On the path to rabies elimination: The need for risk assessments to improve administration of post-exposure prophylaxis

K Rysava,M.E Miranda,R Zapatos,S Lapiz,P Rances,L.M Miranda,M.C Roces,J Friar,S.E Townsend,K Hampson

doi:10.1016/j.vaccine.2018.11.066

K Rysava, M.E Miranda + Show 8 more

Open Access

https://doi.org/10.1016/j.vaccine.2018.11.066

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Abstract

BackgroundCosts of rabies post-exposure prophylaxis (PEP) often remain high in regions where rabies has been controlled in dogs, presenting a challenge for sustaining rabies elimination programmes. We investigated the potential for bite patient risk assessments to improve PEP provision and surveillance in settings approaching elimination of dog-mediated rabies. MethodsWe conducted a longitudinal study of patients presenting to animal bite treatment centres (ABTCs) on the island province of Bohol in the Philippines to investigate the health status of biting dogs and to quantify current expenditure on PEP. ResultsIncidence of bite patients presenting to ABTCs was high (>300/100,000 persons/year) and increasing, resulting in substantial health provider costs. Over $142,000 was spent on PEP in 2013 for a population of 1.3 million. From follow up of 3820 bite patients we found that >92% were bitten by healthy dogs (alive 14 days after the bite) and just 1.4% were bitten by probable or confirmed rabid dogs. The status of dogs that bit 6% of patients could not be determined. During the course of investigations of bites by suspect dogs, we were able to obtain samples for case confirmation, identify exposed persons who had not sought PEP as well as in-contact dogs at risk of developing rabies. We calculate that expenditure on PEP could at least be halved through more judicious approaches to provision of PEP, based on the histories of biting animals determined through risk assessments with bite patients. ConclusionsWe conclude that a One Health approach to surveillance based on Integrated Bite Case Management could improve the sustainability and effectiveness of rabies elimination programmes while also improving patient care by identifying those genuinely in need of lifesaving PEP.

Highlights

Rabies post-exposure prophylaxis (PEP) is required to prevent the fatal onset of disease in the event of a rabies exposure
PEP provision: At the start of the study PEP was available from eight centres in Bohol: five Animal Bite Treatment Centres (ABTCs) and three ABCs (Fig. 1)
At least 2 ABTCs were completely destroyed, and for the final 3 months of the study until the beginning of 2014 bite patients were instead referred to the ABTC in the provincial capital

Summary

Introduction

Rabies post-exposure prophylaxis (PEP) is required to prevent the fatal onset of disease in the event of a rabies exposure. An important premise of controlling and eliminating rabies at source through mass dog vaccination is that the public health sector will benefit through reduced rabies risk and reduced expenditure on PEP [3]. This requires sensitive surveillance for decisions to be made about whether PEP is necessary, leading to appropriate and cost-effective PEP recommendations. Conclusions: We conclude that a One Health approach to surveillance based on Integrated Bite Case Management could improve the sustainability and effectiveness of rabies elimination programmes while improving patient care by identifying those genuinely in need of lifesaving PEP.

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