A prospective study on health seeking behaviour and post exposure prophylaxis received by animal bite victims at the anti-rabies clinic in a tertiary care centre of urban Bangalore

Introduction

Animal exposure among humans is a public health problem and poses a potential threat of rabies infection to over 3.3 billion people worldwide.¹ These exposures occurs mainly in underserved populations, both in rural and urban areas, and has been documented for more than 4000 years.² The magnitude and epidemiological pattern differ from country to country. According to data available, most cases occur in Africa and Asia, where children represent about 40% of population exposed to dog bites in those rabies endemic areas.³ A combination of large human and dog populations in congested habitable areas has led to more exposure in WHO’s South East Asia region than in any other part of the world.⁴

In the World Health Organization’s (WHO) South-East Asia (SEA) Region, which includes 11 nations, eight are rabies-endemic, and more than 1.4 billion people are at risk of contracting the disease. As a consequence, it remains a significant public health and economic challenge throughout the region.⁵ Each year, an estimated 12 million people in Asia seek treatment after being exposed to probable rabies-infected animals. Fear and anxiety following a dog bite result in a psychological consequence that is estimated to account for approximately 1,40,000 DALYs in Asia.⁶

An estimated 17.4 million animal bites occur in India each year, having a 1.7% incidence.⁷ In a rabies-endemic nation like India, where every animal bite is suspected of being a rabid exposure, exposed persons should engage in proper health-seeking behavior in order to get early and comprehensive post-exposure prophylaxis (PEP) for rabies antibodies.⁸ The knowledge and attitude regarding the disease prevention among the bite victims is important for their health seeking behaviour.⁹

The act of seeking medical assistance is “any action undertaken by individuals who perceive themselves to have a health problem or to be ill for the purpose of finding an appropriate remedy.” It is not an isolated event determined by individuals concentrating solely on their own self-interest; it is “part and parcel of individuals, families, or community’s identity, which involves a combination of social, personal, cultural, and experiential factors”. It is also part of the more general concept of health behavior, which includes behaviors carried out to preserve good health, refrain from illness, and cope with any deviation from a good state of health.

At the health care facility, whenever a patient comes for a health problem such as animal exposure; the post exposure prophylaxis should be provided depending upon the severity of the animal bite wounds/exposures as per the WHO/NCDC, India guidelines.¹⁰ The PEP consists of thorough wound washing with soap or detergent & water and application of virucidal agents to reduce the viral inoculum at the wound site; post exposure anti-rabies vaccination to induce antibodies which prevents the risk of virus entering peripheral nerves after a bite from a rabid animal and timely administration of rabies immunoglobulin (RIG)/rabies monoclonal antibodies (RMAb) in all category III exposures to neutralize the virus at the wound site.¹¹

Therefore, thorough wound washing with prompt administration of cell culture vaccine and simultaneous administration of RIG/RMAbs in all category III exposures is almost invariably effective in preventing rabies, even after high-risk exposure.¹² It is also essential for animal bite victims to complete the full course of vaccination as recommended by the physician for full protection, as those who do not complete the full course of vaccines are still at risk of developing rabies.¹³ However, compliance with anti-rabies vaccination among bite victims is still a major issue, as it spans over a period of 28 days. Therefore, the health behaviors of animal bite victims are important for the completion of PEP.

Need for the study

To avail immediate and correct post exposure prophylaxis, animal bite victims should have the proper knowledge and attitude to seek proper health care services. Likewise, exposed individuals are supposed to complete the full course of anti-rabies vaccination for complete protection against the disease.

The present study was conducted to determine the health-seeking behavior of animal bite victims, along with their knowledge and attitude, the post exposure prophylaxis received by them, and their compliance with the full course of anti-rabies vaccination. The details regarding these important determinants are important to assemble new evidence for planning specific interventions to accomplish the task of eliminate rabies by 2030.¹⁴

Scope of the study

The study provided details regarding the health-seeking behavior of animal bite victims and assessed their knowledge and attitude toward rabies prophylaxis. It also provided details of the post exposure prophylaxis received by the patients and their compliance with the complete course of anti-rabies vaccination. This information is important for understanding the present situation and for the further implementation of specific strategies to eliminate rabies.

Aim & Objectives

Exclusion criteria

• ➢ Animal bite victims who had already started post exposure prophylaxis elsewhere and seeking further management.

• ➢ Those with previous history of animal exposures and received post exposure prophylaxis or taken pre-exposure prophylaxis for preventing rabies.

