Comparative effectiveness and cost-effectiveness of policies for provisioning rabies post-exposure vaccines

The burden of rabies remains high in low-income countries, where limited access to life-saving post-exposure prophylaxis (PEP) leads to preventable deaths. Lack of evidence on the implications of PEP provisioning strategies impedes policy development. We evaluate three PEP strategies under consideration in Tanzania, comparing current limited access, improved access with free provision, and free provision combined with Integrated Bite Case Management (IBCM).

We examined data from IBCM implementation on PEP delivery practices, healthcare-seeking, and rabies risk across four Tanzanian regions. Using these data within a decision tree model, we evaluate health outcomes and economic impacts of proposed PEP policies from the healthcare provider perspective, projecting vaccine requirements, costs, and deaths across Tanzania over a five-year period (2026-2030).

We project approximately 59,000 (95 % PI: 32,000-96,000) rabies exposures nationwide over five years. With this exposure risk, current PEP access leads to around 800 deaths annually (95 % PI: 400-1200). Improved PEP access increases patients starting PEP, driving vaccine requirements to around 24,000 (95 % CI: 14,000-34,000) vials per year and reducing deaths by >40 %. Introducing IBCM reduces total projected deaths over 2026-2030 from 2300 to 2000 while remaining highly cost-effective at $181 per death averted.

Tanzania's current PEP practice fails to meet the demand for rabies prevention, leading to preventable deaths. Free PEP is a more effective alternative, and implementing IBCM would further strengthen the country's rabies response and accelerate progress toward the target to end human rabies deaths by 2030.