The need to improve access to rabies post-exposure vaccines: Lessons from Tanzania.
Bites and Stings
/ complications
Health Services Accessibility
/ statistics & numerical data
Humans
Immunologic Factors
/ supply & distribution
Incidence
Patient Acceptance of Health Care
/ statistics & numerical data
Post-Exposure Prophylaxis
/ methods
Rabies
/ epidemiology
Rabies Vaccines
/ supply & distribution
Survival Analysis
Tanzania
/ epidemiology
Treatment Outcome
Canine rabies
Dog-mediated rabies
Immunoglobulin
Intradermal
Intramuscular
Post-exposure prophylaxis
Procurement
Rabies prevention
Supply chain
Vaccine regimen
Journal
Vaccine
ISSN: 1873-2518
Titre abrégé: Vaccine
Pays: Netherlands
ID NLM: 8406899
Informations de publication
Date de publication:
03 10 2019
03 10 2019
Historique:
received:
18
06
2018
revised:
22
08
2018
accepted:
31
08
2018
pubmed:
13
10
2018
medline:
16
4
2020
entrez:
13
10
2018
Statut:
ppublish
Résumé
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. 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. 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. PEP access could be improved and rabies deaths reduced through ring-fenced procurement, switching to dose-sparing ID regimens and free provision of PEP.
Sections du résumé
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.
Identifiants
pubmed: 30309746
pii: S0264-410X(18)31243-X
doi: 10.1016/j.vaccine.2018.08.086
pmc: PMC6863039
pii:
doi:
Substances chimiques
Immunologic Factors
0
Rabies Vaccines
0
Types de publication
Journal Article
Research Support, Non-U.S. Gov't
Langues
eng
Sous-ensembles de citation
IM
Pagination
A45-A53Subventions
Organisme : World Health Organization
ID : 001
Pays : International
Organisme : Wellcome Trust
ID : 207569/Z/17/Z
Pays : United Kingdom
Organisme : Wellcome Trust
ID : 106824/Z/15/Z
Pays : United Kingdom
Organisme : Wellcome Trust
ID : 095787/Z/11/Z
Pays : United Kingdom
Informations de copyright
Copyright © 2018. Published by Elsevier Ltd.
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