Assessment of knowledge, attitude and practice of clinicians administering post-exposure-prophylaxis for rabies exposure in Bhutan

For more than two decades no rabies cases have been reported in the interior areas of Bhutan, the occurrence of rabies cases in dogs and livestock being confined to the districts that border India.


Amongst people exposed to the rabies virus, post exposure prophylaxis (PEP) is a vital intervention estimated to prevent approximately 15 human deaths each year in Bhutan.  However, PEP is not always appropriately used, resulting in high costs of treatment, comprising approximately 6% of the essential medicine expenditure in Bhutan.


On the other hand, a very small number of preventable human deaths due to rabies continue to occur, which may be associated with inappropriate PEP administration in areas of high risk for rabies. Potential therefore exists to both save significant costs and prevent rabies mortality by improving decision making of clinicians about the use of PEP.


Two collaborative investigation projects are being conducted on PEP usage in high rabies-risk and low rabies-risk areas by Bhutanese doctors and veterinarians undertaking in a 2-year One Health Epidemiology Fellowship as part of the ‘Integrating Education and Action for One Health’ program funded by the European Union and implemented by Massey University.


The study in high rabies-risk areas will evaluate clinicians’ adherence to the national guidelines for PEP administration and case management to identify gaps in knowledge or practices that may reduce the effectiveness of prevention measures in people potentially exposed to rabies. The second study will identify factors that influence clinicians’ decision making related to PEP usage in low rabies-risk areas, in particular to identify the level of surveillance for rabies and information about risk of rabies that would provide adequate assurance for clinicians not to recommend anti-rabies vaccination to people bitten by animals or experiencing other animal-related exposures in areas of Bhutan classified as rabies-free.


The outcome of the study in the high rabies-risk areas will facilitate the Ministry of Health in its efforts to ensure effective case management and use of PEP in high-risk areas through updating the national rabies management recommendations and designing appropriate training for clinicians. The outcome of the study in the low rabies-risk areas will facilitate the design of an integrated rabies control program that includes targeting control measures at the reservoir dog population in high-risk areas and implementing a surveillance and risk communications program that will provide evidence and assurance of the negligible rabies risk in areas that are classified as rabies-free. This is expected to reduce unnecessary use and associated costs of rabies biologicals (vaccine and immunoglobulins) in low rabies-risk areas.


The resources saved will provide an opportunity for sharing and investing in rabies control in the reservoir animal population within the framework of a One Health approach. This will contribute towards ultimately reaching the goal of eliminating rabies from Bhutan.


The Fellowship participants are from the human health, animal health, and wildlife sectors and are studying together in a Master’s degree program in One Health epidemiology and biosecurity. Through the studies described above, they are applying their knowledge and collaborating to reduce the risks of endemic and emerging epidemic diseases transmitted from animals and wildlife to people in their country.


The ‘Integrating Education and Action for One Health’ program uses a One Health approach to strengthen capability and promote collaborative relationships between the human, animal and wildlife health sectors in Afghanistan, Bangladesh, Bhutan and Nepal. This is key to managing endemic and emerging epidemic and pandemic disease threats.


The ‘Integrating Education and Action for One Health’ program is funded by the European Union and implemented by Massey University. The contents of this article are the sole responsibility of Massey University.