Ministry of Health
and
Ministry of Agriculture, Livestock and Fisheries
Strategic Plan for the Elimination of Human Rabies in Kenya
2014-2030
Republic of Kenya
Ministry of Health
And
Ministry Agriculture, Livestock and Fisheries
Strategic Plan for the Elimination of Human Rabies in Kenya
2014–2030
Strategic Plan for the Elimination of Human Rabies in Kenya 2014-2030
Any part of this document may be freely reviewed, quoted, reproduced or translated in full or in part, provided that the source is properly acknowledged. It may not be sold or used in conjunction with commercial purposes or for profit
Suggested citation: Zoonotic Disease Unit:Strategic Plan for the Elimination of Human Rabies in Kenya 2014-2030.Nairobi: Ministry of Health and Ministry of Agriculture, Livestock and Fisheries; 2014.
Published by: The Zoonotic Diseases Unit
P.O. Box 20811-00202,
Nairobi, Kenya
Website:
FOREWORD
This document describes Kenya’s strategic plan for the elimination of dog-mediated human rabies, an invariably fatal disease in humans, livestock and other mammals by 2030. Rabies is a classic example of a zoonotic disease that is preventable in humans by controlling the disease in animals. Elimination is achievable through mass dog vaccination because dogs are responsible for transmission of over 98% of all human rabies.
Rabies causes approximately 60,000 human deaths worldwide annually, with one person dying of every 10 minutes. The burden associated with rabies remains highest in the developing world, with more than 95% of all human deaths occurring in Africa and Asia.Rural populations, especially children aged below 15 years are at greater risk of rabies exposure. The cost associated with post-exposure prophylaxis in humans is high, and far exceed the cost of rabies control in animals through dog vaccinations.
In comparison to other communicable diseases, rabies is a preventable yet incurable disease; therefore focus should be given to control and eventual elimination. Eliminating rabies from the dog population is the key to the stopping human rabies. Success in canine rabies elimination has been demonstrated in developing countries including Latin Americas and Asia, where sustained mass vaccination of dogs was shown to be the single most cost effective intervention forcontrolling and eliminating canine rabies and consequently human rabies.
In Kenya, the profile of zoonotic diseases has risen following implementation the WHO IHR (2007) regulations, and more so after the establishment of a national One Health office (referred to as Zoonotic Disease Unit). Rabies isamong the top fivepriorityzoonotic diseases in the country.
This rabies elimination strategy will guide systematic reduction of the disease riskthrough sustained mass dog vaccinations, pre and post-exposure prophylaxis in humans, and public education. This strategy is based on activities planned in accordance with the stepwise approach for the country to move from an endemic state to a disease free status. Successful implementation of thisstrategy requires a multi-sectoral collaborative approach with involvement and support of manystakeholders.We are optimistic that each of our partners will join hands and play their role in eliminating dog-mediated human rabies in Kenya by 2030.
Mr James MachariaMr Felix Koskei
Cabinet SecretaryCabinet Secretary
Ministry of HealthMinistry of Agriculture, Livestock and Fisheries
ACKNOWLEDGEMENTS
This strategy plan was developed through an elaborate consultative process involving key stakeholders in rabies prevention and control.The Ministry of Health and the Ministry of Agriculture, Livestock and Fisheries would like to thank all those who contributed to the development of the plan. Special appreciation goes to the team that worked tirelessly to write this plan, including the following:
Name Institution
Dr. Nathan SongokMinistry of Agriculture, Livestock and Fisheries
Dr. R. Murithi MbabuMinistry of Agriculture, Livestock and Fisheries
Dr. Stella KiambiMinistry of Agriculture, Livestock and Fisheries
Dr. Cathryn WanjohiMinistry of Agriculture, Livestock and Fisheries
Dr. William MaritimMinistry of Agriculture, Livestock and Fisheries
Dr. George NjoguMinistry of Agriculture, Livestock and Fisheries
