The need to improve access to rabies post-exposure vaccines: Lessons from Tanzania.
The need to improve access to rabies post-exposure vaccines: Lessons from Tanzania.
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DOI：
10.1016/j.vaccine.2018.08.086
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发表时间：
2019-10-03
期刊：
影响因子：
5.5
通讯作者：
Hampson K
中科院分区：
文献类型：
--
作者：
Changalucha J;Steenson R;Grieve E;Cleaveland S;Lembo T;Lushasi K;Mchau G;Mtema Z;Sambo M;Nanai A;Govella NJ;Dilip A;Sikana L;Ventura F;Hampson K
接触后及时接种疫苗对预防人类狂犬病极为有效。在坦桑尼亚，暴露后皮内接种很容易被卫生工作者采用。政府对PEP的高昂成本影响了供应链，限制了其可获得性。有限的PEP供应导致更高的自付费用和更高的风险。投资促进免费提供PEP将减少狂犬病死亡人数。狂犬病可通过对暴露者迅速实施暴露后预防措施(PEP)来预防，但在许多狂犬病流行国家，获得暴露后预防措施的机会有限。我们调查了如何改善获得PEP的机会，以更好地预防人类狂犬病。使用来自坦桑尼亚不同环境的数据，包括接触者追踪(已确定2367例可能的狂犬病暴露)和基于手机的大规模监测(24,999例患者记录)，我们估计了狂犬病暴露和咬伤的发生率，并检查了与PEP接触有关的健康寻求和健康结果。我们使用调查和对卫生系统内利益相关者的定性访谈来进一步描述PEP的供应特征，并对这些发现进行三角测量。咬伤患者的发病率与狗的数量有关，在人与狗比例较低的地区和城市中心发病率较高。由于成本和对风险的有限认识，相当大比例(25%)的可能狂犬病暴露者没有寻求治疗。在进一步寻求治疗后，15%的可能暴露于狂犬病的人由于短缺、成本障碍或错误建议而没有获得PEP。在发起PEP的人中，46%的人没有完成课程。如果没有注射PEP，在可能的狂犬病暴露后患狂犬病的风险很高(0.165)，其中头部的咬伤风险最大。分散和自由的PEP增加了患者接受PEP的可能性，并减少了启动PEP的延迟。卫生工作者在改用节省剂量的PEP ID给药时没有遇到重大困难。卫生基础设施还包括足够的冷链能力，以支持改进的PEP供应。然而，政府和患者的高昂成本目前限制了供应链和PEP的获取。预算下放加剧了成本障碍，优先考虑为其他疾病购买更便宜的药品。反应性采购导致PEP供应有限且反应迟钝，增加了咬伤受害者的成本和风险。通过圈护采购、改用节省剂量的ID方案和免费提供PEP，可以改善PEP的获取，减少狂犬病死亡。
Prompt post-exposure vaccination is extremely effective in preventing human rabies. Intradermal post-exposure vaccination is easily adopted by health workers in Tanzania. High costs of PEP to government affect the supply chain and limit its availability. Limited PEP supply results in higher out-of-pocket payments and increased risks. Investment to facilitate free PEP provision would reduce rabies deaths. 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.
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