Abstract
Objectives:
We evaluated the data quality, acceptability, sensitivity, simplicity, and representativeness of the surveillance system for suspected human rabies exposure in Washington State to understand current surveillance practices and areas for improvement.
Methods:
We conducted a mixed-methods evaluation of the state’s surveillance system for suspected rabies exposures. Specifically, we compared the number of suspected rabies exposures in the Washington Disease Reporting System (WDRS) with (1) the number of possible rabies exposures captured by syndromic surveillance (Rapid Health Information NetwOrk [RHINO]) and (2) the number of rabies postexposure prophylaxis administrations in the Washington Immunization Information System (WA IIS) from January 2018 through May 2023. We interviewed local health jurisdiction (LHJ) representatives about investigation and reporting of suspected rabies exposure.
Results:
From January 2018 through May 2023, there were 1766 reports of suspected rabies exposure in WDRS, 5054 events in RHINO, and 2378 events in WA IIS; we found substantial differences among LHJs in the ratio of WDRS reports to events in RHINO and WA IIS. Interview data confirmed variability in reporting practices and data management. LHJ partners identified common barriers and weaknesses of the surveillance system, including staff turnover, system complexity, and a lack of resources for data modernization.
Conclusions:
Suspected rabies exposures may not be consistently captured by the existing surveillance system. Variation among data entry procedures and storage systems across LHJs could be attributed to resource availability, population size, and capacity for data modernization. These data will be used to develop recommendations for improvements in rabies exposure surveillance in Washington State.
Keywords: rabies, public health surveillance, data management, program evaluation, health information systems
Rabies is a zoonotic disease caused by Rabies lyssavirus that is transmitted most often through mammal bites. The disease is almost always fatal after symptoms develop. 1 While globally an estimated 70 000 deaths occur each year due to rabies, in the United States, <10 deaths are reported annually.2,3 This low incidence is primarily due to high uptake of canine rabies vaccination, animal control programs, and effective human rabies postexposure prophylaxis (rPEP), which consists of rabies vaccinations and human rabies immune globulin (HRIG). 3 This combination is almost 100% effective at preventing disease after exposure to rabies. 1
All mammals are susceptible to rabies virus infection. Canine rabies was eliminated in the United States in 2007, but other wild mammal species, including raccoons, skunks, foxes, mongooses, and bats, are reservoirs that vary by geographic area.3,4 In Washington State, only bats have been identified as a wildlife reservoir.5,6
Description of the Program Being Evaluated
Human and animal rabies cases are nationally notifiable, and Washington State additionally requires reporting of “suspected human rabies exposure.”7,8 While animal bites to humans or rPEP administration are commonly notifiable in states with rabies endemic in wild terrestrial mammals, neither event alone is reportable in Washington State. Instead, a suspected human rabies exposure is defined as a bite from, or other exposure to, an animal that is suspected of being infected with rabies. In practice, situations that meet the case definition for a suspected rabies exposure are (1) when a human is exposed to an animal that has tested positive for rabies or (2) when the local health jurisdiction (LHJ) conducts a risk assessment of the exposure and recommends rPEP, concurs with a health care provider’s recommendation for rPEP, or does not have enough information available to disagree with the health care provider’s recommendation for rPEP. 9
Most notifiable conditions in Washington State are reported through electronic laboratory reporting. Suspected rabies exposures, however, require reporting from external partners such as health care providers or veterinarians, which likely leads to underreporting. Suspected rabies exposures are not nationally notifiable to the Centers for Disease Control and Prevention, so rabies exposure surveillance is unique to each state. In Washington State, 35 LHJs representing 39 counties conduct surveillance for suspected human rabies exposures. Each LHJ has authority over exposure investigations for residents from its jurisdiction, allowing for substantial variability in public health practice. 10 Prior research found that when LHJs were provided with sample exposure scenarios and asked whether they would recommend rPEP, responses were inconsistent. 10 The combination of a lack of automated reporting and subjective determination of suspicion for rabies exposure complicates the surveillance system for suspected rabies exposures.
