Epidemiological dynamics of rabies in Tanzania and its impacts on local communities.

Rabies is a fatal viral zoonotic infection caused by a Lyssavirus. Rabies exerts a major public health and economic burden; it is responsible for at least 55,000 deaths worldwide, predominantly in Africa and Asia. More than 90% of rabies deaths are caused by domestic dogs. Global expenditure on rabies prevention and control exceeds US$500 million per annum. Although human rabies is 100% preventable, through vaccination of animal reservoirs and post-exposure prophylaxis (PEP) of people exposed to bites, no effective large-scale control of rabies has been achieved in sub-Saharan Africa. Effective implementation of sustainable rabies control and prevention programs, involves full participation of individuals, veterinary and medical services. Veterinary services must control rabies transmission through mass dog vaccination campaigns because human deaths are caused by epidemics in domestic dogs, medical services must provide PEP to prevent disease in exposed individuals and exposed individuals must seek PEP and dog owners must take their dogs to be vaccinated. This thesis focuses on factors affecting individuals and medical services. This thesis examines challenges in the control and prevention of rabies in sub-Saharan Africa. Firstly, to address these challenges, we developed an analytical framework to portray the influence of individual and institutional factors within both the veterinary and medical services, in controlling and preventing rabies. The research carried out in chapters two and three investigate different aspects of this framework. Specifically in Chapter 2, we conducted a knowledge, attitude and practice (KAP) survey in seven districts covering southern, central and northern Tanzania. We used the collected data to investigate factors that influence knowledge of rabies and how knowledge of rabies influences attitudes and practice in control and prevention of rabies. Our findings show that knowledge about rabies in Tanzania is limited. However, we found an indication that those who were more knowledgeable of rabies claimed to practise better rabies control and prevention. In Chapter 3, we collected information using contact tracing and questionnaires to evaluate the burden of rabies and its impacts on local communities. The study demonstrated that rabies is a substantial economic concern to bite victims. A bite victim in Tanzania would be required to spend over US$70 to complete WHO recommended PEP schedules. The costs of PEP disproportionately affect bite victims from rural areas where PEP doses are often not available. Families reported spending family allowances, borrowing money and or selling crops or livestock to pay for PEP. Fewer than 10% of families paid for PEP from their salary compared to 15% of patients from urban areas. Otherwise, patients depended on external financial sources such as contributions from relatives or friends or decided not to seek PEP because of the high costs involved. High PEP costs also affected compliance with PEP schedules. The probability of obtaining the first dose of PEP was about 70%, declined slightly for the second and third doses but declined dramatically for the fourth and fifth doses. We also found that 15% of bite victims who did not receive any PEP went on to develop rabies. The costs of PEP were 2 times higher than costs previously reported from Africa. In Chapter 4 we discuss our overall results and conclude that interventions to control and prevent rabies require multi-sector commitment of all key stakeholders