Imported episodic rabies increases patient demand for and physician delivery of antirabies prophylaxis

Abstract

Background: Imported cases threaten rabies reemergence in rabies-free areas. During 2000-2005, five dog and one human rabies cases were imported into France, a rabies-free country since 2001. The Summer 2004 event led to unprecedented media warnings by the French Public Health Director. We investigated medical practice evolution following the official elimination of rabies in 2001; impact of subsequent episodic rabies importations and national newspaper coverage on demand for and delivery of antirabies prophylaxis; regular transmission of epidemiological developments within the French Antirabies Medical Center (ARMC) network; and ARMC discussions on indications of rabies post-exposure prophylaxis (RPEP).

Methodology/principal findings: Annual data collected by the National Reference Center for Rabies NRCR (1989-2006) and the exhaustive database (2000-2005) of 56 ARMC were analyzed. Weekly numbers of patients consulting at ARMC and their RPEP- and antirabies-immunoglobulin (ARIG) prescription rates were determined. Autoregressive integrated moving-average modeling and regression with autocorrelated errors were applied to examine how 2000-2005 episodic rabies events and their related national newspaper coverage affected demand for and delivery of RPEP. A slight, continuous decline of rabies-dedicated public health facility attendance was observed from 2000 to 2004. Then, during the Summer 2004 event, patient consultations and RPEP and ARIG prescriptions increased by 84%, 19.7% and 43.4%, respectively. Moreover, elevated medical resource use persisted in 2005, despite communication efforts, without any secondary human or animal case.

Conclusions: Our findings demonstrated appropriate responsiveness to reemerging rabies cases and effective newspaper reporting, as no secondary case occurred. However, the ensuing demand on medical resources had immediate and long-lasting effects on rabies-related public health resources and expenses. Henceforth, when facing such an event, decision-makers must anticipate the broad impact of their media communications to counter the emerging risk on maintaining an optimal public health organization and implement a post-crisis communication strategy.

Figure 1. Flow chart of the French surveillance system for prevention of rabies in humans.

*AFFSA denotes for French Agency for Food Safety, http://www.afssa.fr/.

Figure 2. Spatial distribution of French AntiRabies Medical Centers (ARMC).

The minimal distance to any of the 74 ARMC is illustrated (grey scale); 93% of the 36,539 districts are <75 km from an ARMC. France has been divided into three areas, according to their rabies experience: area 1 corresponds to the former zone harboring rabies-infected foxes (19,132,787 inhabitants); area 2, has no history of rabies events (37,423,439 inhabitants); and area 3, where rabies event #6 occurred (1,981,313 inhabitants).

Figure 3. Rabies-exposure notifications to ARMC and numbers of RPEP prescribed to exposed patients in France, 1989–2006.

These data are from the annual NRCR report (http://www.pasteur.fr/sante/clre/cadrecnr/rage/rage-actualites.html).

Figure 4. Flow chart of human data used in the analysis.

Figure 5. Weekly numbers of notified human contacts with animals that led to a consultation at an ARMC.

This figure illustrates the behaviors associated with notified exposures at ARMC (n = 56,446). The model combines a forecasting ARIMA model for 2000–2004. Events #1, #2, #4, #5 and #6 correspond to illegal importations of rabid dogs from Morocco, while event #3 was an imported human case from Gabon. Event #1 could not been analyzed because the duration of observations preceding the event was too short to implement ARIMA modeling. The solid black line traces patients' ARMC consultations; the thick red line corresponds to the step-by-step modeling prediction of those consultations; the dashed red lines for event #3 and #6 represent the upper 95% CI. Note the increased consultation rates for these events, especially #6.

Figure 6. Comparison of the different behaviors observed in the different geographical areas.

Keep in mind that event #6 occurred in area 3. The grey band corresponds to the rabid dog's infectious period (weeks 240–242).