Purpose of the Evaluation
Epidemiologic data inform public health recommendations for animal rabies testing, outreach to groups such as health care providers and animal control officers, recommendations for rPEP administration, public messaging, and understanding of the temporal and geographic distribution of risk. However, mandating reportable conditions places a burden on health care providers to report these conditions and on LHJs to conduct investigations. Additional paperwork burdens, as well as a discordance between the perceived utility of reportable conditions for clinical importance and public health, may result in insufficient and incomplete reporting of potential rabies exposures. 11 To ensure the continued acceptability and utility of surveillance programs, periodic evaluation is needed. We evaluated the data quality, acceptability, sensitivity, simplicity, and representativeness of the surveillance system for suspected human rabies exposure in Washington State from January 2018 through May 2023.
Methods
Datasets
The Washington Disease Reporting System (WDRS) is an electronic disease surveillance system through which notifiable conditions are reported for Washington State residents. Instances of suspected rabies exposures are entered into WDRS by LHJ staff. We included all case reports of suspected rabies exposures in our analysis.
The Rapid Health Information NetwOrk (RHINO) collects syndromic surveillance data in almost real time for anyone seeking care from enrolled hospitals and clinics in Washington State regardless of one’s residence status. We queried this system to identify potential rabies exposures by identifying entries that included either rPEP/HRIG administration or an animal exposure in the complaints, free-text notes, or International Classification of Diseases, Tenth Revision diagnoses. 12 Because RHINO does not always include all information relevant to an exposure investigation, these potential exposures cannot be systematically classified according to the case definition. We manually checked all entries returned by our query to remove data that did not meet our criteria for a primary visit for rPEP/HRIG administration or animal exposure. To further improve specificity to potential rabies exposures, we filtered the remaining entries to include only records that mentioned a bat or did not specify an animal species.
The Washington Immunization Information System (WA IIS) is a lifetime registry that tracks all immunization records for Washington State residents. This system includes rabies vaccines given as rPEP or rabies preexposure prophylaxis (rPrEP). To distinguish between administrations of rPEP and rPrEP, we calculated the days between administrations and assigned events to rPEP or rPrEP based on the recommended schedule from the Advisory Committee on Immunization Practices. 13 To account for slight deviations from the recommended schedule, we allowed for variability of ±2 days for each vaccination. Additionally, any administration of HRIG was considered rPEP because it is not indicated for rPrEP. Our analyses included only entries classified as rPEP. We excluded instances in which the person received a single dose of rPEP without HRIG because of uncertainty about the event being captured and inconsistency with rPEP schedules recommended in Washington State. This exclusion may have led to undercounting rPEP events. We conducted a sensitivity analysis comparing the overlap between data streams and sensitivity of WDRS when including these events (eTable 1 in the Supplement).
Interviews
Each LHJ was asked to identify individuals familiar with all investigators or staff who take rabies calls and/or enter suspected rabies exposure data in WDRS, and these individuals were contacted for interview. We interviewed representatives from each of the 35 LHJs in Washington State to understand investigation procedures for suspected rabies exposure, reporting practices in WDRS, differences in data collection and use, and opportunities for improvement in the surveillance system. Interviews were conducted virtually; data were entered in REDCap and analyzed via internal REDCap tools.14,15
Evaluation Criteria
We defined data quality as the completeness and agreement of data across datasets, and we assessed data quality by calculating the Spearman correlation among WDRS, WA IIS, and RHINO at the state level.
We examined the acceptability of the surveillance system to LHJs by comparing the number of potential exposures captured by RHINO or WA IIS with the number of suspected exposures entered into WDRS by the LHJ. We compared ratios of WDRS entries of suspected rabies exposures with potential exposures captured by RHINO and WA IIS, respectively, across LHJs. We further examined the system’s acceptability to LHJs through interview questions about the perceived weaknesses of the overall system.
