• Peter Costa
  Global Alliance for Rabies Control, USA
  
• Deborah J. Briggs
  Global Alliance for Rabies Control, USA

INTRODUCTION

Most readers of this chapter will have a specific image of fear and horror in their mind when they hear the word “rabies” and yet few people truly understand the actual disease itself including how they might be exposed to the virus causing rabies and what the current recommendations are in the event that they were exposed. Increasing awareness on these two issues could save tens of thousands of lives as a lack of true understanding of how rabies viruses are transmitted and how the disease can be prevented are the root causes of almost every human rabies death. Added to the lack of awareness about disease transmission and prevention is the fact that the majority of human rabies deaths occur in populations belonging to the lower socio-economic group where access to resources, including education and anti-rabies biologicals, are limited or non-existent (WHO, 2010). Finally, an evaluation of the highest incidence of disease per age group reveals that at least 50% of all rabies deaths occur in children under the age of 15 indicating that children are not aware of what rabies is, how they could be exposed to infection, and what to do if they were exposed (Rupprecht et al., 2008).

Rabies is in fact, a neglected viral zoonotic disease that is almost always transmitted from an infected mammal to a human (WHO, 2011; Wilde, Briggs, Meslin, Hemachudha, & Sitprija, 2003). Rabies has the highest case fatality rate of any disease known to infect humans and animals (Rupprecht, 2004; Rupprecht et al., 2008). There have been very few patients that have survived rabies because, once clinical signs are evident, the disease progresses rapidly and almost every patient will succumb to the disease within a few days. The World Health Organization (WHO) reports that there are at least 55,000 human deaths every year, thus one person dies of this horrific disease every 10 minutes (WHO, 2010). There are a number of different types, or variants, of rabies viruses circulating in the world and each rabies virus variant tends to be transmitted within one species of animal although ‘spillover’ of viral infection to other species can and does occur. In fact, it is the spillover of disease to humans that result in human fatalities. Human to human transmission of rabies is extremely rare and has only been laboratory confirmed to have occurred occasionally through organ transplantation although anecdotal transmission of rabies was reported through human bites (Dietzschold & Koprowski, 2004; Fekadu et al., 1996; Lapierre & Tiberghien, 2005). The majority of human rabies deaths, approximately 99% of all estimated global deaths, occur in Africa and Asia after being exposed to (usually through a bite) a rabid dog (WHO, 2005, 2010). Rabies viruses circulate on every continent in the world, with the exception of Antarctica, resulting in over 3.3 billion people living at risk of contracting the disease.

In North America, the circulation of canine rabies virus variants was eliminated through mass dog vaccination programs initially launched in the 1950’s. However, different rabies virus variants continue to circulate within the wildlife population and unvaccinated pets, including dogs and cats, can become infected through exposure to infected wild animals. In the US, between 0 – 6 human rabies deaths are reported annually. Most of these deaths occurred after being exposed to an infected bat for which the patient did not seek prompt medical treatment (Gibbons, Holman, Mosberg, & Rupprecht, 2002; Messenger, Smith, Orciari, Yager, & Rupprecht, 2003).

Despite the extremely high fatality rate of rabies, this disease is almost 100% preventable. Rabies, unlike many other infectious diseases, can be prevented even after an exposure to the infectious agent has occurred. Post-exposure prophylaxis (PEP) consists of washing the wound where rabies virus may have entered, and then administering anti-rabies biologicals to the patient, including vaccine and immunoglobulin (WHO, 2010). In over three decades since modern cell culture rabies vaccines (CCVs) were developed, there have only been a handful of patients that have died of rabies after having received appropriate PEP thus confirming that prompt treatment after exposure could save thousands of lives (Deshmukh, Damle, Bajaj, Bhakre, & Patil, 2011; Hemachudha et al., 1999; Shantavasinkul et al., 2010). Since rabies is preventable and no one would willingly chose to die of rabies if they knew how to prevent the disease, the fact is that the lack of educational awareness on all levels of society is one of the major reasons why humans still die of this disease.

This chapter will outline the role of open source educational awareness in the prevention and control of rabies throughout the world, focusing on three specific initiatives that have used different educational platforms to promote rabies awareness and have resulted in sending rabies prevention messages to over 182 million people in over 150 countries in the past five years. These initiatives include: World Rabies Day; Global Rabies Webinars; and Open Access Rabies Education Bank.

