulting in the control and elimination of the disease (in both the dog and human
populations). This notion is not new, and most national rabies intervention strategies are focused
on this approach. These national campaigns, however, often spread their resources to widely
resulting in limited vaccination coverage.

It is thus advisable to start a control and elimination campaign in a small location (province) and
then roll out the program to neighboring areas in a wave-like manner as success ensures continued
support and buy-in.
The current situation of rabies in the Harare Metropolitan Province
An unabated rabies outbreak has continued within the Harare Metropolitan Province for at least 3
years (2014 – 2016), with countless people being exposed to potentially rabid animals during that
time period. As such, rabies has become endemic within the Harare Metropolitan Province despite
the presence of vaccination campaigns that are hosted annually throughout the country. The current
endemic cycle of rabies in the Harare Metropolitan Province can be summarized as follows:
 Between 2014 and 2016, there has been 97 rabies-positive animals diagnosed within the
city limits of Harare (Figure 2)

Figure 2. Location and animal species of all rabies-positive cases in the city of Harare
between 2014 and 2016

 During the same time period, more than 2000 people have reported to clinics and hospitals
throughout Harare with animal bites. The majority of these bite cases were recorded from
the suburbs where rabies has been confirmed in the animal populations (Figure 3 and 4).
Figure 3. Location of clinics and hospitals reporting bite cases from dogs for the year 2014

Figure 4. Location of clinics and hospitals reporting bite cases from dogs for the year 2015

Considering the current rabies burden in the Harare Metropolitan Province, it is apparent that the
disease is spreading throughout the city due to the lack of structured disease intervention
campaigns. Without some sort of control program, directed by a group of dedicated professionals
focused on elimination, the outbreak will continue unabated and more humans will die needlessly.
Proposed work
This proposal focuses on the development formation of the Harare Metropolitan Rabies Prevention
and Eradication Council (HMRPEC) as a means to form a unified group that can control and
eliminate the disease within the population of the capital city and the neighboring districts. A
secondary focus of this proposal is to indicate how the project will be structured in order to ensure
progress in a stepwise manner.

Background information
Project area: Harare Metropolitan Province
The Harare Metropolitan Province is one of Zimbabwe’s ten provinces and is host to the capital
city – Harare. Based on the most recent census data gathered by Zimstat, the total population of
the Harare province was 2 123 132, of which 1 025 596 were males and 1 097 536 were females
(Table 1). The data further indicated that the Harare Urban constituted 70 % of the population in
the province, whilst the Chitungwiza, Epworth and Harare Rural districts contributed 17%, 8%
and 5% respectively. Of the population currently residing in the Harare Metropolitan Province,
34% are 15 years or younger while 2% are 65 years and older.

Table 1. Population distribution within the Harare Metropolitan Province
Name Status Population
Census
2012-08-17
Harare Province 2,123,132
Chitungwiza Urban District 356,840
Epworth Urban District 167,462
Harare Rural District 113,599
Harare Urban Urban District 1,485,231
Source: Zimbabwe National Statistics Agency (web).
Proposed program responsibilities
This HMRPEC will consist of a taskforce of professionals based in the Harare Metropolitan
Province, and will be responsible for formulating proposals, measures and strategies that would
ensure the implementation and sustainability of the project, while also being responsible for the
overall implementation of the work.

Proposed program management
At the metropolitan level, the Harare Metropolitan Rabies Prevention and Eradication Council
(HMRPEC) can be established. The HMRPEC unit can be managed under the jurisdiction of the
Harare Metropolitan Provincial Minister of State’s office, working in collaboration with the Harare
City Health Services Department. The canine rabies prevention and elimination component of the
HMRPEC will be coordinated by the by the Provincial Veterinary officer (PVO) whilst the human
rabies prevention and elimination will be managed by the Provincial Medical Director (PMD).

Methodology
1. Knowledge, Attitude and Practice (KAP) studies
KAP studies will be used in order to collect data on the owned dog population (population size,
turnover, and ownership and vaccination status) as well as data regarding the dog-human
relationships. This data will be used to assess the current situation within the Harare Metropolitan
Province and evaluate the outcome of the project and to strengthen preparedness and response to
rabies outbreak.

