National Rabies Control and Elimination Strategy 2018-2030

1.1. Introduction 8

1.2. Cost Effectiveness of Rabies Elimination 9

1.3. Epidemiology of Rabies 10

1.3.1. Reservoir 10

1.3.2. Transmission 10

1.3.3. Clinical Features 10

1.4. Diagnosis of Rabies 11

1.5. Prevention and Elimination of Rabies 11

1.6. Rabies Situation in Ethiopia 11

1.6.1. History of Rabies in Ethiopia 11

1.6.2. Burden of Rabies in Ethiopia 12

1.6.3. Availability of rabies vaccines 13

1.6.4. Rabies Surveillance System 13 Rabies surveillance in Addis Ababa 18

1.6.5. Legal Framework for Rabies Control 24

1.6.6. Current Rabies Prevention and Control Activities 27

1.7. Challenges in Rabies Control in Ethiopia 29

1.8. Opportunity for Rabies Elimination 30 CHAPTER TWO: THE STRATEGIC FRAMEWORK 32

2.1. Guiding Principles of the Strategy 32

2.2. Vision 32

2.3. Mission 32

2.4. Goal 32

2.5. General Objective 32

2.6. Strategic framework for the control and elimination of rabies (STOP-R) 33

2.7. Stepwise Approach Towards Rabies Elimination (SARE) 34

2.7.1. Components of the rabies control and elimination program with complementing outcomes and indicator measures 34

2.7.1.1. Surveillance and response systems (SARE: Data collection and analysis) 34

2.7.1.2. Data reporting and sharing (SARE: Data collection and analysis) 34

2.7.1.3. Prevention of rabies in humans 35

2.7.1.4. Control and elimination of rabies in dogs 36

2.7.1.5. Prevention and Elimination of Rabies in Wildlife 36

2.7.1.6. Dog population management plan 36

2.7.1.7. Rabies Diagnostic Laboratory Capacity 37

2.7.1.8. Information, education and Communication 37

2.7.1.9. Multi-sectoral collaboration and sharing 38

2.7.1.10. Legislation 38 CHAPTER THREE: IMPLEMENTATION PLAN OF THE STRATEGY 39

3.1. Phase 1 (2018-2020): Planning and preparation for implementation of the elimination strategy 39

3.2. Phase 2 (2021-2023): Implementation of the elimination strategy in pre-selected local areas 47

3.3. Phase 3 (2024-2017): Implementation of the rabies elimination strategy outside the pre-selected local areas 53

3.4. Phase 4 (2028-2029): Maintaining freedom from canine-mediated rabies and elimination of canine rabies 59

3.5. Phase 5 (2030): Maintain Freedom from rabies in humans and dogs 64

3.6. Action plans for implementing each phase 68

3.7. Monitoring and Evaluation of progress 68 CHAPTER FOUR: EXPENDITURE ESTIMATES 70

4.1. Summary estimated budget 70

4.2. Phase I activity budget with input description 0 REFERENCES: 0 ANNEXES 0 FOREWORD This document describes Ethiopia’s strategic plan for the elimination of dog-mediated human rabies, a consistently fatal disease in humans, livestock and other mammals by 2030. Rabies is a classic example of a zoonotic disease that is preventable in humans by controlling the disease in animals. Elimination of human rabies is achievable through mass dog vaccination because dogs are responsible for transmission of over 98% of all human rabies cases. WHO reports that rabies causes approximately 70,000 human deaths worldwide annually, with one person dying of rabies every 15 minutes. The highest burden of rabies is reported in the developing world, with more than 95% of all human deaths occurring in Africa and Asia. Most populations under rural settings and children aged below 15 years are at greatest risk of rabies exposure. The cost associated with post-exposure prophylaxis in humans is high and exceeds the cost of rabies control in animals through dog vaccinations. In comparison to other communicable diseases, rabies is 100% fatal and 100% preventable; which needs special attention to be given to control and eliminate dog- mediated human rabies in Ethiopia. Elimination of rabies from the dog population is the key target to stopping human rabies. Success in canine rabies elimination has been demonstrated in developing countries including Latin America and Asia, where sustained mass vaccination of dogs was shown to be the most cost effective intervention for controlling and eliminating canine rabies and consequently human rabies. The Ministry of Health (MoH-EPHI) and the Ministry of Livestock and Fisheries (MoLF) collaborated with relevant ministries and developed this rabies prevention and control strategy with technical backstopping and support from international partners. The strategy will guide stepwise reduction of rabies burden through enhanced surveillance, prevention of rabies in dogs, prevention of rabies in humans, and education/advocacy. In 2015, Ethiopia prioritized the top five priority zoonotic diseases from over 200 zoonotic diseases. Rabies is among the top five priority zoonotic diseases identified for inter-sectoral collaboration. Establishment of the inter-sectoral National Rabies Technical Working Group have led to the development of this National Strategy document. This strategy is based on activities planned in accordance with the Stepwise Approach to Rabies Elimination (SARE) tool for the country to move from an endemic state to a disease free status. Successful implementation of this strategy requires inter- sectoral collaborative approach with involvement and support of various stakeholders. Rabies prevention and control in Ethiopia is the responsibility of different local actors and together with support from our international partners we are optimistic that we will eliminate dog-mediated human rabies in Ethiopia by 2030. Dr Kebede Worku Dr. Misrak Mekonnon State Minister State Minister Federal Ministry of Health Federal Ministry of LF EXECUTIVE SUMMARY Rabies, resulting from infection by Rabies virus (RABV) and related lyssa viruses, is one of the most deadly zoonotic diseases known to man. RABV is caused by the Lyssa virus genus in the family Rhabdoviridae. Lack of strong surveillance of lyssa viruses and limited number of diagnostic laboratories through most of the country are large contributors to lack of information about the incidence of these viruses. The lyssa virus has been sporadically identified in different wildlife (fox, hyena and wolf) and domestic species (cats and dogs) throughout Ethiopia (Deressa et al., 2010). According to the World Health Organization (WHO, 2005) human deaths occur worldwide due to rabies, amounting to one fatality and 300 exposures every 15 minutes. Almost all human fatalities occur in developing countries with 56% occurring in Asia and 44% in Africa. This strategy aims to eliminate human cases of dog-mediated rabies by the year 2030 in Ethiopia. The strategy provides a guide for systematic reduction of rabies risk through sustained mass dog vaccinations, pre and post-exposure prophylaxis and public education until the country is completely free of human dog-mediated rabies. This strategy is based on activities planned in accordance with the Stepwise Approach to Rabies Elimination (SARE) for the country to move from an endemic state to a disease free status. SARE is a stepwise progression towards becoming a rabies disease-free country, consisting of 6 stages (Stage 0 to 5), each with a set of activities that build on each other to continuously reduce the risk of disease, with the country being declared completely free of human dog-mediated rabies when it reaches Stage five. The critical steps in the various stages include: 1. developing and adopting a national rabies elimination strategy, 2. implementation of elimination plan in pilot areas, 3. implementation of the elimination strategy throughout the country and 4. Maintaining freedom from human dog- mediated rabies and canine rabies. To move from one stage to the other, a set of targets must be reached and confirmed. The implementation of the strategy will begin with selected pilot areas to gain valuable lessons in creating and maintaining a rabies-free zone that will be used during the roll- out of the elimination campaign in the rest of the country. LIST OF TABLES The technical contributions, commitment and overall leadership of the members of the National Rabies Technical Working Group (NRTWG) in drafting this strategy document are highly appreciated. We specifically like to acknowledge the institutions listed below whose representatives have played a large role in the development of this strategy. 1. Federal Ministry of Health (FMOH) 2. Federal Ministry of Livestock and Fisheries (MOLF) 3. Federal Ministry of Culture and Tourism (MOCT)4. Center for Disease Control (CDC), Global Health Security Agenda (GHSA) 4. Food and Agriculture Organization, (FAO) 5. The Ohio State University (OSU) 6. World Health Organization (WHO ) 7. Global Alliance for Rabies Control (GARC) 8. USAID, P&R A list of major contributors can be found in the annex. LIST OF ABBREVIATIONS ADNIS Animal Disease Notification and Investigation System CDC U.S. Center for Disease Control and Prevention CRF Case-Based Reporting Format DERF-W Daily Epidemic Reporting Format for Woreda DFAT Direct Fluorescent Antibody Test DOVAR Disease Outbreak and Vaccination Activity Reporting DPMP Dog Population Management Program DRIT Direct, Rapid Immunohistochemical Test ENRBS National Rabies Baseline Survey EPHI Ethiopian Public Health Institute ECTAD Emergency Centre for Transboundary Animal Diseases FAO Food and Agriculture Organization of the United Nations FMHACA Food, Medicine and Health Care Administration and Control Authority of Ethiopia FMOH Federal Ministry of Health GARC Global Alliance for Rabies Control IEC Information, Education, and Communication MOLF Ministry of Livestock and Fishery MVC Mass Vaccination Campaign NAHDIC National Animal Health Diagnostic and Investigation Centre NTV Nerve Tissue Vaccine NVI National Veterinary Institute OIE World Organization for Animal Health ORV Oral Rabies Vaccine PANVAC Pan-African Veterinary Vaccine Centre PARACON Pan-African Rabies Control Network PCR Polymerase Chain Reaction PDS Participatory Disease Surveillance PEP Post-Exposure Prophylaxis PV Pasteur Virus Qrt-PCR Quantitative Real Time PCR SARE Stepwise Approach towards Rabies Elimination SOP Standard Operating Procedure STOP-R Strategic Framework for the Control and Elimination of Rabies TWG Technical Working Groups WHO World Health Organization CHAPTER 1

1.1. INTRODUCTION Rabies is present on all continents of the world with the exception of Antarctica and several small pacific islands. However, more than 95% of human deaths due to the disease occur in Asia and Africa. A recent global burden study estimated the human mortality from rabies to be 70,000 per year worldwide, with about 56% of the cases occurring in Asia and 43.6% in Africa, mostly in rural areas. This translates to 1 death due to rabies every 15minutes in the world. Official data on human rabies deaths submitted to World Health Organization (WHO) from Africa are a gross under-estimate of the true burden of the disease. The reasons for this include: rabies victims are often too ill to travel to hospital or die before arrival; families recognize the futility of medical treatment once signs develop so they do not seek treatment; and the difficulty in laboratory confirmation of clinical clinically suspected cases which leads to misdiagnosis. In addition to human mortality, the economic burden attributable to rabies is significant. The high cost of post exposure prophylaxis in human creates a heavy burden to both government and household budgets. At the household level, costs of post-exposure prophylaxis (PEP) arise directly from rabies vaccines and indirectly from costs associated with travel, medical fees and income loss. The indirect household losses represent more than 50% of total costs. The total PEP costs have been estimated at US$40 per patient in Africa and US$ 49 in Asia, accounting for 6% and 4% of annual per capita Gross National Income, respectively. In addition, victims of rabid dog bites and their families suffer from psychological trauma resulting from the uncertainty and resignation to the inevitable outcome. Weak surveillance and lack of reliable data on the number of animal rabies cases is a major constraint to assessing the economic impact of rabies on the local communities when livestock and working animals die due to rabies or infect humans. In addition, the control of rabies in dogs protects wildlife from rabies including the endangered wild canids whose existence is threatened by rabies. Successful elimination of human rabies has been demonstrated in many countries, including in parts of developing countries such as the Philippines, Mexico and Indonesia. In the province of Bohol, located in the Visayas islands region in the Philippines, a rabies elimination program was launched in 2007 involving mass dog vaccination, dog population control, improved dog bite management, public education, and improved diagnosis surveillance and monitoring. Similar control efforts are underway in the south- eastern part of the United Republic of Tanzania and Kwa-Zulu Natal in South Africa (Hampson et al., 2015) In Ethiopia, it is estimated that up to 2,700 human deaths occur annually due to rabies. Progress in preventing human rabies through control of the disease in the dogs has been slow due to a number of barriers including; limited information and awareness about the extent of the problem, lack of suitable diagnostic and response capacity, lack of appropriate and sustainable strategy for prevention and control, lack of inter-sectoral collaboration and organizational and financial challenges. Successful elimination of human rabies in Ethiopia will require a multi-sectoral and collaborative approach. Prevention of dog rabies, effective surveillance in humans and animals, better public awareness and improved access to human rabies vaccines are essential for the elimination of human rabies.

1.2. COST EFFECTIVENESS OF RABIES ELIMINATION The current rabies prevention and control efforts in Ethiopia are restricted to human post-exposure prophylaxis (PEP) and local area dog vaccination campaigns. This approach has not been successful in reducing the incidence of rabies in animals and humans, owing to inadequate vaccination coverage and unavailable or unaffordable PEP for most of the affected individuals. There are three main strategies for the control of rabies; a) Prevention in humans through intensified post-exposure treatment (PEP), b) Controlling the disease in the reservoir host through dog vaccination, c) Combination of the two. To determine the most cost-effective method of the three studies have been conducted in Chad and Philippines. In the Philippines, cost–benefit analysis of mass dog vaccination versus human PEP over a six-year period indicated that the use of intensified human PEP alone was associated with increased medical costs to the government over the years in the absence of a dog vaccination program (Jibat T, 2015). In Chad, the cumulated cost of the combined strategy of human PEP and dog vaccination was found to be more cost effective than the human PEP alone in the first four years, and then it became lower than human PEP cost after the fifth year of the program. The studies also showed that the cumulated cost of PEP alone would be greater than the combined approach after the sixth year of the elimination program. Lessons from these studies indicated that rabies control using the current strategy (ad hoc vaccinations without reaching the optimal 100%, supply of PEP to dog bite victims) is less cost-effective compared to an elimination strategy that focuses on mass dog vaccinations (reaching and maintaining the 70% vaccination coverage) accompanied by residual PEP for dog-bite victims. The benefit of mass dog vaccination and elimination of rabies in the animal reservoir will result to saving human lives, reduction of expenditures on human PEP and additional income from livestock whose death is prevented.

1.3. EPIDEMIOLOGY OF RABIES

1.3.1. RESERVOIR In Africa, evidence indicates that the primary rabies virus maintenance cycle is among domestic dogs, although other carnivores may be involved as non-maintenance populations. This finding suggests that mass vaccination targeting domestic dogs would have the greatest impact in reducing the risk of infection in all other species including humans, livestock and wildlife. The role of bats and other carnivores in human rabies transmission in Africa appears minimal.

1.3.2. TRANSMISSION Humans are usually infected following a bite or scratch by an infected animal. Transmission can also occur when infectious material such as saliva comes into direct contact with human mucosa or fresh skin wounds. Human-to-human transmission through bite is possible but has not been documented; transmission via transplantation of an organ from an infected donor has occurred multiple times. Though cooking of meat would inactivate the virus, there is risk of exposure during the butchering of a rabid animal that could lead to rabies.

1.3.3. CLINICAL FEATURES CLINICAL FEATURES IN ANIMALS The incubation period in animals can vary considerably. In dogs and cats, it is typically between 2 to 12 weeks, although cases have developed up to a year following exposure. There are two distinct forms of rabies in animals; furious and dumb forms. The furious form of rabies is the classic “mad-dog syndrome”, and may be seen in all species. The animal becomes irritable and may viciously and aggressively use its teeth, claws, horns, or hooves to attack humans and other animals, without provocation. Such animals lose caution and fear of humans and other animals. The dumb/paralytic form of rabies manifests with ataxia and paralysis of the throat and jaw muscles, often with profuse salivation and the inability to swallow. These animals may not be vicious. In either form, initial and predominant signs include a marked change in behavior. Rabid dogs or cats die within 10 days of onset of symptoms. CLINICAL FEATURES IN HUMANS In humans, the incubation period for rabies is typically 1–3 months, but may vary from below one week to more than one year. The initial symptoms of rabies are fever and often pain or an unusual or unexplained tingling, pricking or burning sensation (paraesthesia) at the bite site. As the virus spreads through the central nervous system, progressive, fatal inflammation of the brain and spinal cord develops. Two forms of the disease can follow; furious or paralytic rabies. People with furious rabies exhibit signs of hyperactivity, excited behavior, and hydrophobia (fear of water) and death after a few days. Paralytic rabies accounts for about 30% of the total number of human cases. This form of rabies runs a less dramatic and usually longer course than the furious form. The muscles gradually become paralyzed, starting at the site of the bite or scratch. A coma slowly develops, and death eventually occurs. The paralytic form of rabies is often misdiagnosed, contributing to the underreporting of the disease. Once symptoms of the disease develop, the disease is fatal.

1.4. DIAGNOSIS OF RABIES In animals and humans the direct Fluorescent Antibody Test (dFAT) is the recommended diagnostic test. This test detects the presence of rabies antigens in brain tissue. Other diagnostic tests that have been used are quantitative real time PCR (qRT-PCR) and direct, rapid immunohistochemical test (DRIT) assays.

1.5. PREVENTION AND ELIMINATION OF RABIES Prevention and elimination of rabies in humans can be achieved by eliminating rabies in dogs and other reservoirs. Rabies in dogs can be eliminated through sustained mass vaccination programs, control of dog population and responsible dog ownership. To prevent human rabies, rapid intervention following a dog bite incident, consisting of appropriate bite wound management and administration of post exposure prophylaxis when indicated is important. Also critical is an efficient and effective surveillance system that detects exposures in humans and cases in animals followed by the initiation of an integrated approach in the management of identified disease risks.

1.6. RABIES SITUATION IN ETHIOPIA

1.6.1. HISTORY OF RABIES IN ETHIOPIA The early 19thcentury travelers including Edward Ruppel, Rochetd’ Hericourt, A. d’Abbadie and others reported either seeing a rabid dog or people bitten by apparently rabid dogs and the first and only recorded rabies epidemic in Addis Ababa occurred in August 1903(Pankrust,1990). Furthermore, the continued existence of traditional medicine practitioners in the various parts of the country to date is a testimony for the significance of the disease in Ethiopia. Even more alarming is the detection of unique strain of the rabies virus in saliva of dogs that showed remission after the onset of the disease in view of the danger it may pose to people who come in contact with healthy- looking dogs. Within the country, rabies has been known for centuries as a ‘’Mad Dog Disease’’ (Fekadu, 1982). On the other hand, the isolation of two rabies related viruses, Mokola and Lagos bat viruses from domestic animals in Ethiopia by (Mebatsion et al., 1992) is of public and veterinary concern in view of the difficulty of proper diagnosis and lack of effective vaccines against these agents.

