A 100 Years of Rabies in Kenya A Rabies-FREE Kenya by 2030

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1 A 100 Years of Rabies in Kenya A Rabies-FREE Kenya by 2030 Thumbi Mwangi 1,2, Bitek A 3, Nanyingi M 4, Rees Muriithi 3, PM Kitala 4, MK Njenga 1, 2 et al 1 Paul G. Allen School for Global Animal Health, Washington State University 2 Center for Global Health Research, Kenya Medical Research Institute 3 Directorate of Veterinary Services, MOALF, Kenya 4 Department of Public Health, Pharmacology and Toxicology, University of Nairobi, Kenya 50th Annual Scientific Conference, Three Steers Meru, 27th 30TH April 2016 Rabies-free Kenya 1 / 27

2 talk outline 1 The 100-Year History of Rabies in Kenya 2 How and Why we can and will Kick Rabies out of Kenya

3 ancient rabies Evidence of rabies in Kenya during the pre-colonial times Inhabitants of South Nyanza referred to the disease in dogs and jackals as Swao 1 Hudson JR (1944) A short history of rabies in Kenya EA Med J 21:

4 period Official Veterinary reports (1909, 1912) show rabies was not diagnosed in Kenya from First record of a confirmed rabies case in 1912 In a dog attacked and bitten by a jackal Location: Nairobi Confirmation: Negri bodies in its brain and through experimental inoculation Image from the Colonel Robert John Stordy, Chief Veterinary Officer Similar cases followed rapidly in Nairobi and Kiambu Anon (1909, 1912) Annual Report. Veterinary Department Ministry of Agriculture, Kenya

5 Spatial spread: period Outbreak lasted until 1916 Cases confined to Nairobi and Kiambu areas 4 At Fort Smith, Nairobi ( ) and At Kabete (1916) Diagnostics: rabbits inoculated with material from the infected animals No record of human rabies case yet! Kariuki D.P and Ngulo W.K (1983) Epidemiology of Animal Rabies in Kenya ( ) in book E. Kuwert et al Rabies in the Tropics, Springer-Verlag

6 Spatial spread: period First human case a woman in South Nyanza - died a month after dog bite Disease in dogs spreads to Laikipia and Wajir (1928), Wajir and Mandera in Jackals (1929)

7 Spatial spread: period Outbreak in started in Kisumu and South Nyanza spread north-east, by 1950 all districts in Western Kenya had experienced rabies Up to except for a few isolated cases in Wajir, Mandela, Laikipia and Kitui - most cases were in Western Kenya/West of Rift Valley Disease Control <1950: Vaccine from Pasteur Institute Algiers, and destruction of stray dogs

8 Spatial spread: period : Disease persists in Western Kenya, and new outbreaks occur east of the Rift Valley, in Central Province (1957), further spreading to Isiolo and Kitui districts ( ) : First use of locally produced vaccine - passaged through embryonated eggs

9 Spatial spread: period : Adoption of a policy on compulsory annual vaccinations (ear tattooing for vaccinated dogs), baiting and shooting of strays after vaccinations, house to house searches and owners of unvaccinated dogs prosecuted and dogs vaccinated By rabies was virtually eliminated in Kenya - except for isolated cases in a few districts and a persistent foci of infection in Machakos and Kitui where a sylvatic cycle of rabies disease was postulated.

10 Temporal pattern of rabies cases: period End of outbreak in Taveta, spread to the coastal strip including Mombasa Island by a major in incursion in Trans Mara close to Tanzania border - spread northwards to South Nyanza. Same year - yet another outbreak beginning in Bungoma district - near Uganda border.

11 Spatial spread: period Early 80 s: Economic, social and political changes drastically affected disease control programmes negatively, including in neighbouring countries. Additionally, implementation of the Structural Adjustment Policies that converted veterinary services from a public good to the private sector.

12 Spatial spread: period To-date rabies is endemic in all counties in Kenya The magnitude of the disease is masked by the poor surveillance system for rabies disease

13 Samples submitted and results ( ) Species No. samples submitted Number positive % positive Domestic Canine 4,466 2, Feline Bovine 1, Ovine/Caprine Equine Porcine Sub-total 6,919 3, Wildlife Canine Mongoose Honey Badger Feline Others Sub-total Human TOTAL 7,478 4,

14 Rabies burden by county Machakos, Makueni and Nairobi cumulatively had the highest burden ***These data only as good as the surveillance/sample submission

15 Temporal pattern by animals affected: period Pattern of human cases follow those of domestic animals Following the large outbreak in the 80 s, rabies cases have remained higher than observed in the 70 s.

