Table 3:
Potential causes of 122 breakthrough rabies infections with and without deviations from core practices
| Breakthrough infection with reported or possible deviation from core practices (n=68)* | Breakthrough infection without deviation from core practices (n=54)* | |
|---|---|---|
| Health-care provider contributions | ||
| Wound care | ||
| No appropriate wound care | 10/68 (15%) | 0/54 (0%) |
| No information on wound care | 50/68 (73%) | 0/54 (0%) |
| Vaccine administration | ||
| Vaccine administration in the gluteal muscle | 7/68 (10%) | 0/54 (0%) |
| Did not complete vaccine series (reason unknown) | 17/68 (25%) | 0/54 (0%) |
| Received incorrect vaccine regimen† | 2/68 (3%) | 0/54 (0%) |
| Vaccine regimen and series completion unknown | 5/68 (7%) | 0/54 (0%) |
| Developed symptoms before completion of vaccine series‡ | 32/68 (47%) | 30/54 (56%) |
| Rabies immunoglobulin administration | ||
| Given intramuscularly only | 9/25 (36%) | 5/42 (12%) |
| Wound sutured beforehand | 2/25 (8%) | 5/42 (12%) |
| Not all wounds infiltrated | 1/25 (4%) | 3/42 (7%) |
| Not administered | 38/63 (60%) | 12/54 (22%) |
| Anatomic and health status attributes | ||
| Wounds to the head, neck, or face | 28/63 (44%) | 34/53 (64%) |
| Exposed at two or more anatomical locations | 16/63 (25%) | 19/53 (36%) |
| Immunosuppression | 5§/68 (7%) | 3¶/54 (6%) |
| Integrity of post-exposure prophylaxis biologics | ||
| Rabies immunoglobulin potency testing doneǁ | 0**/68 (0%) | 3/54 (6%) |
| Vaccine potency testing doneǁ | 2**/68 (3%) | 2/54 (4%) |
Data are n/N (%).
Breakthrough infections without deviations from core practices were defined as infections for which the study reported wound cleaning (regardless of the thoroughness of wound cleaning), the study did not indicate a concern with the injection site of rabies vaccines (ie, about incorrect administration into the gluteal muscle), and the current authors could determine that vaccine doses had been given according to a validated vaccine schedule. Breakthrough infections with known or possible post-exposure prophylaxis deviations from core practices included those with deviations or possible deviations from at least one of the core practices.
One patient incorrectly received four doses on day 0; a second patient incorrectly received three doses on day 0.
Includes one person who either developed symptoms before they completed their fifth dose of vaccine or received only a four-dose series so would have completed their vaccination (n=1 with deviations).
Immunosuppressive conditions were specified as liver cirrhosis secondary to alcoholism (n=2), age-related immunosuppression (n=1), chronic lymphoproliferative leukaemia (n=1), and unspecified advanced immunodeficiency (n=1).
Immunosuppressive conditions were specified as uncontrolled diabetes (n=1) and liver cirrhosis secondary to alcoholism (n=2).
All rabies immunoglobulins and vaccines that were tested were found to be potent.
There were three patients for whom the study reported that the vaccine and rabies immunoglobulin batches used were found by the manufacturer to be effective or not associated with death in other confirmed recipients of post-exposure prophylaxis (not included in this table) following a bite by a dog with confirmed rabies.16