1.6.2. BURDEN OF RABIES IN ETHIOPIA HUMAN In Ethiopia, about 10,000 human deaths per year were reported to WHO in 1990s’. However, the national rabies baseline survey (ENRBS, 2012) estimates the incidence of human rabies death to be 1.6/100,000 population annually. The most recent estimate showed death incidence of 1.1/100,000 population (Asefa, D., 2017). Human exposure to rabid animals has been reported to be 12 exposure cases/100,000 population (ENRBS, 2012). In addition with regard to more at risk age group, 60% fatal human rabies cases occur in children under 15 years. WILDLIFE All available evidence suggests that domestic dogs are the reservoir for rabies throughout Ethiopia; genetic analysis identified the virus to be of canid type. Though wildlife do not play a significant role in rabies transmission to humans, they are also victims of dog rabies. This has had a significant impact on endangered animals such as the Ethiopian Wolf. More than 32 domestic dogs and 20 cattle exhibiting clinical signs consistent with rabies were reported in communities adjacent to the Bale Mountains National Park in (ENRBS, 2012), and at least three people and ten wolves from the population were bitten by suspect dogs. Efforts have been made to reduce the threat of rabies to Ethiopian wolves in this areas since 1996 through the vaccination of dogs. More than 70% of domestic dogs in core wolf areas within the National Park have been vaccinated against rabies. Where resources have allowed the dog vaccination campaign has been extended to surrounding communities. Case trace back in this outbreak suggests rabies may have been brought into wolf habitat by an unvaccinated immigrant dog accompanying people and livestock searching for seasonal grazing. Rabies was confirmed on October 28, 2003 and advice on its management was sought from a range of person and institutions including the World Conservation Union/Species Survival Commission Canid Specialist Group and Veterinary Specialist Group. After recommendations were submitted, the Ethiopian Wildlife Conservation Organization decided to intervene with a trial emergency measure; on the grounds that the species is rare and endangered and that rabies was apparently in advertently introduced as a byproduct of human activities.

1.6.3. AVAILABILITY OF RABIES VACCINES HUMAN Ethiopia still uses Nervous tissue vaccine (NTV) derived from PV 12 rabies virus strain propagated in the brains of infected sheep. The vaccine is inactivated by phenol. The vaccine requires 17 daily injections given subcutaneously. Even though the vaccine is more affordable, NTV is banned by WHO for its potential serious side effects in the form of vaccine-induced auto-immune encephalomyelitis, which afflicts 1200 vaccines. Additionally, NTV induce a low or a moderate immune response. WHO recommends the use of cell culture-based rabies vaccine for pre-and post- exposure prophylaxis. This type of rabies vaccine is expensive and unaffordable for the majority of Ethiopians. In Ethiopia on average 30,000- 35,000 doses of NTV vaccines are administered annually. When administered appropriately, the cell culture based vaccine is extremely effective at preventing rabies. Production of cell culture based rabies vaccine is underway at the Ethiopian Public Health Institute (EPHI). The vaccine is based on vero and BHK 21 cell lines. EPHI’s strategic plan shows, Nervous Tissue vaccine will be replaced by locally produced cell culture type by June, 2018. ANIMAL Currently, the National Veterinary institute (NVI) produces cell culture based animal rabies vaccine which is certified by PANVAC. The vaccine is also undergoing proficiency and potency testing in CDC Atlanta to check if it meets the OIE standards. In the future, vaccine production capacity of NVI will depend on the demand and request of regions while some of the gaps in vaccine supply will be fulfilled through importation. In 2015 and 2016, NVI produced 15,588 and 7,371 vials of vaccine (5 dose per vial), respectively.

1.6.4. RABIES SURVEILLANCE SYSTEM PUBLIC HEALTH SURVEILLANCE & LABORATORY Surveillance of both human and animal rabies cases is essential to detect high-risk areas and outbreaks quickly and to monitor the impact of canine vaccination and other interventions. Surveillance for rabies exposures (usually bites) to suspected rabid animals is essential to human health as it allows life-saving interventions (including vaccination) to be started early. Rabies events/elements that will be included in rabies surveillance include animal bites, animal rabies cases, post-exposure prophylaxis administered and human rabies cases. As part of the key element of the surveillance system in the public health emergency management (PHEM), the human rabies surveillance and case management has been developed. This includes the standard rabies case definitions in humans for detection of bite exposures, the reporting system and reporting frequency, reporting tools and reporting channels as outlined below; Detection-based on case definition The case definitions are based on: • Standard human rabies clinical case definition • Human exposure to rabies: Classification of Human exposure • Community case definition All cases identified by standard case definition and the exposure cases should be taken as “rabies” and reported. Reporting All detections (cases and exposures) should be reported immediately to Woreda or Health Center or their designated PHEM or local rabies focal person immediately as rabies is one of the immediately reportable diseases. A single suspected case is considered as a suspected outbreak. Disease under surveillance is classified into immediately reportable diseases. Key elements of the immediately reportable diseases 1. Alert notification is based on alert threshold: a single suspected human case OR confirmed human case is considered as a suspected outbreak notified from level to level within 30 minutes of identification. The Federal Ministry of Health MOH/EPHI report to WHO within 24 hours of detection. The notification is the responsibility of the Woreda health office Rapid Response Team (RRT) 2. Verification is also undertaken by the Woreda health office 3. Outbreak investigation and initial response- Jointly by Woreda, zone, region and federal PHEM different reporting format as indicted below • The Case-based Reporting Format (CRF). • The PHEM Line list used to report daily • Daily Epidemic Reporting Format for Woreda (DERF-W) • Weekly reporting format Reporting channel The reporting means include Telephone, E-mail, Short message, Fax, Toll free hot-line (8335) and on line software or web application. NATIONAL ANIMAL HEALTH SURVEILLANCE SYSTEM The primary objective of surveillance is to understand the epidemiological situation of diseases in the country and to identify the level of threat. Surveillance thus assists in preparing for control and eradication. Surveillance systems can also contribute to the identification of priority diseases in the area. Currently both active and passive surveillance systems are being implemented nationally. The implementation of the surveillance system with its passive and active components as well as additional surveys have led to a good understanding of the disease dynamics in the country including status of rabies (Source: Epidemiology Directorate, 2017). Passive surveillance Animal health Information system plays an important role in surveillance and provides information for economic assessment of diseases in addition to fulfilling international reporting needs. The passive surveillance system mainly depends on a paper based system from woreda to the regional veterinary laboratory covering the respective woredas that laboratory is mandated to cover. The monthly disease outbreak reports received from woreda level are entered in a web-based Disease Outbreak and Vaccination Activity Reporting (DOVAR-II) system. This reporting system is designed to collect information of any kind regarding animal health related issues such as diseases occurrences or vaccination activities performed in the woreda, including Rabies. Currently the proportion of woredas reporting is around 50%, which is below the international standard of 80% (Source: DOVAR-II database, 2016). Figure 1. Map of reporting and non-reporting woredas in 2016 (DOVAR) Syndromic surveillance is practiced in some selected areas using a mobile based daily notification system known as Animal Disease Notification and Investigation System (ADNIS). It allows for immediate notification and early detection of some selected animal diseases including Rabies. This system is mainly intended to serve the pastoral areas that have a very low or poor reporting rate. Currently there are around 300 sites practicing this reporting system, and there is a plan to reach 3,600 sites at the end of GTP-2 as a national plan. Figure 2. ADNIS pilot areas - November 11, 2016 Major gaps of passive surveillance system • Low return rate and poor quality of the reports received, as most of the outbreak reports are not confirmed or not supported by laboratory diagnosis. Hence, mapping of the distribution of confirmed clinical outbreaks is only partially practiced due to the low reporting rate of lab confirmed outbreaks. • Lack of good quality internet connection both at regional veterinary labs for the purpose of accessing semi-web based system, DOVAR-II server and for the immediate notification system server from field sites. • Lack of post-assessment evaluation to quantify the clinical and the socio- economic impact of disease outbreaks. • Another gap in the national surveillance system is that it is not able to capture Rabies events in wildlife. There is no list of wildlife susceptible to Rabies and there is no case definition for Rabies in wildlife. Active surveillance Active surveillance is an essential tool for early detection of diseases and introduction of exotic diseases. Additionally, it provides information for declaring a country or a zone disease free. Currently there are 15 regional veterinary laboratories conducting active surveillance, in addition to NAHDIC. • Annual sero-surveillance is being conducted for priority diseases and trade sensitive diseases. • Regarding introduction of exotic diseases, annual risk based sero-surveillance is conducted around border areas of the country and other areas with the risk of introduction of exotic diseases. • For other endemic diseases annual surveillance is conducted to know their status and gathering information for national control program. • In order to detect areas with active disease transmission, participatory disease surveillance (PDS) is conducted for some selected diseases. Major gaps regarding active surveillance Poor planning, lack of alignment of surveillance plans between regional and national plans resulting in redundancy of activities and less result based active surveillance actions. RABIES SURVEILLANCE STATUS Rabies surveillance in Addis Ababa A total of 6392 animal species were brought to EPHI for possible rabies examination. Out of these, 6100(95%) were dogs. Among these, 4880 (80%) of the dogs were unvaccinated. The vaccination status of 509(7.96%) dogs was unknown. Number of examined animals range from 1040 in 2016 to 1672 in 2012. Among the dogs brought for clinical examination 329 (5.4%) dogs were freely roaming. High percentages of FAT confirmed animals for rabies came from Kolfe-Karaniyo, Nifas Silk Lafto and Yeka (16.95%, 16.65% and 16.25%) respectively but lower numbers from Kirkos, Addis-Ketema and Lideta and (3.86%, 5.05% and 5.55% respectively) sub cities (Figure 2). Table 1: Species of animal examined for rabies using FAT from each sub city, Addis Ababa, 2012-2016 Akaki Addis Animal species Arada Bole Gullele Kirkos Kolfe Lafto Lideta Yeka Total Kaliti Ketem Canine 64 46 68 90 103 35 154 152 51 148 911 Feline 4 3 4 5 6 2 9 9 3 8 53 Simian (Ape, 0 0 0 1 1 0 2 1 0 1 6 monney) Bovine 1 1 2 1 0 1 2 1 2 2 13 Equine 0 0 1 1 0 1 0 1 0 2 6 Vulpine (Fox) 1 0 0 0 2 0 2 2 0 2 9 Ovine (Sheep) 0 1 0 1 1 0 1 1 0 0 5 Caprine (Goat) 1 1 0 1 0 0 1 1 0 1 6 Hyenine(Hyena) 0 0 0 0 1 0 0 0 0 0 1 Total FAT positive 71 52 75 100 114 39 171 168 56 164 1010 samples Figure 3. Distribution of FAT confirmed animal rabies cases in Addis Ababa, 2012 - 2016 Figure 4. Time trend of laboratory confirmed rabies in the months of the year 2012-2016 in Addis Ababa Rabies is one of the most significant diseases of animals in Ethiopia due its public health significance. Thus, rabies is selected one of the notifiable diseases through the daily notification system. In 2016 there were 30 rabies outbreaks throughout the country, mainly in Oromia, Amhara and SNNPR regions with 133 cases. All species of animals are susceptible; canines are reported more frequently (Source: DOVAR-II database, 2016). Table 2: Rabies OBs occurrence in 2016 in different species Species Number of OBs Canine (Dog) 19 Bovine (Cattle) 6 Equine (Horses) 5 Total 30 Figure 4a. Rabies hotspots in animals (Source: MOLF Epidemiology Directorate 2007 - 16) Figure 4b. Rabies cases in humans per 100,000 people (EPHI, 2012) LABORATORY DIAGNOSTIC SYSTEM Veterinary rabies diagnostics in Ethiopia is a function of the federal NAHDIC and 15 regional veterinary laboratories following the segregation of mandates at the two hierarchies of the governance. The federal government is mandated with the control and prevention of trans-boundary diseases and quarantine operations. The regional states are mandated with all the remaining diseases of both economic and public health importance. (Source: Ethiopian Animal Health Year book, 2015). NAHDIC, established in 1995, is the national referral and reference laboratory of Ethiopia and works on animal disease surveillance, outbreak investigation, export and import animal testing, research and capacity building. NAHDIC implements a quality management system ISO/IEC 17025/2005 that enables the centre to generate quality diagnostic results and information on animal health. NAHDIC has strong linkages with national, sub-regional and international organizations, OIE reference laboratories and universities working on animal health. It consists of ten laboratories that actively function in various disciplines. Four of the laboratories are engaged in the field of microbiology (viral and bacterial serology, mycology and bacteriology, and virus isolation), two in the field of parasitology (protozoology and acarology-entomology-helminthology), one pathology laboratory with autopsy facilities, one laboratory for molecular diagnosis and one biosecurity level three laboratory (BSL-3) for the diagnosis of zoonotic diseases. NAHDIC has also experimental and laboratory animal facilities to conduct animal health experiments. Currently NAHDIC is accredited for the following 12 tests 1. Detection of AI A and H5 – H7 sub-type influenza viruses using conventional PCR 2. Detection of Newcastle disease virus in clinical samples using conventional PCR 3. Detection of IgM against RVF using ELISA 4. Detection of antibody for RVF using competition ELISA 5. Detection of PPR antibody using ELISA 6. Detection of antibody against FMDV using 3ABC 7. Rose Bengal agglutination test for Brucellosis 8. Complement Fixation Test (CFT) 9. Haemo-agglutination test 10. Haemo-agglutination inhibition from serum 11. Haemo-agglutination inhibition from allantoic fluid 12. Isolation Al and ND virus by inoculation of embryonated chicken eggs for virus isolation. 13. EPHI is the sole lab for Animal rabies testing until NAHDIC build its capacity Table 3. Regional vet Laboratories found in the country. No. Name of Regional Veterinary Lab Regional states Location Scope in diagnosis of PPR Diagnoses, research National Animal Health Diagnostic 1 MOLF Sebeta surveillance and capacity and Investigation Center (NAHDIC) building Mekele Regional veterinary Diagnoses and 2 Tigray Mekele Laboratory surveillance Kombolcha Regional Veterinary Diagnoses and 3 Amhara Kombolcha Laboratory surveillance Bahir Dar Regional Veterinary Diagnoses and 4 Amhara Bahir Dar Laboratory surveillance Semera Regional Veterinary Diagnoses and 5 Afar Semera Laboratory surveillance Diagnoses and 6 Shola veterinary Laboratory Addis Ababa Addis Ababa surveillance Assosa Regional Veterinary Diagnoses and 7 Benshangul Gumuz Assosa Laboratory surveillance Bedelle Regional Veterinary Diagnoses and 8 Oromia Bedelle Laboratory surveillance Diagnoses and 9 Asela Regional Veterinary Laboratory Oromia Arsi surveillance Diagnoses and 10 Hirna Regional Veterinary Laboratory Oromia Hirna surveillance Yabello Regional Veterinary Diagnoses and 11 Oromia Yabello Laboratory surveillance Diagnoses and 12 Sodo Regional Veterinary Laboratory SNNPRS Wolayita Sodo surveillance Diagnoses and 13 Mizan Regional Veterinary Laboratory SNNPRS Mizan Aman surveillance Diagnoses and 14 Jinka Regional Veterinary Laboratory SNNPRS Jinka surveillance Jigjiga Regional Veterinary Diagnoses and 15 Ethiopia Somali Jigjiga Laboratory surveillance Dire Dawa Regional Veterinary Diagnoses and 16 Dire Dawa Dire Dawa Laboratory surveillance

1.6.5. LEGAL FRAMEWORK FOR RABIES CONTROL EXISTING LAWS/PROVISIONS General terms and conditions on rabies management and control are accepted from the WHO/OIE legislation as it listed below. For the purposes of the Legislation, the incubation period for rabies shall be 6 months, and the infective period in domestic carnivores starts 10 days before the onset of the first clinical signs and ends when the animal dies. Standards for diagnostic tests and vaccines are described in the Legislation for Laboratory Diagnosis of Rabies. RABIES REPORTING AND FREEDOM FROM RABIES Rabies must be a reportable disease in Ethiopia. All the rabies cases recorded must be reported to Ethiopian Public Health Institute (EPHI). EPHI reports rabies situation on quarterly reporting system to Ministry of Health and the Veterinary Service of Ministry of Agriculture. A country or region in the country may be considered free from rabies when the disease is notifiable, an effective system of disease surveillance is in operation, all regulatory measures for the prevention and control of rabies have been implemented including effective importation procedures, no case of indigenously acquired rabies infection has been confirmed in man or any animal species during the past 2 years, and no imported case in carnivores has been confirmed outside a border quarantine station for the past 6 months. However, this status would not be affected by the isolation of a Bat Lyssavirus, IMPORT & EXPORT OF ANIMALS When importing from rabies free countries, Ethiopian Veterinary Authorities should require for domestic mammals, and wild mammals reared under confined conditions, the presentation of an international veterinary certificate attesting that the animals: 1. Showed no clinical sign of rabies on the day of shipment; 2. Were kept since birth for the 6 months prior to shipment When importing from rabies free countries, Ethiopian Veterinary Authorities should require for wild mammals not reared under confined conditions the presentation of an international veterinary certificate attesting that the animals: 1. Showed no clinical sign of rabies on the day of shipment; 2. Have been captured in a rabies free country, at a sufficient distance from any infected country. The distance should be defined according to the species exported and the reservoir species in the infected country. When importing from countries considered infected with rabies, Ethiopian Veterinary Authorities should require for dogs and cats the presentation of an international veterinary certificate attesting that the animals: 1. Showed no clinical sign of rabies within 48 hours of shipment; 2. Were vaccinated against rabies: a) Not less than 6 months and not more than one year prior to shipment in the case of a primary vaccination, which should have been carried out when the animals were at least 3 months old; b) Not more than one year prior to shipment in the case of a booster vaccination; c) With an inactivated virus vaccine or with a recombinant vaccine expressing the rabies virus glycoprotein and were identified by a permanent mark (including a microchip) before the vaccination (their identification number shall be stated in the certificate); 3. Were subjected not less than 3 months and not more than 24 months prior to shipment to an antibody test with a positive result equivalent to at least 0.5 IU/ ml; 4. If the animal has not been vaccinated against rabies or does not meet all of the conditions set out in points 1, 2 and 3 above; the Ethiopian Veterinary Authorities may require the placing of the animal in a quarantine station located on its territory, to be held in compliance with the conditions stipulated in its animal health legislation. When importing from countries considered infected with rabies, Ethiopian Veterinary Authorities should require for domestic ruminants, equines and pigs the presentation of an international veterinary certificate attesting that the animals: 1. showed no clinical sign of rabies on the day of shipment; 2. Were kept for the 6 months prior to shipment in an establishment where separation from wild and feral animals was maintained and where no case of rabies was reported for at least 12 months prior to shipment. When importing from countries considered infected with rabies, Ethiopian Veterinary Authorities should require for laboratory reared rodents and lagomorphs, and lagomorphs or wild mammals (other than non-human primates) reared under confined conditions the presentation of an international veterinary certificate attesting that the animals: 1. showed no clinical sign of rabies on the day of shipment; 2. Were kept since birth, or for the 6months prior to shipment, in an establishment where no case of rabies was reported for at least 12 months prior to shipment. When importing from countries considered infected with rabies, Ethiopian Veterinary Authorities should require for wild mammals not belonging to the orders of primates or carnivores and not reared under confined conditions the presentation of an international veterinary certificate attesting that the animals: 1. Showed no clinical sign of rabies on the day of shipment; 2. Were kept in a quarantine station for the 6 months prior to shipment. When importing from countries considered infected with rabies, Ethiopian Veterinary Authorities should require for frozen semen of dogs the presentation of an international veterinary certificate attesting that the donor animals showed no clinical sign of rabies during the 15 days following collection of the semen. BIOSAFETY CONSIDERATIONS Rabies has the highest case-fatality rate of any currently recognized infectious disease. Safety is of paramount importance when working with lyssaviruses. In general, biosafety level 2 safety practices are adequate for routine laboratory activities such as diagnosis and animal handling. Besides basic facility design, precautions should also include appropriate personal protection equipment and pre-exposure vaccination. Certain situations may entail consideration of a biosafety level 3 classification, including production of large quantities of concentrated virus, conducting procedures that may generate aerosols and when working with lyssaviruses for which the effectiveness of current prophylaxis is not known. All national safety guidelines for working with infectious agents should be followed. TRANSPORT OF SPECIMENS Specimens for rabies diagnosis should be shipped according to the national and international regulations to avoid exposure hazards. Information on classification (UN 2814) and packing instructions (P620 packaging) can be found in Transport of infectious substances (WHO). Diagnostic specimens should either be refrigerated or shipped at room temperature in 50% glycerin-saline solution. SOURCE OF SPECIMENS FOR DIAGNOSIS AND STORAGE CONDITIONS Rabies diagnosis can be performed on fresh specimens from several different tissue sources or on appropriate specimens stored at proper temperatures, preferably refrigerated. The choice of specimens depends on the test to be performed and the stage of the disease in humans. Formalin fixation of brain tissues is not recommended. If specimens are nevertheless received in formalin, the duration of fixation should be less than 7 days. The specimens should be transferred rapidly to absolute ethanol for subsequent molecular diagnosis.

