The need to improve access to rabies post-exposure vaccines: Lessons from Tanzania

Joel Changalucha,Rachel Steenson,Eleanor Grieve,Sarah Cleaveland,Tiziana Lembo,Kennedy Lushasi,Geofrey Mchau,Zacharia Mtema,Maganga Sambo,Alphoncina Nanai,Nicodem J Govella,Angel Dilip,Lwitiko Sikana,Francesco Ventura,Katie Hampson

doi:10.1016/j.vaccine.2018.08.086

Abstract

BackgroundRabies is preventable through prompt administration of post-exposure prophylaxis (PEP) to exposed persons, but PEP access is limited in many rabies-endemic countries. We investigated how access to PEP can be improved to better prevent human rabies. MethodsUsing data from different settings in Tanzania, including contact tracing (2,367 probable rabies exposures identified) and large-scale mobile phone-based surveillance (24,999 patient records), we estimated the incidence of rabies exposures and bite-injuries, and examined health seeking and health outcomes in relation to PEP access. We used surveys and qualitative interviews with stakeholders within the health system to further characterise PEP supply and triangulate these findings. ResultsIncidence of bite-injury patients was related to dog population sizes, with higher incidence in districts with lower human:dog ratios and urban centres. A substantial percentage (25%) of probable rabies exposures did not seek care due to costs and limited appreciation of risk. Upon seeking care a further 15% of probable rabies exposed persons did not obtain PEP due to shortages, cost barriers or misadvice. Of those that initiated PEP, 46% did not complete the course. If no PEP was administered, the risk of developing rabies following a probable rabies exposure was high (0.165), with bites to the head carrying most risk. Decentralized and free PEP increased the probability that patients received PEP and reduced delays in initiating PEP. No major difficulties were encountered by health workers whilst switching to dose-sparing ID administration of PEP. Health infrastructure also includes sufficient cold chain capacity to support improved PEP provision. However, high costs to governments and patients currently limits the supply chain and PEP access. The cost barrier was exacerbated by decentralization of budgets, with priority given to purchase of cheaper medicines for other conditions. Reactive procurement resulted in limited and unresponsive PEP supply, increasing costs and risks to bite victims. ConclusionPEP access could be improved and rabies deaths reduced through ring-fenced procurement, switching to dose-sparing ID regimens and free provision of PEP.

Highlights

The burden of human rabies is high in many low- and middleincome countries (LMICs) where the disease is maintained and spread primarily by domestic dogs [1]
We examined the incidence of rabies exposures and bites for which patients sought healthcare, and health seeking behaviours and health outcomes in relation to post-exposure prophylaxis (PEP) access using two sources of data: contact tracing and mobile phone-based surveillance data
We detected an average of 75.6 and 19.3 probable rabies exposures per 100,000 persons per year in northern Tanzania from Serengeti and Ngorongoro districts, respectively, prior to the implementation of regular dog vaccination campaigns. These districts have low human:dog ratios (4.5 and 7, respectively) and bite victims must pay for PEP, as is routine in Tanzania

Summary

Introduction

The burden of human rabies is high in many low- and middleincome countries (LMICs) where the disease is maintained and spread primarily by domestic dogs [1]. Rabies is preventable through prompt administration of post-exposure prophylaxis (PEP) to exposed persons, but PEP access is limited in many rabies-endemic countries. A substantial percentage (25%) of probable rabies exposures did not seek care due to costs and limited appreciation of risk. Upon seeking care a further 15% of probable rabies exposed persons did not obtain PEP due to shortages, cost barriers or misadvice. Of those that initiated PEP, 46% did not complete the course. High costs to governments and patients currently limits the supply chain and PEP access. Reactive procurement resulted in limited and unresponsive PEP supply, increasing costs and risks to bite victims.

Methods

Results

Conclusion