Journal of Public Health Advance Access originally published online on June 8, 2007
Journal of Public Health 2007 29(3):310; doi:10.1093/pubmed/fdm030
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Possible rabies exposures require expert clinical assessment
Natasha Crowcroft
Centre for Infections Immunisation Department, UK
David Brown
Centre for Infections Virus Reference Department, UK
E-mail: natasha.crowcroft{at}hpa.org.uk
The Health Protection Agency (HPA) Centre for Infection welcomes audits of management of possible rabies exposures such as the one by our colleagues at Aintree.1 We have carried out three audits in the past few years, only one of which has been published, with the aim of modifying and clarifying our advice.2 The HPA duty doctor protocol has been updated several times since the version which Folb and Cooke refer to was circulated in 2004.3 This includes a change to the advice for UK bat exposures in recognition of how difficult it proved to be for duty doctors to carry out a risk assessment of these exposures.
The protocol aims to help in decision making rather than to be prescriptive. This is because rabies exposures require expert clinical assessment, and judgement is required. The decision needs to balance the use of public resources, the potential hazards of pooled blood product, an often unquantifiable risk of exposure to rabies virus, and the potentially catastrophic consequences of getting it wrong. No wonder clinicians tend to err on the side of caution. The global epidemiology of rabies changes from year to year, particularly since the widespread use of wild animal vaccination and for some parts of the world information is, and is likely to remain, incomplete, with conflicting information from different sources. In addition, the veterinary priorities in monitoring rabies in animal populations in developing countries do not always coincide with the priorities for human public health. So decisions about rabies exposures are often not easy to make.
The reorganisation necessitated by the establishment of the HPA, with the move of former Public Health Laboratories into the NHS, may have disrupted the communication pathways we previously used for disseminating internal advice we develop for duty doctors to colleagues in the NHS and Universities. Internal advice is more flexible and informal and can be rapidly updated. There will never be a perfect protocol, and the final arbiter should be the Department of Health's ‘Green Book’ chapter on rabies.4 However, such formal advice takes many years to finalize, as shown by the decade between the last two editions. For rabies, we have made our protocol available on the HPA website, but a mechanism for drawing the attention of our NHS colleagues to the information or to updated versions is not yet well established, and we will explore how this situation may be improved.
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- Folb JE, Cooke RP. Issues of human rabies immunoglobulin and vaccine: policy versus practice. J Public Health (Oxf) (2007) 29(1):83–7.[CrossRef][Medline]
- Hossain J, Crowcroft NS, Lea G, et al. Audit of rabies post-exposure prophylaxis in England and Wales in 1990 and 2000. Commun Dis Public Health (2004) 7(2):105–11.[Medline]
- HPA Duty Doctor Joint Protocol. Available at http://www.hpa.org.uk/infections/topics_az/rabies/HPA_Rabies_protocol_jan_2007.pdf.
- Immunisation against Infectious Disease. (2006) http://www.dh.gov.uk/en/Policyandguidance/Healthandsocialcaretopics/Greenbook/DH_4097254.
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