1.6.6. CURRENT RABIES PREVENTION AND CONTROL ACTIVITIES RABIES CONTROL IN DOGS Dog vaccination Many countries have successfully reduced the number of human deaths and exposures through prevention of rabies in animals, particularly in dog populations. Dog vaccination is an effective way to prevent rabies cases in dogs and other animals. In Ethiopia, mass dog vaccination is carried out annually in some regions by local animal health offices. Successful mass dog vaccination campaign is being carried out in Ethiopia by collaborative efforts of EPHI, MoLF, Addis Ababa urban agriculture bureau, CDC and OSU through central and door to door vaccination methods. The campaign is being carried out in 4 sub cities (Kirkos, Gulele, Addis Ketema and Lideta) and over 8000 dogs and 1000 cats are vaccinated. Dog population management The risk of rabies can be reduced by controlling dog population through surgical or chemical sterilization. Selective removal of unwanted dogs through humane killing has also proven beneficial in other countries provided vaccination levels remain high and other population control measures are also implemented. Reduction of food sources for free-roaming dogs is also recommended. In Ethiopia, dog population management is done annually through removal of unwanted/free rooming dogs by chemicals means which is inhumane. PREVENTION IN HUMANS The current prevention and control of rabies in public health is mainly based on: Pre-Exposure anti-rabies vaccination Recommended for persons in high-risk groups, such as animal handlers, dog catchers, veterinarians, and persons working with live rabies virus in diagnostic laboratories, vaccine production and research laboratories First-Aid Immediately or as soon as possible wash the wound as described in the SOP and take the bite victim to the closest hospital or clinic. At Health Facility: - Immediately wash the wound with soap and running water in case suspicion arise in the at home first aid. Tetanus prophylaxis and measures to control bacterial infection also should be administered as per the prescription by clinicians. Prophylactic antibiotics should be administered as per the algorithm. Post-Exposure Prophylaxis (PEP) Currently both nerve tissue vaccine and cell culture vaccines are being used as post- exposure prophylaxis in Ethiopia. Though, the initiation is towards the use of modern, safer and effective cell culture vaccine in the future, the nerve tissue anti-rabies vaccine is still extensively used throughout the country mainly because of unavailability, and costs incurred to the cell culture vaccines. Health Education Though Education for the general public and to children under 16 can reduce or prevent human exposures to potentially rabid animals and decreases human exposure to rabies it has not been extensively undertaken in the country. Prevention and control of rabies related to wildlife The public should be warned not to handle or feed wild mammals. Wild mammals and hybrids that bite or otherwise expose persons, pets, or livestock to rabies should be considered for euthanasia and rabies diagnosis. A person exposed by any wild mammal should immediately wash the wound as described in the SOP visit the closest hospital or clinic. At Health Facility: - Immediately wash the wound with soap and running water in case suspicion arise in the at home first aid. Tetanus prophylaxis and measures to control bacterial infection also should be administered as per the prescription by clinicians. Prophylactic antibiotics should be administered as per the algorithm. Carnivores: The use of oral rabies vaccines (ORV) for the mass vaccination of free- ranging wildlife should be considered in selected situations under the regulation of appropriate authorities. There have been documented successes using ORV to control rabies in wildlife in North America. This method should be considered for the protection of valuable wildlife species in Ethiopia. In addition, parenteral vaccination (trap-vaccinate-release) of wildlife rabies reservoirs may be integrated into coordinated ORV programs to enhance their effectiveness. Continuous and persistent programs for trapping or poisoning wildlife are not effective in reducing wildlife rabies reservoirs on a state wide basis. However, limited population control in high-contact areas (e.g., picnic grounds, camps, and suburban areas) might be indicated for the removal of selected high-risk species of wildlife.

1.7. CHALLENGES IN RABIES CONTROL IN ETHIOPIA Inadequate laboratory capacity • Limited supply of diagnostic materials • Lack of regional laboratory capacity on rabies diagnosis • Lack of infrastructure and quarantine facilities Inadequate Surveillance • Under reporting of rabies exposures and cases • No laboratory based surveillance Inadequate inter-sectoral collaboration and partnerships • Poor joint rabies investigation and response • No data sharing and surveillance linkage between sectors • Lack of One Health/multi-sectoral approach to address rabies Low awareness of rabies prevention and control • Poor public education and awareness on rabies prevention and control • Neglected disease with less focus on its burden and control Inadequate Enforcement of Laws and Regulations • No inter-sectoral legal framework for coordination of rabies prevention and control • Lack of Integrated National Guidelines and directives on Rabies Prevention and Control • Inadequate legal enforcement on rabies prevention and control Inadequate Research on Rabies Limited supply of rabies vaccine • Inadequate supply and access to PEP • No cell-cultured rabies vaccine production • Lack of infrastructure for rabies vaccine and PEP distribution and use Funding Constraints • Less funding due to competing priorities Inadequate human resource capacity on rabies prevention and control • Inadequate knowledge and skill on rabies case management and vaccine administration by health care providers and animal health professionals

1.8. OPPORTUNITY FOR RABIES ELIMINATION ESTABLISHMENT OF ONE HEALTH COORDINATION MECHANISM • Establishment of national One Health Steering committee • Establishment of disease specific technical working groups • Development of multi-sectoral zoonotic diseases memorandum of understanding • Government commitment to rabies prevention and control, identified as a Priority disease • Global and regional initiatives on dog-medicated rabies elimination by 2030 INCREASED INTEREST IN RABIES ELIMINATION BY PARTNERS The burden of rabies and the fact that rabies is a neglected zoonotic disease that affects almost all mammalian species has resulted in many different agencies working together towards its control and elimination by 2030. Additionally, there is global recognition that human rabies is primarily caused by canine rabies and that it can be eliminated by sustained mass dog vaccination. The partners interested in rabies prevention include major international agencies such as WHO FAO, OIE, GARC, OSU and CDC in partnership with regional organizations like the Pan-African Rabies Control Network (PARACON) and vaccine manufacturing companies are all working towards elimination of rabies. CHAPTER 2: THE STRATEGIC FRAMEWORK

2.1. GUIDING PRINCIPLES OF THE STRATEGY • Rabies control is a public good (for the benefit or well-being of the public); elimination of human rabies in Ethiopia requires a multi-sectorial collaborative approach. • Domestic dogs cause upwards of 95% of human rabies deaths on the African continent • The strategic maintenance of a vaccination rate of at least 70% in identified dog populations will result in the elimination of endemic canine rabies cycles, resulting in the elimination of canine-mediated human rabies and continued / maintained vaccination. • Rabies elimination through mass dog vaccination is a cost-effective strategy, saves lives and results in decline in the use of costly human post exposure prophylaxis (PEP)

2.2. VISION To eliminated human rabies in Ethiopia by 2030

2.3. MISSION To undertake and lead the multi-sectoral activities, projects and programs related with prevention and control of rabies in domestic dogs and humans in Ethiopia

2.4. GOAL To effectively eliminate all human rabies deaths by 2030, as a result of strategic vaccination campaign that achieves and maintains a vaccination rate of at least 70% of the domestic dog population in the country

2.5. GENERAL OBJECTIVE • To strengthen sectoral and multi-sectoral rabies surveillance systems • To strengthen rabies diagnostic laboratory capacity • To increase anti-rabies vaccine production and accessibility (cell culture) • To undertake rabies prevention and control activities • To enhance rabies control and prevention capacity in terms of trained personnel and communication/education materials • To enhance commitment by decision makers • To improve resource and community mobilization • To increase strategic information on rabies prevention and control (M&E)

2.6. STRATEGIC FRAMEWORK FOR THE CONTROL AND ELIMINATION OF RABIES (STOP-R) Many steps towards international control and elimination of dog-transmitted human rabies have already been taken. At the global level, FAO, OIE and WHO declared rabies a priority disease. Besides national strategies developed by individual countries, several regional strategies for the elimination of dog-mediated human rabies already exist or are under development. In December 2015, the global rabies meeting in Geneva, Switzerland, developed a framework for the elimination of dog-mediated human rabies. The strategic vision of this framework is to reach zero human deaths from dog rabies by 2030. The framework, developed by the OIE, WHO, FAO and GARC, revolves around 5 pillars, abbreviated as STOP-R. S: Socio-cultural This context influences rabies perceptions and dog-keeping practices of at-risk populations. Socio-cultural activities include aspects of rabies awareness, responsible dog ownership, bite prevention and treatment, and community engagement. T: Technical Activities in this pillar include efficacious vaccines and vaccination programs/strategies, logistical support, diagnostics and surveillance. O: Organization Rabies is a very good model/fit for One Health (OH) and activities include promotion of this OH concept, coordination, governance, monitoring and evaluation. P: Political Political will and support are critical for the elimination of rabies. Activities include international support, legal frameworks and regional engagement. R: Resources Sustained long-term support is necessary for the ultimate elimination of rabies. The framework promotes the case for investment in rabies control, as well as the development of a business plan and vigorous encouragement for investment in the elimination of rabies as a global public good.

2.7. STEPWISE APPROACH TOWARDS RABIES ELIMINATION (SARE) The Stepwise Approach towards Rabies Elimination (SARE) has been developed as a practical planning, monitoring and evaluation tool to guide, develop and refine rabies control programs. The SARE assessment was developed to simplify and capture the vital information and demarcate the critical steps that need to be achieved to systematically progress the control and elimination of rabies. In this manner, governmental stakeholders and policy-makers are exposed to a simplified, yet comprehensive, tool that enables productive discussions and establishment of structured decisions that may facilitate any disease intervention programs. The SARE tool is aligned with the STOP-R framework, and follows the principle of strengthening inter-sectoral collaboration with the goal of sustained rabies risk reduction over time.

2.7.1. COMPONENTS OF THE RABIES CONTROL AND ELIMINATION PROGRAM WITH COMPLEMENTING OUTCOMES AND INDICATOR MEASURES

2.7.1.1. SURVEILLANCE AND RESPONSE SYSTEMS (SARE: DATA COLLECTION AND ANALYSIS) Surveillance is a critical element in the elimination of rabies. Effective rabies surveillance in humans and animals enhances early detection and reporting of cases, vital for initiating timely responses and enabling informed decisions about when and where to intensify rabies control efforts. Once rabies interventions are implemented, surveillance is essential in generating data to monitor progress or impact of the control efforts, which is essential for their sustainable implementation. As control efforts progress towards rabies elimination, surveillance becomes even more critical in ascertaining rabies-free status. Specific objectives and activities include the following: 1. Strengthen existing national animal and human rabies surveillance systems 2. Establish a multi-sectoral and linked rabies surveillance and response system (Integrated Bite Case Management) 3. Strengthen national and subnational level capacity to analyze dog and human rabies data

2.7.1.2. DATA REPORTING AND SHARING (SARE: DATA COLLECTION AND ANALYSIS) There is an inordinate disconnect between the data that is officially reported by governments and that of the estimates provided by predictive models (Hampson et al. 2015). The ultimate goal of each country and stakeholder involved in rabies control and elimination should be to drive accurate data collection, reporting and analysis in order to ensure that the reported data reflects the true burden of rabies in their country. Specific objectives and activities include the following: 1. Establish a mechanism (database) to strengthen and improve reporting of all cases of human and animal rabies from the local to national 2. Establish a mechanism for linking reports of suspected rabid animals, rabies exposures, and lab results between relevant sectors. 3. Establish a national and subnational level database linking animal and human rabies surveillance and laboratory data. 4. Establish a mechanism for reporting, feedback, and information sharing of rabies data among stakeholders and relevant sectors (national and international). 5. Establish and maintain communication with countries within the East African Rabies Community (e.g. PARACON)

2.7.1.3. PREVENTION OF RABIES IN HUMANS Strategies for the prevention of human rabies are aimed at protecting those at highest risk of exposure, post exposure treatment and supportive management for the clinically ill. Specific objectives and activities include the following: 1. Increase access to modern cell culture rabies vaccines for human post-exposure prophylaxis. 2. Increase access to pre-exposure prophylaxis using modern cell culture rabies vaccine for human among high-risk professionals. 3. Strengthen local cell culture vaccine production capacity based on WHO quality and safety standards at EPHI in order to phase-out nerve tissue vaccine utilization. 4. Strengthen national regulatory authority capacity for licensing of locally produced human vaccines (e.g. FMHACA). 5. Reduce overutilization and unnecessary administration of human rabies vaccine for post-exposure prophylaxis (PEP).

2.7.1.4. CONTROL AND ELIMINATION OF RABIES IN DOGS Domestic dogs are the main source of infection to humans, with at least 95% of human rabies cases attributable to rabid domestic dogs. The principal method of dog rabies control is mass vaccination, and has been successfully used to eliminate human dog- mediated rabies in areas including Malaysia, Philippines, Tunisia, Western Europe and North America among others. Rabies elimination in Ethiopia will therefore be achieved through mass dog vaccinations, targeting 70% and above vaccination coverage for consecutive years followed by a maintenance phase to ensure that the rabies-free status is ensured. Specific objectives and activities include the following: 1. Increase national capacity to accurately estimate dog population size. 2. Increase access to quality cell culture animal rabies vaccine for dogs in Ethiopia. 3. Increase local cell culture animal rabies vaccine production capacity at National Veterinary Institute. 4. Improve quality and safety of locally produced cell culture rabies vaccine based on OIE quality and safety standards. 5. Increase national capacity to mass vaccinate at least 70% of dogs. 6. Establish a legal framework for quarantine, inspection, and vaccination of animals involved in transboundary movement.

2.7.1.5. PREVENTION AND ELIMINATION OF RABIES IN WILDLIFE Even though dogs account for upwards of 95% of all human rabies cases, Ethiopian wildlife should also be considered when working towards rabies control and elimination. This consideration is due to the fact that wild carnivores, including the endangered Ethiopian wolf (Canis simensis), are threatened by spillover infections from domestic dogs. Specific objectives and activities include the following: 1. Enhance wildlife and livestock rabies surveillance for intervention

2.7.1.6. DOG POPULATION MANAGEMENT PLAN The uncontrolled increase in domestic dog populations will result in either a reduced vaccination coverage or an increase in resources that are required annually. As such, the building and implementing of a nation-wide comprehensive and sustainable dog management plan and strategy is required. Specific objectives and activities include the following: 1. Increase national and subnational capacity to manage dog population size.

2.7.1.7. RABIES DIAGNOSTIC LABORATORY CAPACITY Laboratory diagnosis plays a key role in confirming the presence of rabies and in turn contributing to the burden indication within the country. Specific objectives and activities include the following: 1. Increase national and regional animal health laboratory capacity for rabies diagnostic testing. 2. Increase national and regional public health laboratory capacity for rabies diagnostic testing. 3. Establish a mechanism for animal sample submission to regional and national level laboratories for rabies diagnostic testing 4. Establish a national rabies reference laboratory. 5. Establish a mechanism to report all test results of animal rabies cases from regions to the national rabies reference laboratory. 6. Establish a quality management program between international OIE/WHO rabies reference laboratory (ies) (e.g. Onderstepoort, CDC, etc) and national rabies reference laboratory for rabies confirmatory testing and variant typing. 7. Establish a mechanism for regular sample collection, transportation, and storage of suspected rabid animals (including livestock and wildlife) to animal rabies laboratories.

