Evaluation of One Health approach measures implemented in response to the human rabies outbreak in the Maxakali Indigenous Land, Brazil

Abstract

Background

This article presents and evaluates the One Health interventions implemented after a rabies outbreak in indigenous Maxakali children living in the Pradinho Village in the municipality of Bertópolis, Minas Gerais, Brazil, which occurred between April and May 2022, in the third month and in the first year after the event.

Methods

This was an evaluation study conducted using official documents. The One Health approaches implemented in response to the outbreak were assessed from the perspective of continuity and self-sustainability, in order to conjecture the tactical and strategic operational measures adopted. The One Health interventions were assessed based on the analysis of qualitative and quantitative data from observations and records of environmental, observational, and animal and human behavior samples. The coordination mechanisms between the Rabies Working Group of the Ministry of Health, composed of the National, State and District Strategic Information Centers for Health Surveillance, the Field Epidemiology Training Program, the Special Secretariat for Indigenous Health, the State Secretariat of Health of Minas Gerais, the Agricultural Institute of Minas Gerais, the Municipal Secretariats of Health and Environment of Bertópolis, hospitals in the region and the Fire Department of Minas Gerais were assessed.

Results

Training activities were carried out for health team professionals; a post-exposure prophylaxis scheme was implemented for susceptible contacts and a pre-exposure prophylaxis scheme was implemented by the vaccination team for all village residents; the animal anti-rabies vaccine was administered to 100% of the canine and feline population in Aldeia Pradinho, within a focal and perifocal radius of 3 to 5 km from the outbreak site. Approximately 100 households were inspected and natural and artificial roosts of sanguivorous bats were identified. An epidemiological survey was carried out in the region to verify attacks by sanguivorous bats on cattle and horses. The evaluation of the operational approaches in the 3rd month showed high efficacy, but after 1 year they were considered of low to medium efficacy. Evaluations of the tactical and strategic approaches after 1 year were considered of low efficacy due to the lack of self-sustainability.

Conclusions

One Health interventions were useful in addressing health challenges and consolidating partnerships. Although not all strategic response actions have proven to be self-sustainable after a year of this rabies outbreak that affected indigenous Maxakali children, gains were observed in terms of trust, community engagement, and intersectoral collaboration.

Background

Human deaths from rabies are preventable and could be eliminated by implementing the One Health approach [1]. However, this disease still threatens the lives of millions of people in up to 150 countries, killing approximately 59,000 people every year [2]. Rabies is a disease that primarily affects low-income communities, almost always associated with dog bites, with most deaths occurring in vulnerable communities in Africa and Asia, or associated with attacks or accidental bites from vampire bats in isolated regions of Latin America [3].

The Quadripartite Alliance (World Health Organization, Food and Agriculture Organization of the United Nations, World Organization for Animal Health, and United Nations Environment Programme) and the Global Alliance for Rabies Control aim to raise awareness of global efforts to eliminate rabies [4, 5]. Both initiatives fully support the Global Strategic Plan to End Human Deaths from Dog-Transmitted Rabies by 2030, reflecting the changing epidemiological scenario in Brazil [6]. However, this requires adapting strategies, increasing financial investment, and implementing measures according to specific local conditions [7].

With the intensification of surveillance and control actions for canine and feline rabies over the last 30 years, Brazil has achieved a significant reduction in human mortality rates from rabies [8]. In recent decades, there have been outbreaks of human rabies associated with exposure to bats in isolated traditional communities in the Amazon region [9]. It is worth noting that, in 2004 and 2005, due to the occurrence of human rabies outbreaks in the states of Pará and Maranhão (Brazil), bats became the main cause of human rabies cases, surpassing canine transmission rates [10].

Between April and May 2022, the first outbreak of human-mediated rabies transmitted by an unidentified bat occurred, killing 4 indigenous Maxakali children living in Pradinho village, Bertópolis, Brazil [11]. This event had national repercussions and mobilized an on-site action coordinated by professionals from federal, state, district and municipal spheres, with the aim of controlling the situation [12]. The “One Health” approach was adopted, considered a strategy that incorporates the expertise of veterinarians, physicians, public health professionals, educators, anthropologists, environmentalists and other professions that deal with the triad of human, animal and environmental health [13].

