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BRIEF RESEARCH ARTICLE
Year : 2015  |  Volume : 59  |  Issue : 1  |  Page : 58-60  

Compliance to anti-rabies vaccination in post-exposure prophylaxis


1 Associate Professor, Department of Community Medicine, Kempegowda Institute of Medical Sciences (KIMS), Bangalore, India
2 Assistant Professor, Department of Community Medicine, Basaveshwara Medical College and Hospital, Chitradurga, Karnataka, India
3 Assistant Professor, Department of Community Medicine, BGS Global Institute of Medical Sciences, Bangalore, India
4 Professor and Head, Department of Community Medicine, Kempegowda Institute of Medical Sciences (KIMS), Bangalore, India

Date of Web Publication9-Mar-2015

Correspondence Address:
Ravish Haradanahalli Shankaraiah
Department of Community Medicine, Kempegowda Institute of Medical Sciences (KIMS), Bangalore - 560 070, Karnataka
India
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/0019-557X.152867

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   Abstract 

Complete post-exposure prophylaxis is necessary to prevent rabies among all animal bite victims. It is essential for the bite victims to complete the full course of vaccination as recommended for complete protection. The present study was conducted to determine the compliance rate for anti-rabies vaccination by both intramuscular route and intradermal route and to determine the major constraints. The study was done at two municipal corporation hospitals in Bangalore, India. The compliance rate for intramuscular rabies vaccination was 60.0% and for intradermal rabies vaccination 77.0%. The major constraints were loss of wages, forgotten dates, cost incurred and distance from the hospital. Hence, the present study showed that the compliance to anti-rabies vaccination for post-exposure prophylaxis is low and is a cause of concern, as animal bite victims who do not complete the full course of vaccination are still at risk of developing rabies.

Keywords: Animal bites, Anti-rabies vaccines, Compliance, Intradermal rabies vaccination, Intramuscular rabies vaccination, Post-exposure prophylaxis


How to cite this article:
Shankaraiah RH, Rajashekar RA, Veena V, Hanumanthaiah AD. Compliance to anti-rabies vaccination in post-exposure prophylaxis. Indian J Public Health 2015;59:58-60

How to cite this URL:
Shankaraiah RH, Rajashekar RA, Veena V, Hanumanthaiah AD. Compliance to anti-rabies vaccination in post-exposure prophylaxis. Indian J Public Health [serial online] 2015 [cited 2019 Nov 21];59:58-60. Available from: http://www.ijph.in/text.asp?2015/59/1/58/152867

Rabies is a viral zoonosis that occurs in more than 100 countries and territories in the world. It is transmitted to humans and other animals through close contact with saliva from infected animals, i.e., through bite, scratches, and licks on broken skin and mucus membranes. Although a number of carnivorous animals serve as natural reservoirs, dogs are the main source of human infections and pose a potential threat to more than 3.3 billion people. [1] In India, animal bites in humans are a public health problem and an estimated 17.4 million animal bites occur annually. [2] In urban areas, the disease is mainly transmitted by dogs, being responsible for 96% of animal bite cases. [3] Timely and complete post-exposure prophylaxis (PEP) for these animal bite victims is necessary to prevent rabies. Therefore, the attending anti-rabies clinic (ARC) physician must provide appropriate PEP which includes proper wound wash, full course of anti-rabies vaccination (ARV), and wound infiltration of rabies immunoglobulin (RIG) in all category III bites to save the life of these animal bite victims. Furthermore, it is also essential for the 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.

There are no published data on the compliance rate for intramuscular rabies vaccination (IMRV), and a study on compliance to intradermal rabies vaccination (IDRV) in India showed the rate to be as low as 35%. [4 ] Therefore, the present study was done to determine the compliance rate for complete course of ARV both by intramuscular route and intradermal route in PEP and to determine the major constraints for not completing the vaccination course.

