Estimating the global burden of endemic canine rabies

Background: Rabies is a notoriously underreported and neglected disease of lowincome countries. This study aims to estimate the public health and economic burden of rabies circulating in domestic dog populations, globally and on a country-by-country basis, allowing an objective assessment of how much this preventable disease costs endemic countries.<p></p> Methodology/Principal Findings: We established relationships between rabies mortality and rabies prevention and control measures, which we incorporated into a model framework. We used data derived from extensive literature searches and questionnaires on disease incidence, control interventions and preventative measures within this framework to estimate the disease burden. The burden of rabies impacts on public health sector budgets, local communities and livestock economies, with the highest risk of rabies in the poorest regions of the world. This study estimates that globally canine rabies causes approximately 59,000 (95% Confidence Intervals: 25- 159,000) human deaths, over 3.7 million (95% CIs: 1.6-10.4 million) disability-adjusted life years (DALYs) and 8.6 billion USD (95% CIs: 2.9-21.5 billion) economic losses annually. The largest component of the economic burden is due to premature death (55%), followed by direct costs of post-exposure prophylaxis (PEP, 20%) and lost income whilst seeking PEP (15.5%), with only limited costs to the veterinary sector due to dog vaccination (1.5%), and additional costs to communities from livestock losses (6%).<p></p> Conclusions/Significance: This study demonstrates that investment in dog vaccination, the single most effective way of reducing the disease burden, has been inadequate and that the availability and affordability of PEP needs improving. Collaborative investments by medical and veterinary sectors could dramatically reduce the current large, and unnecessary, burden of rabies on affected communities. Improved surveillance is needed to reduce uncertainty in burden estimates and to monitor the impacts of control efforts.<p></p&gt

Seroprevalence of hepatitis B in pregnant women in Mexico Seroprevalencia de hepatitis B en mujeres embarazadas en México

OBJECTIVE: To determine the seroprevalence of hepatitis B in pregnant women from several regions of Mexico, as well as the risk factors associated with its occurrence. MATERIAL AND METHODS: A cross-sectional study was conducted between May and August 2000. It included 9 992 pregnant women attending the health services of the Mexican Institute of Social Security (Instituto Mexicano del Seguro Social-IMSS) in five cities: Tijuana, Ciudad Juarez, Acapulco, Cancun, and Mexico City (northeast and southeast regions). RESULTS: The overall prevalence for confirmed cases was 1.65% (165/9 992). The prevalences for individual cities were as follows: Tijuana, 1.27%; Ciudad Juarez, 1.46%; Acapulco, 2.47%; Cancun, 0.93%; northeastern Mexico City, 1.20%, and southeastern Mexico City, 2.52%. The risk factors found to be associated with HBsAg were: age, age at first sexual intercourse, city (Acapulco and southeastern Mexico City), and marital status (single or divorced). CONCLUSIONS: The prevalence of HBsAg in pregnant women (1.65%) was greater than that reported in previous studies and showed geographical differences. This high prevalence suggests that a considerable amount of cases of hepatitis B occurs perinatally and through contact with carriers in the general population. Vaccination of newborns of high-risk pregnant women should be considered.OBJETIVO: Determinar la seroprevalencia de hepatitis B en mujeres embarazadas de varias regiones de México e investigar factores de riesgo asociados. MATERIAL Y MÉTODOS: Durante el periodo de mayo-agosto del año 2000 se realizó un estudio transversal en 9 992 mujeres embarazadas, con acceso a seguridad social (Instituto Mexicano del Seguro Social) en cinco ciudades de México: Tijuana, Ciudad Juárez, Acapulco, Cancún y Distrito Federal (zona noreste y sureste). RESULTADOS: La prevalencia global para casos confirmados fue de 1.65% (165/9 992). Para las ciudades de estudio fue: 1.27% en Tijuana, 1.46% en Ciudad Juárez, 2.47% en Acapulco, 0.93% en Cancún, 1.2% en el noreste del Distrito Federal, y 2.52% en el sureste del Distrito Federal. Los factores de riesgo identificados fueron: edad, edad de inicio de vida sexual, ciudad (Acapulco y región sureste del Distrito Federal) y estado civil (solteras-divorciadas). CONCLUSIONES: La prevalencia de antígeno de superficie del virus de la hepatitis B (HBsAg, por sus siglas en inglés) en embarazadas (1.65%) es mayor a la reportada en investigaciones previas y muestra diferencias geográficas. Esta prevalencia elevada indica un número considerable de casos de hepatitis B ocasionados por vía perinatal y de portadores en nuestra población. Se debe considerar la vacunación en recién nacidos de mujeres embarazadas con alto riesgo

