The evaluation of Animal Bite Treatment Centers in the Philippines from a patient perspective

Amparo, A. C. B., Jayme, S. I., Roces, M. C. R., Quizon, M. C. L., Mercado, M. L. L., Dela Cruz, M. P. Z.,
Licuan, D. A., Villalon, E. E. S., 3rd, Baquilod, M. S., Hernandez, L. M., Taylor, L. H., & Nel, L. H. (2018). The
evaluation of Animal Bite Treatment Centers in the Philippines from a patient perspective. PloS one, 13(7),
e0200873. https://doi.org/10.1371/journal.pone.0200873

Background
The Philippines has built an extensive decentralized network of Animal Bite Treatment Centers (ABTCs)
to help bite victims receive timely rabies post-exposure prophylaxis (PEP) at little cost. This study
surveyed patients in the community and at ABTCs of three provinces to assess animal bite/scratch
incidence, health-seeking behaviour and PEP-related out-of pocket expenses (OOPE).
Methodology and principal findings
During community surveys in 90 barangays (neighbourhoods), 53% of households reported at least one
animal bite /scratch injury over the past 3 years, similar across urban and rural barangays. Overall
bite/scratch incidences in 2016–17 were 67.3, 41.9 and 48.8 per 1,000 population per year for Nueva
Vizcaya, Palawan and Tarlac respectively. Incidences were around 50% higher amongst those under 15
years of age, compared to -those older than 15. Household awareness of the nearest ABTCs was
generally over 80%, but only 44.9% sought proper medical treatment and traditional remedies were still
frequently used. The proportion of patients seeking PEP was not related to the distance or travel time to
the nearest ABTC. For those that did not seek medical treatment, most cited a lack of awareness or
insufficient funds and almost a third visited a traditional healer. No deaths from bite/scratch injuries were
reported. A cohort of 1,105 patients were interviewed at six ABTCs in early 2017. OOPE varied across
the ABTCs, from 5.53 USD to 37.83 USD per patient, primarily dependent on the need to pay for
immunization if government supplies had run out. Overall, 78% of patients completed the recommended
course, and the main reason for non-completion was a lack of time, followed by insufficient funds. Dog
observation data revealed that 85% of patients were not truly exposed to rabies, and education in bite
prevention might reduce provoked bites and demand for PEP. An accompanying paper details the ABTC
network from the health provider’s perspective.
Introduction
Rabies is a fatal disease, and patients bitten by animals that may be carrying rabies require prompt
access to post-exposure prophylaxis (PEP) [1]. Alongside preventative vaccination of animals, access to
PEP is a central tenet of control in rabies endemic countries. Global health organizations are moving
towards the recently set goal of an end to human rabies by 2030 [2], and Gavi is considering investing in
the procurement of human rabies vaccine for the low income countries that it supports [3]. Data that help
determine the optimal allocation of resources between control in human and animal populations will be
critical as more countries advance rabies control efforts and seek to reduce human deaths from this
zoonotic disease.
Access to PEP has been increasing in some rabies endemic countries, particularly in Asia where the
intradermal route of administration has made it more affordable [4], but there has been very little
assessment of how well such provision is serving victims of bites from potentially rabid animals.
Over the last decade the Philippines, where rabies remains endemic, has significantly extended its
network of Animal Bite Treatment Centers to over 500 across the country. Although the target of 1 ABTC /
100,000 population has not been reached everywhere, poorer provinces have equivalent access to ABTC
to wealthier ones [5]. Since 2016, these facilities have been providing free anti-rabies vaccines and
subsidized equine rabies immunoglobulin to animal bite/scratch victims. Each ABTC has trained staff and
since 2016, a complete course of rabies vaccine has been provided free of charge to patients. Alongside
the provision of PEP, national guidelines to vaccinate dogs against rabies are well established throughout
the Philippines, although the coverage achieved may not be as high as ideal [6]. Despite these measures,
human rabies deaths continue to occur in the Philippines, with an average of 248.7 per year from 2008 to
2016 [5].
