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BRIEF RESEARCH ARTICLE
Year : 2020  |  Volume : 64  |  Issue : 1  |  Page : 72-74  

Re-exposure animal bite management among incident animal bite cases in a secondary care Hospital in Delhi, India


1 Senior Resident, Department of Community Medicine, Maulana Azad Medical College, New Delhi, India
2 Postgraduate Resident, Department of Community Medicine, Maulana Azad Medical College, New Delhi, India
3 Director Professor, Department of Community Medicine, Maulana Azad Medical College, New Delhi, India
4 Consultant, Department of Medicine, Maharishi Valmiki Hospital, New Delhi, India

Date of Submission01-Feb-2019
Date of Decision20-Jun-2019
Date of Acceptance01-Feb-2020
Date of Web Publication16-Mar-2020

Correspondence Address:
Warisha Mariam
Department of Community Medicine, Maulana Azad Medical College, New Delhi
India
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/ijph.IJPH_37_19

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   Abstract 


Complete postexposure prophylaxis with 4 doses of anti-rabies vaccine (ARV) in a previously vaccinated (nonnaïve) individual results in administration of two extra ARV doses resulting in wastages of precious resources comprising vaccine logistics, human resources, physician, and patient time. This cross-sectional study conducted in a secondary care hospital in Delhi among 175 incident animal bite cases observed 39 (22.3%) had an animal-bite history within the previous 5 years. A total of 19 (10.8%) cases reported a history of complete ARV vaccination during a previous animal-bite exposure. However, in the absence of supportive patient medical documentation, all the animal bite cases without exception were prescribed a full course of ARV irrespective of their previous exposure status. Rabies immunoglobulins (anti rabies serum) were also re-administered in 13 (81.2%) cases. National guidelines for rabies prophylaxis should, therefore, consider the inclusion of an explicit decision-making algorithmic mechanism when the health-care provider is confronted with this situation carrying the potential for hidden vaccine wastage.

Keywords: Anti rabies serum, anti-rabies vaccine, vaccine wastage


How to cite this article:
Basu S, Mariam W, Santra S, Garg S, Singhal R. Re-exposure animal bite management among incident animal bite cases in a secondary care Hospital in Delhi, India. Indian J Public Health 2020;64:72-4

How to cite this URL:
Basu S, Mariam W, Santra S, Garg S, Singhal R. Re-exposure animal bite management among incident animal bite cases in a secondary care Hospital in Delhi, India. Indian J Public Health [serial online] 2020 [cited 2020 Dec 2];64:72-4. Available from: https://www.ijph.in/text.asp?2020/64/1/72/280770



Rabies is a zoonotic disease of the central nervous system transmitted through animal bites that is potentially 100% fatal in the absence of effective postexposure prophylaxis (PEP).[1] Rabies is attributed to cause over 20,000 human deaths annually.[2] It is well established that the high rabies burden in some developing countries such as India principally arises from the high incidence of animal bites and the failure to initiate and complete anti-rabies vaccination in a large proportion of the animal bite cases.[3] However, the challenges of accessibility, affordability, and requirement of multiple follow-ups can preclude completion of PEP in animal-bite cases, especially among those belonging to the lower socioeconomic classes.[4]

Standard rabies postexposure treatment guidelines recommend the immunologically naïve individuals of all age groups to receive the anti-rabies vaccine (ARV) at two sites intradermal (ID) of 0.1 ml dose on day 0, 3, 7, and 28. In previously vaccinated individuals, two-site ID on day 0 and 3 or a four-site ID schedule on day 0 is recommended.[5] Although, the World Health Organization in its updated 2018 position paper has recommended abbreviated two-site ID dose on day 0, 3, and 7 for immunologically naïve and single-site ID on day 0 and 3 for previously vaccinated individuals, these recommendations have not yet been adopted in India.[6] Rabies immunoglobulins or anti-rabies serum (ARS) is also recommended only in the naïve category III animal-bite cases.

In a high rabies burden country such as India, there exists a large at-risk population due to the permissive social environment promoting human-animal interaction in densely populated urban agglomerates with huge stray canine population and an overwhelming lack of formal dog ownership.[7] Identifying the burden of incident animal-bite cases with a history of re-exposure and their ARV vaccination status indicates the effectiveness of animal bite control strategies. Adherence of health-care providers to the recommended PEP guidelines in re-exposed cases is also essential since complete protection in those who have previously received four doses of ARV with/without ARS can be ensured with only two further doses of ARV. Consequently, a complete ARV (PEP) course in the previously vaccinated nonimmunocompromised individuals results in the administration of potentially extra ARV doses signifying a hidden vaccine wastage that has enormous public health implications. In lower-middle-income countries, including India, the high animal bite incidence rate coupled with the prohibitive retail cost of the vaccine for a large proportion of animal bite victims imposes a huge burden on the government-funded public health-care system and renders it susceptible to frequent ARV outages and limits overall PEP access.[8],[9] Furthermore, receiving the two extra ARV doses contributes to an estimated loss of 2.4 wage days in every animal bite case earning daily wages on account of wage losses and travel costs.[9] This epidemiological study on incident animal-bite cases assessed previous animal-bite exposure history and previous anti-rabies vaccination (ARV) status.

