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Wound characteristics and infiltration with immune globulin for rabies postexposure prophylaxis in the emergency department. Am J Emerg Med 2022; 62:55-61. [DOI: 10.1016/j.ajem.2022.09.046] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/08/2022] [Revised: 09/26/2022] [Accepted: 09/28/2022] [Indexed: 11/06/2022] Open
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da Silva RM, Megid J, Hampson K, Campos AAS, Higashi CS, Medeiros FS, Pereira AS, Benavides JA. Factors Limiting the Appropriate Use of Rabies Post-exposure Prophylaxis by Health Professionals in Brazil. Front Vet Sci 2022; 9:846994. [PMID: 35601400 PMCID: PMC9120864 DOI: 10.3389/fvets.2022.846994] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/31/2021] [Accepted: 03/09/2022] [Indexed: 11/13/2022] Open
Abstract
Post-exposure prophylaxis (PEP) is necessary to prevent the fatal onset of rabies but requires optimization to avoid overuse in populations at risk of rabies. In Brazil, the incidence of dog bites remains high, with almost half of dog-bite patients not receiving the PEP recommended by the Ministry of Health guidelines between 2008 and 2017. In this study, we aimed to identify the factors that limit the appropriate prescribing of PEP by interviewing health professionals responsible for PEP administration and completion of the 'Information System on Diseases of Compulsory Declaration' (SINAN) form reporting human anti-rabies care for patients seeking health care after a dog bite. We conducted 147 questionnaires (45 questions each) in three Brazilian states (i.e., Rio Grande do Sul, Santa Catarina, Rio Grande do Norte) including questions related to the criteria used by professionals to classify a dog as "suspect" or "rabid", knowledge on PEP prescription guidelines, SINAN and communication with veterinarians. Our analyses showed that most health professionals delivering PEP in these three states struggle to identify a rabies "suspect" dog according to the Ministry of Health guidelines, and to indicate the adequate PEP regimen, with only 11% of professionals prescribing the appropriate PEP under various dog-bite patient scenarios. PEP knowledge score was higher among professionals trained on PEP guidelines and working in facilities with the highest incidence of dog bites. In contrast, PEP knowledge scores did not vary significantly between states, and were not correlated to the professional's level of experience, the number of colleagues available at the health unit or the professional's confidence on prescribing appropriate PEP. Our results suggest that knowledge gaps in PEP administration among health professionals of Brazil can be reduced by implementing training programs to differentiate among rabies risk scenarios, prescribe the corresponding appropriate PEP and improve communication between health and veterinary authorities.
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Affiliation(s)
- Ramiro M. da Silva
- Department of Veterinary Hygiene and Public Health, São Paulo State University, Botucatu, Brazil
| | - Jane Megid
- Department of Veterinary Hygiene and Public Health, São Paulo State University, Botucatu, Brazil
| | - Katie Hampson
- Institute of Biodiversity, Animal Health and Comparative Medicine, College of Medical, Veterinary and Life Sciences, University of Glasgow, Glasgow, United Kingdom
| | - Aline Alves Scarpellini Campos
- Programa Estadual de Controle e Profilaxia da Raiva, State Department of Health of Rio Grande do Sul, Porto Alegre, Brazil
| | - Cintia S. Higashi
- Coordenação de Promoção à Saúde, State Department of Health of Rio Grande do Norte, Natal, Brazil
| | - Fabíola S. Medeiros
- Coordenação de Promoção à Saúde, State Department of Health of Rio Grande do Norte, Natal, Brazil
| | - Alexandra S. Pereira
- Diretoria de Vigilância Epidemiológica, State Department of Health of Santa Catarina, Florianópolis, Brazil
| | - Julio A. Benavides
- Department of Veterinary Hygiene and Public Health, São Paulo State University, Botucatu, Brazil
- Institute of Biodiversity, Animal Health and Comparative Medicine, College of Medical, Veterinary and Life Sciences, University of Glasgow, Glasgow, United Kingdom
- Doctorado en Medicina de la Conservación y Centro de Investigación para la Sustentabilidad, Facultad de Ciencias de la Vida, Universidad Andres Bello, Santiago, Chile
