Rabies postexposure prophylaxis in the United States: Opportunities to improve access, coordination, and delivery

Rabies remains a global public health concern that is responsible for more than 59,000 human deaths per year [1].Postexposure prophylaxis (PEP) for humans exposed to rabies virus should include wound cleansing followed by 1 dose of human rabies immunoglobulin (HRIG) and a series of cell culture rabies vaccine doses [2].Symptomatic rabies is nearly always fatal but universally preventable with appropriate PEP.An estimated 30,000 to 60,000 Americans receive rabies PEP each year [3].The stakeholders involved in PEP implementation in the United States are diverse, creating systematic complexity that creates barriers to accessing care, lacks coordination, and delivers suboptimal care.Here, we elaborate on 3 issues of (i) access to, (ii) coordination of, and (iii) delivery of care for suspected rabies exposures; share examples of contemporary quality initiatives from large health systems; and propose novel solutions. Access to rabies PEP is limited and variableSuspected rabies exposures are medical urgencies, which are serious but require relatively few interventions-thus, most patients presenting to the emergency department (ED) for rabies PEP are triaged to Emergency Severity Index level 4 (less urgent) or level 5 (nonurgent) [4].Nevertheless, adequate and timely PEP is mandatory to prevent progression to fatal disease.Commonly, patients with wounds from an animal encounter will seek initial wound care in the ED and may be reasonably initiated on rabies PEP during the same ED encounter.Therefore, many EDs maintain inventory of rabies vaccine and HRIG.However, access to rabies PEP outside of the ED for less severe cases is limited.Sites that rarely care for patients requiring rabies PEP are not incentivized to maintain inventory of expensive rabies vaccine and HRIG.Payer reimbursement for clinic visits where rabies vaccine is administered have thin revenue margins and may lose revenue in some cases, which does not incentivize provider clinics to stock or administer rabies vaccine.Vaccine is infrequently covered by Medicare Part