Health professionals KAP study on rabies exposure assessment and NTV administration in Ethiopia

Introduction

Rabies is a viral zoonotic disease with the highest case fatality rate. The disease is 100% fatal once clinical signs appear. Domestic dogs are responsible for up to 99% of rabies virus transmission to humans. The incubation period can range from days to years, with an average length of 3-8 weeks (WHO, 2018).

The classic signs of rabies include abnormal behavior, altered vocalization, pica, hyper sexuality, drooling saliva, aimless wandering, aggression, incoordination, paralysis and convulsions. Rabies is a highly fatal viral disease of all warm-blooded animals, including humans (Baer et al., 1990). It is widely distributed throughout the world and endemic in most African and Asian countries and estimated to cause at least 60,000 deaths per year worldwide, about 56% of which occur in Asia and 44% in Africa (Knobel et al., 2005; WHO, 2013). Globally, only a few countries, mainly islands and peninsulas, are free of the disease.

Rabies is endemic in developing countries in Africa and Asia, and most human deaths due to the disease occur in these endemic countries. Ethiopia is highly endemic for rabies with approximately 2,700 people estimated to die of rabies annually, which makes it one of the worst affected countries in the world (Deressa et al., 2015; Rohit et al., 2015). The first rabies epidemic in Ethiopia occurred in Addis Ababa in August 1903 as reported by Lincon, a physician at the Italian Legacion. The Ethiopian national rabies baseline survey 2012 showed that the incidence rates of rabies 12 exposure per 100,000 population and 1.6 death/100,000 population with a proportion of exposure is high among those less than 15 years of age (WHO, 2010; Ali et al., 2012). Dogs are the principal source of infection for humans and livestock (CDC, 2017; Reta et al., 2014).

As rabies is one of the worst diseases with no proven effective antiviral or other treatment, palliative care is an imperative to minimize patient suffering. Suspicion of rabies encephalomyelitis depends on recognizing the classic symptomatology and eliciting a history of exposure to a possibly rabid mammal. This type of care center is an important part of health care to minimize suffering of the patient with signs and symptoms of rabies disease (WHO, 2018).

Rabies is a vaccine-preventable disease, and it is still a significant public health problem in Ethiopia as a result of domestic animals, mostly dogs and wildlife, mostly foxes. Mass vaccination of the dog population is the only way to reduce or eliminate rabies. Nerve tissue origin, an old type of anti-rabies vaccine (nerve tissue vaccine) used in Ethiopia since the 1950’s. Currently, the consumption of this vaccine is more than 33,000 full doses annually. The vaccine prepared from small animal brains which contain protein called myelin sheath neural elements responsible for nerve complication as an autoimmune disorder at a rate estimated as 0.3-0.8 per thousand treated patients. Thus, this vaccine is no longer recommended by WHO due to its serious side effects and low immunogenicity (Tullu et al., 2003; WHO, 2007). Even though this vaccine has drawbacks, it is still distributed throughout the country to save the lives of a thousand people each year (Aga et al., 2021).

Even though the nerve tissue vaccine (NTV) has been used for a long period of time in this country, there was no standard guideline for rabies exposure assessment and proper vaccine administration. The other issue is that the patient with sign and symptom of rabies needs an organized palliative care center to minimize suffering due to the disease. Therefore, the main objective of this study was to assess the knowledge, attitude and practice of health professionals in delivering facility-based service for rabies exposure assessment and vaccine administration. The study also identifies NTV vaccine associated complication during the course of vaccination. In addition to that, the study was aimed to assess the availability of a palliative care center for the care required for patients with specific rabies signs and symptoms.

Methods

Health facilities delivering rabies post exposure vaccination (PEP) were selected based on the list available at VDPD, EPHI. Across the country, 28 health facilities delivering this service were included in the study except some western and northern parts which were excluded due to security concerns. Regions and selected health facilities receiving NTV vaccine from EPHI were included for this professional knowledge, attitude and practice (KAP) assessment and vaccine associated adverse event study. Some regions were intentionally excluded as a result of low vaccine demand compared to others.

