Clinicians management of patients potentially exposed to rabies in high-risk areas in Bhutan: A cross-sectional study

Background: Rabies is endemic in southern Bhutan, associated with 1–2 human deaths annually and accounting for about 6% of annual national expenditure on essential medicines. A WHO-adapted National Rabies Management Guidelines (NRMG) is available to aid clinicians in PEP prescription. An understanding of clinical practice in the evaluation of rabies risk in endemic areas could contribute to improve clinicians’ PEP decision-making. Methods: A cross-sectional survey of clinicians was conducted in 13 health centers in high-rabies-risk areas of Bhutan during February–March 2016. Data were collected from 273 patients examined by 50 clinicians. Results: The majority (69%) of exposure was through dog bites. Half the patients were children under 18 years of age. Consultations were conducted by health assistants or clinical officers (55%), or by medical doctors (45%), with a median age of clinicians of 31 years. Rabies vaccines were prescribed in 91% of exposure cases. The overall agreement between clinician’s rabies risk assessment and the NRMG for the corresponding exposure was low (kappa =0.203, p<0.001). Clinicians were more likely to underestimate the risk of exposure than overestimate it. Male health assistants were the most likely to make an accurate risk assessment and female health assistants were the least likely. Clinicians from district or regional hospitals were more likely to conduct accurate risk assessments compared to clinicians in Basic Health Units (Odds Ratios of 7.8 and 17.6, respectively). Conclusions: This study highlighted significant discrepancies between clinical practice and guideline recommendations for rabies risk evaluation. Regular training about rabies risk assessment and PEP prescription should target all categories of clinicians. An update of the NRMG with more specific criterions for the prescription of RIG might contribute to increase the compliance, along with a regular review of decision-making criteria to monitor adherence to the NRMG.