CONCLUSION

This study represents the longest (>5 years) continuous CNVR intervention reported from a religious city in Asia and provides one of the few evaluations simultaneously encompassing owned and free-roaming dog populations, both sexes, and surrounding peri-urban communities. Although no significant reductions were observed in overall effort-adjusted dog counts, the absence of population growth over five years itself indicates substantial control of a population that would otherwise be expected to increase under tropical conditions. Male dog counts declined significantly by 9.7% annually, while owned female counts increased by 24.1%, accompanied by a shift in the overall male:female ratio from 1:2.1 to 1:3.6, suggesting increasing acceptance and adoption of female dogs. The intervention achieved high vaccination coverage among owned dogs, with 94% and 83% of dogs within and outside the municipality vaccinated at least once and 74% and 69%, respectively, receiving regular annual ARV. More than 60% of adult owned dogs and >78% of adult females had been sterilized. Spatial analyses further revealed previously undescribed sex-specific effects of the buffer zone, with each additional dog sterilized in the peripheral region reducing Zone 1 male catches and Zone 3 female catches, supporting the concept of “cutting down the supply and sealing the boundary.”

From a practical perspective, the findings demonstrate that sustained CNVR programs, integrated with community engagement and repeated vaccination campaigns, can achieve vaccination levels that approach or exceed the World Health Organization target for herd immunity, even in low-income and culturally complex environments. The study highlights the importance of addressing owned and free-roaming dogs simultaneously, prioritizing underserved neighborhoods, and strengthening legal frameworks governing sterilization, breeder registration, and responsible ownership. The estimated benefit-cost ratio of 1.5 further indicates that dog sterilization and vaccination are economically justified compared with the societal burden imposed by rabies.

A major strength of this study lies in its long duration, broad geographical coverage, inclusion of buffer zone strategies, and integration of demographic, spatial, behavioral, and economic analyses. The use of DAGs to justify analytical approaches and the identification of high-priority locations with poor sterilization performance provide additional translational value for future intervention planning.

Future studies should incorporate systematic dog population surveys, sex-specific demographic analyses, movement ecology, and longitudinal surveillance of dog bites, human post-exposure prophylaxis, and laboratory-confirmed rabies cases. Particular attention should be given to understanding the contribution of intact owned males to reproduction among free-roaming females and to elucidating the behavioral mechanisms underlying the sex-specific effects of buffer zones.

In conclusion, this study demonstrates that a sustained One Health-based CNVR approach, supported by community participation and strategic expansion beyond administrative boundaries, can stabilize dog populations, improve animal welfare, enhance responsible ownership, and maintain vaccination coverage consistent with rabies elimination goals. The findings introduce the buffer zone concept as a promising addition to domestic dog population management and provide a practical framework that may be adapted for other rabies-endemic regions seeking to achieve the target of zero human dog-mediated rabies deaths.