Health professionals delivering rabies related services; rabies exposure risk assessment, vaccine cold chain management and vaccine administration were asked for their KAP about the service they have been providing. Five to eight health professionals were selected from each health facility based on the service they provide and asked to respond to structured questions provided for this purpose. Nerve tissue vaccine associated adverse events observed were included in the questionnaire. The number of human deaths due to rabies at those facilities, and availability and status of rabies case palliative care centers were included in the questionnaire to identify death due to rabies and case-based palliative care service delivery.

Results and discussion

In this study, health professionals with different education backgrounds and work experience were included to reflect their practice on rabies related service. The majority of the respondents (64.8%) were bachelor’s degree holders, followed by a diploma, which accounted for 19.2% of the study participants (Table 1).

Collective health professional’s KAP about the service they provide were analyzed to identify gaps and recommend appropriate solutions. Majority of respondents obtained general knowledge for this study to be 25%, which is considered as a low level. From comparison of KAP results between professions, medical doctors obtained about 48% of general knowledges which was high compared to diploma and BSc holders. As a general, this study result indicates that it requires appropriate intervention to upgrade the knowledge of health professionals for quality service delivery (Table 1).

In addition to the professionals KAP study, NTV associated vaccine adverse events (VAE) were assessed to estimate professional report within the period of the study time. According to a summary from professionals’ response, majority of respondents (77.6%) report local adverse events (local pain, redness, swelling and pus at injection site) followed by reports of systemic complications as indicated by 20% of respondents. Post-vaccine adverse events were reported by 2.4% of the respondents (Table 2).

This data contradicts with the previous retrospective data collected from health facility documentation and feedback report at EPHI which indicate no NTV associated complication (Aga et al., 2021). On the other hand, recent report by health professionals about NTV related adverse reactions were more closely related to previous WHO report (WHO, 2007).

Rabies related human case and death data reported by health professionals were also analyzed to identify human rabies cases occurring during the study period at the targeted health facilities during this study. Human rabies cases were reported by health professions with the total number of human deaths to be 32 at 28 health facilities included in this study with an average of two deaths reported in each health facility (Table 3).

Conclusion and recommendations

Rabies post exposure prophylaxis is one of the major interventions to prevent rabies cases in humans following exposure to suspected animals. The main vaccine used to prevent rabies in humans in Ethiopia is a nerve tissue anti-rabies vaccine which is produced at EPHI. Currently, more than 32,000 doses of this vaccine are utilized annually for PEP. Even though this vaccine has been used in Ethiopia since 1950’s, no specific guideline to be utilized by health professional regards to exposure case screening, vaccine administration, vaccine handling and transportation. This study identifies gaps in health professionals about KAP in delivering this vaccine for further recommended solutions. Accordingly, the study identifies that there is a gap in professionals’ KAP which requires organized work-related guidelines and a training program for capacity building. Similarly, the study identifies that NTV vaccine associated adverse event is reported by health professionals with 77.6% of reports indicating local adverse event, 20% of respondents reported systemic reaction and 2.4% indicating post-vaccine complications. This data support WHO’s recommendation to replace the NTV vaccine with a safe and effective modern cell culture vaccine for rabies prevention in humans. Based on respondent data, the study has identified rabies cases in humans with 32 cases annually reported at those health facilities with an average of two cases per facility. Availability of a facility-based palliative care center for rabies case handling was also assessed. According to this study, there is no human rabies case isolation center identified. Thus, based on available opportunity and feasibility for rabies palliative care centers, health facilities were identified for further establishment. Generally, training for health professionals is mandatory to fulfill gaps in KAP using specific standard guidelines available for this purpose. In the meantime, it is recommended to facilitate technology transfer to replace the old method of rabies NTV production with a safe and effective cell culture anti-rabies vaccine.