BACKGROUND

Preventing rabies includes three basic steps: Avoiding exposure to infected animal; receiving protective immunization prior to an exposure; and/or receiving prompt PEP after an exposure has occurred (WHO, 2010, 2011). It is irrelevant as to what species of animal was involved in the exposure nor does it matter in what country the patient was exposed, the information about how to prevent rabies is scientifically identical. To avoid being exposed, humans should stay away from wild animals that may be infected with rabies, keep their pets up to date on their rabies vaccination, and understand how to avoid being bitten through treating their pets respectfully and practicing responsible pet ownership. Rabies prevention for people whose vocation puts them at increased risk of exposure to rabies should include administration of preventative immunization, or pre-exposure vaccination (PrEP) (Manning et al., 2008; WHO, 2005). This group of individuals would include veterinarians and their assistants, scientists and technicians working in rabies laboratories or in rabies vaccine production facilities, and children and other populations living in remote regions where access to rabies biologicals is difficult or not possible. Finally rabies prevention in persons exposed to rabies includes prompt wound washing and administration of anti-rabies biologicals including rabies immune globulin (RIG) and a series of rabies vaccination over two to four weeks (Manning et al., 2008; Rupprecht et al., 2010; WHO, 2005). Without prompt wound care and administration of anti-rabies biologicals, there is a high risk that exposed patients will die of rabies.

Transmitting the information about how to prevent rabies in every country across the world where rabies is endemic may seem like a daunting task, especially considering the number of different languages and various cultures involved. However, digital technology is a powerful communication tool that can provide open source access to information to communities in almost every region and when utilized correctly will deliver live-saving educational materials to those that need them. The implementation of digital technology on a global scale to improve awareness about rabies prevention and control through community based action was initiated by the Global Alliance for Rabies Control (GARC) in 2007. It began by bringing major stakeholders together to develop a strategic plan to improve awareness, followed by the selection of one specific day per year when everyone living at risk of rabies could conduct activities in their own regions to improve awareness. The date agreed upon, September 28^th, was designated as “World Rabies Day” (WRD). WRD was launched as a day when all populations across the world living at risk of infection could conduct a multitude of awareness activities, based on their own culturally acceptable messaging, to highlight the ongoing tragedy of rabies and how to prevent infection (Burns, 2009); WRD, 2012).

Outdated or misinformation about how to prevent rabies is not unusual, especially in resource-poor countries where public health professionals responsible for rabies prevention and control do not have the financial resources to travel to international conferences or WHO reference laboratories to learn about new recommendations, diagnostics, surveillance techniques, reduced vaccination protocols etc. (Lapierre & Tiberghien, 2005; Mai le et al., 2010; Rupprecht et al., 2008; Zhang, Zhang, & Yin, 2008). In order to help alleviate this situation, GARC coordinated a series of open access webinars where oral presentations were conducted in ‘real time’ followed by an opportunity for listeners around the world to ask the speaker questions (GARC, 2012). This was the first time that local public health experts involved in rabies prevention activities, previously hampered from relating information about their own region by the cost of travel or lack of access, could provide information about the rabies situation in their own country to listeners tuning into the webinar from around the world. The only cost incurred to presenters and listeners was their own travel cost to reach a local internet connection, and their time to listen to the presentation.

One of the foremost obstacles for individuals wishing to improve educational awareness in their own country was free access to medically correct informational. Although there was a significant amount of educational material produced by reliable sources in different languages across the world, the fact that there was no central access point made it extremely difficult for individuals to find the educational material that they needed. To alleviate this situation, GARC developed a website where copyright-free educational material could be uploaded and retrieved as needed.