16 Temporal pattern by animals affected: period Most rabies cases recorded have been in dogs - followed by cattle Wildlife cases have been reported - but these have remained low in numbers

17 What new things have we learnt about Rabies Disease and its Control/elimination? 1953: Adoption of a policy on compulsory annual vaccinations (ear tattooing for vaccinated dogs), baiting and shooting of strays after vaccinations, house to house searches and owners of unvaccinated dogs prosecuted and dogs vaccinated

18 a) Compulsory annual vaccinations for all dogs? R 0 =2 No. of secondary cases from infected individual in a susceptible population 2 secondary infec.ons Vaccinated animals What proportion of the susceptible dog population should be vaccinated to achieve elimination? % of the dog population Vaccination can break the cycle of transmission Three consecutive years

19 The good news is R 0 for rabies is VERY low ~ On average each rabid dog infects 1.2 others Low value of R 0 suggests that elimination should be feasible 5 5 Hampson et al 2009 PLoS Biol 7:e53

20 R 0 for rabies is lower than for other diseases that have been eliminated and eradicated Smallpox R 0 = 3-5 Polio R 0 = 5-7 Rinderpest R 0 = ~5 Measles R 0 = Based on Rabies R0 - critical vaccination threshold between 20-40% Rabies R 0 =1-2 P crit =1- (1/R 0 ) High dog turn-over (births and deaths) - increase threshold to 70%

21 b) Baiting and shooting of strays? Destruction of stray dogs is NOT an effective strategy! Majority of stray dogs are owned a, b Dog density does not strongly influence rabies transmission c Dog ecology is mediated by humans Easy to cull dogs are the easy to vaccinate a Gsell et al, 2013 b Kaare et al 2009 c Hampson et al 2009 PLoS Biol 7:e53

22 Strategy for the Elimination of Human-Rabies in Kenya 1 Mass dog vaccinations (70% coverage for 3 years consecutively) 2 Provision of PreP and PEP for bite victims 3 Public education and awareness on rabies prevention and control 4 Enhanced surveillance for rabies cases in animals and humans

23 Zone A: Pilot districts: Western Kenya - (Kisumu, Siaya) Eastern Kenya (Machakos, Makueni, Kitui) Zone B close proximity to pilot areas Rest of the country

24 Where are we at? Timelines Stages in the Rabies progressive control pathway STAGE 5 -Maintain freedom-from-rabies status in humans and dogs STAGE 4 -Maintain freedom from dog-mediated human rabies - Elimination of dog rabies STAGE 3 Rabies risk reduction through full-scale implementation of the control strategy STAGE 2 - Implementation of the National Rabies control strategy in pilot districts STAGE 1 - Development and adoption of the National Rabies control strategy - Preparation for its implementation STAGE 0 - Rabies suspected to be present - Scanty information available

25 Where are we at? Kenya at Stage 1: National Rabies Control Strategy developed and adopted in 2014 Makueni in Stage 2: Implementation of the Strategy in the pilot counties (working with World Animal Protection) Dog census (estimated 120,000 dogs) Mass dog vaccinations Rabies education and awareness campaigns

26 Where are we at (funding)? Zoonotic Disease unit in advanced talks with Sanofi Pasteur to start enhanced surveillance for rabies in humans in Makueni Health-facility surveillance for animal bites (creation of Animal Bite Centers) Contact-tracing/case-finding in the communities Toll-free numbers to enhance reporting of animal bites and adherence to PEP Wellcome Trust 3-year funding for Rabies Elimination Implementation Research EU parliament funding to the DVS through the OIE for implementation of Stage 1 and 2 of the Rabies Elimination Strategy (Siaya and Makueni Counties) Sustainable funding for rabies elimination implementation will likely remain from within (County funds, private sector companies and philanthropists)

27 TOWARDS A RABIES-FREE KENYA Vaccinate your dog, Save lives!

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