Research Article: Rabies Exposures, Post-Exposure Prophylaxis and Deaths in a Region of Endemic Canine Rabies

Date Published: November 25, 2008

Publisher: Public Library of Science

Author(s): Katie Hampson, Andy Dobson, Magai Kaare, Jonathan Dushoff, Matthias Magoto, Emmanuel Sindoya, Sarah Cleaveland, Marie Paule Kieny

Abstract: BackgroundThousands of human deaths from rabies occur annually despite the availability of effective vaccines following exposure, and for disease control in the animal reservoir. Our aim was to assess risk factors associated with exposure and to determine why human deaths from endemic canine rabies still occur.Methods and FindingsContact tracing was used to gather data on rabies exposures, post-exposure prophylaxis (PEP) delivered and deaths in two rural districts in northwestern Tanzania from 2002 to 2006. Data on risk factors and the propensity to seek and complete courses of PEP was collected using questionnaires. Exposures varied from 6–141/100,000 per year. Risk of exposure to rabies was greater in an area with agropastoralist communities (and larger domestic dog populations) than an area with pastoralist communities. Children were at greater risk than adults of being exposed to rabies and of developing clinical signs. PEP dramatically reduced the risk of developing rabies (odds ratio [OR] 17.33, 95% confidence interval [CI] 6.39–60.83) and when PEP was not delivered the risks were higher in the pastoralist than the agro-pastoralist area (OR 6.12, 95% CI 2.60–14.58). Low socioeconomic class and distance to medical facilities lengthened delays before PEP delivery. Over 20% of rabies-exposed individuals did not seek medical treatment and were not documented in official records and <65% received PEP. Animal bite injury records were an accurate indicator of rabies exposure incidence.ConclusionsInsufficient knowledge about rabies dangers and prevention, particularly prompt PEP, but also wound management, was the main cause of rabies deaths. Education, particularly in poor and marginalized communities, but also for medical and veterinary workers, would prevent future deaths.

Partial Text: Rabies is an acute viral infection which causes horrifying neurological symptoms that inevitably result in death. Although human rabies encephalitis remains untreatable [1], the infection is entirely preventable, both by post-exposure prophylaxis (PEP) of bite victims, and by population-level vaccination of the zoonotic reservoir, which across most of Africa and Asia is the domestic dog [2]. Modern cell culture vaccines used in combination with rabies immunoglobulins are virtually 100% effective in preventing human deaths if administered promptly to rabies-exposed patients following appropriate wound management [3] and mass vaccination of domestic dogs has successfully eliminated or controlled domestic dog rabies in many parts of the world [4],[5]. It is therefore inexcusable that an estimated 55,000 human deaths from rabies occur annually [6], of which over 99% are in developing countries where the disease is endemic in domestic dog populations [7].

We investigated how risks of rabies exposure and onset of disease vary according to epidemiological and socioeconomic determinants and present evidence-based recommendations to reduce these risks in settings where canine rabies is endemic, addressing perspectives of both the health provider and patient [13].



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