Exposure History, Post-Exposure Prophylaxis Use, and Clinical Characteristics of Human Rabies Cases: A Twelve-Year Retrospective Review at a Tertiary Facility in Ghana.

BACKGROUND: Robust monitoring and reporting systems for rabies are lacking thus increasing the risk of underreporting. Highlighting the rabies cases brings to bear the needed urgent attention for more efforts at preventing and controlling the disease. OBJECTIVE: To describe the epidemiological characteristics of patients managed for clinical rabies at the largest referral facility in Ghana. METHODS: A retrospective single-center hospital-based chart review and data extraction were conducted for persons managed for clinical rabies infection at the Korle-Bu Teaching Hospital from January 2008 to December 2019. Data analysis was done using STATA. Descriptive statistics were used to summarize the epidemiological and clinical characteristics. Fisher's exact test, the Kruskal-Wallis test, and Spearman's correlation coefficient were used to explore significant associations. RESULTS: A total of 28 cases were recorded over the period of review. All of them died and most (68%) of them were males. Twenty-one percent of them were less than 15 years old. Their median age interquartile range (IQR) was 31 years (25.5 years) and the median incubation period for rabies (IQR) was 60 days (60 days). The source of rabies for cases was mainly dog bites. The vaccination status of all the animals could not be ascertained. Majority (80%) of the patients took neither anti-rabies vaccine nor immunoglobulin as post-exposure prophylaxis after the dog bite. The median time of admission before death (interquartile range) was 2 days (2 days). Majority (82%) of the cases were furious rabies. CONCLUSION: Attention should be directed at mass vaccination of dogs as dog bites are common. Ensuring availability and access to post-exposure prophylaxis (PEP) is also critical in averting rabies-related deaths.

CONTEXTE: Des systèmes de surveillance et de déclaration robustes pour la rage font défaut, augmentant ainsi le risque de sousdéclaration. Mettre en lumière les cas de rage suscite l'attention urgente nécessaire pour redoubler d'efforts dans la prévention et le contrôle de la maladie. OBJECTIF: Décrire les caractéristiques épidémiologiques des patients traités pour une rage clinique dans le plus grand établissement de référence au Ghana. MÉTHODES: Une revue rétrospective des dossiers médicaux et une extraction de données basées à l'hôpital ont été réalisées pour les personnes traitées pour une infection à la rage clinique à l'Hôpital d'Enseignement Korle-Bu de janvier 2008 à décembre 2019. L'analyse des données a été effectuée à l'aide de STATA. Des statistiques descriptives ont été utilisées pour résumer les caractéristiques épidémiologiques et cliniques. Le test exact de Fisher, le test de Kruskal-Wallis et le coefficient de corrélation de Spearman ont été utilisés pour explorer les associations significatives. RÉSULTATS: Un total de 28 cas ont été enregistrés sur la période examinée. Tous sont décédés et la plupart d'entre eux (68%) étaient des hommes. Vingt et un pour cent d'entre eux avaient moins de 15 ans. Leur âge médian (plage interquartile) était de 31 ans (25,5 ans) et la période d'incubation médiane de la rage (plage interquartile) était de 60 jours (60 jours). La principale source de rage pour les cas était principalement les morsures de chiens. Le statut vaccinal de tous les animaux n'a pas pu être déterminé. La majorité (80%) des patients n'ont pris ni vaccin antirabique ni immunoglobuline en prophylaxie post-exposition après la morsure de chien. Le délai médian d'admission avant le décès (plage interquartile) était de 2 jours (2 jours). La majorité (82%) des cas étaient atteints de rage furieuse. CONCLUSION: L'attention devrait être dirigée vers la vaccination de masse des chiens car les morsures de chien sont courantes. Assurer la disponibilité et l'accès à la prophylaxie post-exposition (PPE) est également crucial pour éviter les décès liés à la rage. MOTS-CLÉS: Rage, morsure de chien, post-exposition, prophylaxie, vaccination de masse.

Evaluation of contingency actions to control the spread of raccoon rabies in Ohio and Virginia.

