EPIDEMIOLOGY AS A TOOL TO IMPROVE PREVENTION OF HUMAN RABIES LOCAL AND GLOBAL HEALTH IMPLICATIONS OF POSTEXPOSURE PROPHYLAXIS DATA Par Arnaud P. TARANTOLA Thèse de Doctorat d'Epidémiologie Clinique ; L’Epidémiologie Comme Outil Pour l’Amélioration De La Prévention de la Rage Humaine : Implications Locales et Mondiales des Données de Prophylaxie Post Exposition, Institut Pasteur Du Cambodge, 2003 – 2014

Rabies causes more than 60,000 deaths worldwide each year, including 800 in Cambodia, where canine-mediated rabies virus circulates. Death occurs in nearly 100% of rabies cases, a disease which is nearly 100% avoidable by timely and adequate rabies post-exposure prophylaxis (PEP). Improving access to PEP in rural areas of endemic countries will spare human lives in the short term. This epidemiology PhD used the data collected in patients referred to the rabies prevention clinic and tested dogs at Institut Pasteur du Cambodge (IPC), Phnom Penh. After a baseline assessment of access to and obstacles to access timely and adequate PEP in Cambodia, this PhD aims to contribute to improving: 1/ geographical access and 2/ financial access to PEP for rural populations in Cambodia. We developed an original strategy to identify populations with a high risk of PEP noncompletion after a bite by a potentially rabid dog. This should help improve geographical access to PEP following the implementation in July 2018 of a peripheral rabies prevention center in Western Cambodia. This strategy can be applied to identify difficulties in accessing health services relevant to other health issues, under certain conditions. After patient callback and analysis of rabies deaths among those who did and did not complete the 4-sessions/1-month intradermal PEP regimen of their own accord, we were unable to demonstrate a difference in rabies mortality among patients who only received 3 vaccine sessions over the first week compared to those receiving at least 4 sessions/one month. Abridging the protocol to one week would reduce direct and indirect costs and the loss of income during PEP in the Capital. The adoption of this abridged regimen must be associated with a strengthened clinical monitoring system for at least 6 months following patients’ initial PEP.The work presented in this PhD has implications which reach beyond Cambodia: WHO recommends this new IPC regimen – the first approved one-week, abridged rabies PEP regimen – in its April 2018 ...