2.7.1.8. INFORMATION, EDUCATION AND COMMUNICATION The continued training and improvement of professional proficiency ensures that animal and human professionals involved with implementing the project are working in humane and safe ways, while also relying on the most up to date methodology. Raising awareness on rabies prevention and control is essential in preventing exposures, increasing public awareness and practices on bite prevention, proper dog-bite wound management and seeking medical attention and increasing support (political, financial and technical) for the program. Enhanced awareness can also improve rabies control efforts in animals by increasing reporting of potential rabid animals, and practices of responsible dog ownership. Specific objectives and activities include the following: 1. Increase animal and public health professionals’ knowledge on rabies. 2. Increase general public awareness on rabies prevention

2.7.1.9. MULTI-SECTORAL COLLABORATION AND SHARING Partnerships and multi-sectoral collaboration among national and county governments, NGO’s and private sector will be required for successful implementation of the rabies elimination program and for best utilization of the available resources. Government agencies involved in rabies control include; ministries (health, livestock, education, finance, interior and coordination of national government), regulatory bodies responsible for human and animal health, wildlife service and state law office. International organizations like WHO, OIE, FAO, CDC, GARC and OSU are also important in giving technical and financial support for the planning and implementation of the program. A multi-sectoral technical working group (with agreed upon terms of reference) consisting of representation from the various sectors will be established to coordinate rabies implementation of the rabies elimination strategy at the national level. Specific objectives and activities include the following: 1. Strengthen existing national level multi-sectoral rabies technical working groups (TWG). 2. Establish regional multi-sectoral rabies technical working groups (TWG) using a One Health Approach. 3. Obtain buy-in and secure resources for implementation of national rabies plan.

2.7.1.10. LEGISLATION Legislation related to rabies control and elimination allows certain activities to be enforced. Legal documents such as Laws, Ordinances, Decrees, Decisions, Guidance and guiding documents need to be reviewed and improved in order to effectively implement them. Specific objectives and activities include the following: 1. Identify gaps in national and regional level legislation related to rabies prevention and control. 2. Increase enforcement of existing rabies related legislation CHAPTER 2: IMPLEMENTATION PLAN OF THE STRATEGY

3.1. PHASE 1 (2018-2020): PLANNING AND PREPARATION FOR IMPLEMENTATION OF THE ELIMINATION STRATEGY During the first phase of the rabies control and elimination strategy (2018-2020), the Ethiopian rabies multi-sectoral technical working group will focus on working together in a One Health approach to prepare the following items in preparation for the wide- spread implementation of the national rabies control strategy: overall responsibility for implementing rabies elimination strategy, resource mobilization, situation analysis/gap assessment on the existing rabies surveillance, prevention, control, database, reporting and communication systems, training and capacity building, internally monitor (progress reports) implementation of the strategy, provide regular update to the public and stake- holders on implementation of the rabies elimination strategy, review, propose changes and amendments of regulations and laws on rabies prevention and control.

3.1.1. SPECIFIC ACTIVITIES TO BE COMPLETED IN THE STIPULATED TIMEFRAME St. 1. Surveillance and response systems 1.1 Strengthen existing national animal and human rabies surveillance systems

1.1.1. Standardize animal rabies case definition based on international standards

1.1.2. Standardize suspected rabies exposures case definition for humans and for anImals based on international standards

1.1.3. Standardize human rabies case definition based on international standards

1.1.4. Evaluate existing rabies surveillance systems (i.e. Public Health Emergency Management, National Animal Disease Surveillance System, Wildlife surveillance) and compare to international standards and proposed system for Ethiopia to identify gaps

1.1.5. Develop a monitoring and evaluation plan for routine evaluation of rabies surveillance systems

1.1.6. Integrate wildlife animal rabies surveillance into existing animal surveillance system

1.1.7. Train all animal and public health surveillance officers on key principles of rabies surveillance systems (case definitions, reporting, etc) 1.2 Develop a joint SOP for human bite and suspected rabid animal investigations and response

1.2.1. Develop a joint SOP for human bite and suspected rabid animal investigations and response

1.2.2. Customize and standardize data collection forms for joint rabies field investigations (suspected rabid animal investigations, human exposure investigation, lab data collection)

1.2.3. Develop a protocol for quarantine and euthanasia of suspected rabid animals

1.2.4. Train all animal health professionals on safe and humane animal handling, animal sample collection, and euthanasia. (Consider certification)

1.2.5. Jointly identify pilot region(s) to implement a linked rabies surveillance system based on objective data (surveillance, human resource, etc)

1.2.6. Obtain endorsement from pilot region governments and identify resources (funding, human) for implementation

1.2.7. Establish a national level linked rabies surveillance system 1.3. Strengthen national and sub national level capacity to analyze dog and human rabies data 1.3.1. Train all relevant animal and public health surveillance officers on how to collate and analyze rabies surveillance data 1.3.2. Train all relevant animal and public health professionals on development of epidemiological bulletins/reports for data sharing St 2: Data reporting and sharing 2.1. Improve a mechanism (database) to strengthen reporting of all cases of human and animal rabies from the local to national 2.1.1. Explore electronic tools and/or platforms to improve reporting of cases in selected institutions 2.1.2. Provide financial and material resources to improve timely reporting of rabies cases

2.3. Integrate a national and sub national level database linking animal and human rabies surveillance and laboratory data

2.3.1. Select a web-based platform (e.g. DHIS2, etc) to enter, link, and share national and sub national rabies data 2.4. Establish a mechanism for reporting, feedback, and information sharing of rabies data among stakeholders and relevant sectors (national and international) 2.4.1. Share rabies data to Ministry websites (MOLF, EWCA, MOH, etc) on a monthly basis 2.4.2. Report key indicator human rabies and exposure data to WHO 2.4.3. Report key indicator animal rabies data to OIE 2.5. Establish and maintain communication with countries within the East African Rabies Community (e.g. PARACON) 2.5.1. Continue communications with Regional East African Rabies Community 2.5.2. Attend and participate in national, regional and international rabies meetings (i.e. PARACON, East African Regional, etc) St.3: Prevention of rabies in humans 3.1. Increase access to modern cell culture rabies vaccines for human post-exposure prophylaxis 3.1.1. Conduct an assessment to evaluate animal bite incidence in all regions and administrative cities 3.1.2. Evaluate health facilities in all regions and administrative cities in order to identify appropriate facilities for cell culture vaccine distribution

3.1.3. Pilot introduction of cell culture rabies vaccine in 4 regions

3.1.4. Train relevant health care professionals on proper administration of cell culture rabies vaccine (includes vaccination schedule)

3.1.5. Conduct evaluation of cell culture vaccine in pilot introduction regions to generate recommendations for large scale distribution 3.2. Increase access to pre-exposure prophylaxis using modern cell culture rabies vaccine for human among high-risk professionals

3.2.1. Identify all high-risk professionals/workers for rabies pre-exposure vaccination 3.2.2. Provide pre-exposure prophylaxis to all identified high-risk professionals 3.2.2. Perform routine serological testing for adequate anti-rabies antibody titers 3.2.3. Administer booster vaccination for high-risk individuals based on serology testing results 3.3. Strengthen local cell culture vaccine production capacity based on WHO quality anD safety standards at EPHI in order to phase-out nerve tissue vaccine utilization

3.3.1. Seek technical expertise from international and national vaccine production experts

3.3.2. Identify equipment, material and human resource needs for cell culture vaccine production

3.3.3. Train all vaccine production staff on vaccine production and quality assurance methods

3.3.4. Implement and maintain a quality management system for vaccine production

3.3.5. Procure equipment and material resources needed for cell culture vaccine production (e.g. through technology transfer from international institutions, etc)

3.3.6. Promote for vaccine development facility infrastructure improvement in order to meet international GMP standards

3.3.7. Undergo appropriate vaccine licensing and registration procedures for national use 3.4. Strengthen national regulatory authority capacity for licensing of locally produced human vaccines (e.g. FMHACA)

3.4.1. Assess national regulatory capacity to license locally produced human vaccines

3.4.2. Identify resource needs for licensing of human rabies vaccines

3.4.3. Avail resource based on identified needs 3.5. Reduce overutilization and unnecessary/improper administration of human rabies vaccine for post-exposure prophylaxis (PEP) 3.5.1. Revise human PEP recommendations based on confirmed animal rabies diagnostic test results

3.5.2. Revise human PEP recommendations based on animal rabies surveillance system and reliability and timeliness of reporting animal rabies assessment outcomes St. 4: Control and elimination of rabies in dogs

4.1. Increase national capacity to accurately estimate dog population size

4.1.1. Identify responsible authority (ies) for dog population estimation at national, regional and (TWG to explore) zonal level

4.1.2. Develop SOPs for dog population estimation and monitoring

4.1.3. Conduct surveys to estimate dog population and determine owned versus stray dogs 4.2. Increase access to quality cell culture animal rabies vaccine for dogs in Ethiopia

4.2.1. Assess regional and administrative cities’ cold chain and storage capacity, and vaccine supply needs at veterinary clinics (Gov’t and private)

4.2.2. Identify additional sources to obtain vaccine in cases of stock outs and vaccine shortage (e.g. importation)

4.2.3. Distribute appropriate consumable and supplies to all veterinary clinics (private and public)

4.2.4. Conduct routine monitoring of vaccine supply chain, vaccine use, and proper disposal

4.2.5. Conduct regular community surveys to assess affordability and access to dog rabies vaccine

4.2.6. Secure funding to provide additional subsidization of vaccine cost based on survey findings

4.2.7. Assess existing veterinary staff capacity at district

4.2.8. Fill identified gaps in human resource need (e.g. hiring of veterinary staff)

4.2.9. Train veterinary professionals at local veterinary clinics (public and private) 4.3. Increase local cell culture animal rabies vaccine production capacity at National Veterinary Institute

4.3.1. Utilize estimated dog population to assess animal rabies vaccine need

4.3.2. Assess NVI production capacity (including human resources, etc) to meet estimated demand

4.3.3. Procure supplies and equipment necessary for increased production

4.3.4. Hire additional staff for vaccine production

4.3.5. Train additional staff on SOP for cell culture animal rabies vaccine production 4.4. Improve quality and safety of locally produced cell culture rabies vaccine based on OIE quality and safety standards 4.4.1. Perform safety and potency testing for all vaccine batches produced by NVI 4.4.2. Perform efficacy testing of NVI’s rabies vaccines 4.4.2. Obtain external quality assurance certification for local and international distribution 4.4.3. Establish field level vaccine safety and effectiveness monitoring system for local level

4.5. Increase national capacity to achieve and maintain a vaccination rate of at least 70% of dogs

4.5.1. Develop SOP for planning and implementing MVCs and post vaccination monitoring

4.5.2. Distribute SOP for MVC and post vaccination monitoring to all regions and administrative cities

4.5.3. Train relevant professionnels on the MVC and post vaccination monitoring SOP

4.5.4. Select zone(s) in specific regions for piloting canine mass vaccinations

4.5.5. Establish/review existing legislation for annual MVC implementation at federal and regional levels

4.5.6. Revise annual MVC strategy based on risk assessments (e.g. surveillance and lab data) 4.6. Establish a legal framework for quarantine, inspection, and vaccination of animals involved in transboundary movement

4.6.1. Develop legal framework based on assessment

4.6.2. Obtain endorsement from appropriate authorities for legal framework

4.6.3. Monitor enforcement of framework St. 5: Prevention and Elimination of Rabies in Wildlife and Livestock 5.1. Enhance wildlife and livestock rabies surveillance 5.1.1. Utilize routine rabies surveillance data from livestock and wildlife to refine the national rabies strategy for integration St. 6: Dog population management (DPM) plan 6.1. Develop and implement DPM plan

6.1.1. Develop a national DPM strategy using available resources and share with relevant stakeholders 6.1.2.. Sensitize community on DPM strategy prior to implementation

6.1.3. Train animal health professionals on DPM strategy and relevant techniques St. 7: Rabies Diagnostic Laboratory Capacity 7.1. Increase national and regional animal health laboratory capacity for rabies diagnostic testing

7.1.1. Perform assessment of all national and regional Animal health laboratories for rabies diagnostic testing capacity

7.1.2. Select 4 pilot regional/national labs for animal rabies diagnostic testing based on assessment results

7.1.3. Procure all supplies and equipment needed for rabies diagnostic testing

7.1.4. Develop and distribute SOP for rabies diagnostic testing

7.1.5. Train all laboratory staff in pilot labs on SOP

7.3. Establish a mechanism for animal sample submission to regional and national level laboratories for rabies diagnostic testing

7.3.1. Assess local level (woredas) and regionals capacity to submit suspected rabies animal samples to the regional and national level

7.3.2. Develop standardized operating procedures for animal sample collection, storage, and transportation

7.3.3. Train professional on proper sample collection, handling and submission

7.3.4. Supply animal sample collection, transportation and storage materials to district vet clinic and regional labs for sample collection

7.3.5. Supply animal sample collection, transportation and storage materials to district vet clinic and regional labs for sample collection

7.3.6. Review/develop animal sample submission forms to ensure all necessary epidemiologic data are collected on submitted samples

7.5. Establish a mechanism to report all test results of animal rabies cases from regions to the national rabies reference laboratory

7.5.1. Assess regional laboratory level capacity to report test results to national level and identify gaps

7.5.2. Develop a strategy to address identified gaps (e.g. electronic reporting, etc)

7.6. Establish a quality management program between international OIE/WHO rabies reference laboratory (ies) (e.g. Onderstepoort, CDC, etc) and national rabies reference laboratory for rabies confirmatory testing and variant typing

7.6.1. Develop/review/ update SOP for appropriate animal sample packaging and international shipment

7.6.2. Provide training to national reference laboratory staff on SOP for international sample shipment and package

7.6.3. Establish relevant material transfer agreement (s) for shipment of animal sample to international rabies reference laboratory (ies)

7.6.4. Participate on bi-annual proficiency testing of national rabies reference laboratory

7.6.5. Undertake in annual competency testing of national rabies reference laboratory staff

7.6.6. Periodically submit a proportion of rabies positive animal samples to international reference laboratory for variant typing St. 8: Information, education and communication 8.1. Increase animal and public health professionals’ knowledge on rabies

8.1.1. Conduct an assessment of animal and public health professionals on rabies related knowledge (e.g. rabies virus transmission, clinical signs, prevention, etc)

8.1.2. Train animal and public health professionals on identified knowledge gaps (GARC and blue print courses),

8.1.3. Adapt education training materials (GARC and Blueprint materials)

8.1.4. Gather rabies information and education materials in-country and from other relevant sources

8.1.5. Review materials for completeness and cultural appropriateness

8.1.6. Adapt and/or develop materials based on review

8.1.7. Perform field level testing of adapted and/or newly developed materials

8.1.8. Distribute information and education materials to relevant regional public health and animal health institutions 8.2. Increase general public awareness on rabies prevention 8.2.1. Conduct community survey to assess behaviors, knowledge, and practices related to rabies (e.g. KABP survey, etc) in target audience(s) 8.2.2. Develop appropriate rabies related messages based on survey findings from target audience(s) 8.2.3. Develop relevant awareness raising materials based on various communication channels

8.2.4. Develop national rabies communication strategies involving relevant stakeholders (e.g. media, internet, etc)

8.2.5. Train relevant professionnels on communication stratégies

8.2.6. Conduct routine community awareness campaigns for target audience(s) and activities St. 9: Multi-sectoral collaboration and sharing 9.1. Strengthen existing national level multi-sectoral rabies technical working groups (RTWG)

9.1.1. Review existing terms of references (TOR) and revise as necessary

9.1.2. Support regular meeting of the RTWG for information sharing, review implementation progress of activities relevant to each Ministries and encountered challenges 9.2. Establish regional multi-sectoral rabies technical working groups (RTWG) using a One Health Approach 9.2.1. Develop and implement work plans for 4 regional RTWGs 9.3. Obtain buy-in and secure resources for implementation of national rabies plan 9.3.1. Develop an advocacy plan to obtain buy-in (e.g. use of success stories, world rabies day, etc)

9.3.2. Obtain official endorsement of rabies strategy including the budget plan from all relevant Ministries

9.3.3. Identify and secure potential sources of funding for implementation of rabies strategy (e.g. private sector, etc) St. 10: Legislation 10.1. Identify gaps in national and regional level legal framework related to rabies prevention and control 10.1.1. Review existing national, regional, and administrative city legal framework for rabies prevention and control related provisions 10.1.2. Consult relevant experts and authorities for suggested legislation improvements and/or additions 10.2. Increase enforcement of existing rabies related legislation 10.2.1 Publicizing the legal framework 10.2.2. Assess current level of enforcement of any existing rabies related legal framework 10.2.3. Identify methods to improve legislation enforcement at the local level (e.g. fees, etc) in consultation with relevant legal bodies

3.1.2. EXPECTED SARE ASSESSMENT STAGE AT END OF PHASE 1: STAGE 1

3.2. PHASE 2 (2021-2023): IMPLEMENTATION OF THE ELIMINATION STRATEGY IN PRE- SELECTED LOCAL AREAS During this specific phase, the national rabies elimination strategy will be initiated by launching mass vaccination campaigns in pre-selected zones (local areas) in four select- ed regions of the country. These pre-selected zones will act as the starting point from where the progressive roll-out of mass vaccination campaigns will originate, based on lessons learned, will be expanded to other parts of the country in Phase 3 Specific activi- ties to be completed in the stipulated timeframe. St.1: Surveillance and response systems enhanced 1.1 Strengthen existing national animal and human rabies surveillance systems (phase one) 1.1.1. Implement changes to rabies surveillance systems (MOLF, EPHI, EWCA) based on evaluation findings and recommendations 1.1.2. Integrate wildlife animal rabies surveillance into existing animal surveillance system 1.2 Develop a joint SOP for human bite and suspected rabid animal investigations and response

1.2.1. Evaluate linked surveillance system in pilot regions to identify strengths and challenges 1.3. Strengthen national and sub national level capacity to analyze dog and human rabies data 1.3.1. Train all relevant animal and public health surveillance officers on how to collate and analyze rabies surveillance data 1.3.2. Train all relevant animal and public health professionals on development of epidemiological bulletins/reports for data sharing Strategy Output 2: Data reporting and sharing strengthened 2.1. Improve a mechanism (database) to strengthen reporting of all cases of human and animal rabies from the local to national 2.1.1. Explore electronic tools and/or platforms to improve reporting of cases in selected institutions 2.1.2. Provide financial and material resources to improve timely reporting of rabies cases

2.4. Establish a mechanism for reporting, feedback, and information sharing of rabies data among stakeholders and relevant sectors (national and international)

