In 2012, the Queen Elizabeth Central Hospital in Blantyre, Malawi, claimed a grim record. In just nine months, doctors reported the deaths of ten children with rabies. It was the highest number of rabies cases involving children ever recorded in one year by a hospital in Africa.
It made Malawi’s second-largest city a hotspot for a disease that, despite its virtual eradication in the west, still kills 60,000 people worldwide each year, mainly in sub-Saharan Africa and India. Some 40 per cent of these are children, an age group particularly susceptible to dog bites, the main means of the virus’ transmission.
After 2012 the rate in Blantyre dropped to four children dying a year, yet the terrible disease lingered on in the city’s dog population. And then the app arrived.
In 2013 Andy Gibson, a PhD student at the Royal (Dick) School of Veterinary Sciences, started volunteering for the charity Mission Rabies. He is now its Director of Strategic Research, but his first assignment took him onto the streets of Kolkata, India, to vaccinate dogs.
The experience, coupled with his background in using smartphones in epidemiological settings, led him to develop an app to assist and improve the mass dog vaccination programmes that are vital to combat rabies. Some 70 per cent of an area’s dog population needs to be inoculated to keep the disease at bay.
In 2015 Mission Rabies, in partnership with the data-driven expertise at the University of Edinburgh, introduced the app onto the streets of Blantyre.
Visitors to one of the centres set up to vaccinate dogs would not be immediately aware of the innovation behind the experience.
They would come into a local classroom at the weekend, cleared of its jumble of diminutive chairs and tables, meet two volunteers or Mission Rabies staff, one of whom prepares the vaccine, the other helps restrain the dog. On their way out they receive a certificate of vaccination.
Or they might go to one of the pop-up locations, usually found on street corners, its presence announced via a megaphone. These impromptu vaccination centres have been known to inspire hour-long queues of dog owners in the southern African sun.
Peel back the can-do attitude and dust-covered, dog-scented veneer, and a thick stream of data lies beneath.
Dogs and data
Since 2015, every time a dog is vaccinated in Blantyre its GPS location and information such as age, breed, sex and health of each dog is uploaded into the app. At the end of each day the data is analysed and is used to inform future decisions of the vaccination campaign.
For example, information collected in the first few years revealed that the average distance people were willing to walk to vaccinate their dog was 800 metres. This then influenced the location of the fixed point vaccination centres, the ones in classrooms and similar facilities.
The data also suggested that the team stop doing door-to-door calls to vaccinate dogs. The plan has always been to make vaccinations more efficient, easier to scale up and cheaper, which makes them more attractive to cash-strapped governments. Doing house calls was found to be too costly. Since 2018, the practice was stopped and replaced by more strategically located vaccination points.
The data can also change how the vaccines are administered from day to day.
When a campaign is happening, Dr Stella Mazeri, a veterinary epidemiologist at the Royal (Dick) School of Veterinary Studies, receives the information that is uploaded at the end of every day.
“The fact that, from a data-driven perspective, we can have the data in near real time, informs our work continuously,” she says.
Sitting in Edinburgh, Dr Mazeri is able to see where the team have been in Blantyre and where the pop-up vaccination centres, megaphones and all, might go next. “I am able to interrogate the data and build statistical models predicting where we may have low coverage, and then target these areas using supplementary roaming vaccination points.
“It’s really important with rabies that you don’t leave any pockets of unvaccinated dogs. The app is a way to make sure you are doing your job well by visualising dog vaccinations on a map. It’s been a real game changer.”
The result of this continuous refinement is that it now only takes 11 days each year to administer vaccines to 70 per cent of dogs in Blantyre. In 2015, it was 20 days. Mission Rabies has now rolled out its ever more efficient campaign into neighbouring Zomba city. The team also believe that the approach can be adapted to other health care initiatives, in both humans and animals.
For Dr Mazeri, the Covid-19 pandemic has brought back to global attention what rabies is reminding places like Blantyre with depressing regularity – that animal health and human health are mutually dependent.
“Rabies is a very good example of a One Health problem because you have human deaths but the animal health sector is responsible for sorting out the problem,” she says. “Dog vaccinations are the most efficient solution to reduce human deaths.
“The current pandemic has highlighted that everything is interconnected. Researchers are aware but there needs to be more action on the ground. We often reach funding dead ends because of this duality, so One Health falls in a gap.
“Rabies is just an example, but as we’ve seen with Covid, more examples are coming. We just need to learn to work together.”
The latest figures show that Blantyre’s rate of rabies deaths in children is now down to one a year. The team’s data-driven campaign is working, but they are not stopping. Their eyes are set on the global goal to eliminate dog-mediated human rabies deaths by 2030.
“There has been a significant decline, but the problem is still there,” says Dr Mazeri. “We haven’t seen zero cases. We need pan-continental rabies control approaches in order to reach the 2030 goal. There’s no way this is the end. This is the beginning.”
Image credit: Mission Rabies