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Swedberg C, Miranda MEG, Bautista C, Anderson D, Basa-Tulio M, Chng NR, Cruz VDD, Kundegorski M, Maestro J, Manalo D, Maniszewska K, Manzanilla DR, Mazeri S, Mellanby RJ, Pablo-Abarquez S, Quiambao B, Telmo SVM, Trotter C, Yuson M, Hampson K. Using Integrated Bite Case Management to estimate the burden of rabies and evaluate surveillance in Oriental Mindoro, Philippines. ONE HEALTH & IMPLEMENTATION RESEARCH 2023; 3:77-96. [PMID: 37841079 PMCID: PMC7615207 DOI: 10.20517/ohir.2023.02] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Figures] [Subscribe] [Scholar Register] [Indexed: 10/17/2023]
Abstract
Background Despite national elimination efforts, dog-mediated rabies remains endemic in the Philippines. Free provision of post-exposure prophylaxis (PEP) through the widespread establishment of Animal Bite Treatment Centers (ABTCs) has improved accessibility; however, the resulting upsurge in PEP demand is not sustainable, and human rabies deaths continue. Dog vaccination coverage also remains inadequate, and it is unclear whether surveillance is effective. Methods Here, we used Integrated Bite Case Management (IBCM) to collect enhanced rabies surveillance data in Oriental Mindoro Province over a 3-year period (2020-2022). Adapting a probabilistic decision tree model, we estimated the burden of rabies, evaluated surveillance performance, and analyzed the costs and benefits of current rabies prevention and control practices in the province. Results The incidence of bite patients receiving PEP was high in Oriental Mindoro Province (1,246/100,000 persons/year), though < 3% of presenting patients were deemed high-risk for rabies exposure (24/100,000 persons/year). Using a decision tree model, we estimated that around 73.8% of probable rabies-exposed patients sought PEP (95% Prediction Interval, PrI: 59.4%-81.1%) and that routine surveillance confirmed < 2% of circulating animal rabies cases, whereas IBCM resulted in a nearly fourfold increase in case detection. Furthermore, we estimated that an average of 560 (95% PrI 217-1,090) dogs may develop rabies annually in the province, equating to 3-5 cases per 1,000 dogs per year. On average, 20 to 43 human deaths were averted by PEP each year in Oriental Mindoro at an annual cost of $582,110 USD (i.e., $51.44 USD per person) or $20,190 USD (95% PrI $11,565-79,400) per death averted. Conclusion While current practices for PEP provisioning in the Philippines have improved access, a large proportion of people exposed to rabies (> 26%, 95% PrI 18.8%-40.1%) are still not seeking healthcare. Integrating an intersectoral surveillance system, such as IBCM, into national policy could greatly improve case detection if well implemented, with further benefits extending to guidance for PEP administration, potentially reducing unnecessary expenditure on PEP, and situational awareness to inform control of rabies through mass dog vaccination.
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Affiliation(s)
- Catherine Swedberg
- School of Biodiversity, One Health & Veterinary Medicine, College of Medical, Veterinary & Life Sciences, University of Glasgow, Glasgow G12 8QQ, Scotland, United Kingdom
| | - Mary Elizabeth G. Miranda
- Field Epidemiology Training Program Alumni Foundation, Inc. (FETPAFI), Quezon City 1101, Metro Manila, Philippines
| | - Criselda Bautista
- School of Biodiversity, One Health & Veterinary Medicine, College of Medical, Veterinary & Life Sciences, University of Glasgow, Glasgow G12 8QQ, Scotland, United Kingdom
- Research Institute for Tropical Medicine (RITM), Muntinlupa 1781, Metro Manila, Philippines
| | - David Anderson
- School of Biodiversity, One Health & Veterinary Medicine, College of Medical, Veterinary & Life Sciences, University of Glasgow, Glasgow G12 8QQ, Scotland, United Kingdom
| | - Marife Basa-Tulio
- Provincial Health Office, Calapan 5200, Oriental Mindoro, Philippines
| | - Nai Rui Chng
- School of Health and Wellbeing, College of Medical, Veterinary & Life Sciences, University of Glasgow, Glasgow G12 8QQ, Scotland, United Kingdom
| | - Van Denn D. Cruz
- Field Epidemiology Training Program Alumni Foundation, Inc. (FETPAFI), Quezon City 1101, Metro Manila, Philippines
| | - Mikolaj Kundegorski
- School of Biodiversity, One Health & Veterinary Medicine, College of Medical, Veterinary & Life Sciences, University of Glasgow, Glasgow G12 8QQ, Scotland, United Kingdom
| | - Jobin Maestro
- Municipal Health Office, Alcantara 5500, Romblon, Philippines
| | - Daria Manalo
- Research Institute for Tropical Medicine (RITM), Muntinlupa 1781, Metro Manila, Philippines
| | - Klaudyna Maniszewska
- School of Biodiversity, One Health & Veterinary Medicine, College of Medical, Veterinary & Life Sciences, University of Glasgow, Glasgow G12 8QQ, Scotland, United Kingdom
| | - Duane R. Manzanilla
- Field Epidemiology Training Program Alumni Foundation, Inc. (FETPAFI), Quezon City 1101, Metro Manila, Philippines
| | - Stella Mazeri
- Royal (Dick) School of Veterinary Studies and the Roslin Institute, University of Edinburgh, Easter Bush Campus, Midlothian EH25 9RG, Scotland, United Kingdom
| | - Richard J. Mellanby
- Royal (Dick) School of Veterinary Studies and the Roslin Institute, University of Edinburgh, Easter Bush Campus, Midlothian EH25 9RG, Scotland, United Kingdom
| | - Sheryl Pablo-Abarquez
- Field Epidemiology Training Program Alumni Foundation, Inc. (FETPAFI), Quezon City 1101, Metro Manila, Philippines
| | - Beatriz Quiambao
- Research Institute for Tropical Medicine (RITM), Muntinlupa 1781, Metro Manila, Philippines
| | - Shynee Vee M. Telmo
- Department of Agriculture Regional Animal Disease Diagnostic Laboratory (RADDL), Naujan 5204, Oriental Mindoro, Philippines
| | - Caroline Trotter
- Departments of Veterinary Medicine and Pathology, University of Cambridge, Cambridge CB3 0ES, United Kingdom
| | - Mirava Yuson
- School of Biodiversity, One Health & Veterinary Medicine, College of Medical, Veterinary & Life Sciences, University of Glasgow, Glasgow G12 8QQ, Scotland, United Kingdom
- Field Epidemiology Training Program Alumni Foundation, Inc. (FETPAFI), Quezon City 1101, Metro Manila, Philippines
| | - Katie Hampson
- School of Biodiversity, One Health & Veterinary Medicine, College of Medical, Veterinary & Life Sciences, University of Glasgow, Glasgow G12 8QQ, Scotland, United Kingdom
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Bonilla-Aldana DK, Ruiz-Saenz J, Martinez-Gutierrez M, Villamil-Gomez W, Mantilla-Meluk H, Arrieta G, León-Figueroa DA, Benites-Zapata V, Barboza JJ, Muñoz-Del-Carpio-Toia A, Franco OH, Cabrera M, Sah R, Al-Tawfiq JA, Memish ZA, Amer FA, Suárez JA, Henao-Martinez AF, Franco-Paredes C, Zumla A, Rodriguez-Morales AJ. Zero by 2030 and OneHealth: The multidisciplinary challenges of rabies control and elimination. Travel Med Infect Dis 2023; 51:102509. [PMID: 36435448 DOI: 10.1016/j.tmaid.2022.102509] [Citation(s) in RCA: 5] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/20/2022] [Accepted: 11/21/2022] [Indexed: 11/24/2022]
Affiliation(s)
- D Katterine Bonilla-Aldana
- Research Unit, Universidad Continental, Huancayo, Peru; Committee of Tropical Medicine, Zoonoses and Travel Medicine, Asociación Colombiana de Infectología (ACIN), Bogotá, DC, Colombia