However, if treatment at ABTCs remains too difficult, too expensive, or just undesirable for patients to
access, the intended prevention of human deaths may still not be realised. The smallest administrative
units in the Philippines is a barangay, which could be a village, district or ward and in urban areas may
refer to a city neighbourhood. This study used a community survey in 90 barangays (both rural and urban)
across 3 provinces to provide data from the patients’ perspective. We estimated the incidence of animal
bites, assessed the level of awareness of ABTCs in the community, and the level of their use in the event
of a bite incident. We also examined reasons for not using them. The cost per patient to access PEP was
also collected from six ABTCs across the same three provinces and patients who failed to complete the
course of PEP were interviewed to ascertain the reasons for this.
By examining awareness of where to seek PEP, and the frequency with which communities access it, this
study provides data that can be used to determine the best future strategy to minimise human deaths
from rabies in the Philippines and elsewhere. This study was carried out in conjunction with a study of the
operation of the network from a health providers perspective which collected data from the same study
provinces and described the development of the ABTC network across the Philippines, including its costs
and impacts [5].
Methods
The data presented here are tightly linked to that presented in an accompanying paper from the health
care provider’s perspective [5] where more information on the ABTC network in the Philippines can be
found, and where the choice of study provinces and ABTCs are more fully explained. Briefly, three
provinces were selected to reflect a range of different human population densities and geographies most
applicable to Gavi-eligible countries in Africa and Asia. They were Nueva Vizcaya, a mountainous and
mostly rural province with a human population density of 100 people/km2, Palawan, an island archipelago
with a human population density of 65/km2 and Tarlac, mainly lowland with more urban areas and a
human population density of 450/km2.
Community surveys
For each of the three provinces, a total of 30 barangays were selected using cluster sampling, with the
probability of their being selected proportional to their population size. Barangays, which are the smallest
administrative units in the Philippines, have been considered as the sampling unit in this study because of
their clear boundaries and because Filipino social structure is oriented around the barangay and its
officials including health workers We used the classification of barangays as rural or urban from the
Philippine Standard Geographic Code (PSGC) [7]. Household interviews were conducted between March
19th and May 4th 2017. Household sampling in these barangays was random (where household master
list or spot map was available) or systematically started at a randomly assigned house. Subsequent
households that were interviewed were those nearest to the preceding household following a randomly
chosen direction determined prior to the start of the survey in each barangay. At every house surveyed, a
respondent over 16 years old was interviewed about the household size and animal bites or scratches
occurring in the past 3 years to allow estimation of incidence. Bites/scratches occurring outside the
province were excluded from further analysis. More detailed data on health seeking behaviour was
collected in households with bite incidents, and household interviews were continued until a minimum
sample size of 18 bite incidents per barangay was reached. Traditional medicine is still widely practiced in
the Philippines, and most communities will have a tandok (traditional healer) who uses herbal medicine to
treat illnesses. We collected data on how often patients consulted a tandok following bite/scratch injuries.
Travel time to the nearest ABTC was calculated for each barangay surveyed, using Google Maps to
estimate the travel time by car to the ABTC from the central point of the barangay. Central points were
assigned to, in order of priority: the barangay hall, public elementary school, or the geographical center of
the barangay.
ABTC patient survey
In each province, one ABTC situated in the province capital and one ABTC in a rural municipality were
included to assess patient costs in accessing PEP (Table 1, S1 Fig). The Philippines Department of
Health supplies an extensive national network of ABTCs with only high quality, imported rabies vaccine
and equine Rabies Immunoglobulin (eRIG). Human RIG is not provided. Vaccine is delivered almost
exclusively using the intradermal route following the modified 2-site (Thai Red Cross) regimen (4 visits on
days 0, 3, 7 and 28, 8 doses, 2-2-2-0-2), and previously immunised patients are given just two booster
doses (1 dose on each of 2 visits) [5]. ABTCS are allowed to charge patients for consumables, such as
syringes and for eRIG if required, but cannot charge for government provided vaccine. Patients also need
to cover their travel expenses and the cost of their time to attend the ABTC.

