Elsevier

Acta Tropica

Volume 212, December 2020, 105710
Acta Tropica

The Thai Red Cross protocol experience in Côte d'Ivoire

https://doi.org/10.1016/j.actatropica.2020.105710Get rights and content

Abstract

Rabies is a public health problem in the world especially in Côte d'Ivoire. The epidemiological surveillance of rabies revealed 10,197 exposures with 17 deaths in 2015 and 11,481 exposures with 18 deaths in 2016. The management of exposed people was based on WHO's intramuscular (IM) protocols (Essen and Zagreb). The usual results from these anti-rabies protocols showed low compliance corresponding to 45–50% exposed people who did not complete the Post Exposure Prophylaxis (PEP) schedule,mainly due to the cost of vaccines.

The main objective of the project was to test the feasibility of a free rabies PEP based on the Thai Red Cross (TRC) protocol used by intradermal route.

The study population was exposed people (patients) vaccinated in the anti-rabies center of Bouake and San Pédro which were two departments selected for this study. The TRC protocol was implemented in y ear 2017. Patients have been vaccinated according to IM post exposure protocols or by the TRC schedule.This new protocol was administered free of charge to exposed people with their consent. Patients who did not complete the PEP schedule were researched and interviewed for having the reasons related to this non-completion.

In 2017, 1625 exposures were registered including 1121 in Bouaké and 504 in San Pedro.

Overall immunization compliance was 63%. Patients who received the TRC schedule were 829 (52%)With 70% PEP compliance

The PEP compliance of Zagreb protocol was 67%%and the Essen protocol recorded 38% of PEP compliance. The research of exposed people who did not complete the PEP schedule has shown that cost effectively remains the major limiting factor among exposed people vaccinated by Essen or Zagreb protocols. But negligencewas main cause for the non-completion PEP among exposed people who accepted the TRC schedule. Introduction of free rabies PEP through the TRC protocol has found the population support. This experience has been successful with a better PEP compliance, which means safe protection of people from rabies.This study has demonstrate that free rabies vaccine used by ID route is one of the best solutions to improve the PEP compliance in Côte d'Ivoire.Nevertheless, alternatives ways should be provided in order to minimize vaccine wastage rates in anti-rabies center receiving very few exposed persons.Community engagementwould be necessary for more rabies awareness raising and improving bite victim's follow-up.

Introduction

Every year, rabies accounts for more than 59,000 deaths worldwide. It poses a serious public health concern, namely in remote areas in Asia and Africa(WHO, 2018). However, rabies is preventable (Shim et al., 2009) with several Immunization protocols used by intramuscular or intradermal route (Hervé, 2013). Difficulty related to availability and cost of rabies vaccines sometimes complicate the PEP process (Hampson et al., 2011;Changalucha et al., 2018). In addition to these challenges, there is a lack of collaboration between veterinarian and medical services (Mindekem et al., 2017). In Côte d'Ivoire, there are 30 Anti-rabies centers for exposure‘s Immunization in 30 departments. These centers are under the administrative responsibilities of the National Institute of Public Hygiene (NIPH). In addition, there are 21 small anti-rabies units located in 21 other departments. The epidemiological rabies surveillance in Côte d'Ivoire revealed 10,197 exposures including 17 human deaths in 2015 and 11,481 exposures including 18 human deaths in 2016. In the same period, twenty one (21) human rabies cases have been confirmed by the national reference laboratory for rabies diagnosis (Tiembré, 2018). The exposed people were manage by using two World Health Organization (WHO) approved PEP (Essen and Zagreb). But the application of these anti-rabies protocols showed low compliance with 45–50% people lost to follow-up (non-completion), mainly related to the cost of rabies PEP vaccine (Table 1).

