Implementing a One Health approach to rabies surveillance: lessons from integrated bite case management

As part of the ‘Zero by 30’ strategy to end human deaths from dog-mediated rabies by 2030, international organizations recommend a One Health framework that includes Integrated Bite Case Management (IBCM). However, little is understood about the implementation of IBCM in practice. This study aims to understand how IBCM is conceptualized, exploring how IBCM has been operationalized in different contexts, as well as barriers and facilitators to implementation. Semi-structured interviews were conducted with seventeen practitioners and researchers with international, national, and local expertise across Africa, Asia, and the Americas. Thematic analysis was undertaken using both inductive and deductive approaches. Four main themes were identified: 1) stakeholders’ and practitioners’ conceptualization of IBCM and its role in rabies elimination; 2) variation in how IBCM operates across different contexts; 3) barriers and facilitators of IBCM implementation in relation to risk assessment, PEP provisioning, animal investigation, One Health collaboration, and data reporting; and 4) the impact of the COVID-19 pandemic on IBCM programs. This study highlights the diversity within experts’ conceptualization of IBCM, and its operationalization. The range of perspectives revealed that there are different ways of organizing IBCM within health systems and it is not a one-size-fits-all approach. The issue of sustainability remains the greatest challenge to implementation. Contextual features of each location influenced the delivery and the potential impact of IBCM. Programs spanned from highly endemic settings with limited access to PEP charged to the patient, to low endemicity settings with a large patient load associated with free PEP policies and sensitization. In practice, IBCM was tailored to meet the demands of the local context and level of rabies control. Thus, experts’ experiences did not necessarily translate across contexts, affecting perceptions about the function, motivation for, and implementation of IBCM. To design and implement future and current programs, guidance should be provided for health workers receiving patients on assessing the history and signs of rabies in the biting animal. The study findings provide insights in relation to implementation of IBCM and how it can support programs aiming to reach the Zero by 30 goal