The raccoon (Procyon lotor) variant of the rabies virus (RRV) is enzootic in the eastern United States and oral rabies vaccination (ORV) is the primary strategy to prevent and control landscape spread. Breaches of ORV management zones occasionally occur, and emergency "contingency" actions may be implemented to enhance local control. Contingency actions are an integral part of landscape-scale wildlife rabies management but can be very costly and routinely involve enhanced rabies surveillance (ERS) around the index case. We investigated two contingency actions in Ohio (2017-2019 and 2018-2021) and one in Virginia (2017-2019) using a dynamic, multi-method occupancy approach to examine relationships between specific management actions and RRV occurrence, including whether ERS was sufficient around the index case. The RRV occupancy was assessed seasonally at 100-km2 grids and we examined relationships across three spatial scales (regional management zone, RRV free regions, and local contingency areas). The location of a grid relative to the ORV management zone was the strongest predictor of RRV occupancy at the regional scale. In RRV free regions, the neighbor effect and temporal variability were most important in influencing RRV occupancy. Parenteral (hand) vaccination of raccoons was important across all three contingency action areas, but more influential in the Ohio contingency action areas where more raccoons were hand vaccinated. In the Virginia contingency action area, ORV strategies were as important in reducing RRV occupancy as a hand vaccination strategy. The management action to trap, euthanize, and test (TET) raccoons was an important method to increase ERS, yet the impacts of TET on RRV occupancy are not clear. The probability of detecting additional cases of RRV was exceptionally high (>0.95) during the season the index case occurred. The probability of detecting RRV through ERS declined in the seasons following initial TET efforts but remained higher after the contingency action compared to the ERS detection probabilities prior to index case incidence. Local RRV cases were contained within one year and eliminated within 2-3 years of each contingency action.

Cost-effectiveness of One Health interventions for rabies elimination: a systematic review.

The 'One Health' (OH) approach is the most promising idea in realising the global goal of eliminating canine-mediated human rabies by 2030. However, taking an OH approach to rabies elimination can mean many different things to different people. We conducted a systematic review scrutinizing economic evaluations (EEs) retrieved from MEDLINE OVID, Embase OVID, Global Health OVID, CINAHL EBSCO and ECONLIT EBSCO that used the OH approach with the intent of identifying cost-effective sets of interventions that can be combined to implement an optimal OH-based rabies elimination program and highlight key gaps in the knowledge base. Our review suggests that an optimal OH program to tackle rabies should incorporate mass dog vaccination and integrated bite case management in combination with efficient use of post-exposure prophylaxis along with a shift to a 1-week abbreviated intradermal rabies vaccine regimen in humans. We recommend that future EEs of OH interventions for rabies elimination should be performed alongside implementation research to ensure proposed interventions are feasible and adopt a wider societal perspective taking into account costs and outcomes across both the human health and animal welfare sectors. The systematic review has been registered with PROSPERO.

Evaluating the benefit of serology during potential Australian bat lyssavirus and rabies post-exposure prophylaxis.

Post-exposure prophylaxis (PEP) for potential lyssavirus exposures consists of wound management, rabies vaccination and may include rabies immunoglobulin (RIG). Rabies serology is sometimes indicated if there is risk of PEP failure. OBJECTIVES: Evaluate the benefit of serology by indication. METHODS: Chart review of potential lyssavirus exposures managed at a Public Health Unit (June 2015 - December 2022) where serology was requested was conducted. The proportion of non-therapeutic titres was compared by sex, age, Indigenous status, serology indication, and whether RIG was given. RESULTS: 46 notifications with serology were included. Males (5/19) and people over 40 (3/16) were more likely to demonstrate a non-therapeutic response. 2/3 of cases where vaccine doses were not given in the deltoid were non-therapeutic. The rate of non-therapeutic titres was similar for RIG given into the ipsilateral arm (2/11) and given excess RIG for weight (1/4). Although this small sample was inconclusive in isolation, it was also noted that all cases who did not receive RIG had therapeutic serology, whereas 6/35 of those receiving RIG had non-therapeutic serology. CONCLUSIONS: This study supports broader literature questioning the utility of systemic RIG administration as likely limited and potentially detrimental considering the increased risk of immune interference. IMPLICATIONS FOR PUBLIC HEALTH: Highlights a need to review Australian national guidelines to align with World Health Organization advice recommending local RIG administration only.