We assessed the system’s sensitivity by calculating the percentage of matching records between the datasets through probabilistic matching using the fastlink package version 0.6.1 in R (R Foundation for Statistical Computing). We matched records on patient last name, age, county of residence, and date of the WDRS report or clinical encounter in RHINO or WA IIS, with a match certainty threshold of 80%. For this analysis, events in RHINO were filtered to include only instances in which rPEP or HRIG was administered to ensure comparability across data systems. We also used log-linear capture–recapture methodology with a Poisson distribution with the shinyrecap tool version 0.1.0 (R Foundation for Statistical Computing) to estimate the total number of potential rabies exposures, assuming both differential capture probabilities and a heterogenous population. Using this estimation, we then calculated the sensitivity of WDRS to capture rPEP administrations as a proxy for possible rabies exposures.
We assessed the simplicity of the surveillance system through qualitative interviews. Interview participants were asked about data collection and management in their jurisdictions and the sources of exposure reports. After interview completion, we categorized LHJs by type of data management and data storage systems. Participants were also asked about how their LHJ applied the case definition and determined whether a possible exposure should be reported through WDRS. Options included rPEP administration or a decision-making algorithm created by the Washington State Department of Health that provides guidance on rPEP administration, testing, and reporting depending on the exposure scenario.
We assessed representativeness of the system through interview questions about the sources of rabies exposure reports across jurisdictions.
We conducted all quantitative analyses by using R version 4.3.1 (R Foundation for Statistical Computing). This study was considered a public health surveillance activity and was exempt from review by the Washington State Institutional Review Board. Patient consent was not required because it was considered a public health surveillance activity.
Results
Data Quality
At the state level, WDRS, RHINO, and WA IIS showed consistency in the seasonality of records, with peaks in the summer months, but the number of reports meeting inclusion criteria differed substantially across systems: we found 1766 reports in WDRS, 5054 events in RHINO, and 2378 events in WA IIS (Figure 1).
Figure 1.
Monthly records for capturing potential human rabies exposures in WDRS, RHINO, and WA IIS data, Washington State, January 2018 through May 2023. Abbreviations: RHINO, Rapid Health Information NetwOrk (syndromic surveillance); WA IIS, Washington Immunization Information System; WDRS, Washington Disease Reporting System.
The correlation between aggregate state-level WDRS and RHINO data at a monthly level was 0.71, and for WDRS and WA IIS, it was 0.71. The correlation between RHINO and WA IIS was 0.90.
Acceptability of the Surveillance System
At the LHJ level, discordance in the number of records observed among the 3 datasets indicated varied acceptability of WDRS (Figure 2). Across jurisdictions, WDRS had fewer potential rabies exposures than the records identified in RHINO and WA IIS. The magnitude of difference between WDRS and RHINO and between WDRS and WA IIS was similar across counties (eTable 2 in Supplemental Material).
Figure 2.
The number of records captured by WDRS, WA IIS, and RHINO by local health jurisdictions in Washington State, January 2018 through May 2023. Local health jurisdiction names have been removed in accordance with data suppression guidelines. (A) Number of records captured by WA IIS, RHINO, and WDRS in the county with the most RHINO reports (county A). (B) Number of records captured by WA IIS, RHINO, and WDRS in the counties with the next-highest numbers of RHINO reports (counties B-J). (C) Number of records captured by WA IIS, RHINO, and WDRS in counties K-Z. (D) Number of records captured by WA IIS, RHINO, and WDRS in the counties with the lowest numbers of RHINO reports (counties AA-II). Abbreviations: RHINO, Rapid Health Information NetwOrk (syndromic surveillance); WA IIS, Washington Immunization Information System; WDRS, Washington Disease Reporting System.
Of the LHJs reporting suspected rabies exposures, 6 had a ≥10-fold difference in what was reported to WDRS as compared with either RHINO or WA IIS; of these, 3 LHJs had a ≥20-fold difference.
RHINO and WA IIS consistently captured records during the entire study period, including years when LHJs did not report any cases in WDRS. For LHJs with the highest counts of RHINO and WA IIS records, seasonal peaks in occurrence were evident, which were not always evident from WDRS reports.
