Date Published: July 12, 2018
Publisher: Public Library of Science
Author(s): Anna Charinna B. Amparo, Sarah I. Jayme, Maria Concepcion R. Roces, Maria Consorcia L. Quizon, Ernesto E. S. Villalon, Beatriz P. Quiambao, Mario S. Baquilod, Leda M. Hernandez, Louise H. Taylor, Louis H. Nel, Charles E Rupprecht.
The Philippine government has an extensive network of 513 Animal Bite Treatment Centers (ABTCs) to supply rabies post exposure prophylaxis (PEP), reaching over 1 million bite victims in 2016. The network was evaluated using a review of existing national and provincial data, key informant interviews and surveys in sample ABTCs to determine the cost-effectiveness of this network in preventing human rabies deaths.
One urban and one rural ABTC in each of three selected provinces were studied in more detail. PEP delivery generally followed national guidance based on best practices, but there was evidence of operational challenges in supplying all ABTCs with adequate biologics and recently trained staff. Funding was contributed by different levels of government and in some clinics, patients paid for a significant fraction of the total cost. From a health provider perspective including both fixed and variable costs, the average PEP course delivered cost USD 32.91 /patient across urban ABTCs (with higher patient throughput) and USD 57.21 /patient across rural ABTCs. These costs suggests that PEP provision in the Philippines cost USD 37.6 million in 2016, with a cost per life saved of USD 8,290. An analysis of the 2,239 suspected rabies deaths from 2008 to 2016 showed no significant decline, and from 2014–16 an average of 8,534 years of life were lost annually. The incidence of rabies deaths from 2014–16 was not clearly related to the provision of ABTCs (per 100,000 population) or human population density, but deaths were more common in higher income provinces.
In the context of comprehensive rabies control (including dog vaccination and public awareness) ways to reduce this high expenditure on PEP should be explored, to most cost-effectively reach the elimination of human rabies deaths. This paper is accompanied by another containing data on the operation of ABTCs network from a patient perspective.
Wherever rabies is endemic in dogs, potentially exposed bite victims need to be able to access PEP quickly and without great expense. Few rabies endemic countries have been as successful in decentralising the provision of PEP as the Philippines. Here an extensive network of Animal Bite Treatment Centers and trained staff was developed and vaccine is typically provided free of charge to patients.
This analysis focused exclusively on the provision of PEP through government run ABTCs, as government provided services are the most likely model to be replicated in low income rabies endemic countries, and to be potentially supported by Gavi. Private services, especially those using intramuscular administration are unlikely to be affordable to the majority of communities living in low income countries where the bulk of human rabies deaths occur. In addition, there is no centralised data on privately–run ABCs in the Philippines.
The Philippines ABTC network has expanded greatly over the last decade, and currently over 500 government-run ABTCs exist (facilitated by cost-sharing mechanism between national and local governments). Private bite treatment centers are also in operation. Although the target of 1 ABTC / 100,000 population has only been reached in 16 provinces, poorer provinces have similar numbers of ABTCs/100,000 people as wealthier ones. Since 2016, these facilities have been providing free anti-rabies vaccines and subsidized eRIG to animal bite/scratch victims.