The Economic Landscape of Global Rabies: A Scoping Review and Future Directions

Abstract

Rabies remains a significant global public health concern, causing an estimated 59,000–69,000 human fatalities annually. Despite being entirely preventable through vaccination, rabies continues to impose substantial economic burdens worldwide. This study presents a scoping review of the economic research on rabies to determine overlaps and gaps in knowledge and inform future research strategies. We selected 150 studies (1973–2024) to analyze. The review categorizes the literature based on geographic distribution, species focus, and type of study. Findings indicate that economic studies are disproportionately concentrated in developed countries, such as the United States and parts of Europe, where rabies risk is low, while high-risk regions, particularly in Africa and Asia, remain underrepresented. Most studies focus on dog-mediated rabies, reflecting its dominant role in human transmission, while fewer studies assess the economic impacts of wildlife and livestock-mediated rabies. Case studies and modeling approaches dominate the literature, whereas cost–benefit and cost–effectiveness analyses—critical for informing resource allocation—are limited. The review highlights the need for more economic evaluations in rabies-endemic regions, expanded research on non-dog reservoirs, and broader use of economic methods. Addressing these gaps will be crucial for optimizing rabies control and supporting global initiatives to eliminate dog-mediated rabies by 2030.

1. Introduction

Rabies, an acute viral encephalomyelitis caused by the rabies virus, primarily affects the nervous systems of mammals. As one of the oldest known diseases, rabies has been documented for over 4000 years and is characterized by one of the highest case fatality ratios among infectious diseases, approaching 100% once clinical symptoms manifest [1]. It is estimated that rabies results in approximately 59,000 to 69,000 global fatalities each year, underscoring its significance as a public health concern [2,3]. Notably, while rabies is fatal once symptoms appear, it is entirely preventable through effective vaccination strategies.

Globally, the burden of rabies varies, influenced by regional characteristics and local control measures. In developed countries where canine rabies has been largely eliminated, the virus persists primarily in wildlife reservoirs, including bats, foxes, raccoons, and skunks [4]. In contrast, domestic dogs serve as the principal reservoir in many developing nations, accounting for the majority of global human rabies cases [5,6]. The economic and social impacts of rabies in canids are profound, leading researchers to focus on this variant for data collection and analysis. Hampson et al. [2] estimated the cost of human life lost due to rabies, utilizing disability-adjusted life years (DALYs), resulting in a global economic burden of canine rabies estimated at USD 8.6 billion. Similarly, Anderson & Shwiff [3] conducted a Monte Carlo simulation to value human life in this context, estimating the annual global economic impact of canine rabies to be approximately USD 124.2 billion. The ranges for these estimates are quite broad, reflecting the uncertainty in the data and the challenges of estimating the burden of this neglected disease.

Effective strategies to combat dog-mediated rabies hinge on governmental priorities, resource availability, and public education. Various approaches have been implemented globally, including local dog population management, parenteral and oral vaccination campaigns, or combinations thereof [7,8]. The success of rabies control programs relies on collaboration across multiple disciplines [9]. In 2015, a global strategic plan was launched to eliminate dog-mediated rabies by 2030, supported by major organizations such as the WHO, the Food and Agriculture Organization (FAO), the World Organization for Animal Health (OIE), and the Global Alliance for Rabies Control (GARC) [10] (p. 125). Economic evaluations of these interventions are essential for developing cost-effective management strategies and achieving the goal of eliminating dog-mediated rabies.

Several literature reviews have addressed economic aspects of rabies, notably Meltzer and Rupprecht [11], who examined economic questions surrounding postexposure prophylaxis (PEP) in humans and rabies control programs in animals. Systematic reviews of the cost-effectiveness of various control programs have been conducted, often focusing on specific geographic areas such as Africa or the Americas [12,13,14]. Anothaisintawee et al. [15] provided a review concentrated on economic evaluation studies related to rabies mitigation programs.