• ➢ Bite victims < 18 years without accompanying parents/guardians.

Figure 1. Flow chart showing the research participants recruited for the study.

Results

The study included 1058 animal bite cases, who visited the anti-rabies clinic, Preventive Medicine Unit, Kempegowda Institute of Medical Sciences, Bengaluru, to receive post exposure prophylaxis. The details of the study participants are as follows.

The age range of 18–59 years comprised the majority of study participants, making up 57.9% of), followed by children under the age of 18 with 33.1%). The majority of the study participants were male (60.1%), and 84.4% of the respondents reported being literate. According to the Modified B.G. Prasad scale, 46.6% of the study subjects fell under medium socioeconomic class, and 35.6% of the population were employed.

Dogs accounted for the majority (92%) of the biting animals, among whom 65% of them were stray animals. More than 80% of the biting animals either lacked vaccinations or were uncertain about their vaccination status. A significant number of exposures occurred after unprovoked encounters, and for 41.3% of the respondents, the outcome of the animal that bit them was undetermined.

One of the primary predictors of post exposure prophylaxis is health-seeking behavior after exposure. Fortunately, 93.3% washed their wounds right away, and three-quarters of them used detergent soap to scrub the exposed area. The application of virucidal agents or antiseptics is an important component of PEP, and 56% of the study participants used it. A total of 62.4% of study individuals attended another health care institution before coming to the anti-rabies clinic, while 30.8% arrived at the study setting directly after exposure. 74.3% landed at the study sites within one day of exposure, implying that a significant number received the PEP within 24 h (Table 1).

An essential component for receiving early and appropriate PEP is knowledge and attitude towards rabies prophylaxis. Subjects’ general knowledge of rabies was satisfactory, as evidenced by the largest percentage of precise responses (88.8%) for ‘animals that transmit the disease’ and the lowest percentage (41%) for ‘disease severity’. Despite a maximum of 41.4% for the total number of ARVs to be given in PEP and a minimum of 17% for PrEP, the study subjects’ comprehension of PEP fell short of expectations.

The attitude responses were satisfactory among study subjects which have a maximum right response of 92.1% for ‘availability of ARV’ followed by ‘rabies as a preventable disease’ (88.6%) and ‘importance of wound wash after exposure’ (82.6%). The attitude regarding pre-exposure prophylaxis was directly related to their knowledge regarding same as only 31% replied that PrEP was equally important in preventing rabies (Table 2).

The perceived risk of disease transmission by the study subjects was assessed based on a 1 to 5 Likert scale, in which 1 is the lowest rating and 5 is the highest rating. The perceived risk of disease transmission by various animals among the study participants varied from person to person. The perception was poor for risk of disease transmission through other animals, apart from dogs, viz. disease transmission by cats, livestock, mongoose, monkey, and other wild animals was <25%. Rodents that were not considered potential transmitters of rabies were rated by the respondents (Table 3).

PEP was provided to those with Category II (ARV) or III exposures. In most of the cases, PVRV was the type of ARV administered, and more than 61% of the patients with Category III exposures decided to receive rabies monoclonal antibody as passive immunization, followed by ERIG (38%). Prior to the administration of ERIG, the subjects underwent a skin sensitivity test; however 89% of them showed no reactions. Based on the anatomical feasibility, RIG/RMAB was infiltrated into and around the wound site. In 90% of the study subjects, it was infiltrated locally, while the remaining study subjects received the required amount both locally and by an intramuscular systemic injection.

Compliance with the full course of the anti-rabies vaccine among the study participants showed a considerable drop off after each vaccination schedule. Out Of the 1058 subjects, 9.1% was the drop out for the 2^nd dose of vaccination, which came down to 11.7%, 18.8%, and subsequently to the lowest of 22.1% for the last and final dose of ARV.

A total of 234 dropouts and the reasons for dropout mentioned by the study subject after each telephonic interview were listed as long distance of travel, negligence, forgotten dates, interference with work timing, and school timings (Table 4).

The safety of post exposure prophylaxis was assessed in all study subjects up to day 28. The local adverse reactions included pain, erythema, itching, and swelling, and the systemic adverse events included body ache, fever, and malaise. All study subjects with adverse drug reactions were treated free of cost at the study center, and all subsided without any complications.

All study subjects were followed up for 6 months and were found to be healthy, showing that the post exposure prophylaxis provided at the anti-rabies clinic was effective in preventing the disease.

