ORIGINAL ARTICLE
Epidemiological Characteristics of Patients Attending for Rabies Post-Exposure Prophylaxis at the Infectious Diseases Hospital of Lucknow, India Krishna Kumar Sahu, Manish K Manar1, Shivandra K Singh1, Harshwardhan Singh2 Department of Social and Preventive Medicine, MLB Medical College, Jhansi, 1Department of Community Medicine and Public Health, King George’s Medical University, Lucknow, 2Department of Community Medicine, S N Medical College, Agra, Uttar Pradesh, India
ABSTRACT Aims: The objective of the study was to assess epidemiological and anti-rabies vaccination status in animal bite patients attending the Infectious Diseases Hospital, Lucknow. Materials and Methods: A longitudinal survey was conducted in the Infectious Diseases Hospital of Lucknow from January to December 2013. During this duration a total of 390 patients presenting with animal bites were included. Results: A majority (63.3%) of patients were in the 16-59 years age group. 75% of patients had attended the IDH for rabies post-exposure prophylaxis (PEP) within 24 hours. The male to female ratio was 2.98:1. A majority (79.5%) of patients were injured by dogs. 9.0% patients were in close contact with rabies patient. On the basis of WHO classification, 4.2% of animal bite patients were placed in grade I, 88.2 in grade II and 7.6% in grade III. In 73.3% of patients wound were in lower limbs. Complete vaccination was found in 65.0% and the use of human rabies immune globulin was only in 11.1%. Conclusion: Outcome of an animal bite can be fatal. The only preventive/curative measure available is anti-rabies vaccination and the use of human rabies immune globulin, hence to assure 100% compliance for the same awareness campaign is required. Key words: Animal bite, Animal bite patient, Anti-rabies vaccination, Epidemiology, Infectious disease hospital, Lucknow, Rabies post-exposure prophylaxis
INTRODUCTION
R
abies is a public health problem. It is estimated that the South East Asia Region accounts for approximately 60% of human deaths due to rabies in the world.[1] In India, it is estimated that 20,000 deaths occur due to rabies annually.[2] Rabies is a viral neurological disease affecting all mammals, including human beings. It is known to be 100% fatal once symptoms have set in, prevention through post-exposure prophylaxis (PEP) is the only proven means to save rabies-infected patients. Considering the gravity of rabies and that animal vaccination and control measures for animals such as dogs in the country are far from ideal, pre-exposure and PEP are of utmost importance.[3] Access this article online Quick Response Code:
MATERIALS AND METHODS
Lucknow is the capital city of Uttar Pradesh Situated on the northern Gangetic plains of India. The geographical location of Lucknow is between 26.50° North and 80.50° East. Lucknow is located at an elevation of 123 meters above sea level. The population of Lucknow, according to the India Census 2011, was 4,588,455 of which males and females were 2,407,897 and 2,180,558, respectively. There was an increase
Website: www.jgid.org
DOI: 10.4103/0974-777X.150888
30
The treatment of human animal-bite victims in India is poor, only 47.9% received any rabies PEP, and nearly half of these received only nerve tissue vaccine,[4] which is not recommended by the WHO.[5] Immunoglobulins were received by only 2.1% of the patients, and compliance in completing the course of PEP was only 40.5%.[4] The objective of the study was to assess epidemiological features and rabies PEP, patients attending the Infectious Disease Hospital.
Address for correspondence: Dr. Krishna Kumar Sahu, E-mail: [email protected]
Journal of Global Infectious Diseases / Jan-Mar 2015 / Vol-7 / Issue-1
Sahu, et al.: Epidemiological characteristics of patients attending post-exposure prophylaxis at IDH
of 25.79% in the population in 2011 as compared to the population in 2001 census. The initial provisional census data suggests a population density of 1815 in 2011. Total area under the Lucknow District is about 2528 sq.km. The average literacy rate in Lucknow according to the Census 2011 was 79.33% while the sex ratio was 906 per 1000 males. This study was conducted in the Infectious Diseases Hospital (IDH) of Lucknow from January to December 2013. It was a cross-section study. In this study all patients who attended the IDH for anti-rabies immunization following an animal bite were included. A predesigned and pretested form was used for data collection. At the time of registration in the study their biosocial correlates, source of exposure, type of wound, location of the wound and anti-rabies vaccination were documented. For the grading of wound WHO criteria was used.[5] Written consent was taken from the patient. Data analysis Collected data were entered into Microsoft Excel and analyzed by using the software SPSS, version 17.0. Frequency distributions and percentage were calculated for all variables. RESULTS
the patients received tetanus immunization. Use of human rabies immunoglobulin was very poor (11.1%) [Table 4]. Table 1: Biosocial characteristics of animal bite patients attending IDH (n = 390) Age ≤5 years
No. (%) 31 (7.9)
5-15 years
97 (24.9)
16-59 years
247 (63.3)
≥60 years
15 (3.8)
Gender Male
292 (74.9)
Female
98 (25.1)
Male and female ratio
2.98:1
Place of residence Urban
289 (74.1)
Rural
101 (25.9)
Time between animal bite and rabies PEP 0-6 hours
136 (34.9)
6- 12 hours
55 (14.1)
12- 24 hours
99 (25.4)
More than 24 hours
100 (25.6)
Table 2: Source of exposure (n = 390) Type of animal bite Dog
No. (%) 310 (79.5)
Monkey
20 (5.1)
Cat
9 (2.3)
Mouse
6 (1.5)
Jackal
2 (0.5)
In the study sample size was 390, in which a majority (63.3%) of patients were aged 16-59 years and children (below 15 years) was 32.8%. The male to female ratio was 2.98:1. In the total, 74.1% of patients were from urban area and 25.9% from rural area. 75% of patients had attended the IDH for anti-rabies vaccination (ARV) within 24 hours. Out of which, 34.9% patients had attended ARV clinic within 6 hours [Table 1].