2.4.1. Share rabies data to Ministry websites (MOLF, EWCA, MOH, etc) on a monthly basis

2.4.2. Report key indicator human rabies and exposure data to WHO

2.4.3. Report key indicator animal rabies data to OIE 2.5. Establish and maintain communication with countries within the East African Rabies Community (e.g. PARACON) 2.5.1. Continue communications with Regional East African Rabies Community 2.5.2. Attend and participate in national, regional and international rabies meetings (i.e. PARACON, East African Regional, etc) Strategy Output 3: Prevention of rabies in humans 3.1. Increase access to modern cell culture rabies vaccines for human post-exposure prophylaxis 3.1.1. Conduct an assessment to evaluate animal bite incidence in all regions and administrative cities 3.1.2. Evaluate health facilities in all regions and administrative cities in order to identify appropriate facilities for cell culture vaccine distribution

3.1.3. Conduct evaluation of cell culture vaccine in pilot introduction regions to generate recommendations for large scale distribution 3.1.4. Conduct operational research to assess best method to increase access and cost-effectiveness 3.2. Increase access to pre-exposure prophylaxis using modern cell culture rabies vaccine for human among high-risk professionals 3.2.1. Provide pre-exposure prophylaxis to all identified high-risk professionals 3.2.2. Perform routine serological testing for adequate anti-rabies antibody titers 3.2.3. Administer booster vaccination for high-risk individuals based on serology testing results 3.3. Strengthen local cell culture vaccine production capacity based on WHO quality and safety standards at EPHI in order to phase-out nerve tissue vaccine utilization 3.3.1. Implement and maintain a quality management system for vaccine production 3.3.2. Procure equipment and material resources needed for cell culture vaccine production (e.g. through technology transfer from international institutions, etc) 3.3.3. Promote for vaccine development facility infrastructure improvement in order to meet international GMP standards

3.3.4. Undergo appropriate vaccine licensing and registration procedures for national use 3.4. Strengthen national regulatory authority capacity for licensing of locally produced human vaccines (e.g. FMHACA) 3.4.1. Avail resource based on identified needs 3.5. Reduce overutilization and unnecessary/improper administration of human rabies vaccine for post-exposure prophylaxis (PEP) 3.5.1. Revise human PEP recommendations based on confirmed animal rabies diagnostic test results

3.5.2. Revise human PEP recommendations based on animal rabies surveillance system and reliability and timeliness of reporting animal rabies assessment outcomes St.4: Control and elimination of rabies in dogs 4.2. Increase access to quality cell culture animal rabies vaccine for dogs in Ethiopia 4.2.1. Identify additional sources to obtain vaccine in cases of stock outs and vaccine shortage (e.g. importation) 4.2.2. Distribute appropriate consumable and supplies to all veterinary clinics (private and public) 4.2.3. Conduct routine monitoring of vaccine supply chain, vaccine use, and proper disposal 4.2.4. Conduct regular community surveys to assess affordability and access to dog rabies vaccine 4.2.5. Secure funding to provide additional subsidization of vaccine cost based on survey findings

4.2.6. Fill identified gaps in human resource need (e.g. hiring of veterinary staff)

4.2.7. Aware the community to mass dog vaccination 4.3. Increase local cell culture animal rabies vaccine production capacity at National Veterinary Institute 4.3.1. Procure supplies and equipment necessary for increased production 4.3.2. Hire additional staff for vaccine production 4.4. Improve quality and safety of locally produced cell culture rabies vaccine based on OIE quality and safety standards 4.4.1. Perform safety and potency testing for all vaccine batches produced by NVI 4.4.2. Obtain external quality assurance certification for local and international distribution

4.4.3. Establish field level vaccine safety and effectiveness monitoring system for local level 4.5. Increase national capacity to mass vaccinate at least 70% of dogs

4.5.1. Conduct MVCs in the selected rabies pilot areas 4.5.2. Use information from pilot MVCs to inform future MVCs (scale up implementation based on findings and availability of resources)

4.5.3. Conduct post-vaccination monitoring to obtain coverage estimates 4.6. Establish a legal framework for quarantine, inspection, and vaccination of animals involved in transboundary movement 4.6.1. Monitor enforcement of framework St.5: Prevention and Elimination of Rabies in Wildlife and Livestock 5.1. Enhance wildlife and livestock rabies surveillance 5.1.1. Utilize routine rabies surveillance data from livestock and wildlife to refine the national rabies strategy for integration 5.1.2. Conduct wildlife rabies research to explore potential reservoirs, estimate burden, and identify resources St.6: Dog population management (DPM) plan 6.1. Develop and implement DPM plan 6.1.1.. Sensitize community on DPM strategy prior to implementation

6.1.2. Implement the national DPM strategy at the local and national levels

6.1.3. Revise national DPM strategy based on epidemiological and ecology surveys (e.g. KAP survey, etc) St. 7: Rabies Diagnostic Laboratory Capacity strengthened 7.1. Increase national and regional animal health laboratory capacity for rabies diagnostic testing 7.1.1. Procure all supplies and equipment needed for rabies diagnostic testing 7.2. Establish a mechanism for animal sample submission to regional and national level laboratories for rabies diagnostic testing

7.3.1. Supply animal sample collection, transportation and storage materials to district vet clinic and regional labs for sample collection

7.3. Establish a national rabies reference laboratory

7.3.1. Identify laboratory to serve as the national rabies reference laboratory

7.4. Establish a quality management program between international OIE/WHO rabies reference laboratory (ies) (e.g. Onderstepoort, CDC, etc) and national rabies reference laboratory for rabies confirmatory testing and variant typing

7.4.1. Establish relevant material transfer agreement (s) for shipment of animal sample to international rabies reference laboratory (ies)

7.4.2. Participate on bi-annual proficiency testing of national rabies reference laboratory

7.4.3. Undertake in annual competency testing of national rabies reference laboratory staff

7.4.4. Periodically submit a proportion of rabies positive animal samples to international reference laboratory for variant typing St. 8: Information, education and communication 8.1. Increase animal and public health professionals’ knowledge on rabies 8.1.1. Adapt education training materials (GARC and Blueprint materials) 8.1.2. Gather rabies information and education materials in-country and from other relevant sources 8.1.3. Review materials for completeness and cultural appropriateness 8.1.4. Adapt and/or develop materials based on review 8.1.5. Perform field level testing of adapted and/or newly developed materials 8.1.6. Distribute information and education materials to relevant regional public health and animal health institutions 8.2. Increase general public awareness on rabies prevention 8.2.1. Conduct community survey to assess behaviors, knowledge, and practices related to rabies (e.g. KABP survey, etc) in target audience(s) 8.2.2. Develop appropriate rabies related messages based on survey findings from target audience(s) 8.2.3. Develop relevant awareness raising materials based on various communication channels 8.2.4. Train relevant professionnels on communication stratégies 8.2.5. Conduct routine community awareness campaigns for target audience(s) and activities

8.2.6. Train relevant professionnels on communication stratégies St. 9: Multi-sectoral collaboration and sharing strengthened 9.1. Strengthen existing national level multi-sectoral rabies technical working groups (RTWG) 9.1.1. Support regular meeting of the RTWG for information sharing, review implementation progress of activities relevant to each Ministries and encountered challenges 9.2. Establish regional multi-sectoral rabies technical working groups (RTWG) using a One Health Approach 9.2.1. Establish regional TWG in all regions 9.2.2. Develop and implement work plans for 4 regional RTWGs 9.3. Obtain buy-in and secure resources for implementation of national rabies plan 9.3.1. Identify and secure potential sources of funding for implementation of rabies strategy (e.g. private sector, etc) St. 10: Legislation 10.2. Increase enforcement of existing rabies related legislation

10.2.1. Publicizing the legal framework

3.2.2. EXPECTED SARE ASSESSMENT STAGE AT END OF PHASE2: STAGE 1,5

3.3. PHASE 3 (2024-2017): IMPLEMENTATION OF THE RABIES ELIMINATION STRATEGY OUTSIDE THE PRE-SELECTED LOCAL AREAS The third phase of implementing the rabies elimination strategy will rely on the system- atic roll-out of the mass vaccination campaigns beyond the pilot areas identified during the first phase and covered during the second phase. The roll-out will continue until the mass vaccination campaigns are implemented throughout the country up until appar- ent elimination of dog mediated human rabies and suppression of canine rabies in the country.

3.3.1. SPECIFIC ACTIVITIES TO BE COMPLETED IN THE STIPULATED TIMEFRAME St.1: Surveillance and response systems 1.1 Strengthen existing national animal and human rabies surveillance systems 1.1.1. Implement changes to rabies surveillance systems (MOLF, EPHI, EWCA) based on evaluation findings and recommendations 1.1.2. Integrate wildlife animal rabies surveillance into existing animal surveillance system

1.1.3. Train all animal and public health surveillance officers on key principles of rabies surveillance systems (case definitions, reporting, etc)

1.2 Develop a joint SOP for human bite and suspected rabid animal investigations and response

1.2.1. Train all animal health professionals on safe animal handling, animal sample collection, and euthanasia. (Consider certification)

1.2.2. Scale up implementation of linked surveillance system based on evaluation findings and availability of resources to increase national coverage

1.3. Strengthen national and sub national level capacity to analyze dog and human rabies data

1.3.1. Train all relevant animal and public health surveillance officers on how to collate and analyze rabies surveillance data

1.3.2. Train all relevant animal and public health professionals on development of epidemiological bulletins/reports for data sharing Strategy Output 2: Data reporting and sharing strengthened 2.1. Improve a mechanism (database) to strengthen reporting of all cases of human and animal rabies from the local to national 2.1.1. Explore electronic tools and/or platforms to improve reporting of cases in selected institutions 2.1.2. Provide financial and material resources to improve timely reporting of rabies cases

2.4.3. Share rabies data to Ministry websites (MOLF, EWCA, MOH, etc) on a monthly basis

2.4.4. Report key indicator human rabies and exposure data to WHO

2.4.5. Report key indicator animal rabies data to OIE

2.5. Establish and maintain communication with countries within the East African Rabies Community (e.g. PARACON)

2.5.1. Continue communications with Regional East African Rabies Community

2.5.2. Attend and participate in national, regional and international rabies meetings (ie PARACON, East African Regional, etc) St.3: Prevention of rabies in humans 3.1. Increase access to modern cell culture rabies vaccines for human post-exposure prophylaxis 3.1.1. Conduct an assessment to evaluate animal bite incidence in all regions and administrative cities 3.1.2. Evaluate health facilities in all regions and administrative cities in order to identify appropriate facilities for cell culture vaccine distribution

3.1.3. Train relevant health care professionals on proper administration of cell culture rabies vaccine (includes vaccination schedule)

3.1.4. Conduct operational research to assess best method to increase access and cost-effectiveness 3.2. Increase access to pre-exposure prophylaxis using modern cell culture rabies vaccine for human among high-risk professionals 3.2.1. Provide pre-exposure prophylaxis to all identified high-risk professionals 3.2.2. Perform routine serological testing for adequate anti-rabies antibody titers 3.2.3. Administer booster vaccination for high-risk individuals based on serology testing results 3.3. Strengthen local cell culture vaccine production capacity based on WHO quality and safety standards at EPHI in order to phase-out nerve tissue vaccine utilization

3.3.1. Train all vaccine production staff on vaccine production and quality assurance methods

3.3.2. Implement and maintain a quality management system for vaccine production

3.3.3. Procure equipment and material resources needed for cell culture vaccine production (e.g. through technology transfer from international institutions, etc)

3.3.4. Promote for vaccine development facility infrastructure improvement in order to meet international GMP standards 3.4. Strengthen national regulatory authority capacity for licensing of locally produced human vaccines (e.g. FMHACA) 3.4.1. Avail resource based on identified needs 3.5. Reduce overutilization and unnecessary/improper administration of human rabies vaccine for post-exposure prophylaxis (PEP) 3.5.1. Revise human PEP recommendations based on confirmed animal rabies diagnostic test results

3.5.2. Revise human PEP recommendations based on animal rabies surveillance system and reliability and timeliness of reporting animal rabies assessment outcomes St.4: Control and elimination of rabies in dogs

4.2. Increase access to quality cell culture animal rabies vaccine for dogs in Ethiopia

4.2.1. Identify additional sources to obtain vaccine in cases of stock outs and vaccine shortage (e.g. importation) 4.2.2. Distribute appropriate consumable and supplies to all veterinary clinics (private and public) 4.2.3. Conduct routine monitoring of vaccine supply chain, vaccine use, storage and proper disposal 4.2.4. Conduct regular community surveys to assess affordability and access to dog rabies vaccine 4.2.5. Secure funding to provide additional subsidization of vaccine cost based on survey findings

4.2.6. Train veterinary professionals at local veterinary clinics (public and private) 4.3. Increase local cell culture animal rabies vaccine production capacity at National Veterinary Institute 4.3.1. Procure supplies and equipment necessary for increased production

4.3.2. Hire additional staff for vaccine production

4.3.3. Train additional staff on SOP for cell culture animal rabies vaccine production) 4.4. Improve quality and safety of locally produced cell culture rabies vaccine based on OIE quality and safety standards 4.4.1. Perform safety and potency testing for all vaccine batches produced by NVI 4.4.2. Obtain external quality assurance certification for local and international distribution 4.5. Increase national capacity to mass vaccinate at least 70% of dogs

4.5.1. Train relevant professionnels on the MVC and post vaccination monitoring SOP

4.5.2. Use information from pilot MVCs to inform future MVCs (scale up implementation based on findings and availability of resources)

4.2.3. Secure funding to provide additional subsidization of vaccine cost based onsurvey findings

4.5.4. Conduct post-vaccination monitoring to obtain coverage estimates

4.6. Monitor enforcement of framework St.5: Prevention and Elimination of Rabies in Wildlife and Livestock 5.1. Enhance wildlife and livestock rabies surveillance 5.1.1. Utilize routine rabies surveillance data from livestock and wildlife to refine the national rabies strategy for integration 5.1.2. Conduct wildlife rabies research to explore potential reservoirs, estimate burden, and identify resources St.6: Dog population management (DPM) plan 6.1. Develop and implement DPM plan

6.1.1. Train animal health professionals on DPM strategy and relevant techniques 6.1.4. Implement the national DPM strategy at the local and national levels 6.1.2. Revise national DPM strategy based on epidemiological and ecology surveys (e.g. KAP survey, etc) St. 7: Rabies Diagnostic Laboratory Capacity 7.1. Increase national and regional animal health laboratory capacity for rabies diagnostic testing 7.1.1. Procure all supplies and equipment needed for rabies diagnostic testing

7.1.2. Train all laboratory staff in pilot labs on SOP

7.1.3. Include additional laboratories for rabies diagnostic testing as resources become available

7.2. Establish a mechanism for animal sample submission to regional and national level laboratories for rabies diagnostic testing 7.2.1.Train professional on proper sample collection ,handling and submission

7.2.2. Supply animal sample collection, transportation and storage materials to district vet clinic and regional labs for sample collection

7.3. Establish a quality management program between international OIE/WHO rabies reference laboratory (ies) (e.g. Onderstepoort, CDC, etc) and national rabies reference laboratory for rabies confirmatory testing and variant typing

7.3.1. Select international OIE/WHO rabies reference laboratories for rabies confirmatory testing of suspected animal rabies samples submitted to national rabies reference laboratory

7.3.2. Provide training to national reference laboratory staff on SOP for international sample shipment and package

7.3.3. Establish relevant material transfer agreement (s) for shipment of animal sample to international rabies reference laboratory (ies)

7.3.4. Participate on bi-annual proficiency testing of national rabies reference laboratory

7.3.5. Undertake in annual competency testing of national rabies reference laboratory staff

7.3.6. Periodically submit a proportion of rabies positive animal samples to international reference laboratory for variant typing St. 8: Information, education and communication 8.1. Increase animal and public health professionals’ knowledge on rabies

8.1.1. Train animal and public health professionals on identified knowledge gaps (GARC and blue print courses)

8.1.2. Adapt education training materials (GARC and Blueprint materials)

8.1.3. Gather rabies information and education materials in-country and from other relevant sources

8.1.4. Review materials for completeness and cultural appropriateness

8.1.5. Adapt and/or develop materials based on review

8.1.6. Perform field level testing of adapted and/or newly developed materials

8.1.7. Distribute information and education materials to relevant regional public health and animal health institutions 8.2. Increase general public awareness on rabies prevention 8.2.1. Conduct community survey to assess behaviors, knowledge, and practices related to rabies (e.g. KABP survey, etc) in target audience(s) 8.2.2. Develop appropriate rabies related messages based on survey findings from target audience(s) 8.2.3. Develop relevant awareness raising materials based on various communication channels 8.2.4. Train relevant professionnels on communication stratégies 8.2.5. Conduct routine community awareness campaigns for target audience(s) and activities St. 9: Multi-sectoral collaboration and sharing strengthened 9.1. Strengthen existing national level multi-sectoral rabies technical working groups (RTWG) 9.1.1. Support regular meeting of the RTWG for information sharing, review implementation progress of activities relevant to each Ministries and encountered challenges 9.2. Establish regional multi-sectoral rabies technical working groups (RTWG) using a One Health Approach

9.2.1. Establish regional TWG in all regions 9.2.2. Develop and implement work plans for 4 regional RTWGs 9.3. Obtain buy-in and secure resources for implementation of national rabies plan 9.3.1. Develop an advocacy plan to obtain buy-in (e.g. use of success stories, world rabies day, etc) 9.3.2. Identify and secure potential sources of funding for implementation of rabies strategy (e.g. private sector, etc) St. 10: Legislation

10.1. Identify gaps in national and regional level legal framework related to rabies prevention and control

10.1.1. Review existing national, regional, and administrative city legal framework for rabies prevention and control related provisions

10.1.2. Consult relevant experts and authorities for suggested legislation improvements and/or additions

10.2. Increase enforcement of existing rabies related legislation

10.2.1 Publicizing the legal framework

10.2.2. Assess current level of enforcement of any existing rabies related legal framework

10.2.3. Identify methods to improve legislation enforcement at the local level (e.g. fees, etc) in consultation with relevant legal bodies

3.3.2. EXPECTED SARE ASSESSMENT STAGE AT END OF PHASE 3: STAGE 2

3.4. PHASE 4 (2028-2029): MAINTAINING FREEDOM FROM CANINE-MEDIATED RABIES AND ELIMINATION OF CANINE RABIES During the fourth phase of the rabies elimination strategy, mass vaccination campaigns and the accompanying analysis of vaccination coverage will continue until all regions of the country can be publically declared free from all dog and human rabies cases.

