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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 93

following exposure (P rabies|exposure ) were from a different context (Tanzania), potentially limiting the accuracy
of results specific to the Philippines. While the probability of infection following exposure (P rabies|exposure ) likely
has minimal variation between contexts, the probability that a rabid dog will bite (P bites|rabid_dog ) may be
context-specific due to differences in factors such as the dynamics of animal/human behaviors within the
community, cultural norms (e.g., whether dogs are allowed to roam), and the density of human and dog
populations. Further research estimating these parameters specific to the Philippines would be useful for
future studies.

Uncertainty in P rabies|exposure had little impact on model estimates; however, P bites|rabid_dog affected estimates of
rabid dogs, and lower assumptions of P obs|death led to estimates of P seekPEP deemed implausibly low for the
province. We consider it reasonable to assume that most human rabies deaths in the Philippines are
reported and captured in provincial and national statistics in contrast to some other contexts, for example,
in Sub-Saharan Africa, where much fewer deaths are reported. This means that the P obs|death parameters used
in this model are specific to the Philippines and would require adjustment when applied to other countries
or regions.

Wider context
Our results from Oriental Mindoro were comparable to findings from other IBCM case studies in the
Philippines. A high incidence of bite patients presenting to ABTCs was found in the provinces of Bohol in
2013 (> 300/100,000 persons per year) and Albay in 2018-2019 (> 600/100,000 persons per year), with most
bitten by healthy animals (> 92% in Bohol and > 97% in Albay) [12,13] . Similar to our estimates from Oriental
Mindoro Province (24 per 100,000 persons per year), these data roughly translate into an estimated
incidence of rabies exposures of 24 (Bohol) and 18 (Albay) per 100,000 persons per year. This consistency in
findings indicates that while PEP-seeking behaviors have increased unsustainably in the Philippines since
the initiation of the free PEP policy in 2007, the average risk of rabies exposure has remained relatively
consistent across much of the country. Moreover, over the last decade, the number of human rabies cases
reported has continued to fluctuate between 200 to 300 deaths per year, despite the continuous expansion of
[7,8]
ABTC infrastructure and increased expenditure on and access to free government-supplied PEP .

Conclusions and recommendations
The NRPCP has executed a comprehensive package of rabies control measures, engaging community and
intersectoral involvement from the national to local level and vastly expanding PEP accessibility. Even so,
the current animal surveillance system does not sufficiently capture the burden of rabies in the dog
population, and dog vaccination coverage remains inadequate. While government-allocated budgets for
rabies control continually shift with different administrations, the human health sector typically receives
funding upwards of tenfold higher than the animal health sector. To achieve rabies elimination, emphasis
must be placed on developing effective strategies and funding dog vaccination to reduce the incidence of
rabies in the reservoir dog population. Although free PEP policies are important to ensure the accessibility
of these emergency measures, they will not eliminate rabies or reduce the risk of exposure.

Our study suggests that for improved access to PEP to remain cost-effective, it should be implemented in
conjunction with strengthened rabies surveillance that provides more accurate data on the risk of exposure
[3]
for bite patients . Using a risk-based approach to inform PEP decisions has the potential to reduce
unnecessary spending on PEP for events that pose no risk of rabies exposure. However, switching to more
judicious PEP provisioning is likely to be difficult in the Philippines given current established practices.
Considerable training and local buy-in would be needed to ensure that health workers are confident and
supported in their decision-making and, more critically, that the risk of rabies exposure is reduced and
ideally eliminated through mass dog vaccination.