Rabies Death after Complete Post-exposure Prophylaxis

In Madagascar, dog-mediated rabies has been endemic for over a century, however there is little data on its incidence or impact. We collected data over a 16-month period on provisioning of post-exposure prophylaxis (PEP) at a focal clinic in the Moramanga District and determined the rabies status of biting animals using clinical and laboratory diagnosis. We find that animal rabies cases are widespread, and clinic-based triage and investigation are effective ways to increase detection of rabies exposures and to rule out non-cases. A high proportion of rabies-exposed persons from Moramanga sought (84%) and completed PEP (90% of those that initiated PEP), likely reflecting the access and free provisioning of PEP in the district. Current clinic vial sharing practices demonstrate the potential for intradermal administration of PEP in endemic African settings, reducing vaccine use by 50% in comparison to intramuscular administration. A high proportion of PEP demand was attributed to rabies cases, with approximately 20% of PEP administered to probable rabies exposures and an additional 20% to low-to-no risk contacts with confirmed/probable animal or human cases. Using a simplified decision tree and our data on rabies exposure status and health-seeking behavior, we estimated an annual incidence of 42–110 rabies exposures and 1–3 deaths per 100,000 persons annually. Extrapolating to Madagascar, we estimate an annual burden of 282–745 human rabies deaths with current PEP provisioning averting 1499–3958 deaths each year. Data from other clinics and districts are needed to improve these estimates, particularly given that PEP availability is currently limited to only 31 clinics in the country. A combined strategy of mass dog vaccination, enhanced surveillance, and expanded access to PEP along with more judicious guidelines for administration could effectively reduce and eventually eliminate the burden of rabies in Madagascar.

Sexual violence (SV) affects millions globally and has a well-documented bidirectional association with HIV. Post-exposure prophylaxis (PEP) is a critical, yet often underutilized, HIV prevention tool in post-SV care. Despite its potential impact to reduce HIV transmission, SV care remains an overlooked service delivery point for HIV prevention. The U.S. Centers for Disease Control and Prevention (CDC), as part of the President's Emergency Plan for AIDS Relief (PEPFAR), supports PEP provision within broader post-violence care (PVC) services. Understanding PEP utilization is crucial for optimizing service delivery and HIV prevention efforts. Using Monitoring Evaluation and Reporting data from fiscal years 2018-2023, we conducted a descriptive analysis of clients who received PVC and SV services through CDC-supported programming in 14 sub-Saharan African countries. From 2018 to 2023, the annual number of clients receiving any PVC, and specifically SV, services increased by 233% (in 2018, n = 206,764; in 2023, n = 689,349) and 163% (in 2018, n = 42,848; in 2023, n = 112,838), respectively. Fewer than half of SV clients completed PEP (38% in 2018, n = 16,103; 31% in 2023, n = 35,118). Across all years combined, most SV clients (female: 185,414; male: 59,618) were aged 15-19 years. The age band and sex with the lowest proportion of clients completing PEP were males aged 15-19 (4%, n = 2296). The findings underscore a critical gap between the scaling of SV services and the completion of PEP within violence response programmes. Innovative implementation science approaches may help to identify and address barriers inhibiting effective PEP delivery and uptake within PVC service delivery programmes. Enhancing PEP uptake and completion can support mitigating the bidirectional relationship between violence and HIV acquisition, particularly among vulnerable populations like adolescents and young adults. Low PEP coverage also reflects missed opportunities, particularly among adolescent girls and young women, who experience disproportionate rates of HIV acquisition.

Background: Timely initiation and completion of post-exposure prophylaxis (PEP) following animal bite is critical to prevent rabies, a uniformly fatal but vaccine-preventable disease. Despite availability of effective vaccines, delays in initiation and administration of PEP are frequently reported in India. Objective was to describe the various reasons for delay in initiation and administration of PEP following animal bite. Methods: A hospital based cross-sectional study was conducted among animal bite victims attending the anti-rabies clinic of GMC Nagpur from 10th June to 10th September 2024. Data were collected using a pre-tested structured questionnaire on socio-demographic profile, characteristics of the bite, and reasons for delay in seeking or receiving PEP. Descriptive statistics were used to summarize findings. Results: A total of 184 animal bite cases were enrolled, of whom 86% experienced delay in initiation of PEP. Socio-economic distribution showed that more than two-thirds of participants belonged to the middle and lower-middle classes (69.6%), with very few from upper strata (1.1%). Dogs were the predominant biting animal (90.2%) with most common bite sites being hands (35.9%) and legs (25.5%). Major reasons reported for delay included referral to other health centers (22.8%), facility closed (17.9%) and non-availability of vaccine at local health facilities (16.3%). Conclusions: Multiple individual, social, and system-related barriers contribute to delay in initiation and administration of PEP. Strengthening awareness campaigns, improving accessibility and uninterrupted availability of vaccines, and community-level counselling are essential to ensure timely prophylaxis and prevent rabies deaths.

