On the path to rabies elimination: The need for risk assessments to improve administration of post-exposure prophylaxis.

BACKGROUND: Costs of rabies post-exposure prophylaxis (PEP) often remain high in regions where rabies has been controlled in dogs, presenting a challenge for sustaining rabies elimination programmes. We investigated the potential for bite patient risk assessments to improve PEP provision and surveillance in settings approaching elimination of dog-mediated rabies. METHODS: We conducted a longitudinal study of patients presenting to animal bite treatment centres (ABTCs) on the island province of Bohol in the Philippines to investigate the health status of biting dogs and to quantify current expenditure on PEP. RESULTS: Incidence of bite patients presenting to ABTCs was high (>300/100,000 persons/year) and increasing, resulting in substantial health provider costs. Over $142,000 was spent on PEP in 2013 for a population of 1.3 million. From follow up of 3820 bite patients we found that  >92% were bitten by healthy dogs (alive 14 days after the bite) and just 1.4% were bitten by probable or confirmed rabid dogs. The status of dogs that bit 6% of patients could not be determined. During the course of investigations of bites by suspect dogs, we were able to obtain samples for case confirmation, identify exposed persons who had not sought PEP as well as in-contact dogs at risk of developing rabies. We calculate that expenditure on PEP could at least be halved through more judicious approaches to provision of PEP, based on the histories of biting animals determined through risk assessments with bite patients. CONCLUSIONS: We conclude that a One Health approach to surveillance based on Integrated Bite Case Management could improve the sustainability and effectiveness of rabies elimination programmes while also improving patient care by identifying those genuinely in need of lifesaving PEP.

Towards Canine Rabies Elimination in Cebu, Philippines: Assessment of Health Economic Data.

Rabies is endemic in the Philippines. In 2010, with support from the Bill and Melinda Gates Foundation, a canine rabies elimination project was initiated in the Philippine Archipelago of Visayan. We conducted an analysis of dog vaccination and human PEP costs for dog bite patients in a highly urbanized area and a low-income rural municipality in Cebu Province, Philippines, from 2010 to 2012. Our findings indicated that eliminating rabies in dogs through mass vaccination is more cost-effective than treating rabies exposures in humans. The average costs (in USD) per human life saved through PEP were $1620.28 in Cebu City and $1498 in Carmen. Costs per dog vaccinated ranged from $1.18 to $5.79 in Cebu City and $2.15 to $3.38 in Carmen. Mass dog vaccination campaigns conducted in each village were more cost-effective than fixed-site campaigns. The costs of dog vaccination can be reduced further through bulk vaccine purchase by the national government or large donor agency, for example the BMGF. As communities achieve canine rabies elimination, more judicious use of PEP will result in significant public savings. The study affirms the willingness of local governments to invest and reassure donors of their cooperation and resource contribution to sustain disease elimination efforts.

Two clustered cases of confirmed influenza A(H5N1) virus infection, Cambodia, 2011.

In February 2011, a mother and her child from Banteay Meanchey Province, Cambodia, were diagnosed, postmortem, with avian influenza A(H5N1) virus infection. A field investigation was conducted by teams from the Cambodian Ministry of Health, the World Health Organization and the Institut Pasteur in Cambodia. Nasopharyngeal, throat and serum specimens collected from 11 household or three neighbour contacts including two suspect cases tested negative by reverse transcriptase-polymerase chain reaction (RT-PCR) for A(H5N1). Follow-up sera from the 11 household contacts also tested negative for A(H5N1) antibodies. Twenty-six HCW who were exposed to the cases without taking adequate personal protective measures self-monitored and none developed symptoms within the two following weeks. An unknown number of passengers travelling with the cases on a minibus while they were symptomatic could not be traced but no clusters of severe respiratory illnesses were detected through the Cambodian surveillance systems in the two weeks after that. The likely cause of the fatal infection in the mother and the child was common-source exposure in Preah Sdach District, Prey Veng Province. Human-to-human transmission of A(H5N1) virus was unlikely but genetic susceptibility is suspected. Clusters of A(H5N1) virus infection should be systematically investigated to rule out any human-to-human transmission.

STI declines among sex workers and clients following outreach, one time presumptive treatment, and regular screening of sex workers in the Philippines.