To assess the overall effect of the study variables on wound washing practiced as a health behavior, the multiple logistic regression model was applied to the variables that were statistically significant in the univariate logistic regression analysis. It was found that there was a significant association between the socioeconomic status of the animal bite victims, fate of biting animals, and type of wounds with their health behavior.

A multiple logistic regression model was applied to the study variables that were statistically significant in the univariate logistic regression analysis with regard to the time interval for receiving post exposure prophylaxis. A significant association was found between the socioeconomic status of bite victims, vaccination status, and fate of biting animals.

A multiple logistic regression model was applied to the study variables that were statistically significant in the univariate logistic regression analysis with regard to the association between the study variables and health care sought by bite victims. This showed that there was a significant association between the occupation of bite victims and vaccination status of the biting animals (Table 5).

Discussion

The present study provided details regarding the health-seeking behavior of animal bite victims and assessed their knowledge and attitude toward rabies prophylaxis and perceived risk of disease transmission. It also provided details of the post exposure prophylaxis received by the patients and their compliance with the complete course of the anti-rabies vaccine.

The health behavior in the present study showed that 93.3% of the subjects had washed their wounds, and 55.9% had applied local antiseptics. Similarly, a cross sectional study on epidemiology of animal bite cases attending the anti-rabies clinic of a rural tertiary care hospital of Haryana among 3897 animal bite victims revealed that only 54.1% animal exposed cases had washed their wound with either only water or with soap and water.¹⁶ Another descriptive study on epidemiological determinants of animal bite cases attending the anti-rabies clinic in Sassoon hospital, Pune including 3226 animal bite cases showed that only 33.7% had washed their wounds with soap and water after the bite.¹⁷

The present study also showed that 62.4% of the patients had visited other health care facility before coming to the anti-rabies clinic viz. corporation dispensaries, private hospitals, private clinics, etc.; 4.8% of them visited AYUSH doctors, and 2% consulted veterinarians. Likewise, 7.3% of them came to anti-rabies clinic for post exposure prophylaxis within an hour after exposure/bite and 67% of them came for treatment within 24 hours, whereas 25.7% came to anti-rabies clinic after 24 hours of exposure to seek post exposure prophylaxis. Similarly, a study from Kolkata of 257 people residing in rural areas showed that only 73.2% of the exposed individuals would like to go to allopathic doctors, whereas others would visit some local practitioners/religious practices.¹⁸

The present study also showed that there was a significant association between some of the characteristics such as occupation of the bite victims (OR = 1.7; 95% CI 1.1-2.7); socioeconomic status of bite victims (OR = 3.9; 95% CI 1.5-10.3), vaccination status of the biting animal (OR = 2.8; 95% CI 1.7-4.6), and fate of the biting animal (OR = 1.5 95% CI 1.1-1.7) and the wound characteristics such as site of wound (OR = 16.5; 95% CI 10.8-23.9) and type of wound (OR = 1.6; 95% CI 1.2-2.3) with their health seeking behavior. All these studies showed that the health-seeking behavior of the exposed was inadequate and must be addressed through continuous social and behavior change communication (SBCC) activities. Increased awareness engages communities and empowers people to save themselves by seeking proper health care, thereby helping to eliminate dog-mediated human rabies by 2030.

The present study showed that the knowledge regarding prevention of rabies was incomplete, as only 54.8% had heard about the disease, 41% new about the severity of the disease, 41.4% knew about the number of anti-rabies vaccination doses to be taken after the bite, 37.1% knew about the site of vaccination, 32.5% knew about the need for rabies immunoglobulin for severe exposures, and 17% knew about pre-exposure prophylaxis. Similarly, the attitude of the study subjects was not satisfactory with regard to type of exposures transmitting disease (67.8%), need for first aid measures after exposure (82.6%), 100% preventable disease (88.6%), need for post exposure prophylaxis (68.7%), place of anti-rabies vaccine availability (92.1%), correct system of medicine for prevention of rabies (74.9%), and need and dosage for pre-exposure prophylaxis (30.9%).

Similarly, other studies also showed that KAP for the prevention of rabies was not adequate. In Mandya, Karnataka, a survey on medical school students’ awareness of rabies prevention indicated that only 45.1% of the respondents knew the extent to which rabies is throughout India and only 36.3% of them was aware how to safeguard themselves from dog bites.¹⁹ A study of 220 schoolchildren found that their understanding of rabies transmission was only 33%, while their knowledge of animals transmitting the disease was 65%.²⁰ Similarly a study conducted on Accredited social health activists in rural Karnataka region had a poor understanding of animals spreading rabies (23.8%), the proper amount of ARV (25.7%), and the site of vaccine administration (54.1%).²¹ These findings suggest that frequent health education sessions on rabies prevention at all levels are necessary to improve our understanding.

