| Objective: 1.To give an insight into the exposure and PEP(Post-exposure prophylactic) history of the human rabies cases to identify the main causes of the human rabies and explore the potential problems in the process of PEP practice and rabies diagnosis in China.Analyzing the clinical feature of rabies cases and the influential factors of PEP and incubation period to provide the theoretical basis for policy formulation of rabies preventing and control in China.2.To exhibit the distribution of rabies PEP clinics and evaluate residents' geographic accessibility to rabies PEP clinics,to provide sound basis for the rational allocation of medical resource related to rabies PEP.3.To describe and evaluate the rabies cases' geographic accessibility to rabies PEP clinics,and analyzing the influence factors of the accessibility,to provide the proof for increasing the ratio of receiving PEP by improving the geographic accessibilityi to rabies PEP clinic.Methods: 1.the epidemiological investigation records of human rabies cases reported during 2006 from 2012 in China were collected and cleaned,the demographic feature and exposure history,PEP,and clinical feature of the human rabies case were described.Multivariate logistic regression model was applied to identify the influential factors of wound treatment,vaccination,passive immune agent injection of rabies cases.Cox regression was applied to identify the influential factors of incubation period.2.The address and service information of rabies PEP clinics in China,2013 were collected.the number and kernel density of clinics were calculated by different areas and different services provided by clinic.3.the road network,landcover,elevation,inland waterbody data in 2013 downloaded from websites were combined,and cost distance model in Arc GIS software was used to calculate the accumulated traffic-cost score and travel time for residents reaching the nearest rabies PEP clinic by different areas.4.The basic information of the human rabies cases in China,2013 was collected,and then according to the resident address of human rabies cases,the travel times to the nearest rabies PEP clinic for cases were extracted from the residents',after that,compare cases' travel time to the nearest clinic by different service it provided.Multivariate ordinal logistic regression was applied to identify the influential factors of travel time to the nearest rabies PEP clinic for cases.Compare the difference of travel time to the nearest rabies PEP clinic between residents and cases.Result: 1.10971 rabies cases were included,among them,males and farmers were accounted for 69.41% and 71.82% respectively.92.02% of cases were bitted by animal.40.50% of cases' anatomic locations,which nerves were highly distributed,were bitted(face,head,neck,hand).58.67% of cases with category ? exposure.55.80% of animals were domestic dogs and 29.6% for stray dogs.Among the domestic dogs,4.79% had been vaccinated.2.1095 cases(9.98%)received wound treatment in medical facility,of which 52.69% were experienced wound flush and disinfect.Male(OR=0.67,95%CI: 0.59-0.78),farmer(OR=0.70,95%CI=0.54-0.90),and case at the age between 15 and 54 years(OR=0.81,95%CI: 0.69-0.95)were less likely to receive wound treatment in medical facility than female,other occupation,and case older than 55 years.1187 cases(11.68%)were vaccinated after exposure,among them,19.29% of cases completed the course of vaccination.Male(OR=0.80,95%CI: 0.70-0.92)and farmer(OR=0.67,95%CI: 0.53-0.85)were less likely to initial vaccination than female and other occupation.3.02% of cases received passive immune agent,Male(OR=0.75,95%CI: 0.57-0.98)and case at the age between 15 and 54 years(OR=0.66,95%CI: 0.47-0.93)were less likely to receive passive immune agent than female and case older than 55 years.3.The median incubation period of rabies cases was 66 days.Cases who were males compare with females,aged between 15 and 54 years compare with older than 55 years,had bites located at position where nerves were highly distributed compare with other wound,received wound treatment at medical facility compare with no wound treatment,initiate vaccination compare with not initiate,injected passive immune agent compare with not injected,the hazard odds were 0.94,1.17,1.34,1.10,1.36,1.50,1.50.99.15% of cases appeared clinical manifestation of furious rabies,and 98.61% of cases were clinical diagnosed.4.There were 28571 rabies PEP clinics,of which,89.41% of clinics provide wound treatment and 48.91% for passive immune agent.Among different administrative regions,regardless of what kind of service was provided,southwest