ISSUES, CONTROVERSIES, PROBLEMS

Previous Situation

Over the past two decades, a regional rabies prevention and control program overseen by the Pan American Health Organization (PAHO) in collaboration with experts from the Centers for Disease Control and Prevention (CDC) in Atlanta Georgia USA has been underway in Latin America (A. Belotto, Leanes, Schneider, Tamayo, & Correa, 2005; Schneider et al., 2005). PAHO has driven the regional approach by bringing together public health ministries to work together on a regional strategy (A. J. Belotto, 2004). With most Latin American countries complying with the steps outlined in the regional plan, canine rabies control has been greatly reduced throughout the continent although a few countries continue to face challenges including Haiti and Bolivia. However, in Africa and Asia, no regional approach to rabies prevention and control exists, rabies prevention is not a priority and therefore, canine rabies continues to take a heavy toll on human lives. The inability to implement a regional plan in Africa and Asia could be a result of many factors including the existence of multiple languages and the wide variety of cultures present in the regions. In Latin America, there are fewer major languages to contend with although the problem of providing messaging sensitive to some indigenous populations continues to be a challenge.

In general, prior to the global educational initiatives initiated by GARC, the approach from international public health agencies in Africa and Asia has been to use a “top down” approach where recommendations were developed and passed along to the national governments to implement. When countries have many other diseases to contend with and have limited budgets for public health, financially investing in rabies prevention is often low on the priority list of countries combating HIV, tuberculosis, childhood infectious diseases, poor sanitation, etc. Clearly, the rabies prevention and control recommendations developed by the experts at the international level continue to be important in the overall development of regional and national rabies control strategies. However, understanding how to implement these recommendations at a local level, where citizens live at daily risk of exposure to rabies, required a new strategy.

Outdated Information and Attitudes

Going global with innovative programs to improve rabies awareness had some initial controversial issues and an array of different types of oppositions to overcome. A quick review of history reveals that the disease of rabies has been with mankind since antiquity and has had an impressive past. For example, rabies was the third disease in history (after smallpox and chicken cholera) for which a vaccine was produced (Wu, Smith, & Rupprecht, 2011). It was Louis Pasteur and his colleagues that finally developed a means by which people exposed to the disease could be saved thus rabies and Louis Pasteur are inextricably linked (Teigen, 2012; Vignal, 1886). In fact, the contribution of Pasteur to rabies prevention is immortalized forever in the beautiful mosaic work depicting a rabid dog on the wall of his crypt beneath what was his home and is now part of the Pasteur Institute in Paris France. The achievements that Louis Pasteur and his colleagues made regarding the development of a rabies vaccine that included multiple injections of a crude preparation into the abdomen to save lives, is so famous that most people do not realize that modern human rabies vaccines are administered into the upper arm, similarly to other modern vaccines. Additionally, the rabies vaccine developed by Louis Pasteur and his colleagues in 1885 was always administered after an exposure occurred, as PEP, and was never administered before an exposure occurred as a preventative measure, as PrEP. This historical precedent has in fact hampered the extended use of PrEP as one of the valuable tools for governments to use to prevent rabies in populations living in high risk areas with no access to vaccines, or in children the population at highest risk of dog bites and rabies. Changing the attitude of medical professionals to promote the use of PrEP as a means to save human lives was a challenge.

Building Partnerships

Rabies is a zoonotic disease, meaning that rabies virus circulates within one or more animal species and is almost always transmitted from an infected animal to a human. Human to human transmission rarely ever occurs. Thus human rabies could be greatly reduced or eliminated totally if rabies was eliminated from circulating within animals, the source of human infection. Since dogs are the main source of infection currently causing more than 99% of all human rabies, mass vaccination of dogs would eliminate 99% of the present number of human deaths. The complicated issue to overcome is that the responsibility for monitoring and enforcing dog rabies control is not clearly established in most resource poor countries. Since rabies is not a notifiable disease in most countries in Africa and Asia and few diagnostic laboratories exist, rabid dogs and dog bites often go unreported and not treated. There is a disconnection between animal health institutions responsible for animal health issues and human health institutions responsible for purchasing and administering PEP to prevent human rabies. There are other ministries that also need to be involved in rabies prevention and control, including the legislative branch, responsible for passing and enforcing laws regarding rabies prevention; waste control, responsible for reducing the amount of garbage and food sources available to dogs; finance departments, required to fund rabies prevention projects; etc. Bringing diverse groups together to discuss common issues of importance and how interrelated programs could save money and lives is not easy and required innovative strategies to overcome obvious communication problems. Bringing the global stakeholders together to work toward common solutions presented a unique opportunity to utilize the time, talent and treasure of various individuals and groups in the field of rabies prevention and control. However, initially it was a challenge to find common ‘talking points’ and to agree on an overarching strategy that was not biased toward one particular stakeholder.