| | - Julian Ruiz-Saenz
- Committee of Tropical Medicine, Zoonoses and Travel Medicine, Asociación Colombiana de Infectología (ACIN), Bogotá, DC, Colombia; Grupo de Investigación en Ciencias Animales-GRICA, Universidad Cooperativa de Colombia, Bucaramanga, Colombia
| | - Marlen Martinez-Gutierrez
- Committee of Tropical Medicine, Zoonoses and Travel Medicine, Asociación Colombiana de Infectología (ACIN), Bogotá, DC, Colombia; Grupo de Investigación en Microbiología Veterinaria, Escuela de Microbiología, Universidad de Antioquia, Medellín, Colombia
| | - Wilmer Villamil-Gomez
- Committee of Tropical Medicine, Zoonoses and Travel Medicine, Asociación Colombiana de Infectología (ACIN), Bogotá, DC, Colombia; Secretaría de Salud de Barranquilla, Barranquilla, Atlántico, Colombia
| | - Hugo Mantilla-Meluk
- Colección de Mastozoología y Centro de Estudios de Alta Montaña, Universidad del Quindío, Carrera 15 Calle 12N, Armenia, Quindío, Colombia
| | - German Arrieta
- Committee of Tropical Medicine, Zoonoses and Travel Medicine, Asociación Colombiana de Infectología ACIN, Bogotá, DC, Colombia; Universidad de Córdoba, Instituto de Investigaciones Biológicas del Trópico, Clínica Salud Social Sincelejo, Corporación Universitaria del Caribe: CECAR, Sucre, Colombia
| | - Darwin A León-Figueroa
- Facultad de Medicina Humana, Universidad de San Martín de Porres, Chiclayo, Peru; Unidad de Revisiones Sistemáticas y Meta-Análisis, Tau-Relaped Group, Trujillo, Peru
| | - Vicente Benites-Zapata
- Unidad de Investigación para la Generación y Síntesis de Evidencias en Salud, Universidad San Ignacio de Loyola, Lima, Peru
| | - Joshuan J Barboza
- Vicerrectorado de Investigación, Universidad Norbert Wiener, Lima, Peru
| | | | - Oscar H Franco
- Julius Center for Health Sciences and Primary Care, University Medical Center Utrecht, Utrecht, the Netherlands
| | - Maritza Cabrera
- Centro de Investigación de Estudios Avanzados del Maule CIEAM, Universidad Católica del Maule, Talca, 3480094, Chile; Facultad Ciencias de la Salud, Universidad Católica del Maule, Talca, 3480094, Chile
| | - Ranjit Sah
- Tribhuvan University Teaching Hospital, Institute of Medicine, Kathmandu, Nepal; Research Scholar, Harvard Medical School, Boston, MA, USA; Dr. D.Y Patil Medical College, Hospital and Research Centre, Dr. D.Y. Patil Vidyapeeth, Pune, Maharashtra, India
| | - Jaffar A Al-Tawfiq
- Specialty Internal Medicine and Quality Department, Johns Hopkins Aramco Healthcare, Dhahran, Saudi Arabia; Infectious Diseases Division, Department of Medicine, Indiana University School of Medicine, Indianapolis, IN, USA; Infectious Diseases Division, Department of Medicine, Johns Hopkins University School of Medicine, Baltimore, MD, USA
| | - Ziad A Memish
- Al-Faisal University, Riyadh, Saudi Arabia; King Saud Medical City, Ministry of Health, Riyadh, Saudi Arabia; Hubert Department of Global Health, Rollins School of Public Health, Emory University, Atlanta, GA, USA
| | - Fatma A Amer
- Medical Microbiology and Immunology Department, Faculty of Medicine, Zagazig, Egypt; Chair of Viral Infection Working Group, and Executive Committee Member, International Society for Antimicrobial Chemotherapy VIWG/ISAC, Egypt
| | - José Antonio Suárez
- Instituto Conmemorativo Gorgas de Estudios de la Salud, Investigator 1 of the SNI, Senacyt, Panama City, Panama
| | - Andres F Henao-Martinez
- Division of Infectious Diseases, School of Medicine, University of Colorado Anschutz Medical Campus, 12700 E. 19th Avenue, Mail Stop B168, Aurora, CO, 80045, USA
| | - Carlos Franco-Paredes
- Hospital Infantil de México, Federico Gómez, México City, Mexico; Department of Microbiology, Immunology, and Pathology, Colorado State University, Fort Collins, CO, USA
| | - Alimuddin Zumla
- Division of Infection and Immunity, University College London, London, UK; NIHR Biomedical Research Centre, University College London Hospitals, London, UK
| | - Alfonso J Rodriguez-Morales
- Committee of Tropical Medicine, Zoonoses and Travel Medicine, Asociación Colombiana de Infectología ACIN, Bogotá, DC, Colombia; Gilbert and Rose-Marie Chagoury School of Medicine, Lebanese American University, Beirut, Lebanon; Master of Clinical Epidemiology and Biostatistics, Universidad Científica del Sur, Lima, 4861, Peru; Grupo de Investigación Biomedicina, Faculty of Medicine, Fundación Universitaria Autónoma de las Américas - Institución Universitaria Visión de las Américas, 660003, Pereira, Risaralda, Colombia; Editor-in-Chief, Travel Medicine and Infectious Diseases.
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Swedberg C, Mazeri S, Mellanby RJ, Hampson K, Chng NR. Implementing a One Health Approach to Rabies Surveillance: Lessons From Integrated Bite Case Management. FRONTIERS IN TROPICAL DISEASES 2022; 3:829132. [PMID: 36945698 PMCID: PMC7614337 DOI: 10.3389/fitd.2022.829132] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022] Open
Abstract
As part of the 'Zero by 30' strategy to end human deaths from dog-mediated rabies by 2030, international organizations recommend a One Health framework that includes Integrated Bite Case Management (IBCM). However, little is understood about the implementation of IBCM in practice. This study aims to understand how IBCM is conceptualized, exploring how IBCM has been operationalized in different contexts, as well as barriers and facilitators to implementation. Semi-structured interviews were conducted with seventeen practitioners and researchers with international, national, and local expertise across Africa, Asia, and the Americas. Thematic analysis was undertaken using both inductive and deductive approaches. Four main themes were identified: 1) stakeholders' and practitioners' conceptualization of IBCM and its role in rabies elimination; 2) variation in how IBCM operates across different contexts; 3) barriers and facilitators of IBCM implementation in relation to risk assessment, PEP provisioning, animal investigation, One Health collaboration, and data reporting; and 4) the impact of the COVID-19 pandemic on IBCM programs. This study highlights the diversity within experts' conceptualization of IBCM, and its operationalization. The range of perspectives revealed that there are different ways of organizing IBCM within health systems and it is not a one-size-fits-all approach. The issue of sustainability remains the greatest challenge to implementation. Contextual features of each location influenced the delivery and the potential impact of IBCM. Programs spanned from highly endemic settings with limited access to PEP charged to the patient, to low endemicity settings with a large patient load associated with free PEP policies and sensitization. In practice, IBCM was tailored to meet the demands of the local context and level of rabies control. Thus, experts' experiences did not necessarily translate across contexts, affecting perceptions about the function, motivation for, and implementation of IBCM. To design and implement future and current programs, guidance should be provided for health workers receiving patients on assessing the history and signs of rabies in the biting animal. The study findings provide insights in relation to implementation of IBCM and how it can support programs aiming to reach the Zero by 30 goal.