Case Report: Survival from Clinical Rabies in a Young Child from Maharashtra, India, 2022.

A 3.5-year-old male child from Maharashtra, India, presented with features of meningoencephalitis approximately 1 month after sustaining severe bite injuries on the right hand from a stray dog. He had received four doses of post-exposure intradermal rabies vaccination (on days 0, 3, and 7 of the bite and erroneously on day 20, instead of day 28 as recommended in the updated Thai Red Cross regimen) as well as local and systemic injections of equine rabies immune globulin. The child was initially diagnosed with and treated for acute encephalitis syndrome before rabies encephalitis was confirmed by detection of rabies virus neutralizing antibodies in the cerebrospinal fluid. During the emergent period, he also received the antimalarial drug artesunate, recently reported to have antiviral effects against rabies virus. With intensive and supportive care, the child showed substantial clinical improvement over the next few weeks. He has now survived for more than 10 months after disease onset, albeit with severe neurological sequelae including diffuse cerebral and cerebellar atrophy.

[Interpretation of the National Regulation for the Rabies Exposure Prophylaxis (2023 Edition)].

Rabies is one of the important zoonotic infectious diseases, with a mortality rate of almost 100%. Rabies is a vaccine preventable disease, and proper rabies exposure prophylaxis can effectively prevent the occurrence of human rabies. In recent years, there has been significant progress in clinical research on the rabies exposure prophylaxis both domestically and internationally. World Health Organization (WHO) released the Rabies Vaccine: WHO Position Paper-April 2018. In order to guide medical institutions of all levels in rabies exposure prophylaxis, the National Administration of Disease Prevention and Control, in conjunction with the National Health Commission of the People's Republic of China, organized the Rabies Vaccine Working Group of the National Immunization Program Technical Working Group and invited experts to revise and issue the National Regulation for the Rabies Exposure Prophylaxis (2023 Edition). This article compares the National Regulation for the Rabies Exposure Prophylaxis (2009 Edition) and interprets the updated key points and supporting basis of the new version of the guidelines to guide clinical application and implementation.

Benefit-cost analysis of coordinated strategies for control of rabies in Africa.

Previous research suggests that dog mass vaccination campaigns can eliminate rabies locally, resulting in large human and animal life gains. Despite these demonstrated benefits, dog vaccination programs remain scarce on the African continent. We conducted a benefit-cost analysis to demonstrate that engaging into vaccination campaigns is the dominant strategy for most countries even in the absence of coordinated action between them. And quantify how coordinated policy measures across countries in Africa could impact rabies incidence and associated costs. We show that coordinated dog mass vaccination between countries and PEP would lead to the elimination of dog rabies in Africa with total welfare gains of USD 9.5 billion (95% CI: 8.1 - 11.4 billion) between 2024 and 2054 (30 years). Coordinated disease control between African countries can lead to more socially and ecologically equitable outcomes by reducing the number of lost human lives to almost zero and possibly eliminating rabies.

Antiviral mechanisms of two broad-spectrum monoclonal antibodies for rabies prophylaxis and therapy.

Rabies is an acute and lethal encephalomyelitis caused by lyssaviruses, among which rabies virus (RABV) is the most prevalent and important for public health. Although preventable through the post-exposure administration of rabies vaccine and immunoglobulins (RIGs), the disease is almost invariably fatal since the onset of clinical signs. Two human neutralizing monoclonal antibodies (mAbs), RVC20 and RVC58, have been shown to be effective in treating symptomatic rabies. To better understand how these mAbs work, we conducted structural modeling and in vitro assays to analyze their mechanisms of action, including their ability to mediate Fc-dependent effector functions. Our results indicate that both RVC20 and RVC58 recognize and lock the RABV-G protein in its pre-fusion conformation. RVC58 was shown to neutralize more potently the extra-cellular virus, while RVC20 mainly acts by reducing viral spreading from infected cells. Importantly, RVC20 was more effective in promoting effector functions compared to RVC58 and 17C7-RAB1 mAbs, the latter of which is approved for human rabies post-exposure treatment. These results provide valuable insights into the multiple mechanisms of action of RVC20 and RVC58 mAbs, offering relevant information for the development of these mAbs as treatment for human rabies.

