#### Original Paper

### Abstract

Background: Rabies is an acute infectious disease of the central nervous system caused by the rabies virus. The mortality rate of rabies is almost 100%. For some countries with poor sanitation, the spread of rabies among dogs is very serious.

Objective: The objective of this paper was to study the ecological transmission mode of rabies to make theoretical contributions to the suppression of rabies in China.

Methods: A mathematical model of the transmission mode of rabies was constructed using relevant data from the literature and officially published figures in China. Using this model, we fitted the data of the number of patients with rabies and predicted the future number of patients with rabies. In addition, we studied the effectiveness of different rabies suppression measures.

Results: The results of the study indicated that the number of people infected with rabies will rise in the first stage, and then decrease. The model forecasted that in about 10 years, the number of rabies cases will be controlled within a relatively stable range. According to the prediction results of the model reported in this paper, the number of rabies cases will eventually plateau at approximately 500 people every year. Relatively effective rabies suppression measures include controlling the birth rate of domestic and wild dogs as well as increasing the level of rabies immunity in domestic dogs.

Conclusions: The basic reproductive number of rabies in China is still greater than 1. That is, China currently has insufficient measures to control rabies. The research on the transmission mode of rabies and control measures in this paper can provide theoretical support for rabies control in China.

**JMIR Med Inform 2020;8(5):e18627**

doi:10.2196/18627

### Keywords

### Introduction

Since ancient times, infectious diseases have brought much distress to human beings, and recorded deaths from infectious diseases abound. For example, the Black Death that killed a quarter of the European population during the medieval period was transmitted by fleas and black rats. In the mid-14th century, a plague killed another 25 million people [

]. The number of diseases transmitted from animals to humans has been increasing. By mutating, viruses become better adapted to their environment and the physiological status of various hosts [ ]. More than 6% of infectious diseases that affect human beings originate from animals, and more than half of animal diseases can be transmitted to humans; as such, researchers pay particular attention to such diseases [ ]. The zoonotic disease studied in this paper is rabies, which is caused by the rabies virus and can damage the central nervous system in humans. Rabies has a fatality rate of 100%, the highest in the world [ ]. Although the fatality rate of rabies is extremely high, effective control measures can prevent the transmission of the disease.Rabies is a zoonotic acute infectious disease of the central nervous system caused by the rabies virus. As patients with rabies have the clinical manifestation of being afraid of drinking water, this disease was previously called hydrophobia. However, animals with rabies do not have this characteristic [

]. The main symptoms are mania, anxiety, fear of wind and water, salivation, and pharyngeal muscle spasm. Paralysis is a life-endangering symptom. One of the characteristics of this disease is that different patients have incubation periods of different lengths. Most cases occur within 3 months of infection, with 4%-10% occurring after more than 6 months, and about 1% of cases exceeding 1 year. The longest incubation time reported in the literature is 10 years [ ]. Factors that affect the length of the incubation period are age (shorter in children), wound site (shorter if on the head or face), depth of wound (shorter with deeper wounds), the amount of virus, the virulence of the strain, and whether formalized debridement processing and preventive vaccination were performed. Factors such as trauma, cold, and overwork may contribute to early onset [ ].Humans have been aware of the disease rabies since the time of Ancient Babylonians. At that time, there were no effective rabies control methods. Due to the pain and high fatality rate of rabies, many people committed suicide after being bitten by dogs [

]. Today, there are more than 150 countries in the world that have a large number of deaths contributed to the wild spread of rabies. At present, only one-quarter of the world’s countries effectively control the occurrence of rabies. In some countries where severe health conditions are prevalent, the number of rabies cases is high and the spread is difficult to control. In Asia, India has the most severe rabies situation, with an annual incidence of 20,000 cases, followed by Southeast Asia and most parts of Africa.In China, the vaccination rate of dogs is relatively low, especially in rural areas, where free-range dogs are rarely vaccinated. As such, the death toll from rabies is significant. Over the past two decades, the number of people who died of rabies in China first increased and then decreased. The number of deaths from rabies rose rapidly in the 1990s, reaching a peak in 2007. After the unremitting efforts of relevant personnel in China, the number of deaths from rabies began to decrease; deaths had decreased by about 76% as of 2013 [

]. Wild dogs are a source of rabies infections that cannot be ignored as they are not domesticated and may bite humans. Therefore, we conducted a comprehensive study of domestic dogs, wild dogs, and humans in the context of rabies transmission.Due to the highly infectious nature of the rabies virus, it is being studied by researchers worldwide. Simulation research is a research method that can transform complex biological phenomena into mathematical problems; such mathematical methods may enable better logical reasoning and disease transmission analysis. Some researchers have established mathematical models of rabies transmission from dogs to other animals and studied the transmission mode of rabies in animals to ascertain the optimal time for vaccine control [

