Healthcare utilization, provisioning of post-exposure prophylaxis, and estimation of human rabies burden in Madagascar

Rajeev, Malavika; Edosoa, Glenn; Hanitriniaina, Chantal; Andriamandimby, Soa Fy; Guis, Hélène; Ramiandrasoa, Ravo; Ratovoson, Rila; Randrianasolo, Laurence; Andriamananjara, Mamitiana; Heraud, Jean‐Michel; Baril, Laurence; Metcalf, C. Jessica E.; Hampson, Katie

doi:10.1016/j.vaccine.2018.11.011

Cited by 28 publications

(76 citation statements)

References 30 publications

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“…where is the maximum reporting, estimated from the Moramanga ARMC data for the commune of Moramanga Ville, the closest commune to the ARMC (average of 3.12 minutes travel time to the clinic), and where we find that approximately 2% of rabies exposures go unreported [15].…”

Section: Formentioning

confidence: 78%

“…both bites due to non-rabid and rabid animals) is proportional to rabies incidence (i.e. the more bites reported in a location, the higher the incidence of rabies exposures), and that reporting to clinics for PEP is uniform across space [8,14,15]. If applied subnationally, these assumptions would likely underestimate rabies deaths in places with poor access to PEP and may overestimate rabies deaths in places with better access to PEP.…”

Section: Introductionmentioning

confidence: 99%

“…In Madagascar, the Institut Pasteur de Madagascar (IPM) provides PEP to 30 Ministry of Health clinics, in addition to it's own vaccine clinic, where PEP is available at no direct cost to patients [15]. Other than at these 31 anti-rabies medical centers (ARMC), PEP is not available at any other public clinics or through the private sector.…”

Section: Introductionmentioning

confidence: 99%

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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

Rajeev

Guis

Edosoa³

et al. 2020

Preprint

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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 travel times to the closest clinic providing PEP (N=31) as a proxy for access. We find that travel times strongly predict reported bite incidence across the country. Using resulting estimates in an adapted decision tree framework 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: 800 (95% PI: 640 - 970) each year. Under these assumptions, we find that expanding PEP to one clinic per district could reduce deaths by 19%, but even with all major health centers 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. Our framework could be used to guide PEP expansion and improve targeting of interventions in similar endemic settings where PEP access is geographically restricted. While better PEP access should save many lives, improved outreach and surveillance is needed and if rolled out with Gavi investment could catalyze progress towards achieving zero rabies deaths.

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Section: Formentioning

confidence: 78%

Section: Introductionmentioning

confidence: 99%

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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

Rajeev

Guis

Edosoa³

et al. 2020

Preprint

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“…We also only consider a range of travel costs to clinics but in practice the location of clinics and transport access would affect indirect costs and delays to PEP provision. Moreover, we do not consider clustering of presentations as frequently occurs due to the same dog biting multiple people [38][39][40][41], which increases opportunities for vial sharing. Finally, an opened vial may be additionally used for PrEP in non-bitten family members or individuals whose occupation increases their risk of exposure.…”

Section: Discussionmentioning

confidence: 99%

Health Data in Dentistry: An Attempt to Master the Digital Challenge

Joda

Waltimo

Probst‐Hensch

et al. 2019

Public Health Genomics

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a b s t r a c tBackground: The Strategic Advisory Group of Experts (SAGE) Working Group on rabies vaccines and immunoglobulins was established in 2016 to develop practical and feasible recommendations for prevention of human rabies. To support the SAGE agenda we developed models to compare the relative costs and potential benefits of rabies prevention strategies. Methods: We examined Post-Exposure Prophylaxis (PEP) regimens, protocols for administration of Rabies Immunoglobulin (RIG) and inclusion of rabies Pre-Exposure Prophylaxis (PrEP) within the Expanded Programme on Immunization (EPI). For different PEP regimens, clinic throughputs and consumables for vaccine administration, we evaluated the cost per patient treated, costs to patients and potential to treat more patients given limited vaccine availability. Results: We found that intradermal (ID) vaccination reduces the volume of vaccine used in all settings, is less costly and has potential to mitigate vaccine shortages. Specifically, the abridged 1-week 2-site ID regimen was the most cost-effective PEP regimen, even in settings with low numbers of bite patients presenting to clinics. We found advantages of administering RIG to the wound(s) only, using considerably less product than when the remaining dose is injected intramuscularly distant to the wound(s). We found that PrEP as part of the EPI programme would be substantially more expensive than use of PEP and dog vaccination in prevention of human rabies. Conclusions: These modeling insights inform WHO recommendations for use of human rabies vaccines and biologicals. Specifically, the 1-week 2-site ID regimen is recommended as it is less costly and treats many more patients when vaccine is in short supply. If available, RIG should be administered at the wound only. PrEP is highly unlikely to be an efficient use of resources and should therefore only be considered in extreme circumstances, where the incidence of rabies exposures is extremely high.

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“…In Tanzania, for example, the incidence of human rabies is estimated to be more than 100-fold higher than the official human deaths reported [7]. In Madagascar, a projected burden of 246 to 758 human rabies deaths with current PEP averting 1307-4028 human deaths per year was recently estimated [8]. In animals, the underestimation of the burden could be even greater.…”

Section: Introductionmentioning

confidence: 99%

Enabling animal rabies diagnostic in low-access areas: Sensitivity and specificity of a molecular diagnostic test from cerebral tissue dried on filter paper

Rasolonjatovo¹,

Guis²,

Rajeev³

et al. 2020

PLoS Negl Trop Dis

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Rabies is a lethal zoonotic encephalomyelitis that causes an estimated 59,000 human deaths yearly worldwide. Although developing countries of Asia and Africa bear the heaviest burden, surveillance and disease detection in these countries is often hampered by the absence of local laboratories able to diagnose rabies and/or the difficulties of sample shipment from low-access areas to national reference laboratories. Filter papers offer a convenient cost-effective alternative for the sampling, shipment, and storage of biological materials for the diagnosis of many pathogens including rabies virus, yet the properties of diagnostic tests using this support have not been evaluated thoroughly. Sensitivity and specificity of molecular diagnosis of rabies infection using a reverse transcription followed by a hemi-nested polymerase chain reaction (RT-hn-PCR) either directly on brain tissue or using brain tissue dried on filter paper were assessed on 113 suspected field animal samples in comparison to the direct fluorescent antibody test (FAT) recommended by the World Health Organization as one of the reference tests for rabies diagnosis. Impact of the duration of the storage was also evaluated. The sensitivity and the specificity of RT-hn-PCR i) on brain tissue were 96.6% (95% CI: [88.1-99.6]) and 92.7% (95% CI: [82.4-98.0]) respectively and ii) on brain tissue dried on filter paper 100% (95% CI: [93.8-100.0]) and 90.9% (95% CI: [80.0-97.0]) respectively. No loss of sensitivity of RT-hn-PCR on samples of brain tissue dried on filter paper left 7 days at ambient temperature was detected indicating that this method would enable analyzing impregnated filter papers sent to the national reference laboratory at ambient temperature within a 1-week shipment time. It could therefore be an PLOS NEGLECTED TROPICAL DISEASES

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Healthcare utilization, provisioning of post-exposure prophylaxis, and estimation of human rabies burden in Madagascar

Cited by 28 publications

References 30 publications

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

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

Health Data in Dentistry: An Attempt to Master the Digital Challenge

Enabling animal rabies diagnostic in low-access areas: Sensitivity and specificity of a molecular diagnostic test from cerebral tissue dried on filter paper

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