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Prompt provision of post-exposure-prophylaxis (PEP) including vaccines and rabies immunoglobulin (RIG) to persons bitten by suspect rabid dogs is a key strategy to eliminating human deaths from dog-mediated rabies in Kenya by 2030. We assessed the availability, forecasting and supply chain logistics for rabies PEP in Kenya, compared with the system used for vaccines in the expanded program of immunization (routine vaccines). Semi-structured questionnaires capturing data on forecasting, procurement, distribution, cold chain and storage, monitoring and reporting for routine vaccines and rabies vaccines and RIG were administered to 35 key personnel at the national, county, sub-county and health facility levels in five counties. Results showed large variability in PEP availability (stockouts ranged from 3 to 36 weeks per year) with counties implementing rabies elimination activities having shorter stockouts. PEP is administered intramuscularly using the 5-dose Essen regimen (day 0, 3, 7, 14 and 28). PEP costs to bite patients were reported to range from 10 to 15 US dollars per dose; RIG was seldom available. A less robust supply and logistics infrastructure is used for rabies PEP compared to routine vaccines. Forecasting and monitoring mechanisms for rabies PEP was poor in the study counties. The supply of vaccines from the national to the sub-national level is mainly through two government agencies and a private agency. Since government decentralization, the National Vaccine and Immunization Program has remained as the main supplier of the routine vaccines, playing a lesser role in the supply of rabies biologicals. Adoption of the dose-saving intradermal route for PEP administration, reduction of PEP costs to patients, and placing rabies vaccines within the routine vaccines supply and logistics system would significantly improve PEP availability and accessibility to persons at risk of rabies; a critical step to achieving elimination of human deaths from rabies.

Background: Domestic dogs transmit 99% of the estimated 59,000 human rabies deaths occurring globally annually. To achieve the global target of zero human deaths from rabies by 2030, effective mass dog vaccination campaigns that break rabies transmission cycles in dog populations are required. This study describes the design of a dog health and demographic surveillance study established within a human health and demographic surveillance study in Western Kenya. Using baseline data from the dog cohort study, we quantify demographic parameters and describe management practices relevant for rabies transmission. Methods: All dogs in 1213 households participating in a linked human and animal health syndromic surveillance study were recruited. Data on household demographics, dog ownership, dog age and sex ratios, reproductive indices, rabies vaccination, management practices, dog movement and health status were collected at least monthly. Results: 460 of 1213 (38%) of the study households owned dogs (mean 2 dogs/household), and 526 (70%) of those without dogs had owned dogs previously. 802 dogs were recruited into the study, more than half (52%) of those with known ages were ≤ 1 year old. The dog:human ratio in the study population was 1:7, the dog density 54 dogs/km2, and the female: male dog sex ratio was 1:1.3. Rabies vaccination was low (5% coverage), and only 48 (12%) male dogs and 13 (5%) female dogs were castrated and spayed, respectively. Dogs were predominantly local breed (99%), mainly kept for security purposes, almost always (97%) left to scavenge for leftovers and 61% roamed freely. Conclusion: Low vaccination coverage, unrestricted dog movement, and high dog population turnover with a large proportion of dogs below one-year-old support endemic rabies circulation in this population. These gaps present opportunities for the design of effective dog rabies control plans to break rabies transmission cycles in this part of Kenya.

Genomic surveillance is an important aspect of contemporary disease management but has yet to be used routinely to monitor endemic disease transmission and control in low- and middle-income countries. Rabies is an almost invariably fatal viral disease that causes a large public health and economic burden in Asia and Africa, despite being entirely vaccine preventable. With policy efforts now directed towards achieving a global goal of zero dog-mediated human rabies deaths by 2030, establishing effective surveillance tools is critical. Genomic data can provide important and unique insights into rabies spread and persistence that can direct control efforts. However, capacity for genomic research in low- and middle-income countries is held back by limited laboratory infrastructure, cost, supply chains and other logistical challenges. Here we present and validate an end-to-end workflow to facilitate affordable whole genome sequencing for rabies surveillance utilising nanopore technology. We used this workflow in Kenya, Tanzania and the Philippines to generate rabies virus genomes in two to three days, reducing costs to approximately £60 per genome. This is over half the cost of metagenomic sequencing previously conducted for Tanzanian samples, which involved exporting samples to the UK and a three- to six-month lag time. Ongoing optimization of workflows are likely to reduce these costs further. We also present tools to support routine whole genome sequencing and interpretation for genomic surveillance. Moreover, combined with training workshops to empower scientists in-country, we show that local sequencing capacity can be readily established and sustainable, negating the common misperception that cutting-edge genomic research can only be conducted in high resource laboratories. More generally, we argue that the capacity to harness genomic data is a game-changer for endemic disease surveillance and should precipitate a new wave of researchers from low- and middle-income countries.

Rabies kills tens of thousands of people every year despite being entirely vaccine preventable. Key global health actors have launched a country-driven plan to achieve zero human deaths from dog-mediated rabies by 2030 worldwide. This partnership has recently been strengthened by Gavi, the Vaccine Alliance's decision to invest in human rabies vaccines for post-exposure prophylaxis (PEP). While nation states are key to rabies elimination, the importance of Gavi's role cannot be understated. Unlike any other actor, Gavi can directly address an otherwise intractable market failure in the inadequate supply of rabies PEP. In this commentary, we employ the Capabilities Approach to identify the barriers to PEP access that lead to this market failure and, as a result, unnecessary deaths and suffering. We show the role that Gavi can play in reducing exposure of PEP supply to market forces as a matter of social justice, and hence redress the inequity underlying human rabies deaths.