High rabies mortality and barriers to effective management in Tigray during prolonged war and deadly siege

Global efforts has been undertaken to eliminate dog mediated human rabies deaths by 2030. This target was proposed to undertake various prevention and control measures including the integrated surveillance system and optimal dog vaccination. However, the impact of a collapsed healthcare system during the prolonged war and siege in Tigray, Ethiopia, remains poorly understood on the status of the surveillance system, and the burden of rabies. Therefore, this study assessed clinical rabies mortality patterns and explored challenges in rabies prevention and control methods. A mixed method approach with retrospective analysis of surveillance data (2017–2023) and in-depth interviews with human health and animal health experts were conducted in Tigray region of the Northern Ethiopia. Surveillance data from 2017 to 2023 were analyzed across the pre-war period (2017–2019), the transition year in which the war began in November (2020), the wartime period (2021–2022), and the early post-war recovery period (2023), when health and surveillance services had not yet been fully restored. Data were analysed using MS Excel and Arc GIS, while qualitative data were thematically examined. During the pre-war period (2017–2019), 8384 suspected rabies exposures and eight clinical rabies deaths were reported. In the 2020 transition year, 1881 exposures and two deaths were reported. During the wartime period (2021–2022), reported exposures declined to 501 while 49 deaths were recorded. In the early post-war recovery period (2023), 1481 exposures and 20 deaths were reported. Rabies deaths were notably higher in Central, North-western, and Southern zone of Tigray during the war while reporting completeness declined to below 12% in 2021. Qualitative data revealed significant disruption of rabies control were identified such as, decreased health-seeking behaviour, disruption of rabies prevention and control measures, and weak coordination among the One Health sectors. Reported clinical rabies deaths increased markedly during the wartime period and remained elevated during early post-war recovery, when healthcare, surveillance, PEP provision, and rabies-control services had not yet been fully restored. Strengthening surveillance, restoring PEP access, and enhancing One Health collaboration are essential.