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Affiliation(s)
- Catherine Swedberg
- Institute of Biodiversity, Animal Health and Comparative Medicine, University of Glasgow, Glasgow, United Kingdom
| | - Stella Mazeri
- Royal (Dick) School of Veterinary Studies and the Roslin Institute, University of Edinburgh, Easter Bush Campus, Roslin, United Kingdom
| | - Richard J. Mellanby
- Royal (Dick) School of Veterinary Studies and the Roslin Institute, University of Edinburgh, Easter Bush Campus, Roslin, United Kingdom
| | - Katie Hampson
- Institute of Biodiversity, Animal Health and Comparative Medicine, University of Glasgow, Glasgow, United Kingdom
| | - Nai Rui Chng
- Institute of Health and Wellbeing, College of Medical, Veterinary and Life Sciences, University of Glasgow, Glasgow, United Kingdom
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da Silva RM, Megid J, Hampson K, Campos AAS, Higashi CS, Medeiros FS, Pereira AS, Benavides JA. Factors Limiting the Appropriate Use of Rabies Post-exposure Prophylaxis by Health Professionals in Brazil. Front Vet Sci 2022; 9:846994. [PMID: 35601400 PMCID: PMC9120864 DOI: 10.3389/fvets.2022.846994] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/31/2021] [Accepted: 03/09/2022] [Indexed: 11/13/2022] Open
Abstract
Post-exposure prophylaxis (PEP) is necessary to prevent the fatal onset of rabies but requires optimization to avoid overuse in populations at risk of rabies. In Brazil, the incidence of dog bites remains high, with almost half of dog-bite patients not receiving the PEP recommended by the Ministry of Health guidelines between 2008 and 2017. In this study, we aimed to identify the factors that limit the appropriate prescribing of PEP by interviewing health professionals responsible for PEP administration and completion of the ‘Information System on Diseases of Compulsory Declaration’ (SINAN) form reporting human anti-rabies care for patients seeking health care after a dog bite. We conducted 147 questionnaires (45 questions each) in three Brazilian states (i.e., Rio Grande do Sul, Santa Catarina, Rio Grande do Norte) including questions related to the criteria used by professionals to classify a dog as “suspect” or “rabid”, knowledge on PEP prescription guidelines, SINAN and communication with veterinarians. Our analyses showed that most health professionals delivering PEP in these three states struggle to identify a rabies “suspect” dog according to the Ministry of Health guidelines, and to indicate the adequate PEP regimen, with only 11% of professionals prescribing the appropriate PEP under various dog-bite patient scenarios. PEP knowledge score was higher among professionals trained on PEP guidelines and working in facilities with the highest incidence of dog bites. In contrast, PEP knowledge scores did not vary significantly between states, and were not correlated to the professional's level of experience, the number of colleagues available at the health unit or the professional's confidence on prescribing appropriate PEP. Our results suggest that knowledge gaps in PEP administration among health professionals of Brazil can be reduced by implementing training programs to differentiate among rabies risk scenarios, prescribe the corresponding appropriate PEP and improve communication between health and veterinary authorities.
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Affiliation(s)
- Ramiro M. da Silva
- Department of Veterinary Hygiene and Public Health, São Paulo State University, Botucatu, Brazil
| | - Jane Megid
- Department of Veterinary Hygiene and Public Health, São Paulo State University, Botucatu, Brazil
| | - Katie Hampson
- Institute of Biodiversity, Animal Health and Comparative Medicine, College of Medical, Veterinary and Life Sciences, University of Glasgow, Glasgow, United Kingdom
| | - Aline Alves Scarpellini Campos
- Programa Estadual de Controle e Profilaxia da Raiva, State Department of Health of Rio Grande do Sul, Porto Alegre, Brazil
| | - Cintia S. Higashi
- Coordenação de Promoção à Saúde, State Department of Health of Rio Grande do Norte, Natal, Brazil
| | - Fabíola S. Medeiros
- Coordenação de Promoção à Saúde, State Department of Health of Rio Grande do Norte, Natal, Brazil
| | - Alexandra S. Pereira
- Diretoria de Vigilância Epidemiológica, State Department of Health of Santa Catarina, Florianópolis, Brazil
| | - Julio A. Benavides
- Department of Veterinary Hygiene and Public Health, São Paulo State University, Botucatu, Brazil
- Institute of Biodiversity, Animal Health and Comparative Medicine, College of Medical, Veterinary and Life Sciences, University of Glasgow, Glasgow, United Kingdom
- Doctorado en Medicina de la Conservación y Centro de Investigación para la Sustentabilidad, Facultad de Ciencias de la Vida, Universidad Andres Bello, Santiago, Chile
- MIVEGEC, IRD, CNRS, Université de Montpellier, Montpellier, France
- *Correspondence: Julio A. Benavides
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Rysava K, Espineda J, Silo EAV, Carino S, Aringo AM, Bernales RP, Adonay FF, Tildesley MJ, Hampson K. One Health Surveillance for Rabies: A Case Study of Integrated Bite Case Management in Albay Province, Philippines. FRONTIERS IN TROPICAL DISEASES 2022. [DOI: 10.3389/fitd.2022.787524] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022] Open
Abstract
Canine rabies is a significant public health concern and economic burden in the Philippines. Animal Bite Treatment Centers (ABTCs) that provide post-exposure prophylaxis (PEP) to bite patients have been established across the country, but the incidence of bite patient presentations has grown unsustainably, whilst rabies transmission in domestic dogs has not been controlled. Moreover, weak surveillance leads to low case detection and late outbreak responses. Here we investigated the potential for Integrated Bite Case Management (IBCM) to improve rabies detection in Albay province. Using information obtained from animal bite histories combined with phone follow-ups and field investigations, we demonstrated that IBCM resulted in a fourfold increase in case detection over 13 months of study compared to the prior period. Bite patient incidence across Albay was very high (>600/100,000 persons/year) with PEP administered mostly indiscriminately. Clinic attendance reflected availability of PEP and proximity to ABTCs rather than rabies incidence (<3% of patient presentations were from “probable” or confirmed rabies exposures) and is therefore not a suitable indicator of rabies burden. Further analysis of the IBCM data suggests that rabies transmission is mostly localized with focal cases from the previous month and current cases in neighbouring villages being most predictive of future rabies occurrence. We conclude that investigations of suspicious biting incidents identified through IBCM have potential to foster intersectoral relationships, and collaborative investments between public health and veterinary services, enabling the One Health ethos to be applied in a more sustainable and equitable way. Triage of patients and investigations of suspect dogs offer an effective tool for improved PEP provisioning and reduction of unnecessary expenditure, whilst targeted field investigations should lead to increased and earlier detection of rabid dogs. Given the enduring risk of re-introductions from neighbouring populations, enhanced surveillance is critical to achieving and maintaining rabies freedom.