Cost-Effectiveness Analysis of Integrated Bite Case Management and Sustained Dog Vaccination for Rabies Control.

The successful prevention, control, and elimination of dog-mediated rabies is challenging due to insufficient resource availability and inadequate placement. An integrated dog bite case management (IBCM) system plus dog vaccination can help address these challenges. Based on data from the IBCM system in Haiti, we conducted a cost-effectiveness evaluation of a newly established IBCM system plus sustained vaccination and compared it with 1) a no bite-case management (NBCM) and 2) a non-risk-based (NRB) program, where bite victims presenting at a health clinic would receive post-exposure prophylaxis regardless of risk assessment. We also provide cost-effectiveness guidance for an ongoing IBCM system and for sub-optimal dog vaccination coverages, considering that not all cost-effective interventions are affordable. Cost-effectiveness outcomes included average cost per human death averted (USD/death averted) and per life-year gained (LYG). The analysis used a governmental perspective. Considering a sustained 5-year implementation with 70% dog vaccination coverage, IBCM had a lower average cost per death averted (IBCM: $7,528, NBCM: $7,797, NRB: $15,244) and cost per LYG (IBCM: $152, NBCM: $158, NRB: $308) than NBCM and NRB programs. As sensitivity analysis, we estimated cost-effectiveness for alternative scenarios with lower dog-vaccination coverages (30%, 55%) and lower implementation costs. Our results suggest that better health and cost-effectiveness outcomes are achieved with the continued implementation of an IBCM program ($118 per life-year saved) compared with a newly established IBCM program ($152 per life-year saved). Our results suggest that IBCM is more cost-effective than non-integrated programs to eliminate dog-mediated human rabies.

Households' Practices towards Rabies Prevention and Control in Rural Nepal.

Rabies is a vaccine-preventable, zoonotic, viral disease and a major public health concern for developing countries such as Nepal. A study was conducted from October-December 2021 among 308 household heads from three districts in Nepal (Siraha, Parsa, and Nawalparasi West) through an in-person interview to examine the rural people's practices towards rabies. Of 70 respondents owning pet animals, 82.9% vaccinated them against rabies but 87.9% (51/58) of them kept a vaccination record. Nearly all respondents (99.7%, 307/308) said they would visit hospitals after being bitten by rabid or rabies suspected animals, and 18.2% (56/308) of them said they would also opt to visit traditional healers seeking treatment against rabies. Seven in ten respondents knew that they should wash bitten body area with soap and water. Around 60% (184/308) of respondents said they would not bother to notify or report to the local authorities if they saw someone bitten by a presumed rabid dog or observed animal behavior suggestive of rabies. The Chi-square test showed a significant association between the socio-demographic characteristics of respondents with practices (good practice and poor practice) towards rabies. The study findings suggest that rural people in Nepal need to be educated with applied rabies control and prevention practices and made aware of health seeking behavior and the role that a community members have to play to control, prevent, and eradicate rabies.

Human rabies despite post-exposure prophylaxis: a systematic review of fatal breakthrough infections after zoonotic exposures.

Post-exposure prophylaxis (PEP) for rabies is widely administered and highly effective. Nevertheless, sporadic breakthrough infections (ie, rabies in people who have started PEP) have been reported. We conducted a systematic review of articles published between Jan 1, 1980 and June 1, 2022 to characterise breakthrough infections. After reviewing 3380 articles from across all continents, we identified 52 articles, which included a total of 122 breakthrough infections. We classified breakthrough infections on the basis of adherence to core practices (ie, wound cleaning and vaccine administration). Of 86 breakthrough infections with data, median time from exposure to symptom onset was 20 days (IQR 16-24). Most (89 [77%] of 115) participants received PEP within 2 days of an exposure. Severe wounds (defined as those involving multiple wound sites or bites to the head, face, or neck) were common (80 [69%] of 116 [with data]). Deviations from core practices were reported in 68 (56%) of 122 cases. Other possible causes for breakthrough infections included errors in the administration of rabies immunoglobulin, delays in seeking health care, and comorbidities or immunosuppression. Cold-chain integrity assessments and potency testing of PEP biologics were only rarely assessed (8 [7%] of 122 cases), neither of which were found to be a cause of breakthrough infections. Timely and appropriate administration of PEP is crucial to prevent rabies, and although people with high-risk exposures or immunosuppression can develop rabies despite adherence to core practices, this occurrence remains exceedingly rare.

