An epidemiological study of suspected rabies exposures and adherence to rabies post-exposure prophylaxis in Eastern Thailand, 2015
An epidemiological study of suspected rabies exposures and adherence to rabies post-exposure prophylaxis in Eastern Thailand, 2015
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DOI：
10.1371/journal.pntd.0007248
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发表时间：
2020-02-01
影响因子：
3.8
通讯作者：
Wallace, Ryan M.
中科院分区：
文献类型：
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作者：
Yurachai, Onphirul;Hinjoy, Soawapak;Wallace, Ryan M.
人类狂犬病在泰国是一种应报告的疾病，2010-2015年报告了46例确诊和可能病例;泰国东部报告了11例。虽然狂犬病可以通过疫苗预防，但在泰国死于狂犬病的人中，超过90%没有接受或不适当地停止了暴露后预防（PEP）。2012年，泰国启动了一项国家动物狂犬病消除计划，目标是到2020年消除狂犬病。该国家计划的政策之一是改善动物狂犬病暴露的检测、PEP的获取以及疫苗接种时间表的遵守。为了实现这一目标，几个医院为基础的电子PEP监测系统已经制定了整个Thailand.MethodData从一个自愿的，电子医院为基础的，狂犬病暴露和PEP监测系统进行了分析，从泰国东部8个省份的时间段1月1日至2015年12月31日。该监测系统收集所有前往R36综合医疗机构疑似接触狂犬病的人的数据，包括咬人动物的特征、狂犬病接触的分类以及对PEP建议的遵守情况。按省份评估了因疑似狂犬病暴露而寻求医疗保健的粗比率，并开发了一个多变量线性回归模型，以确定由于在不使用R36系统的医疗机构进行咬伤治疗而导致未检测到狂犬病暴露的潜在程度。疑似狂犬病暴露通过患者人口统计学、伤口位置和肇事动物的处置进行描述。比较肌肉内和皮内接种方案的依从性，并计算与不建议的PEP终止相关因素的比值比。结果泰国东部8个省报告了6，204例疑似狂犬病暴露，得出的粗暴露率为每10万人106例报告的狂犬病暴露。当调整由于非参与医院和省级人口统计学差异导致的检测不足时，估计的疑似狂犬病暴露率为204/100，000。狗是主要接触源（77.8%），60岁儿童的总体报告接触率最高（189.7/100，000和189.2/100，000）。对肌内注射5剂或皮内注射4剂PEP方案的依从性较低（分别为15.8%和46.5%）;只有15%的人接受了狂犬病免疫球蛋白。如果是男性、年龄在16-45岁、接受免疫球蛋白或肌肉注射，狂犬病暴露者更有可能违背医嘱停止疫苗接种。结论当调整报告医院数量、省份人口密度、人均医院数量和平均家庭收入时，预期报告率增加1.9倍，这表明，对因疑似狂犬病暴露而寻求医疗护理的人可能存在很高的检测不足水平。扩大电子监测系统的实施可能会改善狂犬病暴露的报告和流行病学知识。对从该系统收集的数据进行的分析显示，对狂犬病疫苗接种建议的遵守率非常低。PEP坚持是更好的皮内途径，这提供了更多的支持，其使用的情况下，它是经济可行的。作者summaryWhile狂犬病是一种疫苗可预防的疾病，尽管在获得医疗保健的巨大改善，人类狂犬病死亡继续发生在泰国。从一个自愿的，电子医院为基础的，狂犬病暴露和PEP监测系统的数据进行了分析，从泰国东部的八个省份。在2015年1月1日至12月31日期间，共报告了6，204例疑似狂犬病暴露，得出的粗暴露率为每10万人口106例报告的狂犬病暴露，或经低报调整后为204/10万。狗是主要的接触源，60岁的儿童< 15 years and elderly aged >报告的总体接触率最高。肌内或皮内PEP方案的依从性较低（IM为15.8%，ID为46.5%）。在泰国东部，对因疑似狂犬病暴露而寻求医疗护理的人的检测可能很低，但扩大电子监测系统的实施可能会改善报告。需要进一步调查，以了解为什么坚持PEP率低。皮内途径的粘附性更好，这为在经济上可行的情况下使用提供了更多支持。
BackgroundHuman rabies is a notifiable condition in Thailand, and 46 confirmed and probable cases were reported from 2010-2015; eleven were reported from Eastern Thailand. Although rabies is vaccine preventable, more than 90% of persons who died of rabies in Thailand either did not receive or inappropriately discontinued post-exposure prophylaxis (PEP). In 2012 Thailand launched a national animal rabies elimination program with the goal of elimination by 2020. One of the policies of this national program is to improve detection of animal rabies exposures, access to PEP, and adherence to vaccine schedules. To achieve this goal, several hospital-based electronic PEP surveillance systems have been instituted throughout Thailand.MethodData from a voluntary, electronic hospital-based, rabies exposure and PEP surveillance system was analyzed from eight provinces in Eastern Thailand for the time period January 1 -December 31, 2015. The surveillance system collects data from all persons who present to an R36-integrated healthcare facility with a suspected rabies exposure, including characteristics of the biting animals, categorization of the rabies exposure, and adherence to PEP recommendations. The crude rate of healthcare seeking for a suspected rabies exposure was assessed by province, and a multivariable linear regression model was developed to determine the