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Chuchu VM, Kitala PM, Bichanga P, Ksee D, Muturi M, Mwatondo A, Nasimiyu C, Maritim M, Mutono N, Beyene TJ, Druelles S, Hampson K, Thumbi SM. Rabies Elimination in Rural Kenya: Need for Improved Availability of Human Vaccines, Awareness and Knowledge on Rabies and Its Management Among Healthcare Workers. Front Public Health 2022; 10:769898. [PMID: 35356016 PMCID: PMC8960031 DOI: 10.3389/fpubh.2022.769898] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/02/2021] [Accepted: 01/31/2022] [Indexed: 12/25/2022] Open
Abstract
BackgroundIn Africa, rabies causes an estimated 24,000 human deaths annually. Mass dog vaccinations coupled with timely post-exposure prophylaxis (PEP) for dog-bite patients are the main interventions to eliminate human rabies deaths. A well-informed healthcare workforce and the availability and accessibility of rabies biologicals at health facilities are critical in reducing rabies deaths. We assessed awareness and knowledge regarding rabies and the management of rabies among healthcare workers, and PEP availability in rural eastern Kenya.MethodologyWe interviewed 73 healthcare workers from 42 healthcare units in 13 wards in Makueni and Kibwezi West sub-counties, Makueni County, Kenya in November 2018. Data on demographics, years of work experience, knowledge of rabies, management of bite and rabies patients, and availability of rabies biologicals were collected and analyzed.ResultsRabies PEP vaccines were available in only 5 (12%) of 42 health facilities. None of the health facilities had rabies immunoglobulins in stock at the time of the study. PEP was primarily administered intramuscularly, with only 11% (n = 8) of the healthcare workers and 17% (7/42) healthcare facilities aware of the dose-sparing intradermal route. Less than a quarter of the healthcare workers were aware of the World Health Organization categorization of bite wounds that guides the use of PEP. Eighteen percent (n = 13) of healthcare workers reported they would administer PEP for category I exposures even though PEP is not recommended for this category of exposure. Only one of six respondents with acute encephalitis consultation considered rabies as a differential diagnosis highlighting the low index of suspicion for rabies.ConclusionThe availability and use of PEP for rabies was sub-optimal. We identified two urgent needs to support rabies elimination programmes: improving availability and access to PEP; and targeted training of the healthcare workers to improve awareness on bite wound management, judicious use of PEP including appropriate risk assessment following bites and the use of the dose-sparing intradermal route in facilities seeing multiple bite patients. Global and domestic funding plan that address these gaps in the human health sector is needed for efficient rabies elimination in Africa.
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Affiliation(s)
- Veronicah Mbaire Chuchu
- Department of Public Health, Pharmacology and Toxicology, University of Nairobi, Nairobi, Kenya
- Center for Global Health Research, Kenya Medical Research Institute, Kisumu, Kenya
- Washington State University Global Health Program, Nairobi, Kenya
| | - Philip Mwanzia Kitala
- Department of Public Health, Pharmacology and Toxicology, University of Nairobi, Nairobi, Kenya
| | - Philet Bichanga
- Government of Makueni County, Department of Health Services, Wote, Kenya
| | - Daniel Ksee
- Government of Makueni County, Department of Agriculture, Irrigation, Livestock, and Fisheries Development, Wote, Kenya
| | - Mathew Muturi
- Zoonotic Disease Unit, Ministry of Health and Ministry of Agriculture, Livestock and Fisheries, Nairobi, Kenya
| | - Athman Mwatondo
- Zoonotic Disease Unit, Ministry of Health and Ministry of Agriculture, Livestock and Fisheries, Nairobi, Kenya
| | - Carolyne Nasimiyu
- Washington State University Global Health Program, Nairobi, Kenya
- Zoonotic Disease Unit, Ministry of Health and Ministry of Agriculture, Livestock and Fisheries, Nairobi, Kenya
| | - Marybeth Maritim
- Department of Clinical Medicine and Therapeutics, University of Nairobi, Nairobi, Kenya
| | - Nyamai Mutono
- Washington State University Global Health Program, Nairobi, Kenya
- Center for Epidemiological and Modelling Analysis, Institute of Tropical and Infectious Diseases, University of Nairobi, Nairobi, Kenya
| | - Tariku J. Beyene
- Center for Health Equity and Outcomes Research, The Research Institute at Nationwide Children's Hospital, Columbus, OH, United States
| | - Sophie Druelles
- Vaccine Epidemiology and Modeling, Sanofi Pasteur, Lyon, France
| | - Katie Hampson
- Institute of Biodiversity, Animal Health & Comparative Medicine, University of Glasgow, Glasgow, United Kingdom
| | - S. M. Thumbi
- Center for Global Health Research, Kenya Medical Research Institute, Kisumu, Kenya
- Center for Epidemiological and Modelling Analysis, Institute of Tropical and Infectious Diseases, University of Nairobi, Nairobi, Kenya
- Institute of Immunology and Infection Research, School of Biological Sciences, University of Edinburgh, Edinburgh, United Kingdom
- NIHR Global Health Research Unit Tackling Infections to Benefit Africa (TIBA), The University of Edinburgh, Edinburgh, United Kingdom
- Paul G Allen School for Global Health, Washington State University, Pullman, WA, United States
- *Correspondence: S. M. Thumbi
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Li Y, Rainey JJ, Yang H, Tran CH, Huai Y, Liu R, Zhu H, Wang Z, Mu D, Yin W, Guo C, Shiferaw M, Chen Q, Hu S, Li Z. Assessing clinicians' Post-Exposure Prophylaxis recommendations for rabies virus exposures in Hunan Province, China. PLoS Negl Trop Dis 2021; 15:e0009564. [PMID: 34228714 PMCID: PMC8284641 DOI: 10.1371/journal.pntd.0009564] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/10/2020] [Revised: 07/16/2021] [Accepted: 06/14/2021] [Indexed: 11/05/2022] Open
Abstract
Background Timely and appropriate administration of post-exposure prophylaxis (PEP) is an essential component of human rabies prevention programs. We evaluated patient care at rabies clinics in a high-risk county in Hunan Province, China to inform strategies needed to achieve dog-mediated human rabies elimination by 2030. Methods We collected information on PEP, staff capacity, and service availability at the 17 rabies clinics in the high-risk county during onsite visits and key staff interviews. Additionally, we conducted observational assessments at five of these clinics, identified through purposive sampling to capture real-time information on patient care during a four-week period. Wound categories assigned by trained observers were considered accurate per national guidelines for comparison purposes. We used the kappa statistic and an alpha level of 0.05 to assess agreement between observers and clinic staff. Results In 2015, the 17 clinics provided PEP to 5,261 patients. Although rabies vaccines were available at all 17 clinics, rabies immune globulin (RIG) was only available at the single urban clinic in the county. During the assessment period in 2016, 196 patients sought care for possible rabies virus exposures. According to observers, 88 (44%) patients had category III wounds, 104 (53%) had category II wounds and 4 (2%) had category I wounds. Observers and PEP clinic staff agreed on approximately half of the assigned wound categories (kappa = 0.55, p-value< 0.001). Agreement for the urban county-level CDC clinic (kappa = 0.93, p-value<0.001) was higher than for the township clinics (kappa = 0.16, p-value = 0.007). Using observer assigned wound categories, 142 (73%) patients received rabies vaccinations and RIG as outlined in the national guidelines. Conclusion Rabies PEP services were available at each town of the project county; however, gaps between clinical practice and national rabies guidelines on the use of PEP were identified. We used these findings to develop and implement a training to rabies clinic staff on wound categorization, wound care, and appropriate use of PEP. Additional risk-based approaches for evaluating human rabies virus exposures may be needed as China progresses towards elimination. Members of the United Nations agreed on a goal of eliminating dog-mediated rabies by 2030. To achieve this goal, China and other endemic rabies countries will need to increase dog rabies vaccination coverage as well as ensure proper administration of rabies post-exposure prophylaxis (PEP) for patients with animal wounds. PEP includes wound washing, timely vaccination, and rabies immune globulin (RIG) according to the type and severity of patients’ wounds. The authors conducted an observational assessment of PEP clinics in a high-risk county in Hunan Province. Most patients at these clinics received PEP according to the national guidelines; however, certain patients received PEP, when not warranted, and others did not receive RIG, as recommended for severe animal wounds. Wound type categorization and corresponding use of PEP were most accurate at the single urban clinic and least accurate at the rural clinics in the project county. RIG was only available at the single urban clinic. These findings highlight the importance of improving the use of PEP and access to RIG, particularly in rural areas, and exploring the use of risk-based approaches for evaluating human rabies virus exposures. These steps can contribute to eliminating dog-mediated rabies in the project county as well as elsewhere in China.