BackgroundThousands of human deaths from rabies occur annually despite the availability of effective vaccines following exposure, and for disease control in the animal reservoir. Our aim was to assess risk factors associated with exposure and to determine why human deaths from endemic canine rabies still occur.Methods and FindingsContact tracing was used to gather data on rabies exposures, post-exposure prophylaxis (PEP) delivered and deaths in two rural districts in northwestern Tanzania from 2002 to 2006. Data on risk factors and the propensity to seek and complete courses of PEP was collected using questionnaires. Exposures varied from 6–141/100,000 per year. Risk of exposure to rabies was greater in an area with agropastoralist communities (and larger domestic dog populations) than an area with pastoralist communities. Children were at greater risk than adults of being exposed to rabies and of developing clinical signs. PEP dramatically reduced the risk of developing rabies (odds ratio [OR] 17.33, 95% confidence interval [CI] 6.39–60.83) and when PEP was not delivered the risks were higher in the pastoralist than the agro-pastoralist area (OR 6.12, 95% CI 2.60–14.58). Low socioeconomic class and distance to medical facilities lengthened delays before PEP delivery. Over 20% of rabies-exposed individuals did not seek medical treatment and were not documented in official records and <65% received PEP. Animal bite injury records were an accurate indicator of rabies exposure incidence.ConclusionsInsufficient knowledge about rabies dangers and prevention, particularly prompt PEP, but also wound management, was the main cause of rabies deaths. Education, particularly in poor and marginalized communities, but also for medical and veterinary workers, would prevent future deaths.

SUMMARYAnthrax, an uncommon disease in humans, is caused by a large bacterium, Bacillus anthracis. The risk of inhalation infection is the main indication for anthrax vaccination. Pre-exposure vaccination is provided by an acellular vaccine (anthrax vaccine adsorbed or AVA), which contains anthrax toxin elements and results in protective immunity after 3 to 6 doses. Anthrax vaccine precipitated (AVP) is administered at primovaccination in 3 doses with a booster dose after 6 months. To evoke and maintain protective immunity, it is necessary to administer a booster dose once at 12 months. In Russia, live spore vaccine (STI) has been used in a two-dose schedule. Current anthrax vaccines show considerable local and general reactogenicity (erythema, induration, soreness, fever). Serious adverse reactions occur in about 1% of vaccinations. New second-generation vaccines in current research programs include recombinant live vaccines and recombinant sub-unit vaccines.

BackgroundAdhering to post-exposure prophylaxis (PEP): wound treatment, vaccine, and rabies immunoglobulin (RIG) is a crucial step in preventing rabies mortality. When PEP is widely available, a lack of adherence to the recommended treatment guidelines can also lead to death. Our objective was to understand characteristics associated with adherence to the vaccine regimen and RIG in Vietnam. MethodsWe obtained individual-level data on PEP adherence from registries at 10 sites located in five provinces. From these registries, we extracted epidemiologic characteristics of patients including the timing of PEP initiation and completion. We used descriptive analyses and logistic regression to examine patient characteristics associated with initiation and completion of RIG and vaccine. Based on reported rabies mortality, the government defined provincial rabies burden as medium-burden (<5 and >2 deaths) and high-burden (≥5 deaths). ResultsDuring 2014–2016, 15,646 patients received PEP in our study. Among 14,296 vaccinated patients, only 41.4% (5847) completed their five-dose intramuscular (IM) injections and 81.6% (133) of patients completed their eight-dose intradermal (ID) injections. Approximately 26% of patients received RIG. Patient characteristics associated with vaccine completion were females (44%), <15 years of age (44%), category 1 exposure (68%, bite location on leg (46%), bite from bat (56%), bite from a healthy animal (45%), high-burden province (86%), and district preventive center (49%). Disparities were revealed among provinces, with high-burden provinces having highest (86%) and lowest (7%) vaccine completion rates. Conclusions and relevanceVietnam has made tremendous progress towards reducing the burden of rabies. However, despite the wide availability of PEP, we found relatively low rates of vaccine completion. Our findings suggest provider training and patient education is needed to ensure appropriate treatment is completed. Moreover, our data suggest changes to information reported through the national surveillance system for monitoring good clinical practice for rabies prevention and control.

