Rabies Postexposure Prophylaxis Surveillance in the United States

Brief Summary
Cases of human and animal rabies have been nationally notifiable since the 1930s. However, rabies exposure or administration of rabies postexposure prophylaxis (PEP) is not. Currently PEP is explicitly reportable in only 14 states. Current understanding of the epidemiology of rabies PEP in the United States is based on discrete cross-sectional studies conducted at state or local levels. The last national data driven evaluations of PEP occurred in the early 1980s, just as modern cell culture rabies vaccines were becoming available. At that time approximately 20,000-40,000 persons were estimated to receive PEP each year. Compared to that study, a recent knowledge and practices survey conducted in 2008 found that few jurisdictions require risk assessment consultations with public health professionals before a practitioner administers PEP. In addition, most respondents also believed that PEP was over-administered in their jurisdiction. The importance of having better situational awareness of PEP usage has been underscored by recent concerns related to rabies vaccine and immune globulin supplies in the United States. Currently only two rabies vaccines and immune globulin products are licensed in the United States. A severe vaccine supply limitation during 2008 resulted in restricted use, requiring health department risk assessments for all PEP and implementation of a passcode system for providers to order rabies vaccine. Less severe supply interruptions have continued to occur since that time. In addition, the economic burden of PEP is believed to be high. Some preliminary data of state emergency department visits suggest the median costs may have doubled compared to commonly cited values from 10 years ago. Reports of medical charges greater than $10,000 for a course of PEP are not uncommon. Even at the older cost estimates, medical charges for PEP are likely to cost more than $120 million annually. A national discussion is needed to evaluate best practices for PEP surveillance; to improve our awareness of its utilization in relation to vaccine supplies, appropriate administration, and health care costs. Alternative sources to traditional public health surveillance should be explored in jurisdictions where PEP is not a reportable event.