In interviews, 2 LHJs (6%) reported not using WDRS for reporting suspected exposures, suggesting low acceptability for these jurisdictions (Table 1). LHJs noted common weaknesses of the surveillance system, including the complexity of WDRS, the lack of data storage options for nonreportable exposures, reliance on passive surveillance, and a lack of automated linkage between animal rabies test results and WDRS cases. LHJs also shared common strengths of the surveillance system, including state-level investigative support and WDRS configuration to capture information necessary for an investigation.
Sensitivity of the Surveillance System
We observed poor overlap among the 3 datasets (Figure 3). A total of 1931 records were in RHINO after including only instances in which rPEP or HRIG was administered. RHINO and WA IIS had the highest overlap, with 26.6% (905 of 3404) of the records matching between datasets. WDRS and WA IIS had 22.2% (753 of 3391) of records matching, and RHINO and WDRS had only 12.7% (417/3280) of records matching.
Figure 3.
Venn diagram depicting overlap among 3 datasets—WDRS, RHINO, and WA IIS—reporting potential rabies exposures in Washington State, January 2018 through May 2023. Potential rabies exposures were matched on the basis of last name, county of residence, age, and date by using a Fellegi–Sunter probabilistic model with a match certainty threshold of 80%. RHINO records were subset to instances in which the person received rabies postexposure prophylaxis or human rabies immune globulin to allow for comparability across systems. Abbreviations: RHINO, Rapid Health Information NetwOrk (syndromic surveillance); WA IIS, Washington Immunization Information System; WDRS, Washington Disease Reporting System.
Using capture–recapture methodology, we estimated approximately 5755 (SE = 62) total possible rabies exposures receiving rPEP or HRIG that could be captured by any surveillance system. This finding indicates that WDRS had an estimated sensitivity of 30.7%.
Simplicity of the Surveillance System
Interviews with LHJ representatives revealed substantial variation in investigation procedures, data entry and storage systems, and reporting practices. LHJs differed in their interpretation of a suspected rabies exposure, with 19 of 35 LHJs (54.3%) using rPEP administration as a criterion for determining whether an exposure was reportable (Table). Of these 19 LHJs, 8 reported suspected rabies exposures in situations when a health care provider administers rPEP but public health risk assessment does not recommend rPEP. Eleven LHJs used a decision-making algorithm provided by the Washington State Department of Health to determine whether the exposure was reportable according to the animal species, the circumstances of the exposure, and whether rabies testing or an observation period for the animal was possible.
Table.
Investigation practices for suspected rabies exposure in 35 local health jurisdictions in Washington State, January 2018 through May 2023
| Investigation practice | No. (%) |
|---|---|
| Criterion used to determine suspected rabies exposure | |
| Use rPEP administration a | 19 (54) |
| Use WA DOH decision-making algorithm | 11 (31) |
| Main reporting source b | |
| Person who was exposed (or their caretaker) | 13 (37) |
| Health care provider | 12 (34 |
| Veterinarian or animal control | 5 (14) |
| Both person who was exposed (or their caretaker) and health care provider | 3 (9) |
| Data management | |
| Use both WDRS and an internal data system | 29 (83) |
| Only use WDRS | 4 (11) |
| Do not use WDRS and only use an internal data management system | 2 (6) |
| Record-keeping c | |
| Record rPEP recommendations d | 33 (94) |
| Record animal testing results d | 31 (89) |
| Record animal testing recommendations d | 30 (86) |
| Keep records of all initial reports | 16 (46) |
| Data storage c | |
| WDRS | 33 (94) |
| Paper filing system | 11 (31) |
| Electronic spreadsheet | 10 (29) |
| Online database | 9 (26) |
| Electronic filing system | 5 (14) |
| Investigation stages during which a possible exposure is entered into WDRS c | |
| After case classified as confirmed or suspected rabies exposure | 20 (57) |
| When an animal tests positive for rabies | 13 (37) |
| When an animal is submitted for testing | 10 (29) |
| During 10-day observation period for dogs, cats, or ferrets | 4 (11) |
Abbreviations: rPEP, rabies postexposure prophylaxis; WA DOH, Washington State Department of Health; WDRS, Washington Disease Reporting System.
rPEP is mentioned as a central criterion in determining if an exposure is notifiable, and the local health jurisdiction generally predicates the timing of reporting on whether rPEP is administered.