Close contact with rabies patient
35 (9.0)
Other
8 (2.1)
Biting animals were predominantly dog (79.5%) followed by monkey (5.1%), cats (2.3%), other peri-domestic animals (3.6%) and wild animals (0.5%). 9.0% patients were of close contact with a rabid patient [Table 2].
Head, neck and face
21 (5.9)
Upper extremities (Hands, fingers, etc.)
64 (18.0)
Lower extremities (Foot, leg, thigh, etc.)
260 (73.3)
On the basis of WHO wound classification, 4.2% animal bites were placed in grade I, 88.2% in grade II and 7.6% in grade III. Regarding wound location majority of injuries (73.3%) were in the lower extremities including foot, legs, /thigh and buttock. Only 5.9% of patients had wound located on head, neck and face [Table 3].
Table 4: Immunization in animal bite patients (n = 380)
65.0% of patients received a complete rabies vaccine course (Essen intramuscular 5 dose schedule). All
Table 3: Type of animal bite (n = 355) Type of Bite (WHO category)
No. (%)
Grade I
15 (4.2)
Grade II
313 (88.2)
Grade III
27 (7.6)
Wound location
Others (Grade I)
10 (2.8)
Anti-rabies vaccination
No. (%)
Only 1st dose
28 (7.4)
Up to 2nd dose
12 (3.2)
Up to 3rd dose
24 (6.3)
Up to 4th dose
69 (18.2)
Up to 5th dose (complete vaccination)
247 (65.0)
Human rabies immune globulin Tetanus immunization
Journal of Global Infectious Diseases / Jan-Mar 2015 / Vol-7 / Issue-1
3 (11.1) 390 (100.0)
31
Sahu, et al.: Epidemiological characteristics of patients attending post-exposure prophylaxis at IDH
DISCUSSION
In the present study children and adult were commonly affected by animals bite. It is probably due to outdoor activity. Similar findings were observed in other studies.[6-9] The overall male/female ratio of animal bite victims among Asian countries was 1.6:1.[10] In a WHO survey conducted in India male and female ratio was 2.19:1.[11] In our study, the male/female ratio was slightly higher. It is important for the effectiveness of rabies PEP that treatment should be as early as possible after animal bite. In our study approximate two-third animal bite patients received rabies PEP within 24 hours. In this study main biting animal was dog followed by monkey, cat and other animals which confirm previous studies.[7,8] However, the proportion of injuries caused by monkeys in our survey was higher than in a national multicentre survey conducted in 2007.[11] This may be related to a recent increase in monkey population in the urban area, due to deforestation. About 7.6% of animal bite patients belonged to grade III bite. These types of bites require the use of both the vaccine and human rabies immunoglobulin. Completion of full course of vaccination was poor (65.0%) when it should be 100%. In a multi-centre study in India, completion of full course of vaccination was 42%. The use of life-saving human rabies immunoglobulin was very poor. It was due to the high cost of immune globulin. Similar findings were seen in another study.[11] CONCLUSION
Our study provides strong evidence that the problem of rabies exposure is widespread in our region, dog being the main culprit and lack of compliance due to ignorance among the patients as reflected by the failure to take the complete
32
course of vaccination. In order to increase compliance, awareness campaigns along with the use of electronic media highlighting the severity of disease and availability of highly effective vaccination should be emphasized upon. REFERENCES 1.
