Pilot programme review of human rabies prevention services in a rural district of South Africa

Abstract

Background: The high burden of infectious diseases in South Arica meansdistrict clinic staff must be familiar with, and treat, many different diseases including HIV, TB and malaria. Rabies is relatively less common, but if not prevented will be fatal. There were126 laboratory confirmed human rabies cases in South Africa between 2001 and 2010. Rabies deaths may be underestimated due to lack of awareness, limited access to, or incorrect use of post exposure prophylaxis (PEP), and diagnostic limitations. This study evaluated the human rabies prevention service in a rural district of South Africa with an estimated population of nearly one million citizens. This project was carried out as part of the work of National Institute for CommunicableDisease onbehalf of Provincial and District Departments of Health. Methods & Materials: Structured interviews were conducted with 12 staff at local facilities (6 clinic sisters, 2 doctors and2nurses in emergency departments, 2 hospital pharmacists). Where necessary, education on rabies prevention was given following the interview.A discussion groupwith local communicable disease coordinators and state veterinary services was held. The availability of policy guidance and quality of documentation was reviewed. Results: Staff knew most components of the rabies exposure risk assessment, but had limited understanding of its purpose and application, notably the categorisation of wounds. Most wound management stepswere being performed, but further improvement was possible. Decisions to give rabies immunoglobulin (RIG) were being made incorrectly, raising the likelyhood of RIG being given or withheld inappropriatley. Availability of guidelines and maintenance of bite registers was poor. There were challenges with PEP supply and cold chainmanagement. Staff believed limited training, drug shortages and communication challanges between stakeholders hampered service improvement. Conclusion: Rabies is a health concern in this community. The recommendations for service improvement following the evaluation are being taken forward at a local level. The tools developed by this pilot can be used in other districts to assess human rabies prevention services. Whilst many of the challenges for the service were already known to individual staff, having independent evaluation, bringing together all stakeholders, allowed these challenges to be openly acknowledged, and solutions discussed in a systems improvement context.