Rabies persistence in Tunisia: rapidly shifting hotspots reveal a One Health endemic equilibrium trap

Despite a national control programme active since 1982, dog-mediated rabies persists in Tunisia. In this study, we examine the period surrounding the Tunisian revolution (2006–2016) as a pivotal analytical window to uncover the systemic mechanisms driving the country's half-century of endemicity. We conducted an integrated One Health analysis combining historical records (1898–2025) with high-resolution spatial epidemiology, canine vaccination coverage, post-exposure prophylaxis (PEP) trends, dog population ecology, and socio-behavioural surveys.Results show that hotspots swung rapidly across the country from the south (2008) to the centre (2010), the northwestern(2013), and finally the northeastern coast (2016). Canine vaccination coverage plateaued at ~60%, below the WHO 70% threshold, despite 85–94% owned-dog accessibility. Concurrently, rapid dog population turnover and high free-roaming activity continuously replenished the susceptible reservoir. High-volume PEP delivery (~306,000 courses, 2009–2016) successfully minimised human mortality but reflected unabated canine transmission. Surveys further revealed a persistent societal preference for reactive culling over preventive vaccination.Together, these findings demonstrate that rabies persistence in Tunisia is systemic rather than operational, reflecting the redistribution not the elimination of viral circulation. We define this configuration as a "One Health endemic equilibrium trap": a self-maintaining structure where interventions mitigate human deaths but fail to interrupt animal transmission. The mechanisms identified in this analytical window are likely relevant to the long-term trajectory of rabies in Tunisia and to other endemic low- and middle-income countries (LMICs) settings. Breaking this trap requires realistic canine demographic estimates, adaptive hotspot-focused vaccination, and integrated dog management lessons critical for LMICs striving to meet the WHO 2030 elimination target.