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Affiliation(s)
- Yu Li
- Division of Infectious Disease, Key Laboratory of Surveillance and Early-Warning on Infectious Disease, Chinese Center for Disease Control and Prevention, Beijing, China
| | - Jeanette J. Rainey
- Division of Global Health Protection, United States Centers for Disease Control and Prevention, Beijing, China
| | - Hao Yang
- Hunan Province Center for Disease Control and Prevention, Changsha, China
| | - Cuc H. Tran
- Division of High Consequence Pathogens and Pathology, United States Centers for Disease Control and Prevention, Atlanta, Georgia, United States of America
| | - Yang Huai
- Division of Global Health Protection, United States Centers for Disease Control and Prevention, Beijing, China
| | - Rongqiang Liu
- Shuangfeng Center for Disease Control and Prevention, Shuangfeng, China
| | - Hongwei Zhu
- Shuangfeng Center for Disease Control and Prevention, Shuangfeng, China
| | - Zhengliang Wang
- Shuangfeng Center for Disease Control and Prevention, Shuangfeng, China
| | - Di Mu
- Division of Infectious Disease, Key Laboratory of Surveillance and Early-Warning on Infectious Disease, Chinese Center for Disease Control and Prevention, Beijing, China
| | - Wenwu Yin
- Division of Infectious Disease, Key Laboratory of Surveillance and Early-Warning on Infectious Disease, Chinese Center for Disease Control and Prevention, Beijing, China
| | - Chun Guo
- School of Public Health, Huazhong University of Science and Technology, Wuhan, China
| | - Miriam Shiferaw
- Division of High Consequence Pathogens and Pathology, United States Centers for Disease Control and Prevention, Atlanta, Georgia, United States of America
| | - Qiulan Chen
- Division of Infectious Disease, Key Laboratory of Surveillance and Early-Warning on Infectious Disease, Chinese Center for Disease Control and Prevention, Beijing, China
- * E-mail: (QC); (SH)
| | - Shixiong Hu
- Hunan Province Center for Disease Control and Prevention, Changsha, China
- * E-mail: (QC); (SH)
| | - Zhongjie Li
- Division of Infectious Disease, Key Laboratory of Surveillance and Early-Warning on Infectious Disease, Chinese Center for Disease Control and Prevention, Beijing, China
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8
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How geographic access to care shapes disease burden: The current impact of post-exposure prophylaxis and potential for expanded access to prevent human rabies deaths in Madagascar. PLoS Negl Trop Dis 2021; 15:e0008821. [PMID: 33901194 PMCID: PMC8102000 DOI: 10.1371/journal.pntd.0008821] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/06/2020] [Revised: 05/06/2021] [Accepted: 02/24/2021] [Indexed: 11/24/2022] Open
Abstract
Background Post-exposure prophylaxis (PEP) is highly effective at preventing human rabies deaths, however access to PEP is limited in many rabies endemic countries. The 2018 decision by Gavi to add human rabies vaccine to its investment portfolio should expand PEP availability and reduce rabies deaths. We explore how geographic access to PEP impacts the rabies burden in Madagascar and the potential benefits of improved provisioning. Methodology & principal findings We use spatially resolved data on numbers of bite patients seeking PEP across Madagascar and estimates of travel times to the closest clinic providing PEP (N = 31) in a Bayesian regression framework to estimate how geographic access predicts reported bite incidence. We find that travel times strongly predict reported bite incidence across the country. Using resulting estimates in an adapted decision tree, we extrapolate rabies deaths and reporting and find that geographic access to PEP shapes burden sub-nationally. We estimate 960 human rabies deaths annually (95% Prediction Intervals (PI): 790–1120), with PEP averting an additional 800 deaths (95% PI: 640–970) each year. Under these assumptions, we find that expanding PEP to one clinic per district (83 additional clinics) could reduce deaths by 19%, but even with all major primary clinics provisioning PEP (1733 additional clinics), we still expect substantial rabies mortality. Our quantitative estimates are most sensitive to assumptions of underlying rabies exposure incidence, but qualitative patterns of the impacts of travel times and expanded PEP access are robust. Conclusions & significance PEP is effective at preventing rabies deaths, and in the absence of strong surveillance, targeting underserved populations may be the most equitable way to provision PEP. Given the potential for countries to use Gavi funding to expand access to PEP in the coming years, this framework could be used as a first step to guide expansion and improve targeting of interventions in similar endemic settings where PEP access is geographically restricted and baseline data on rabies risk is lacking. While better PEP access should save many lives, improved outreach, surveillance, and dog vaccination will be necessary, and if rolled out with Gavi investment, could catalyze progress towards achieving zero rabies deaths. Canine rabies causes an estimated 60,000 deaths each year across the world, primarily in low- and middle-income countries where people have limited access to both human vaccines (post-exposure prophylaxis or PEP) and dog rabies vaccines. Given that we have the tools to prevent rabies deaths, a global target has been set to eliminate deaths due to canine rabies by 2030, and recently, Gavi, a multilateral organization that aims to improve access to vaccines in the poorest countries, added human rabies vaccine to it’s portfolio. In this study, we estimated reported incidence of patients seeking PEP in relation to travel times to clinics provisioning PEP and extrapolate human rabies deaths in Madagascar. We find that PEP currently averts around 800 deaths each year, but that the burden remains high (1000 deaths/year), particularly in remote, hard-to-reach areas. We show that expanding PEP availability to more clinics could significantly reduce rabies deaths in Madagascar, but our results reaffirm that expansion alone is will not achieve the global goal of zero human deaths from dog-mediated rabies by 2030. Combining PEP expansion with outreach, surveillance, and mass dog vaccination programs will be necessary to move Madagascar, and other Low- and Middle-Income countries, forward on the path to rabies elimination.