One Health interventions advocate close intersectoral cooperation, interdisciplinary expertise, engagement and training [14]. Although there are few examples of One Health implementation in Brazil [15], as well as evaluation of the effectiveness of interventions employed in epidemic outbreaks, this study presents the main interventions adopted in response to the crisis, and the evaluation of the strategies used at three different hierarchical levels [16]. In view of this, we propose an evaluation of One Health interventions implemented three months and one year after the outbreak.

Methods

Study design and location

This is an evaluation study conducted using official documents, based on the detailed description of the surveillance, prevention, and control measures for all cases of human rabies that occurred between April and May 2022 in the Pradinho indigenous village, located in the municipality of Bertópolis, Minas Gerais, Brazil [11].

The actions implemented by the Working Group were evaluated from its establishment until it remained in the field after the outbreak was controlled. The actions carried out by the group during this period included: epidemiological investigation, notification and communication of risks, technical support for the clinical management of cases (transfer to a referral hospital, discussion of treatment, collection of exams, and differential diagnosis), construction of the definition of a suspected case of human rabies and the flow of care in the health network, monitoring of hospitalized indigenous people and support for their companions, inspections in the region to verify spoliations by bats in production animals, presence or notification of deaths of animals with neurological clinical signs [12].

Study scenario and population

The history of the outbreak was related to 4 Maxakali children, aged between 4 and 12 years (2 boys and 2 girls), from the Maravilha and Nova villages, who were playing with a bat of an unidentified species. Two of them were bitten, one on the left forearm and the other on the left lower lip. Two of these children were cousins ​​and the others were friends [17]. The first case was reported on April 2, 2022; the second on April 5, 2022; the third on April 14, 2022; and the fourth on May 26, 2022. All cases were referred to municipalities with greater care capacity. Despite the efforts involved in treatment, no cure was achieved. The cases were confirmed by laboratory criteria and, since case 2 was confirmed before death, treatment according to the Millwalkee Protocol was carried out, but without success. With the occurrence of the first case, the district health authority issued a risk communication, declared a state of public health emergency of regional importance and requested response interventions to control the aforementioned outbreak [12].

The Maxakali people are the second largest indigenous population in the state of Minas Gerais. This population is under the jurisdiction of the Special Indigenous Health District of Minas Gerais/Espírito Santo, totaling 2,500 indigenous people. The largest demographic concentration is in the age groups of 0 to 4 years (406) and 5 to 9 years (445), representing 36.15% (851) of the entire population [12].

The Maxakali are distributed in 28 villages in the Indigenous Lands (ILs) of Pradinho, Água Boa, Verde, Cachoeirinha and Escola Floresta (located in the municipalities of Bertópolis, Santa Helena de Minas, Ladainha and Teófilo Otoni), totaling 6,000 hectares in the extreme northeast of Minas Gerais, on the border with the state of Bahia, as shown in Fig. 1.

Fig. 1.

Geographic location of Brazil and the state of Minas Gerais highlighting the Maxakali Indigenous Land

Data source

Information was extracted from the Technical Report prepared by the Rabies Working Group of the Ministry of Health, composed of the National, State and District Centers for Strategic Health Surveillance Information, Field Epidemiology Training Program, Special Secretariat for Indigenous Health, State Secretariat for Health of Minas Gerais, Institute of Agriculture and Livestock of Minas Gerais, Municipal Health and Environment Secretariats of Bertópolis, Hospital São Vicente de Paulo (Águas Formosas-MG), Hospital Cura D’Ars (Machacalis-MG), Vale do Rio Doce University and the Minas Gerais Fire Department [12].