- MIVEGEC, IRD, CNRS, Université de Montpellier, Montpellier, France
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Burke RV, Russo P, Sicilia M, Wolowich W, Amega N, Nguyen HB. Epidemiology of rabies immune globulin use in paediatric and adult patients in the USA: a cross-sectional prevalence study. BMJ Open 2022; 12:e055411. [PMID: 35473745 PMCID: PMC9045048 DOI: 10.1136/bmjopen-2021-055411] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/25/2022] Open
Abstract
OBJECTIVES To compare the epidemiology of paediatric and adult patients receiving rabies immune globulin (RIG). DESIGN Cross-sectional prevalence study. SETTING Eligible participants from the Symphony Integrated Dataverse presenting between 2013 and 2019. PARTICIPANTS All adult and paediatric patients with integrated claims and demographic data associated with RIG use from the Symphony Integrated Dataverse from 2013 to 2019. PRIMARY AND SECONDARY OUTCOME MEASURES Prevalence of diagnoses and procedures associated with paediatric and adult patient population based on frequency of International Classification of Diseases (ICD-9/ICD-10) and Current Procedural Terminology codes, respectively. METHODS We used mutual information to identify features that differentiate the paediatric from adult patient population. Prevalence ratios were calculated to compare adult and paediatric patients. RESULTS There were 79 766 adult and 20 381 paediatric patients who met the inclusion criteria. Paediatric patients had a 5.92-fold higher prevalence of 'open wounds to the head; neck; and trunk', 3.10-fold higher prevalence of 'abrasion or friction burn of face; neck; and scalp except eye; without mention of infection', 4.44-fold higher prevalence of 'open wound of scalp; without mention of complication' and 6.75-fold higher prevalence of 'laceration of skin of eyelid and periocular area | laceration of eyelid involving lacrimal passages'. Paediatric patients had a 3.83-fold higher prevalence of complex repairs compared with adult patients (n=157, 0.7% vs n=157, 0.2%, respectively). CONCLUSIONS Paediatric patients represent a significant proportion of the patient population receiving RIG, and are associated with higher prevalence of codes reporting repair of larger, more complex wounds in highly innervated anatomical regions. Dosing and administration of RIG must be informed by animal bite wound characteristics; clinicians should understand the differences between presentations in adults and children and treat accordingly.
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Affiliation(s)
- Rita V Burke
- Department of Population and Public Health Sciences, Keck School of Medicine, University of Southern California, Los Angeles, California, USA
| | | | - Michael Sicilia
- Eversana Life Science Services, Milwaukee (HQ), Wisconsin, USA
| | | | - Novinyo Amega
- Department of Medical Affairs, Kedrion Biopharma, Fort Lee, New Jersey, USA
| | - Huy-Binh Nguyen
- Department of Medical Affairs, Kedrion Biopharma, Fort Lee, New Jersey, USA
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Bookstaver PB, Akpunonu P, Nguyen HB, Swan JT, Howington GT. Administration of rabies immunoglobulin: Improving evidence-based guidance for wound infiltration. Pharmacotherapy 2021; 41:644-648. [PMID: 34224157 DOI: 10.1002/phar.2604] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/22/2021] [Revised: 05/06/2021] [Accepted: 05/10/2021] [Indexed: 11/08/2022]
Abstract
Rabies virus causes a fatal infection of the brain and spinal cord, accounting for approximately 59,000 deaths globally each year. Rabies postexposure prophylaxis (PEP), including both rabies immunoglobulin (RIG) and vaccination, is administered to 55,000 patients annually in the United States. With a nearly 100% case fatality rate, the optimal administration of rabies PEP cannot be understated. Updated rabies PEP guidelines issued by the World Health Organization (WHO) in 2018 recognized that local wound infiltration of RIG is the primary mechanism of protection, and the WHO now recommends only infiltration of wounds without distal intramuscular injection. We highlight potential points of failure involving wound infiltration of RIG, small-volume doses, and large-volume doses that may lead to suboptimal care and discuss implications of recent shifts toward evidence-based guidelines using wound type and RIG volumes.