* Does not provide eRIG

In each province, a minimum sample size of 355 to 370 patients arriving for their first visit were targeted
across the two ABTCS selected and followed for their entire treatment period. Because of the very
different numbers of patients treated per month this could not be evenly divided across the rural and
urban ABTCs, but generally all patients at rural ABTCs were interviewed. Where there were more patients
available for interview, the patients interviewed were divided across the 6-week data collection period.
These patients were selected randomly, and as often as possible, were interviewed in adequately spaced
intervals to represent those coming in for consultation at different times of the day.
Patients were interviewed between February and April 2017, during their scheduled PEP visits (Days 0, 3,
7, and 28) in the ABTC. Those who did not return for their scheduled dose were followed-up through
phone or home visits (where possible). Data about their bite/scratch incident and all costs associated with
their wound treatment were collected. These included direct costs (vaccines and other medical supplies
needed) and indirect costs (transportation, meals, and salaries lost). Reasons for missing the scheduled
visits were collected from those who had not returned. During the Day 28 follow-up, the status of the
biting animal (alive, dead, killed, missing/lost, or unknown after 14 days) was also recorded. The 14 day
observation period is stipulated by the Philippines National Rabies Committee for the collection of this
data.
Statistical analysis
Regression and ANOVA analyses were carried out in Excel 2013, Professional edition using the Excel
add-in Analysis ToolPak.
Ethics statement
Ethical clearance was granted by the National Ethics Committee of the Philippines Council for Health
Research and Development (NEC Code: 2017-008-Taylor-ABTC, Study Title: The Evaluation of
Operating Animal Bite Treatment Centers in the Philippines).
Written informed consent was obtained from adults included in the survey, or from parents or guardians if
the subject was a minor.
Results
Findings from the community surveys
A total of 1,011, 1,395 and 1,131 households were interviewed from 30 barangays of Nueva Vizcaya,
Palawan and Tarlac respectively (Table 2). Overall, an average of 33.7, 45 and 37.7 households per
barangay were interviewed for Nueva Vizcaya, Palawan and Tarlac respectively, with a minimum of 12
and a maximum of 86 (both in Palawan).

In all urban barangays and in the rural barangays in Palawan, over 80% of respondents were aware of
where to seek PEP (Table 2). In rural barangays of Nueva Vizcaya and Tarlac this fell to 66.1% and
68.0% respectively. Of those who knew where to seek PEP, government health workers were a key
source of this information (44.4%, 73.5% and 58.6% of respondents in Nueva Vizcaya, Palawan, and
Tarlac) together with neighbours and family (56.8%, 20.9% and 40.3%). Less than 5% of respondents in
each province had learned this information from television.
Across all barangays 46.1% of respondents said that they would not have to pay for PEP at an ABTC,
and this was lower in the urban barangays for Nueva Vizcaya and Tarlac (Table 2).
Overall 1,642 households reported bites or scratches (46.4%) and a total of 1,891 bite/scratch incidents
(suffered by 1,830 bite victims) were reported, with a maximum of 5 injuries (suffered by up to 5 different
households members) reported per household. No injuries were reported as having resulted in death. The
average numbers of bites/scratches reported per household over the whole 3.25 year period recorded
were 0.66, 0.43 and 0.54 for Nueva Vizcaya, Palawan and Tarlac respectively with no strong differences
between rural and urban barangays noted (Table 2).
Bite/scratch incidence for the years 2014, 2015 and 2016–17 (the latter based on 1.25 years of data up to
March 2017) was calculated for each province by dividing the bites recorded during that year by the total
household population that year (accounting for family members born, moved in or out and died). It was
further disaggregated by age class to compare incidence in the under 15 age category from that in over
15 age category and by rural and urban barangays (Table 3).