We conducted this cross-sectional observational study in a secondary care government hospital in a rural area, located at the outskirts of Delhi from March to May 2018. The hospital constitutes the only source of free of cost rabies PEP treatment within a 10 km radius. We included any incident animal bite case above the age of 5 years who reported to either the pediatric and medicine outpatient departments of the hospital for the initiation of ARV or for follow-up after receiving their first ARV dose at the casualty department of the same hospital. We excluded those cases that were initiated and received at least one dose of ARV from a different health facility for the management of their current animal bite condition. We conducted exit interviews outside the vaccination room of the hospital.

We used a patient interview schedule for data collection. We asked the participants with a previous history of animal-bite exposure the total number of visits when they received injections for treating the animal-bite. We considered a history of four visits as a proxy for a previously complete vaccinated (ARV) individual. Similarly, we assessed the history of rabies immunoglobulin (ARS) administration by asking the participants whether they had received injection around the site of the bite wound during any previous animal-bite exposure incident.

We obtained verbal consent from all participants before asking them questions. In pediatric cases, we interviewed the parents or guardians accompanying the child. All the participants receive standard care for animal bite management as per the clinical judgment of their treating physicians. The study was approved by the Institutional Ethics Committee of the Maharishi Valmiki Hospital, PoothKhurd, Delhi. We analyzed the data with SPSS for Windows, version 17.00 (IBM, Chicago, IL, USA).

We enrolled 175 individuals reporting with the animal bite of which 124 (70.9%) were male, and 51 (29.1%) were female. The median age of the participants was 24 years.

A total of 171 (97.7%) participants presented with a dog bite, 2 (1.1%) with cat bite, and 2 (1.1%) with monkey bite. There were 30 (17.1%) participants with category II bites and 140 (80%) cases with category III bites. The participants had applied chili powder on their wound-site in 71 (40.6%) cases, whereas only 58 (33.1%) cases had washed the wound with soap and water.

A total of 39 (22.3%) participants reported an animal-bite exposure history occurring within the past 5 years. The mean age of the incident cases with the previous animal-bite exposure (26.84 ± 15.63) and without exposure (28.03 ± 17.07) was not significantly different (P = 0.683).

On bivariate analysis, the male gender was found to be a significant predictor of previous animal-bite exposure [Table 1].
Table 1: Distribution of animal bite exposure cases according to previous exposure status and age and gender (n=175)

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In participants with past animal exposure (n = 39), 19 (48.7%) participants self-reported having received a 4 dose complete ARV vaccination course during their previous animal bite incident, 11 (28.2%) probably received an incomplete ARV vaccination course (<4 doses), and 9 (23.1%) were not sure of their vaccination status. However, we could not validate the self-reported prior ARV status of the participants since none were in possession of documentation recording the medical management accorded during the previous animal bite episode. We observed that all the participants were prescribed a complete four-dose ID ARV schedule by their treating physicians for the management of their current animal bite incident irrespective of their past animal-bite exposure and vaccination status. Potentially, excess anti-rabies vaccination occurred in an estimated 19 (10.8%) participants who received two extra ARV doses accounting for a total of possibly 38 excess ARV doses.

Of the 39 participants with animal bite re-exposure, 16 (41%) reported having received ARS during their previous bite exposure, 11 (28.2%) did not receive ARS, and 12 (30.8%) could not recall their status. Among these 16 cases who received ARS during previous exposure, 13 (81.2%) were again prescribed ARS for the current animal bite episode.

Although rabies PEP through the intradermal route being provided in most government health facilities in India is recognized as highly cost-effective,[3] a complete PEP course in previously vaccinated (nonnaïve) individual results in unwarranted administration of two additional ARV doses. This results in wastage of precious resources comprising vaccine logistics, human resource efficiency, and time while also increasing patient out-of-pocket expenses.

The present study conducted in a secondary care hospital in Delhi observed that nearly one in every ten animal bite cases (10.82%) was receiving extra ARV doses, whereas 13 (7.4%) cases also received ARS that was probably not required. Furthermore, nearly one in four (22.3%) animal bite cases had a history of animal-bite exposure within the past 5 years. A previous study at a health center in Northern India reported 28% of animal bite cases with previous dog bite exposure.[10] However, most hospital-based epidemiological studies from India have not reported the burden of repeat exposure in incident animal bite cases.

