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Preplanned Studies: Epidemiological Study of Outpatients in Rabies Post-Exposure Prophylaxis Clinics — Tianjin Municipality, China, 2020

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  • Summary

    What is already known on this topic?

    Rabies remains a serious public health problem in China. The only way to prevent the fatal disease was through timely and adequate post-exposure prophylaxis (PEP).

    What is added by this report?

    Among all the 126,133 cases visited Tianjin PEP clinics during 2020, more than 90% of the patients were injured by domestic dogs or cats, and about 70% of the animals received vaccination. Most outpatients have knowledge of rabies and show high compatibility with PEP.

    What are the implications for public health practice?

    To better control rabies, we need to pay more attention to people who lack knowledge of rabies and help them gain awareness of PEP.

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  • [1] Guo C, Li Y, Huai Y, Rao CY, Lai SJ, Mu D, et al. Exposure history, post-exposure prophylaxis use, and clinical characteristics of human rabies cases in China, 2006–2012. Sci Rep 2018;8(1):17188. http://dx.doi.org/10.1038/s41598-018-35158-0CrossRef
    [2] Liu YF, Lyv J, Su C, Li L. Epidemiological characters and clinical features of human rabies in Tianjin, 2005–2017. Int J Virol 2018;25(4):255–8. https://d.wanfangdata.com.cn/periodical/ChlQZXJpb2RpY2FsQ0hJTmV3UzIwMjEwOTA5EhNnd3l4LWJkeGZjMjAxODA0MDEyGgg3bnlwdWRhZA%253D%253D. (In Chinese). https://d.wanfangdata.com.cn/periodical/ChlQZXJpb2RpY2FsQ0hJTmV3UzIwMjEwOTA5EhNnd3l4LWJkeGZjMjAxODA0MDEyGgg3bnlwdWRhZA%253D%253D
    [3] World Health Organization. Guide for ribies pre and post-exposure prophylaxis in humans. 2010. https://www.who.int/rabies/PEP_prophylaxis_guidelines_June10.pdf. [2021-7-8].https://www.who.int/rabies/PEP_prophylaxis_guidelines_June10.pdf
    [4] Romero-Sengson RF. Factors affecting compliance to rabies post-exposure prophylaxis among pediatric patients seen at the research institute for tropical medicine. http://pidsphil.org/pdf/Journal_12312013/jo45_ja01.pdf. [2021-7-8].http://pidsphil.org/pdf/Journal_12312013/jo45_ja01.pdf
    [5] Tran CH, Afriyie DO, Pham TN, Otsu S, Urabe M, Dang AD, et al. Rabies post-exposure prophylaxis initiation and adherence among patients in Vietnam, 2014–2016. Vaccine, 2019;37 Suppl 1: A54–63. https://www.sciencedirect.com/science/article/pii/S0264410X19300933#!.https://www.sciencedirect.com/science/article/pii/S0264410X19300933#!
    [6] Yurachai O, Hinjoy S, Wallace RM. An epidemiological study of suspected rabies exposures and adherence to rabies post-exposure prophylaxis in Eastern Thailand, 2015. PLoS Negl Trop Dis 2020;14(2):e0007248. http://dx.doi.org/10.1371/journal.pntd.0007248CrossRef
  • TABLE 1.  Characteristics of the patients visited post-exposure prophylaxis clinics in Tianjin Municipality, China, 2020.

    Characteristics No. of reported exposures Percent (%)
    Sex
    Male 61,842 49.03
    Female 64,291 50.97
    Exposure category
    I 2,859 2.01
    II 59,893 47.61
    III 63,381 50.38
    Exposure site
    Hands 65,032 51.56
    Legs 26,600 21.09
    Arms 16,244 12.88
    Foots 7,900 6.26
    Head/face/neck 5,372 4.26
    Trunks 4,985 3.95
    Multi-sites (more than one area) 2,668 2.12
    Animal
    Dog 70,707 56.06
    Cat 51,433 40.78
    Other 3,993 3.16
    Owner status
    Owned 116,292 92.2
    Not owned 9,841 7.80
    Animal vaccination history
    At lease one 80,793 64.54
    Never/unknown 45,340 35.46
    Type of exposure
    Bite 77,417 61.38
    Scratches 45,011 35.69
    Others 3,705 2.93
    Interval between exposure and medical attention
    2 hours 50,974 40.41
    2–6 hours 21,828 17.31
    24 hours 39,953 31.68
    >24 hours 13,378 10.60
    Wound washing
    By one’s own 116,164 92.10
    By the clinics 72,944 57.83
    History of exposure and
    re-exposure
    Within 6 months 3,528 2.27
    6 months to 1 year 4,785 3.79
    1–3 years 8,192 6.49
    Download: CSV

