The return of human rabies: A foretold case in Latin America Through the Lens of One Health.

Background: Despite ongoing rabies control efforts in Arequipa, Peru-including mass dog vaccination campaigns and reactive ring interventions-the region has failed to reduce the number of rabid dogs, leading to the first reported human dog-mediated rabies case after 8 years. The gaps in the rabies control program and the complex dynamics among stakeholders are unknown. Objective: To integrate epidemiologic, socio-ecological, and policy data to identify the factors contributing to the 2023 human rabies case and propose strategies to make this a 'never event'. Methods: We used stakeholder mapping and field quantitative and qualitative data to identify the roles and connections of key actors in rabies control, identifying gaps in their functions. We then applied the Swiss Cheese model to characterize the defense layers against dog-mediated rabies, highlighting critical vulnerabilities across these protective barriers. Conclusions: We identified multiple breaches in the defense against dog-mediated human rabies. Weak surveillance, insufficient dog vaccination, and inadequate management of free-roaming and feral dogs, coupled with bureaucratic inefficiencies, were key gaps. Outbreak responses were delayed and insufficient, and access to post-exposure prophylaxis (PEP) remained limited. Communication breakdowns exacerbated the problem. Systemic issues, such as outdated public health policies, insufficient training of health professionals, and fragmented efforts, further hindered timely exposure response. Dog ecology and demographic factors also contributed to dog rabies spread. These failures in policy, response, capacity, and external factors led to the 2023 human rabies case. Despite awareness of these challenges, the contributing conditions remain unchanged. Eliminating dog-mediated human rabies by 2030 will require targeted interventions, including enhanced surveillance, context-specific policy reforms, stronger community and institutional collaboration, and better management of free-roaming dogs.