2. Census of the dog population and dog vaccination
Without determining the estimated dog population size within a project site, the vaccination
coverage cannot be determined and no measures of success can be obtained. This data is
unfortunately very limited in most countries on the African continent, as resource-limited countries
do not have the capacity to undertake dog census programs.

Fortunately, the dog population size can be estimated by relying on a mean human: dog ratio that
has been applied in many studies in many African countries (Knobel et al. 2005). The formula
relies on the mean human: dog ratio being 1:22.2 in urban areas and 1:7.4 for rural areas in Africa
(Knobel et al. 2005). Using this formula, and the known human population of the Harare
Metropolitan Province, it can be estimated that dog population in Harare Metropolitan Province is
approximately 95 700 dogs in Harare.

By relying on the estimated dog population for the Harare Metropolitan Province, an adequate
number of dog vaccines can be purchased in order to ensure that at least 70% of the dogs are
vaccinated annually for three consecutive years. This would result in the Harare Metropolitan
Province incurring approximately USD 45 000 per year for rabies vaccine, and a total of USD
USD 135 000 over the three-year period. Although the procurement of this vaccine would be a
greater capital investment, the cost associated with providing post-exposure prophylaxis to ±1000
bite victims per year over the same three-year period would be approximately USD350 000
(calculations available upon request).

The following data will be collected for monitoring and evaluation purposes in order to determine
the success and progress of the program.
I. Estimated number of vaccinated dogs
II. Covered areas

3. Dog population and management
In order to prevent the introduction of dogs that are not vaccinated into the current population
residing in the study site, the dog population turnover and movement will be restricted and
monitored. The dog population turnover and movement control measures will be guided by
enforcing the existing by-laws and Animal Health regulation acts.

The legal framework for implementing a Rabies Prevention and Control Program (RPCP) will be
guided by the Harare (Dog Licensing and Control) by-laws as follows:
Statutory Instrument 79 of 1993 which was enacted in terms of section 180 of the Urban Council
Act (Chapter 214) as well as the Animal Health Act [Chapter 19:01] and the Public Health Act
[Chapter 15:09].
The Harare (Dog Licensing and Control) by-laws defines the following roles and responsibilities
of the Harare City council:
The organization of dogs and dog ownership (licensing)
I. Limitation of the number of dogs per household
II. Collection of dog ownership license fees
III. Breeding of dogs
IV. Promotion of responsible dog ownership
V. Elimination of stray dogs
VI. Dissemination of information and understanding of the legislation
VII. Settlement of disputes/agreements between bite victims and owners

The Animal Health Act and the Public Health Act takes amongst its responsibility
I. Dog vaccinations
II. Surveillance of human and animal rabies and dog bite cases
III. Dissemination of information and understanding of the legislation

4. Laboratory Diagnosis of animals
Animals involved in bite incidents will, where possible, be placed in quarantine and observed for
10-14 days. Cases where any biting animals demonstrate clinical signs of rabies during the
observation period, including behavioral changes and illness, the animal will be euthanized and
submitted for testing at the Central Veterinary Research and Diagnostic Laboratory (CVL).
Specimen submitted to CVL will be processed and diagnosed using the gold standard direct
fluorescent antibody (DFA) test within a 24 hour period and results will be reported. All of the
diagnostic results will be confirmed by a secondary assay, the direct rapid immunohistochemical
test (DRIT) in a twinning approach to diagnosis.

5. Surveillance
An Integrated Bite Case Management (IBCM) for both human and animal rabies cases should be
established to ensure immediate and reliable transfer of information and follow-up in the case of
human or animal exposure to a confirmed rabid animal. The IBCM consists of Animal Bite
Investigations and Verbal Autopsies, which will be integrated into the existing reporting channel
were bite cases are reported to either the nearest veterinarian or police officer. The fact that rabies
is a notifiable disease should be communicated to all stakeholders so that necessary measures are
taken to avoid or contain outbreaks.

6. Clinical Management of Human Rabies exposures
With reference to the Zimbabwe Rabies Control Guidelines in Human and Animals, each reported
case of human dog bite case will be assessed using the clinical case definition procedure. Medical
personnel will be trained on how to administer post-exposure prophylaxis and handling and
management of human rabies infected patience. The HMRPEC will also lobby the government
and municipality of Harare to subsidize the biologics (vaccines and Rabies immunoglobulin- RIG)
as well as decentralization of the centers where bite victims can access the vaccines.