potential extent of undetected rabies exposures due to bite treatment at healthcare facilities that do not utilize the R36 system. Suspected rabies exposures were described by patient demographics, location of wound, and disposition of the offending animal. A comparison of adherence to intramuscular and intradermal vaccination regimens was performed and odds ratios were calculated for factors related to unadvised PEP discontinuation.Result6,204 suspected rabies exposures were reported from eight Eastern Thailand provinces, yielding a crude exposure rate of 106 reported rabies exposures per 100,000 population. When adjusted for under-detection due to non-participating hospitals and province-level demographic differences, the estimated suspected rabies exposure rate was 204/100,000. Dogs were the main source of exposure (77.8%) and children age 60 years had the highest overall reported exposure rate (189.7 and 189.2/100,000). Adherence to either the intramuscular 5-dose or the intradermal 4-dose PEP regimen was low (15.8% and 46.5%, respectively); rabies immunoglobulin was received by only 15% of persons for whom it was indicated. Persons with rabies exposures were more likely to discontinue the vaccination series against medical advice if they were male, aged 16-45, if they received immunoglobulin, or if received the intramuscular regimen.ConclusionWhen adjusting for number of reporting hospitals, province population density, number of hospitals per population and average family income, the expected report rate increased 1.9-fold, indicating that there is likely a high level of under-detection of persons seeking medical care for suspected rabies exposures. Expanded implementation of electronic surveillance systems will likely improve reporting and the epidemiologic knowledge of rabies exposures. Analysis of data collected from this system revealed very low rates of adherence to rabies vaccination recommendations. PEP adherence was better by the intradermal route, which provides more support for its use in situations where it is economically feasible.Author summaryWhile rabies is a vaccine preventable disease, and despite tremendous improvements in access to healthcare, human rabies fatalities continue to occur in Thailand. Data from a voluntary, electronic hospital-based, rabies exposure and PEP surveillance system was analyzed from eight provinces in Eastern Thailand. In total 6,204 suspected rabies exposures were reported between January 1 -December 31, 2015, yielding a crude exposure rate of 106 reported rabies exposures per 100,000 population or 204/100,000 when adjusted for under-reporting. Dogs were the main sources of exposure and children age < 15 years and elderly aged > 60 years had the highest overall reported exposure rate. Adherence to either the intramuscular or the intradermal PEP regimen was low (15.8% for IM and 46.5% for ID). There is likely a high level of under-detection of persons seeking medical care for suspected rabies exposures in Eastern Thailand, but expanded implementation of electronic surveillance systems will likely improve reporting. Further investigation is needed to understand why rates of adherence to PEP were low. Adherence was better by the intradermal route, which provides more support for its use in situations where it is economically feasible.