Evaluation of country infrastructure as an indirect measure of dog-mediated human rabies deaths

Abstract

Background: Rabies is a neglected disease, primarily due to poor detection stemming from limited surveillance and diagnostic capabilities in most countries. As a result, there is limited ability to monitor and evaluate country, regional, and global progress towards the WHO goal of eliminating human rabies deaths by 2030. There is a need for a low-cost, readily reproducible method of estimating rabies burden and elimination capacity in endemic countries.

Methods: Publicly available economic, environmental, political, social, public health, and One Health indicators were evaluated to identify variables with strong correlation to country-level rabies burden estimates. A novel index was developed to estimate infrastructural rabies elimination capacity and annual case-burden for dog-mediated rabies virus variant (DMRVV) endemic countries.

Findings: Five country-level indicators with superior explanatory value represent the novel "STOP-R index:" (1) literacy rate, (2) infant mortality rate, (3) electricity access, (4) political stability, and (5) presence/severity of natural hazards. Based on the STOP-R index, 40,111 (95% CI 25,854-74,344) global human rabies deaths are estimated to occur in 2022 among DMRVV-endemic countries and are projected to decrease to 32,349 (95% CI 21,110-57,019) in 2030.

Interpretation: The STOP-R index offers a unique means of addressing the data gap and monitoring progress towards eliminating dog-mediated human rabies deaths. Results presented here suggest that factors external to rabies programs influence the successes of rabies elimination, and it is now possible to identify countries exceeding or lagging in expected rabies control and elimination progress based on country infrastructure.

Keywords: country infrastructure; dog-mediated human rabies elimination; dog-mediated rabies; evaluation; human rabies deaths; rabies; rabies surveillance; rabies—epidemiology.

Figure 1

Distribution of average Global Burden Study-Rabies Susceptibility (GBS-RS) Score components among countries included in analysis by sub-regions.

Figure 2

Independent variable selection process for bivariate and multivariate modelling. HAQ = Healthcare Access and Quality; GARC = Global Alliance for Rabies Control.

Figure 3

Categorical assessment of countries by infrastructure and rabies burden.

Figure 4

Projected human rabies deaths and STOP-R index values by country between 2022 and 2030:(A) Estimated STOP-R index values, (B) Estimated human rabies death rate per 100,000 people, (C) Global rabies deaths*. *Median values shown in legend. Countries in grey not included in analysis; death estimates were not calculated for countries without dog-mediated rabies virus variant in panels B and C; Mexico considered DMRVV-free as of 2019.

Figure 5

Models selected to achieve human rabies death rates and estimates for (A) Asia, (B) Africa, and (C) all other countries. GBS-RS Score DR=Global Burden Study-Rabies Susceptibility Score Death Rate.