Prevention and control of rabies in South-East Asia Region. World Health Organization, Regional Office for South East Asia. New Delhi: SEA-Rabies 23; 2004. p.1-17. 2. Ichhpujani RL, Bhardwaj M, Chhabra Mala, Datta KK. Rabies in India. Country report, 4th International Symposium on Rabies Control in Asia. Vietnam: John Libbey Eurotext Paris 2001. p. 35. 3. PSMD Task Force Recommendation for Rabies Pre and Post exposure prophylaxis. Phil J Microbiol Infect Dis 1997;26:25-9. 4. ANON. Assessing the Burden of Rabies in India. WHO Sponsored National Mult-Icentric Rabies Survey 2003. Bangalore, Association for Prevention and Control of Rabies in India. 2004. http://rabies.org.in/rabiesjournal/ rabies-06/SpecialArticle1.htm. [Last accessed on 2014 Feb 07]. 5. WHO Technical Report Series. WHO Expert Consultation on Rabies. Geneva: World Health Organization; 2005. http://apps.who.int/iris/ bitstream/10665/85346/1/9789241209823_eng.pdf. [Last accessed on 2014 Feb 07]. 6. Sudarshan MK, Nagaraj S, Savitha B, Veena SG. An epidemiological study of rabies in Bangalore city. J Indian Med Assoc 1995:93:14-7. 7. Singh J, Jain DC, Bhatia R, Ichhpujani RL, Harit AK, Panda RC, et al. Epidemiological characteristics of rabies in Delhi and surrounding areas, 1998. Indian Pediatr 2001;38:1354-60. 8. Sudarshan MK, Mahendra BJ, Narayan DH. A community survey of dog bites, anti-rabies treatment, rabies and dog population management in Bangalore city. J Commun Dis 2001;33:245-51. 9. Agrawal N, Reddaiah VP. Knowledge, attitude and practice following dog bite: A community based epidemiological study. Health and Promotion. Perspective and issue 2002;26:154-61. 10. Dodet B, Goswami A, Gunasekera A, de Guzman F, Jamali S, Montalban C, et al. Rabies awareness in eight Asian countries. Vaccine 2008;26:6344-8. 11. Sudarshan MK, Madhusudana SN, Mahendra BJ, Rao NS, Ashwath Narayana DH, Abdul Rahman S, et al. Assessing the burden of human rabies in India: Results of a national multi-centre epidemiological survey. Int J Infect Dis 2007;11:29-35. How to cite this article: Sahu KK, Manar MK, Singh SK, Singh H. Epidemiological characteristics of patients attending for rabies postexposure prophylaxis at the infectious diseases hospital of Lucknow, India. J Global Infect Dis 2015;7:30-2. Source of Support: Nil. Conflict of Interest: None declared.
Journal of Global Infectious Diseases / Jan-Mar 2015 / Vol-7 / Issue-1
Copyright of Journal of Global Infectious Diseases is the property of Medknow Publications & Media Pvt. Ltd. and its content may not be copied or emailed to multiple sites or posted to a listserv without the copyright holder's express written permission. However, users may print, download, or email articles for individual use.
Epidemiological Characteristics of Patients Attending for Rabies Post-Exposure Prophylaxis at the Infectious Diseases Hospital of Lucknow, India Krishna Kumar Sahu, Manish K Manar1, Shivandra K Singh1, Harshwardhan Singh2 Department of Social and Preventive Medicine, MLB Medical College, Jhansi, 1Department of Community Medicine and Public Health, King George’s Medical University, Lucknow, 2Department of Community Medicine, S N Medical College, Agra, Uttar Pradesh, India
ABSTRACT Aims: The objective of the study was to assess epidemiological and anti-rabies vaccination status in animal bite patients attending the Infectious Diseases Hospital, Lucknow. Materials and Methods: A longitudinal survey was conducted in the Infectious Diseases Hospital of Lucknow from January to December 2013. During this duration a total of 390 patients presenting with animal bites were included. Results: A majority (63.3%) of patients were in the 16-59 years age group. 75% of patients had attended the IDH for rabies post-exposure prophylaxis (PEP) within 24 hours. The male to female ratio was 2.98:1. A majority (79.5%) of patients were injured by dogs. 9.0% patients were in close contact with rabies patient. On the basis of WHO classification, 4.2% of animal bite patients were placed in grade I, 88.2 in grade II and 7.6% in grade III. In 73.3% of patients wound were in lower limbs. Complete vaccination was found in 65.0% and the use of human rabies immune globulin was only in 11.1%. Conclusion: Outcome of an animal bite can be fatal. The only preventive/curative measure available is anti-rabies vaccination and the use of human rabies immune globulin, hence to assure 100% compliance for the same awareness campaign is required. Key words: Animal bite, Animal bite patient, Anti-rabies vaccination, Epidemiology, Infectious disease hospital, Lucknow, Rabies post-exposure prophylaxis