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9
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Suijkerbuijk AWM, Mangen MJJ, Haverkate MR, Luppino FS, Bantjes SE, Visser LG, Swaan CM, Ruijs WLM, Over EAB. Rabies vaccination strategies in the Netherlands in 2018: a cost evaluation. Euro Surveill 2020; 25:1900716. [PMID: 32975187 PMCID: PMC7533619 DOI: 10.2807/1560-7917.es.2020.25.38.1900716] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/29/2022] Open
Abstract
BackgroundThe risk of contracting rabies is low for travellers. However, the number of Dutch travellers potentially exposed abroad following an animal-associated injury and needing post-exposure prophylaxis (PEP) has increased, resulting in increased costs.AimHere, we evaluated the costs and the cost-effectiveness of different pre- and post-exposure interventions in the Netherlands, taking into account the 2018 World Health Organization (WHO) recommendations for the prevention of rabies.MethodsA decision tree-based economic model was constructed. We calculated and compared the cost of different WHO pre-exposure prophylaxis (PrEP) recommendations, intramuscular vs intradermal vaccination and PEP subsequent to increased vaccination coverage in risk groups. We estimated cost-effectiveness, expressed as incremental costs per rabies immunoglobulin (RIG) administration averted, using a societal perspective. Statistical uncertainty regarding number of travellers and vaccination coverage was assessed.ResultsTotal costs at the national level were highest using previous WHO recommendations from 2012, estimated at EUR 15.4 million annually. Intradermal vaccinations in combination with the current recommendations led to the lowest costs, estimated at EUR 10.3 million. Higher vaccination uptake resulted in higher overall costs. The incremental costs per RIG administration averted varied from EUR 21,300-46,800.ConclusionsThe change in rabies PrEP and PEP recommendations in 2018 reduced total costs. Strategies with increased pre-travel vaccination uptake led to fewer RIG administrations and fewer vaccinations after exposure but also to higher total costs. Although larger scale intradermal administration of rabies vaccine can reduce total costs of PrEP and can positively influence vaccination uptake, it remains a costly intervention.
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Affiliation(s)
- Anita WM Suijkerbuijk
- National Institute for Public Health and the Environment, RIVM, Bilthoven, the Netherlands
| | - Marie-Josee J Mangen
- National Institute for Public Health and the Environment, RIVM, Bilthoven, the Netherlands,These authors contributed equally to this manuscript
| | - Manon R Haverkate
- National Institute for Public Health and the Environment, RIVM, Bilthoven, the Netherlands,These authors contributed equally to this manuscript
| | | | - Sabine E Bantjes
- National Institute for Public Health and the Environment, RIVM, Bilthoven, the Netherlands
| | - Leo G Visser
- Leiden University Medical Center, Leiden, the Netherlands,Department of Infectious Diseases, Leiden University, Leiden, the Netherlands
| | - Corien M Swaan
- National Institute for Public Health and the Environment, RIVM, Bilthoven, the Netherlands
| | - Wilhelmina LM Ruijs
- National Institute for Public Health and the Environment, RIVM, Bilthoven, the Netherlands
| | - Eelco AB Over
- National Institute for Public Health and the Environment, RIVM, Bilthoven, the Netherlands
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10
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Zero human deaths from dog-mediated rabies by 2030: perspectives from quantitative and mathematical modelling. Gates Open Res 2020; 3:1564. [PMID: 32596645 PMCID: PMC7308633 DOI: 10.12688/gatesopenres.13074.2] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 02/24/2020] [Indexed: 11/20/2022] Open
Abstract
Dog-mediated rabies continues to kill tens of thousands of people every year in low- and middle-income countries despite being an entirely vaccine-preventable disease. WHO and partners have launched a global campaign to reach zero human deaths from dog-mediated rabies by 2030. The primary tools for reaching this target are mass dog vaccination to interrupt transmission in domestic dog populations that maintain infection, appropriate post-exposure prophylaxis (PEP) for rabies-exposed persons to prevent the fatal onset of disease, together with education to support their effective uptake. Models have been developed to assess the feasibility, impact and cost-effectiveness of these measures. From these models, we argue that the 2030 target of zero human rabies deaths is achievable, but will require concerted effort, engagement and investment. A proposed Gavi investment in human rabies vaccines has potential to drive progress towards the 2030 target; however, concomitant investment is needed to scale up mass dog vaccination or this target will be missed. Predicted economic benefits of mass dog vaccination vary according to national PEP provisioning and healthcare access. Integrated Bite Case Management can enhance surveillance and rationalize PEP use, but needs adapting to and integrating within local health systems and international reporting systems to improve PEP accountability, monitor impacts and support verification of disease freedom. Modelling approaches need refining to project realistic and geographically specific timelines for achieving targets. Model iterations informed by data on the implementation of interventions can be used to evaluate progress and guide future strategies. Critically such models are needed to advocate for investment, since the greatest risk to the ‘Zero by 30’ strategy is the limited long-term cross-sectoral or targeted financing to support countries to deliver and sustain mass dog vaccination.
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11
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Quiambao B, Varghese L, Demarteau N, Sengson RF, Javier J, Mukherjee P, Manio LC, Preiss S. Health economic assessment of a rabies pre-exposure prophylaxis program compared with post-exposure prophylaxis alone in high-risk age groups in the Philippines. Int J Infect Dis 2020; 97:38-46. [PMID: 32450291 DOI: 10.1016/j.ijid.2020.05.062] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/24/2020] [Revised: 05/18/2020] [Accepted: 05/18/2020] [Indexed: 10/24/2022] Open
Abstract
OBJECTIVES Once symptoms appear, rabies is almost always fatal and accounts for 200-300 deaths annually in the Philippines. Available rabies vaccines can be administered either in pre- exposure prophylaxis (PrEP) or post-exposure prophylaxis (PEP). After exposure, PrEP-immunized individuals require fewer doses of PEP and no rabies immunoglobulin. METHODS A static decision-tree model was developed to assess cost-effectiveness of a PrEP+PEP program vs PEP alone. Philippines-specific data for people seeking medical advice at the Research Institute for Tropical Medicine between July 2015 and June 2016 were used in the model, together with data from published literature. RESULTS Over a 20-year period, in a cohort of 1 million 5-year-old children in the Philippines, PrEP+PEP was expected to prevent 297 deaths compared with PEP alone. From both payer and societal perspectives, the resulting incremental cost-effectiveness ratios were 36 035 (US$759; 2016 US$ conversion) and 18 663 (US$393) Philippine Pesos (PHP) - quality-adjusted life-years gained - respectively, which are both below the willingness-to-pay threshold of PHP140 255 (US$2 953). CONCLUSION These data suggest that a universal PrEP program targeting 5-year-olds would be cost-effective in the Philippines.
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Affiliation(s)
- Beatriz Quiambao
- Research Institute for Tropical Medicine, Filinvest Corporate City, 9002 Research Dr, Alabang, Muntinlupa, 1781 Metro Manila, Philippines.
| | | | | | | | - Jenaline Javier
- Research Institute for Tropical Medicine, Filinvest Corporate City, 9002 Research Dr, Alabang, Muntinlupa, 1781 Metro Manila, Philippines.
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12
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Zero human deaths from dog-mediated rabies by 2030: perspectives from quantitative and mathematical modelling. Gates Open Res 2020; 3:1564. [PMID: 32596645 PMCID: PMC7308633 DOI: 10.12688/gatesopenres.13074.1] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 02/24/2020] [Indexed: 09/09/2023] Open
Abstract
Dog-mediated rabies continues to kill tens of thousands of people every year in low- and middle-income countries despite being an entirely vaccine-preventable disease. WHO and partners have launched a global campaign to reach zero human deaths from dog-mediated rabies by 2030. The primary tools for reaching this target are mass dog vaccination to interrupt transmission in domestic dog populations that maintain infection, appropriate post-exposure prophylaxis (PEP) for rabies-exposed persons to prevent the fatal onset of disease, together with education to support their effective uptake. Models have been developed to assess the feasibility, impact and cost-effectiveness of these measures. From these models, we argue that the 2030 target of zero human rabies deaths is achievable, but will require concerted effort, engagement and investment. A proposed Gavi investment in human rabies vaccines has potential to drive progress towards the 2030 target; however, concomitant investment is needed to scale up mass dog vaccination or this target will be missed. Predicted economic benefits of mass dog vaccination vary according to national PEP provisioning and healthcare access. Integrated Bite Case Management can enhance surveillance and rationalize PEP use, but needs adapting to and integrating within local health systems and international reporting systems to improve PEP accountability, monitor impacts and support verification of disease freedom. Modelling approaches need refining to project realistic and geographically specific timelines for achieving targets. Model iterations informed by data on the implementation of interventions can be used to evaluate progress and guide future strategies. Critically such models are needed to advocate for investment, since the greatest risk to the 'Zero by 30' strategy is the limited long-term cross-sectoral or targeted financing to support countries to deliver and sustain mass dog vaccination.
