Key Findings
The CARE program in Ilocos Norte, Philippines, effectively curtailed rabies transmission through a comprehensive approach involving mass vaccination, post-exposure prophylaxis (PEP), and public education. Within two years, both human and canine rabies cases were completely eliminated.
Accurately estimating vaccination coverage presented a significant challenge in the CARE program. Due to the lack of immediate post-vaccination assessments, researchers had to rely on estimates of the total dog population. However, different estimation methods yielded substantially varying results.
Personnel expenses were the primary cost component of the vaccination campaign, although the cost per dog vaccinated decreased with increasing vaccination numbers. Expanding the use of volunteers could further mitigate these costs. Conversely, vaccine costs predominated in the overall cost of providing PEP.
Summary
While academic studies have shown that canine rabies elimination is achievable, even in high-risk regions like Africa and Asia, government-led programs often prioritize broad health benefits over detailed impact assessment. This lack of comprehensive documentation hinders our ability to learn from successful initiatives.
A prime example is the Philippines’ National Rabies Prevention and Control Program, which has successfully eliminated rabies in Bohol and Ilocos Norte. The study, “The Ilocos Norte Communities against Rabies Exposure Elimination Project in the Philippines: Epidemiological and Economic Aspects”, provides a detailed case study of this success. By documenting the program’s structure, partnerships, and lessons learned, we can inform future efforts to combat rabies globally.
Background
Ilocos Norte is a province in the northwest of Luzon Island in the Philippines, with a 2015 population of 593,081. The majority of the population (81.3%) resides in rural areas, but poverty rate is relatively low at 12.3% in 2015.
Rabies control in the Philippines is well-supported by legislation, particularly through the Republic Act 9482 (the Anti-Rabies Act of 2007), which outlines mass dog vaccination, responsible pet ownership, and access to post-exposure prophylaxis (PEP). The Provincial Government of Ilocos Norte has local rabies control ordinances that align with the national law.
Before the CARE project, rabies control efforts in Ilocos Norte were sporadic, often triggered by outbreaks, such as one in 2010. From 2008 to 2011, the province reported 19 to 50 confirmed rabies cases in dogs and about 2 human rabies deaths annually.
The Ilocos Norte Communities Against Rabies Exposure (CARE) Project
The Ilocos Norte Communities Against Rabies Exposure (CARE) project ran from April 2012 to September 2016. It was led by the Provincial Rabies Control Committee in collaboration with the Provincial Veterinary Office, Provincial Health Office, and other local agencies. The project received rabies vaccine donations from the World Animal Health Organisation (OIE, now WOAH), along with technical input from the Global Alliance for Rabies Control (GARC).
The project’s goal was to eliminate canine-mediated human rabies cases by 2015 through mass dog vaccinations (targeting 70% coverage) and raising community awareness via school and community programs. The program also introduced a rigorous monitoring system and extensive training for sustainability. After the project ended, local government partners continued implementing its initiatives to maintain public health benefits.
See Also: Full List of Project Key Activities in the CARE Project
Animal Rabies Cases, Dog Bites, and Human Cases
The Ilocos Norte CARE project conducted surveillance of animal rabies cases, dog bites, and human rabies cases in the Philippines. Data was collected from national databases, animal testing laboratories, and municipal agricultural offices’ monthly reports.
Prior to the project (2008-2011), an average of 35.5 dog rabies cases were confirmed annually, with a positive test rate of 38.8%. However, following the project’s implementation, rabies cases in dogs declined. In 2012, only eight dogs tested positive for rabies (23%), but by 2014, all tested negative. Since then, no rabies-suspect animals have been reported by municipal offices. Human rabies cases also decreased from 2012 (two cases) onwards, with none reported after 2014.
Consultations for animal bites increased significantly during the project, peaking in 2014. Around 40% of bite victims were children under 15, and dogs were the primary source of bites. Educational and community-based activities likely increased the reporting of bites, potentially masking any decrease in actual bite incidents. The project’s focus on bite prevention and treatment, including government subsidies for post-exposure prophylaxis (PEP), likely led to a high percentage of bite victims seeking treatment. The decrease in bite consultations after 2014 may indicate a reduction in bite incidents, although further data is needed to confirm this.
