Difficulties in estimating the human burden of canine rabies

[Display omitted] •Human rabies reporting is poor in endemic countries because of the disease’s neglect and fatality.•Active surveillance shows that passive reporting systems can result in underreporting by up to two orders of magnitude.•Our best estimates of the true burden of canine rabies come from modelling studies.•Surveillance systems need to be strengthened and used in order for them to demonstrate their value. Current passive surveillance data for canine rabies, particularly for the regions where the burden is highest, are inadequate for appropriate decision making on control efforts. Poor enforcement of existing legislation and poor implementation of international guidance reduce the effectiveness of surveillance systems, but another set of problems relates to the fact that canine rabies is an untreatable condition which affects very poor sectors of society. This results in an unknown, but potentially large proportion of rabies victims dying outside the health system, deaths that are unlikely to be recorded by surveillance systems based on health center records. This article critically evaluates the potential sources of information on the number of human deaths attributable to canine rabies, and how we might improve the estimates required to move towards the goal of global canine rabies elimination.