Research on the economics of rabies has identified critical areas of concern, including the economic burden from healthcare expenses, lost productivity, and PEP costs [2]. Furthermore, the economic impact extends to livestock and wildlife, indirectly affecting agricultural sectors and tourism [11]. Public health costs, particularly those associated with vaccination initiatives for pets and wildlife, are significant. The effectiveness of interventions, such as mass dog vaccination campaigns, wildlife vaccination efforts, and public awareness initiatives, has also been a focus of study [7,8]. Despite these valuable insights, a comprehensive examination of the literature on the global economics of rabies remains lacking. A thorough review is essential to assess data variability, long-term economic impacts, comprehensive cost analyses, and regional differences in economic estimates.

This paper presents a scoping review of the economic impact and the economic evaluation of rabies on a global scale. This study contributes to the existing literature in three important ways: first, it categorizes economic studies by location, species, and type of analysis; second, it identifies overlaps in research efforts and gaps in knowledge; and third, it discusses the implications of these findings and suggests potential avenues for future research. The remainder of this manuscript is organized as follows: In the next section, we outline the methodological strategy employed to collect the articles considered in this analysis. We then describe the methods employed to categorize each article by certain factors, followed by the results of our analysis. Lastly, the Section 4 examines the broader implications for rabies management and policy.

2. Materials and Methods

We used a scoping review to identify the literature based on the methodological guidelines outlined by the Preferred Reporting Items for Systematic reviews and Meta-Analyses (PRISMA), with focus on the extension for Scoping Reviews (PRISMA-ScR) [16,17] (File S1). The literature search flow diagram for this scoping review is provided in Figure 1. The protocol of this scoping review has not been registered or published previously.

To capture the breadth of studies investigating the potential economic impact of rabies, the literature evaluating a myriad of costs associated with the disease was considered eligible and is reflected in the use of broad search terms. The scientific peer-reviewed literature from journals, edited book volumes, government reports, or other similar documents was considered eligible based on PRISMA-ScR guidance [17]. The following bibliographic databases were searched: Web of Science, EBSCO, PubMed, and Scopus. Primary search terms were looked for within the title, abstract, and keywords. The term “rabies” was paired with terms associated with economic impacts: economic(s), financial, cost, bioeconomic, and dollar(s). Publications published in any year were considered eligible, and the initial search yielded 744 articles. Details of the full electronic search strategy are outlined in Appendix A.

Publication titles and abstracts were screened and were excluded if they were a duplicate version of an already encountered publication (n = 230), did not report an economic cost of the disease (n = 19), were incomplete/unavailable text (n = 2), were in response to already encountered papers and were not relevant to economics (n = 5), or were a review with no novel economic findings (n = 9). Duplicates were screened and removed using Zotero software version 6.0.26 and then manually checked [18]. Additional articles were added manually from the references of the review articles included in the initial search (n = 9). The same primary search terms in the title, abstract, and index terms were considered as in the first stage. Once all relevant sources were identified and retrieved, each source was reviewed to ensure relevance. Based on these criteria, a total of 544 articles were excluded.

In the final eligibility stage, 204 articles were included. The next step was sorting these articles into categories—case studies, reviews, modeling, and letters. We removed any articles that were strictly related to human vaccination development or procedures (n = 54). The remaining 150 articles were compiled into a database (Table S1) to describe and summarize various characteristics of the publication. Using this database, we investigated the selected articles to summarize the research completed so far on the economics of rabies, specifically on variables such as location, species, institution, year, and methods.

3. Results

3.1. Timeline

For this analysis, the final database included 150 rabies-related economic studies published between 1973 and 2024 over the six continents with the presence of rabies (Figure 2). The number of studies published each year varies, with peaks in 2017 (15 studies) and 2019 (13 studies). The earliest study noted that met our review criteria was a case study in Argentina published in 1973 that included economic loss estimates in its summary of bat-transmitted rabies in the country [19]. The first formal cost–benefit analysis model was published by the Centers for Disease Control and Prevention (CDC) using North America-based data in 1996 [20]. The 2024 studies included research on trends in animal bites and rabies-related deaths in Northern Iran, along with an evaluation of the monetary costs, and a Canadian modeling study that assessed the efficiency of local rabies vaccination strategies for raccoons in an urban setting using individual-based modeling [21,22].