Logistics

To physically go to every locality, or even to visit one location in each country to promote rabies prevention and control is a daunting task, and the cost and time required to undertake such a mission is not feasible. Additionally, translating rabies educational messages into each language required to reach people living at risk of dying of rabies in different countries (keeping in mind the need to be sensitive to the local culture) using the expertise of a small team that did not comprehend more than five languages between them was not possible. Therefore, GARC needed to develop a different strategy in order to make the educational messages about rabies prevention freely available to the millions of people that needed them to save their lives. An additional logistic challenge was that of how to conduct real-time webinars aimed at connecting people living in every time zone around the world and having access to different types of internet connections.

SOLUTIONS AND RECOMMENDATIONS

World Rabies Day

In 2007, World Rabies Day (WRD) was coordinated by GARC and supported by numerous international partners with the single mission of increasing global awareness about rabies and its prevention because all stakeholders agreed that by increasing awareness about rabies, lives could be saved. It was understood that one of the most important reasons why people continue to die from rabies is because they are not properly informed about what constitutes an exposure to rabies and what they need to do after an exposure has occurred. Additionally, lingering challenges as old as the disease itself continued to hinder the implementation of effective prevention measures including linguistic, religious and cultural barriers, pervasiveness of traditional and ineffective therapeutic practices by local healers and generational inheritance of false local myths, inaccuracies and superstitions. WRD was launched as a health communications campaign and has been the single largest and most successful rabies awareness effort ever conducted. The WRD Campaign is a unique example of a fully functioning One Health effort and has been included as one of the ‘annual awareness events’ on the United Nation’s calendar of international observances (United Nations, 2012). WRD has involved collaboration by and between every leading human and animal health organization in the world including the World Health Organization, World Organization for Animal Health (OIE), Food and Agricultural Organization of the United Nations (FAO), Centers for Disease Control and Prevention (CDC), and numerous other governmental, private, non-profit and charitable organization partners. WRD has united all of these organizations towards the common goal of human rabies prevention through improved educational initiatives including eliminating rabies at the source of infection.

By inviting everyone across the world to join in the fight against rabies, WRD has helped restart previously abandoned rabies control programs, build new organizational and societal partnerships and strengthen existing collaborative efforts in nations that formerly thought nothing could be done to stop rabies. Much of what has been accomplished through WRD is attributed to the incorporation of health communications to a field that was vastly dominated by scientists and researchers. Increasingly recognized as a necessary element to improve public health, health communications is critical for people’s accessibility and exposure to health information and their resultant ability to make positive health behavior changes (US DHHS, 2003). With the single mission of educating everyone, and especially young people about rabies, WRD sought to convert the endless amounts of relatively stagnant technical data about rabies into freely downloadable, dynamic and intuitive information for lay person utilization. As a grassroots movement needing to quickly surmount numerous and varying behavioral, cultural, demographic and physical barriers to health behavior change, WRD focused on leveraging electronic communications through its own websites and through websites of multi-national partners to reach its target audience members. Sign-ups to the WRD website led to the creation of a global rabies network allowing for instant global communication to more than half a million people in a moment’s notice. Additionally, with a focus on ‘One Health’, WRD eyed intersectoral collaboration from its inception and focused heavily on collaborative engagement by Ministries of Health, Agriculture and Education. This approach not only led to increased participation but illustrated to the world that rabies was a disease that everyone could work together to prevent and the support and dedication of numerous governmental sectors in a single effort signified a united front against a disease of both humans and animals.

The momentum created by WRD has increased the number of global participants involved in improving educational awareness at all levels of society. In the five years since the campaign was launched, 182 million people in 150 countries have received educational messages about how to prevent rabies and close to 8 million animals have been vaccinated against rabies.

