Optimising human rabies vaccine supply chains: A modelling study.

BACKGROUND: Rabies causes thousands of deaths annually in low- and middle-income countries. Despite effective vaccines for post-exposure prophylaxis (PEP), their expense, coupled with supply chain failures, leads to stockouts and preventable deaths. Investment by Gavi, the Vaccine Alliance, aims to improve access to post-exposure vaccines. We evaluate PEP demand in Tanzania and Kenya and examine stock management strategies for improving supply chains in Gavi-eligible countries. METHODS: We fitted negative binomial distributions to five years of bite patient data from Tanzania (6646 patients, 20 districts) and Kenya (199,112 patients, 47 counties) to parameterise simulations of post-exposure vaccine demand under WHO-recommended intramuscular (IM) and intradermal (ID) regimens. We compared simulated vaccine use, stockouts, and the impact of stock management strategies across the observed range in demand. RESULTS: Bite patient incidence varied dramatically; demand surges far exceeded monthly averages (in 6 % of months exceeding 3× average monthly bite patient presentations) and were most extreme in low-incidence settings. ID vaccination reduces vial use by >55 % and reduces stockout risk. Under ID vaccination vial savings are greatest in high-throughput settings, whilst risk mitigation is maximised in low-throughput settings. Decentralizing PEP to more facilities improves access, though reduces vial-sharing opportunities and so increases vial use. Resilient supply chain strategies were identified according to patient throughput, allowing for adaptation to changing demand. CONCLUSIONS: ID vaccination reduces vial use and stockouts, even in low-throughput settings. Tailoring stock management-through adjusted alert thresholds and restocking volumes-can simplify the integration of rabies vaccines into essential immunisation supply chains, improving their availability and preventing unnecessary deaths. However, logistical trade-offs must also be considered.