Clinicians’ management of patients potentially exposed to rabies in high-risk areas in Bhutan: A cross-sectional study

Abstract

23Background: Rabies is endemic in southern Bhutan, associated with 1-2 human deaths annually and 24 accounting for about 6% of annual national expenditure on essential medicines. A WHO-adapted 25 National Rabies Management Guidelines (NRMG) is available to aid clinicians in PEP prescription. An 26understanding of clinical practice in the evaluation of rabies risk in endemic areas could contribute to 27 improve clinicians' PEP decision-making. 28 Methods: A cross-sectional survey of clinicians was conducted in 13 health centers in high-rabies-risk 29 areas of Bhutan during February-March 2016. Data were collected from 273 patients examined by 50 30 clinicians. 31 Results: The majority (69%) of exposure was through dog bites. Half the patients were children under 18 32 years of age. Consultations were conducted by health assistants or clinical officers (55%), or by medical 33 doctors (45%), with a median age of clinicians of 31 years. Rabies vaccines were prescribed in 91% of 34 exposure cases. The overall agreement between clinician's rabies risk assessment and the NRMG for the 35 corresponding exposure was low (kappa =0.203, p<0.001). Clinicians were more likely to underestimate 36 the risk of exposure than overestimate it. Male health assistants were the most likely to make an 37 accurate risk assessment and female health assistants were the least likely. Clinicians from district or 38 regional hospitals were more likely to conduct accurate risk assessments compared to clinicians in Basic 39 Health Units (Odds Ratios of 7.8 and 17.6, respectively). 40 Conclusions: This study highlighted significant discrepancies between clinical practice and guideline 41 recommendations for rabies risk evaluation. Regular training about rabies risk assessment and PEP 42 prescription should target all categories of clinicians. An update of the NRMG with more specific 43 criterions for the prescription of RIG might contribute to increase the compliance, along with a regular 44 review of decision-making criteria to monitor adherence to the NRMG. 45Author summary 46 Human rabies remains an important public health threat in Bhutan, especially in southern regions where 47 canine rabies is endemic. The steady increase in number of patients reporting to hospitals following dog 48 bites means escalating costs of post-exposure prophylaxis for the country. We investigated attitudes and 49 practices of clinicians who manage patients with potential rabies exposure, in the endemic area. The risk 50 of rabies exposure in the study area is mostly associated with dog bites, involving children half the time. 51Rabies vaccines were prescribed in 9 out of 10 exposure cases, while immuno-globulins were rarely 52 prescribed. The study confirmed the perceived lack of compliance of clinicians with guideline 53 recommendations for assessing rabies risk. This results in under-estimating the rabies risk in potentially 54 risky exposures in high-rabies-risk areas. Our work underscore the importance of targeted training of 55 female health assistants, do...