Variables of interest

The variables of interest for the study were the effectiveness of the results of the outbreak response actions implemented by the working group, which took place between April and May 2022, namely: human and animal rabies vaccination actions, training actions for multidisciplinary health teams on the management and flow of care for rabies cases, awareness of the Maxakali indigenous community about the risk of rabies transmission through exposure to bats and, finally, the culling of captured sanguivorous bats (SB). The interventions of the One Health program were evaluated based on the analysis of qualitative and quantitative data from observations and records of environmental, observational, and animal and human behavior samples.

Procedures performed

After evaluating the Technical Report, the response actions implemented by the team were classified as strategic, tactical and operational One Health interventions. These measures were evaluated from the perspective of continuity and self-sustainability, considering the periods during the outbreak (3 months after) and post-outbreak (1 year) [12, 18].

The assessment of effectiveness was based on the operational feasibility of the prevention or control measures. It is conditioned on the possibility of being used at an adequate level of coverage and intensity that allows the reduction or interruption of transmission. The factors considered in the process of determining the operational feasibility of the measures were: the extent and organization of health services; the value or cost of the measure to be applied; the type and quantity of personnel required; the team; the necessary instruments and the complexity of their administration; the frequency of application of the measure; the side effects of the measures and the acceptability by the population [19, 20].

Data analysis

The data analysis was descriptive, with the results presented in a discursive text, supported by bibliographic citations [21]. The content analysis technique and the literature review occurred in a complementary manner. This analysis was divided into pre-analysis, exploration of the material and interpretation of the results, relating the emerging categories to the research objectives and the theoretical basis used [22].

Ethics statement

As this research used only de-identified secondary health data from the Technical Report of the Rabies Working Group of the Brazilian Ministry of Health, the Ethics Committee of the Vale do Rio Doce University waived the need for approval of the study, since there was no need for referral to the National Research Ethics Commission, as per item 4 of Resolution 466/2012 of the National Health Council and Technical Note No. 16/2020, of the Department of Indigenous Health Care and Coordination of Management of Indigenous Health Care of the Ministry of Health, in addition to the supervisory action provided for in Federal Law No. 8,080/1990.

Informed consent was obtained from all subjects and/or their legal guardians for the publication of identifying information/images in an open access online publication. All methods were performed in accordance with the Declaration of Helsinki (1964) and its subsequent revisions, as well as pertinent guidelines and regulations. All experimental protocols were approved by the Ethics Committee of the Vale do Rio Doce University. Since our study involved children, written informed consent was obtained from the participants. In addition, consent forms were obtained for the publication of the images in open access.

The researchers committed to using the research data exclusively for scientific purposes, ensuring confidentiality, privacy and non-use of the information to the detriment of individuals and/or communities.

Results

A survey was conducted of health care records, such as medical records, care forms and death certificates. In addition, awareness-raising and guidance actions were carried out for health teams regarding the management, differential diagnosis and treatment of suspected cases of human rabies, in addition to the dissemination of the new care flow, as illustrated in Fig. 2A.

Fig. 2.

Training and awareness-raising of professionals from the multidisciplinary indigenous health team regarding the management and flow of care for rabies cases (A). Health education in the Pradinho community about the importance of seeking immediate health care in the event of an accident with animals that are potentially transmitters of human rabies (B)

Training activities were carried out for professionals from the health teams involved, health education through discussion groups, meetings, lectures in schools and individualized guidance for indigenous leaders, which facilitated the good acceptance of human and animal rabies vaccination. In addition, there was joint development of strategies to combat human rabies and the preparation of culturally adapted materials, such as videos and a booklet for health education and communication, since this is a subject related to contact with bats, as illustrated in Fig. 2B.