    TABLE 2.  Adherence to rabies vaccination advice among persons who visited the post-exposure prophylaxis clinics in Tianjin Municipality, China, 2020.

    DoseNo. of people actually vaccinatedNo. of people should be vaccinated
    (5 doses/2-1-1 regimin)
    Completion rate (%)
    1103,221106,76996.68
    2102,470106,76995.97
    3101,917106,76995.46
    4101,415106,76994.99
    5 95,488100,89994.64
    Download: CSV

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Epidemiological Study of Outpatients in Rabies Post-Exposure Prophylaxis Clinics — Tianjin Municipality, China, 2020

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Summary

What is already known on this topic?

Rabies remains a serious public health problem in China. The only way to prevent the fatal disease was through timely and adequate post-exposure prophylaxis (PEP).

What is added by this report?

Among all the 126,133 cases visited Tianjin PEP clinics during 2020, more than 90% of the patients were injured by domestic dogs or cats, and about 70% of the animals received vaccination. Most outpatients have knowledge of rabies and show high compatibility with PEP.

What are the implications for public health practice?

To better control rabies, we need to pay more attention to people who lack knowledge of rabies and help them gain awareness of PEP.

  • Rabies remains a serious public health problem in China. The disease is preventable through timely provision of adequate post-exposure prophylaxis (PEP), and designated PEP clinics exist in China to provide PEP treatment. This study aimed to understand the characteristics of outpatients in rabies PEP clinics to provide a basis for follow-up work. Data in this study was from an electronic, PEP clinic-based case registration system, including case information, exposure history, PEP recommendations, and vaccination status, which covered all 91 clinics in Tianjin Municipality from January 1 to December 31, 2020. Among all the 126,133 first-visit cases, more than 90% of the patients washed the wound by themselves and went to PEP clinics within 24 hours after exposure; 97.04% of the outpatients received the first dose of the rabies vaccine; and 94.64% of the outpatients completed the whole schedule of doses (5-doses/2-1-1 regimen). The result showed that most of the outpatients have knowledge of rabies. To better control rabies, we need to pay more attention to people who do not know about rabies and help them establish awareness of PEP.

    A total of 126,133 first-visit cases sought a consultation to PEP clinics in Tianjin Municipality from January 1 to December 31, 2020. The reported exposure rate was 909.66/100,000 population. Among all the cases, 50.97% were female (n=64,291). The mean age was 36.3 years (range: 3 months to 99 years). The major exposure animal was dogs (56.06%) and cats (40.78%); most of the animals were domesticated with identified owners (92.20%), and 69.47% of them had rabies vaccination history. Among total exposures, 50.38% (n=63,381) were classified as category III (single or multiple transdermal bites or scratches, etc.). Hands (56.56%, n=65,032) and legs (21.09%, n=26,000) were the most common sites for exposures. More than 90% of patients washed their wounds before arriving to PEP clinics and 57.98% of the cases finished wound-washing in the PEP clinics; 89.40% of the cases went to the PEP clinics within 24 hours after exposure (Table 1).