3.4.1. SPECIFIC ACTIVITIES TO BE COMPLETED IN THE STIPULATED TIMEFRAME St.1: Surveillance and response systems

1.1 Strengthen existing national animal and human rabies surveillance systems

1.1.1. Implement changes to rabies surveillance systems (MOLF, EPHI, EWCA) based on evaluation findings and recommendations

1.1.2. Integrate wildlife animal rabies surveillance into existing animal surveillance system St.2: Data reporting and sharing 2.1. Improve a mechanism (database) to strengthen reporting of all cases of human and animal rabies from the local to national 2.1.1. Explore electronic tools and/or platforms to improve reporting of cases in selected institutions 2.1.2. Provide financial and material resources to improve timely reporting of rabies cases 2.2. Establish a mechanism for reporting, feedback, and information sharing of rabies data among stakeholders and relevant sectors (national and international) 2.2.1. Share rabies data to Ministry websites (MOLF, EWCA, MOH, etc) on a monthly basis 2.2.2. Report key indicator human rabies and exposure data to WHO 2.2.3. Report key indicator animal rabies data to OIE 2.3. Establish and maintain communication with countries within the East African Rabies Community (e.g. PARACON) 2.3.1. Continue communications with Regional East African Rabies Community For joint surveillance and intervention) 2.3.2. Attend and participate in national, regional and international rabies meetings (i.e. PARACON, East African Regional, etc) St.3: Prevention of rabies in humans 3.1. Increase access to modern cell culture rabies vaccines for human post-exposure prophylaxis 3.1.1. Conduct an assessment to evaluate animal bite incidence in all regions and administrative cities 3.1.2. Evaluate health facilities in all regions and administrative cities in order to identify appropriate facilities for cell culture vaccine distribution 3.2. Increase access to pre-exposure prophylaxis using modern cell culture rabies vaccine for human among high-risk professionals 3.2.1. Provide pre-exposure prophylaxis to all identified high-risk professionals 3.2.2. Perform routine serological testing for adequate anti-rabies antibody titers 3.2.3. Administer booster vaccination for high-risk individuals based on serology testing results 3.3. Strengthen local cell culture vaccine production capacity based on WHO quality and safety standards at EPHI in order to phase-out nerve tissue vaccine utilization 3.3.1. Implement and maintain a quality management system for vaccine production 3.3.2. Procure equipment and material resources needed for cell culture vaccine production (e.g. through technology transfer from international institutions, etc) 3.3.3. Promote for vaccine development facility infrastructure improvement in order to meet international GMP standards 3.4. Strengthen national regulatory authority capacity for licensing of locally produced human vaccines (e.g. EFMHACA) 3.4.1. Avail resource based on identified needs 3.5. Reduce overutilization and unnecessary/improper administration of human rabies vaccine for post-exposure prophylaxis (PEP) 3.5.1. Revise human PEP recommendations based on confirmed animal rabies diagnostic test results

3.5.2. Revise human PEP recommendations based on animal rabies surveillance system and reliability and timeliness of reporting animal rabies assessment outcomes St.4: Control and elimination of rabies in dogs 4.1. Increase access to quality cell culture animal rabies vaccine for dogs in Ethiopia 4.1.1. Identify additional sources to obtain vaccine in cases of stock outs and vaccine shortage (e.g. importation)

4.1.2. Distribute appropriate consumable and supplies to all veterinary clinics (private and public)

4.1.3. Conduct routine monitoring of vaccine supply chain, vaccine use, and proper disposal

4.1.4. Conduct regular community surveys to assess affordability and access to dog rabies vaccine

4.1.5. Secure funding to provide additional subsidization of vaccine cost based on survey findings

4.1.6. Aware the community to mass dog vaccination

4.2. Increase local cell culture animal rabies vaccine production capacity at National Veterinary Institute

4.2.1. Procure supplies and equipment necessary for increased production

4.3. Improve quality and safety of locally produced cell culture rabies vaccine based on OIE quality and safety standards

4.3.1. Perform safety and potency testing for all vaccine batches produced by NVI

4.3.2. Obtain external quality assurance certification for local and international distribution

4.4. Increase national capacity to mass vaccinate at least 70% of dogs

4.4.1. Conduct post-vaccination monitoring to obtain coverage estimates

4.5. Establish a legal framework for quarantine, inspection, and vaccination of animals involved in transboundary movement St.5: Prevention and Elimination of Rabies in Wildlife and Livestock 5.1. Enhance wildlife and livestock rabies surveillance 5.1.1. Utilize routine rabies surveillance data from livestock and wildlife to refine the national rabies strategy for integration 5.1.2. Conduct wildlife rabies research to explore potential reservoirs, estimate burden, and identify resources St.6: Dog population management (DPM) plan established 6.1. Develop and implement DPM plan 6.1.1. Implement the national DPM strategy at the local and national levels 6.1.2. Revise national DPM strategy based on epidemiological and ecology surveys (e.g. KAP survey, etc) St. 7: Rabies Diagnostic Laboratory Capacity 7.1. Increase national and regional animal health laboratory capacity for rabies diagnostic testing 7.1.1. Procure all supplies and equipment needed for rabies diagnostic testing 7.2. Establish a mechanism for animal sample submission to regional and national level laboratories for rabies diagnostic testing 7.2.1. Supply animal sample collection, transportation and storage materials to district vet clinic and regional labs for sample collection

7.3. Establish a quality management program between international OIE/WHO rabies reference laboratory(ies) (e.g. Onderstepoort, CDC, etc) and national rabies reference laboratory for rabies confirmatory testing and variant typing 7.3.1. Establish relevant material transfer agreement (s) for shipment of animal sample to international rabies reference laboratory (ies) 7.3.2. Participate on bi-annual proficiency testing of national rabies reference laboratory 7.3.3. Undertake in annual competency testing of national rabies reference laboratory staff 7.3.4. Periodically submit a proportion of rabies positive animal samples to international reference laboratory for variant typing St. 8: Information, education and communication 8.1. Increase animal and public health professionals’ knowledge on rabies 8.1.1. Adapt education training materials (GARC and Blueprint materials) 8.1.2. Gather rabies information and education materials in-country and from other relevant sources 8.1.3. Review materials for completeness and cultural appropriateness 8.1.4. Adapt and/or develop materials based on review 8.1.5. Perform field level testing of adapted and/or newly developed materials 8.1.6. Distribute information and education materials to relevant regional public health and animal health institutions 8.2. Increase general public awareness on rabies prevention 8.2.1. Conduct community survey to assess behaviors, knowledge, and practices related to rabies (e.g. KABP survey, etc) in target audience(s) 8.2.2. Develop appropriate rabies related messages based on survey findings from target audience(s) 8.2.3. Develop relevant awareness raising materials based on various communication channels 8.2.4. Train relevant professionnels on communication stratégies 8.2.5. Conduct routine community awareness campaigns for target audience(s) and activities St. 9: Multi-sectoral collaboration and sharing 9.1. Strengthen existing national level multi-sectoral rabies technical working groups (RTWG) 9.1.1. Support regular meeting of the RTWG for information sharing, review implementation progress of activities relevant to each Ministries and encountered challenges 9.2. Establish regional multi-sectoral rabies technical working groups (RTWG) using a One Health Approach

9.2.2. Develop and implement work plans for 4 regional RTWGs 9.3. Obtain buy-in and secure resources for implementation of national rabies plan

9.3.1. Develop an advocacy plan to obtain buy-in (e.g. use of success stories, world rabies day, etc)

9.3.2. Identify and secure potential sources of funding for implementation of rabies strategy (e.g. private sector, etc) St. 10: Legislation 10.1. Increase enforcement of existing rabies related legislation

10.1.1 Publicizing the legal framework

3.5. PHASE 5 (2030): MAINTAIN FREEDOM FROM RABIES IN HUMANS AND DOGS During the fifth, and final, phase of the rabies elimination strategy in Ethiopia, the disease intervention strategies will be modified and contiguously maintained through risk-based approach in the country. This phase will be lead by a contingency plan to prevent re-intro- duction/re-emergence of rabies while clearing foci areas based on risk assessment. This approach will ensure that Ethiopia maintains its freedom from dog and human rabies. Specific activities to be completed in the stipulated timeframe St. 2: Data reporting and sharing strengthened

2.1. Improve a mechanism (database) to strengthen reporting of all cases of human and animal rabies from the local to national

2.1.1. Explore electronic tools and/or platforms to improve reporting of cases in selected institutions

2.1.2. Provide financial and material resources to improve timely reporting of rabies cases

2.2. Establish a mechanism for reporting, feedback, and information sharing of rabies data among stakeholders and relevant sectors (national and international)

2.2.1. Share rabies data to Ministry websites (MOLF, EWCA, MOH, etc) on a monthly basis

2.2.2. Report key indicator human rabies and exposure data to WHO

2.2.3. Report key indicator animal rabies data to OIE

2.3. Establish and maintain communication with countries within the East African Rabies Community (e.g. PARACON)

2.3.1. Continue communications with Regional East African Rabies Community

2.3.2. Attend and participate in national, regional and international rabies meetings (i.e. PARACON, East African Regional, etc) St.3: Prevention of rabies in humans

3.1. Increase access to modern cell culture rabies vaccines for human post-exposure prophylaxis

3.1.1. Conduct an assessment to evaluate animal bite incidence in all regions and administrative cities

3.1.2. Evaluate health facilities in all regions and administrative cities in order to identify appropriate facilities for cell culture vaccine distribution

3.2. Increase access to pre-exposure prophylaxis using modern cell culture rabies vaccine for human among high-risk professionals

3.2.1. Provide pre-exposure prophylaxis to all identified high-risk professionals

3.2.2. Perform routine serological testing for adequate anti-rabies antibody titers

3.2.3. Administer booster vaccination for high-risk individuals based on serology testing results

3.3. Strengthen local cell culture vaccine production capacity based on WHO quality and safety standards at EPHI in order to phase-out nerve tissue vaccine utilization

3.3.1. Implement and maintain a quality management system for vaccine production

3.3.2. Procure equipment and material resources needed for cell culture vaccine production (e.g. through technology transfer from international institutions, etc)

3.3.3. Promote for vaccine development facility infrastructure improvement in order to meet international GMP standards (All)

3.4. Strengthen national regulatory authority capacity for licensing of locally produced human vaccines (e.g. EFMHACA)

3.4.1. Avail resource based on identified needs

3.5. Reduce overutilization and unnecessary/improper administration of human rabies vaccine for post-exposure prophylaxis (PEP)

3.5.1. Revise human PEP recommendations based on confirmed animal rabies diagnostic test results

3.5.2. Revise human PEP recommendations based on animal rabies surveillance system and reliability and timeliness of reporting animal rabies assessment outcomes St.4: Control and elimination of rabies in dogs

4.1. Increase access to quality cell culture animal rabies vaccine for dogs in Ethiopia

4.1.1. Identify additional sources to obtain vaccine in cases of stock outs and vaccine shortage (e.g. importation)

4.2.2. Distribute appropriate consumable and supplies to all veterinary clinics (private and public)

4.2.3. Conduct routine monitoring of vaccine supply chain, vaccine use, and proper disposal

4.2.4. Conduct regular community surveys to assess affordability and access to dog rabies vaccine

4.2.5. Secure funding to provide additional subsidization of vaccine cost based on survey findings

4.3. Increase local cell culture animal rabies vaccine production capacity at National Veterinary Institute

4.3.1. Procure supplies and equipment necessary for increased production

4.4. Improve quality and safety of locally produced cell culture rabies vaccine based on OIE quality and safety standards

4.4.1. Perform safety and potency testing for all vaccine batches produced by NVI

4.4.2. Obtain external quality assurance certification for local and international distribution

4.5. Increase national capacity to mass vaccinate at least 70% of dogs

4.5.1. Conduct post-vaccination monitoring to obtain coverage estimates

4.6. Establish a legal framework for quarantine, inspection, and vaccination of animals involved in transboundary movement

4.6.1. Monitor enforcement of framework St.5: Prevention and Elimination of Rabies in Wildlife and Livestock

5.1. Enhance wildlife and livestock rabies surveillance

5.1.1. Utilize routine rabies surveillance data from livestock and wildlife to refine the national rabies strategy for integration

5.1.2. Conduct wildlife rabies research to explore potential reservoirs, estimate burden, and identify resources St.6: Dog population management (DPM) plan

6.1. Develop and implement DPM plan

6.1.1. Implement the national DPM strategy at the local and national levels

6.1.2. Revise national DPM strategy based on epidemiological and ecology surveys (e.g. KAP survey, etc) St. 7: Rabies Diagnostic Laboratory Capacity

7.1. Increase national and regional animal health laboratory capacity for rabies diagnostic testing

7.1.1. Procure all supplies and equipment needed for rabies diagnostic testing

7.2. Establish a mechanism for animal sample submission to regional and national level laboratories for rabies diagnostic testing

7.2.1. Supply animal sample collection, transportation and storage materials to district vet clinic and regional labs for sample collection

7.3. Establish a quality management program between international OIE/WHO rabies reference laboratory(ies) (e.g. Onderstepoort, CDC, etc) and national rabies reference laboratory for rabies confirmatory testing and variant typing

7.3.1. Establish relevant material transfer agreement (s) for shipment of animal sample to international rabies reference laboratory (ies)

7.3.2. Participate on bi-annual proficiency testing of national rabies reference laboratory

7.3.3. Undertake in annual competency testing of national rabies reference laboratory staff

7.3.4. Periodically submit a proportion of rabies positive animal samples to international reference laboratory for variant typing St. 8: Information, education and communication

8.1. Increase animal and public health professionals’ knowledge on rabies

8.1.1. Adapt education training materials (GARC and Blueprint materials)

8.1.2. Gather rabies information and education materials in-country and from other relevant sources

8.1.3. Review materials for completeness and cultural appropriateness

8.1.4. Adapt and/or develop materials based on review

8.1.5. Perform field level testing of adapted and/or newly developed materials

8.1.6. Distribute information and education materials to relevant regional public health and animal health institutions

8.2. Increase general public awareness on rabies prevention

8.2.1. Conduct community survey to assess behaviors, knowledge, and practices related to rabies (e.g. KABP survey, etc) in target audience(s)

8.2.2. Develop appropriate rabies related messages based on survey findings from target audience(s)

8.2.3. Develop relevant awareness raising materials based on various communication channels

8.2.4. Train relevant professionnels on communication stratégies

8.2.5. Conduct routine community awareness campaigns for target audience(s) and activities St. 9: Multi-sectoral collaboration and sharing

9.1. Strengthen existing national level multi-sectoral rabies technical working groups (RTWG)

9.1.1. Support regular meeting of the RTWG for information sharing, review implementation progress of activities relevant to each Ministries and encountered challenges

9.2. Establish regional multi-sectoral rabies technical working groups (RTWG) using a One Health Approach

9.2.1. Develop and implement work plans for 4 regional RTWGs

9.3. Obtain buy-in and secure resources for implementation of national rabies plan

9.3.1. Identify and secure potential sources of funding for implementation of rabies strategy (e.g. private sector, etc) St. 10: Legislation

10.1. Increase enforcement of existing rabies related legislation

10.1.1. Publicizing the legal framework

3.5.1. EXPECTED SARE ASSESSMENT STAGE AT END OF PHASE 5: STAGE 5

3.6. ACTION PLANS FOR IMPLEMENTING EACH PHASE The implementation of each phase’s activities will be based on a phase-specific action plan that will be developed by the Ethiopian rabies multi-sectoral technical working group. The phase-specific action plans will be detailed documents that will supplement the national elimination strategy by providing in-depth detail on the following items: • Specific activities and how they will be prioritized within the stipulated timeframe of the specific phase • Stakeholders that will take responsibility for specific activities • Key indicators that will result in an activity being considered as “accomplished” • Budgetary requirements to complete the phase. This budget will form part of the larger budget allocated to the rabies elimination strategy

3.7. MONITORING AND EVALUATION OF PROGRESS As this strategy is based on the comprehensive SARE assessment model, the objective is for Ethiopia to address the rabies-specific activities discussed in this national strategy in order to progress from Stage 0 (country endemic for rabies) to Stage 5 (country free from dog rabies). The SARE assessment consists of six stages (stage 0 to 5) and these stages can be broadly summarized as follows (see figure below): • Stage 0: No information on rabies available, but rabies is suspected to be present • Stage 1: Assessment of the local rabies epidemiology, elaboration of a short- term rabies action plan: • Stage 2: Development of a national rabies prevention and control strategy • Stage 3: Full-scale implementation of the national rabies control strategy • Stage 4: Maintenance of human rabies freedom, elimination of dog rabies • Stage 5: Freedom from human and dog rabies being monitored The monitoring and evaluation will rely on regular SARE assessment undertaken by the Ethiopian rabies multi-sectoral technical working group in order to ensure a progressive reduction of disease risk, enabling regional or synchronized activities towards disease elimination. CHAPTER 4: EXPENDITURE ESTIMATES

4.1. SUMMARY ESTIMATED BUDGET (Summary description of the total amount of the budget to implement activities listed under phase 1 of the implementation period. Brief description of the budget items as depicted in the table below and the amount of budget as compared to the total, expressed in percentages. Brief description of the strategic pillar areas and the major responsible government sectors) Table 4. Rabies Prevention and Control Strategy - Phase 1 No. Name of Regional Veterinary Lab Amount - ETB Amount - USD 1 Training (Workshop) 31,845,100 1,161,806 2 Consultant Subject Matter Expert (SME) 1,818,800 66,355 3 Travel 5,445,771 198,678 4 Supplies and equipment 507,498,002 18,515,068 5 Shipment, commuication and others 222,500 8,117 Total 546,830,173 19,950,025

