1. Economic burden of rabies and its impacts on local communities in Tanzania Maganga Sambo smaganga@ihi.or.tz

2. Introduction What is rabies? Challenges in controlling and preventing rabies Challenges of seeking human pre exposure prophylaxis (PEP) Methods Results Bite and death incidence Costs associated with receiving PEP Conclusions Talk overview

3. What are major challenges associated with canine rabies control? Low dog vaccination coverage Poor estimate of dog population - insufficient/ ineffective vaccination campaigns Poor dog management and control (roaming dogs and High dog population turnover ) OUTCOMES: - High probability of being bitten by unvaccinated dog - High demand for human rabies prevention

4. PEP seeking process HOSPITAL Get there on foot or bicycle, few costs Get there on bicycle or bus, pay fare, food and medical costs Get there on bus/ train, pay fare, food, lodge and medical costs

5. Costs facing patients after a bite Indirect Medical costs Travel costs, Accommodation costs, other costs like food, airtime, Direct Medical costs PEP cost, Consultation fees, Syringes and needles, Wound treatment costs and antibiotics Exposure to a rabid dog Loss of labour force due to incapacity or severe wound, Loss of labour force due to escorts or care of the victims Loss of school due to treatment seeking or severe wound Medical costs Opportunity costs Total Costs

6. Bulletin of the World Health Organization | May 2005, 83 (5) Note: These estimate did not fully capture indirect medical costs or inequalities between rural and urban areas

7. Research Objectives 1) To compare previous costs and estimated burden (Knobel 2005) with empirical data with consideration of rural-urban settings 2) To quantify the economic burden of rabies (incidence of bites, costs of PEP, rabies deaths and their related costs) 3) To identify who are worst affected by these costs

8. Methodology Compilation of hospital and livestock records as starting point for contact tracing Contact tracing to estimate human death and bite incidence Questionnaire surveys to capture costs incurred by patients and validate them using receipt and market price Human demographic data (census) to estimate population structure and growth rate Tanzanian Household Budget Survey (HBS) of 2007 used to estimate daily income and annual income for rural and urban bite victim

9. Study area

10. Contact tracing and questionnaire After interviews I normally take GPS code of area where bites happened and educate them concerning rabies

11. Results  A questionnaire was administered to in April to Sept 2009  706 people bitten by animals from Jan 2006 to Dec 2009 were interviewed. Of these, 415 (59%) were suspect rabid cases  About 53% were to children <15 years of age (overall range 1-80 years)  Of these 63% of suspect bites were from rural areas

12. People bitten by suspected rabid animal (Jan 2008-Dec 2008)

13. Bite and death incidence/per 100,000 people (Jan 2006 - Dec 08) District Human population* Human growth rate (%) Average annual incidence/100000 bite death Ulanga1932802.437.92.5 Kilombero3216113.811.20.8 Serengeti1760573.333.41.6 * according to the 2002 census

14. Estimated average costs Components Estimated cost ($) per dose RuralUrban Direct medical costs12.018.19 Travel costs4.791.99 Accommodation cost1.111.98 Other costs1.000.24 Lost income[days lost from work]3.638.06 Total costs22.5420.46 Note: Knobel 2005 study estimated only $2 per single clinic visit

15. What are major implications of these costs? Delays to hospital (delays in receiving PEP) Poor compliance Poverty (absence from work, high interest loans) Deaths

16. What are implications and coping strategies to these costs?

17. Compliance to PEP regimens

18. Sources of fund to pay for PEP

19. How can we reduce the burden and increase compliance? Make PEP available locally (increase access) Subsidy PEP (increase affordability) Vaccinate dogs (reduce chances of being bitten by unvaccinated dogs) Use ID regimen (share PEP and reduce clinic visits)

20. Compliance with 5 dose Essen regimen (1ml/dose, IM) Cost scenarioCost of PEP/cost scenario (in US$) Percentage of annual income RuralUrban Rural Urban No subsidies112.75102.2845%18% 100% subsidised52.761.3121%11% 100% subsidised and decentralised 23.241.489%7% Note: PEP costs are often prohibitive, Hampson et al (2008) Majority of Tanzanians survive at <$1 a day

21. Compliance with 4 dose Essen regimen (0.1 mil/dose, ID) Cost scenarioCost of PEP/cost scenario (in US$) Percentage of annual income RuralUrban Rural Urban No subsidies90.2081.8236%14% 100% subsidised42.1649.0517%9% 100% subsidised and decentralised 18.5633.187%6%

22. Compliance with 3 dose Tanzanian regimen(1 ml/dose, IM) Cost scenarioCost of PEP/cost scenario (in US$) Percentage of annual income RuralUrban Rural Urban No subsidies67.65 27%12% 100% subsidised31.6236.7913%7% 100% subsidised and decentralised 13.9224.896%4%

23. Note: Knobel 2005 study estimation based on free/ subsidized PEP (at cost to government of $10/dose) which costs

24. Conclusions 24 The rural poor are worst affected The burden of rabies is substantially underestimated Rabies need national and global attention and its burden should be re-evaluated PEP should be subsidised and decentralized Shortages of PEP is common at district hospitals

25. Acknowledgements The Wellcome Trust: For funding the project University of Glasgow: Sunny Townsend, Sarah Cleaveland, Tiziana Lembo, Zacharia Mtema, Heather Ferguson and Katie Hampson Ifakara Health Institute: Lwitiko Sikana, Joel Changalucha, Kennedy Lushashi and Honorathy Urassa Sokoine University of Agriculture: Rudovick Kazwala and Gurdeep Jaswant Afya Serengeti: Cleophas Simon, Zilpah Kaare and Matthias Magoto Staff from District veterinary and medical office, village leaders and to the community

26. Asanteni sana