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Page 82 Swedberg et al. One Health Implement Res 2023;3:77-96 https://dx.doi.org/10.20517/ohir.2023.02

Institute for Tropical Medicine (RITM) in Manila for confirmatory DFA. All diagnostic test results for
samples from Oriental Mindoro were consolidated in RADDL records.

To summarize bite patient characteristics, we relied on Provincial Health Office (PHO) quarterly and
annual reports compiled from ABTC patient logbooks. Initially recorded on paper, these records were later
entered electronically at the end of each month. Collected for the National Rabies Information System
(NaRIS) since 2007, these records included patient details such as demographics, wound location, WHO
category of contact, species of biting animal, and information about PEP administration and compliance .
[21]
These data were used to estimate the incidence of bite patient presentations for prospective comparison
with IBCM records to determine the completeness of risk assessments performed (numerator) over total
bite patients visiting ABTCs (denominator), and for subsequent extrapolation. We used reports from
investigations of human deaths by the PHO to summarize human rabies cases from 2020-2022.

Lastly, we utilized PHO budget/procurement reports to gather data inputs related to PEP costs, including
the average number of doses received per bite patient, as well as the frequency of ERIG usage. For
estimating PEP costs, we considered both human rabies vaccine and ERIG expenses. However, the estimates
used to evaluate cost-effectiveness did not include PEP administration costs (e.g., personnel, syringes, etc.),
as these were covered by the health system budget. When extrapolating estimates across the Philippines, we
referred to NRPCP/DOH records to determine the average number of bite patient presentations and human
[8]
rabies deaths reported nationally .

IBCM data
IBCM data were collected over 3 years (January 2020 to December 2022). ABTC nurses received training to
perform risk assessments for bite patients, while animal health workers from the MAO were trained to
investigate suspect animals. In addition to data required for NaRIS, we requested nurses to record
information about the biting animal (e.g., health, vaccination, and ownership status) and circumstances of
the bite event. Similarly, animal health workers were tasked with collecting initial and follow-up data on the
biting animal throughout the observation period, requesting Pro-Vet support to euthanize if necessary,
collecting, storing, and transporting samples to RADDL, and conducting LFD testing in the field. Risk
assessment and animal investigation data were submitted via standardized forms through a bespoke mobile
[22]
phone-based application adapted for the Philippines . IBCM data for this study were not integrated into
NRPCP records.

IBCM protocols specified that nurses trigger an investigation by contacting their designated animal health
counterpart at the MAO if the biting animal was suspected of rabies. Animal health workers would then
conduct the animal investigation either via phone or in person. If the animal was found alive and healthy,
MAO staff would follow up with the animal owners over the 14-day observation period, as specified by
NRPCP guidelines (Administrative Order No. 2018-0013) . In cases where the animal displayed signs of
[7]
rabies, protocols dictated that the Pro-Vet should assist in euthanizing the animal, and a sample should be
collected to test for rabies. However, animals had often died or were killed by the owners/community prior
to the investigation.

If the animal died or was euthanized, a brain sample was collected by trained MAO or RADDL staff for
diagnostic testing, usually within one day. LFDs (BioNote, Inc, Hwaseong, Korea) were provided to animal
health workers and RADDL staff for in-field and laboratory-based testing. Findings from a study in the
Philippines (184 samples) reported Bionote LFD sensitivity of 0.95 and specificity of 1.00 compared to DFA
results . For the majority of cases, the MAO staff brought the animal’s head or carcass to RADDL for
[23]