Dr. Jane GithinjiMinistry of Agriculture, Livestock and Fisheries
Dr. J.T. KariukiMinistry of Agriculture, Livestock and Fisheries
Dr. Austine Bitek Ministry of Agriculture, Livestock and Fisheries
Dr. Waqo D. EjersaMinistry of Health
Dr. Ian Njeru Ministry of Health
Mr. Hilary LimoMinistry of Health
Mr. Wycliffe Matini Ministry of Health
Dr. David OluochMinistry of Health
Dr. Tatu KamauMinistry of Health
Dr. Mariam Mwanje Neglected Tropical Diseases Programme, Nairobi
Dr. Eric OsoroMinistry of Health
Prof. Philip KitalaUniversity of Nairobi
Dr. Peter B. GathuraUniversity of Nairobi
Prof. William OgaraUniversity of Nairobi
Dr. Juliana Tonui Ministry of Health
Dr. Francis GakuyaKenya Wildlife Services
Dr. Dominic MijeleKenya Wildlife Services
Dr. Elizabeth OukoKenya Veterinary Association
Dr. Geoffrey Mutai Kenya Veterinary Vaccines Production Institute
Dr. Eric Ogola Kenya Medical Research Institute
Dr. James ZingeserFood and Agriculture Organization, Rome
Dr. Tabitha KimaniFood and Agriculture Organization - ECTAD
Dr. Sam OkutheFood and Agriculture Organization – ECTAD
Dr. Kariuki NjengaCenters for Disease Control and Prevention
Dr. Peninah MunyuaCenters for Disease Prevention and Control
Dr. Nick de SouzaWorld Society for Protection of Animals
Ms. Beryl Mutonono-WatkissWorld Society for Protection of Animals
Dr. Emily MudogaWorld Society for Protection of Animals
Ms. Jean GilchristKenya Society for Protection of Animals
Prof. Jonathan YoderWashington State University
Dr. Thumbi MwangiWashington State University
Dr. Felix LankesterWashington State University
Dr. Samuel KadivaneField Epidemiology and Laboratory Training Program
Dr. Nelson MuriuField Epidemiology and Laboratory Training Program
Dr. Allan OgendoField Epidemiology and Laboratory Training Program
Dr. Josephat MuemaField Epidemiology and Laboratory Training Program
Dr. Dickens OnyangoMinistry of Health
Dr. Samuel AmwayiField Epidemiology and Laboratory Training Program
Dr. Athman MwatondoField Epidemiology and Laboratory Training Program
Dr. Mathew MuturiField Epidemiology and Laboratory Training Program
Dr. James OumaZoonotic Disease Unit
Mr. Maurice KiboyeVeterinaires Sans Frontieres – Germany
Dr. Bernadette TionySharon’s Rabies Project, Nandi
Ms. Grace WanjauZoonotic Disease Unit
Ms. Kaitlin SandhausGlobal Implementation Solutions
Ms. Mariko WilcoxGlobal Implementation Solutions
Dr Sarah CleavelandUniversity of Glasgow
Prof. Fred H. K. Segor Dr Khadijah Kassachoon
Principal Secretary Principal Secretary
Ministry of Health State Department of Livestock
Ministry of Agriculture, Livestock and Fisheries
TABLE OF CONTENTS
FOREWORD
ACKNOWLEDGEMENTS
TABLE OF CONTENTS
EXECUTIVE SUMMARY
CHAPTER ONE
1.1 Introduction
1.2 Cost Effectiveness of Rabies Elimination
1.3 Rabies Epidemiology
1.3.1 Reservoir
1.3.2 Transmission
1.3.3 Clinical Features
1.4 Diagnosis of Rabies
1.5 Prevention and Elimination of Rabies
1.6 Rabies Situation in Kenya
1.6.1 History of Rabies in Kenya
1.6.2 Burden of Rabies
1.6.2 Availability of anti-rabies vaccines
1.6.3 Rabies Surveillance System
1.6.4 Legal framework for rabies control
1.6.5 Current rabies control activities
1.7Challenges in Rabies Control in Kenya
1.7.8 Funding constraints
1.7.9 Lack of integrated national guidelines on rabies prevention and control
1.8 Opportunity for Rabies Elimination
CHAPTER TWO: THE STRATEGIC FRAMEWORK
2.1 Guiding Principles of the Strategy
2.2 Vision
2.3 Mission
2.4 Goal
2.5 General Objective
2.6 Strategies for Rabies Elimination
2.6.1Elimination of rabies in dogs
2.6.2 Prevention of rabies in humans
2.6.3 Strengthen Surveillance and Response
2.6.4 Conduct and Promote Operational Research
2.6.5 Advocacy, Communication and Social mobilization
2.6.6 Enhance Partnerships and Inter-Sectoral coordination
2.6.7 Resource Mobilisation
CHAPTER THREE: IMPLEMENTATION PLAN OF THE STRATEGY
3.1 Stage 1 (2013-2015): Planning for implementation of the strategy
3.1.1 Establishment of a national rabies task force (NRTF)
3.1.2 Establish County Rabies Working Group (CRWG)
3.1.3 Establish Rabies Action Groups
3.1.4 Selection of focal pilot areas
3.1.5 Strengthen Surveillance for Rabies
3.1.6 Development of guidelines
3.1.7 Supply and distribution of vaccines and RIG