OBJECTIVES: This intervention linked research aimed to reduce prevalence of Neisseria gonorrhoeae (Ng) and Chlamydia trachomatis (Ct) among female sex workers by means of one round of presumptive treatment (PT), and improved prevention and screening services. METHODS: A single round of PT (azithromycin 1 g) was given to all female sex workers reached during a 1 month period of enhanced outreach activity. Routine sexually transmitted infection (STI) screening services were successfully introduced for two groups of unregistered sex workers who work in brothels (BSWs) and on the street (SSWs). No changes were made to existing screening methods for registered sex workers (RSWs) or lower risk guest relations officers (GROs). Cross sectional prevalence of Ng and Ct was measured by PCR on three occasions, and stratified by type of sex work. Ng/Ct prevalence was assessed twice in clients of BSWs. RESULTS: Prevalence of Ng and/or Ct at baseline, 1 month post-PT, and 7 months post-PT was BSWs: 52%, 27%, 23%; SSWs: 41%, 25%, 28%; RSWs: 36%, 26%, 34%; GROs: 20%, 6%, 24%, respectively. Ng/Ct declines 1 month post-PT were significant for all groups. 6 months later prevalence remained low for BSWs (p<0.001), and SSWs (p = 0.05), but had returned to pre-intervention levels for the other groups. Prevalence of Ng/Ct among clients of BSWs declined from 28% early in the intervention to 15% (p = 0.03) 6 months later. CONCLUSIONS: In this commercial sex setting, one round of PT had a short term impact on Ng/Ct prevalence. Longer term maintenance of STI control requires ongoing access to effective preventive and curative services.

Epidemiology of Ebola (subtype Reston) virus in the Philippines, 1996.

Ebola (subtype Reston [EBO-R]) virus infection was detected in macaques imported into the United States from the Philippines in March 1996. Studies were initiated in the Philippines to identify the source of the virus among monkey-breeding and export facilities, to establish surveillance and testing, and to assess the risk and significance of EBO-R infections in humans who work in these facilities. Over a 5-month period, acutely infected animals were found at only one facility, as determined using Ebola antigen detection. Three of 1732 monkeys and 1 of 246 animal handlers tested had detectable antibodies; all were from the same facility, which was the source of infected monkeys imported to the United States. Virus transmission, which was facilitated by poor infection-control practices, continued for several months in one facility and was stopped only when the facility was depopulated. None of the 246 employees of the facilities or 4 contacts of previously antibody-positive individuals reported an Ebola-like illness. This investigation suggests that human EBO-R infection is rare.

Risk factors for injuries due to the 1990 earthquake in Luzon, Philippines.

On 16 July 1990, an earthquake measuring 7.7 on the Richter scale struck the island of Luzon, Philippines. A case-control study was carried out to identify the risk factors for earthquake-related injuries and at the same time observations were made on the rescue efforts. Being hit by falling objects was the leading cause of injury (34%). Those injured during the tremor were more likely to have been inside buildings constructed of concrete or mixed materials (odds ratio, 2.6; 95% confidence interval (CI), 1.7-4.1) and to have been on the middle floors of multistorey buildings (odds ratio, 3.4; 95% CI, 2.2-5.5). Leaving a building during the earthquake was a protective behaviour (odds ratio, 0.3; 95% CI, 0.2-0.8). Of the 235 survivors who were trapped and rescued alive from the rubble, 99% were rescued within 48 hours of the impact of the tremor. These findings should prove useful in developing seismic safety codes. People should be taught proper evasive actions to take during earthquakes, and training in basic first aid and methods of rescue should be an integral part of community preparedness programmes.

Risk factors for injuries due to the 1990 : Earthquake in Luzon, Philippines

On 16 July 1990, an earthquake measuring 7.7 on the Richter scale struck the island of Luzon, Philippines. A case-control study was carried out to identify the risk factors for earthquake-related injuries and at the same time observations were made on the rescue efforts. Being hit by falling objects was the leading cause of injury (34

). Those injured during the tremor were more likely to have been inside buildings constructed of concrete or mixed materials (odds ratio, 2.6; 95

confidence interval (CI), 1.7-4.1) and to have been on the middle floors of multistorey buildings (odds ratio, 3.4; 95

CI, 2.2-5.5). Leaving a building during the earthquake was a protective behaviour (odds ratio, 0.3; 95

CI, 0.2-0.8). Of the 235 survivors who were trapped and rescued alive from the rubble, 99

were rescued within 48 hours of the impact of the tremor. These findings should prove useful in developing seismic safety codes. People should be taught proper evasive actions to take during earthquakes, and training in basic first aid and methods of rescue should be an integral part pf community preparedness programmes.(AU)