To assess adverse events associated with antiretroviral regimens for human immunodeficiency virus (HIV) postexposure prophylaxis (PEP), with a particular focus on the treatment combination of zidovudine, lamivudine, and tenofovir (ZDV-3TC-TDF). Retrospective chart review for individuals who received HIV PEP for occupational and nonoccupational exposure, and multivariate analyses to identify risk factors for noncompletion of PEP and adverse events associated with PEP. University of Rochester Health Service Occupational Health Program and University of Rochester AIDS Center. Healthcare workers who received HIV PEP for occupational exposure from January 1, 1999, to December 31, 2004, and individuals who received HIV PEP for nonoccupational exposure from January 1, 2002, to December 31, 2004.Results. We found increased rates of nausea among subjects who received treatment with ZDV-3TC-TDF and subjects who received treatment with zidovudine, lamivudine, and indinavir (ZDV-3TC-IDV). Analyses showed that female sex was a risk factor for nausea. Compared with subjects who received treatment with ZDV-3TC-TDF, subjects who received treatment with ZDV-3TC-IDV were less likely to not complete the HIV PEP for occupational exposure. Preventive treatment of adverse events may be necessary to ensure completion of HIV PEP.

INTRODUCTION Timely and complete post exposure prophylaxis is necessary for the animal bite victims to prevent rabies. Henceforth this study is done to know the profile ofanmal bite victims attending Anti bull Rabies Clinic and also to estimate their compliance rate to complete course ofAnti-Rabies Vaccination by intradermal route IDRV.METHODS A Retrospective record based review was conducted in the Anti bull Rabies Clinic of Victoria Hospital. Bengaiuru from January 21a to July 31 2015. The number ofstudy subjects was 1418 aner excluding rat and human bite re-exposure and pre-exposure cases. The compliance rate to IDRV was found outfrom records and also by interviewing the patientortheirguardian through thetelephone.RESULTS This study shows that males were predominantly affected 75.8 constituting the male female ratio 3.11. Majority of the cases were children S 15 years 28.9.96.7 of the vactims were bitten by dogs. of which 65 were from stray dogs whereas the rest from pet dogs ofwhich only 14 were immunized. Lower limbs 32.4 were the most commonEy Involved biting site. Majority 64 had category Ill exposure. Only 25.3 of the victims reported for treatmentwithin 24 hours and 76 4 had compteted the full course of vaccination.CONCLUSION From this study we observed that males have higher incidence of animal bite than the females and most of the cases were children S15 years old. Mapnty had category Ill exposure. Only 76.4 had completed the full course of IDRV which is considerably low for this highly fatal disease. Communities especially the parents and the teachers should be educated through a strong Information Education and Communication programme.

Methamphetamine use has been associated with HIV transmission among men who have sex with men (MSM). However, providers have been hesitant to utilize post-exposure prophylaxis (PEP) in populations of stimulant users. This single-arm, open label pilot study sought to demonstrate the safety, feasibility, and acceptability of PEP combined with the drug abstinence intervention of contingency management (CM) in methamphetamine-using MSM. HIV-uninfected MSM reporting recent methamphetamine use were recruited to a CM intervention. Those who reported a recent high-risk sexual or injection drug exposure to an HIV-infected or serostatus unknown source were initiated on tenofovir/emtricitabine (Truvada)-based PEP. Participants were followed over 3 months for infectious/biologic, behavioral, and drug use outcomes. Fifty-three participants enrolled in the study; 35 participants (66%) initiated PEP after a high-risk exposure. The median time from exposure to medication administration was 37.8 h (range 12.5-68.0 h). Twenty-five (71.4%) PEP initiators successfully completed the treatment course. Median medication adherence was 96% (IQR 57-100%), and medication was generally well tolerated. Methamphetamine abstinence during CM treatment increased PEP adherence (2% [95% CI +1-+3%]) per clean urine toxicology sample provided), and increased the odds of PEP course completion (OR 1.17, 95% CI 1.04-1.31). One incident of HIV seroconversion was observed in a participant who did not complete PEP treatment, and reported multiple subsequent exposures. Findings demonstrate that PEP, when combined with CM, is safe, feasible, and acceptable as an HIV prevention strategy in methamphetamine-using MSM.