3.1.8 Conduct and promote operational research
3.1.9 Develop Communication Strategy
3.2 Stage Two (2015 - 2019):Implementation of the elimination strategy in pilot areas
3.3 Stage 3 (2019-2023): Implementation of the rabies eelimination strategy outside the pilot areas
3.4 Stage 4 (2023-2025) - Maintaining freedom from dog-mediated human rabies and elimination of canine rabies
3.5Stage 5 (2025-2027) –Maintain Freedom from rabies in humans and dogs
4.0: MONITORING AND EVALUATION
5.0 ANNEXES
ANNEX 1: MONITORING AND EVALUATION PLAN (2014-2018)
ANNEX 2: BUDGET OF THE RABIES ELIMINATION STRATEGY (2014-2018)
LIST OF ABBREVIATIONS AND ACRONYMS
AMREFAfrican Medical and Research Foundation
ANAWAfrica Network for Animal Welfare
AU-IBARAfrican Union Inter-African Bureau of Animal Resources
CDCCentres for Disease Control and Prevention
CRWGCounty Rabies Working Group
CORTCounty Outbreak Response Team
CVLCentral Veterinary Laboratories
DALYsDisability Adjusted Life Years
DSRUDivision of Disease Surveillance and Response Unit
DFZDisease Free Zone
SCMOHSub-County Medical Officer of Health
dRITDirect Rapid Immunohistochemistry Test
UVISUnit of Vaccines and Immunization Services
SCVOSub-County Veterinary Officer
FAOFood and Agriculture Organization
FATFluorescent Antibody Test
FMDFoot and Mouth Disease
IECInformation, Education and Communication
IPRInstitute of Primate Research
KARIKenya Agriculture Research Institute
KEMRIKenya Medical Research Institute
KEVEVAPIKenya Veterinary Vaccine Production Institute
SPERK Strategic Plan for Elimination of Human Rabies in Kenya
KSPCAKenya Society for Care and Protection for Animals
KVBKenya Veterinary Board
KWSKenya Wildlife Service
MALFMinistry of Agriculture, Livestock and Fisheries
MoHMinistry of Health
NGONon Governmental Organizations
NRTFNational Rabies Task Force
OIEWorld Organization for Animal Health
PEP Post Exposure Prophylaxis
PETPost Exposure Treatment
PBSPhosphate Buffered Serum
PPBPharmacy and Poisons Board
RAGRabies Action Groups
RNARibonucleic acid
RVILRegional Veterinary Investigation Laboratories
SAStepwise Approach
SEARGSouthern and Eastern African Rabies Group
SOPStandard Operating Procedure
UoN University of Nairobi
VEEUVeterinary Epidemiology and Economics Unit
WHOWorld Health Organization
ZDUZoonotic Disease Unit
EXECUTIVE SUMMARY
Rabies is a neglected zoonotic disease which is almost invariably fatal in humans, livestock and other mammals. It kills up to 60,000 people a year, most of them(95%) in Africa and Asia. It is estimated that up to 2,000 human deaths due to rabies occur annually in Kenya.
In Kenya, rabies has been ranked as one of the top five priority zoonotic diseases with the goal of eliminating dog-associated rabies in the country. Success in rabies elimination has been demonstrated in developing countries including Latin Americas and Asia, where sustained mass vaccination of dogs has been shown to be the single most cost effective intervention to control and eliminate canine rabies and consequently human rabies. Studies conducted in sub-Saharan Africa show that most of the rabies cases in animals and humans are caused by canine rabies virus, transmitted by domestic dogs. Wildlife including wild carnivores and stray dogs play an insignificant role in maintenance of the virus. Consequently, comprehensive and sustained dog vaccination is sufficient intervention in reduction and eventual elimination of human rabies in a region.
This strategy aims at eliminating dog mediated human rabies by the year 2030 in Kenya. The strategy provides a guide for systematic reduction of rabies riskthrough sustained mass dog vaccinations, pre and post-exposure prophylaxis and public education until the country is completely free of dog-mediated human rabies. This strategy is based on activities planned in accordance with the Stepwise Approach (SA) for the country to move from an endemic state to a disease free status. The SA is a stepwise progression towards becoming a disease-free country, consisting of 6 stages (Stage 0 to 5), each with a set of activities that build on each other to continuously reduce the risk of disease, with the country being declared completely free of dog-mediated human rabies when it reaches Stage 5.
