Rabies post-exposure prophylaxis in Germany − What are the challenges?

Meyerhoff, P.; Manekeller, Steffen; Saleh, Nadia; Boesecke, Christoph; Schlabe, Stefan; Wasmuth, JC; Bremen, Kathrin van; Eis‐Hübinger, A. M.; Fischer-Treuenfeld, J. von; Menting, Tanja; Rockstroh, JK; Schwarze-Zander, C

doi:10.1017/s0950268821000601

Cited by 9 publications

(5 citation statements)

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“…These clinical decision support features were designed to help address previously identified knowledge gaps related to suboptimal HRIG wound infiltration, administration of HRIG near rabies vaccine, and unnecessary administration of HRIG into the buttock . The low adherence to quality indicators observed preimplementation is not unique to our center, as a 2021 study from Germany reported deviations from guideline recommendations regarding HRIG selection and wound infiltration in 51% of patients.…”

Section: Discussionmentioning

confidence: 99%

Implementation of Clinical Decision Support on Emergency Department Delivery of Human Rabies Immune Globulin

et al. 2022

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IMPORTANCEFatal human rabies infections can be prevented through appropriate rabies postexposure prophylaxis (PEP). Errors in patient selection and administration of human rabies immune globulin in the emergency department (ED) setting were identified in a previous study of rabies PEP administration. OBJECTIVE To test the a priori hypothesis that implementation of a rabies PEP bundle in the ED would improve full adherence to 6 human rabies immune globulin quality indicators compared with preimplementation controls. DESIGN, SETTING, AND PARTICIPANTS This quality improvement study was conducted in 15 EDs in a US multihospital health system. Patients who received human rabies immune globulin or rabies vaccine in the ED from January 2015 to June 2018 were included in the preimplementation control group and from December 2019 to November 2020 were included in the postimplementation intervention group. Data were analyzed in January 2021. EXPOSURE The PEP bundle was implemented in December 2019 and consisted of electronic health record enhancements, including clinical decision support, ED staff education, and patient education. MAIN OUTCOMES AND MEASURES Full adherence to 6 human rabies immune globulin quality indicators: patient selection, dose, timing, infiltration into wounds, administration distant from rabies vaccine site, and administration that avoids the buttock. RESULTS The study included 324 patients; 254 patients were in preimplementation group (mean [SD] age, 39 [21] years; 135 [53%] women) and 70 in the postimplementation group (mean [SD] age, 38 [19] years; 33 [47%] women). Most patients presented to EDs embedded in a community hospital (231 patients [71%]). Full adherence increased from 37% in the preimplementation group to 61% postimplementation (absolute increase, 24%; 95% CI, 11% to 37%; P < .001). Adherence improved for quality indicators for infiltration into wounds (137 of 254 patients [54%] to 50 of 70 patients [71%]; P = .009), administration distant from rabies vaccine site (180 of 254 [71%] to 58 of 70 [83%]; P = .04), and administration that avoids the buttock (168 of 254 [66%] to 58 of 70 [83%]; P = .007). No instances of sciatic nerve injury or compartment syndrome were observed. CONCLUSIONS AND RELEVANCE In this quality improvement study, implementation of a rabies PEP bundle was associated with improved patient selection and delivery of human rabies immune globulin in EDs across a multihospital health system. Although the bundle included ED staff education and patient discharge education, the observed improvement was likely driven by clinical (continued) Key Points Question Is implementation of a rabies postexposure prophylaxis bundle, consisting of electronic health record enhancements, staff education, and patient education, associated with improved human rabies immune globulin (HRIG) patient selection and delivery in the emergency department? Findings In this quality improvement study that included 324 patients, the primary outcome of full adherence to 6 HRIG quality indicators increased...

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Section: Discussionmentioning

confidence: 99%

Implementation of Clinical Decision Support on Emergency Department Delivery of Human Rabies Immune Globulin

et al. 2022

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“…Like surveillance in the U.S., studies have also showed that even when data on PEP administration are collected, key variables such as completion of PEP are often missing. One study in Vietnam found vaccine completion rates as low as 7% in some districts and in Cameroon was approximately 50% [ 22 ]; in Germany, a study found that 51% of cases (n = 41/80) had a deviation in PEP guidelines such as administration of only RIG, highlighting the importance of collecting sufficient data about PEP to assess appropriate administration [ 26 ]. Key steps to improving PEP surveillance could be considering sentinel sites, shared monitoring and distribution of rabies and other vaccines associated with immunization programs, incorporation of PEP administration data into integrated bite case management systems used for animal bite monitoring and follow-up [ 27 ], standardizing data collection tools to promote systematic documentation of sufficient information, and considering the use of mobile technology or electronic records to facilitate data collection and sharing, all in line with WHO recommendations [ 1 , 6 ].…”