As for the first emergency measure taken, a post-exposure prophylaxis scheme was instituted for susceptible contacts and a pre-exposure scheme by the vaccination team for all residents of the village, taking into account the constant contact of the Maxakali People with wild animals, including bats (Fig. 3). 100% of contacts residing in the Pradinho Community (43 people) were immunized and received the doses on days 0, 3 and 7. Of these 43, only 38 (88.0%) received the dose on day 14. Regarding the 43 contacts related to the administration of human anti-rabies serum and/or human anti-rabies immunoglobulin, only 25 (58.0%) received the dose. For the pre-exposure prophylaxis instituted, 99.8% of the population (2,500 individuals) was immunized with the dose on day 0; for the individuals who received the dose on day 7, there was 98.2% coverage among the 2,500 eligible individuals residing in the municipalities of Bertópolis, Santa Helena de Minas, Ladainha and Teófilo Otoni.

Fig. 3.

Preparation of the multidisciplinary health team to begin vaccination activities in the Pradinho community (A). Rabies vaccination of a Maxakali child in the Pradinho community (B)

After the first human rabies case was reported, the animal rabies vaccine was promptly made available and administered to nearly 100% of the susceptible canine and feline population in the village of Pradinho, within a focal and perifocal radius of 3 to 5 km from the outbreak site. A total of 84 dogs and 14 cats received the 0.5 ml dose intramuscularly. Vaccination was performed at specific points in each village, although in some cases it was necessary for vaccinators to restrain the animals or actively search for animals in more distant locations to immunize them (Fig. 4). Due to the high percentage of dogs and cats present in nearly all villages, there was a need for programmatic immunization to cover the five Maxakali indigenous communities (Pradinho, Água Boa, Escola Floresta, Verde, and Cachoeirinha).

Fig. 4.

Capture of dogs for rabies vaccination in the Pradinho community (A). Application of rabies vaccine to cats in the Escola Floresta community (B)

Between April and May, four teams of inspectors from the Minas Gerais Institute of Agriculture and Livestock were assigned to work in the focal area of ​​the rabies outbreak in the village of Pradinho, where they inspected approximately 100 households and identified natural and artificial roosts of SB. In the first stage, only colonies of insectivorous and frugivorous bats were identified. In a cave capture, 46 SB were captured from a maternity colony located 800 m from Maravilha Village, where two of the rabies victims lived (Fig. 5A). In total, 230 bats were treated with vampiricidal paste containing warfarin for effective control of the species (Fig. 5B). Five bats found fallen were sent for direct immunofluorescence, which showed negative results for rabies. An epidemiological survey was conducted in the region to verify attacks by sanguivorous bats to cattle and horse herds, the presence or reports of deaths of animals with neurological clinical signs, in addition to providing guidance on ways to prevent rabies in herbivores and the importance of rabies vaccination. Lectures on rabies in herbivores and bat identification were also given to the indigenous population, rural producers, teachers and health professionals. Such actions were also implemented in other Maxakali indigenous communities, in the municipalities of Santa Helena de Minas, Ladainha and Teófilo Otoni.

Fig. 5.

Capture of sanguivorous bats in an artificial cave in the Pradinho community (A). Application of vampire paste on the dorsal region of sanguivorous bats to control the population of the species in the Pradinho community (B)

An evaluation was carried out of the surveillance, prevention and control interventions adopted in response to the aforementioned human rabies outbreak in the Maxakali indigenous territory (Fig. 6). According to the 1-year post-outbreak assessment, the strategic (long-term) level actions were considered to be of low effectiveness, as they were not capable of ensuring the implementation of serological control of the vaccinated human population and the inclusion of the human rabies vaccine in the basic vaccination schedule for the entire Maxakali population. According to the 1-year post-outbreak assessment, the tactical (medium-term) level actions were considered to be of low effectiveness, as they did not guarantee the control of on-site environmental inspections aimed at assessing the need to implement direct chemical control in sanguivorous bats and indirect chemical control in production animals, and the active search for epizootics in this region. The evaluation after 3 months of the outbreak, regarding short-term measures, considered that the emergency measures implemented were highly effective, such as the vaccination of domestic animals. However, regarding the evaluation 1 year after the outbreak, this was considered to be of medium to low effectiveness due to the lack of regular health education actions focused on the risk of rabies in this population.

Fig. 6.

