(5.9)--9.9外科护理学外科护理学Aretrospectiveevaluationofbit.pdf

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1、RESEARCH ARTICLEA retrospective evaluation of bites at risk ofrabies transmission across 7 years:The needto improve surveillance and reportingsystems for rabies eliminationPasquale De Nardo1,2,Elisa Gentilotti1,3,Francesco Vairo2,Boniface Nguhuni1,2*,Zainab Chaula1,Emanuele Nicastri2,Abbas Ismail4,G

2、iuseppe Ippolito21 Resource Centre for Infectious Diseases,Department of Internal Medicine,Dodoma Regional ReferralHospital,Dodoma,Tanzania,2 Lazzaro Spallanzani National Institute for InfectiousDiseases INMI-IRCCS,Rome,Italy,3 Departmentof Infectious Diseases,Tor Vergata University Hospital,Rome,It

3、aly,4 Universityof Dodoma-UDOM,Department of Statistics,Dodoma,Tanzania*AbstractThe vast majority of rabies deaths occur in developing countries and rural areas.Due to theabsence of surveillance and the lack of reliable information,many endemic countries are notable to assess their rabies burden and

4、 implement appropriate solutions.This study reportsthe incidence of animal bites considered at risk of rabies transmission,along with rates anddeterminants of the adherence to post-exposure prophylaxis(PEP)between 2008 and 2014in Dodoma Region,Tanzania.A retrospective analysis of rabid animal bites

5、considered atrisk of rabies transmission at Dodoma Regional Referral Hospital(DRRH)during 20082014 was conducted.Data were collected from the registers of patients presenting to thehospital because of a potential rabies exposure.The patients were assessed by a trainedhealth worker and each bite was

6、considered as“at risk of rabies”based on the victimsdescription of the event.Overall,10,771 patients coming from Dodoma Region attendedDRRH because of a bite from a suspected rabid animal,giving a mean incidence of 74 bitesat risk of rabies transmission per 100,000 persons per year.Overall,only 46.0

7、%of peopleexposed received a complete course of PEP and 61.6%attended the clinic within 48 hoursafter the bite.Multivariate analysis shows that people age 15 years,residence in ruralareas and occurrence during the rainy season were independently associated to delayedaccess to care.Male gender,age be

8、low 15 years.and bites occurring during the dry seasonwere associated with completion of PEP.In this area with a high rate of at-risk bites,severalfactorsmainly related to health care access and to the affordability and delivery of rabiesvaccinesstill need to be addressed in order to reduce gender a

9、nd social inequalities inrabies prevention and control.Further efforts are required to establish an efficient rabies sur-veillance system in Dodoma Region.PLOS ONE|https:/doi.org/10.1371/journal.pone.0197996July 2,20181/10a1111111111a1111111111a1111111111a1111111111a1111111111OPENACCESSCitation:DeNa

10、rdoP,GentilottiE,VairoF,NguhuniB,ChaulaZ,NicastriE,etal.(2018)Aretrospectiveevaluationofbitesatriskofrabiestransmissionacross7years:Theneedtoimprovesurveillanceandreportingsystemsforrabieselimination.PLoSONE13(7):e0197996.https:/doi.org/10.1371/journal.pone.0197996Editor:WandaMarkotter,UniversityofP

11、retoria,SOUTHAFRICAReceived:July12,2017Accepted:May12,2018Published:July2,2018Copyright:2018DeNardoetal.ThisisanopenaccessarticledistributedunderthetermsoftheCreativeCommonsAttributionLicense,whichpermitsunrestricteduse,distribution,andreproductioninanymedium,providedtheoriginalauthorandsourcearecre

12、dited.DataAvailabilityStatement:AllrelevantdataarewithinthepaperanditsSupportingInformationfiles.Funding:ThissurveywassupportedbytheResourceCenterforInfectiousDiseasesofDodomaRegionalReferralHospital-TanzaniaandtheItalianDevelopmentCooperation-MinistryofForeignAffairsAID9562andRicercaCorrenteoftheIt

13、alianMinistryofHealth.Thefundershadnoroleinstudydesign,datacollectionandanalysis,IntroductionRabies is one of the earliest infection recorded.Descriptions compatible with rabies werefound in ancient text from Egypt,Persia and China 1.Moreover,rabies is the infectiousdisease with the highest case-fat

14、ality ratio;once clinical signs appear,the disease is almostunavoidably fatal 2.Despite the existence of post-exposure vaccines for victims of rabid-ani-mal bites since 1885,an average 59,000 people die worldwide of rabies each year 3,the vastmajority of these deaths occurring in Asia and Africa wit

15、h little changes in its global distribu-tion 4.This deadly disease affects especially poor and vulnerable populations in remote ruralcommunities with limited access to human vaccine and specific immunoglobulins 4.In Tanzania,canine rabies is endemic,with more than 40,000 dog bites reported for theye

16、ar 2000 and around 1500 human rabies deaths estimated to occur annually,giving a nation-wide annual incidence of around 5 cases cases/100,000 5.However,the extent of the problemmay be heavily underestimated 4.Although all age groups are susceptible,rabies is mostcommon in children younger than 15 ye