Dog Vaccinations and Coverage
Before the CARE project, dog vaccination rates were relatively low, averaging around 12,000 vaccinations per year. In response to a rabies outbreak in 2010, the number of vaccinations surged to over 28,000. The CARE project implemented annual mass dog vaccination campaigns from 2012 to 2016, using both fixed-point and door-to-door strategies and targeting both owned and free-roaming dogs. Coverage increased significantly during this period, reaching 87% of the barangays (the smallest administrative division) and an average of 38,276 dogs vaccinated annually.
Initial estimates of the dog population in Ilocos Norte in 2012, based on historical vaccination data, suggested a population of approximately 35,000 dogs, with a dog-to-human ratio of 1:10. However, these were likely underestimated. To obtain more accurate figures, the CARE project conducted comprehensive dog censuses and community-based surveys.
Beginning 2013, dog censuses were conducted by the volunteers every first quarter of the year before the start of the annual mass dog vaccination. These records yielded estimates of the owned dog population of 76,628 for 2013, 68,655 for 2014, and 63,815 for 2015.
A community-based survey (CBS) was carried out in 2014. Staff conducted house-to-house interviews utilizing cluster sampling of households and completing a structured questionnaire. It found that 65.9% of houses owned dogs, with 71% of those houses owning one or two dogs and 5% more than four dogs. The calculated dog:human ratio was 1:3.8, generating an estimated owned dog population of the province of 149,748, of which 67% were free roaming.
A more comprehensive dog population survey in 2016 refined these estimates, categorizing dogs by human population density. The final estimate concluded a dog-to-human ratio of 1:2.24, with a total population of 278,691 dogs.
Vaccination coverage estimates varied significantly depending on the population data used. While surveys suggested that around 30% of dogs were vaccinated, estimates based on dog population censuses indicated lower coverage rates, ranging from 13.7% to 50%.
One potential improvement for future vaccination campaigns is to use mark-recapture methods to estimate vaccination coverage more accurately. This technique involves capturing, marking, and releasing dogs, followed by subsequent captures to estimate the proportion of marked dogs in the population. This method can provide real-time data on vaccination coverage and help guide targeted vaccination efforts.
Financial Costs of Project
The CARE project analyzed the economic costs of dog vaccination and post-exposure prophylaxis (PEP) in Ilocos Norte. Data was collected from 2012 to 2014 in both urban (Laoag City) and rural (Dingras) areas, and information was gathered through interviews with key personnel.
Dog Vaccination Costs
The cost of vaccinating dogs decreased as the number of vaccinations increased. In Laoag City, the cost fell from $7.03 per dog in 2012 to an average cost of $4.54 over the period of 2012 to 2014. in Dingras Municipality, it was $8.65. Personnel expenses (73% in Laoag City, 84% in Dingras) were the most significant cost, followed by vaccine costs (14% in Laoag City, 6% in Dingras). Local governments provided the majority of funding for the vaccination programs.
Governments must invest in personnel training and resources for successful vaccination campaigns. Utilizing volunteers can help maximize the effectiveness of limited personnel and enhance community involvement. By increasing vaccination numbers and optimizing resource allocation, the cost per dog vaccinated can be reduced.
The cost of providing PEP decreased over time due to increased patient numbers and lower vaccine prices. Vaccines accounted for approximately 70-80% of PEP costs, followed by personnel expenses. During the CARE campaign, patients bore about half of PEP costs, while local governments covered the remaining portion. However, since 2016, the Philippine national government has assumed full responsibility for funding PEP courses for patients.
Miscellaneous
Data From Study:
Rabies / Elimination History
Year of Publication:
2017
External Link:
Valenzuela LM, Jayme SI, Amparo ACB, Taylor LH, Dela Cruz MPZ, Licuan DA, Gamal-Bitao R and Nel LH (2017) The Ilocos Norte Communities against Rabies Exposure Elimination Project in the Philippines: Epidemiological and Economic Aspects. Front. Vet. Sci. 4:54. doi: 10.3389/fvets.2017.00054
https://doi.org/10.3389/fvets.2017.00054