Assessment of One Health interventions aimed at surveillance, prevention and control adopted in response to the aforementioned human rabies outbreak in the Maxakali indigenous territory

Discussion

Unlike public health emergencies of national importance, which require emergency operations centers [23], the rabies outbreak in the Pradinho indigenous community only required the creation of a situation room and the formation of a working group composed of professionals from different areas of knowledge [12], combining efforts to develop a specific action protocol, defining the roles and responsibilities of the various actors and professionals from different areas involved in the operational, tactical and strategic response actions [24].

The meetings aimed at professionals from the multidisciplinary indigenous health teams involved content based on the One Health panel of high-level experts, being crucial in the management and flow of care for rabies cases [18]. They promoted integration between local teams and representatives of hospital teams in the region, favoring integration for appropriate prevention and treatment actions [12]. This collective effort enabled more efficient and coordinated care, ensuring that patients were treated quickly and appropriately, minimizing the impacts of the outbreak [25].

The initiatives included not only the clinical management of cases, but also health education, aiming to raise awareness about the risks and prevention and control measures to be developed by health professionals working in the indigenous communities served and also by hospital teams in the region [12]. As a challenge faced by the team that made up the working group, the mobilization of the Maxakali population, especially women and children, because they do not speak Portuguese was one of the biggest challenges [26]. To overcome the language barrier, the team’s professionals gave lectures in a technically accessible and slow manner, with the collaboration of teachers, indigenous health agents and indigenous leaders who acted as translators [27].

This challenging process also allowed the dissemination of information about the importance of rabies vaccination in all age groups [12]. Vaccination implemented in response to the human rabies outbreak helped prevent the resurgence of this neglected disease in this region, whose main vector is the bat [28]. The availability of human, material and logistical resources was essential to meet population demand, especially to achieve the optimal coverage standard for human rabies vaccines [25].

Aspects related to the lack of high vaccination coverage for this event were related to the refusal by some individuals, often associated with fear, insecurity, mourning and absence from home [12]. A limitation in completing the vaccination schedules for this population was related to the characteristics of the vaccination schedule, which involves multiple administrations at different times, in addition to the centralization of rabies serum or immunoglobulin in a distant hospital unit [29].

The challenges of correctly following prophylaxis are not restricted to the reality presented by this population group; political, geographic and cultural factors may have contributed to the low continuity of treatment [12], as occurred in the surveillance of the rabies outbreak in the municipality of Barcelos, in the state of Amazonas [30], and in the rabies outbreak that occurred in Melgaço, in the state of Pará, where no post-exposure rabies prophylaxis was even administered [28].

Although the WHO has recommended pre-exposure prophylaxis for residents of rabies-endemic areas since 2019, especially for groups that have difficulty accessing the vaccine immediately after the attack, this strategy has not yet been adopted in the case of the Maxakali indigenous population [31]. Positive results of this strategy can be observed in 67 riverside locations in the municipality of Portel, whose project aims to evaluate the vaccination action in the riverside population, living in an area at risk of rabies transmission by SB in the Amazon biome, with 61.4% of the vaccinated population developing protective antibodies against human rabies one year after receiving the vaccine [32].

The project carried out in the riverside region of Pará differed from the actions carried out in response to the outbreak in Pradinho village, in which children from birth were vaccinated with two 0.5 mL doses of the vaccine. In Pará, two 0.1 mL doses of the human rabies vaccine were administered to individuals aged three years or older, with a seven-day interval between the two doses [32]. The team that conducted and investigated the Pradinho outbreak considered it more convenient to recommend the intramuscular route of administration because it is faster, given the urgency and severity of the situation [12].

Although serological monitoring of immunized and non-immunized indigenous people in the Maxakali territory has not yet been carried out, indigenous health teams believe that, at some point, the human rabies vaccine will be included in the basic vaccination schedule for this population, which has not yet occurred [12]. In Portel, a region of Pará with a recent history of bat-mediated rabies outbreaks, individuals who received two doses of the vaccine presented higher antibody titers compared to those who received only one dose [32].