17、ars.In the north-western part of Tanzania,the inci-dence of rabies was 5 times higher in children under 15 than in adults 3,4.Rabies is described as being“100percent fatal,100percent preventable”6.Rabies preven-tion and control can be achieved through the implementation of vaccine coverage among the

18、dogs 6.To effectively break the transmission cycle,approximately 70.0%of the local dog pop-ulation needs to be vaccinated 7.To prevent the risk of developing rabies in humans,the WHO recommends immediatetreatment of the bite-victim through Post-Exposure Prophylaxis(PEP)measures dependingon the type

19、of contact with the suspected rabid animal 8.For the categories at risk(categoryII and III),washing and flushing of all bite wounds and scratches for about 15 minutes withsoap or detergent and copious amounts of water should be done as early as possible 8.Indi-viduals with WHO category II or III exp

20、osures should receive PEP without delay as an emer-gency procedure.Currently,the recommended WHO option is intradermal PEP regimenadministered on days 0,3 and 7.Intramuscular regimens are still considered valid options tobe administered as follows:1-site vaccine administration on days 0,3,7 and the

21、fourth dosebetween days 14 to 28;2-site vaccine administration on day 0 and 1-site on days 7 and 21 8.RIG should be administered for severe category III exposures.The availability and accessibilityof PEP is extremely limited in most of Sub-Saharan Africa 9.In particular,national studiesshow that off

22、icial reports may underestimate rabies incidence by more than 100-fold,becausemost deaths occur in communities rather than in hospitals 7,9,and those occurring in hospi-tals are frequently misdiagnosed as encephalitis of unknown origin 10.Generating accuratedata on rabies incidence will be key to ac

23、hieving control and elimination of this neglected dis-ease in endemic areas 11.We conducted a retrospective study to determine the incidence of humans being bitten bysuspected rabid animals,the rate of adherence to the PEP and its determinants over the period20082014 in Dodoma Region,Tanzania.Materi

24、als and methodsStudy site and procedures for rabies exposure management at DRRHThe study was conducted at Dodoma Regional Referral Hospital(DRRH),serving a popula-tion of 2,083,588.Data were retrospectively collected from the registers of patients attendingthe health facility because of a potential

25、rabies exposure between 2008 and 2014.The riskassessment of developing rabies after an exposure was performed by trained health person-nel.The WHO approachbased on epidemiology,characteristics of exposure and clinicalBites at risk of rabies transmission in Dodoma Region,TanzaniaPLOS ONE|https:/doi.o

26、rg/10.1371/journal.pone.0197996July 2,20182/10decisiontopublish,orpreparationofthemanuscript.Competinginterests:Theauthorshavedeclaredthatnocompetinginterestsexist.criteriawas adopted during the study period 8.The following exposure modalities wereconsidered at risk of rabies transmission,thus requi

27、ring PEP:“nibbling of uncovered skin,minor scratches or abrasions without bleeding,licks on broken skin”(category II)and“sin-gle or multiple transdermal bites or scratches,contamination of mucous membrane withsaliva from licks;exposure to bat bites or scratches”(category III).The Anti-Rabies Vaccine

28、(ARV)regimen offered during the reporting period consisted in multiple intramuscularadministrations of the human diploid-cell vaccine(H-DCV,Rabivax1)at day 0,7,and 28.This schedule is not included among those recommended by WHO.Rabies immunoglobulinwas not available at DRRH in 20082014.Data collecti

29、on and statistical analysisA dataset including only the patients coming from Dodoma Region and considered at risk ofdeveloping rabies was created.The statistical analysis was conducted on this dataset.Informa-tion collected from the registers included patients age,sex and geographical location(distr

30、ict),the month and year of bite occurrence,the delay in attending the hospital categorized in?2days,37 days and 7 days of delay,the species of the biting animal,and the number of vac-cine doses administered to the patient.All the districts outside Dodoma municipality wereclassified as“rural area”.Ad

31、herence to ARV and rabies awareness were calculated as numberof doses received and time between the bite and hospital attendance(delay),respectively.Data were aggregated by districts,years,age,and sex.Incidence was calculated using the popu-lation estimates from the 2012 population and housing censu

32、s 12.Descriptive,univariateand multivariate logistic regression analyses were performed using SAS software version 9.3SAS Institute,Inc.,Cary,NC,USA with the aim to investigate the predictors of delay inattending health care and the variables associated with complete PEP intake(defined asreceipt of

33、all three doses,according to the regimen offered at DRRH)among individualsexposed.Statistical significance was assessed at =0.05.Tanzania map showed in Fig 1 wascreated using Landsatlook,available at https:/landsatlook.usgs.gov/.Dodoma region mapshowed in Fig 1 was created by using Paintbrush(Micros

34、oft)and Adobe Photoshop(AdobeSystems Incorporated).The study received approval from the Dodoma Regional Health Management Team.Alldata analyzed were anonymized.ResultsFrom 1st January 2008 to 31st December 2014,14,624 patients attended the DRRH because ofanimals bites.Eighty-three per cent(12,098)in