Main source of initial reports of potential rabies exposures to local health jurisdictions.
Local health jurisdictions’ practices could be included in >1 category.
In any data storage system.
With respect to data management, 20 LHJs (57.1%) conducted investigations using an internal data management system and reported a case in WDRS only once an exposure was classified as confirmed or suspected. Most LHJs (n = 31; 88.6%) used internal data management systems in addition to WDRS, while 5 LHJs (14.3%) used WDRS as their sole means of data management. LHJs typically used data storage systems consisting of 1 or more of the following: WDRS (n = 33), paper filing system (n = 11), electronic filing system (n = 5), electronic spreadsheet (n = 10), or an online database (n = 9). Online databases included REDCap surveys, Microsoft SharePoint, internal web-based data management systems, structured query language, and electronic medical records.
Representativeness of the Surveillance System
During interviews, LHJs approximated the proportion of initial reports of potential rabies exposures received from various reporting sources. Thirteen LHJs (37.1%) received the highest proportion of reports from the person exposed or one’s caretaker, 12 (34.3%) from health care providers, and 5 (14.3%) from either veterinarians or animal control/law enforcement; 3 (9%) received an even proportion of reports from health care providers and the person exposed or one’s caretaker (Table). Only 1 LHJ conducted active surveillance using RHINO, through which it received 8% of its initial reports. Although LHJs can use WA IIS after receiving a report, data visibility restrictions prevent LHJs from using WA IIS to actively detect new cases.
Discussion
Substantial discordance in the number of records of potential rabies exposures among WDRS, RHINO, and WA IIS indicates that WDRS may not be capturing most suspected exposures. Our findings suggest that state-level estimates of the prevalence of suspected rabies exposures have limited usefulness because of differences in reporting among LHJs.
The relative lack of reports in WDRS as compared with RHINO and WA IIS, along with interview findings, indicates an underreporting of suspected rabies exposures to LHJs, barriers to investigating exposures, and inconsistent reporting depending on staff resources. Wide variation in the ratio of WDRS reports to WA IIS or RHINO records among LHJs indicates that the surveillance system has limited acceptability at the state and local levels. The low sensitivity of WDRS demonstrates the difficulty in applying a standardized case definition to a condition without discrete laboratory testing criteria. Although WDRS has low sensitivity to capture rPEP administrations, it is likely the most specific of the 3 surveillance systems because it rules out more false exposure reports during the investigation process. However, it should also be noted that this sensitivity was based on detecting rPEP administrations rather than detecting an exposure that meets the current case definition. Finally, LHJs may be capturing biased samples of exposure reports depending on the reporter type, which could lead to low representativeness. LHJs that receive reports from multiple sources will also likely be more representative of the population than LHJs that receive all or most of their reports from a single type of reporter.
While useful as comparators, RHINO and WA IIS records represent potentially different events from what should be recorded in WDRS as a suspected rabies exposure. Estimates of WDRS sensitivity are caveated by this limitation, as RHINO and WA IIS records likely include events that would not be classified as suspected rabies exposures after an investigation, thereby skewing sensitivity lower than what may be true. It is probable, given the lack of information in WA IIS and RHINO, that a number of these entries would not be classified as a case. However, while there may be events captured by RHINO that would not meet the case definition, the use of syndromic surveillance should capture potential exposures that would ideally be reported for further investigation. Overall, poor overlap among the 3 data streams and a low sensitivity of WDRS indicate relatively low data quality.