One Health responses to prevent the occurrence of rabies due to attacks by a rabid stray dog.

BACKGROUND: The number of human rabies cases caused by pet dogs in Guangzhou has been decreasing after years of comprehensive interventions. Consequently, attacks by stray dogs become a major issue in rabies control. OBJECTIVES: To share our experience of successfully dealing with rabies to provide some inspiration for prevention and control in countries and regions affected by it. METHODS: A multidisciplinary One Health response was initiated to control this outbreak. Rabies virus was detected by PCR in the brain tissue of the associated stray dog. The sequences were aligned with reference sequences downloaded from GenBank using ClustalX. The maximum likelihood method implemented in MEGA 5.0 software package was used in a phylogenetic analysis of the aligned sequences. RESULTS: Twelve patients with exposure to the stray dog were identified in the field investigation. Rabies vaccines and immunoglobulin were administered to all patients within 48 h. After 1 year of follow-up, no exposed patients showed symptoms. Maximum likelihood analysis of the nucleotide sequences obtained from the PCR products indicated that the rabies virus in the dog was closely related to isolates from neighbouring provinces of Guangdong as well as those from surrounding countries of China. CONCLUSIONS: Multidisciplinary One Health intervention is effective not only in the control of rabies but also in rapid emergency responses to attacks by rabid stray dogs.

Clinical features and management of animal bites in an emergency department: a single-center experience.

OBJECTIVES: This study aimed to evaluate the clinical features, management, and outcomes of patients with animal bites presented to the pediatric emergency department of a tertiary center. METHODS: Patients with ICD-10 code W54 (contact with dog) and W55 (contact with other mammals) between March 1st, 2017, and July 1st, 2021, were included in the study. Demographic characteristics of the patients, type of contacted animal, wound characteristics (muscle involvement, soft tissue defect, vascular injury, type of nerve injury, and Lackmann's classification), wound care measurements, tetanus prophylaxis, administration of rabies immunoglobulin and antibiotics, location of the injury, existing fractures, suturing, splinting, surgical consultations and hospitalization status were recorded. RESULTS: Four hundred and nineteen incidents of animal bites (240 males and 179 females) occurred over a four-year period. 51% was due to a dog bite; 47% was by a cat. The median age was nine years (IQR: 5-14 years). Most bites (91.6%) involved only a single anatomical site. The extremities were the commonly involved part (right upper limb [35.3%], left upper limb [21.2%], right lower limb [12.6%], left lower limb [16%]). Head-neck and face injury ratio was 17.6%. Torso (5.7%) and genitalia (5.2%) were uncommonly involved. A consultation was requested from at least one surgical department for 8% of the patients. 97.1% of patients received a rabies vaccine. Most attacks were trivial and did not require hospitalization. CONCLUSION: Animal bites often cause minor injuries. However, multiple dog attacks can be seen related to a high number of stray animals in our country. Therefore, these patients may present with major traumas. Surgical intervention and hospitalization may be required. Emergency physicians play an essential role in acute management and rabies prophylaxis in these patients.

Rabies: who should care?