Four years, 2016–2019, stand out as notable publication years from the data, with 10, 15, 10, and 13 publications per year, respectively (Figure 2). Several interesting patterns emerge from these years, including that, in 2019, the total number of studies was driven up by the number of studies conducted in the USA (four studies) and globally (three studies). This cannot be said for the previous high publication years. In 2016 and 2017, each year had only one publication from the USA, while 2018 had none. In terms of global studies, 2017 and 2018 each had one publication, while 2016 had none. Examining the temporal changes by aggregating the countries to the continent or global study level indicates that studies conducted in Asia were mainly responsible for the spike from 2016 to 2019 (Figure 3).

3.2. Location and Research Institution

Over the study period, the database comprises rabies-related economic studies from 46 unique countries and 6 continents. The most frequently represented countries are the USA (31 studies), Haiti (8 studies), the Philippines (7 studies), Canada (7 studies), and India (6 studies) (Figure 4). A significant number of global or multi-country studies are also represented (18 studies). The first study included in this analysis was from South America (Argentina) in 1973 and focused on bat rabies (Figure 2). Europe was next with studies in Italy (1975) and Germany (1978). Economics-related studies from North America were first recorded in 1980 for the US and 1988 for Canada. The first global economic study was also conducted in 1988. Asia (Philippines) and Africa (Tunisia) conducted their first studies on the economics of rabies in 1991 and 1998, respectively (Figure 3).

Across the globe, 111 countries are considered at high risk for human rabies exposure [23]. Of those high-risk countries, only 19, or roughly 17%, had published studies on the economics of rabies. Of those 19 countries, 7 were in Africa, 6 in Asia, 3 in South America, and the final 3 were in the Middle East and the Caribbean. This result indicates that most of the high-risk areas in Africa and Asia have not examined the economics of rabies. Overlapping the 19 countries with rabies economic studies, which are also high risk for human rabies exposure, with basic country economic conditions, reveals that six of these countries fall into the category of “least developed countries” (Figure 4). The remaining fall into the category of “developing countries”.

Examining the number of studies from regions where rabies exposure risk levels for humans are moderate to low provides insight into the relationship between the potential for human rabies exposure and economic development. For example, the US is considered at low risk for human exposure to rabies, likely because of the presence of rabies in wildlife as opposed to dogs. However, it leads the world in the number of studies conducted on the economics of rabies. Canada, parts of Europe (France, Germany, Switzerland, Italy, the UK, the Netherlands, Finland, Slovenia, and Croatia), Argentina, and Australia have also conducted numerous studies. They, too, are considered at low risk for human exposure to rabies for the same reasons as the US and, for the most part, are considered “developed countries” (Figure 5).

The dataset includes papers affiliated with a diverse range of institutions. In total, publications from over 90 different institutions were identified. The most frequently represented institutions include the United States Department of Agriculture’s National Wildlife Research Center (23 papers) and the Centers for Disease Control and Prevention (15 papers). Beyond these top contributors, the remaining papers are evenly distributed among other institutions, suggesting a widespread interest across government agencies, public health organizations, and academic institutions both nationally and internationally. Funding sources, when explicitly stated, also came from a widespread range of sources. Notable contributors were the UBS Optimus Foundation (18 papers), the Wellcome Trust (14 papers), and the Global Alliance for Rabies Control (6 papers). These organizations, representing philanthropic, global health, and disease-specific initiatives respectively, highlight the multifaceted support driving rabies research.