Raising awareness among indigenous people about the importance of pre-exposure rabies immunization and serological monitoring of antibodies will continue to be essential to identify situations in which booster vaccination is necessary [33]. Training and awareness-raising actions should be intensified among health teams responsible for rabies care in order to ensure adequate care for these individuals [25]. In this sense, performing and disseminating the results of serological tests to assess the titer of protective antibodies against rabies are extremely important elements, together with an agile and timely laboratory network for rabies control in this region [34].

The boundaries of the focus areas considered for blocking viral transmission from domestic animals were based on the survey carried out through epidemiological investigation [35]. Animal vaccination in this focus area was carried out using the house-to-house system, covering the area identified as the one through which the rabid animal had passed during the investigation of the outbreak [36].

For animals vaccinated for the first time, a booster dose was administered 30 days after the first dose [37]. Since there were no cases of rabies in dogs, vaccination and revaccination of animals of this species at any time after the first dose was not recommended, since some vaccinated animals may not obtain a vaccine response after a single vaccination challenge [36]. According to the assessment of the working group, it was not necessary to vaccinate production animals, since, according to the focal situation, they were not involved in the area of ​​occurrence [12].

Although there have been no cases of canine or feline rabies, as a precaution, an excellent standard of vaccination coverage for domestic animals was implemented in order to achieve the necessary level of herd immunity in this susceptible population with high population turnover [38]. Just like indigenous people, these domestic animals can also be victims of aggression, since it is common in many of these homes for dogs, cats, bats and children to coexist harmoniously, who maintain this habit for recreational and cultural reasons [17]. In addition, the lack of a population control policy for domestic animals in this region increasingly intensifies this contact, posing risks to the health of this human and animal population [17].

The animal rabies vaccination carried out in Pradinho and other villages in the Maxakali territory was timely and assertive, with no record of wasted doses [12]. No adverse events related to any post-vaccination reactions in vaccinated domestic animals were recorded [35], unlike the campaign in some municipalities of São Paulo in 2010, where serious adverse events and deaths of dogs and cats were recorded after vaccination [39].

No work incidents were recorded with the vaccinators due to bites, scratches and exposure to mucous membranes, as both were properly equipped with personal protective equipment [25], overcoming the operational and logistical challenges associated with the execution of this emergency action in different geographic and cultural contexts [40].

The collaboration of indigenous people who took their animals to vaccination points and helped to contain the animals is noteworthy [12]. In this sense, community participation was essential to achieve 100% vaccination coverage, exceeding the WHO target of 70% in non-endemic regions and 80% in endemic regions [38]. According to the working group’s opinion, revaccination of these animals 30 days after the first dose was not recommended, since vaccinated animals generally obtain a satisfactory vaccine response after a single vaccination stimulus, and high-quality vaccines normally provide a duration of immunity of 2 to 3 years [40].

The control methods used by agricultural and livestock defense agents in this region were selective and carried out in such a way as to affect only sanguivorous bats of the species D. rotundus, without causing disturbance to other species [41]. To this end, direct control of the SB was carried out, which, after being captured, was treated with a vampiricidal paste containing warfarin on the back of each individual before being released to return to its colony [42]. The effectiveness of this measure was confirmed 10 days after the start of treatment. By observing the presence of dried bat feces in the roosts, it was possible to preliminarily verify that there was a reduction of this species in the region [27].

Although 10 bleeding points were identified on the hides of herbivores caused by SB in this delimited area [27], there was no need for indirect control, since direct selective treatment of SB has been carried out previously [43] and the method used proved to be considerably efficient when, 30 days after the action, the presence of only 3 SB and dried bat feces was observed in the cave closest to Pradinho [27].

Epidemiological research carried out on herds in search of identification of attacks caused by SB has shown that preventive and systematic vaccination of cattle against rabies on these properties neighboring the Maxakali indigenous reserve is a necessary measure, since the strategy to combat bats is not efficient enough to reduce the risks [27]. This strategy is not easy to implement, since rabies vaccination of herbivores is the responsibility of rural landowners and is not fully funded by the public health service, as is the case with rabies vaccination of domestic animals throughout the country [43]. Thus, it became clear that the spread of rabies may be related to the geographic expansion of artificial and natural SB roosts in this region [44].

