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Page 78 Swedberg et al. One Health Implement Res 2023;3:77-96 https://dx.doi.org/10.20517/ohir.2023.02

Centers (ABTCs) has improved accessibility; however, the resulting upsurge in PEP demand is not sustainable, and
human rabies deaths continue. Dog vaccination coverage also remains inadequate, and it is unclear whether
surveillance is effective.

Methods: Here, we used Integrated Bite Case Management (IBCM) to collect enhanced rabies surveillance data in
Oriental Mindoro Province over a 3-year period (2020-2022). Adapting a probabilistic decision tree model, we
estimated the burden of rabies, evaluated surveillance performance, and analyzed the costs and benefits of current
rabies prevention and control practices in the province.

Results: The incidence of bite patients receiving PEP was high in Oriental Mindoro Province (1,246/100,000
persons/year), though < 3% of presenting patients were deemed high-risk for rabies exposure (24/100,000
persons/year). Using a decision tree model, we estimated that around 73.8% of probable rabies-exposed patients
sought PEP (95% Prediction Interval, PrI: 59.4%-81.1%) and that routine surveillance confirmed < 2% of circulating
animal rabies cases, whereas IBCM resulted in a nearly fourfold increase in case detection. Furthermore, we
estimated that an average of 560 (95% PrI 217-1,090) dogs may develop rabies annually in the province, equating
to 3-5 cases per 1,000 dogs per year. On average, 20 to 43 human deaths were averted by PEP each year in
Oriental Mindoro at an annual cost of $582,110 USD (i.e., $51.44 USD per person) or $20,190 USD (95% PrI
$11,565-79,400) per death averted.

Conclusion: While current practices for PEP provisioning in the Philippines have improved access, a large
proportion of people exposed to rabies (> 26%, 95% PrI 18.8%-40.1%) are still not seeking healthcare. Integrating
an intersectoral surveillance system, such as IBCM, into national policy could greatly improve case detection if well
implemented, with further benefits extending to guidance for PEP administration, potentially reducing unnecessary
expenditure on PEP, and situational awareness to inform control of rabies through mass dog vaccination.
Keywords: Dog-mediated rabies, integrated bite case management, one health, post-exposure prophylaxis,
surveillance

INTRODUCTION
Rabies, a lethal viral zoonotic disease, requires prompt administration of post-exposure prophylaxis (PEP)
[1]
to prevent the onset of infection . Nearly all of the estimated 59,000 annual human rabies deaths are
attributed to transmission through bites from domestic dogs in low- and middle-income countries (LMICs)
[2,3]
across Africa and Asia . However, like other neglected diseases, the true burden of rabies remains
unknown, with only a fraction of human and animal cases reported in official medical and veterinary
records. This assumed underreporting is primarily due to the ineffectiveness and unreliability of passive
surveillance systems in endemic regions, resulting in reduced advocacy, funding, and engagement in rabies
[4,5]
control initiatives . Implementation of effective strategies to enhance case detection is therefore imperative
for championing, guiding, and evaluating rabies control programs to achieve elimination.

Dog rabies was first confirmed in the Philippines in 1910 when a human case was reported and Negri bodies
were identified in the brain of the biting dog . Since then, the national government has been leading rabies
[6]
control efforts aimed at eliminating rabies from the country. In 2007, the National Rabies Prevention and
Control Program (NRPCP) was mandated under the Anti-Rabies Act (Republic Act No. 9482), which
included the widespread establishment of Animal Bite Treatment Centers (ABTCs) and their free provision
[7]
of PEP to bite victims . However, despite this policy’s success in improving the accessibility of PEP, the
number of patients seeking care for dog bites has increased more than fivefold since its introduction (from
[8]
~200 to over 1,000 patients per 100,000 people/year) . Moreover, dog-mediated rabies remains endemic
throughout most of the Philippines and reductions in rabies deaths have plateaued at around 200-300