Analysis of qualification for post-exposure prophylaxis against rabies in children in Poland

BACKGROUND

Rabies is a fatal disease caused by the rabies virus, usually transmitted by a bite by an infected animal. Because there is no effective treatment, prophylaxis is crucial. The aim of the study was to analyse the circumstances of exposure, characterise the animals that were a potential source of infection and evaluate the frequency of post-exposure prophylaxis in children.

METHODS

This was a retrospective analysis of the medical records of 494 children who had been bitten, scratched or salivated on by an animal and were seen consecutively between 2015 and 2019 in the Department of Paediatric Infectious Diseases, Medical University of Warsaw.

RESULTS

The study group was children aged 10 months to 17 years 11 months. The animals most commonly involved were dogs (347/494, 70.24%), cats (81/494 (16.40%) and squirrels (10/494, 2.02%). The contact was mainly with tame but unfamiliar animals (359/494, 72.67%, p < 0.001). The most common type of exposure was a bite (457/494, 92.51%). Surgical wound care was required most often after exposure in a town (64/90, 71.11%). A total of 412 children (80.83%) received post-exposure vaccination, including 333/412 using the Essen regimen. In 13/412 cases, the vaccination schedule (3.16%) was not completed because of an absence of signs of disease during veterinary observation of the animal. Anti-rabies immunoglobulin was administered to 13/412 (3.16%).

CONCLUSION

Most children who are referred after being bitten by an animal require post-exposure prophylaxis. Children are usually bitten by tame dogs with which they are unfamiliar, mostly on the hand. Surgical wound care is needed more often for urban patients than others.

The first report evaluating the post-exposure rabies prophylaxis in children exposed to animals in the Lublin Province (Eastern Poland) in 2010-2016 - a retrospective study

INTRODUCTION

Rabies continues to be one of the most important viral diseases and remains a significant threat to public health across the globe. The World Health Organization (WHO) has determined that most rabies cases occur in children. Dog bites on humans are a major public-health problem. Poland has not achieved rabies free status yet. Post-exposure prophylaxis (PEP) in humans can effectively prevent death after exposure to a potentially infected animal.

THE AIM

The main objective of this study was to estimate the frequency of PEP among children exposed to animals, who had attended consultations at the Department of Infectious Diseases for Children in the Jan Boży Hospital in Lublin.

PATIENTS AND METHODS

We retrospectively analyzed the medical records from the period of 2010-2016 of all pediatric patients (0-17 years of age) who had been exposed to animals and attended consultations at the Department of Infectious Diseases for Children in the Jan Boży Hospital in Lublin.

RESULTS

During the studied period, 519 children who had been exposed to animals attended consultations, and a prophylactic procedure consisting of active immunization was applied to 32.8%. The male children accounted for 55.3%. The mean age was 9.2 years. The biggest group of children (406) had been exposed to dogs, 62 children to cats, and 15 to rats. Most children had upper-limbs injuries. During the studied period, i.e. 2010-2016, there were 1713 confirmed cases of rabid animals in Poland, and 60 cases were recorded in the Lublin Province. We did not observe any cases of rabies in our exposed and vaccinated patients.

CONCLUSIONS

The number of rabid animals in the Lublin Province had decreased to low levels, but the expected decrease in the number of PEP's administered did not occur. Since all children were vaccinated in accordance with the recommendations, the possible reason for vaccination's being administered in the quantities greater than the number of rabid animals recorded in the Lublin Province are bites by animals unavailable for veterinary observations and also the lack of more frequent reports regarding the current epizootic situation of rabies. The use of rabies immunoglobulin (RIG) in children in the Lublin Province is at a very low level, i.e. at 0.58%. The yearly numbers of exposed pediatric patients were at similar levels, which indicates that education programs should be introduce to reduce the number of animal bites in children.

Post-exposure rabies prophylaxis in humans exposed to animals in Lublin province (Eastern Poland) in 2012-2015 - A retrospective study

Rabies continues to be one of the most important viral diseases and remains a significant threat to public health across the globe. The post-exposure prophylaxis in humans can effectively prevent death after exposure to a potentially infected animal. In Poland, recommendations for rabies PEP followed the national guidelines which recommend that people should receive PEP when bitten by an animal suspected to be infected by rabies. PEP in humans includes cleansing and disinfecting the wound or point of contact, and administering anti-rabies immunization. Rabies vaccine should be given for contacts of category II and category III exposures. RIG should be given for category III contact. The vaccination schedule includes 5 doses given within a 30 day period (the Essen regimen).

