A change in rabies post-exposure treatment guidelines after decision analysis in Israel

Background: Rabies remains a significant public health problem in Israel. Some 16 000–20 000 persons come yearly to the district health offices after being bitten by animals and 16–18% receive rabies post-exposure treatment. A quality assessment of the rabies post-exposure prophylaxis decisions was never held in Israel before. The purpose of this study was to analyse the decision-making process and to update our rabies prevention guidelines accordingly. Methods: A retrospective evaluation study of physicians' compliance with rabies post-exposure treatment guidelines in Haifa District Health Office, Ministry of Health, during 1/11/1999 to 31/12/2002. Records of all persons seeking advice (5037) following exposure to animals during the 3 years of the study were examined. Of these 2477 were eligible for the quality audit. The remaining files were analysed for the relative contribution of the different variables considered in the decision-making process. Results: Observed agreement rate and Kappa coefficient were 0.984 and 0.803, respectively. The probability of recommending vaccination was greater when the exposure was from stray dogs as opposed to cats (OR = 48.9; 95% CI 17.9–133.3), if the wound was a bite rather than a scratch (OR = 29.0; 95% CI 19.5–43.2) or in a location defined as rabies enzootic as opposed to rabies free (OR = 7.6; 95% CI 5.8–10.1). Conclusions: The study demonstrated high compliance with the written guidelines. We weighted the relative importance of the variables determining the decisions. This information was used in formulating the updated guidelines.