Multi-national resolutions to observe WRD each year have been implemented by organizations such as the Association for Southeast Asian Nations (ASEAN), World Organization for Animal Health (OIE) and Rabies Expert Bureaus in Africa, Asia and the Middle East (AfroREB, AREB and MEEREB respectively); recognizing WRD as an opportunity for member countries to pool resources, share expertise and work together in a common concerted effort. WRD has revitalized national programs in numerous countries (Cleaveland, 2010) Governments that had previously abandoned national rabies control efforts are now focusing on understanding the rabies situation in their own countries by self-identifying core capacity deficiencies and requesting technical support and training in areas such as pathology, diagnosis, surveillance, post exposure prophylaxis and communications. New animal vaccination programs have also emerged and with renewed vigor in nations such as Haiti, catalyzed by a mass donation of 500,000 doses of animal vaccine from Brazil in honor of WRD (Schneider et al., 2008) and in Mozambique where previous to WRD it was forbidden to vaccinate dogs as local folklore told that a vaccinated dog was not a good watch dog. World Rabies Day has been instrumental in helping to dispel such myths and make the case for renewed efforts towards controlling rabies in dogs. In absence of WRD, it is unknown how long local customs and beliefs would have endured resulting in additional human deaths, all due to the lack of correct information. Finally, it is worth mentioning the influx of new and novel partnerships that have been established to help address the need for rabies education. Organizations once separated by now seemingly trivial constraints such as geography or health specialty are now beginning to see the added benefits of working together. One such example is the multi-agency collaborative poster outreach initiative to Africa for WRD; involving participation by seven organizations on three continents and delivering more than 30,000 posters to 22 African nations. Posters were made available in numerous sizes, languages and formats and in many African villages serve as the only means for rabies education (Figure 1).

Figure 1. African posters distributed by the Global Alliance for Rabies Control and its partners including the Centers for Disease Control and Prevention, the Food and Agricultural Organization, University of Pretoria, Washington State University, and Veterinarians without Borders

Education Bank of Materials

A major focus of World Rabies Day is to increase free access to scientifically accurate rabies prevention educational materials to as many people as possible. For decades, the information to prevent rabies has been understood at higher organizational levels but has not necessarily reached individuals ‘on the ground’ who are often most at risk and least informed. This has led to the chronic misinterpretation and delivery of erroneous rabies prevention information by ill-informed citizens; conceivably contributing to needless human deaths. Often times materials are simply not in the appropriate language, are culturally or pictorially inaccurate, are inaccessible or limited in their distribution, or may otherwise be rendered unavailable due to funding or copyright constraints. To increase access to educational materials about rabies, an education resource library was constructed and embedded within the WRD website. The WRD website (www.worldrabiesday.org) serves as the campaign’s communication hub and has been visited by nearly half a million visitors from over 210 countries and territories since 2007. Since the educational messages to prevent rabies are basically the same all over the world and with so many countries and cultures working individually to control rabies locally, the campaign focused not on working with every community separately but rather to serve as a point source for accurate information and guidance on what material is freely available and helping to create new materials as needed (Wunner et al., 2010). Rabies educational materials, including the WRD logo have been translated into over 40 languages and placed in the public domain.

Educational materials continue to be the most sought after resource on and subsequently the most visited section of the WRD website. Site visitor data is collected through the implementation of an analytics program. Website analytics uses unique internet provider addresses to track visitors coming to the WRD website in a non-identifiable manner. Statistics collected include but are not limited to: pages viewed, length of visit, and keywords and referring sites leading visitors to a particular webpage. In addition to providing insight into who is visiting the WRD website, analytics, perhaps more importantly, allow for a greater understanding of who is not visiting the website and thus provides an opportunity to compare and contrast those populations with their overall risk of rabies exposure. For example, by looking at website analytics from China (Figure 2), it is clear to see that web visitors from western China are nearly non-existent. Given that rabies is one of the top three most important infectious diseases in China, one would expect visitation to the WRD website, even from poorer, more rural areas of China. To better understand where additional rabies educational efforts may be needed, a physical map of China could be compared to the website analytics visitor map to help define locations for enhanced, targeted rabies education efforts.

Figure 2. Web visitors to www.worldrabiesday.org originating in China, 2007-2011

Global Webinars

More than half of the world’s population lives at daily risk to rabies (WHOa, 2011). In order to reach these individuals en masse, health educators need to move beyond traditional approaches to public health education and begin to leverage electronic communication facilities. Webinars, or web seminars, have evolved over the last decade as an open source solution to educate nearly limitless numbers of people and to reach populations traditionally unable to access accurate and culturally correct health information in a timely manner. Placing information online, for example, on a website, has significantly increased access and helped educate more people but is a static process requiring health information seeking behavior. Therefore, if someone is not actively looking for health information online, the resource may likely be un-utilized or under-utilized and therefore rendered ineffective. Clearly there is a need to not only develop and place information on the world-wide-web but also to actively promote and incentivize its availability.