]. Other researchers have designed a rabies transmission model based on transmission in the domestic population. In building the model described in this paper, dogs and humans were classified into the following 4 categories: susceptibility, latency, infection, and recovery. The transmission mode of rabies among populations was determined and effective rabies prevention methods were proposed [ ]. Other researchers previously designed a transmission model for domestic and wild dogs. Studies have shown that to control the spread of rabies, the management of domestic dog breeding must be strengthened [ ]. Therefore, we conducted a simulation study of the ecological infection model of rabies to provide theoretical support for rabies research.To study the transmission mode of rabies and determine effective measures for suppressing rabies, we first constructed a mathematical model for the transmission mode of rabies. To construct the mathematical model, data from the literature and officially published data in China was used. The model fits the number of patients with rabies and predicts the number of patients with rabies in the future. In addition, we studied the effectiveness of different rabies suppression measures. This paper will provide theoretical support for rabies suppression in China.

### Methods

#### Establishment of a Mathematical Model of Rabies Transmission

Rabies transmission models of humans, wild dogs, and domestic dogs were established. Dogs and humans were divided into 4 categories: susceptibility, latency, infection, and recovery. S_{a}, E_{a}, I_{a}, and R_{a} represent the 4 categories of susceptibility, latency, infection, and recovery in wild dogs. S_{b}, E_{b}, I_{b}, and R_{b} indicate the 4 categories of susceptibility, latency, infection, and recovery in domestic dogs. S_{c}, E_{c}, I_{c}, and R_{c} represent the 4 categories of susceptibility, latency, infection, and recovery in humans. Before the simulation study, it was hypothesized that only dogs that have been in contact with an infected person would become infected and dogs in the incubation period have both vaccination and autoimmunity. The transmission model of rabies is shown in . The arrows in the figure represent the direction of rabies transmission.

According to this, the corresponding mathematical model was established. The mathematical models for transmission among dogs are shown in Equations 1-8.

The mathematical models for human transmission are shown in Equations 9-12.

Corresponding to the actual situation, the parameters in Equations 1-12 are nonnegative.

For both dog groups, A indicates the birth rate and p indicates the ratio of the two dog groups that are classified as susceptible in the incubation period of rabies but that have not developed disease.

*b _{a}S_{a}I_{a}* and

*b*indicate the number of rabies infections in wild dogs in two dog groups within a unit of time.

_{a}^{’}S_{a}I_{b}*b*and

_{b}S_{b}I_{b}*b*indicate the number of rabies infections in domestic dogs in two dog groups within a unit of time. Additionally, γ indicates the rate of immunity of the two dog groups, μ indicates the natural mortality rate of the two dog groups, α indicates the fatality rate of the two dog groups, λ indicates the failure rate of vaccination in dogs,

_{b}^{’}S_{b}I_{a}*c*indicates the killing rate of wild dogs,

_{a}*c*indicates the killing rate of immune wild dogs, σ indicates the removal rate between the two dog groups in the incubation and infected periods.

_{a}’For the human population, *H* indicates the birth rate in the human population, *p* indicates the ratio of the human population that is classified as susceptible during the incubation period of rabies but has not developed disease, and λ_{c} indicates the failure rate of vaccination in the human population. *b _{c}S_{c}I_{a}* and

*b*indicate the number of rabies infections in humans caused by the two dog groups within a unit time, γ indicates the rate of immunity of the human population,

_{c}^{’}S_{c}I_{b}*m*indicates the natural mortality rate of humans, and α indicates the fatality rate of the human population.

#### Model Dynamics

Model dynamics is used to study the relationship between rabies suppression measures and the number of patients with rabies. For dog groups, it is obtained as follows.

According to the actual situation, the number of groups in this mathematical model is always greater than 0. Then, the equation is obtained as shown below.

Thus, α can obtain the positive invariant set X of the model as follows.

Similarly, the positive invariant set X of the human situation can be obtained as follows:

The rabies-free equilibrium point in a dog group can be found using Equations 1-8. The rabies-free equilibrium point in a human population can be found using Equations 9-12. Therefore, the basic reproductive number (BRN) of this rabies transmission mode is shown below.

In dog groups, the BRN is . The occurrence of cross infection greatly affects the BRN. Therefore, cross infection should be considered in regard to daily protection.

