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Global Health Update

Global Health Update. January 19, 2011 Ann Settgast, MD, DTM&H Center for International Health. For which of these patients would you recommend rabies PrEP (Pre-exposure Prophylaxis) and why?. A. Adult male backpacking across India for 6 months

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Global Health Update

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  1. Global Health Update January 19, 2011 Ann Settgast, MD, DTM&HCenter for International Health

  2. For which of these patients would you recommend rabies PrEP (Pre-exposure Prophylaxis) and why? A. Adult male backpacking across India for 6 months B. Toddler child moving to Costa Rica for the year with her missionary parents C. Adult female working with MSF in Angola for 4 months D. Adult female working in Tanzania for 2 weeks on a filming project about HIV awareness E. Adult male visiting Mumbai for 5 days for business F. Adult female PhD candidate spending one month in Bangladesh to do diarrhea research G. Adult female bikeriding around the island of Bali for 3 weeks H. Adult male med/peds resident doing a two-month rotation in Bolivia

  3. Why rabies discussion is important in travel medicine • ~ 55,000 human rabies deaths per year world-wide • Likely under-reported, especially due to misdiagnosis of paralytic form • Only way to guarantee survival in an exposed unimmunized patient is to give post-exposure prophylaxis (PEP) • PEP= vaccine plus RIG

  4. Where in the world is rabies? • Over 100 countries and all continents • Vast majority of deaths in Africa & Asia • 20,000 deaths in India • China second to India in # of deaths • 24,000 deaths in Africa • 80% in rural areas

  5. Bangladesh • Highest per capita death rate from rabies - one in every 30,000 • This would = 100 rabies deaths per year in the Twin Cities!!

  6. Bali – rabies free Until…

  7. Sept 2008, two adults died two months after being bitten, “… it would be a major concern if the dogs were infected with rabies, because no vaccine … is stored on the island.” (Jakarta Post) • Dec 2008, the Indonesian authorities reported a rabies outbreak in dogs on Bali • Jan 2009, “Commendable efforts being made … to achieve control by culling and (dog) vaccination. Strangely, medical authorities seem reluctant to employ post-exposure vaccination to protect human population.” • Mar 2009, “Little precise information has been reported concerning the course of the outbreak and… consequent human fatalities. In particular, there is concern about the extent of the dog vaccination program and the availability of vaccine and immunoglobulin for PEP.”

  8. Sept 2009, 21 y/o female bitten by dog; rushed to regional hospital; wound was cleaned and sutured. 15 days later presented with inability to move legs, restlessness, and phobic to water. Given two rabies vaccines. Died. 9th fatality. • Oct 2009, Indonesia MOH reported 15 deaths - most cases near popular tourist destinations on the southern tip of Bali • April 2010, “…important for patients and families to seek medical advice as soon as any of the classic rabies symptoms are exhibited…They should get anti-rabies vaccines immediately," he said. • September 2010, 93 deaths (165 people bitten by dogs daily) • As of last week, 118 deaths recorded

  9. How many do NOT die of rabies? • Estimated that in the absence of PEP (post-exposure prophylaxis), 327,000 persons in Africa and Asia would die each year • Manufacturer data suggest that > 15 million people receive PEP annually (majority in India and China) “Rabies vaccines: WHO position paper”, No. 32, 2010

  10. Rabies Immune Globulin (RIG) • Produced by a limited # of companies in the developing world • In the developing world, < 1% of those w/ serious exposures receive it! • Human (HRIG) preferred (longer half-life) • Newer Equine formulations (ERIG): potent, highly purified, safe, much less $$ • Small, but real risk of anaphylaxis and serum-sickness J Travel Med 2005; 12:s30-s40

  11. Vaccine • All cell culture vaccines induce prompt and high neutralizing Ab response • Intradermal regimens well-proven (assuming proper administration) and widely used • Nerve tissue vaccines (still used in a few countries): less immunogenic +more severe reactions “Rabies vaccines: WHO position paper”, No. 32, 2010

  12. Not all travelers need PrEP(Pre-Exposure Prophylaxis) • But all need education! • Rabies vaccine at Health Partners Travel Clinic is $329 + admin fee • But…once correctly immunized w/ PrEP, no need for RIG • 76% of 300 surveyed German and Swiss GPs seeing patients (going to developing countries) for pre-travel advice did not discuss rabies with the traveler (J Trav Med 1999; 6:163-167)

  13. Factors to consider in pre-travel consultation… • Probability of exposure: • Incidence of rabies in the area • Probability of contact with infected animal *Children • Ability to access local after-care (remoteness of travel and time to reach medical care) • Competence of local after-care

  14. Back to Bali • One million tourists visited Bali Jan to June 2009 • PrEP for all would cost $750,000,000 (at U.S. rates) • If risk of being bitten is 1 in 6000 (based on study of tourists in Nepal), then total cost of giving PEP to only those who exposed would be 166 times $4000, which equals $664,000

  15. However… • Sometimes decision to give PEP is a no-brainer, but process can still be very stressful for patient and provider • Situation is much easier if PrEP has been given (especially when severity of exposure is less obvious).

  16. Mumbai, India – H Most other cities in India - E Islamabad, Pakistan – H Kathmandu, Nepal – H Bangkok – H 64% of 500 Thai Hospitals surveyed (J Trav Med 1998) Hong Kong Singapore HCMC and Hanoi, Viet Nam only at Int’l SOS clinic Beijing, China – “controlled & limited” Ulanbatter, Mongolia Lagos, Nigeria – “occasionally E, but none at the moment” Acra, Ghana Durban, South Africa Large cities in Brazil – B Lima, Peru – E Medellin, Columbia – E Costa Rica Cuzco, Peru Bali How do you know where RIG is available? You don’t! Source: informal email survey sent to 40 clinics (ISTM) in 20 developing countries ~ 75% response rate

  17. Counseling a traveler • Avoid stray or unknown domestic animals • If bitten, immediately flush wound with soap/water • Seek urgent medical attention, preferably in specialized center • Request cell culture vaccine only • Insist on RIG

  18. Now, for which of these patients would you recommend rabies PrEP (Pre-exposure Prophylaxis) and why? • A. Toddler child moving to Costa Rica for the year with her missionary parents • B. Adult female bikeriding around Bali for 3 weeks • C. Adult female PhD candidate spending one-month in Bangladesh to do diarrhea research • D. Adult male backpacking across India for 6 months • E. Adult female working with MSF in Angola for 4 months • F. Adult female working in Tanzania for 2 weeks on a filming project about HIV awareness • G. Adult male visiting Mumbai, India for 5 days for business • H. Adult male med/peds resident doing a two-month rotation in Bolivia

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