In the present study, a total of 97% of the study subjects received PVRV and remaining PCEC vaccine. Along with vaccine, 61% of the study participant preferred to receive RmAb and 38.2% of the study subjects received ERIG; among whom the skin sensitivity test was positive among 11% who developed mild hypersensitivity reactions. Patients with hypersensitivity were provided symptomatic treatment, and a full dose of RIG was administered.

Likewise, another study conducted at the antirabies clinic in Bangalore among 65 subjects who had wild animal exposures showed that all of them had received complete post exposure prophylaxis according to WHO, which included thorough wound wash (100%) and infiltration of rabies immunoglobulin; equine in 93.8% and humans in 6.2% cases. All study subjects received anti- rabies vaccination via intramuscular route using various types of vaccines i.e.: PCECV (60%), PVRV (33.9%), PDEV (4.6%), and HDCV (1.5%).²²

A full course of anti-rabies vaccine and RIG/RMAb is an important component of PEP, which has to be provided at all health care centers to prevent rabies, even after high-risk exposure. In the present study, the compliance with full course of antirabies vaccination was 77.9%. The compliance for vaccination doses slowly reduced from 90.9% for the 2nd dose on day 3 to 88.3% for 3rd dose on day 7, 81.2% to 4th dose on day 14, and 77.9% for the last dose on day 28. The reasons for the dropout were long distance of travel to the anti-rabies clinic, interference with school timings, negligence, forgotten dates, and interference with work timings. None of them stopped the vaccination course after day 10, even though the biting dog/cat was alive and healthy, as they wanted to complete the course.

Similarly, a multicentric study conducted across the country among 529 animal bite victims, showed that majority (54.4%) of the animal bite victims had Category III exposures; the overall compliance to complete course of vaccination was 78.8%, namely 65.9% for intramuscular rabies vaccination (IMRV) and 85.1% for IDRV.⁹ Another cross-sectional study on compliance to anti-rabies vaccine among dog bite victims in an urban slum of Chennai showed that the compliance to complete course of vaccination was found to be 55.1%. The reasons for not completing the vaccination course were loss of wages, forgotten dates, and interference with school timing.²³

In the present study, among the 1058 study subjects who received post exposure prophylaxis, 103 (9.9%) had adverse drug events. The local adverse reactions included pain, erythema, itching, and swelling, and the systemic adverse events included body ache, fever, and malaise. All adverse drug reactions were mild and subsided spontaneously or with symptomatic medications. Comparably, a study carried out in Bangalore on 550 victims of animal bites who were attending an anti-rabies clinic showed that an overall 7.1% of ADEs were reported by the study participants. The most common local adverse events were pain (8.5%), erythema (7.3%), and itching (5.8%); the most common systemic adverse reactions were fever, malaise, headache, and body ache.²⁴ Likewise, a prospective, multicentric, post-marketing surveillance study on 168 subjects showed that immediate ADRs to ERIG administration were seen in 31.5%, including pain (30.4%), swelling (5.4%), pruritis (3.6%), induration (1.2%), itching, and erythema (0.6%).²⁵

Each of the studies showed that the adverse events to post-exposure prophylaxis (ADEs) were negligible and minor, and that they resolved on their own with symptomatic therapy without any further consequences. This indicates that PEP is safe for victims of animal bites. All subjects were followed up for six months and were found to be healthy, showing that the post exposure prophylaxis provided at the anti-rabies clinic was effective in preventing the disease.

Conclusion

Rabies is a preventable disease with timely and appropriate post exposure prophylaxis, which includes thorough wound washing, full course of anti-rabies vaccination, and infiltration of rabies immunoglobulin/rabies monoclonal antibodies into all category III wounds and exposures.

In the present study, the health-seeking behavior of the exposed individuals, their knowledge and attitude toward the prevention of rabies, and the perceived risk of disease transmission by various animals was inadequate and must be addressed appropriately.

Adverse drug reactions for PEP were seen in a minimal number of study subjects, which were mild and subsided on their own or by symptomatic treatment, which showed that post exposure prophylaxis for all animal bite victims is safe and tolerable. Likewise, all study subjects were healthy and alive after a follow-up of six months, showing that the post exposure prophylaxis provided was effective in preventing the disease.

Recommendations

Limitations of the study