The rabies surveillance program is now well established in China, and provides a comprehensive overview of the rabies situation throughout the country. At the same time, it is possible to use the data to review the situation within a specific region at the provincial, county or even within a specific group of villages. With this information it is possible to identify hotspots that may be associated with a local outbreak and provide the necessary control measures to prevent further spread.
Analysis of the collected data allowed the identification of rabies hotspots so they could be prioritized for control measures. Furthermore, statistical analysis revealed a number of trends that were facilitating the spread of the virus as well as increasing fatality rates. Based on these findings the government was able to implement strategies that could effectively curb further increases in fatality rates. One key factor was the identification of “at risk” populations, raising their awareness of the disease, informing them of risks from infectious animals as well as how to recognize the symptoms, and the importance of seeking PEP treatment in the event of potential exposure. Secondly, the introduction of the new rural cooperative medical subsidies for PEP costs made it easier for people in low income areas to seek treatment. Finally, introductory efforts for dog management and free immunization in high-incidence areas have highlighted the effectiveness of this approach for controlling the spread of rabies.
Although the annual number of rabies cases in China has been decreasing since 2008, this has been achieved by controlling cases in high and medium incidence provinces. The surveillance data from reported cases reveals that rabies is gradually expanding from the southern and eastern regions to the northern and western regions of China. Although the rapid economic development in China has made it possible to implement a surveillance program and fund PEP costs, it is the changes in lifestyle that are a consequence of this development that have helped to create an environment to facilitate the spread of rabies. As personal wealth has increased, so has dog ownership , where they generally serve as pets in cities or as guard dogs in the countryside. Furthermore, the ownership of private vehicles has also grown together with an efficient transportation infrastructure. Thus, the host population primarily responsible for human cases has not only grown rapidly, but has also become more mobile.
The question of how to manage and immunize the rapidly-increasing domestic dogs population has developed into an important social issue. Furthermore, efforts in the last decade to restore the natural environment in China has promulgated a series of laws and regulations, such as the “Wildlife Conservation Law” and the “Regulation on Terrestrial Wildlife Protection” act which has established more than 2000 nature reserves as major habitats for wild animals. Additionally, projects such as the natural forest protection project and the Grain for Green Project has prohibited hunting in these areas protecting these wildlife species . Thus, while these efforts have helped to restore these natural environments, it has facilitated the rapid recovery of wildlife populations in these areas, which serve as effective reservoirs for rabies. This is supported by the increase in reported rabies cases in wildlife in these regions .
The situation in China contrasts with that found in North America  and Europe . In these regions, an effective vaccination program has eliminated the virus in domestic animals and a comprehensive oral vaccine bait effort has helped to significantly control the disease in wildlife. However, repeated reports of outbreaks in local wildlife populations, raccoons in particular, e.g., [20, 21] highlights the continued threat from this pathogen.
Despite the importance of PEP treatment following potential exposure to rabies, in many fatal cases patients failed to obtain this treatment. Our analysis indicates that there are two reasons for this. Firstly, in the mid-1990s, rabies had been effectively brought under control in China, with only low-incidence or scattered cases and, as public awareness of the disease fell, there was little effort directed to rabies prevention and control. Even after an attack by a dog, people rarely sought medical treatment. Secondly, even after the number of cases began to increase again and people became more aware of the importance of proper treatment, the costs were prohibitively high in many low income areas. Additionally, many health departments or clinics in villages lacked the facilities for providing PEP or had a shortage of rabies vaccine. Hence, efforts to improve awareness in the population in high incident regions as well as subsidization for PEP treatment together with education of the medical personnel for storage and delivery of PEP treatment according to WHO recommendations were key to reducing rabies cases in these regions.
Continued efforts are needed to further control rabies and to prevent its reemergence in new areas. This is remains a priority with the State Council and the relevant state departments such as the Ministries of Health, Public Security and Agriculture . The State Council outlined their future plan in the document Long-term Animal Disease Prevention and Control Plan (2012–2020), which lists the rabies as one of 16 domesticated animal diseases to be prioritized for prevented and controlled. This plan will be implemented in part via agricultural sectors and public security departments, and includes introduction of a pilot program for identifying dogs that have been immunized and by introducing further training courses on animal rabies prevention and diagnosis for the professionals in veterinary departments . All these policies and efforts will be important factors for further control of rabies in China.