Historically, online education programs developed for distance learning opportunities at colleges and universities targeted busy students with demanding schedules that wanted to advance their skills and training but were not able to attend traditional, time-fixed classroom learning environments. The provision of online courses offered an alternative for students to learn and earn course credits in a self-study, self-paced manner. Akin to other great digital discoveries during the last decade, the use of this technology gained immediate popularity. Recently, these online platforms for information dissemination have evolved beyond academia and have been embraced by additional sectors, becoming the most cost effective tool for interacting with customers (Monaghan, 2009). For example, private for-profit companies now advertise their products and services via monthly webinar offerings and public health institutions are marketing healthy behavior by hosting regularly scheduled programs on various topics such as diet and nutrition, preventing occupational injuries, cancer prevention and infectious diseases just to name a few. For many public health professionals, participation in webinars offers the opportunity to learn about a variety of new subjects while gaining continuing education credits without having to leave the workspace.

Given the extreme need for rabies education and the fact that most of the population at risk cannot afford to attend expensive international conferences, GARC began experimenting with ways to best leverage its ever growing online community. Realizing that internet communications through WRD had clearly led to a sea change in the delivery of rabies information, planning began to implement a freely accessible worldwide rabies webinar. In 2010, in observance of WRD, GARC and CDC coordinated the first intercontinental rabies webinar. The motivation behind the webinar was simply to provide information about rabies to as many people as possible over the internet and at no cost to attendees. As a young non-profit organization, GARC was not positioned to host a physical conference. So in line with its mission to educate the world about rabies, GARC leveraged its global network of advocates and available webinar technology to deliver open source rabies education en masse. Instead of hefty registration fees and travel considerations, webinar participation from anywhere in the world required only a computer with an internet connection. After downloading the webinar software and logging in to the online meeting, individuals across the world were instantly connected with rabies subject matter experts in real time.

Similar to a traditional in-person conference, much advance planning is necessary to successfully execute a webinar. Considerations include content, speakers, technology, timing and promotion (Monaghan, 2009). For a global webinar, it is also vital to consider speakers’ familiarity (or lack thereof) with the webinar platform, who will facilitate and moderate the webinar and how, when and by whom the webinar will be advertised across different communities, cultures and languages. Similar to any health intervention, formative evaluation measures should also be considered at the outset of webinar planning to assess both the process and impact of the webinar meeting amongst facilitators, speakers and attendees. Similar to traditional meetings in any physical space, the first task is to set a date for the planned webinar. The first intercontinental rabies webinar coordinated in 2010 was held on World Rabies Day (September 28) as GARC’s contribution to the annual observance. However, upon evaluation it was discovered that many individuals could not participate in the webinar because they were involved in their own local WRD events. Unlike most traditional meetings, however, webinar meetings can be recorded, depending on the software and technology used. Therefore, those who were unable to attend the live broadcast were still able to listen and learn from the archived recording.

After receiving numerous accolades from the 2010 webinar, GARC and CDC decided to organize and host a second webinar in September 2011 to be conducted over two days with more speakers and timed one week prior to WRD so that more people could attend. Two separate webinars were coordinated over 16 hours at times convenient for each respective target audience to participate. The first webinar ran overnight (Eastern, US) to accommodate participation from the far-East. Speaker assignments were also aligned by location and time zones. For example, at the outset of the webinar, speakers joined from Australia, Philippines and Japan. As the webinar progressed, speakers joined from India, Nepal, Ghana and the UK, slowly moving westward over an eight hour period until finally reaching the last presenter, located in the United States. Timing of message delivery is a vital component to effective health communications. In order to successfully execute a global webinar, particularly when targeting rabies-vulnerable populations in Asia and Africa, precise timing must be considered for the webinar organizers and speakers but most importantly for the anticipated attendees. When handled correctly, appropriate and precise webinar timing, especially during a time of heightened awareness such as WRD, will result in capturing a much larger portion of the intended target audience. (Table 1).

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