Rabies is the deadliest viral infection known, with no reliable treatment, and although it is entirely preventable, rabies continues to kill more than 60,000 people every year, mostly children in countries where dog rabies is endemic. America is only 1 generation away from the time when rabies killed more than 10,000 animals and 50 Americans every year, but 3 to 5 Americans continue to die annually from rabies. Distressingly, > 50,000 Americans undergo rabies prevention therapy every year after exposure to potentially rabid animals. While enormous progress has been made, more must be done to defeat this ancient but persistent, fatal zoonosis. In the US, lack of public awareness and ambivalence are the greatest dangers imposed by rabies, resulting in unnecessary exposures, anxiety, and risk. Veterinarians have a special role in informing and reassuring the public about prevention and protection from rabies. This summary of current facts and future advances about rabies will assist veterinarians in informing their clients about the disease.

Wound characteristics and infiltration with immune globulin for rabies postexposure prophylaxis in the emergency department.

OBJECTIVE: This study described characteristics of wounds caused by animal exposures and evaluated patient factors and wound factors associated with wound infiltration of human rabies immune globulin (HRIG). MATERIALS AND METHODS: This retrospective cohort study evaluated wound characteristics among patients who had visible wounds and received HRIG or rabies vaccine for rabies postexposure prophylaxis (PEP) at 15 emergency departments from May 2016 to June 2018. RESULTS: Of 110 included patients (9 children, 82 adults, and 19 older adults), 21% (n = 23) had ≥2 wounds, and 10% (n = 11) had infected wounds. Twenty-eight (25%) patients had severe wounds, defined as receiving sutures (n = 20) or reaching subcutaneous tissue or bone (n = 20). Wounds were present on upper extremities for 42% (n = 46) of patients, lower extremities for 35% (n = 38), head/face for 3% (n = 3), and in multiple locations for 21% (n = 23). Wounds were < 3 cm in length for 64% (n = 70) of patients. Puncture wounds were present in 60% (n = 66) of patients, abrasions in 45% (n = 49), and lacerations in 38% (n = 42). Among 108 wounds from 82 patients with documented HRIG administration sites, 57% (n = 62) of wounds received HRIG infiltration. Infiltration occurred less frequently for wounds on the face/head/torso (adjusted odds ratio [aOR] = 0.07, 95% confidence interval [CI] = 0.01 to 0.49), wounds on hands/fingers (aOR = 0.20, 95% CI = 0.06 to 0.65), and abrasion-only wounds (aOR = 0.26, 95% CI = 0.08 to 0.80) after adjusting for age. CONCLUSIONS: Upon presentation for rabies PEP, most patients did not have severe wounds and did not require emergency services or complex wound management. Wounds on the face, head, torso, hands, or fingers and abrasions were less likely to receive HRIG infiltration.

Implementation of Clinical Decision Support on Emergency Department Delivery of Human Rabies Immune Globulin.

Importance: Fatal human rabies infections can be prevented through appropriate rabies postexposure prophylaxis (PEP). Errors in patient selection and administration of human rabies immune globulin in the emergency department (ED) setting were identified in a previous study of rabies PEP administration. Objective: To test the a priori hypothesis that implementation of a rabies PEP bundle in the ED would improve full adherence to 6 human rabies immune globulin quality indicators compared with preimplementation controls. Design, Setting, and Participants: This quality improvement study was conducted in 15 EDs in a US multihospital health system. Patients who received human rabies immune globulin or rabies vaccine in the ED from January 2015 to June 2018 were included in the preimplementation control group and from December 2019 to November 2020 were included in the postimplementation intervention group. Data were analyzed in January 2021. Exposure: The PEP bundle was implemented in December 2019 and consisted of electronic health record enhancements, including clinical decision support, ED staff education, and patient education. Main Outcomes and Measures: Full adherence to 6 human rabies immune globulin quality indicators: patient selection, dose, timing, infiltration into wounds, administration distant from rabies vaccine site, and administration that avoids the buttock. Results: The study included 324 patients; 254 patients were in preimplementation group (mean [SD] age, 39 [21] years; 135 [53%] women) and 70 in the postimplementation group (mean [SD] age, 38 [19] years; 33 [47%] women). Most patients presented to EDs embedded in a community hospital (231 patients [71%]). Full adherence increased from 37% in the preimplementation group to 61% postimplementation (absolute increase, 24%; 95% CI, 11% to 37%; P < .001). Adherence improved for quality indicators for infiltration into wounds (137 of 254 patients [54%] to 50 of 70 patients [71%]; P = .009), administration distant from rabies vaccine site (180 of 254 [71%] to 58 of 70 [83%]; P = .04), and administration that avoids the buttock (168 of 254 [66%] to 58 of 70 [83%]; P = .007). No instances of sciatic nerve injury or compartment syndrome were observed. Conclusions and Relevance: In this quality improvement study, implementation of a rabies PEP bundle was associated with improved patient selection and delivery of human rabies immune globulin in EDs across a multihospital health system. Although the bundle included ED staff education and patient discharge education, the observed improvement was likely driven by clinical decision support from the rabies PEP ED order set. Future research should evaluate implementation of this clinical decision support at other health systems.

