Assessing clinicians’ Post-Exposure Prophylaxis recommendations for rabies virus exposures in Hunan Province, China

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 that of the rural 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 of PEP and recommendations of national rabies guidelines 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.

Epidemiological Characteristics of Human Rabies in Urban and Suburban Districts in Shanghai, 2006–2021

“…Our results indicated that most human rabies cases in Shanghai were in males (81.40%) and people ≥50 years (41.86%), followed by children; these findings were similar to those in other areas of China [5,29]. Another WHO report has indicated that children under 15 years of age are the highest risk population, accounting for 40% of total cases globally [16].…”

“…Standardized PEP is a crucial step in preventing rabies, consisting of immediate, thorough wound treatment, a series of rabies vaccinations and, if indicated, administration of rabies immunoglobulin or monoclonal antibodies [16,29]. The fatality rate was 100% in this study, and no cases were treated with the entire standardized PEP process.…”

Progress towards dog-mediated rabies elimination in PR China: a scoping review

“…The rabies bite treatment rate in China has increased over the years, with the rate of outpatient treatment exceeding 70%, but standardization for outpatient treatment needs to be improved [ 44 ]. There are large differences in the accuracy of wound type categorization and the corresponding use of post-exposure prophylaxis in urban and rural areas [ 103 ]. Effective management in all parts of wound care and rabies vaccination decision making and ensuring nursing staff compliance and productivity, is essential [ 104 ].…”

Factors Associated with Dog Rabies Immunization in Changsha, China: Results of a Cross-Sectional Cluster Survey, 2015–2021

“…Vaccine immunization is the most effective approach for preventing and controlling canine rabies, and the level of antibody after immunization is an important indicator for evaluating the effectiveness of vaccine immunization [ 19 , 20 ]. According to the Changsha City Dog Breeding Management Regulations, puppies are required to have their initial rabies vaccination at three months, a second vaccination at one year of age, and subsequent vaccinations every other year, and regular testing of antibody levels in dogs to ensure a positive serum antibody rate.…”