In 2016, Gavi Rabies Project "Impact of Rabies and Immunization in Central and West Africa" ​​was initiated in two departments of Côte d'Ivoire (Bouaké and San pedro). Considering the difficulties linked to the Intra muscular protocols compliance in this country, it was agreed to experiment in 2017 a free rabies PEP vaccine based on the TRC that was administered by intradermal route. This study has a limitation linked to the use of two rabies vaccines stocks in anti-rabies centers: free vaccine for TRC and another stock of paid rabies vaccine which belonged to the national party (NIPH). Despite this limitation, the study remains relevant for several reasons: TRC protocol which was effectively implemented by ID route is a new PEP schedule which has never been used in Côte d'Ivoire, the selection of the people was based on voluntary consent, the results of this study will be determinant for a better orientation of the new ID vaccination as recommended by the WHO in the future. The reduction of cost to the free and the painlessness of the vaccination act related to the ID route could lead the exposed persons to follow the PEP until the end. The main objective of this study was to test the feasibility of a PEP using TRC protocol with free vaccines.

Section snippets

Study site and population

The study took place in two departments of Côte d'Ivoire: Bouaké and San pedro (Fig. 1) in 2017. The choice of theses departments was justified by the fact that Bouake records yearly the highest number of exposed people while San Pédro regularly reports rabies death (Tiembré et al., 2018).

These two study sites have respectively 680,700 and 631,200 inhabitants (RGPH, 2014). In the department of Bouaké, especially, the main part of the people resides in urban area and account for 80% of the

Summary of PEP following-up from 2016 to 2017

In 2016, the Bouaké and San Pedro anti-rabies centers have received 1,263 rabies exposures. Overall completion rate of the PEP was 37%, which means that 63% of exposed people did not complete their PEP protocol. This assessment was estimated at 42% of the PEP completion for patients who received the Zagreb protocol against 26% for the people vaccinated by the Essen protocol.

In 2017, the amount of exposed people raised up to 1,625 for the two study areas; 1,121 persons in Bouaké and 504 in San

Discussion

During the first year of the study, bite victims PEP, which were mainly based on the Essen and Zagreb protocols, revealed a high rate of exposed people who had not completed the PEP course, namely for the Essen protocol. That gap might certainly be linked to the long duration of the said protocol (28 days), its high number (5) of administered doses which lead excess cost. Coulibaly et al. (2017) had already recorded 54.4% patients who did not completed the PEP in Bouaké and 76% of them had

Conclusion

Essen and Zagreb protocols that have been used for PEP in Côte d'Ivoire for several years causing many non-completion cases. The introduction of free of charge PEP through the TRC protocol revealed wastage of doses in anti-rabies center that receiving very few bite victims. Nevertheless, this free protocol found the population adherence, successful with better PEP completion and reflecting safe protection against rabies. The few cases of PEP non completion were mainly related to negligence.

Author statement

ACTROP_2019_781_R2: Risk factors for rabies in Côte d'Ivoire

The co-authors of this article contributed as stated below

M= Minimal

I= Intermediate

E= Extensive

ActivityAuthorEmpty CellEmpty CellEmpty CellEmpty CellEmpty CellEmpty CellEmpty CellEmpty CellEmpty CellEmpty Cell
mathilde
tetchi
m'begnan coulibalyvessaly
kallo
gnamien
sylvain traoré
tiembre issakabenie josephfelix gerberjasmina saricmonique lechennejakob zinsstagbassirou bonfoh
Organisation and planningeiiimiMmiim
Data collectionEEEIMMMMMMIM
Data analysisEMMIMMMMMMM
Article writingEEIMIIMIMEM
Article revisionEMMMMMMMMEE
Quality controlEEIMMMMMMMM

Declaration of Competing Interest

The authors declare no conflict of interest.

Acknowledgement

This article is based on GAVI project experience in Côte d'Ivoire. It was prepared with the support of the DELTAS Africa Initiative [Afrique One-ASPIRE /DEL-15–008]. Afrique One-ASPIRE is funded by a consortium of donor including the African Academy of Sciences (AAS) Alliance for Accelerating Excellence in Science in Africa (AESA), the New Partnership for Africa's Development Planning and Coordinating (NEPAD) Agency, the Wellcome Trust [107753/A/15/Z] and the UK government.We thank the agents

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