4.2. PHASE I ACTIVITY BUDGET WITH INPUT DESCRIPTION Table 5. Detailed activity budget - Phase 1 Budget headings and inputs description Amount - ETB Amount - USD Training (Workshop) Standardize animal rabies case definition based on international 263,000 9,595 standards (workshop) Standardize suspected rabies exposures case definition for humans and for animals and human rabies case definitions based on international 284,200 10,368 standards (Activities 1.1.2 and 1.1.3) Train all animal and public health surveillance officers on key principles 3,801,000 138,672 of rabies surveillance systems (case definitions, reporting, etc) Develop a joint SOP for human bite and suspected rabid animal investigations and response; and protocol for quarantine and euthanasia 261,200 9,529 of suspected rabid animals (writeshop and validation workshop) Budget headings and inputs description Amount - ETB Amount - USD Train all animal health professionals on safe animal handling, animal 1,172,400 42,773 sample collection, and euthanasia Obtain endorsement from pilot region governments and identify 125,700 4,586 resources (funding, human) for implementation (stakeholder workshop) Train all relevant animal and public health surveillance officers on how to collate, analysis and development of epidemiological bulletins on rabies 724,200 26,421 surveillance data Provide financial and material resources to improve timely reporting of 724,200 26,421 rabies cases Train relevant health care professionals on proper administration of cell 1,294,200 47,216 culture rabies vaccine (includes vaccination schedule) Train all vaccine production staff on vaccine production and quality 1,314,000 47,939 assurance methods Develop SOPs for post-mass dog population estimation vaccination 261,200 9,529 monitoring (Write work shop) Training to conduct surveys to estimate dog population 1,361,600 49,675 Train veterinary professionals at local veterinary clinics (public and 1,714,000 62,532 private) Train additional staff on SOP for cell culture animal rabies vaccine 193,000 7,041 production (technical training) Develop SOP for planning and implementing MVCs and post vaccination 295,000 10,762 monitoring( write work shop) Train relevant professionals on the MVC and post vaccination monitoring 434,400 15,848 SOP Establish/review existing legislation for annual MVC implementation at 284,200 10,368 federal and regional levels (Write work shop) Obtain endorsement from appropriate authorities for legal framework 278,700 10,168 (validation) Develop a national DPM strategy using available resources and share 572,200 20,876 with relevant stakeholders Sensitize community on DPM strategy prior to implementation 2,136,000 77,928 Train animal health professionals on DPM strategy and relevant 686,200 25,035 techniques Develop and distribute SOP for rabies diagnostic testing (2 writeshop 418,500 15,268 and a validation) Train all laboratory staff in pilot labs on SOP 1,672,800 61,029 Develop standardized operating procedures for animal sample collection, 418,500 15,268 storage, and transportation (2 writeshops and a validation) Train professional on proper sample collection, handling and 1,672,800 61,029 submission Review/develop animal sample submission forms to ensure all necessary epidemiologic data are collected on submitted samples (2 418,500 15,268 writeshop and a validation) Develop strategy to address identified gaps (e.g. electronic reporting, 166,700 6,082 etc) (validation of 7.3.2) Develop/review/ update SOP for appropriate animal sample packaging 139,500 5,089 and international shipment Budget headings and inputs description Amount - ETB Amount - USD Provide training to national reference laboratory staff on SOP for 418,200 15,257 international sample shipment and package Train animal and public health professionals on identified knowledge 1,672,800 61,029 gaps (GARC and blue print courses) Adapt education training materials (GARC and Blueprint materials) 279,000 10,179 Review materials for completeness and cultural appropriateness 139,500 5,089 Adapt and/or develop materials based on review (writeshop and 279,000 10,179 validation) Develop appropriate rabies related messages based on survey findings 125,700 4,586 from target audience(s) (validation of what the consultant developed) Develop relevant awareness raising materials based on various 251,400 9,172 communication channels (1 writeshop and 1 validation workshop) Develop national rabies communication strategies involving relevant stakeholders (e.g. media, internet, etc) (1 writesop and 1 validation 251,400 9,172 workshop) Train relevant professionals on communication strategies 125,700 4,586 Conduct routine community awareness campaigns for target 2,136,000 77,928 audience(s) and activities Support regular meeting of the RTWG for information sharing, review implementation progress of activities relevant to each Ministries and 1,534,800 55,994 encountered challenges Develop and implement work plans for 4 regional RTWGs 1,023,200 37,329 Obtain official endorsement of rabies strategy including the budget plan 269,100 9,818 from all relevant Ministries (validation workshop of the strategy) Consult relevant experts and authorities for suggested legislation 125,700 4,586 improvements and/or additions (expert consultation) Identify methods to improve legislation enforcement at the local level 125,700 4,586 (e.g. fees, etc) in consultation with relevant legal bodies Total 31,845,100 1,161,806 Consultant Subject Matter Expert (SME) Seek technical expertise from international and national vaccine 1,000,000 36,483 production experts Assess national regulatory capacity to license locally produced human 82,800 3,021 vaccines Develop quarantine, inspection, and vaccination legal framework based 184,000 6,713 on assessment Assess local level (wereda) and regionals capacity to submit suspected 138,000 5,035 rabies animal samples to the regional and national level Conduct community survey to assess behaviors, knowledge, and practices related to rabies and develop rabies related messages and 138,000 5,035 awareness raising materials (e.g. KAP survey, etc) in target audience(s) Review existing national, regional, and administrative city legal 184,000 6,713 framework for rabies prevention and control related provisions Assess current level of enforcement of any existing rabies related legal 92,000 3,356 framework Total 92,000 66,355 Budget headings and inputs description Amount - ETB Amount - USD Travel Evaluate existing rabies surveillance systems (i.e. Public Health Emergency Management, National Animal Disease Surveillance System, 329,132 12,008 Wildlife surveillance) and compare to international standards and proposed system for Ethiopia to identify gaps Attend and participate in national, regional and international rabies 1,702,800 62,123 meetings (i.e. PARACON, East African Regional, etc) Conduct an assessment to evaluate animal bite incidence in all regions 246,849 9,006 and administrative cities Conduct evaluation of cell culture vaccine in pilot introduction regions to 161,849 5,905 generate recommendations for large scale distribution Conduct surveys to estimate dog population 858,264 31,312 Distribute appropriate consumable and supplies to all veterinary clinics 858,264 31,312 (private and public) Conduct routine monitoring of vaccine supply chain, vaccine use, and 830,547 30,301 proper disposal Conduct regular community surveys to assess affordability and access 412,283 15,041 to dog rabies vaccine Assess NVI production capacity (including human resources, etc) to 22,283 813 meet estimated demand Perform field level testing of adapted and/or newly developed materials 23,500 857 Total 5,445,771 198,678 Supplies and equipment Provide financial and material resources to improve timely reporting of 18,700,000 682,233 rabies cases Pilot introduction of cell culture rabies vaccine in 4 regions 45,135,000 1,646,662 Perform routine serological testing for adequate anti-rabies antibody 9,600,000 350,237 titers Identify equipment, material and human resource needs for cell culture 9,600,000 350,237 vaccine production Procure equipment and material resources needed for cell culture vaccine production (e.g. through technology transfer from international 19,093,813 696,600 institutions, etc) Procure supplies and equipment necessary for increased vaccine 25,369,188 925,545 production Total 127,498,002 4,651,514 Budget headings and inputs description Amount - ETB Amount - USD Shipment, communication and others Obtain external quality assurance certification from OIE for local and 2,500 91 international distribution Periodically submit a proportion of rabies positive animal samples to 100,000 3,648 international reference laboratory for variant typing Distribute information and education materials to relevant regional 40,000 1,459 public health and animal health institutions Publicizing the legal framework 80,000 2,919 Total 222,500 8,117 GRAND TOTAL 166,830,173 6,086,471 Table 6: Budget summary Phase Two $10,705,500 Phase Three $5,398,469 Phase Four $608,018 Phase Five $353,653 REFERENCES Abraham Ali (2012): Ethiopian National Rabies Baseline Survey report. Asefa Deressa, Abraham Ali, Mekoro Beyene, Bethelheim Newaye selassie, Eshetu Yimer and Kedir Hussen (2010): The status of rabies in Ethiopia: retrospective record review. Ethiopian Journal of Public Health Development. Vol. 24 No.2. Asefa Deressa (2017): Molecular epidemiology of rabies virus circulating in Ethiopia. Dissertation. DOVAR-II data base (2016): Ministry of Livestock and Fisheries Annual Report. Epidemiology Directorate (2017): Ministry of Livestock and Fisheries Annual Report. Fekadu, M. (1997): Human rabies surveillance and control in Ethiopia. In: Proceedings of the Southern and Eastern Africa Rabies Group Meeting Nairobi, Kenya. Jibat T, Hogeveen H and Mourits MCM (2015): Review on Dog Rabies Vaccination Coverage in Africa: A Question of Dog Accessibility or Cost Recovery? PLoS Neglected Tropical Diseases, 9(2): 1-13. Hampson K, Coudeville L, Lembo T, Sambo M, Kieffer A, Attlan M, et al. (2015): Estimating the global burden of endemic canine rabies. PLoS Neglected Tropical Diseases 9: e0003709. doi:10.1371/journal.pntd.000370 MebatsionT, Sillero-Zubiri C, Gottelli D, CoxJH. (1992): Detection of rabies anti body by ELISAand RFFIT in unvaccinated dogs and in the endangered Simien jackal (Canis simensis) ofEthiopia.ZentralblVeterinarmed. 39:233-235 Pankhurst R. (1990): An introduction to the medical history of Ethiopia. The Red Sea Press. Inc. Trenton, New Jersey: 101. WHO expert consultation on rabies. (2005): Technical Report Series 931, World Health Organization, Geneva World Health Organization (1990): Expert consultation on Rabies. Geneva, Switzerland.

ANNEX 1: WORK PLAN AND BUDGET (PHASE ONE) NATIONAL RABIES CONTROL AND ELIMINATION STRATEGY; WORK PLAN AND BUDGET (PHASE ONE) Vision: To see Ethiopia with eliminated dog mediated human rabies by 2030 Mission: To significantly reduce and ultimately control the public health impact of Rabies in humans and animals in Ethiopia through sustained surveillance, laboratory diagnosis, prevention and control system and community awareness. Goal: To effectively eliminate all human rabies deaths by 2030, as result of strategic vaccination of 70% of the domestic dog population in the country Strategic Plan Owner- EPHI/MoLF/EWCA Strategy Budget Respon- Activities Detail Activities Progress Remark Output Required sibility 1.1.1. Standardize animal 263,000 rabies case definition based on international standards 1.1.2. Standardize 284,000 suspected rabies exposures case definition for humans and for animals based on international standards 1.1.3. Standardize human Budget rabies case definition included with based on international Activity 1.1.2 standards 1.1.4. Evaluate existing 329,132 rabies surveillance systems (i.e. Public Health Emergency Management, National Animal Disease St.1. 1.1 Strengthen Surveillance System, Surveillance existing national Wildlife surveillance) and and response animal and human compare to international systems rabies surveillance standards and proposed enhanced systems system for Ethiopia to identify gaps 1.1.5. Develop a monitoring and evaluation plan for routine evaluation of rabies surveillance systems (desktop) 1.1.6. Integrate wildlife animal rabies surveillance into existing animal surveillance system (through official communications) 1.1.7. Train all animal 3,801,000 and public health surveillance officers on key principles of rabies surveillance systems (case definitions, reporting, etc) Strategy Budget Respon- Activities Detail Activities Progress Remark Output Required sibility 1.2.1. Develop a joint 161,200 SOP for human bite and suspected rabid animal investigations and response 1.2.2. Customize and standardize data collection forms for joint rabies field investigations (suspected rabid animal investigations, human exposure investigation, lab data collection) (desktop and official communication) 1.2.3. Develop a protocol Budget for quarantine and included euthanasia of suspected under 1.2. rabid animals St.1. 1.2 Develop a 1.2.4. Train all animal 1,172,400 Surveillance joint SOP for health professionals on and response human bite and safe animal handling, systems suspected rabid animal sample collection, enhanced animal and euthanasia 1.2.5. Jointly identify pilot region(s) to implement a linked rabies surveillance system based on objective data (surveillance, human resource, etc) 1.2.6. Obtain 125,700 endorsement from pilot region governments and identify resources (funding, human) for implementation 1.2.7. Establish a national level linked rabies surveillance system (through official communications) Strategy Budget Respon- Activities Detail Activities Progress Remark Output Required sibility 1.3.1. Train all relevant 724,200 animal and public health surveillance officers on how to collate 1.3. Strengthen and analyze rabies St.1. national and surveillance data Surveillance sub national and response 1.3.2. Train all relevant Budget level capacity to systems animal and public included analyze dog and enhanced human rabies data health professionals under 1.3.1 on development of epidemiological bulletins/reports for data sharing 2.1.1. Identify appropriate electronic 2.1. Improve tools and/or platforms a mechanism to improve reporting (database) of cases in selected to strengthen institutions (official reporting of all communications and cases of human desktop analysis) and animal rabies from the local to 2.1.2. Provide financial 18,700,000 national and material resources to improve timely reporting of rabies cases 2.2. Integrate 2.2.1. Select a web- Linked with a national and based platform (e.g. Activity 2.1.1 St.2. Data subnational level DHIS2, etc) to enter, link, reporting database linking and share national and and sharing animal and human sub national rabies data strengthened rabies surveillance and laboratory data 2.3.1.Share rabies data to 2.3. Establish Ministry websites (MOLF, a mechanism EWCA, MOH, etc) on a for reporting, monthly basis (MOU and feedback, and official communication) information 2.3.2. Report key sharing of rabies indicator human rabies data among and exposure data to stakeholders and WHO relevant sectors (national and 2.3.3. Report key international) indicator animal rabies data to OIE Strategy Budget Respon- Activities Detail Activities Progress Remark Output Required sibility 2.4.1. Continue 2.4. Establish communications with and maintain Regional East African St.2. Data communication Rabies Community reporting with countries 2.4.2. Attend and 1,702,800 and sharing within the East participate in national, strengthened African Rabies regional and international Community (e.g. rabies meetings (ie PARACON) PARACON, East African Regional, etc) 3.1.1. Conduct an 246,849 assessment to evaluate animal bite incidence in all regions and administrative cities 3.1.2. Evaluate health facilities in all regions and administrative cities in order to identify appropriate facilities for cell culture 3.1. Increase vaccine distribution access to modern (Communication with St.3. regional bureaus) cell culture Prevention rabies vaccines 3.1.3. Pilot introduction 45,135,000 of rabies in for human of cell culture rabies humans post-exposure vaccine in 4 regions prophylaxis 3.1.4. Train relevant 1,294,200 health care professionals on proper administration of cell culture rabies vaccine (includes vaccination schedule) 3.1.5. Conduct evaluation 161,849 of cell culture vaccine in pilot introduction regions to generate recommendations for large scale distribution Strategy Budget Respon- Activities Detail Activities Progress Remark Output Required sibility 3.2.1. Identify all high-risk professionals/workers for rabies pre-exposure vaccination 3.2. Increase 3.2.2. Provide pre- access to exposure prophylaxis pre-exposure to all identified high-risk prophylaxis using professionals modern cell 3.2.3. Perform routine 9,600,000 culture rabies serological testing for vaccine for human adequate anti-rabies among high-risk antibody titers 3.2.4. Administer booster vaccination for high-risk individuals based on serology testing 3.3.1. Seek technical ex- 1,000,000 pertise from international and national vaccine production experts 3.3.2. Identify equipment, 9,600,000 material and human resource needs for St.3. cell culture vaccine Prevention production of rabies in 3.3.3. Train all vaccine 1,314,000 humans production staff on vac- cine production and qual- 3.3. Strengthen ity assurance methods local cell 3.3.4. Implement and culture vaccine mentain a quality production management system for capacity based on vaccine production WHO quality and safety standards 3.3.5. Procure equipment 19,093,813 at EPHI in order to and material resources phase-out nerve needed for cell culture tissue vaccine vaccine production (e.g. utilization through technology transfer from internation- al institutions, etc) 3.3.6. Promote for vaccine development facility infrastructure improvement in order to meet international GMP standards 3.3.7. Undergo appropri- ate vaccine licensing and registration procedures for national use Strategy Budget Respon- Activities Detail Activities Progress Remark Output Required sibility 3.4. Strengthen 3.4.1. Assess national 82,800 national regulatory regulatory capacity to authority capacity license locally produced for licensing of human vaccines locally produced 3.4.2.Identify resource human vaccines needs for licensing of (e.g. EFMHACA) human rabies vaccines 3.5.1. Revise human PEP St.3. recommendations based Prevention 3.5. Reduce on confirmed animal of rabies in overutilization rabies diagnostic test humans and unnecessary/ results improper 3.5.2. Revise human administration PEP recommendations of human rabies based on animal rabies vaccine for surveillance system and post-exposure reliability and timeliness prophylaxis (PEP) of reporting animal rabies assessment outcomes 4.1.1. Identify responsible authority (ies) for dog population estimation at national St.4. 4.1. Increase ,regional and (TWG to Control and national capacity find out) zonal level elimination to accurately 4.1.2. Develop SOPs 261,200 of rabies in estimate dog for post-mass dog dogs population size population estimation vaccination monitoring 4.1.3. Conduct surveys to 858,264 estimate dog population and Determine Strategy Budget Respon- Activities Detail Activities Progress Remark Output Required sibility 4.2.1. Assess regional and administrative cities’ cold chain and storage capacity ,and vaccine supply needs at veterinary clinics (Gov’t and private) 4.2.2. Identify additional sources to obtain vaccine in cases of stock outs and vaccine shortage (e.g. importation) 4.2.3. Distribute 858,264 appropriate consumable and suppliesto all veterinary clinics (private and public) 4.2.4. Conduct routine 830,547 monitoring of vaccine St.4. 4.2. Increase supply chain, vaccine Control and access to quality use, and proper disposal elimination cell culture animal 4.2.5. Conduct regular 412,283 of rabies in rabies vaccine for community surveys to dogs dogs in Ethiopia assess affordability and access to dog rabies vaccine 4.2.6. Secure funding to provide additional subsidization of vaccine cost based on survey findings 4.2.7. Assess existing veterinary staff capacity at district 4.2.8. Fill identified gaps in human resource need (e.g. hiring of veterinary staff) 4.2.9. Train veterinary 1,714,000 professionals at local veterinary clinics (public and private) Strategy Budget Respon- Activities Detail Activities Progress Remark Output Required sibility 4.3.1. Utilize estimated dog population to assess animal rabies vaccine need 4.3.2. Assess NVI 22,283 production capacity (including human resources, etc) to meet estimated demand 4.3.3. Procure supplies 25,369,188 4.3. Increase local and equipment cell culture animal necessary for increased rabies vaccine production production 4.3.3. Procure supplies 193,000 capacity and equipment at National necessary for increased Veterinary production Institute 4.3.4. Hire additional staff for vaccine St.4. production Control and 4.3.5. Hire additional elimination staff for vaccine of rabies in production dogs 4.3.6. Train additional staff on SOP for cell culture animal rabies vaccine production 4.4.1. Perform safety and potency testing for all vaccine batches produced by NVI 4.4. Improve 4.4.2. Perform efficacy quality and testing of NVI’s rabies safety of locally vaccines produced cell culture rabies 4.4.3. Obtain external 2,500 vaccine based on quality assurance OIE quality and certification for local and safety standards international distribution 4.4.4. Establish field level vaccine safety and effectiveness monitoring system for local level Strategy Budget Respon- Activities Detail Activities Progress Remark Output Required sibility 4.5.1. Develop SOP 295,000 for planning and implementing MVCs and post vaccination monitoring 4.5.2. Distribute SOP for MVC and post vaccination monitoring to all regions and administrative cities 4.5.3. Train relevant 434,400 professionnels on the MVC and post 4.5. Increase vaccination monitoring national capacity SOP to mass vaccinate at least 70% of 4.5.4. Select zone(s) dogs in specific regions for piloting canine mass St.4. vaccinations Control and 4.5.5. Establish/review 284,200 elimination existing legislation of rabies in for annual MVC dogs implementation at federal and regional levels 4.5.6. Revise annual MVC strategy based on risk assessments (e.g. surveillance and lab data) 4.6.1. Develop legal 184,000 4.6. Establish a framework based on legal framework assessment for quarantine, 4.6.2. Obtain 278,700 inspection, and endorsement from vaccination of appropriate authorities animals involved for legal framework in transboundary 4.6.3. Monitor 45,000 movement enforcement of framework St.5. 5.1.1. Utilize routine Prevention rabies surveillance 5.1. Enhance and data from livestock and wildlife and Elimination wildlife to refine the livestock rabies of Rabies in national rabies strategy surveillance Wildlife and for integration Livestock Strategy Budget Respon- Activities Detail Activities Progress Remark Output Required sibility 6.1.1. Develop a national 572,200 DPM strategy using available resources and share with relevant St.6. Dog stakeholders population 6.1. Develop and 6.1.2.. Sensitize 2,136,000 management implement DPM community on DPM (DPM) plan plan strategy prior to established implementation 6.1.3. Train animal health 686,200 professionals on DPM strategy and relevant techniques 7.1.1. Perform 7,283 assessment of all national and regional Animal health laboratories for rabies diagnostic testing capacity 7.1.2. Select 4 pilot 7.1. Increase regional/national St.7. Rabies labs for animal rabies national and Diagnostic diagnostic testing based regional animal Laboratory on assessment results health laboratory Capacity capacity for rabies (desktop work) strengthened diagnostic testing 7.1.3. Procure all 20,000,000 supplies and equipment needed for rabies diagnostic testing 7.1.4. Develop and 418,500 distribute SOP for rabies diagnostic testing 7.1.5. Train all laboratory 1,672,800 staff in pilot labs on SOP Strategy Budget Respon- Activities Detail Activities Progress Remark Output Required sibility 7.2.1. Assess local level 138,000 (wereda) and regionals capacity to submit suspected rabies animal samples to the regional and national level 7.2.2. Develop standard- 418,500 ized operating proce- dures for animal sample 7.2. Establish a collection, storage, and mechanism for transportation animal sample 7.2.3.Train professional 1,672,800 submission to on proper sample regional and collection, handling and national level submission laboratories for 7.2.4. Supply animal 4,000,000 rabies diagnostic sample collection, trans- testing portation and storage materials to district vet clinic and regional labs for sample collection 7.2.5. Review/develop 418,500 animal sample submis- St.7. Rabies sion forms to ensure all Diagnostic necessary epidemiologic Laboratory data are collected on Capacity submitted samples strengthened 7.3. Establish a 7.3.1. Assess regional 7,283 mechanism to laboratory level capacity report all test to report test results to results of animal national level and identify rabies cases gaps from regions 7.3.2. Develop strategy to 166,700 to the national address identified gaps rabies reference (e.g. electronic reporting, laboratory etc) 7.4. Establish a 7.4.4. Participate on 147,000 quality manage- bi-annual proficiency ment program testing of national rabies between interna- reference laboratory tional OIE/WHO 7.4.5. Undertake in Budget rabies reference annual competency included laboratory (ies) testing of national rabies under Activity (e.g. CDC) and reference laboratory staff 7.4.4 national rabies 7.4.6. Periodically submit 100,000 reference labo- a proportion of rabies ratory for rabies positive animal samples confirmatory to international reference testing and variant laboratory for variant typing typing Strategy Budget Respon- Activities Detail Activities Progress Remark Output Required sibility 8.1.1. Conduct an 2,500 assessment of animal and public health professionals on rabies related knowledge (e.g. rabies virus transmission, clinical signs, prevention, etc) 8.1.2. Train animal 1,672,800 and public health professionals on identified knowledge gaps (GARC and blue print courses) 8.1.3. Adapt education 279,000 training materials (GARC and Blueprint materials) 8.1. Increase St. 8: In- 8.1.4. Gather rabies animal and formation, information and public health education education materials in- professionals’ and commu- country and from other knowledge on nication relevant sources rabies 8.1.5. Review materials for completeness and cultural appropriateness 8.1.6. Adapt and/or 279,000 develop materials based on review 8.1.7. Perform field level 23,500 testing of adapted and/ or newly developed materials 8.1.8. Distribute 40,000 information and education materials to relevant regional public health and animal health institutions Strategy Budget Respon- Activities Detail Activities Progress Remark Output Required sibility 8.2.1. Conduct 138,000 community survey to assess behaviors, knowledge, and practices related to rabies (e.g. KAP survey, etc) in target audience(s) 8.2.2. Develop 125,700 appropriate rabies related messages based on survey findings from target audience(s) 8.2.3. Develop relevant 251,400 St. 8: In- awareness raising 8.2. Increase materials based on formation, general public various communication education awareness on channels and commu- rabies prevention nication 8.2.4. Develop national 251,400 rabies communication strategies involving relevant stakeholders (e.g. media, internet, etc) 8.2.5. Train relevant 125,700 professionals on communication strategies 8.2.6. Conduct routine 2,136,000 community awareness campaigns for target audience(s) and activities 9.1.1. Review existing terms of references (TOR) and revise as 9.1. Strengthen necessary existing national 9.1.2. Support regular 1,534,500 level multi- meeting of the RTWG sectoral rabies for information St. 9: Multi- technical working sharing, review sectoral groups (RTWG) implementation progress collaboration of activities relevant and sharing to each Ministries and strengthened encountered challenges 9.2. Establish 9.2.1. Develop and 1,023,200 regional multi- implement work plans sectoral rabies for 4 regional RTWGs technical working groups (RTWG) using a One Health Approach Strategy Budget Respon- Activities Detail Activities Progress Remark Output Required sibility 9.3.1. Develop an advocacy plan to obtain buy-in (e.g. use of success stories, world rabies day, etc) (Office work) 9.3.2. Obtain official 269,100 9.3. Obtain buy- St. 9: Multi- endorsement of rabies in and secure sectoral strategy including the resources for collaboration budget plan from all implementation and sharing relevant Ministries of national rabies strengthened 9.3.3. Identify and Total budget plan secure potential secured for sources of funding implementa- for implementation of tion of this rabies strategy (e.g. strategy private sector, etc) (GTP planning for next fiscal year) 10.1.1. Review existing 184,000 national, regional, and 10.1. Identify administrative city legal gaps in national framework for rabies and regional level prevention and control legal framework related provisions related to rabies 10.1.2. Consult relevant 125,700 prevention and experts and authorities control for suggested legislation improvements and/or St. 10: additions Legislation 10.2.1 Publicizing the 80,000 reviewed legal framework 10.2.2. Assess current 92,000 level of enforcement 10.2. Increase of any existing rabies enforcement of related legal framework existing rabies 10.2.3. Identify methods 125,700 related legislation to improve legislation enforcement at the local level (e.g. fees, etc) in consultation with relevant legal bodies