Section: Discussionmentioning

confidence: 99%

Evaluating Surveillance for and Estimating Administration of Rabies Postexposure Prophylaxis in the United States, 2012–2018

et al. 2021

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Background An evaluation of postexposure prophylaxis (PEP) surveillance has not been conducted in over 10 years in the United States. An accurate assessment would be important to understand current rabies trends and inform public health preparedness and response to human rabies. Methodology/Principle findings To understand PEP surveillance, we sent a survey to public health leads for rabies in 50 U.S. states, Puerto Rico, Washington DC, Philadelphia, and New York City. Of leads from 54 jurisdictions, 39 (72%) responded to the survey; 12 reported having PEP-specific surveillance, five had animal bite surveillance that included data about PEP, four had animal bite surveillance without data about PEP, and 18 (46%) had neither. Although 12 jurisdictions provided data about PEP use, poor data quality and lack of national representativeness prevented use of this data to derive a national-level PEP estimate. We used national-level and state specific data from the Healthcare Cost & Utilization Project (HCUP) to estimate the number of people who received PEP based on emergency department (ED) visits. The estimated annual average of initial ED visits for PEP administration during 2012–2017 in the United States was 46,814 (SE: 1,697), costing upwards of 165 million USD. State-level ED data for initial visits for administration of PEP for rabies exposure using HCUP data was compared to state-level surveillance data from Maryland, Vermont, and Georgia between 2012–2017. In all states, state-level surveillance data was consistently lower than estimates of initial ED visits, suggesting even states with robust PEP surveillance may not adequately capture individuals who receive PEP. Conclusions Our findings suggest that making PEP a nationally reportable condition may not be feasible. Other methods of tracking administration of PEP such as syndromic surveillance or identification of sentinel states should be considered to obtain an accurate assessment.

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“…Auch wenn in Deutschland das Tollwutimmunglobulin (TIG) breit verfügbar ist, kommt es bei der PEP-Durchführung häufiger zu Fehlanwendungen [ 4 ], sodass Expositionen prinzipiell vermieden werden sollten und bei der PEP-Durchführung auf qualifizierte Expertise im eigenen Haus oder extern (Tollwutberatungsstellen) zurückgegriffen werden sollte [ 3 ]. Empfehlungen zum Umgang mit gefundenen Fledermäusen gibt beispielsweise der Naturschutzbund Deutschland (NABU; [ 5 ]).…”

Section: Diskussionunclassified

Postexposure prophylaxis after bite of a broad-winged bat with evidence of European bat lyssavirus 1 (EBLV-1)

Fasse,

Trawinski,

Hardt

et al. 2023

Innere Medizin

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ZusammenfassungDeutschland gilt infolge intensiver Impf- und Überwachungsbemühen seit 2008 als frei von terrestrischer Tollwut. Reservoire der Lyssaviren EBLV‑1 und EBLV‑2 persistieren jedoch weiter in Fledermauskolonien und stellen somit ein potenzielles Infektionsrisiko dar. Wir berichten von einer Patientin, die einen Fledermausbiss im städtischen Umfeld erlitt. Bei der euthanasierten Fledermaus konnte das Europäische Fledermaus-Lyssavirus 1 (EBLV-1) nachgewiesen werden. Wir führten eine aktive und passive Postexpositionsprophylaxe (PEP) durch. Dieses Fallbeispiel illustriert die anhaltende Tollwutinfektionsgefahr durch enge Fledermauskontakte in Deutschland und soll erstbehandelnde Ärzte dafür sensibilisieren, entsprechende Expositionsereignisse ernst zu nehmen und eine regelrechte PEP einschließlich Applikation von Tollwutimmunglobulin durchzuführen.

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Rabies post-exposure prophylaxis in Germany − What are the challenges?

Cited by 9 publications

References 11 publications

Implementation of Clinical Decision Support on Emergency Department Delivery of Human Rabies Immune Globulin

Implementation of Clinical Decision Support on Emergency Department Delivery of Human Rabies Immune Globulin

Evaluating Surveillance for and Estimating Administration of Rabies Postexposure Prophylaxis in the United States, 2012–2018

Postexposure prophylaxis after bite of a broad-winged bat with evidence of European bat lyssavirus 1 (EBLV-1)

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