Evaluating Surveillance for and Estimating Administration of Rabies Postexposure Prophylaxis in the United States, 2012-2018

Background An evaluation of postexposure prophylaxis (PEP) surveillance has not been conducted in over 10 years in the United States. An accurate assessment would be important to understand current rabies trends and inform public health preparedness and response to human rabies. Methodology/Principle findings To understand PEP surveillance, we sent a survey to public health leads for rabies in 50 U.S. states, Puerto Rico, Washington DC, Philadelphia, and New York City. Of leads from 54 jurisdictions, 39 (72%) responded to the survey; 12 reported having PEP-specific surveillance, five had animal bite surveillance that included data about PEP, four had animal bite surveillance without data about PEP, and 18 (46%) had neither. Although 12 jurisdictions provided data about PEP use, poor data quality and lack of national representativeness prevented use of this data to derive a national-level PEP estimate. We used national-level and state specific data from the Healthcare Cost & Utilization Project (HCUP) to estimate the number of people who received PEP based on emergency department (ED) visits. The estimated annual average of initial ED visits for PEP administration during 2012–2017 in the United States was 46,814 (SE: 1,697), costing upwards of 165 million USD. State-level ED data for initial visits for administration of PEP for rabies exposure using HCUP data was compared to state-level surveillance data from Maryland, Vermont, and Georgia between 2012–2017. In all states, state-level surveillance data was consistently lower than estimates of initial ED visits, suggesting even states with robust PEP surveillance may not adequately capture individuals who receive PEP. Conclusions Our findings suggest that making PEP a nationally reportable condition may not be feasible. Other methods of tracking administration of PEP such as syndromic surveillance or identification of sentinel states should be considered to obtain an accurate assessment.
Author summary Although rabies is nearly always fatal, it is also almost 100% preventable. While thousands of people receive PEP each year, the total amount of PEP administered in the United States and whether it is administered correctly, is unknown. To understand PEP use nationally, the National Association of State Public Health Veterinarians in collaboration with the Centers for Disease Control and Prevention (CDC), sent a survey to public health professionals in the 50 U.S. states, Puerto Rico, Washington DC, Philadelphia, and New York City. Only half of responding jurisdictions had some method of tracking the number of people who had an animal bite or received rabies PEP; these methods differed in quality and completeness. For three states that had PEP data from their surveillance systems and also state-level emergency department (ED) data on the number of initial ED visits for PEP administration, discordant numbers suggested that the number of people who receive PEP may be much higher than estimated. Monitoring PEP administration through ED data could be one way to ensure that people receive appropriate PEP after an exposure and that costs are better understood.