(The 2016–17 estimates are based on data from the 1.25 year period up until March 2017, adjusted to
an annual incidence)
There was strong evidence of recall bias, with the time period 2016–17 (1.25 years) showing incidences
from 1.97 to 2.66 times higher than 2014 for each province (Table 3). Across all 3 provinces, the
percentage of these injuries that were scratches rose from 2014 to 2016–17 in all provinces, and across
all provinces it rose from 15.0% to 17.0% to 23.5% of injuries (see S1 Table). This suggests that
scratches may be more likely to be forgotten than bites injuries over longer time periods.
Bite/scratch incidences were consistently higher for Nueva Vizcaya across the years, with the 2016–17
mean incidence being 67.3 injuries per 1,000 people per year) compared to 48.8 for Tarlac and 41.9 for
Palawan. The number of injuries reported for 2016–17 varied significantly across the provinces compared
to that expected if all had the same basic incidence (Chi-sq = 45.33, d.f. = 2, p<0.01).
Overall incidences were consistently higher for the under 15 years of age group compared to the over 15
of years group. For 2016–17, the incidence was 1.49, 1.40 and 1.60 times higher in the under 15 years of
age category compared to the over 15 years category for Nueva Vizcaya, Palawan and Tarlac
respectively (Fig 1A). There was no consistent pattern across rural and urban barangays (Fig 1B).
Fig 1
Incidences of animal bites and scratches by year across the three provinces, (A) by age
categories and by year (B).
The 2016–17 period was 1.25 years, but adjusted to a yearly incidence.
Proportion of bite victims reporting to bite treatment facilities Given the evidence of recall bias in the data,
and the changes in ABTC policy regarding payment for treatment, only the data from 2016 and 17 (total of
1,111 injuries) were included in the following analyses.
Of the 1,111 bites/scratches, most were caused by dogs, but overall almost a third of injuries were
caused by cats (Table 4). Most injuries caused by cats (56.9% of 346) were scratches without bite
wounds. In contrast 91.9% of the 752 injuries caused by dogs involved bites.
*a tandok is a traditional healer
Overall, less than half (44.9%) of victims sought treatment for wounds in a medical facility, but in all
provinces a higher percentage of victims sought treatment for bites (average 52.1%) compared to
scratches (average 21.5%). Victims seeking treatment did so overwhelmingly at ABTCs (83.0% of all
wounds treated) and other government facilities (11.2% of wounds treated), with only 3.8% seeking
treatment at private facilities (Table 4). In addition to seeking medical treatment 10.2% of all victims
across all provinces also visited a tandok (traditional healer), though this was markedly less common in
Palawan, where the proportion of bites treated in a medical facility was also higher than the other two
provinces (Table 4).
In total, 478 wounds were suffered by those under 15 years, and 632 by those aged 15 years and over.
The proportion of wounds treated was slightly higher for the under 15 years group (49.6% across all
provinces) compared to the over 15 years group (41.3% across all provinces).
Across the 90 barangays sampled, the proportion of victims seeking treatment for wounds in 2016 and
2017 was not influenced by the distance from the barangay to the nearest ABTC, or by the travel time to
the nearest ABTC (Fig 2).
Fig 2
The proportion of victims that sought treatment in 2016 and 2017, related to the barangays
distance from (A) and travel time to (B) the ABTC.
Wound management practices by those who do not seek medical attention Data was collected on a total
of 612 wounds sustained in 2016–7 where no medical treatment was sought. Overall, 32.7% of victims
did nothing at all (not even washing the wound), but there was evidence of a variety of practices, and
variations in the number of people practicing them across the provinces (Table 5).
Between 47.8% and 63.8% of these victims washed the wound with soap and water, and in Nueva
Vizcaya and Tarlac, 37.5% and 47.4% respectively went to a tandok (traditional healer). Interestingly, no
victims visited a tandok in Palawan, despite them being available. A variety of different herbal home
remedies were applied, sometimes in combination (see Table 5). In Palawan, but not the other provinces,
residents believe that a local plant called the ‘rabies tree’ can prevent rabies, and several respondents
reported using this as a home remedy. Between 2.7% and 5.6% bled the wound.
