LFD implementation uncovers hidden rabies burden: Pre- and post-implementation analysis and comparison with non-implementation sites in the Philippines

Background: Despite accumulating evidence supporting lateral flow devices (LFDs) in rabies diagnosis, their impacts of decentralizing diagnostic capacity on surveillance in endemic settings have not been systematically evaluated. Methods: We established low-resource decentralized rabies diagnostic laboratories in a target area of the Philippines, where rabies testing was previously unavailable, and evaluated both the diagnostic performance of LFD and their impacts on surveillance. Interrupted time series analysis further supported a significantly increasing trend in case detection after the implementation (coefficient = 0.565, p < 0.001), which was not observed in non-implementation provinces. Through 69 outbreak investigations triggered by LFD-positive cases, 22 unvaccinated human bite victims and 66 exposed animals were additionally identified. However, while case investigations were performed in 54.8 % of cases, integrated One Health investigations involving coordinated actions by local health and veterinary offices were conducted in only 5.6 %. Conclusion: LFD-based decentralization markedly improved case detection and enabled critical outbreak responses at the local level, demonstrating its value for rabies control in endemic settings though sustained One Health approach remains a challenge following the detection of rabid animals using LFD.