Abstract
An effective surveillance system is critical for the elimination of canine rabies in Latin America. Brazil has made substantial progress towards canine rabies elimination, but outbreaks still occurred in the last decade in two states. Brazil uses a health information system (SINAN) to record patients seeking post-exposure prophylaxis (PEP) following contact with an animal suspected of having rabies. This study evaluated: (i) whether SINAN can be reliably used for rabies surveillance; (ii) if patients in Brazil are receiving appropriate PEP and (iii) the benefits of implementing the latest World Health Organization (WHO) recommendations on PEP. Analysing SINAN records from 2008 to 2017 reveals an average of 506,148 bite-injury patients/year [range: 437k-545k] in the country, equivalent to an incidence of 255 bite-injuries/100,000 people/year [range: 231–280]. The number of reports of bites from suspect rabid dogs generally increased over time. In most states, records from SINAN indicating a suspect rabid dog do not correlate with confirmed dog rabies cases reported to the Regional Information System for Epidemiological Surveillance of Rabies (SIRVERA) maintained by the Pan American Health Organization (PAHO). Analyses showed that in 2017, only 45% of patients received appropriate PEP as indicated by the Brazilian Ministry of Health guidance. Implementation of the latest WHO guidance using an abridged intradermal post-exposure vaccination regimen including one precautionary dose for dog bites prior to observation would reduce the volume of vaccine required by up to 64%, with potential for annual savings of over USD 6 million from reduced vaccine use. Our results highlight the need to improve the implementation of SINAN, including training of health workers responsible for delivering PEP using an Integrated Bite Case Management approach so that SINAN can serve as a reliable surveillance tool for canine rabies elimination.
Highlights
Dog-mediated rabies in humans has been reduced by over 99% in Latin America, but 106 cases in dogs were still reported in 2014 [1]
These data suggest that health workers report dog rabies in many states where the disease is likely to be absent, with false positive cases frequently reported into the surveillance system
We estimated that Brazil could save up to USD 6 million per annum on vaccine by reducing the number of doses administered during prophylaxis and adopting the intradermal vaccine delivery technique following the latest World Health Organization (WHO) recommendations
Summary
Dog-mediated rabies in humans has been reduced by over 99% in Latin America, but 106 cases in dogs were still reported in 2014 [1]. Dog vaccination and prompt administration of post-exposure prophylaxis (PEP) for bite victims are essential to the successful reduction of human cases of rabies across Latin America [2,3]. Control of rabies in dogs is expected to reduce bites by rabid dogs but not necessarily bites by healthy dogs for which patients do not require PEP. Unnecessary and indiscriminate use of PEP strains local and national healthcare budgets, and is a missed opportunity for improving the detection of rabies cases [5,6]
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