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

狂犬病是一种可怕但可以预防的疾病，每年在菲律宾造成200多人死亡。菲律宾的国家狂犬病预防和控制计划已经推动了狂犬病控制工作，一些省份现在的目标是宣布摆脱疾病。然而，入侵和疫情仍在继续，人类死亡仍在发生。虽然改善接触后预防（PEP）的可及性降低了死亡率，但它已被证明是昂贵的。事实上，尽管狂犬病的传播有所下降，但PEP使用的增加给地方和国家预算带来了压力，这就提出了如何维持这些努力的问题。与此同时，菲律宾的常规狂犬病监测存在重大缺陷，对国际机构来说不够敏感，无法识别无狂犬病地区或迅速应对在其他省份传播狂犬病时仍然存在风险的入侵。因此，监测措施需要加强，PEP的使用需要合理化，以便菲律宾充分受益于目前正在实施的狂犬病控制措施。我们的总体目标是提供一套具有成本效益的、流行病学上强有力的监测方案，可以在菲律宾各地推广，以指导和维持犬狂犬病的消除。通过实施研究，我们将制定加强监测方法的最佳做法，将综合咬伤病例管理（IBCM）作为发现狂犬病动物的战略，并对咬伤患者进行风险评估，引发流行病学调查。IBCM已被确定为一种潜在的战略，可以充分加强监测，使国际组织能够核实狂犬病是否存在，并迅速发现入侵，以便有效应对疫情，保持狂犬病的存在。将IBCM作为加强监测的一个关键组成部分实施，将立即在菲律宾境内产生有益的应用，对到2030年消除人类狂犬病死亡的全球运动至关重要。IBCM也被证明是改善PEP管理的有效方法，确保有风险的人得到治疗，减少不必要的PEP使用。在我们的实施研究中，我们将进行一项实用的楔形聚类随机对照试验，以评估通过合理化PEP节省成本和改善患者护理的潜力。我们估计，如果有效实施，合理化的PEP每年可以在菲律宾节省900多万美元。该项目将重点关注隆布隆、西民都洛岛和东民都洛岛等社会经济阶层较低的省份，包括地理上孤立和处境不利的社区，为当地卫生和兽医专业人员提供学习机会，并支持社区实现疾病自由，为菲律宾的发展目标（2014年Kalusugang Pangkalahatan（“全民健康”）路线图）做出贡献。国际机构提倡综合的、跨部门的监测和反应系统，但很少在资源贫乏的环境中实施。利用我们对狂犬病流行病学的详细了解和部署新技术的经验，我们将开发一个综合监测和应对系统，使各部门能够在多个治理尺度上有效开展工作。这很重要；世界卫生组织和世界动物卫生组织等国际机构认识到，必须制定有效的监测和可持续的方法来指导狂犬病消除规划。因此，对于实现到2030年实现人类狂犬病零死亡的全球目标而言，speedy提供的工具和最佳做法将是非常宝贵的。

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.