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13
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Lushasi K, Steenson R, Bernard J, Changalucha JJ, Govella NJ, Haydon DT, Hoffu H, Lankester F, Magoti F, Mpolya EA, Mtema Z, Nonga H, Hampson K. One Health in Practice: Using Integrated Bite Case Management to Increase Detection of Rabid Animals in Tanzania. Front Public Health 2020; 8:13. [PMID: 32117850 PMCID: PMC7034360 DOI: 10.3389/fpubh.2020.00013] [Citation(s) in RCA: 17] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/09/2019] [Accepted: 01/15/2020] [Indexed: 12/25/2022] Open
Abstract
Rabies is a neglected zoonotic disease that causes an estimated 59,000 human deaths worldwide annually, mostly in Africa and Asia. A target of zero human deaths from dog-mediated rabies has been set for 2030, and large-scale control programs are now advocated. However, in most low-income endemic countries surveillance to guide rabies control is weak and few cases of rabies are recorded. There is an urgent need to enhance surveillance to improve timely case detection and inform rabies control and prevention, by operationalizing a “One Health” approach. Here we present data from a study piloting Integrated Bite Case Management (IBCM) to support intersectoral collaboration between health and veterinary workers in Tanzania. We trained government staff to implement IBCM, comprising risk assessments of bite patients by health workers, investigations by livestock field officers to diagnose rabid animals, and use of a mobile phone application to support integration. IBCM was introduced across 20 districts in four regions of Tanzania and results reported after 1 year of implementation. Numbers of bite patient presentations to health facilities varied across regions, but following the introduction of IBCM reporting of bite patients at high-risk for rabies more than doubled in all regions. Over 800 high-risk investigations were carried out, with 49% assessed as probable dog rabies cases on the basis of clinical signs, animal outcome, and rapid diagnostic testing. The status of a further 20% of biting animals could not be determined but rabies could not be ruled out. Livestock field officers reported that use of rapid diagnostic tests (RDTs) were useful for confirming rabies occurrence. Overall, our study provides further evidence that IBCM is a practical approach that can improve rabies detection in endemic countries, and be used to monitor the impact of mass dog vaccinations, including potential to verify rabies freedom. However, the main challenges to implementation are limited training of health workers in rabies, perceived burden of real-time recording and limited resources for livestock field officers to undertake investigations. Nonetheless, IBCM dramatically improved case detection and communication between sectors and we recommend further implementation research to establish best practice and applicability to other settings.
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Affiliation(s)
- Kennedy Lushasi
- Environmental Health and Ecological Sciences Department, Ifakara Health Institute, Ifakara, Tanzania.,Boyd Orr Centre for Population and Ecosystem Health, College of Medical, Institute of Biodiversity, Animal Health and Comparative Medicine, Veterinary and Life Sciences, University of Glasgow, Glasgow, United Kingdom.,Global Health and Biomedical Sciences, School of Life Sciences and Bioengineering, Nelson Mandela African Institution of Science and Technology, Arusha, Tanzania
| | - Rachel Steenson
- Boyd Orr Centre for Population and Ecosystem Health, College of Medical, Institute of Biodiversity, Animal Health and Comparative Medicine, Veterinary and Life Sciences, University of Glasgow, Glasgow, United Kingdom
| | - Jubilate Bernard
- Department of Epidemiology, Ministry of Health, Community Development, Gender, Elderly and Children (MoHCDGEC), Dodoma, Tanzania
| | - Joel Jackson Changalucha
- Environmental Health and Ecological Sciences Department, Ifakara Health Institute, Ifakara, Tanzania
| | - Nicodem James Govella
- Environmental Health and Ecological Sciences Department, Ifakara Health Institute, Ifakara, Tanzania
| | - Daniel T Haydon
- Boyd Orr Centre for Population and Ecosystem Health, College of Medical, Institute of Biodiversity, Animal Health and Comparative Medicine, Veterinary and Life Sciences, University of Glasgow, Glasgow, United Kingdom
| | - Husna Hoffu
- Environmental Health and Ecological Sciences Department, Ifakara Health Institute, Ifakara, Tanzania
| | - Felix Lankester
- Paul G. Allen School for Global Animal Health, Washington State University, Washington, DC, United States.,Global Animal Health Tanzania, Arusha, Tanzania
| | - Frank Magoti
- Environmental Health and Ecological Sciences Department, Ifakara Health Institute, Ifakara, Tanzania
| | - Emmanuel Abraham Mpolya
- Global Health and Biomedical Sciences, School of Life Sciences and Bioengineering, Nelson Mandela African Institution of Science and Technology, Arusha, Tanzania
| | - Zacharia Mtema
- Environmental Health and Ecological Sciences Department, Ifakara Health Institute, Ifakara, Tanzania
| | - Hesron Nonga
- Director of Veterinary Services, Ministry of Livestock Development and Fisheries, Dodoma, Tanzania
| | - Katie Hampson
- Environmental Health and Ecological Sciences Department, Ifakara Health Institute, Ifakara, Tanzania.,Boyd Orr Centre for Population and Ecosystem Health, College of Medical, Institute of Biodiversity, Animal Health and Comparative Medicine, Veterinary and Life Sciences, University of Glasgow, Glasgow, United Kingdom
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14
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Benavides JA, Megid J, Campos A, Rocha S, Vigilato MAN, Hampson K. An evaluation of Brazil's surveillance and prophylaxis of canine rabies between 2008 and 2017. PLoS Negl Trop Dis 2019; 13:e0007564. [PMID: 31381564 PMCID: PMC6709922 DOI: 10.1371/journal.pntd.0007564] [Citation(s) in RCA: 14] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/08/2019] [Revised: 08/26/2019] [Accepted: 06/20/2019] [Indexed: 11/18/2022] Open
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. Dog-mediated rabies has declined to only a few cases in Latin America over the last decade. Brazil has the largest human and dog population of Latin America. Despite the decline of canine rabies, the country’s public health system still spends millions of dollars annually on half a million patients seeking health care for dog bites. In this study, we analysed a decade of national surveillance data on dog bites. 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. In addition, only half of patients appear to receive the appropriate rabies post-exposure prophylaxis as recommended by the Ministry of Health. 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 WHO recommendations. Our study highlights an urgent need for updating health care workers on canine rabies knowledge, prophylaxis and assessment of dog bites to improve prophylaxis provision and surveillance of dog rabies.
