Integrating human rabies vaccines into routine immunization services in Tanzania: A participatory systems mapping study

Abstract Study aim: Human rabies is 100% preventable with post-exposure prophylaxis (PEP) administered immediately after exposure to a rabid animal. In low-income countries, access to PEP is hampered by challenges, including frequent vaccine stockouts, limited facilities providing PEP, weak referral systems with inadequate involvement of animal health workers, and unaffordable costs to bite victims. The WHO and Gavi recommends integrating PEP into routine immunization services to improve access; however, the integration process has yet to be operationalized. We aimed to understand how interest-holders in Tanzania view the feasibility of integrating PEP into routine immunization services. Methods: We employed a participatory, systems-thinking, process mapping approach to examine the expectations of interest-holders on feasibility of integrating PEP into routine immunization services in Tanzania. We (i) undertook a desk review and expert consultation (n = 15) to map interest-holders from local to national levels across both services; (ii) conducted in-depth interviews with national-level actors (n = 6) and implementers (n = 22) from involved sectors and with community members (n = 4); (iii) analyzed resulting data using content analysis and mapped out processes for provision of PEP and routine immunization services; and (iv) organized a 2-day multisectoral co-creation workshop with interest-holders to refine and validate these maps. Finally, we assessed expectations of this integrated design using a consolidated framework we developed from three WHO guides on integrating immunization services. Main findings: Our process mapping approach revealed uncertainty and differing interpretations among interest-holders regarding the meaning of integration of PEP into routine immunization services. However, our facilitated workshop supported engaged dialogue that led to a consensus. Interest-holders considered integration to be feasible, given adequate support among health decision makers, infrastructure (vaccine management systems) and human resource skills. However, interest-holders also articulated anticipated barriers to integration, including (i) potential vaccine waste due to the lack of a resourced and operationalized One Health system for rabies risk assessments; (ii) high staff turnover that could precipitate substandard service provision; (iii) an absence of linked data systems for rabies cases and PEP utilization to inform demand forecasts; and (iv) routine immunization units working only limited days and hours, requiring staff redeployment and workflow redesign for emergency PEP provision. Principal Conclusions: Our results demonstrated enthusiasm for integrating PEP provision into routine immunization services in Tanzania to improve access to PEP through an operationalized One Health approach. Our co-creation process enhanced the possibility of integration by facilitating multisectoral problem identification and problem solving to address intervention uncertainties and complexities. We identified an important need to develop and employ integration guidance, protocols and roadmaps to systematically and comprehensively ensure readiness of the routine immunization systems to accommodate PEP provision. One Health impact statement Human rabies transmitted from domestic dogs is virtually 100% preventable with timely vaccination following exposure, yet access in Tanzania and similar settings is limited by vaccine availability, few facilities, weak referral systems, and high costs. WHO recommends integrating rabies post-exposure vaccine provisioning into routine immunization services, but how to do this remains unclear.Using participatory systems-thinking (process mapping), we brought together animal, human and environmental health sectors, and local government interest-holders, including community members, to analyse current post-exposure vaccine and routine immunization systems. Initially divergent understandings of “integration” gave way to consensus through facilitated co-production. Participants considered integration feasible, but identified multiple One Health challenges including a lack of: procedures for risk assessments, integrated information systems, as well as operational service differences. Sustained multisectoral, participatory engagement, together with integration guidance and roadmaps was identified as being essential to realize improved integrated services.