3.3. Species

Much of the world is impacted by dog rabies, except in the cases of developed countries, where dog rabies has been eliminated, and wildlife has become the main reservoir for rabies [10]. Studies on the economics of dog-mediated rabies form the majority of those included in this analysis (Figure 6). For these studies, research was focused on canine vaccination programs, post-exposure prophylaxis (PEP), epidemiological surveillance, and economic assessments. Case studies document rabies outbreaks in dogs, particularly in endemic regions such as Africa, Asia, and Latin America. Modeling studies related to dog rabies assess transmission dynamics and vaccination strategies. When looking at specifically dog-focused studies, there was a noticeable difference in study location compared to all species, with more representation from Africa and Asia (Figure 6). Non-dog-related rabies studies examine wildlife reservoirs, such as bat rabies, and rabies in wild carnivores, such as foxes, raccoons, and skunks, and were primarily focused on North America and Europe. Livestock studies assess economic impacts and spillover risks in agricultural settings of rabies mediated by a variety of hosts to livestock, most especially cattle.

3.4. Type of Analysis

The dataset is comprised of various study types, with the most common being case studies (72 studies). Case studies within the context of this review tended to focus on examining the economics of a particular rabies prevention or elimination campaign or human rabies exposure. Case studies were often limited by species and location, meaning that broad extrapolation of findings was limited. Modeling-based studies (64 studies), which include both prospective and retrospective approaches, were most often represented by studies that attempted to examine the hypothetically optimal level and mix of rabies control measures to determine the most cost-effective strategy. The dataset also contains systematic reviews (13 studies) (Figure 7). Cost–benefit analyses (CBAs) or Cost–effectiveness analysis (CEA) comprised 38 studies. A CBA typically involves comparing the monetary costs associated with management or elimination of the disease against the monetary benefits of preventing or avoiding the disease in humans, companion animals, wildlife, and livestock. Costs are typically measured by things such as vaccines, baits, and personnel, while benefits are measured as the prevention or cessation of PEP, PrEP, livestock losses, companion animal losses, medical treatment, and DALYs. CEA is a method used to evaluate the efficiency of healthcare interventions by comparing their costs with their health outcomes. It aims to determine which intervention provides the best value for money in terms of health benefits. For example, in the case of wildlife rabies prevention, a CEA might compare the costs of an oral rabies vaccine campaign vs. trap–vaccinate–release vs. culling to determine which method resulted in the largest reduction in PEP. A total of 61 studies did not incorporate any type of formal economic assessment.

4. Discussion

As the primary objective of this scoping review was to map the breadth and nature of the economic literature on rabies, our findings demonstrate that this body of evidence is imbalanced, showing a pronounced lack of economic studies from high-risk, endemic regions and an underutilization of comprehensive economic evaluation methods such as cost–benefit and cost–effectiveness analyses. While rabies remains a substantial public health and economic burden, particularly in regions where dog-mediated transmission persists, the distribution of research efforts does not align proportionally with areas of highest risk. The majority of economic studies originate from developed countries, such as the United States and parts of Europe, where the risk of human rabies exposure is relatively low due to well-established control measures. Conversely, many high-risk regions in Africa and Asia, where rabies poses the greatest human and economic threat, have produced comparatively few economic studies. This discrepancy underscores the need for increased research efforts in endemic regions to better inform cost-effective prevention and control strategies.

A notable pattern emerging from this review is the dominance of case studies and modeling-based analyses. Case studies, while valuable for assessing the effectiveness of specific interventions, are often geographically and temporally limited, making broad generalizations difficult. Modeling studies provide crucial insights into cost-effective strategies, yet their accuracy depends on the availability of high-quality data, which remains scarce in many high-risk regions. For example, rabies deaths are significantly underreported across the globe, likely due to inadequate reporting systems, limited access to healthcare in rural areas, and a lack of awareness about the disease [25]. Cost–benefit analyses and cost–effectiveness studies, though essential for guiding resource allocation, are underrepresented in the literature, particularly in countries with limited rabies control infrastructure. Expanding such studies in these areas could offer a clearer understanding of the economic feasibility of various intervention strategies, helping policymakers allocate resources more effectively.