35、dividuals came from Dodoma Region.Amongthem,89.0%(10,771)were considered exposed to potentially rabid animals based on clinicianassessment,giving a mean incidence of 74 bites considered at risk of rabies transmission per100,000 persons per year.A dataset of all patients coming from Dodoma Region and

36、 consid-ered at risk was created and the statistical analysis was conducted on this dataset.DodomaMunicipality and Chamwino District reported the higher number animal bites considered atrisk of rabies transmission over the period of study,accounting for 32.0%(3500)and 23.5%(2537)of bites,respectivel

37、y(Fig 1).The number of bites considered at risk of rabies transmis-sion has been progressively increasing over the 7-years period.The animal responsible for thebites was most frequently a dog(Fig 2).During the study period,children under 15 years old accounted for 53.0%(5705)of sus-pected rabid anim

38、al bites.Only 61.6%(6632)of the patients attended the clinic within 48hours after the bite,while 27.0%(2917)referred to DRRH within 7 days and 11.4%(1222)even more than one week after being bitten(Table 1).Bites at risk of rabies transmission in Dodoma Region,TanzaniaPLOS ONE|https:/doi.org/10.1371/

39、journal.pone.0197996July 2,20183/10At univariate and multivariate analysis,adults were more likely to delay the access to thehospital compared to children(p0.001)as well as people living in rural area compared tothose living in urban area(p0.001).Similarly,during rainy season people were more likely

40、 todelay the access to care(p=0.03).Gender was not significantly associated with delay(Table 2).Overall,46.0%(5955)of the total number of individuals exposed to potentially rabid ani-mals completed the PEP course,while 6.5%(698)did not receive any dose.Regarding the over-all completion of ARV,childr

41、en and males were more likely to receive all the scheduled doses(p0.001).Bites occurring during the rainy season were inversely associated with completionof PEP(p0.001)(Table 3).Living in rural area was statistically associated with loss to follow up after the first dose(p0.001)or after the second d

42、ose(p0.001)Females were more likely to be lost after the firstdose(p=0.006).Both age and season were not related to loss to follow up.DiscussionDuring the study period,DRRH was the only health care facility in Dodoma Region identifiedas reference centre for rabies prevention and control,serving all

43、the districts within theFig 1.Total number of suspected rabid animal bites in Dodoma region.(a)Total number of suspected rabid animal bites from 2008 to 2014distributed per district.(b)Diagram of number of suspected rabid animal bites per district and year.https:/doi.org/10.1371/journal.pone.0197996

44、.g001Bites at risk of rabies transmission in Dodoma Region,TanzaniaPLOS ONE|https:/doi.org/10.1371/journal.pone.0197996July 2,20184/10Fig 2.Characteristics of reported suspected rabid animal bites and post-exposure prophylaxis.(a)Proportion ofsuspected rabid animal bites over total number of bites p

45、er year.(b)Animal species responsible for bites.(c)Post-exposureprophylaxis administered between 2008 and 2014.https:/doi.org/10.1371/journal.pone.0197996.g002Bites at risk of rabies transmission in Dodoma Region,TanzaniaPLOS ONE|https:/doi.org/10.1371/journal.pone.0197996July 2,20185/10regional bor

46、ders and nearby regions.Therefore,the data presented in this study largely reflectthe trend of exposure to potentially rabid animals and ARV administration in the entire regionfrom 2008 to 2014.During the same period,48 suspected rabies deaths occurred at DRRH,although post-mortem confirmation was n

47、ot available(data retrieved from hospitals records).The rate of suspected rabid animal bites has been rising over the years(Fig 2a).A possibleexplanation of this could be a more accurate adoption of the WHO approachbased onTable 1.Patients characteristics,delay,PEP administration and follow up of su

48、spected rabid animal bites.2008200920102011201220132014TotalSuspected rabies bites(N)94211231530139019111950192510,771Sex(column%)Male528(56.1)648(57.7)851(55.6)788(56.7)1124(58.8)1156(59.3)1130(58.7)6225(57.8)Female407(43.2)475(42.3)679(44.4)599(43.1)781(40.9)794(40.7)795(41.3)4530(42.1)Not known7(

49、0.7)003(0.2)6(0.3)0016(0.1)Age(years old),N(column%)Median(IQR)=13(24)7118(12.5)158(14.1)187(12.2)183(13.2)225(11.8)198(10.2)153(7.9)1222(11.4)Completion of PEP,N(column%)Complete prophylaxis372(39.5)540(48.0)735(48.0)662(47.6)900(47.1)918(47.1)828(43.0)4955(46.0)Incomplete prophylaxis461(48.9)533(4

50、7.5)708(46.3)614(44.2)920(48.1)901(46.2)981(51.0)5118(47.5)No dose received109(11.6)50(4.5)87(5.7)114(8.2)91(4.8)131(6.7)116(6.0)698(6.5)Loss at follow up N(column%)Lost after I dose166(36.0)154(28.9)292(41.2)207(33.7)347(37.7)368(41.1)395(41.8)1929(38.0)Lost after II dose295(64.0)379(71.1)416(58.8)