What factors prevent patients from accessing bite treatment facilities? Reasons given for not accessing
medical treatment are given in Table 6, with not knowing about the need to seek medical treatment and a
lack of money being the primary reasons given. Less than 5% of people overall, and notably none in
Palawan listed that they did not know where the ABTC was as the reason for not seeking medical
treatment.
Details of the other reasons given are included in S2 Table. Interestingly a small number of people said
that they did not seek treatment because the dog was vaccinated, that the victim was already vaccinated,
or that they chose to observe the dog instead.
Findings from the ABTC patient cohort
A total of 1,105 patients were interviewed over a 6 week period in early 2017 in the 6 ABTCs, with the
vast majority of these patients treated by the urban ABTCs (Table 7). A total of 43 (3.9%) patients across
all the sites were lost to follow-up by Day 28.
5 patients were bitten by pigs, 1 was bitten by a monkey and 6 patients in the NV rural ABTC were
exposed to a patient with rabies.
*The 6 patients exposed to the human patient are excluded
Overall 52% of all the patients included in the study were male, and 45% of all patients were below 15
years old with some minor variation across ABTCs (Table 7). The majority of the incidents involved dogs
and almost all of the biting animals were owned. Willingness to travel to an alternative ABTC was
generally high, but lower for the rural ABTC in Tarlac.
Patient completion rates Overall, 78% of the patients who needed vaccine completed their recommended
number of doses. This falls short of the 90% completion rate target set by the national Department of
Health (DOH) for 2016. The vast majority (927/1,105) of bite patients were recommended a shortened
schedule based on information that the biting animal was still alive after 14 days. The highest observed
completion rates were in the Tarlac rural ABTC (85%) and Nueva Vizcaya urban ABTC (81%). The lowest
(61%) was observed in the rural ABTC in Nueva Vizcaya. (Fig 3).
Fig 3
Completion rates of patients requiring PEP in the 6 study ABTCs, 2017.
The overall completion rates are further disaggregated in Table 8 to compare the average number of
visits each patient completed and the number recommended. In general, these figures are consistent with
the overall rates per ABTC. Those involved in incidents where the biting animal died however, are more
likely to miss visits, particularly on day 28.
Reasons for not completing PEP series Reasons for not returning to the ABTC on their scheduled PEP
visits are listed in S3 Table. Reasons differed across all ABTCs but having no time to go back to the
ABTC was the most common. Failure to remember the schedule was high (53%) in the rural ABTC in
Nueva Vizcaya, which was not observed in the other ABTCs. Lack of funds was cited the most for the
rural ABTC in Tarlac (38%). Around a third of the defaulters from both Palawan ABTCs felt that they did
not need to return to the ABTC for their Day 28 dose.
Status of the biting animal and rabies risks Of the 1,105 patients interviewed in the 6 ABTCs, 939 (85%)
of the biting animals involved were still alive and had not developed rabies after the 14th day, when
patients were asked at the day 28 follow-up (S5 Table). Of the 15% incidents involving suspicious biting
animals, 66 (40%) died within 14 days while the remaining 100 had unknown statuses. Thus in retrospect
we can say that only 9% to 19% of all the patients across the 6 ABTCs, with the highest in the rural ABTC
in Palawan, were involved in bite incidents considered high risk (i.e. the dog died).
Of the 166 patients bitten by animals that died or whose status was unknown, 56% received an
incomplete course of PEP (S6 Table). Incomplete in this context was defined as less than 8 doses (4
visits). The completion rate was highest in the Tarlac rural ABTC at 83%, while the lowest was in the
Palawan urban ABTC (19%).