The study was initiated following clearance from the institutional ethics committee of Kempegowda Institute of Medical Sciences, Bangalore, India. The study was done at two municipal corporation hospitals in Bangalore, India: One of them providing IMRV by Essen regimen, i.e., one dose of rabies vaccine administered intramuscularly on days 0, 3, 7, 14, and 28 as PEP, and the other providing IDRV by updated Thai Red Cross (TRC) regimen, i.e., 0.1 ml × 2 sites intradermally on days 0, 3, 7, and 28 as PEP. All the animal bite victims who came to the selected hospitals for PEP during January-December, 2012 were included in the study.

The socio-demographic characteristics and details of exposure were collected using structured proforma. The follow-up was done to know the compliance for complete course of ARV. The animal bite victims who discontinued the vaccination at any point during the recommended course (except those who discontinued vaccination after 3 doses, where the dog/cat remains healthy and alive for at least 10 days after the exposure) [1] were considered as non-compliant bite victims/dropouts. The compliance rates were calculated separately for both the routes of administration. The major constraints to compliance in both the groups were found out by interviewing the non-compliant bite victims or their guardians through telephone. The data collected was analyzed using SPSS version 16.0, (SPSS Inc. IBM Company, Chicago, USA). The statistical analysis included percentages and chi-square test (to determine the difference in the compliance rate between IMRV and IDRV). The results obtained were considered statistically significant whenever P < 0.05.

The present study included 215 animal bite victims who received intramuscular rabies vaccination (IMRV group) and 521 who received intradermal rabies vaccination (IDRV group). In both the study centers, the anti-rabies vaccine was continuously available throughout the study period.

Majority of the bite victims in both the study centers were males (65.1% in IMRV group and 68.3% in IDRV group) and most of them were aged below 15 years (41.4% in IMRV group and 45.1% in IDRV group). Similarly, most of the animal bite victims were students (41.4% in IMRV group and 45.1% in IDRV group) followed by daily wage workers (31.6% in IMRV group and 29.9% in IDRV group) and postal/courier men (12.6% in IMRV group and 8.5% in IDRV group). In both the study populations, dog was the biting animal in majority of the cases (98.5% in IMRV group and 97% in IDRV group) and most of the bites were unprovoked bites (65.6% in IMRV group and 67.2% in IDRV group). The most common site of wound was on the limbs (87.5% in IMRV group and 89.7% in IDRV group) and majority of them had category III bites (79.0% in IMRV group and 70.8% in IDRV group). Wound wash at home was done only in 66.0% of IMRV group subjects and in 68.2% of IDRV group subjects.

The compliance rate for full course of IMRV was 60% and for IDRV was 77% [Table 1]. The compliance rate to full course of ARV by intradermal route was found to be higher when compared to intramuscular route and the difference was found to be statistically significant (Chi-square value: 6.697, P = 0.009659).
Table 1: Compliance to anti-rabies vaccination

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Among 86 non-complaints in IMRV group, 54 could be contacted for inquiry regarding their constraints to complete the course. Similarly, among 120 non-complaints in IDRV group, 90 could be contacted for inquiry regarding their constraints. The major constraints were loss of wages, forgotten dates, cost incurred, interference with working hours/school timings, and distance from the hospital [Table 2].
Table 2: Constraints for compliance to complete course of anti-rabies vaccines

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In rabies-endemic countries, completing the full course of PEP is essential to prevent the disease. The present study showed that the compliance to complete course of ARV for PEP was only 60% for IMRV and 77% for IDRV. Similarly, previous studies conducted only on IDRV by Vinay et al. showed the compliance rate to complete course of IDRV to be only 35% and by Sathpathy et al. showed the compliance rate to be as low as 65%. [4],[5] In the present study, the compliance to IDRV was found to be higher when compared to IMRV, and the difference was found to be statistically significant, which may be because of the reduced number of visits that led to reduction in the cost of travel and loss of wages. The study also revealed that in both IMRV and IDRV, the major constraints were social factors and not any adverse reactions to anti-rabies vaccines. Therefore, every bite victim has to be motivated through proper communication and behavioral change has to be made to complete the full course of vaccination in order to save their own lives.