area had the largest number of clinics per capita followed by south-central region,and northwest region had the least number of clinics per capita;south-central region had the largest geometrical mean kernel density of rabies PEP clinics with the smallest geometric standard deviation,while southwest region had the smallest geometrical mean kernel density of rabies PEP clinics.Among different economic areas,no matter what kind of service was provided,east area had the most clinics per capita,on the contrary,west area had the least clinics per capita;east area had the largest geometrical mean kernel density of rabies PEP clinics with the smallest geometric standard deviation,while west area had the smallest geometrical mean kernel density of rabies PEP clinics with the largest geometric standard deviation regardless of what kind of service was provided.5.Among different administrative regions,regardless of what kind of service was provided,eastern region had the smallest geometrical mean traffic-cost score for residents reaching the nearest rabies PEP clinic followed by south-central region,while northwest region had the largest geometrical mean traffic-cost score;south-central region had smallest geometric standard deviation of traffic-cost score followed by eastern region,while southwest region had largest geometric standard deviation.Among different economic areas,regardless of what kind of service was provided,east area had the smallest geometrical mean and geometric standard deviation of traffic-cost score for residents reaching the nearest rabies PEP clinic,while had the largest geometrical mean and geometric standard deviation.In nationwide,the percentage of population for residents reaching the nearest rabies PEP clinic,PEP clinic which provide wound treatment,and PEP clinic which provide passive immune agent within 15 minutes were 40.08%,38.16% and 33.17% respectively.6.The median travel times for rabies cases reaching the nearest rabies PEP clinic,PEP clinic which provide wound treatment,and PEP clinic which provide passive immune agent were 35 minutes,37 minutes,53 minutes,moreover,the travel times to different rabies PEP clinics were statistically significant(P < 0.001).Cases from all the economic areas or administrative regions spent shorter travel time to the nearest rabies PEP than residents regardless of service the clinic provide(P<0.001).7.Rabies case who lived in rural area compared with urban area(OR=1.99,95%CI=1.47-2.70),case who was famer compared with other occupation(OR=1.91,95%CI: 1.30-2.80),and case who lived in west area compared with central area(OR=1.56,95%CI: 1.16-2.10) spent longer travel time to the nearest PEP clinic.Rabies case who lived in rural area compared with urban area(OR=1.94,95%CI=1.43-2.61),case who was famer compare with other occupation(OR=1.91,95%CI: 1.30-2.79),and case who lived west area compared with central area(OR=1.43,95%CI: 1.06-1.93)spent longer travel time to the nearest PEP clinic which provide wound treatment.Rabies case who lived in rural area compared with urban area(OR=2.33,95%CI=1.73-3.15),case who was famer compare with other occupation(OR=1.81,95%CI: 1.24-2.63) and case who lived west area compared with central area(OR=1.87,95%CI: 1.37-2.53) spent longer travel time to the nearest PEP clinic which provide passive immune agent.Conclusions: 1.The main onset reason for rabies cases were complete and standardized PEP treatment,therefore,it is necessary to enhance the regulate the PEP clinical practice and improve the proportion of initiating and competing PEP after rabies exposure,especially males and farmers.Dog management and vaccination need to be strengthened,meanwhile,increase the proportion for laboratory diagnosis of rabies.2.Residents geographic accessibility to rabies PEP clinic was worse than the general medical resource,thus,the geographic accessibility to medical resource related to rabies PEP need to be improved.There were distribution and geographic accessibility disparity among different regions or areas,and the number of rabies PEP clinics need to be increased in north region,meanwhile,clinics in southeast region were suggested to be conveniently located.3.The difference among the travel times to each service type of rabies PEP clinic were consistence with the proportions of each step of PEP schedule,suggesting it is possible to increase the proportion of conducting PEP by enhancing the geographic accessibility to medical resource related to rabies PEP,especially in the rural area,then control rabies epidemic situation sequentially. |
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