#### Parameter Estimation

There is currently no fixed database of rabies in China. Therefore, the data in this paper were obtained from previously published literature and reports. The number of patients with rabies used for this paper corresponds to the data reported by the Public Health Scientific Data Center and the National Health and Family Planning Commission. Taking the year as the unit, the data shown in

was obtained.Parameter | Symbol | Value |

Average number of wild dogs born each year | A_{a} | 2.47×10^{5} |

Infection rate of susceptible dogs by wild dogs in unit time | β_{a} | 2.91×10^{-6} |

Infection rate of susceptible dogs by domestic dogs per unit time | β_{b} | 2.20×10^{-7} |

Infection rate of susceptible human by wild dogs in unit time | β_{c} | 3.39×10^{-12} |

Killing rate of wild dogs | c_{a} | 0.06 |

Migration rate from latent wild dogs to infected dogs | σ_{a} | 0.35 |

Failure rate of vaccination in dogs | λ | 0.5 |

Average number of domestic dog births per year | A_{b} | 1.80×10^{6} |

Infection rate of susceptible wild dogs by domestic dogs in unit time | β_{a’} | 6.01×10^{-7} |

Infection rate of susceptible domestic dogs by wild dogs in unit time | β_{b’} | 5.01×10^{-7} |

Infection rate of susceptible humans by domestic dogs in unit time | β_{c’} | 6.79×10^{-12} |

Killing rate of domestic dogs | c_{a’} | 0.4 |

Immunity rate of wild dogs | γ_{a} | 0.05 |

Migration rate of humans from incubation period to infection period | σ_{c} | 0.33 |

Birth rate in the human population | H | 1.49×10^{7} |

The ratio of wild dogs and domestic dogs during the incubation period that did not have rabies outbreak and recovered to susceptible persons | p_{a} | 0.35 |

The ratio of domestic dogs in incubation period who did not have rabies outbreak and recovered to susceptible population | p_{b} | 0.37 |

The ratio of people in incubation period who did not have rabies outbreak and recovered to susceptible population | p_{c} | 0.33 |

Natural mortality of wild dogs | μ_{a} | 0.24 |

Disease-caused mortality of wild dogs | α_{a} | 1 |

Failure rate of vaccination in people | λ_{c} | 1 |

### Results

#### Fitting and Prediction Results of the Number of Infected Patients

According to the number of patients with rabies in China in the past 10 years, the rabies disease data in the model were fitted. The initial values of each parameter are detailed below.

The initial values of susceptible individuals in the wild dog group, the domestic dog group, and the human population were 2×10^{6}, 3×10^{7}, and 1.29×10^{9}, respectively. The initial values of the latent individuals in the wild dog group, the domestic dog group, and the human population were 7×10^{4}, 2×10^{5}, and 400, respectively. The initial values of infected individuals in the wild dog group, the domestic dog group, and the human population were 2×10^{4}, 5×10^{4}, and 158, respectively. The initial values of recovered individuals in the wild dog group, the domestic dog group, and the human population were 1×10^{5}, 5×10^{6}, and 2×10^{5}, respectively.

Fitting of the model image was performed. During the image fitting process, other unknown parameters were obtained.

shows the predicted future number of patients with rabies based on this model.It can be seen from the above figure that the number of people with rabies rises at first and then decreases. From the fitted data, the number of patients with rabies peaked around 2005. As people's awareness of rabies increases, more people will be vaccinated after being injured by a dog, which will reduce the incidence of rabies and the number of cases. Additionally, due to the development of modern medicine, the effectiveness of the rabies vaccine is gradually increasing, which greatly reduces the number of patients with rabies. Compared to the number of rabies cases in 2016, the number of infected patients is undergoing a continuous decline. In about 10 years, the number of rabies cases is forecasted to be controlled within a relatively stable range. According to the prediction results of this model, the number of rabies cases will eventually be controlled to about 500 people every year. According to the values of the parameters in the model, the BRN is estimated to be 1.069.

#### Effect Results of Each Parameter on the BRN

The effect of the birth number of wild (A_{a}) and domestic dogs (A_{b}) on the BRN is shown in .

It can be seen from the figure above that when more wild dogs are killed, fewer wild dogs are born. Therefore, the value of the BRN can be reduced to less than 1 by killing wild dogs. A reduction in the BRN means that the number of people with rabies will also decrease. Therefore, by killing wild dogs, the incidence of rabies can be effectively reduced. Due to the Chinese people's love of dogs and the tradition of having dogs as pets, the number of domestic dogs is far higher than the number of wild dogs. Therefore, the management of domestic dogs in China is also challenging. As can be seen from the figure above, by controlling the birth number of domestic dogs, the value of the BRN can also be effectively controlled. Thus, the management of domestic dogs in China needs to be strengthened to a certain extent, especially the birth number of domestic dogs, which requires strict control.