The provision of starter packs for human immunodeficiency virus postexposure prophylaxis (PEP) is practiced in many settings to facilitate rapid initiation by nonexperts and encourage adherence. However, the impact of starter packs on PEP completion rates has not been systematically assessed. We systematically reviewed the evidence on outcomes associated with starter packs for PEP compared to full prescriptions. Four databases and 2 conference abstract sites were searched up to December 2013; this search was updated in 1 database in June 2014. PEP completion rates, stratified by prescribing practice, were pooled using random-effects meta-analysis. Fifty-four studies provided data on 11 714 PEP initiations. Thirty-seven studies, including 3 randomized controlled trials (RCTs) and 34 observational cohorts, provided information on starter packs (although none of the RCTs specifically assessed starter packs), and 17 studies, including 2 RCTs and 15 observational cohorts, provided information on full prescriptions. Overall, outcomes were better when participants were offered a full 28-day course of PEP at initial presentation to healthcare, with fewer refusals (11.4% [95% confidence interval {CI}, 5.3%-17.5%] vs 22% [95% CI, 16.7%-28.1%]) and higher completion rates (70% [95% CI, 56.7%-77.3%] vs 53.2% [95% CI, 44.4%-62.2%]). More than a quarter (28% [95% CI, 21.4%-34.5%]) of individuals provided with a PEP starter pack failed to return for their subsequent appointment and therefore defaulted prior to receiving a full course of PEP. The quality of the evidence overall was rated as very low. The findings of this review suggest that starter packs do not improve adherence to PEP and may result in lower adherence and completion rates.

The prompt administration of post-exposure prophylaxis (PEP) is one of the key strategies for ending human deaths from rabies. A delay in seeking the first dose of rabies PEP, or failure to complete the recommended dosage, may result in clinical rabies and death. We assessed the efficacy of short message system (SMS) phone texts in improving the adherence to scheduled PEP doses among bite patients in rural eastern Kenya. We conducted a single-arm, before-after field trial that compared adherence among bite patients presenting at Makueni Referral Hospital between October and December 2018 (control) and between January and March 2019 (intervention). Data on their demographics, socio-economic status, circumstances surrounding the bite, and expenditures related to the bite were collected. A total of 186 bite patients were enrolled, with 82 (44%) in the intervention group, and 104 (56%) in the control group. The odds of PEP completion were three times (OR 3.37, 95% CI 1.28, 10.20) more likely among patients who received the SMS reminder, compared to the control. The intervention group had better compliance on the scheduled doses 2 to 5, with a mean deviation of 0.18 days compared to 0.79 days for the control group (p = 0.004). The main reasons for non-compliance included lack of funds (30%), and forgetfulness (23%) on days for follow-up treatment, among others. Nearly all (96%, n = 179) the bite patients incurred indirect transport costs, at an average of USD 4 (USD 0-45) per visit. This study suggests that the integration of SMS reminders into healthcare service delivery increases compliance with PEP, and may strengthen rabies control and elimination strategies.

Background: Wound management is a critical component of post-operative care particularly for mothers recovering from caesarean sections. Proper wound care can significantly impact recovery times, reduce infection risk, and improve maternal health outcomes. However, the effectiveness of wound management is influenced by many factors including health workers, health facilities, and health-related variables. Therefore, this study seeks to determine the health worker, health facility, and health-related factors affecting proper wound management by health workers attending cesarean section mothers seeking health services in Mukono General Hospital Mukono District. Methodology: A descriptive cross-sectional study was used with a purposive sampling method to select 30 study participants. Structured questionnaires were used to collect data being analyzed using Microsoft Excel and presented using tables, figures, graphs, and charts. Results: The study findings on health worker-related factors were that 17(56.7%) were certificate holders, 20(66.7%) rarely washed their hands during cesarean section incision site care and 24(80%) reported a shortage of time. Health facility-related factors included; 16(53.3%) reporting the absence of policies about wound care at the unit, 24(80%) never received supervision during wound care, and 28(93.3%) reporting the absence of guidelines on wound management. Patient-related factors; 21(70%) reported patients weighing above 75 kilograms, 17(56.7%) reported diabetes and 16(69.6%) reported alcohol intake was challenging with wound healing. Conclusion: Factors that affected proper wound management health workers, health facilities, and health-related factors consisted of low academic qualification, inconsistent hand washing, shortage of time, absence of policies, supervision, guidelines, and training, high body weight, alcohol intake, comorbidities especially diabetes, herb medicine use and absence of support from family members. Recommendation: Stakeholders should improve the quality of health facility management systems and sensitize mothers about appropriate cesarean wound care.