The critical steps in the various stages include developing and adopting a national rabies elimination strategy;starting implementation of elimination plan in pilot areas,implementation of the elimination strategy throughout the country; and maintaining freedom from dog mediated human rabies and canine rabies. To move from one stage to the one above it, a set of targets must be reached and confirmed. The implementation of the strategy will begin with selected pilot areas to gain valuable lessons in creating and maintaining a rabies-free zone that will be used during the roll-out of the elimination campaign in the rest of the country
Dr. Francis Kimani, Dr. Kisa Ngeiywa
Director of Medical ServicesAg. Directorof Veterinary Services
CHAPTER ONE
1.1 Introduction
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 ofthe 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 60,000per 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;and laboratory confirmation of clinically suspected cases is difficult.
Beside human mortality, the economic burden of rabiesis significant. The high cost of post exposure prophylaxis in human creates a heavy burden toboth government and household budgets. At the household level, costs of post-exposure prophylaxis (PEP) arise directly from anti-rabies vaccines and indirectly from costs associated with travel, medical fees and income loss. The indirect householdlosses represent more than 50% of total costs. The total PEP costs have been estimated at US$40 per patient in Africa and US$49 in Asia, accounting for 6% and 4% of annual per capita gross national income, respectively. In Kenya, the direct medical cost associated with a complete regime of PEP is estimated at $85 per person. Poor households face difficulties paying for PEP, which results in considerable financial hardship and substantial delays or failure in PEP delivery. Shortages of PEPare also common in many rural remote locations of Africa, further increasing the costs as victims who are forced to travel to far flung centres to obtain treatment.In addition, victims of rabid dog bites and their families suffer frompsychological trauma resulting from the uncertainty and resignation to the inevitable outcome.
Rabies also impactslivestock and other animals such as donkeys, camels and horses.Weak surveillance and a lack of reliable data on the number of animal rabies cases is a major constraint to assessing the economic impact of rabies on the local communities when livestock and working animals die due to rabies or infect humans.
Successful elimination of human rabies has been demonstrated in many countries, including in developing countries such as thePhilippines, Mexico and Indonesia. In Philippines, arabies elimination programme was launched in 2007 involving mass dog vaccination, dog population control, improved dog bite management, public education, and improved diagnosis surveillance and monitoring. Within three years, human deaths due to rabies were reduced from eightpersons per million to zero. Similar control efforts are underway in the south-eastern part of the United Republic of Tanzania and Kwa-Zulu Natal in South Africa.
In Kenya,it is estimated that up to 2,000 human deaths due to rabies occur annually. Progress in preventing human rabies through control of the disease inthe dogs has been slowdue to a number of barriersincluding technical, 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 animal 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 between at the animal, human and ecosystem interface towards better prevention and control of zoonotic diseases. The ZDU also serves as a secretariat for the multi-sectoral Zoonotic Technical Working Group (ZTWG), which advises the government on zoonotic diseases. The ZDU, therefore, presents an opportunity to promote inter-sectoral collaboration for the national rabies elimination strategy.
There is also increased interest in rabies elimination by various partners and ongoing control programmes in Tanzania and South Africa that Kenya can borrow from. In the early 1970s, Kenya hadsuccessfully suppressing rabies through sustained dog vaccination campaigns. However, a breakdown of these efforts allowed the disease to spread to a point where it is now endemic in every region of the country. Both the Ministry of Health and the Ministry of Agriculture Livestock and Fisheries are committing to this rabies elimination strategy and look towards a rabies-free Kenya.
1.2 Cost Effectiveness of Rabies Elimination
The current efforts for rabies prevention and control in Kenya are restricted to human post-exposure prophylaxis(PEP), voluntary and ad hoc dog vaccinations. Unfortunately, PEP is often unavailable or unaffordable to most affected individuals. Elimination of rabies at the reservoir species (dogs) is the ultimate strategy to prevent human rabies deaths and also reduce recurring cost of human PEP.
A number of studies have been conducted in Philippines and Chad to assess the cost effectiveness of rabies control strategies. In the Philippines, cost–benefit analysis of mass dog vaccination versus human PEP over a 6 year period indicated that the use of intensified human PEP alone was associated withincreasing medical costs to the government over the years in the absence of a dog vaccination program. In Chad, the cumulated cost of the combined strategy of human PEPand dog vaccination was foundto be more efficient than the human PEP alone in the first 4 years, and then was it became lower than human PEP cost after the 5th year of the program. The studies also showed that the cumulated cost of PET alone would be greater than the combined approach after the 6th year of elimination program[1],[2]