Availability of free vaccine and RIG Since 2016, the Philippine government has aimed to provide a
complete course of vaccine and 1 vial of RIG free to all patients requiring PEP. Table 9 shows the actual
number of patients given vaccine or eRIG, and the number who had to pay for at least 1 vial of vaccine,
when free stocks had run out in the ABTC. A patient who needed eRIG was defined as any patient
classified as Category 3 who tested negative for the skin test. With the exception of Tarlac urban ABTC,
almost all of the vaccine given to patients were provided for free by the government. In contrast, the
Tarlac urban ABTC had the highest availability of free eRIG. All the other ABTCs were only able to
provide 4% to 55% of the total Category 3 patients needing eRIG. 32 patients were prescribed RIG but
did not receive it, with the main reason given being not enough money to buy it.
However, the time period of data collection for 2017 was very short, and vaccine shortages later in the
year could easily reverse the trend seen at this time point.
Patient expenses Across all ABTCs, the percentage of patients arriving unaccompanied at the ABTCs
was 0% for children under 15 years old, and 40.2% for those over 15. Overall, 50.1% of all patients under
15 and 43.6% of patients over 15 years were accompanied by one other person, and the remainder were
accompanied by more than one person (up to a maximum of 5).
Patients’ total out of pocket expenses (OOPE) for PEP are shown in Fig 4. Almost all of the expenses
shouldered by the patients are indirect costs (transportation, lost salaries and other costs such as meals
and wound care prior to going to the ABTC), but in several ABTCS patients had to contribute to the cost
of RIG. Only at the urban ABTC in Tarlac did patients have to pay a considerable amount for rabies
vaccine. This ABTC had the highest number of patients compared to the other 5 ABTCs in the study and
suffered from considerable vaccine stock outs (shortages), forcing patients to buy vaccine in the local
pharmacies at a cost two to three times tha paid by the national government [5]. A detailed breakdown of
OOPE by category of expense is provided in S4 Table.
Fig 4
Total out-of-pocket expenses grouped by category and ABTC, 2017 in USD.
TT/ATS = Tetanus Toxoid / Anti Tetanus Serum. The RIG in the rural ABTC in Nueva Vizcaya was
bought by a patient and administered in an ABTC in another province.
The total costs were divided among the total number of patients interviewed to get the average
expenditure of each patient (Table 10). Across all six clinics, the average OOPE for patients was 20.38
USD (PHP 960.48). Using data from the Department of Labor and Employment’s list of minimum wages
by region, the average OOPE per visit in the 6 ABTCs (assuming 3 visits) represented 30%-160% of daily
wage. The highest costs per patient were observed in both ABTCs in Tarlac. The lowest OOPE were in
both of the ABTCs in Nueva Vizcaya. The OOPE at the rural Tarlac ABTC were seven times those at the
rural Nueva Vizcaya ABTC, demonstrating large inequality in the cost of accessing treatment for bite
wounds.
The proportion of out-of-pocket expenses (OOPE) related to PEP shouldered by the patients varied
across all the ABTCs (Fig 5). Transportation costs comprised the majority of the OOPE in the Palawan
urban ABTC and in both ABTCs in Nueva Vizcaya. While transportation was still a major expense in the
other 3 ABTCs, other factors represented a significant portion of patient costs. The biggest percentage in
the rural ABTC in Palawan was salaries not received by the patient and companions because of
scheduled ABTC visits. Anti-rabies vaccines comprised a majority in the Tarlac urban ABTC, while RIG
and other expenses such as Out-Patient Department fees made up the bulk of the total expenses in its
rural counterpart.
Fig 5
Proportion of out-of-pocket expenses by category and ABTC, 2017.
TT/ATS = Tetanus Toxoid / Anti Tetanus Serum.
Discussion
The community surveys showed that bite incidences were high in both rural and urban settings, with an
overall average of around 50 injuries per 1,000 population per year (5%), around a quarter of which were
scratches and the rest involved bites. Overall 45% of patients sought medical treatment for their injuries,
almost always in the ABTCs, and the distance to the ABTC did not seem to influence this likelihood. Of
those who did not seek medical treatment, around half washed the wounds with soap and water, a third
visited the traditional healer (tandok) and a third did nothing at all.
