The Burden of Rabies in Tanzania and Its Impact on Local Communities

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. Author Summary: Rabies remains a major public health problem, although the means to control and prevent this disease are available through mass dog vaccination and provision of post-exposure prophylaxis (PEP) to people exposed to bites by rabid or suspect rabid animals. Despite its necessity as a life-saving measure to prevent the fatal onset of rabies, access to PEP is a major problem in developing countries. We used extensive investigative interviews to estimate rabies incidence (deaths and exposures) and questionnaires to bite victims and their families to investigate health-seeking behaviour and costs associated with receiving PEP, in four districts covering both rural and urban Tanzania. Frequent shortages at health centres limited prompt access to PEP. Suspect bite victims often had to travel long distances to major hospitals to receive costly PEP, causing delays and increasing the risk of developing rabies. We calculated that an average patient in rural Tanzania would need to spend over $100 to complete the WHO recommended PEP schedules, unaffordable for many Tanzanians, who survive under the poverty line. Our data shows that rabies imposes a disproportionate financial hardship and high risk of dying of rabies to rural poor families and highlights the need to re-evaluate the burden of rabies in Africa.