Research Article: Rabies Post-Exposure Prophylaxis in the Philippines: Health Status of Patients Having Received Purified Equine F(ab’)2 Fragment Rabies Immunoglobulin (Favirab)

Date Published: May 28, 2008

Publisher: Public Library of Science

Author(s): Beatriz P. Quiambao, Hazel Z. DyTioco, Ruby M. Dizon, Marilyn E. Crisostomo, Thelma M. Laot, Dirk E. Teuwen, Marie Paule Kieny

Abstract: BackgroundRecommended treatment for severe rabies exposure in unvaccinated individuals includes wound cleaning, administration of rabies immunoglobulins (RIG), and rabies vaccination. We conducted a survey of rabies treatment outcomes in the Philippines.MethodsThis was a case series involving 7,660 patients (4 months to 98 years of age) given purified equine RIG (pERIG) at the Research Institute for Tropical Medicine (Muntinlupa, Philippines) from July 2003 to August 2004 following Category II or III exposures. Data on local and systemic adverse reactions (AR) within 28 days and biting animal status were recorded; outcome data were obtained by telephone or home visit 6–29 months post-exposure.ResultsFollow-up data were collected for 6,464 patients. Of 151 patients with laboratory-confirmed rabies exposure, 143 were in good health 6–48 months later, seven could not be contacted, and one 4-year-old girl died. Of 16 deaths in total, 14 were unrelated to rabies exposure or treatment. Two deaths were considered PEP failures: the 4-year old girl, who had multiple deep lacerated wounds from a rabid dog of the nape, neck, and shoulders requiring suturing on the day of exposure, and an 8-year-old boy who only received rabies PEP on the day of exposure.ConclusionsThis extensive review of outcomes in persons with Category III exposure shows the recommended treatment schedule at RITM using pERIG is well tolerated, while survival of 143 laboratory-confirmed rabies exposures confirms the intervention efficacy. Two PEP intervention failures demonstrate that sustained education and training is essential in rabies management.

Partial Text: Rabies is a zoonotic disease characterized by progressive and incurable viral encephalitis, invariably fatal if untreated and usually transmitted by the bite(s) or scratches of an infected animal. Data from the Department of Health show that every year, over 100,000 people at risk in the Philippines receive rabies post-exposure prophylaxis (PEP), which varies according to the categorization of the exposure as defined by the World Health Organization (Table 1). The most severe cases, Category III, require wound cleaning, rabies vaccination, and direct wound infiltration with rabies immunoglobulin (RIG) and where possible, observation of the biting animal if it does not already display clinical symptoms of rabies for a period of 10 days [1],[2].

For the purpose of this case series, only records of patients given commercial lots of pERIG (Favirab) at the Research Institute of Tropical Medicine (RITM) rabies Admitting Section from July 2003 to August 2004 were analyzed. RITM is a government research institution that serves as a major referral center for rabies and animal bite patients. The study was approved by the RITM Institutional Review Board. A verbal consent was obtained from the patient or parents/guardians of children immediately prior to the follow-up interview.

A total of 7,660 records of subjects having received pERIG at the time of their potential rabies exposure during the period July 2003 to August 2004 could be retrieved and were reviewed for this study; 3,502 (45.7%) subjects came from the Metro Manila area, 3,382 (44.2%) subjects came from the four neighboring provinces, Bulacan (in the north) Rizal (in the East), Cavite and Laguna (in the south) and the remaining 776 (10.1%) from other provinces as far as Camarines Norte located 350 km south of Metro Manila. The most affected age group was the under -10’s, in which almost twice as many boys as girls were treated, and overall 61.8% of the cases reported were in children less than 15 years of age. The length of follow-up varied between 35 days and 29 months.

This primary objective of the evaluation was to document the health status of subjects given rabies PEP which included use of the purified equine rabies immunoglobulin (pERIG), Favirab. The health status of patients treated after Category II/III exposure with the standard of care described in the RITM guidelines was documented by an active survey by telephone or home visits. The RITM guidelines are in accordance with the WHO guidelines [2],[6], the local Philippine recommendations and those developed in other countries [7].



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