The effect of the degree of immunity of wild (γ_{a}) and domestic (γ_{b}) dogs on the value of the BRN is shown in .

It can be seen in

that although an increase in the degree of immunity in wild dogs can reduce the BRN, its effect on the BRN is small and it cannot reduce the BRN to less than 1. This may be because wild dogs are friendly or fearful of humans and generally do not attack humans. Therefore, the degree of immunity in wild dogs does not play a significant role in reducing the number of people with rabies. Conversely, domestic dogs spend a lot of time with people. When playing, it is possible that they will accidentally injure people if their strength is not well-controlled. Thus, for domestic dogs, the degree of immunity can greatly affect the number of people with rabies. Improving the degree of immunity of domestic dogs can greatly reduce the BRN to less than 1.The values in

also show that increasing the immunity of wild dogs can reduce the number of patients with rabies, but it cannot achieve the effect of eliminating rabies. Increasing the immunity of domestic dogs is a practical and effective way to reduce the number of patients with rabies.### Discussion

#### Overview

Rabies is caused by the rabies virus and can cause damage to the human central nervous system, with a fatality rate of 100%. Among infectious diseases, rabies has the highest fatality rate in the world [

]. Although the fatality rate of rabies is extremely high, the disease can be prevented if effective control measures are taken. The number of patients with rabies in China has declined in recent years, but the number of cases is still relatively high. Therefore, we conducted a study on the transmission mode of rabies and effective suppression measures. First, a mathematical model of the transmission mode of rabies was constructed by drawing relevant data from the officially published data in China and research data from previously published papers. According to this model, the study fit the present number of patients with rabies and predicts the future number of patients with rabies. In addition, we studied the effectiveness of different rabies suppression measures.In the process of data fitting, through the observation and calculation of each parameter, the BRN of rabies in China was determined to be about 1.069. This figure indicates that the current rabies response is not ideal and cannot effectively prevent the occurrence of rabies. In this paper, when analyzing the effects of each parameter on the BRN, it was found that the higher the number of wild dogs killed, the smaller the number of wild dogs born. Therefore, the value of the BRN can be reduced to less than 1 by killing wild dogs. Controlling the number of births of domestic dogs can also effectively control the value of the BRN. Therefore, the management of domestic dogs in China needs to be strengthened, especially the number of births of domestic dogs, which requires strict control. Although an increase in the degree of immunity of wild dogs can effectively reduce the BRN, the effect of this parameter on the BRN is small and cannot reduce the BRN to less than 1. Improving the degree of immunity of domestic dogs can reduce the value of the BRN to less than 1. The research results in this paper are similar to the results of research conducted by others on how rabies suppression measures affect the number of patients with rabies [

].#### Conclusion

Due to the large number of patients with rabies in China and the severity of this condition, this paper investigated the transmission mode of rabies and rabies suppression measures. By counting the number of patients with rabies in China for many years and using software to fit the data, our model forecast an increase in the number of patients with rabies in China in the next few decades. In addition, this paper studied the effect of various measures on reducing the number of patients with rabies. Ultimately, controlling the birth rate of domestic dogs and wild dogs as well as increasing the degree of immunity in domestic dogs are all relatively effective rabies suppression measures. The BRN of rabies in China is still greater than 1. Therefore, in terms of rabies control, China still needs more research, policy formulation, and grassroots implementation.

Although the research in this paper obtained relatively considerable results, there are still some limitations: (1) The number of wild dogs in China is relatively high, and effective sterilization measures have not been implemented for wild dogs. Therefore, this problem was not considered during the construction of the model used in this paper. (2) The research in this paper is still in the theoretical stage, and further studies are required to determine whether it is effective in practice. Therefore, future research will be based on the results of this paper, and will observe whether the results are correct and feasible in practice.

#### Conflicts of Interest

None declared.

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#### Abbreviations

BRN: basic reproductive number |

Edited by Z Du; submitted 09.03.20; peer-reviewed by X Fu, S Wang, F Yao; comments to author 21.03.20; revised version received 26.03.20; accepted 26.03.20; published 27.05.20

Copyright©Yihao Huang, Mingtao Li. Originally published in JMIR Medical Informatics (http://medinform.jmir.org), 27.05.2020.

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