ABSTRACT
Background Dog-mediated rabies is endemic across Africa causing thousands of human deaths annually. A One Health approach to rabies is advocated, comprising emergency post-exposure vaccination of bite victims and mass dog vaccination to break the transmission cycle. However, the impacts and cost-effectiveness of these components are difficult to disentangle. Methods We combined contact tracing with whole-genome sequencing to track rabies transmission in the animal reservoir and spillover risk to humans from 2010-2020, investigating how the components of a One Health approach reduced the disease burden and eliminated rabies from Pemba island, Tanzania. With the resulting high-resolution spatiotemporal and genomic data we inferred transmission chains, estimated case detection and quantified the public health burden to evaluate these interventions. Results We resolved five transmission chains co-circulating on Pemba from 2010 that were all eliminated by May 2014. During this period, rabid dogs, human rabies exposures and deaths all progressively declined following initiation and improved implementation of annual islandwide dog vaccination. We identified two introductions to Pemba in late 2016 that seeded re-emergence after dog vaccination had lapsed. The ensuing outbreak was eliminated in October 2018 through reinstated islandwide dog vaccination. While post-exposure vaccines were highly cost-effective ($405 per death averted), their accessibility was limited and only dog vaccination interrupted transmission. A combined One Health approach rapidly eliminated rabies, was highly cost-effective ($1865 per death averted) and saved 20-120 families from rabid dog bites annually. Conclusions A One Health approach underpinned by dog vaccination is an efficient, cost-effective, equitable and feasible approach to rabies elimination, but needs scaling up across connected populations to sustain the benefits of elimination, as seen on Pemba, and for similar progress to be achieved elsewhere. Funding Wellcome [207569/Z/17/Z, 095787/Z/11/Z, 103270/Z/13/Z], the UBS Optimus Foundation, and the DELTAS Africa Initiative [Afrique One-ASPIRE/DEL-15-008] comprising a donor consortium of the African Academy of Sciences (AAS), Alliance for Accelerating Excellence in Science in Africa (AESA), the New Partnership for Africa’s Development Planning and Coordinating (NEPAD) Agency, Wellcome [107753/A/15/Z] and the UK government. The rabies elimination demonstration project from 2010-2015 was supported by the Bill & Melinda Gates Foundation (OPP49679) and whole-genome sequencing was partially supported at APHA by Defra grant SE0421.
ABSTRACT
Background: The Coronavirus disease pandemic reveals political and structural inequities of the world’s poorest people who have little or no access to health care and with the largest burdens of poor health. This is in parallel to a more persistent but global health crisis, antimicrobial resistance (AMR). We explore the fundamental challenges of health care in humans and animals in relation to AMR in Tanzania. Methods: We conducted 57 individual interviews and focus groups with providers and patients in high, middle and lower tier health care facilities and communities across three regions of Tanzania between April 2019 and February 2020. We covered topics from health infrastructure and prescribing practices to health communication and patient experiences. Findings: Three interconnected themes emerged about systemic issues impacting health. First, there are challenges around infrastructure and availability of vital resources such as healthcare staff and supplies. Second, health outcomes are predicated on patient and provider access to services as well as social determinants of health. Third, health communication is critical in defining trusted sources of information, and narratives of blame emerge around health outcomes with the onus of responsibility for action falling on individuals. Interpretation: Entanglements between infrastructure, access and communication exist while constraints in the health system lead to poor health outcomes even in ‘normal’ circumstances. These are likely to be relevant across the globe and highly topical for addressing pressing global health challenges. Redressing structural health inequities can better equip countries and their citizens to not only face pandemics but also day-to-day health challenges. Funding Statement: This research was funded by the Antimicrobial Resistance Cross-Council Initiative through a grant from the Medical Research Council, a Council of UK Research and Innovation and the National Institute for Health Research (MRC/AMR/ MR/S004815/1). Hilton’s time was also funded by a core grant for the Medical Research Council/Chief Scientist Office (MRC/CSO) Social and Public Health Sciences Unit (MC_UU_12017/14; SPHSU14; MC_UU_12017/15; SPHSU15). This publication was supported by the University of Edinburgh and the University of Glasgow Jointly Funded PhD studentships (Loosli).Declaration of Interests: There are no conflicts of interests between the authors and/or institutions.Ethics Approval Statement: The study received approval from the Kilimanjaro Christian Medical University College Ethics Review committee with certificate n. 2408 and the Catholic University Health and Allied Sciences committee with certificate n. CREC/318/2018; National Institute for Medical Research (NIMR), Tanzania, with Reference Number NIMR/HQ/R.8a/Vol. IX/3017; Tanzanian Commission for Science and Technology (Davis, permit n. 2020-335-NA-2019-205; Lembo, permit n. 2020-333-NA-2019-205; Laurie, permit n. 2020-332-NA-2019-205; Mutua, permit n. 2020-334-NA-2019-205; Nthambi, permit n. 2020-336-NA-2019-205; Matthews, permit n. 2019-482-NA-2019-205; and Hilton, permit n.2019-476-NA-2019-205); and College of Medical Veterinary and Life Sciences ethics committee at the University of Glasgow (project application number 200180046). Permission for research in communities was obtained from relevant local and district authorities. All participants were explained study objectives and written and/or verbal informed consent was obtained. Verbal consent was utilised instead of written consent with participants who were unable to write. Informed consent forms and participant information sheets were approved by all ethics panels.