Although the team of inspectors found 5 dead bats on the ground during the investigation period, with negative direct immunofluorescence results for rabies [27], it was found that the native population and many health professionals working in the region were unaware of the importance of reporting epizootics and the epidemiological investigation of the deaths of any animals capable of transmitting rabies that presented neurological clinical signs of rabies, which should be collected for referral to the state laboratory service for diagnosis of animal rabies [44], enabling a timely assessment of the characterization of the rabies virus in different animal hosts, in order to improve the early detection of epizootic events in this endemic territory [45].

Until the National Immunization Program takes the initiative to include the human anti-rabies vaccine in the Basic Vaccination Calendar for the Maxakali indigenous population [46], we recommend that pre-exposure human anti-rabies prophylaxis and serological monitoring of immunity to the rabies virus be maintained in this region, as these actions are important to enable the protection of these indigenous peoples and also for the economy of health products and services [12], which is very important for this region, considering the geographical distances and the difficulties of access that health authorities face in reaching these populations [46].

Intersectoral partnerships have proven to be an essential component for a timely and effective response during the fight against this outbreak [28]. The contribution of the Minas Gerais Fire Department with its helicopter was essential to ensure the airlift of one of the critically ill patients to the state referral hospital, in addition to facilitating the movement of the task force to the Maxakali Base Pole and taking them back to their places of origin [35]. This collaboration exemplifies the strength of integration between government sectors, local communities and health institutions in dealing with public health crises [47].

We assess that all operational, tactical and strategic One Health response actions implemented were equally important in containing this rabies outbreak [18]. However, some long- and medium-term activities, such as environmental inspections to monitor the SB population, definitive vaccination of all indigenous people with the rabies pre-exposure scheme, serological monitoring of the vaccinated population to assess their immune status, and short-term health education actions aimed at preventing and controlling rabies, did not have the necessary continuity to ensure a self-sustainable response, from the point of view of human, animal and environmental care, in order to minimize the risks of future threats to this vulnerable indigenous population [12].

The evaluation of the processes of cooperation, collaboration, training and coordination of work teams focused on outbreak response is vital to strengthen the One Health approach and ensure timely and effective interventions [18]. Successful evaluations are important for identifying bottlenecks and good practices in the 4Cs in the demands of epidemic crises, in addition to providing recommendations for improving intersectoral strategies, increasingly strengthening the One Health approach adopted [20].

Conclusion

In this assessment, One Health interventions have been instrumental in addressing health challenges and consolidating partnerships. Although not all strategic response actions have proven to be self-sustaining after a year of the rabies outbreak affecting indigenous Maxakali children, gains in trust, community engagement, and intersectoral collaboration have been observed, which in turn have strengthened the capacity of a fragile regional health system to respond to emerging zoonosis threats and other future health challenges.

Abbreviations

IL

Indigenous land

mL

Milliliter

SB

Sanguivorous bat

Author contributions

D.S.T.J., M.S.V.M. and J.O.Z.P. wrote the main manuscript text and R.C.O. prepared Figs. 1, 2, 3, 4, 5 and 6. All authors reviewed the manuscript.

Funding

There was no funding source for this article.

Data availability

Data is provided within the manuscript.

Declarations

Ethics approval and consent to participate

All experimental protocols were approved by the Ethics Committee of Vale do Rio Doce University. Informed consent from all subjects and/or their legal guardians was duly obtained for publication of identifying information/images in an open access online publication. All methods were performed in accordance with the Declaration of Helsinki (1964) and its subsequent revisions, as well as relevant guidelines and regulations.

Consent for publication

Informed consent from all subjects and/or their legal guardians was duly obtained for publication of identifying information/images in an open access online publication.

Competing interests

The authors declare no competing interests.