SPEEDIER - Surveillance integrating Phylogenetics and Epidemiology for Elimination of Disease: Evaluation of Rabies Control in the Philippines

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Rabies, a horrific but preventable disease, kills over 200 people annually in the Philippines. The National Rabies Prevention and Control Program in the Philippines has catalysed rabies control efforts with some provinces now aiming to declare freedom from disease. However, incursions and outbreaks continue and human deaths still occur. While improved postexposure prophylaxis (PEP) access has reduced mortality, it has proven expensive. Indeed rising PEP use has put a strain on local and national budgets, even as rabies circulation has declined, raising the question of how these efforts can be sustained. Meanwhile, routine rabies surveillance in the Philippines has major shortcomings and is not sufficiently sensitive for international agencies to recognize rabies free areas or to rapidly respond to incursions which remain a risk while rabies circulates in other provinces. As a result, surveillance measures need strengthening and use of PEP needs rationalizing for the Philippines to fully benefit from rabies control measures that are currently underway.Our overarching aim is to deliver a cost-effective, epidemiologically robust surveillance package that can be rolled out across the Philippines to guide and sustain the elimination of canine rabies. Through implementation research we will develop best practice for an enhanced surveillance approach using Integrated Bite Case Management (IBCM) as a strategy to detect rabid animals, with risk assessment of bite patients triggering epidemiological investigations. IBCM has been identified as a potential strategy that can sufficiently enhance surveillance to enable verification of rabies freedom by international organizations and rapid detection of incursions for effective outbreak responses to maintain rabies freedom. Operationalizing IBCM as a key component of enhanced surveillance will have immediately beneficial applications within the Philippines and is of critical importance for the global campaign to eliminate human rabies deaths by 2030.IBCM has also been demonstrated as an effective way to improve PEP administration, ensuring at risk persons are treated and unnecessary PEP use is reduced. Within our implementation study, we will conduct a pragmatic stepped-wedge cluster randomized controlled trial to evaluate the potential for cost savings and improved patient care through rationalized PEP. We estimate that if implemented effectively, rationalized PEP could save over $9 million every year in the Philippines.Focusing on the low socio-economic class provinces of Romblon, Occidental Mindoro, and Oriental Mindoro, that include geographically isolated and disadvantaged communities, SPEEDIER will provide learning opportunities to local health and veterinary professionals and support communities to attain disease freedom, contributing to the Philippines developmental goals (2014 Kalusugang Pangkalahatan ('Universal Health') Road Map). Integrated, intersectoral, surveillance and response systems are advocated by international agencies, but rarely operationalized in resource-poor settings. Using our detailed epidemiological understanding of rabies and experience of deploying new technologies, we will develop an integrated surveillance and response system that enables effective working between sectors at multiple scales of governance. This is important; international agencies like the World Health Organisation and the World Organisation for Animal Health recognize the essential need to develop effective surveillance and sustainable approaches to guide rabies elimination programmes. The tools and best practice produced by SPEEDIER will therefore be invaluable for the global target to achieve zero human rabies deaths by 2030.