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Affiliation(s)
- Julio A. Benavides
- Departamento de Ecología y Biodiversidad, Facultad de Ciencias de la Vida, Universidad Andrés Bello, Santiago, Chile
- UNESP - Faculdade de Medicina Veterinária e Zootecnia, Departamento De Higiene Veterinária e Saúde Pública, Botucatu, São Paulo, Brazil
- Institute of Biodiversity, Animal Health and Comparative Medicine, University of Glasgow, Glasgow, United Kingdom
- Centro de Investigación para la Sustentabilidad, Facultad de Ciencias de la Vida, Universidad Andrés Bello, Santiago, Chile
- * E-mail:
| | - Jane Megid
- UNESP - Faculdade de Medicina Veterinária e Zootecnia, Departamento De Higiene Veterinária e Saúde Pública, Botucatu, São Paulo, Brazil
| | - Aline Campos
- Programa Estadual de Controle e Profilaxia da Raiva, Health Secretary of Rio Grande do Sul, Porto Alegre, Brazil
| | - Silene Rocha
- Pan-American Health Organization, Veterinary Public Health Unit – PANAFTOSA, Rio de Janeiro, Brazil
| | - Marco A. N. Vigilato
- Pan-American Health Organization, Veterinary Public Health Unit – PANAFTOSA, Rio de Janeiro, Brazil
| | - Katie Hampson
- Institute of Biodiversity, Animal Health and Comparative Medicine, University of Glasgow, Glasgow, United Kingdom
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15
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Rupprecht CE, Salahuddin N. Current status of human rabies prevention: remaining barriers to global biologics accessibility and disease elimination. Expert Rev Vaccines 2019; 18:629-640. [PMID: 31159618 DOI: 10.1080/14760584.2019.1627205] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/26/2022]
Abstract
Introduction: Rabies is a serious, neglected tropical disease. Zoonotic agents are RNA viruses (Genus Lyssavirus, Family Rhabdoviridae), global in distribution. As an acute, progressive, incurable encephalitis, rabies has the highest case fatality of any infectious disease. Warm-blooded vertebrates are susceptible hosts. Major mammalian reservoirs include mesocarnivores and bats. Given wildlife perpetuation, rabies is not eradicable, but is preventable and controllable, especially under newly available international guidelines. Areas covered: Literature review over the past 5 years reveals development of sensitive, specific diagnostic tests and safe and highly effective human and veterinary vaccines. Yet, tens of thousands of human fatalities occur annually, usually in Africa and Asia, primarily after canine exposure. Human and domestic animal vaccination, before or after exposure, is the single greatest preventative strategy following a rabid animal bite. Expert opinion: Significant progress occurred during the twenty-first century regarding vaccine development, doses, and schedules. Remaining barriers to widespread rabies vaccination include an inter-related set of economic, cultural, social, educational, ecological and technological factors. A basic understanding of local and regional root causes of cases historically allows for broader accessibility to vaccination in a trans-disciplinary fashion to meet the global elimination of human rabies caused via dogs (GEHRD) by 2030.
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Affiliation(s)
| | - Naseem Salahuddin
- b Infectious Disease Division, Department of Medicine , The Indus Hospital , Karachi , Pakistan
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16
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Changalucha J, Steenson R, Grieve E, Cleaveland S, Lembo T, Lushasi K, Mchau G, Mtema Z, Sambo M, Nanai A, Govella NJ, Dilip A, Sikana L, Ventura F, Hampson K. The need to improve access to rabies post-exposure vaccines: Lessons from Tanzania. Vaccine 2018; 37 Suppl 1:A45-A53. [PMID: 30309746 PMCID: PMC6863039 DOI: 10.1016/j.vaccine.2018.08.086] [Citation(s) in RCA: 37] [Impact Index Per Article: 6.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/18/2018] [Revised: 08/22/2018] [Accepted: 08/31/2018] [Indexed: 12/25/2022]
Abstract
Prompt post-exposure vaccination is extremely effective in preventing human rabies. Intradermal post-exposure vaccination is easily adopted by health workers in Tanzania. High costs of PEP to government affect the supply chain and limit its availability. Limited PEP supply results in higher out-of-pocket payments and increased risks. Investment to facilitate free PEP provision would reduce rabies deaths.
Background Rabies is preventable through prompt administration of post-exposure prophylaxis (PEP) to exposed persons, but PEP access is limited in many rabies-endemic countries. We investigated how access to PEP can be improved to better prevent human rabies. Methods Using data from different settings in Tanzania, including contact tracing (2,367 probable rabies exposures identified) and large-scale mobile phone-based surveillance (24,999 patient records), we estimated the incidence of rabies exposures and bite-injuries, and examined health seeking and health outcomes in relation to PEP access. We used surveys and qualitative interviews with stakeholders within the health system to further characterise PEP supply and triangulate these findings. Results Incidence of bite-injury patients was related to dog population sizes, with higher incidence in districts with lower human:dog ratios and urban centres. A substantial percentage (25%) of probable rabies exposures did not seek care due to costs and limited appreciation of risk. Upon seeking care a further 15% of probable rabies exposed persons did not obtain PEP due to shortages, cost barriers or misadvice. Of those that initiated PEP, 46% did not complete the course. If no PEP was administered, the risk of developing rabies following a probable rabies exposure was high (0.165), with bites to the head carrying most risk. Decentralized and free PEP increased the probability that patients received PEP and reduced delays in initiating PEP. No major difficulties were encountered by health workers whilst switching to dose-sparing ID administration of PEP. Health infrastructure also includes sufficient cold chain capacity to support improved PEP provision. However, high costs to governments and patients currently limits the supply chain and PEP access. The cost barrier was exacerbated by decentralization of budgets, with priority given to purchase of cheaper medicines for other conditions. Reactive procurement resulted in limited and unresponsive PEP supply, increasing costs and risks to bite victims. Conclusion PEP access could be improved and rabies deaths reduced through ring-fenced procurement, switching to dose-sparing ID regimens and free provision of PEP.
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Affiliation(s)
- Joel Changalucha
- Ifakara Health Institute, P.O. Box 78373, Dar es Salaam, Tanzania.
| | - Rachel Steenson
- Boyd Orr Centre for Population and Ecosystem Health, Institute of Biodiversity, Animal Health and Comparative Medicine, University of Glasgow, UK
| | - Eleanor Grieve
- Health Economics and Health Technology Assessment (HEHTA), Institute of Health and Wellbeing, 1 Lilybank Gardens, University of Glasgow, UK
| | - Sarah Cleaveland
- Boyd Orr Centre for Population and Ecosystem Health, Institute of Biodiversity, Animal Health and Comparative Medicine, University of Glasgow, UK
| | - Tiziana Lembo
- Boyd Orr Centre for Population and Ecosystem Health, Institute of Biodiversity, Animal Health and Comparative Medicine, University of Glasgow, UK
| | - Kennedy Lushasi
- Ifakara Health Institute, P.O. Box 78373, Dar es Salaam, Tanzania
| | - Geofrey Mchau
- Ministry of Health, Community Development, Gender, Elderly and Children, P.O. Box 573 Dodoma, Tanzania
| | - Zacharia Mtema
- Ifakara Health Institute, P.O. Box 78373, Dar es Salaam, Tanzania
| | - Maganga Sambo
- Ifakara Health Institute, P.O. Box 78373, Dar es Salaam, Tanzania; Boyd Orr Centre for Population and Ecosystem Health, Institute of Biodiversity, Animal Health and Comparative Medicine, University of Glasgow, UK
| | - Alphoncina Nanai
- World Health Organization, Tanzania Country Office, P.O. Box 9292, Dar es Salaam, Tanzania
| | | | - Angel Dilip
- Ifakara Health Institute, P.O. Box 78373, Dar es Salaam, Tanzania
| | - Lwitiko Sikana
- Ifakara Health Institute, P.O. Box 78373, Dar es Salaam, Tanzania
| | - Francesco Ventura
- Boyd Orr Centre for Population and Ecosystem Health, Institute of Biodiversity, Animal Health and Comparative Medicine, University of Glasgow, UK
| | - Katie Hampson
- Boyd Orr Centre for Population and Ecosystem Health, Institute of Biodiversity, Animal Health and Comparative Medicine, University of Glasgow, UK
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