Rabies is a viral infectious disease of mammals including humans, characterised by the development of severe nervous symptoms that lead to paralysis and death. Once symptoms of the disease develop, rabies is invariably fatal. The disease affects domestic and wild animals, and is spread to humans through close contact with infectious material, usually via bites or scratches. Rabies is present on all continents of the world with the exception of the Antarctica; however, more than 95% of human deaths due to the disease occur in Asia and Africa. Human mortality from canine rabies is estimated to be 60,000 per year worldwide, with about 56% of the cases occurring in Asia and 43.6% in Africa, mostly in rural areas. This translates to 1 death due to rabies every 10 minutes in the two continents. Official data on human rabies deaths submitted to World Health Organization (WHO) from Africa are a gross under-estimate of the true burden of the disease. The reasons for this include: rabies victims are often too ill to travel to hospital or die before arrival; families recognize the futility of medical treatment for rabies; misdiagnosis of rabies and laboratory confirmation of clinically suspected cases is difficult.
In Kenya, it is estimated that up to 2,000 human deaths occur annually due to rabies occur annually. Progress in preventing human rabies through control of the disease in the dogs has been slow due to a number of barriers including; limited information and awareness about the extent of the problem, lack of suitable diagnostic and managerial capacity, lack of appropriate and sustainable strategy for prevention and control, lack of inter-sectoral collaboration and organizational and financial challenges. Successful elimination of human rabies in Kenya will require a multi-sectoral and collaborative approach. Prevention of dog rabies, effective surveillance in humans and animals, better public awareness and improved access to human rabies vaccines are essential for the elimination of human rabies. Due to the threat of emerging and re-emerging zoonotic diseases globally and the emphasis on these threats through the International Health Regulations (IHR), Kenya has established a One Health coordinating office, referred to as Zoonotic Disease Unit (ZDU), with the focus on prevention and control of zoonotic diseases. The ZDU is nestled between the Ministry of Health (MOH) and Ministry of Agriculture, Livestock and Fisheries (MALF) with each ministry deploying an epidemiologist as the joint coordinator of the unit. The mission of ZDU is to establish and maintain active collaboration at the animal-human ecosystem interface towards better prevention and control of zoonotic diseases. The ZDU also serves as a secretariat for the multi-sectoral Zoonoses Technical Working Group (ZTWG), which advises the government on prevention and control of zoonotic diseases. The ZDU, therefore, presents an opportunity to promote inter-sectoral collaboration for the national rabies elimination strategy
Burden of Rabies in Kenya
Lack of effective surveillance systems and diagnostic capacity has resulted in underestimation of the burden of rabies in Kenya. The current figures captured by the passive surveillance system underestimate the incidence and burden of the disease by 70 times in animals and 200 times in humans6,7. Between 1983 and 1990, domestic dogs accounted for 63% of the 2,149 confirmed animal rabies cases whereas between 2002 and 2012, they accounted for 45% of the 858 confirmed cases.
Challenges in Rabies Control in Kenya
There are a number of challenges in the prevention and control of rabies in Kenya as listed below:
Inadequate laboratory capacity
- Human rabies diagnosis and management is largely dependent on diagnosis of rabid animals.
- Countrywide, there are only three animal laboratories that have the capacity to confirm rabies in humans or animals. However, these laboratories often lack reagents for timely testing of specimens.
- At the grass root level, there are inadequate resources for sample collection, packaging and shipping to diagnostic laboratories.
- There are no public health laboratories which carry out human rabies diagnosis
- In the IDSR system, dog bites are used as a proxy for suspect rabies cases in humans. However dog bites are under-reported in health facilities resulting in missed cases and misclassification of deaths due to rabies.
- There is underreporting of suspected rabies cases in dogs and other livestock due to the passive nature of the surveillance system.
- There is inadequate sharing of surveillance data between the human and animal health sectors at both local and national levels, often resulting in loss of opportunities to prevent human rabies, early detection and timely response to rabies outbreak.
- The national surveillance data is unreliable, meaning that the true burden of the disease in the country or high risk areas remains undefined; making it difficult to target prevention and control measures.
Inadequate inter-sectoral collaboration and partnerships
- There is little coordination and collaboration between the human and animal health sectors and other agencies responsible for rabies control.
- Most of the rabies control and prevention activities in the country have been ad hoc, uncoordinated (carried out by line ministries, NGOs, private practitioners), and without welldefined objectives or evaluation of progress (e.g. vaccination coverage, goals and indicators to measure success and the costs of these control activities).
Low awareness on rabies prevention and control
- There is low awareness among the public, human and animal health workers on management of dog bite wounds, and pre- and post-exposure prophylaxis.
- Most patients who die from rabies are either misdiagnosed or do not receive timely and appropriate post-exposure treatment. In particular, many dog bites in children are not reported and may go completely unrecognized or be discovered late by both parents and health care providers.
- Knowledge of the benefits of responsible dog ownership and dog population management among the public is low. In addition, there is little understanding among the public of the value of timely response following dog bites and the value of timely PET.
- Compliance with completion of PEP regimens is low. Factors affecting PEP compliance of patients are not well known
- There is low awareness among policy makers on the importance and burden of rabies and the cost-effectiveness of rabies control through dog vaccination
Inadequate Enforcement of Laws and Regulations
- Whereas there is adequate legislation requiring mandatory registration of, licensing of, and vaccination of dogs and cats against rabies, and responsible dog ownership, there is inadequate implementation and enforcement of the law. There are also county laws on responsible animal ownership that are not adhered to. This laxity in enforcement has resulted in a large population of unvaccinated dogs.
- Another weakness in legislation is that the rabies act applies only to designated rabies control areas, which are supposed to be gazetted. At the moment there are no gazetted rabies control areas.
Inadequate Research on Rabies
- There is inadequate research that can enhance rabies control. Data on important topics such as the economic benefits of rabies control, dog demographics and ecology, and alternative dog population management methods is lacking
Limited supply of anti-rabies vaccine
- There is limited supply of animal rabies vaccine in the animal sector and also inadequate PET and PEP biologics in public health. Whereas these biologics may be available in private facilities, the cost is prohibitive. The possibility of producing rabies vaccines locally have been explored but never implemented. The table below shows the number of vaccines procured by MALF and MOH for use in public facilities.
Strategies for Rabies Elimination
The following strategies will be deployed in the rabies elimination plan.
- Elimination of rabies in dogs
By conducting mass dog vaccination targeting greater than 70% of dog population
- Coverage annually for three consecutive years.
- Dog population management comprising education, legislation, registration, sterilization, holding facilities, euthanasia and controlling access to garbage and leftovers.
- Prevention of rabies in humans
By Providing timely access to appropriate Post Exposure Treatment (wound cleaning,
- Vaccination and rabies immunoglobulin) to all human cases of dog-bites suspected to be rabid.
- By Increasing knowledge and skills among animal and human health workers on rabies in general and post-exposure management
- Strengthen Surveillance and response to outbreaks
By strengthening surveillance to monitor and evaluate key indicators
- By strengthening preparedness and response to rabies outbreaks
- Conduct and promote operational research
- By conducting and promoting operational research to support implementation
- Advocacy, communication and social mobilization
- By increasing community awareness and education on rabies prevention and control
- Through enhancing community participation in rabies control activities
- Enhance partnerships and coordination
- Through strengthening capacity for planning, partnerships and coordination of the
- National Rabies Elimination Strategy
- By strengthening capacity in program management in order to achieve rabies elimination objectives at all levels
- Resource mobilisation
- Through mobilization resources to support rabies elimination program