THE AIM

The aim of our study was to determine the frequency of post-exposure prophylaxis among patients exposed to animals and also to assess the animal species suspected as a source of rabies exposure.

METHODS

We have retrospectively analyzed medical records from the years 2012-2015 of all adult patients who were exposed to animals and consulted at the Dispensary of Rabies Prophylaxis in the Department of Infectious Diseases at the Medical University in Lublin, Poland. All consulted patients were asked to give an informed consent in case of decision to use collected data for future research work. Ethical approval was obtained from the Ethics Committee of the Medical University of Lublin, Poland, and all patients included in this study gave an informed consent during consultation after the exposure to animals.

RESULTS

During the studied 4-year period, 511 persons exposed to animals were consulted and prophylactic procedure consisting of active immunization were applied in 54.2% of the total consulted. Dogs and cats were the most common animal species suspected as the source of the rabies exposure. Anti-rabies prophylaxis was applied in 45.8% of all vaccinated patients exposed to dogs, and in 24.2% exposed to cats. All patients with bite wounds were consulted at the Department of Surgery and wound care followed surgical recommendations. In the study group, 45 patients had category III contact. There were 38 patients exposed to dogs, and 7 exposed to cats. There were no people exposed to wildlife in this group. All animals were available for veterinary observation. During and after exposure, none of the animals that serve as a potential source of infection presented with symptoms of rabies. The local epidemiological data indicated that during exposures of our patients, there were no confirmed cases of rabies among animals in Lublin province. Based on the data mentioned above, RIG was not applied. During the studied period in Lublin province, rabies was confirmed mainly in wildlife, and only in 2 dogs.

CONCLUSIONS

In Lublin province, people are still at risk of exposure to rabid animals. The majority of our patients were vaccinated after domestic animals exposure, but rabies was confirmed mainly in wildlife, and since 2013, there were no cases of rabies among domestic animals.

Bat rabies, public health and European bat conservation

Most records of European bat lyssaviruses (EBLVs) are confined to three species - the serotine bat for EBLV1 (900 records) and Daubenton's bat and the pond bat for EBLV2 (25 records). High levels of seroprevalence, which may vary from year to year, are also recorded. All bat vectors of EBLVs are synanthropic, some exclusively so. Despite this, there have been only five cases of human rabies resulting from EBLV infection in the 590 million people of greater Europe during the last 35 years. These have triggered major programmes of surveillance in many European countries. The emphasis on active versus passive surveillance and the intensity with which they have been carried out has varied from country to country. Both involve cooperation between bat researchers, virologists and public health officials and the latter, in particular, engages amateur bat workers and members of the public. Bat NGOs throughout Europe have worked to persuade the public not to handle bats or to do so only with gloved hands and, in the case of bat workers, to receive pre-exposure immunization. They have also countered negative media coverage of bat rabies. Householders with bat roosts in their dwellings have in general been persuaded to retain their bats. Attempts have been made to persuade all European countries to establish comparable EBLV surveillance programmes. In the last 25 years, virologists, public health officials, bat biologists and conservationists, both amateur and professional have worked closely and collaboratively for the protection of the public and the conservation of bats, with little polarization of views.

[Evaluation of rabies post-exposure prophylaxis in humans injured by dogs and cats in the municipality of Jaboticabal, SP, from 2000 through 2006]

The present study aimed to evaluate rabies post-exposure prophylaxis (PEP) in humans in the municipality of Jaboticabal, São Paulo from 2000 through 2006. A descriptive and retrospective study was conducted by collecting data available in patient records. Vaccination costs were also calculated; 2,493 patients injured by animals received PEP, totaling R$ 179,105.14 and 7,108 doses; 2,184 (71.5%) out of the total reports were caused by dogs and cats clinically healthy at the moment of the attack. These animals remained sound throughout the 10-day observation period. The observation was conducted by the victim or by the owner. Considering animal observation and the epidemiological status of rabies in the municipality, all of these patients could have been dismissed from PEP treatment. Instead, only 464 were dismissed, meaning that 1,720 patients were unnecessarily vaccinated. An estimated 4,590 doses and R$114,420.81 could have been saved. In comparison with rates of other municipalities of the State of São Paulo and with the national mean, the number of PEP in Jaboticabal is very high and it became evident that management evaluated neither the health status of the animal nor the epidemiological status of the area for rabies. Permanent awareness and education of public health professionals with respect to rabies epidemiology and the need to perform correct observation of the aggressors are recommended. It is essential that medical and veterinary services be integrated to provide better assessment of cases and safer decisions on the institution of PEP.