This study estimated the frequency of exposure of meat workers to carcasses infected with Leptospira serovars Hardjobovis or Pomona in a sheep-only abattoir in New Zealand. A stochastic spreadsheet model was developed to assess the daily risk of exposure of eviscerators, meat inspectors and offal handlers to live leptospires in sheep carcasses from May to November 2004 (high-risk period), and from December 2004 to June 2005 (low-risk period). The average sheep processed per day were 225 for an eviscerator, 374 for a meat inspector, and 1123 for an offal handler. The median daily exposures during high- and low-risk periods were 11 [95% distribution interval (DI) 5–19] and three (95% DI 1–8) infected carcasses/day for eviscerators, 18 (95% DI 9–29) and six (95% DI 2–12) for meat inspectors, and 54 (95% DI 32–83) and 18 (95% DI 8–31) for offal handlers, respectively. Stochastic risk modelling provided evidence that processing of sheep carcasses exposed meat workers regularly to live leptospires with substantial seasonal variation.

Background: Rabies continues to pose significant public health challenges in many developing countries including Bhutan. A probable case of rabies was admitted to our hospital and its reporting led to the uncovering of an outbreak in domestic and wild animals. We discuss the challenges in the diagnosis and management of rabies in a resource-limited setting. Case presentation: A 35-year-old male presented with intermittent fever, bilateral lower limb weakness that was rapidly progressive, urinary incontinence with episodes of palpitations and sweating. He had sustained a Category III bite on the right lower thigh with four bite marks, inflicted by a stray dog. He had received post-exposure prophylaxis with intra-dermal anti-rabies vaccine. On initial examination, the patient was in distress but cooperative for the interview. He had pulse rate ranging from 60 to 100/min with episodes of diaphoresis and palpitations, but with normal capillary blood glucose. In the lower limb, the muscle power was zero with absent tendon reflexes in the lower limb and impaired abdominal reflex below T₁₀ level. He had hyperaesthesia below T₈, hydrophobia, aerophobia and photophobia. He had multiple spontaneous fasciculations in both the thighs and right deltoid and these later involved the intercostal muscles, neck and face muscles. He had altered sensorium and desaturation for which he required mechanical ventilation. Polymerase chain reaction for rabies virus was negative in cerebrospinal fluid and saliva. Rabies virus neutralizing antibody was negative in cerebrospinal fluid but had high titres in the serum. He received Human Rabies Immunoglobulin after admission. He was managed in the intensive care unit and died 23 days later. After this case was notified, a rapid response team was deployed in the field, and uncovered rabies outbreak in animals in the locality. Conclusions: This case called for a serious evaluation of the country’s efforts in achieving zero rabies deaths by 2030. The management of this case identified several critical areas of context-specific interventions in Bhutan. There is also an urgent need to improve diagnostic capabilities at the national reference laboratory and enhance the technical competencies of healthcare workers in the management of dog bite cases. Graphical

SARS-CoV-2 rapidly mutated, causing different waves of outbreaks worldwide. Bhutan experienced three major outbreaks of COVID-19 before experiencing the outbreak driven by the Omicron variant in January 2022. The data collected by the National Outbreak Investigation and Surveillance Team during the Delta variant-driven outbreak and Omicron outbreak were accessed and analyzed. The data were analyzed using R statistical software. Descriptive analysis was carried out for the entire dataset and the statistical comparison between the two outbreaks was carried out using student’s t-test and Pearson’s chi-square test. During the Delta variant-driven outbreak, a total of 1648 cases were reported, with a daily average of 13 cases. The highest one-day case number reported was 99. On the contrary, within 33 days, a total of 3788 cases were reported with a daily average of 115 cases during the Omicron outbreak. The highest one-day case number reported was 312. The median incubation period was 3 days (range = 0–18 days) and 1 day (range = 0–14 days) during the Delta and Omicron-driven outbreaks, respectively. The number of symptomatic cases was significantly higher during the Delta outbreak (p-value < 0.0001). Of the total cases reported during the Delta outbreak, 1175 (71.3%) had received a single dose of the vaccine, 79 (5%) received two doses, while 394 (24%) were unvaccinated. During the Omicron outbreak, 1957 (52%) cases had received their booster (third dose), 904 (23.8%) received two doses and only 40 (1%) received a single dose of the vaccine. The number of unvaccinated cases was 887 (23.4%), of which 375 (10%) were children below 12 years. Our findings corroborate the enhanced transmissibility of the Omicron variant as reported elsewhere. We report significantly less symptomatic cases during the Omicron outbreak. Further, our data show that the incubation period for the Omicron variant is shorter compared to the Delta variant (p-value < 0.0001).

Background: Rabies is endemic in southern Bhutan, associated with 1–2 human deaths annually and accounting for about 6% of annual national expenditure on essential medicines. A WHO-adapted National Rabies Management Guidelines (NRMG) is available to aid clinicians in PEP prescription. An understanding of clinical practice in the evaluation of rabies risk in endemic areas could contribute to improve clinicians’ PEP decision-making. Methods: A cross-sectional survey of clinicians was conducted in 13 health centers in high-rabies-risk areas of Bhutan during February–March 2016. Data were collected from 273 patients examined by 50 clinicians. Results: The majority (69%) of exposure was through dog bites. Half the patients were children under 18 years of age. Consultations were conducted by health assistants or clinical officers (55%), or by medical doctors (45%), with a median age of clinicians of 31 years. Rabies vaccines were prescribed in 91% of exposure cases. The overall agreement between clinician’s rabies risk assessment and the NRMG for the corresponding exposure was low (kappa =0.203, p<0.001). Clinicians were more likely to underestimate the risk of exposure than overestimate it. Male health assistants were the most likely to make an accurate risk assessment and female health assistants were the least likely. Clinicians from district or regional hospitals were more likely to conduct accurate risk assessments compared to clinicians in Basic Health Units (Odds Ratios of 7.8 and 17.6, respectively). Conclusions: This study highlighted significant discrepancies between clinical practice and guideline recommendations for rabies risk evaluation. Regular training about rabies risk assessment and PEP prescription should target all categories of clinicians. An update of the NRMG with more specific criterions for the prescription of RIG might contribute to increase the compliance, along with a regular review of decision-making criteria to monitor adherence to the NRMG. Author summary: Human rabies remains an important public health threat in Bhutan, especially in southern regions where canine rabies is endemic. The steady increase in number of patients reporting to hospitals following dog bites means escalating costs of post-exposure prophylaxis for the country. We investigated attitudes and practices of clinicians who manage patients with potential rabies exposure, in the endemic area. The risk of rabies exposure in the study area is mostly associated with dog bites, involving children half the time. Rabies vaccines were prescribed in 9 out of 10 exposure cases, while immuno-globulins were rarely prescribed. The study confirmed the perceived lack of compliance of clinicians with guideline recommendations for assessing rabies risk. This results in under-estimating the rabies risk in potentially risky exposures in high-rabies-risk areas. Our work underscore the importance of targeted training of female health assistants, doctors, and clinicians in basic health units to improve the management of rabies exposure. In particular there is need to update the national guidelines regarding indications and use of rabies immune-globulins.