Animal bite and rabies post-exposure prophylaxis reporting in Central Zone, Alberta, Canada

Description of the Problem and Objectives: Rabies risk assessment and follow up in Central Zone, Alberta, Canada can be time consuming and, given that Environmental Public Health (EPH) receives an average of 615 animal exposure reports every year, this program is resource-intensive. Evaluation of this program requires accurate information, and it was believed that the EPH database that reports animal exposures was incomplete. The aim of this project was to improve the quality and efficiency of the animal bite and rabies post exposure prophylaxis (PEP) reporting process in Central Zone, Alberta, Canada by investigating the sources of the present errors in the current EPH database, facilitating discussion on how to mitigate those errors for future reporting processes, and identifying indicators for the EPH program to evaluate the efficiency of the animal bite response process. This project was carried out in two stages. Method(s) Used: The first stage aimed to understand why the EPH database was incomplete. The Communicable Disease Control (CDC) database was used as a “gold standard” for all cases who had been offered PEP from January 2011 through May 30, 2015. The EPH database and Animal Exposure Investigation Report files were searched for these cases, and reports missing from the EPH database were identified. Errors in the reporting process were listed and categorized using a fishbone analysis diagram. The second stage was data analysis and query development. First, any CDC PEP referrals missing from the EPH database were entered into the EPH database to create a single source with a complete list of the cases of interest. Descriptive statistics were generated for parameters of interest for all of the PEP referrals and for a domestic animal subset using Microsoft Excel and pivot tables. Results: There were 198 PEP referrals in the CDC database for the time period in question of which, only 141 were recorded by the EPH database. It was identified that 30% of the PEP referrals were missing from the EPH database of which, 14% were due to in-zone exposures and 15% were due to out of zone exposures. The fishbone analysis diagram showed that the most prevalent category of error that led to an incomplete EPH database was data entry such as illegible handwriting on the original form. The evaluation process in stage two showed that 60% of the PEP referrals were due to provoked animal exposures. In 84% of the victims who were offered PEP, the mechanism of exposure was a bite, 47% of which were bites to the hand. It was also found that approximately 40% of the PEP referrals were due to domestic animal exposures of which, 71% were to domestic dogs. Furthermore, 60% of the domestic animal exposures for which PEP was offered was due to a provoked exposure, 70% of which were from domestic dogs. It was further identified that only 12% of the domestic animals involved in an incident roamed unsupervised, but approximately 60% of the domestic animals involved in an incident were not available for quarantine. Discussion: The fishbone analysis demonstrates that there are many errors that contribute to the current incomplete EPH database, most notably, data entry. Data evaluation identified that PEP recommendations include many apparently low risk exposures, based on the summary statistics, however the incomplete and inconsistent nature of many of the reports does not permit a robust conclusion. This is public health relevant because although rabies infection leads to fatal encephalitis once clinical symptoms manifest, rabies PEP may not be cost-effective in a low rabies risk country. These results were discussed with the Central Zone public health team responsible for animal bite risk assessment and follow up, who identified that more work is required to understand how practitioners decide how to code different exposures, and how this would inform the interpretation of the summary statistics from this project. They plan to organize an EPH committee who will oversee improvement in the collection, storage and use of animal bite data; as well as to ensure that resources are utilized effectively