Similarly, the animal bite victims have to be informed that in rabies-endemic areas, re-exposures are common and the rate is about 15%. [6] In these cases, if an individual has received complete PEP any time in the past, there is no need for RIG, which is costly and may not always be available; instead only two booster doses of ARV on days 0 and 3 are recommended. [7 ] This will save the cost and time during re-exposures.

To facilitate the completion of PEP and to improve compliance to ARV, anti-rabies vaccines should be made continuously available at all government hospitals and have to be provided free of charge to all animal bite victims, so that they can continue their course in any hospital, near their house/school/work place without interfering with their working hours/school timings and they need not lose their wages. Similarly, telephonic remainders can be given to all animal bite victims regarding their next dose of vaccination. A coordinated effort should be made by all concerned, in order to complete the PEP to prevent rabies and to eliminate the disease as a public health problem.

In conclusion, the current emphasis should be on motivating the patients to complete the full course of vaccination and reducing the long duration PEP by shorter course and reduced dose schedules, resulting in savings in vaccine, reduced number of visits, and reduced travel costs. [6] In this regard, an expert committee at CDC, USA determined the potential utility of reducing the current 5-dose IMRV. Based upon the review of literature and available evidence, a reduced 4-dose schedule on days 0, 3, 7, and 14 given in conjunction with RIGs was supported and recommended by the United States Advisory Committee on Immunization Practices (ACIP). [8 ] Similarly, studies have been done to evaluate the safety and efficacy of 1-week, three-visit, four-site, intradermal regimen with 0.1 ml per site in Thailand and India. [9],[10 ] The results were promising and have shown to be safe and effective for PEP. These may facilitate compliance and have the added benefit of earlier complete protection reducing the anxiety for bite victims. These may be further evaluated through well-designed studies, which should be a research priority.

 
   References Top

1.
World Health Organization. Rabies vaccines: WHO position paper, Weekly Epidemiological Record, No. 32. 2010;85:309-20.  Back to cited text no. 1
    
2.
, et al. Assessing the burden of human rabies in India: Results of a national multi-center epidemiological survey. Int J Infect Dis 2007;11:29-35.  Back to cited text no. 2
[PUBMED]    
3.
National guidelines for rabies prophylaxis and intra-dermal administration of cell culture rabies vaccines, National Institute of Communicable Diseases, Ministry of Health and Family welfare, New Delhi, India. 2007. p. 5.  Back to cited text no. 3
    
4.
Vinay M, Mahendra BJ. Compliance to intra dermal rabies vaccination schedule at the anti rabies clinic, mandya institute of medical sciences hospital, Mandya, Karnataka State. Journal of APCRI 2011;13:35-7.  Back to cited text no. 4
    
5.
Satapathy DM, Reddy SS, Prathap AK, BehraTR, Malini DS, Tripathy RM, et al. "Drop-out" in IDRV: A cause of concern. Journal of APCRI 2010;12:40-1.  Back to cited text no. 5
    
6.
Sudarshan MK, Ravish HS, Ashwath Narayana DH. Time interval for booster vaccination following re-exposure to rabies in previously vaccinated subjects. Asian Biomed 2011;5:589-94.  Back to cited text no. 6
    
7.
World Health Organization. WHO expert consultation on rabies. Technical report series 982. WHO Geneva, 2013. p. 58.  Back to cited text no. 7
    
8.
, et al. Evidence for a 4-dose vaccine schedule for human rabies post-exposure prophylaxis in previously non-vaccinated individuals. Vaccine 2009;27:7141-8.  Back to cited text no. 8
[PUBMED]    
9.
, , et al. Postexposure rabies prophylaxis completed in 1 week: Preliminary study. 2010;50:56-60.  Back to cited text no. 9
    
10.
, et al. Evaluation of a one week intradermal regimen for rabies post-exposure prophylaxis: Results of a randomized, open label, active-controlled trial in healthy adult volunteers in India. 2012;8:1077-81.  Back to cited text no. 10
[PUBMED]    



 
 
    Tables

  [Table 1], [Table 2]


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