Other health workers will be asked to familiarize themselves with rabies using different platforms
such as the Global Alliance for Rabies Control (GARC) Education Platform where multiple freely
available courses are available online. These courses include the Rabies Educator Certification
(REC), Community Coordinator for Rabies Certificate (CCC) and the Rabies Healthcare
Certificate (RHC).

7. Information and educational campaign
The education of the public on rabies prevention, responsible pet ownership and humane treatment
of animals should always remain of the highest priority. The following social mobilization plan
can be implemented in order to address this need.
i. Community–focused program to increase awareness and enhance community
participation and support including discussions on rabies as a disease, its epidemiology
and its prevention and control. This campaign can take the form of newspaper, radio
and TV adverts, or can display of flyers and banners at strategic areas
ii. School based education program. This will be designed to improve awareness about
rabies prevention and will be developed and implemented in close supervision with the
Ministry of Primary and Secondary Education.
Communication Management
All communications regarding the HMPRPEP will be managed in such a manner to ensure the
integration of all of the components of the program as it progresses through the development,
initiation, implementation, maintenance and sustainability phases.

As part of the communication strategy a handbook will be developed, published and distributed to
all stakeholders as a reference for all field units working within the program. This handbook will
provide a web of operational activities among stakeholders and a common approach in controlling
rabies within the province

Stepwise Approach toward Rabies Elimination (SARE) assessment of Harare Metropolitan
Province
The HMRPEC activities will be guided, in principles, by the outcome of the Stepwise Approach
toward Rabies Elimination (SARE) tool. The SARE was developed to simplify and capture the
vital information and demarcate the critical steps that need to be achieved in order to systematically
progress the control and elimination of rabies (FAO & GARC 2012). In this manner, governmental
stakeholders and policy-makers are exposed to a simplified, yet comprehensive, tool that enables
productive discussions and establishment of structured decisions that may facilitate any disease
intervention programs. The Rabies Blueprint Platform (http://caninerabiesblueprint.org) plays a
critical role in addressing questions relating to country-specific needs identified through SARE
assessment. In summary, the SARE tool provides countries with measurable stages to progress
from Stage 0 to Stage 5 in their efforts towards becoming canine-rabies free. A country typically
begin at Stage 0, where little or no epidemiological understanding of, or control efforts for, rabies
are in place. The country can then progress to the next stages once certain critical and non-critical
activities have been achieved, until they eventually reach Stage 5 – being canine-rabies free. The
SARE tool is divided into seven relevant categories, viz: legislation, data collection and analysis,
laboratory diagnosis, information, education and communication, prevention and control, dog
population related issues, and cross cutting issues.
Funding
The funding of such a project can originate from Funding for the program can come from cost-
sharing activities amongst the sectors involved.

1. References
2. Banyard, A.C. et al., 2013. Control and prevention of canine rabies: The need for building
laboratory-based surveillance capacity. Antiviral Research, 98(3), pp.357–364.
3. FAO & GARC, 2012. Developing a stepwise approach for rabies prevention and control,
Rome.
4. Hampson, K. et al., 2015. Estimating the global burden of endemic canine rabies. PLoS
Negl Trop Dis, 9(4), p.e0003709.
5. Knobel, D.L. et al., 2005. Re-evaluating the burden of rabies in Africa and Asia. Bulletin
of the World Health Organization, 83(5), pp.360–368.
6. Lapiz SMD, Miranda MEG, Garcia RG, Daguro LI, Paman MD, et al. (2012).
Implementation of Intersectoral Program to Eliminate Human and Canine Rabies: The
Bohol Rabies Prevention and Elimination Project .PLos Negl Trop Dis 6(12).
E1891’dol:10.137/jounal.pntd.0001891
7. Zimbabwe National Statistics Agency (Zimstat), Zimbabwe Population Census 2012,
Provincial Report Harare.
8. Zimbabwe Rabies Control Guidelines in Humans and Animals 1st Edition (2012)