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Affiliation(s)
- P Brandon Bookstaver
- Department of Clinical Pharmacy and Outcomes Science, University of South Carolina College of Pharmacy, Columbia, South Carolina, USA.,Department of Pharmacy, Prisma Health Midlands - Richland, Columbia, South Carolina, USA
| | - Peter Akpunonu
- Department of Emergency Medicine, University of Kentucky HealthCare, Lexington, Kentucky, USA.,Kentucky Poison Control Center, Louisville, Kentucky, USA
| | - Huy-Binh Nguyen
- Department of Medical Affairs, Kedrion Biopharma Inc., Fort Lee, New Jersey, USA
| | - Joshua T Swan
- Department of Surgery, Houston Methodist Hospital, Houston, Texas, USA.,Department of Pharmacy, Houston Methodist Hospital, Houston, Texas, USA
| | - Gavin T Howington
- Department of Pharmacy Practice and Science, University of Kentucky College of Pharmacy, Lexington, Kentucky, USA.,Department of Pharmacy Services, University of Kentucky HealthCare, Lexington, Kentucky, USA
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Hobart-Porter N, Stein M, Toh N, Amega N, Nguyen HB, Linakis J. Safety and efficacy of rabies immunoglobulin in pediatric patients with suspected exposure. Hum Vaccin Immunother 2021; 17:2090-2096. [PMID: 33563087 PMCID: PMC8189119 DOI: 10.1080/21645515.2020.1854000] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/25/2022] Open
Abstract
Rabies is a deadly viral zoonosis with global disease burden. Following exposure to a rabid animal, post-exposure prophylaxis (PEP) is the standard of care for unvaccinated persons. Despite the large proportion of pediatric cases, limited safety and efficacy data exist for use in pediatric patients. We report the safety, efficacy, and immunogenicity of a phase 4, prospective, 2-center, open-label, single-arm clinical trial evaluating human rabies immunoglobulin (HRIG150; KEDRAB 150 IU/mL) as part of PEP in patients (aged <17) with suspected or confirmed rabies exposure, where PEP was indicated. Thirty participants received 20 IU/kg HRIG150 infiltrated into the detectable wound site(s), with any remainder injected intramuscularly, concomitantly with the first of a 4-dose series (days 0, 3, 7, and 14) of rabies vaccine. Rabies virus neutralizing antibody (RVNA) titers and tolerability were assessed on day 14 following administration. Participant safety was monitored for 84 days. No serious adverse events, rabies infections, or deaths were recorded. Twenty-one participants (70.0%) experienced a total of 57 treatment-emergent adverse events (TEAEs) within 14 days following administration. Twelve participants (40.0%) experienced a total of 13 adverse events deemed treatment related. All TEAEs were mild in severity. On day 14, 28 participants (93.3%) had RVNA levels of ≥0.5 IU/mL (mean±standard deviation: 18.89 ± 31.61). These results demonstrate that HRIG150 is well tolerated and effective in pediatric patients as a component of PEP. To the authors' knowledge, this study is the first to establish pediatric safety and efficacy of HRIG in the US.
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Affiliation(s)
- Nicholas Hobart-Porter
- Department of Pediatrics, Division of Pediatric Emergency Medicine, University of Arkansas for Medical Sciences, Little Rock, AR, USA
| | - Michal Stein
- Department of Medical Affairs, Kamada Ltd., Beit Kama, Israel
| | - Naveh Toh
- Department of Medical Affairs, Kamada Ltd., Beit Kama, Israel
| | - Novinyo Amega
- Department of Medical Affairs, Kedrion Biopharma Inc., Fort Lee, NJ, USA
| | - Huy-Binh Nguyen
- Department of Medical Affairs, Kedrion Biopharma Inc., Fort Lee, NJ, USA
| | - James Linakis
- Departments of Emergency Medicine and Pediatrics, The Warren Alpert Medical School of Brown University, Rhode Island Hospital, Providence, RI, USA
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