There is still no cure for rabies and survival from clinical rabies is extremely rare. It is a preventable disease if the post exposure prophylaxis is initiated in time and administered as per WHO guidelines including administration of rabies immunoglobulin. The role of passive rabies immunization products is to provide the immediate availability of neutralizing antibodies at the site of the exposure before it is physiologically possible for the patient to begin producing his or her own antibodies after vaccination. In this case report, the same dog has bitten to a boy and to an adult. Local wound treatment and use of human rabies immunoglobulin as well as gluteal region as a site of bite were the probable reasons for survival of the boy. On the other hand no local wound treatment, no use of rabies immunoglobulin and finger as a site of bite are the probable reasons for death of an adult due to rabies.

Zoonotic infections remain to present a remarkable worldwide health burden because of their multifaceted route of spread and intimate link with humans, animals, and their surrounding environments. However, of these infections, rabies ranks among those viral infections that not only remain highly lethal but are preventable. Nevertheless, these are mostly encountered and documented in low- and middle-income nations where canine rabies predominates. In addition, through various evidences presented and discussed in this review, it is seen that rabies and other such infections have continued to persist because of poor surveillance and access to vaccines, public education, and intersectoral struggle connecting human and animal health. In the present day, the efficacy of existing therapeutic interventions such as postexposure prophylaxis, which entails wound care along with immunization and the administration of immunoglobulin, is very high if done on a prompt basis. Still, cases of delayed interventions have led to increasing mortalities. Although improvements have been made to the efficacy and protect of cell culture-vaccine platforms, availability of such vaccines varies in endemic regions. More so, there is a rise in information pertaining to the possibility of the application of natural products such as nanoparticles of plant origin, which have been recognized to have antimicrobial, antiviral, and immune modulatory activities. Although such interventions deserve a trial from a clinical point of view, just a little validation has been done of such interventions on a live scale. One Health is another topic that has been recognized to effectively address all factors pertaining to zoonotic disease such as Rabies. Despite these advances, there are still many areas to be filled in via further studies with particular emphasis on translating unique developed in the laboratory into community-applicable interventions, optimizing community-based vaccine approaches, and advancing interdisciplinary approaches to community-based disease surveillance. Also important are vaccine distribution systems, rigorous evaluation of innovative plant-based therapy approaches, and policy-driven approaches to One Health. All these areas will ensure not only control and hopefully eradication of rabies but also a lower effect of zoonotic diseases in particular and infections in general worldwide.

Background: Until April 2023, it has been documented about 31,113 cases of animal rabies-borne bites, of which 23,211 cases were given Post Exposure Prophylaxis (PEP) Anti Rabies Vaccine and 11 death cases in Indonesia, and 95% of them were caused by dog bite. This case report was conducted to describe a rare case of an 8-year-old child presenting with the late complication of encephalitis in Borong General Hospital due to the delayed case finding, management, and proper prophylaxis for Rabies infection. Case Presentation: One day before admission, an 8-year-old girl with irritability, aggressive behavior, and severe speech abnormalities was reported to the emergency room. These symptoms quickly escalated to confusion and disturbed mental status. One month before to presentation, the patient's parents stated that his right arm had been bitten by a stray dog. Because there were no obvious bite marks and the family was not aware of the dog bite, PEP was not requested. In the previous five days, her parents described experiences of hydrophobia, photophobia, and aerophobia. The patient's health deteriorated two hours after admission, and palpating the carotid artery revealed that there was no pulse. Despite performing cardiopulmonary resuscitation, ROSC was not reached. Conclusion: Animal rabies control and surveillance are essential, particularly in locations where the disease is endemic. PEP is extremely effective and ought to be given as soon as possible following exposure to reduce the high fatality rate.