The community surveys showed a high animal injury incidence, but low health seeking behaviour similar
to that observed elsewhere in the Philippines [8] and in other rabies endemic countries [9–13]. Awareness
of where to seek treatment in the Philippines was high, but the surveys also suggested that out of pocket
expenses played a role in preventing people from seeking treatment. Tandoks (traditional healers) were
still consulted frequently for the treatment of bite wounds, but this was notably less prevalent in Palawan.
In Palawan, considerable efforts have been put into community awareness of the need for PEP and
training of tandoks to encourage them to refer patients for PEP at ABTCs. There was anecdotal evidence
that a few patients were carrying out their own risk assessment of the bite and choosing not to seek
treatment accordingly.
Across the cohort of 1,105 bite victims in 2017, patients incurred out of pocket expenses of between 5.53
and 37.83 USD (PHP 260.57 and 1782.55) for PEP, depending on the clinic visited and whether free
government vaccine and RIG was available. Expenses incurred during each ABTC visit represented from
a third up to 160% of a minimum wage earner’s daily income.
The interpretation of the data analysis assumes that the ABTCs and 30 randomly selected barangays
produced representative data for each province at that these results are generally applicable to similar
geographic settings in the Philippines. Vaccines are, in general, supplied to the ABTC on a quarterly
basis. Since the ABTC patient survey was conducted during the first quarter of the year, interviews may
have coincided with periods before these scheduled vaccine distributions. Vaccine stock outs (shortages)
were identified in Tarlac that significantly affected the patients’ OOPEs.
The ABTC cohort survey showed a relatively high completion rate in 2017, but the main reason for non-
completion of the PEP schedule was “no time”, likely because the patients were working, and lost salary
was the 2nd largest proportion of the patient out of pocket expenses.
Taken together the two surveys suggest that awareness of how to access to PEP provision is high and
the travel and patient expenses do not limit patient’s access to PEP in these three provinces of the
Philippines where high investment in providing PEP has been made. However, despite this, over 200
deaths from rabies a year still occur in the Philippines [5]. There is no doubt that PEP is saving thousands
of lives in the Philippines each year, but before investment in opening more ABTCs is made, thorough
investigation of the reasons for these remaining deaths would be helpful in determining the best course of
action. In a previous study, 92% of human rabies death in the Philippines were found to be bite victims
who did not seek PEP and none received timely and complete PEP [14]. There is also limited evidence of
people made aware of the need for PEP and with reasonable access who still choose not to seek it and
died of rabies as a result. In this context, only elimination of the disease from dogs through
comprehensive vaccination campaigns will prevent human suffering and death.
Despite the relatively low treatment seeking behaviour observed at the community level, none of the
households interviewed reported a death as a result of an animal injury over the past 3 years. It is likely
that the most severe and risky wounds were those where treatment was sought, but of patients
interviewed in the ABTCs, 85% reported that after 14 days the biting animal was alive and healthy. Other
data from Philippines has indicated that only 2.2% of PEP was delivered to patients exposed to a rabid
dog [15]. Information on the status of the dog 14 days after the bite proved valuable information from a
health care provider’s perspective, as it lead to the vast majority of bite patients being recommended a
shortened schedule. However, it is also clear that the vast majority of PEP is being used to treat injuries
that were not (in retrospect) a rabies risk, and a large number were from animals known to the victim.
Strengthening of dog bite prevention education strategies could reduce provoked injuries from healthy
dogs and therefore the need for and cost of PEP for patients bitten. Finally there is provision in the
national guidance for the Philippines that PEP can be delayed in the event of a bite from an animal with a
current rabies vaccination status [16]. Good documentation of the vaccination status of animals and better
coordination between animal and human health supported by this guidance could reduce PEP costs.
The surveys revealed that 5% of the population suffered a dog bite or scratch injury each year. Although
awareness of local bite treatment centers was high, fewer than half of bite victims sought medical
treatment, and a third sought treatment from traditional healers. Under these circumstances in a dog
rabies endemic country, it is likely that costs to provide PEP will remain high and yet human deaths from
rabies still continue, until effective dog vaccination programmes can eliminate the public health risk.
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