Seroprevalence of hepatitis B in pregnant women in Mexico

Objetivo. Determinar la seroprevalencia de hepatitis B en mujeres embarazadas de varias regiones de México e investigar factores de riesgo asociados. Material y métodos. Durante el periodo de mayo-agosto del año 2000 se realizó un estudio transversal en 9 992 mujeres embarazadas, con acceso a seguridad social (Instituto Mexicano del Seguro Social) en cinco ciudades de México: Tijuana, Ciudad Juárez, Acapulco, Cancún y Distrito Federal (zona noreste y sureste). Resultados. La prevalencia global para casos confirmados fue de 1.65% (165/9 992). Para las ciudades de estudio fue: 1.27% en Tijuana, 1.46% en Ciudad Juárez, 2.47% en Acapulco, 0.93% en Cancún, 1.2% en el noreste del Distrito Federal, y 2.52% en el sureste del Distrito Federal. Los factores de riesgo identificados fueron: edad, edad de inicio de vida sexual, ciudad (Acapulco y región sureste del Distrito Federal) y estado civil (solteras-divorciadas). Conclusiones. La prevalencia de antígeno de superficie del virus de la hepatitis B (HBsAg, por sus siglas en inglés) en embarazadas (1.65%) es mayor a la reportada en investigaciones previas y muestra diferencias geográficas. Esta prevalencia elevada indica un número considerable de casos de hepatitis B ocasionados por vía perinatal y de portadores en nuestra población. Se debe considerar la vacunación en recién nacidos de mujeres embarazadas con alto riesgo. El texto completo en inglés de este artículo también está disponible en: http://www.insp.mx/salud/index.htm

Incidence of Category II and III Dog Bites among 5-14 year old children in El Nido estimated from passive and active surveillance, 2011 to 2012

<p><u>Active surveillance</u></p> <p> At enrollment, a questionnaire was completed in order to collect the history of potential rabies exposures (animal bites and scratches) over the past 6 months in the cohort children. Information about a child’s possible rabies exposures was collected retrospectively through home visits, mobile phone contact, and through consultations with midwives and village health workers, teachers and neighbors. During the 18 months of follow-up beginning July 2011, active detection of rabies exposures was conducted every three months until December 2012 and included the interview of the exposed patient’s parent regarding incidents of contact with a suspected rabid animal. Parents were contacted and asked whether their child had experienced contact with a suspect rabid animal since the previous interview and follow-up forms were completed. All patients that had experienced a potential exposure during the previous three months were visited at home and standardized rabies exposure forms (REF) were completed. All follow-up questionnaires administered during the study were similar except the questionnaire provided in March 2012, in which questions regarding the PrEP were added. Also in 2012, a small survey was carried out of the parents of 328 randomly chosen children who were not vaccinated, to determine the reasons for this.</p> <p> During the follow-up period, the ABTC data were collected on all children with a reported contact with a suspect rabid animal. Every three months thereafter, an ABTC data retrieval form was completed for every rabies exposure consultation for a child included in the study cohort. </p> <p> </p> <p><u>Passive surveillance</u></p> Data on animal bite consultations of children in the same age group as the study cohort at the ABTC were collected retrospectively for the period from January 2011 to December 2012 in order to establish a temporal trend of exposures. Bite incidence was calculated from the number of bites amongst children divided by the total number of children aged 5-14 years old based on the 2007 Population Census

Incidence of Category II and III Dog Bites among 5-14 year old children in El Nido estimated from passive and active surveillance, 2011 to 2012

