The burden of rabies in Tanzania and its impact on local communities

Abstract

Background: Rabies remains a major public health threat in many parts of the world and is responsible for an estimated 55,000 human deaths annually. The burden of rabies is estimated to be around US$20 million in Africa, with the highest financial expenditure being the cost of post-exposure prophylaxis (PEP). However, these calculations may be substantial underestimates because the costs to households of coping with endemic rabies have not been investigated. We therefore aimed to estimate the household costs, health-seeking behaviour, coping strategies, and outcomes of exposure to rabies in rural and urban communities in Tanzania.

Methods and findings: Extensive investigative interviews were used to estimate the incidence of human deaths and bite exposures. Questionnaires with bite victims and their families were used to investigate health-seeking behaviour and costs (medical and non-medical costs) associated with exposure to rabies. We calculated that an average patient in rural Tanzania, where most people live on less than US$1 per day, would need to spend over US$100 to complete WHO recommended PEP schedules. High costs and frequent shortages of PEP led to poor compliance with PEP regimens, delays in presentation to health facilities, and increased risk of death.

Conclusion: The true costs of obtaining PEP were twice as high as those previously reported from Africa and should be considered in re-evaluations of the burden of rabies.

Figure 1. Map of Tanzania showing the study districts where incidences of rabies and cost data were collected.

Gray shading indicates where extensive investigative interviews were administered and black shading where only cost data were collected.

Figure 2. People bitten by suspected rabid animals traced per quarter from January 2006 to December 2008 in Ulanga, Kilombero and Serengeti districts, Tanzania.

Figure 3. Distribution of delays before bite victims received their first dose of PEP.

Figure 4. Sources of funds used by bite victims from rural and urban areas to pay for PEP.

Figure 5. The probability of victims of bites by suspect rabid animals receiving and completing PEP vaccine doses.

The situation for bite victims in Kilombero and Ulanga may not be representative as St Francis Mission Hospital in Kilombero received donated vaccine through Ifakara Health Institute as a result of the outbreak, therefore the population in the Kilombero valley is likely better served than in some other rural parts of Tanzania.