    Characteristics No. of reported exposures Percent (%)
    Sex
    Male 61,842 49.03
    Female 64,291 50.97
    Exposure category
    I 2,859 2.01
    II 59,893 47.61
    III 63,381 50.38
    Exposure site
    Hands 65,032 51.56
    Legs 26,600 21.09
    Arms 16,244 12.88
    Foots 7,900 6.26
    Head/face/neck 5,372 4.26
    Trunks 4,985 3.95
    Multi-sites (more than one area) 2,668 2.12
    Animal
    Dog 70,707 56.06
    Cat 51,433 40.78
    Other 3,993 3.16
    Owner status
    Owned 116,292 92.2
    Not owned 9,841 7.80
    Animal vaccination history
    At lease one 80,793 64.54
    Never/unknown 45,340 35.46
    Type of exposure
    Bite 77,417 61.38
    Scratches 45,011 35.69
    Others 3,705 2.93
    Interval between exposure and medical attention
    2 hours 50,974 40.41
    2–6 hours 21,828 17.31
    24 hours 39,953 31.68
    >24 hours 13,378 10.60
    Wound washing
    By one’s own 116,164 92.10
    By the clinics 72,944 57.83
    History of exposure and
    re-exposure
    Within 6 months 3,528 2.27
    6 months to 1 year 4,785 3.79
    1–3 years 8,192 6.49

    Table 1.  Characteristics of the patients visited post-exposure prophylaxis clinics in Tianjin Municipality, China, 2020.

    Among the 106,769 persons with category II or III exposure who had no history of prior rabies vaccination (or re-exposure >3 years), 96.68% (n=103,221) received the first dose of rabies vaccination. Nearly 95% of the cases completed the whole schedule of doses. Adherence to rabies is shown in Table 2. Only 25.21% (n=15,979) of the cases with category III received the rabies immunoglobulin (RIG).

    DoseNo. of people actually vaccinatedNo. of people should be vaccinated
    (5 doses/2-1-1 regimin)
    Completion rate (%)
    1103,221106,76996.68
    2102,470106,76995.97
    3101,917106,76995.46
    4101,415106,76994.99
    5 95,488100,89994.64

    Table 2.  Adherence to rabies vaccination advice among persons who visited the post-exposure prophylaxis clinics in Tianjin Municipality, China, 2020.

    • Tianjin is one of the four municipalities of China with a population of roughly 14 million people. This study shows that the annual incidence of rabies exposure was 909.66/100,000 population. But the actual incidence may be much higher than our data since almost none of the reported rabies patients went to see a doctor after they got rabies exposure (1-2).

      The standard PEP treatment comprises of wound treatment, rabies vaccine, and RIG if warranted (3). The fear of acquiring rabies and knowledge of the gravity of the disease, as well as the cost of PEP were main factors affecting PEP compliance (4).

      Among all the exposures, more than 90% were caused by domestic dogs or cats, and the animal vaccination rate was much higher than that in the other studies (1,5-6). Almost 10% of the patients were re-exposed. The high proportion of outpatients who cleaned the wound after exposure, visited PEP clinics within 24 hours (h) after exposure, and adhered to rabies vaccination showed that the majority of outpatients in the PEP clinics understood the risks of rabies.

      The adherence to rabies vaccination was very high in Tianjin. The completed inoculation rate was close to 95%, which was much higher than the results in other studies (6). However, it should also be noted that there were still a small number of patients who had not been vaccinated, the causes of which need to be further explored. Taking a 60 kg person as an example, the cost of RIG is about 5 times of the rabies vaccine. The high price may be a barrier to practical use.

      Almost all rabies cases were not treated with regular PEP (1-2). We can find that many of the outpatients in our study were not at high risk to rabies exposure (injured by immunized domestic animals, exposure sites were not on the face or the head, etc.). This is a reminder to prioritize providing education on rabies knowledge to the high-risk groups, e.g., populations in rural areas with large populations of dogs, low animal immunization rates, and little knowledge of rabies — so they would be more aware of the harm of the disease.

      The study was subject to at least two limitations. First, the data comes from PEP clinic-based case registration system. There may be duplicate cases in our study because the ID numbers were not required for entry into the system. Second, data only covered information in Tianjin Municipality; if a patient went to another province for vaccination after the first consultation, this could not be reflected in the data.

      In conclusion, to better control rabies, we need to pay more attention to people who lack knowledge of rabies and help them gain awareness of PEP. Meanwhile, we should also continue to manage PEP clinics to ensure the standardization and effectiveness of the treatment.

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