<p><u>Active surveillance</u></p> <p> At enrollment, a questionnaire was completed in order to collect the history of potential rabies exposures (animal bites and scratches) over the past 6 months in the cohort children. Information about a child’s possible rabies exposures was collected retrospectively through home visits, mobile phone contact, and through consultations with midwives and village health workers, teachers and neighbors. During the 18 months of follow-up beginning July 2011, active detection of rabies exposures was conducted every three months until December 2012 and included the interview of the exposed patient’s parent regarding incidents of contact with a suspected rabid animal. Parents were contacted and asked whether their child had experienced contact with a suspect rabid animal since the previous interview and follow-up forms were completed. All patients that had experienced a potential exposure during the previous three months were visited at home and standardized rabies exposure forms (REF) were completed. All follow-up questionnaires administered during the study were similar except the questionnaire provided in March 2012, in which questions regarding the PrEP were added. Also in 2012, a small survey was carried out of the parents of 328 randomly chosen children who were not vaccinated, to determine the reasons for this.</p> <p> During the follow-up period, the ABTC data were collected on all children with a reported contact with a suspect rabid animal. Every three months thereafter, an ABTC data retrieval form was completed for every rabies exposure consultation for a child included in the study cohort. </p> <p> </p> <p><u>Passive surveillance</u></p> Data on animal bite consultations of children in the same age group as the study cohort at the ABTC were collected retrospectively for the period from January 2011 to December 2012 in order to establish a temporal trend of exposures. Bite incidence was calculated from the number of bites amongst children divided by the total number of children aged 5-14 years old based on the 2007 Population Census

Costs of Rabies Post-Exposure Prophylaxis According to Pre-Exposure Prophylaxis Status

<p>Costs of PrEP were assessed for the cohort of 4,666 children in the study at the time of PreP administration. PrEP schedule followed the WHO guidelines, with intradermal administration of 0.1 ml volume per site (one site each day) given on days 0, 7 and 28. </p> <p>The direct medical costs included cost of biologicals (rabies vaccine), cost per shipment, considered as 2% of the vaccine cost, cost of needles, alcohol and cotton used. Costs related to health care staff were not included. The number of doses per vial assumed for the analysis is 4, although in theory 1 vial could be used to deliver 5 x 0.1 mL doses, thus 20% vaccine wastage is built into the calculations.</p><p>In addition, to explore further the benefits of such vaccination program, projected costs of two hypothetical cohorts of children bitten by a dog were assessed according to two scenarios: </p><p>(i) Scenario 1, no PrEP: </p><p> Assessment of the costs related to the expected annual number of children among the study cohort bitten by a dog, assuming they did not have PrEP. These children were considered to follow the standard of care for Post-Exposure Prophylaxis (PEP) defined as 2-site intradermal method (2-2-2-0-1) for use with PVRV (complete PEP), with RIG given for category III bites.</p><p> </p><p> </p><p>(ii) Scenario 2, with PrEP</p><p> Assessment of the costs related to the expected annual number of children among the study cohort bitten by a dog benefiting from PrEP. Following the national guidelines, such patients should be given only two booster doses on days 0 and 3, but no RIG. </p><p> Costs associated with wound care (e.g. antibiotics, tetanus immunization) were not included in the analysis since these do not depend on rabies vaccination status of the patient. Indirect costs were also not included in the analysis.</p><p> Time horizon for the comparison of the economic benefit of the two strategies was projected to 1 year, 5 years and 10 years. All medical costs were expressed in terms of Philippine peso (PhP), and converted to US dollars (USD) using the average exchange rate of USD 1 = PhP 43. <br></p

Percentages of Students who knew about Rabies based on pre and post-tests of students in El Nido Elementary Schools, School Year 2012-13

The rabies education manual was used during the 2012 to 13 school year. It contains modules on rabies which teachers could integrate into Science and Health, Makabayan (Civics, Social Studies, Geography, and History), Filipino, English and Mathematics subjects for the different grade levels throughout the year. An assessment of the impact of the education program was conducted among students in 12 randomly selected elementary schools in the municipality. Pre- and post-intervention tests were conducted among a sample of the students to assess the impact of the education materials, testing the students’ knowledge of rabies, its transmission, dog bite prevention, dog bite management, and responsible pet ownership. The pre-tests were conducted in July 2012 while the post-tests were conducted in March 2013