In our study, none of the participants with previous animal bite exposure history had medical records of the treatment received in the last episode. A similar finding was also observed in a community-based study in rural and urban slums of Delhi where most dog bite victims lacked any records for past vaccination, and few were aware that ARV was specifically given for protection against rabies.[11]

We observed that all the animal bite cases irrespective of their prior history of animal-bite exposure and ARV/ARS vaccination were prescribed a complete four-dose PEP course with or without ARS in the current episode. Consequently, nearly one in ten incident animal bite case was potentially receiving extra doses of ARV with or without additional ARS. Our findings are hence suggestive of a hidden modality of ARV wastage that results in economic losses for the public health system and the opportunity costs for patients visiting the health-facility to receive additional ARV doses that were probably not required. This signifies the need for health-care providers to explain the details of rabies PEP vaccination to animal bite cases.

It is understood that health-care providers can lack confidence in accepting oral histories from patients affirming the reception of rabies PEP treatment due to the 100% lethality of the disease and especially among cases from the low socio-educational background. National guidelines for rabies prophylaxis, therefore, should consider the inclusion of an explicit decision making algorithmic mechanism when the health-care provider is confronted with a situation with the potential for administration of extra ARV (PEP) doses which are unwarranted. This is particularly important when the patient's history of previous exposure and receiving a full course of PEP-ARV lacks supportive medical documentation. Moreover, patients should also be instructed to preserve their medical records documenting their ARV (PEP) vaccination status, and present them in the event of subsequent re-exposure.

Although conducted in a small sample, this study is the first of its kind from India that provides evidence and highlights the problem of hidden ARV (PEP) vaccine wastage. A limitation of the present study is that we did not estimate patient anti-rabies antibody levels through serological testing to ensure the validity of their self-reported previous rabies PEP status. Self-reported history of previous vaccination status is certainly a limitation of the present study. Furthermore, we did not assess knowledge of animal bite PEP among the treating physicians of the hospital although it was previously reported that health-care providers might lack adequate knowledge for the management of animal bite patients. A study in Delhi revealed that only 40.4% of allopathic doctors knew the correct PEP schedule in previously vaccinated animal bite cases.[12] Therefore, future studies should ascertain if training sessions for physicians and nurses handling animal bite cases improves adherence to standard treatment guidelines for rabies prophylaxis, especially in cases with animal-bite re-exposure.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.



 
   References Top

1.
World Health Organization. WHO Guide for Rabies Pre and Post Exposure Prophylaxis in Humans General Considerations in Rabies Post-Exposure Prophylaxis (PEP). World Health Organization; 2013. p. 1-29.  Back to cited text no. 1
    
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Abbas SS, Kakkar M. Rabies control in India: A need to close the gap between research and policy. Bull World Health Organ 2015;93:131-2.  Back to cited text no. 3
    
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Garg S, Basu S, Dahiya N. A review of current strategy for rabies prevention and control in the developing world. Indian J Comm Health 2017;1:10-6.  Back to cited text no. 4
    
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National Guidelines for Rabies Prophylaxis and Intra-Dermal Administration of cell Culture Rabies Vaccines, National Institute of Communicable Disease; 2007. p. 17.  Back to cited text no. 5
    
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WHO/Department of Control of Neglected Tropical Diseases. Rabies vaccines: WHO position paper – April 2018. Weekly Epidemiol Record 2018;93:201-20.  Back to cited text no. 6
    
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Abbas SS, Kakkar M, Rogawski ET; Roadmap to Combat Zoonoses in India (RCZI) initiative. Costs analysis of a population level rabies control programme in Tamil Nadu, India. PLoS Negl Trop Dis 2014;8:e2721.  Back to cited text no. 7
    
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Changalucha J, Steenson R, Grieve E, Cleaveland S, Lembo T, Lushasi K, et al. The need to improve access to rabies post-exposure vaccines: Lessons from Tanzania. Vaccine 2019;37 Suppl 1:A45-53.  Back to cited text no. 8
    
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Sudarshan M. Assessing burden of rabies in India: WHO sponsored national multicentric rabies survey, 2003. Indian J Community Med 2005;30:100-1.  Back to cited text no. 9
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Jain P, Jain G. Study of general awareness, attitude, behavior, and practice study on dog bites and its management in the context of prevention of rabies among the victims of dog bite attending the OPD services of CHC muradnagar. J Family Med Prim Care 2014;3:355-8.  Back to cited text no. 10
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11.
Sharma S, Agarwal A, Khan AM, Ingle GK. Prevalence of dog bites in rural and urban slums of Delhi: A community-based study. Ann Med Health Sci Res 2016;6:115-9.  Back to cited text no. 11
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12.
Garg A, Kumar R, Ingle GK. Knowledge and practices regarding animal bite management and rabies prophylaxis among doctors in Delhi, India. Asia Pac J Public Health 2013;25:41-7.  Back to cited text no. 12
    


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