Clinicians’ management of patients potentially exposed to rabies in high-risk areas in Bhutan: A cross-sectional study
Authors: Penjor Kinley , Marquetoux Nelly , Dorji Chendu , Penjor Kinley , Dorjee Sithar , Dorjee Chencho , Jolly Peter D , Morris Roger S , McKenzie Joanna S. 
Published: September 2018

Background

Rabies is endemic in southern Bhutan, associated with 1–2 human deaths annually and accounting for about 6% of annual national expenditure on essential medicines. A WHO-adapted National Rabies Management Guidelines (NRMG) is available to aid clinicians in PEP prescription. An understanding of clinical practice in the evaluation of rabies risk in endemic areas could contribute to improve clinicians’ PEP decision-making.

Methods

A cross-sectional survey of clinicians was conducted in 13 health centers in high-rabies-risk areas of Bhutan during February–March 2016. Data were collected from 273 patients examined by 50 clinicians.

Results

The majority (69%) of exposure was through dog bites. Half the patients were children under 18 years of age. Consultations were conducted by health assistants or clinical officers (55%), or by medical doctors (45%), with a median age of clinicians of 31 years. Rabies vaccines were prescribed in 91% of exposure cases. The overall agreement between clinician’s rabies risk assessment and the NRMG for the corresponding exposure was low (kappa =0.203, p<0.001). Clinicians were more likely to underestimate the risk of exposure than overestimate it. Male health assistants were the most likely to make an accurate risk assessment and female health assistants were the least likely. Clinicians from district or regional hospitals were more likely to conduct accurate risk assessments compared to clinicians in Basic Health Units (Odds Ratios of 7.8 and 17.6, respectively).

Conclusions

This study highlighted significant discrepancies between clinical practice and guideline recommendations for rabies risk evaluation. Regular training about rabies risk assessment and PEP prescription should target all categories of clinicians. An update of the NRMG with more specific criterions for the prescription of RIG might contribute to increase the compliance, along with a regular review of decision-making criteria to monitor adherence to the NRMG.

Author summary

Human rabies remains an important public health threat in Bhutan, especially in southern regions where canine rabies is endemic. The steady increase in number of patients reporting to hospitals following dog bites means escalating costs of post-exposure prophylaxis for the country. We investigated attitudes and practices of clinicians who manage patients with potential rabies exposure, in the endemic area. The risk of rabies exposure in the study area is mostly associated with dog bites, involving children half the time. Rabies vaccines were prescribed in 9 out of 10 exposure cases, while immuno-globulins were rarely prescribed. The study confirmed the perceived lack of compliance of clinicians with guideline recommendations for assessing rabies risk. This results in under-estimating the rabies risk in potentially risky exposures in high-rabies-risk areas. Our work underscore the importance of targeted training of female health assistants, doctors, and clinicians in basic health units to improve the management of rabies exposure. In particular there is need to update the national guidelines regarding indications and use of rabies immune-globulins.