Safety and immunogenicity of human rabies vaccine for the Chinese population after PEP: A systematic review and meta-analysis.

AIM: To evaluate the safety and immunogenicity of rabies vaccine for human use after post-exposure in China. METHODS: A systematic search was performed from PubMed, EMBASE, CNKI and Cochrane Library database, supplemented by manual retrieval. According to the inclusion and exclusion criteria, a meta-analysis was performed using Stata 16.0 software after independent literature screening, data extraction and quality assessment by two evaluators. RESULTS: A total of 32 studies were included. It was found that rabies vaccination after PEP could induce the body to produce sufficient RVNA. Both Essen and Zagreb regimens showed good immunogenicity, with no significant difference in systemic events and local events after PEP, but a relatively high incidence of local and systemic events after PEP under the Zagreb regimen. CONCLUSION: For the Chinese population, rabies vaccination after PEP has shown relatively a good immune efficacy and acceptable safety for preventing human rabies. The survey also found that the Zagreb regimen was comparable to the Essen regimen in terms of rabies prophylaxis with an acceptable safety profile.

[A study about the epidemiological characteristics of rabies of the cases of medical treatment from a certain hospital in Beijing from 2011 to 2020].

From 2011 to 2020, there were 111 213 cases of rabies exposed people recruited from the rabies immunization clinic of a hospital in Beijing. The monthly distribution of patients in each year was not statistically significant (P>0.05). The distribution of patients showed remarkable seasonality, with the exposure peak from May to October. The ratio of male to female was 1∶1.3. The majority of patients were aged 20-29 years old (39.1%) and in-service personnel (56.5%). Level-Ⅱ wounds (84.2%) were more common than level-Ⅲ wounds (14.9%). The number of visits to level-Ⅲwounds increased rapidly since 2017. The most common injured body part was hand (60.7%). Dogs were the most common animal for injuries (60.6%), followed by cats (32.3%), of which most were host animals (75.5%). The vaccination rate from 2016 to 2020 [49.8% (24 276/48 703)] was significantly higher than that from 2011 to 2015[18.6% (6 559/35 272)](χ²=8597.18, P<0.001).

Commentary on the implications of safety and efficacy studies in pediatric patients with administration of human rabies immune globulin (HRIG)?

The FDA strongly encourages rigorous safety and efficacy studies in all age groups for which vaccines and treatments for pervasive and severe diseases are intended. Until recently, there had been no safety and efficacy studies conducted in children for human rabies immune globulins. The publication," Safety, and efficacy of rabies immunoglobulin in pediatric patients with suspected exposure", Human Vaccines & Immunotherapeutics, 17:7, 2090-2096, was the first study that prospectively reviewed the use of KEDRAB® 150 IU/ml in 30 pediatric patients ages 0.5-14.9 years old. The results showed that 93.3% achieved RVNA titer >/ = 5 IU/ml, on day 14. Also, no participants reported a serious adverse event (SAE), or an adverse event (AE) leading to study discontinuation, and there were no deaths. The most common treatment emergent adverse events (TEAE) were injection-site pain. Currently there are 3 HRIG products on the US market, KEDRAB®, HyperRab® and Imogam® Rabies HT, but only KEDRAB® has published safety and efficacy data in a pediatric population. While it is common practice to prescribe medications for pediatric patients "off-label" there now exists one product with safety data in children. It is worth considering if this creates a higher medical liability for the prescriber and institution.