ANNEX 2: PERFORMANCE MONITORING PLAN OF THE NATIONAL RABIES PREVENTION AND CONTROL STRATEGY (BRIEF DESCRIPTION OF THE IMPORTANCE OF THE AN M&E PLAN AND RESPONSIBLE SECTORS) Measurable Means of Activity Subactivity indicators of Deliverable Target verification achievement Strategy Output 1: Surveillance and response systems enhanced (SARE: Data collection and analysis) 1.1.1. Standardize animal Approved animal rabies case definition case definitions based on international for Ethiopia standards 1.1.2. Standardize Approved case suspected rabies definitions # of rabies Jointly exposures case for human case definitions 3 endorsed definition for humans exposures standardized document and for animals based on and animal international standards exposures 1.1 Strengthen existing national 1.1.3. Standardize human animal and rabies case definition Approved human human rabies based on international case definitions surveillance standards systems 1.1.4. Evaluate existing rabies surveillance systems (i.e. Public Health Emergency Management, Rabies National Animal Disease Existing rabies surveillance Assessment Surveillance System, surveillance N/A gaps Report Wildlife surveillance) and system described documented compare to international standards and proposed system for Ethiopia to identify gaps Measurable Means of Activity Subactivity indicators of Deliverable Target verification achievement Proportion 1.1.5. Implement changes of gaps / to rabies surveillance recommendations Fully functional Performance/ systems (MOLF, EPHI, in the rabies surveillance N/A evaluation EWCA) based on surveillance system imple- report evaluation findings and systems mented recommendations assessment addressed 1.1.6. Develop a Existence of M&E M&E plan for 1.1 Strengthen monitoring and evaluation plan for rabies rabies surveil- existing national plan for routine evaluation surveillance lance systems 1 M&E plan animal and of rabies surveillance systems developed human rabies systems surveillance Animal systems 1.1.7. Integrate wildlife surveillance Integrated rabies animal rabies surveillance Survelance system integrating surveillance N/A into existing animal reports wildlife animal system surveillance system rabies described 1.1.8. Train all animal and # of professionals Competencies in public health surveillance trained on key key principles of officers on key principles TBD based principles of rabies surveil- Training report of rabies surveillance on 1.1.5 rabies surveillance lance system systems (case definitions, systems acquired reporting, etc) SOP for SOP for human SOP for human human bite 1.2.1. Develop a joint bite and suspect- bite and suspected and suspected SOP for human bite and ed rabid animal rabid animal rabid animal suspected rabid animal investigations 1 investigations investigations investigations and and response and response and response response developed and described adopted and approved implemented 1.2 Develop a 1.2.2. Customize joint SOP for and standardize data human bite #, list of data Data collection collection forms for joint and suspected collection tools tools adopted rabies field investigations Data collection TBD based rabid animal for joint rabies and data (suspected rabid animal tools approved on 1.2.1 investigations field investigations summary investigations, human and response developed reports exposure investigation, lab data collection) Protocol for Summary Protocol for 1.2.3. Develop a protocol quarantine and reports of quarantine and for quarantine and euthanasia of quarantine and euthanasia of 1 euthanasia of suspected suspected rabid euthanasia/ suspected rabid rabid animals animals devel- testing animals described oped activities Measurable Means of Activity Subactivity indicators of Deliverable Target verification achievement Proportion of 1.2.4. Train all animal Competencies professionals health professionals on in safe animal trained on safe safe animal handling, handling, animal animal handling, TBD Training report animal sample collection, sample collec- animal sample and euthanasia. (Consider tion and eutha- collection, and certification) nasia acquired euthanasia 1.2.5. Jointly identify pilot region(s) to implement a 2-3 small, # of pilot regions linked rabies surveillance Pilot regions well- Pilot site rec- selected for rabies system based on objective prioritized defined ommendations surveillance data (surveillance, human sites resource, etc) 1.2.6. Obtain endorsement Signed from pilot region # of endorsed Endorsement agreement governments and instruments with instruments 2-3 that includes 1.2 Develop a identify resources resources. (MOU/TOR) responsibilities joint SOP for (funding, human) for and resources human bite implementation and suspected Gaps and rabid animal strengths in sur- investigations 1.2.7. Evaluate linked Surveillance veillance system and response surveillance system in Assessment system in pilot documented N/A pilot regions to identify report regions described including recom- strengths and challenges mendations for change 1.2.8. Scale up implementation of linked # of new regions New regions surveillance system based Surveillance (with necessary implementing on evaluation findings and TBD reports from resources) surveillance availability of resources new regions identified system to increase national coverage National surveillance 1.2.9. Establish a national National rabies National rabies reports level linked rabies surveillance surveillance sys- 1 summarizing surveillance system system described tem established data from all zones Measurable Means of Activity Subactivity indicators of Deliverable Target verification achievement Strategy Output 2: Data reporting and sharing strengthened (SARE: Data collection and analysis) 2.1.1. Explore electronic 2.1. Improve tools and/or platforms Assessment Assessment #, list of le tools a mechanism to improve reporting findings docu- TBD and recommen- available (database) of cases in selected mented dations report to strengthen institutions reporting of all Document re- cases of human 2.1.2. Provide financial sources availed and animal # of reporting Asset register and material resources to by relevant rabies from the resources TBD and/or improve timely reporting agencies (MOLF, local to national distributed handover notes of rabies cases EPHI, EWCA, etc.) 2.3. Establish an interoperable national and 2.3.1. Select a web-based Web-based plat- subnational platform (e.g. DHIS2, etc) Web-based form for rabies Joint national level database to enter, link, and share platform for rabies data integrated 1 data summary linking national and sub national data described with existing reports animal and rabies data system human rabies surveillance and laboratory data 2.4. Establish 2.4.1.Share rabies data to Existence of Rabies data a mechanism Ministry websites (MOLF, web-based data in uploaded and Database 12 for reporting, EWCA, MOH, etc) on a Ministry websites shared on a reports feedback, and monthly basis and shared reports monthly basis information # of human sharing of 2.4.2. Report key indicator Disease rabies cases and rabies data human rabies and WHI notfied TBD notification exposure reported among exposure data to WHO reports timely to WHO stakeholders and relevant # of animal rabies Disease sectors 2.4.3. Report key indicator cases reported OIE notified N/A notification (national and animal rabies data to OIE timely to OIE reports international) Communication 2.5.1. Continue summaries # of 2.5. Establish communications with Documented (ie. Agendas, communications N/A and maintain Regional East African communications minutes, made communication Rabies Community summary with countries reports, emails) within the East 2.5.2. Attend and Meeting African Rabies participate in national, communique Community regional and international # of meetings Meeting agenda (ie. Agendas, (e.g. PARACON) TBD rabies meetings (ie attended and proceedings minutes, PARACON, East African summary Regional, etc) reports) Measurable Means of Activity Subactivity indicators of Deliverable Target verification achievement Strategy Output 3: Prevention of rabies in humans (SARE: Prevention and Control) 3.1.1. Conduct an assessment to evaluate animal bite incidence in all number of Animal bite inci- Assessment 1 per year regions and administrative assessment dences recorded reports cities (Addis Ababa, Dire Dawa) 3.1.2. Evaluate health facilities in all regions #, list of health and administrative facilities Health facilities cities in order to identify assessed for cell TBD Asset register identified appropriate facilities culture vaccine for cell culture vaccine distribution distribution 3.1. Increase 3.1.3. Pilot introduction of proportion of exposed people Vaccination access to cell culture rabies vaccine people vaccinated 100% vaccinated reports modern cell in 4 regions from exposed culture rabies 3.1.4. Train relevant health vaccines for # of professionals Competencies care professionals on human post- trained on in cell culture proper administration of exposure administration of rabies vaccine 1005 Training report cell culture rabies vaccine prophylaxis cell culture rabies administration (includes vaccination vaccine acquired schedule) 3.1.5. Conduct evaluation of cell culture vaccine # of regions where in pilot introduction Cell culture vac- Assessment cell culture vaccine 4piot area regions to generate cine scaled up report has been scaled up recommendations for large scale distribution Findings for 3.1.6. Conduct operational best methods access and cost research to assess best to increase effectiveness method to increase access and cost- 1 Study report of cell culture access and cost- effectiveness vaccine docu- effectiveness determined mented Measurable Means of Activity Subactivity indicators of Deliverable Target verification achievement #, list of identified 3.2.1. Identify all high-risk high-risk Database High risk profes- professionals/workers professionals/ of high risk sionals invento- TBD for rabies pre-exposure workers for rabies professionals/ ried vaccination pre-exposure workers 3.2. Increase vaccination access to 3.2.2. Provide pre- pre-exposure Proportion of high- High risk profes- exposure prophylaxis Vaccination prophylaxis risk professionals sionals vacci- 100% to all identified high-risk report using modern vaccinated nated professionals cell culture rabies vaccine Proportion of 3.2.3. Perform routine for human professionals Level of protec- serological testing for Lab results among high-risk serologically tion assessed 100% adequate anti-rabies report professionals tested among and documented antibody titers vaccinated 3.2.4. Administer booster proportion of All professional vaccination for high-risk individual who vaccination at high risk are 100% individuals based on receive booster records protected serology testing results vaccination 3.3.1. Seek technical expertise from # of expert List of recom- international and national recommendations mendations TBD Project reports vaccine production adopted proposed experts # and type of Supplies and re- 3.3.2. Identify equipment, equipment and sources needed material and human supplies for cell Assessment for cell culture TBD 3.3. Strengthen resource needs for cell culture vaccine report vaccine produc- local cell culture vaccine production production tion documented culture vaccine identified production 3.3.3. Train all vaccine Competencies # of professional capacity based production staff on in vaccine staff trained on on WHO quality vaccine production production and TBD Training report vaccine production and safety and quality assurance QA methods and QA methods standards at methods acquired EPHI in order to Quality phase-out nerve Quality manage- 3.3.4. Implement a quality management tissue vaccine ment system for third party management system for system for vaccine 1 utilization vaccine produc- accreditation vaccine production production tion rolled out described 3.3.5. Procure equipment and material resources national lab Vaccine produc- needed for cell culture equipped with tion supplies vaccine production (e.g. vaccine production TBD Asset register and equipment through technology equipment and received transfer from international supplies institutions, etc) Measurable Means of Activity Subactivity indicators of Deliverable Target verification achievement 3.3. Strengthen 3.3.6. Advocate for # of policy local cell vaccine development makers reached culture vaccine facility infrastructure Policy makers Advocacy with advocacy TBD production improvement in order to sensitized materials for vaccine capacity based meet international GMP development on WHO quality standards and safety standards at 3.3.7. Undergo appropriate EPHI in order to license and Vaccine licenses vaccine licensing and vaccine phase-out nerve registration and registration 1 registration procedures for licenses tissue vaccine acquired obtained national use utilization Measurable Means of Activity Subactivity indicators of Deliverable Target verification achievement