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Swedberg et al. One Health Implement Res 2023;3:77-96 https://dx.doi.org/10.20517/ohir.2023.02 Page 79

reported annually. Yet, due to incomplete surveillance data, the true number of deaths is presumably higher.

Integrated Bite Case Management (IBCM) is recommended by WHO and global partners as a gold standard
method to strengthen rabies surveillance in LMICs and support the goal of ending human deaths from dog-
mediated rabies by the year 2030 (Zero by 30) [9,10] . Embracing a One Health approach, IBCM fosters
intersectoral collaboration and coordination, acknowledging the interdependence of the health of humans,
[11]
animals, and their shared environment . Previous case studies of IBCM have been implemented in the
Philippines on the island of Bohol and in Albay Province . IBCM utilizes bite patient risk assessments to
[12]
[13]
identify potential rabies exposures from suspect rabid animals, which are then investigated, with samples
collected for laboratory confirmation in dead/euthanized animals. By enhancing surveillance, IBCM has the
potential to provide more accurate estimates of rabies burden and to be used for informing the
implementation of control and prevention measures, including PEP administration decisions to reduce
unnecessary use, and evaluation of the progress/impact of elimination programs, including advocating for
increased investment .
[14]

This study aims to assess the value of integrating an intersectoral surveillance system such as IBCM into
national policy to enhance rabies case detection and support the Philippines in achieving rabies freedom by
2030. In this research, we adapted a decision tree framework with the following objectives: (1) to improve
[15]
the accuracy of estimations for the burden of rabies in the province of Oriental Mindoro; (2) to evaluate the
performance of existing surveillance systems; and (3) to analyze the costs and benefits of current prevention
and control measures, including PEP policies, with extrapolation across the Philippines.

METHODS
From January 2020 to December 2022, we established a 3-year implementation study of IBCM in Oriental
Mindoro Province, Region IV-B, MIMAROPA, Philippines. Here, we utilized a decision tree framework
adapted from previous studies [2,15,16] to estimate annual numbers of rabid dogs, human rabies exposures,
human rabies deaths/disability-adjusted life years (DALYs) averted, the cost per human death/DALY
averted, and the probability of rabies-exposed persons receiving PEP. Within this framework, we used
government health and population data, enhanced surveillance data collected through IBCM, and
parameter values derived from country-specific data and the literature. Model estimates were used to
evaluate current surveillance system performance and analyze the cost-effectiveness of PEP policies for the
province, which were extrapolated across the country. Data analysis and figures were undertaken using the
[17]
R programming language . Code and de-identified data to replicate analyses are provided via the GitHub
repository: https://github.com/boydorr/OrMin_IBCM_decision_tree.

Study site and health/agriculture systems
Canine rabies is endemic throughout Oriental Mindoro [Figure 1], located in the MIMAROPA region
which consists of five provinces: Occidental Mindoro, Oriental Mindoro, Marinduque, Romblon, and
Palawan. With a human population of 908,339 (2020), the province of Oriental Mindoro comprises 15
municipalities, including the capital city of Calapan . At the time of the study, the dog population size and
[18]
demographics (including ownership status) were unknown. As of 2022, there were nine health facilities with
accredited ABTCs administering PEP and nine Rural Health Units (RHU), without ABTCs, providing
wound care and referring patients (to ABTCs) for PEP. Of the nine ABTCs, three were major hospitals
where most bite patients presented, while the other six were community-level clinics that received fewer
patients.