Another key insight from this review is the strong focus on dog-mediated rabies, which reflects the global burden of the disease. However, economic research on non-dog reservoirs, such as wildlife, remains limited despite their relevance in rabies transmission and control. In high-income countries where canine rabies has been largely eliminated, wildlife species such as bats, raccoons, and foxes serve as primary reservoirs, influencing public health costs, livestock losses, and rabies prevention efforts. Future research should explore the economic implications of wildlife-mediated rabies and the cost-effectiveness of control strategies, such as oral vaccination programs.

The observed temporal trends in publication frequency also highlight shifting research priorities. Peaks in publication output during specific years suggest that external factors, such as international funding initiatives, disease outbreaks, or policy changes, influence the research agenda. However, the lack of consistent growth in rabies economic studies indicates that sustained investment in economic research remains a challenge. Given the ongoing global push to eliminate dog-mediated rabies by 2030, continued economic evaluation of intervention strategies is essential to assess progress and adapt policies accordingly.

This scoping review primarily focused on mapping the broad characteristics and gaps in the rabies-related economic literature, highlighting the diverse methodologies employed within these studies. Economic evaluations of rabies captured in this review utilize various modeling techniques, ranging from simple cost calculations to more sophisticated decision-analytic models (e.g., SEIR (susceptible–exposed–infectious–removed) models, decision trees) that simulate disease progression and intervention impacts over time. The choice of measured health outcomes, such as DALYs (disability-adjusted life years), QALYs (quality-adjusted life years), or simply averted cases/deaths, significantly influences the interpretation and comparability of economic findings [15]. Ultimately, these models are helpful for estimating long-term costs and benefits of potential medical interventions, revealing potential paths forward towards elimination of this zoonosis [15]. The elimination of any zoonosis is extremely complex, requiring thorough and thoughtful examination of all the tools available, especially those tools that are economically efficient [9]. While economics cannot capture all of the potential benefits and costs of zoonotic interventions, it does provide a standardized methodology by which interventions can be compared, allowing for an optimal utilization of limited resources in the fight against zoonosis.

Several recommendations for further research can be identified from this review and grouped into general categories, including economic studies in high-risk endemic regions, economic evaluation of non-dog rabies reservoirs, and methodological advancements in rabies economic research. This review identified the need for targeted CBA or CEA analyses, longitudinal economic impact studies, assessments of current reporting systems, and economic evaluation of integrated control programs, especially in high-risk endemic regions. One such suggestion may be to examine the benefits and costs of a more judicious use of PrEP to prevent human rabies deaths. In terms of potential economic evaluations of non-dog rabies reservoirs, particular emphasis should be focused on a CEA of wildlife rabies control, estimating the economic impact of wildlife-mediated rabies on specific sectors and modeling the economic consequences of spillover events. A suggestion for a study for this group may be to examine successful raccoon rabies elimination programs in Canada or the US. Lastly, to make methodological advancements in rabies economic research, future studies should promote the development of a standardized economic evaluation framework, refine data collection methods, and integrate non-monetary benefits and costs. Futures studies should focus on creating and validating standardized frameworks and guidelines for conducting economic evaluations of rabies interventions, particularly tailored for low-resource settings, to improve comparability across studies.

In conclusion, while substantial progress has been made in understanding the economics of rabies, critical gaps remain in geographic coverage, study diversity, and economic assessment methodologies. Addressing these gaps through targeted research in high-risk regions, increased focus on non-dog reservoirs, and broader application of cost–benefit and cost–effectiveness analyses will be essential for optimizing global rabies control efforts. Strengthening interdisciplinary collaborations and enhancing data collection efforts will further support evidence-based decision-making, ultimately contributing to the success of global rabies elimination initiatives.