While WDRS entries of suspected rabies exposures should adhere to a uniform definition, this does not appear to be the case. Interview findings demonstrate low simplicity at the state and local levels because of differential data collection and data management strategies, as well as variability in the application of the case definition. This variation may contribute to inaccurate reporting in WDRS and unreliable statewide case counts. Notably, a substantial number of LHJs reported confirmed or suspected cases for any instance in which rPEP was administered, when rPEP administration itself is not notifiable in Washington State. WDRS reporting depends on investigator judgment, meaning that there is likely more inherent variation in WDRS estimates than in RHINO or WA IIS reports of rPEP administration. Most LHJs also preferred to conduct their investigations in internal data systems and used WDRS only once an exposure was deemed to be reportable, which suggests that WDRS may not meet all investigation needs.
Limitations
Our evaluation was limited by several factors. First, before May 2020, up to 49 emergency departments were not submitting data to RHINO, which may have led to an underestimation of exposures captured by RHINO in some LHJs. Second, although animal exposure events in RHINO that did not mention a species were counted as possible exposures, uncertainty around these events could have contributed to inflated counts. Third, we excluded WA IIS events with 1 dose of rabies vaccination and no HRIG, because it was unclear what events were being captured. However, this exclusion may have resulted in undercapture of true exposure events, including instances in which someone began the rPEP series but discontinued it because of financial burdens, or instances in which data capture in WA IIS was incomplete.
Public Health Implications
Regular evaluation of surveillance systems is vital to ensure that system attributes support surveillance objectives. Although terrestrial mammals are not known to be rabies reservoirs in Washington State, our findings can nevertheless inform future surveillance evaluation in states with more complex rabies epidemiology. The use of syndromic surveillance data is particularly of note, because it can be used in any region to identify possible rabies exposures and can be integrated into existing protocols as a form of active surveillance.16,17 Furthermore, because Washington State does not conduct surveillance for animal bites or rPEP administration specifically, it can be used as a comparator for various surveillance methods that track these proxy measures of exposure. However, overall generalizability in other contexts may be limited given the focus on Washington State–specific data systems.
To advance the findings of this evaluation, further assessment should be conducted to validate whether RHINO and WA IIS data are capturing suspect rabies exposures. A robust and well-defined surveillance system is necessary to understand the true incidence of rabies exposures and to inform the appropriate assessment of rabies risk and rPEP administration. Our findings identified several areas for improvement in the existing surveillance system that will ideally be solved through collaboration between state and local health authorities to reestablish surveillance priorities and update protocols. The system could be improved by modifying the statewide notifiable condition while providing support to LHJs to streamline their existing investigation processes.
Supplemental Material
Supplemental material, sj-docx-1-phr-10.1177_00333549251376265 for Evaluation of Surveillance for Suspected Human Exposure to Rabies, Washington State, 2018-2023 by Keely Paris, Arran Hamlet, Beth Lipton and Hanna Oltean in Public Health Reports
Footnotes
The authors declared no potential conflicts of interest with respect to the research, authorship, and/or publication of this article.
Funding: The authors disclosed receipt of the following financial support for the research, authorship, and/or publication of this article: This study was supported in part by an appointment to the Applied Epidemiology Fellowship Program administered by the Council of State and Territorial Epidemiologists and funded by the Centers for Disease Control and Prevention (cooperative agreement 1NU38OT000297-03-00).
ORCID iD: Keely Paris, MPH 
https://orcid.org/0000-0002-1403-3845
Supplemental Material: Supplemental material for this article is available online. The authors have provided these supplemental materials to give readers additional information about their work. These materials have not been edited or formatted by Public Health Reports’s scientific editors and, thus, may not conform to the guidelines of the AMA Manual of Style, 11th Edition.
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Associated Data
This section collects any data citations, data availability statements, or supplementary materials included in this article.
Supplementary Materials
Supplemental material, sj-docx-1-phr-10.1177_00333549251376265 for Evaluation of Surveillance for Suspected Human Exposure to Rabies, Washington State, 2018-2023 by Keely Paris, Arran Hamlet, Beth Lipton and Hanna Oltean in Public Health Reports