Rabies Postexposure
Prophylaxis
in Maryland 2008-2012
May 8, 2015
Daniel Laucks
Preceptors: Katherine Feldman and
Kimberly Mitchell
Maryland Department of Health and Mental Hygiene
Organization
 Center for Zoonotic and Vector-Borne Disease
 Mission – To reduce the incidence and associated impact
of rabies and other zoonotic and vector-borne diseases in
Maryland
 Coordinate management of human exposures to known
or suspected rabid animals, coordinating rabies testing ,
and provide guidance to Local Health Departments on
rabies prevention
Rabies
 Viral disease the affects all mammals; almost always fatal once
symptoms begin
 Present in most regions globally
 Globally, WHO estimates as many as 60,000 human rabies deaths
worldwide annually
 <10 human deaths annually in the US
 Postexposure prophylaxis (PEP) administered to people
potentially exposed to rabies is a key element of prevention
 Rabies is 100% preventable if PEP administered appropriately
 PEP: HRIG on day 0, vaccines on days 0,3,7,14
Rabies in Maryland - 2013
Species
# Positive
% Total
Raccoon
234
62%
Bat
50
13%
Fox
33
9%
Cat
24
6%
Skunk
19
5%
Groundhog
10
3%
Goat
2
2%
Dog
1
<1%
Horse
1
<1%
Opossum
1
<1%
Total
375
100%
PHASE Analysis
 Goal: Characterize use of rabies PEP in Maryland
 Prior studies have evaluated frequency of PEP use in other
regions, but most rely on reporting from hospitals or health
departments
 Reported rates range from: 2.2 to 15.6 per 100,000 persons per
year
 Maryland Local Health Departments (LHD’s) are required to
report PEP courses to DHMH
 Using the Maryland Health Services Cost Review
Commission (HSCRC) data, we were able to capture a more
complete picture of PEP
Methods
 Searched HSCRC outpatient data for all records with
ICD-9CM codes related to rabies
 Used the dataset generated to determine rates of PEP
utilization and describe patient demographics and cost
 Multiple linear regression used to analyze predictors of
cost and examine PEP use patterns over time
 Compared LHD to HSCRC reports
Population Demographics
 Total numbers
 6,718 courses initiated
 2,297 complete courses
 Sex
 47% Male, 53% Female
 Age
 Mean age 33 years
 27% under age 18
 Race
 71% White
 21% Black
 8% Other
 Concurrent Diagnosis
 Dog bites 14%
 Other bites 14%
 Wounds 18%
 Upper body 2/3
 Lower body 1/3
PEP Initiation by month 20082012
350
Courses initiated
300
250
200
150
100
50
0
Date
4500
35
PEP Initiation per 100,000 People
% of submissions testing positive
5000
4000
30
3500
25
3000
20
PEP Initiation Rate per 100,000
% of Submissions testing positive
15
2500
2000
Animal Rabies testing submissions
1500
10
1000
5
500
0
0
2008
2009
2010
2011
Year
2012
2013
Rabies Test Submission
40
Annual Rate of PEP Initiation
Cost of PEP Initiation and 4 Dose
Course
6000
5000
Cost in 2010 $
Initial visit cost
4000
4 dose cost
3000
2000
1000
0
2008
2009
2010
2011
Year
2012
2013
LHD vs. HSCRC data
LHD vs. HSCRC data
Frederick
59 16 368%
LHD vs. HSCRC data
Montgomery
0%
133%
77.59%
0%
53%
LHD vs. HSCRC data
Total
62.39% 75.38%
65.00%
32.68%
39.41%
Discussion
 PEP utilization rates were found to be higher than
reported in the literature
 Both rates and cost more than doubled during the study
period of 2008-2012
 Differences reported may be partially accounted for by
underestimates in other studies
 Trends may be due to changes in exposure risk
assessment practices
Conclusions
 PEP rates and charges have continued to rise, in spite
of steady rates of rabies in animal populations
 While charges may be difficult to control, improved
exposure risk assessment may allow us to conserve
healthcare resources while providing rabies protection
to those who need it.
Acknowledgements
 Drs. Katherine Feldman and Kimberly Mitchell for
overseeing the PHASE experience
 Dr. Megan Davis for assistance with statistical methods
 Brenna Hogan and Andrea Bankowski for assistance
extracting data from the HSCRC database
 Mary Armolt for compiling LHD reporting and animal testing
results.
 Everyone at CZVBD and IDEORB for their support and
assistance.