An evaluation of Brazil’s surveillance and prophylaxis of canine rabies between 2008 and 2017

An effective surveillance system is critical for the elimination of canine rabies in Latin America. Brazil has made substantial progress towards canine rabies elimination, but outbreaks still occurred in the last decade in two states. Brazil uses a health information system (SINAN) to record patients seeking post-exposure prophylaxis (PEP) following contact with an animal suspected of having rabies. This study evaluated: (i) whether SINAN can be reliably used for rabies surveillance; (ii) if patients in Brazil are receiving appropriate PEP and (iii) the benefits of implementing the latest World Health Organization (WHO) recommendations on PEP. Analysing SINAN records from 2008 to 2017 reveals an average of 506,148 bite-injury patients/year [range: 437k-545k] in the country, equivalent to an incidence of 255 bite-injuries/100,000 people/year [range: 231–280]. The number of reports of bites from suspect rabid dogs generally increased over time. In most states, records from SINAN indicating a suspect rabid dog do not correlate with confirmed dog rabies cases reported to the Regional Information System for Epidemiological Surveillance of Rabies (SIRVERA) maintained by the Pan American Health Organization (PAHO). Analyses showed that in 2017, only 45% of patients received appropriate PEP as indicated by the Brazilian Ministry of Health guidance. Implementation of the latest WHO guidance using an abridged intradermal post-exposure vaccination regimen including one precautionary dose for dog bites prior to observation would reduce the volume of vaccine required by up to 64%, with potential for annual savings of over USD 6 million from reduced vaccine use. Our results highlight the need to improve the implementation of SINAN, including training of health workers responsible for delivering PEP using an Integrated Bite Case Management approach so that SINAN can serve as a reliable surveillance tool for canine rabies elimination.高效的监测系统对于拉丁美洲消除犬狂犬病至关重要。巴西在犬狂犬病消除工作中已取得长足进展，但近十年来仍有两个州暴发过疫情。巴西通过健康信息系统（SINAN）记录因接触疑似狂犬病动物而寻求暴露后预防（PEP）的患者。本研究评估了三个方面：(i) SINAN能否可靠应用于狂犬病监测；(ii) 巴西患者是否获得了恰当的PEP；(iii) 落实世界卫生组织（WHO）最新PEP指南的益处。对2008至2017年的SINAN记录进行分析后发现，该国每年平均有506148名咬伤患者[区间：43.7万-54.5万]，对应咬伤发生率为每10万人每年255例[区间：231-280例]。疑似狂犬咬伤的报告数量总体呈逐年上升趋势。在大多数州，SINAN记录中疑似狂犬的相关数据，与泛美卫生组织（PAHO）维护的狂犬病流行病学监测区域信息系统（SIRVERA）上报的确诊犬狂犬病病例并不匹配。分析显示，2017年仅有45%的患者按照巴西卫生部指南的要求接受了恰当的PEP。若采用世界卫生组织最新指南推荐的简化皮内暴露后接种方案（包括在观察前为犬咬伤患者追加一剂预防剂量），可将所需疫苗剂量减少至多64%，预计每年可因疫苗使用量降低节省超600万美元。本研究结果凸显了优化SINAN落地应用的必要性，包括对负责实施PEP的医护人员开展咬伤病例综合管理相关培训，从而使SINAN能够成为犬狂犬病消除工作中可靠的监测工具。