INTRODUCTION
R
abies is a public health problem. It is estimated that the South East Asia Region accounts for approximately 60% of human deaths due to rabies in the world.[1] In India, it is estimated that 20,000 deaths occur due to rabies annually.[2] Rabies is a viral neurological disease affecting all mammals, including human beings. It is known to be 100% fatal once symptoms have set in, prevention through post-exposure prophylaxis (PEP) is the only proven means to save rabies-infected patients. Considering the gravity of rabies and that animal vaccination and control measures for animals such as dogs in the country are far from ideal, pre-exposure and PEP are of utmost importance.[3] Access this article online Quick Response Code:
MATERIALS AND METHODS
Lucknow is the capital city of Uttar Pradesh Situated on the northern Gangetic plains of India. The geographical location of Lucknow is between 26.50° North and 80.50° East. Lucknow is located at an elevation of 123 meters above sea level. The population of Lucknow, according to the India Census 2011, was 4,588,455 of which males and females were 2,407,897 and 2,180,558, respectively. There was an increase
Website: www.jgid.org
DOI: 10.4103/0974-777X.150888
30
The treatment of human animal-bite victims in India is poor, only 47.9% received any rabies PEP, and nearly half of these received only nerve tissue vaccine,[4] which is not recommended by the WHO.[5] Immunoglobulins were received by only 2.1% of the patients, and compliance in completing the course of PEP was only 40.5%.[4] The objective of the study was to assess epidemiological features and rabies PEP, patients attending the Infectious Disease Hospital.
Address for correspondence: Dr. Krishna Kumar Sahu, E-mail: [email protected]
Journal of Global Infectious Diseases / Jan-Mar 2015 / Vol-7 / Issue-1
Sahu, et al.: Epidemiological characteristics of patients attending post-exposure prophylaxis at IDH
of 25.79% in the population in 2011 as compared to the population in 2001 census. The initial provisional census data suggests a population density of 1815 in 2011. Total area under the Lucknow District is about 2528 sq.km. The average literacy rate in Lucknow according to the Census 2011 was 79.33% while the sex ratio was 906 per 1000 males. This study was conducted in the Infectious Diseases Hospital (IDH) of Lucknow from January to December 2013. It was a cross-section study. In this study all patients who attended the IDH for anti-rabies immunization following an animal bite were included. A predesigned and pretested form was used for data collection. At the time of registration in the study their biosocial correlates, source of exposure, type of wound, location of the wound and anti-rabies vaccination were documented. For the grading of wound WHO criteria was used.[5] Written consent was taken from the patient. Data analysis Collected data were entered into Microsoft Excel and analyzed by using the software SPSS, version 17.0. Frequency distributions and percentage were calculated for all variables. RESULTS
the patients received tetanus immunization. Use of human rabies immunoglobulin was very poor (11.1%) [Table 4]. Table 1: Biosocial characteristics of animal bite patients attending IDH (n = 390) Age ≤5 years
No. (%) 31 (7.9)
5-15 years
97 (24.9)
16-59 years
247 (63.3)
≥60 years
15 (3.8)
Gender Male
292 (74.9)
Female
98 (25.1)
Male and female ratio
2.98:1
Place of residence Urban
289 (74.1)
Rural
101 (25.9)
Time between animal bite and rabies PEP 0-6 hours
136 (34.9)
6- 12 hours
55 (14.1)
12- 24 hours
99 (25.4)
More than 24 hours
100 (25.6)
Table 2: Source of exposure (n = 390) Type of animal bite Dog
No. (%) 310 (79.5)
Monkey
20 (5.1)
Cat
9 (2.3)
Mouse
6 (1.5)
Jackal
2 (0.5)
In the study sample size was 390, in which a majority (63.3%) of patients were aged 16-59 years and children (below 15 years) was 32.8%. The male to female ratio was 2.98:1. In the total, 74.1% of patients were from urban area and 25.9% from rural area. 75% of patients had attended the IDH for anti-rabies vaccination (ARV) within 24 hours. Out of which, 34.9% patients had attended ARV clinic within 6 hours [Table 1].
Close contact with rabies patient
35 (9.0)
Other
8 (2.1)
Biting animals were predominantly dog (79.5%) followed by monkey (5.1%), cats (2.3%), other peri-domestic animals (3.6%) and wild animals (0.5%). 9.0% patients were of close contact with a rabid patient [Table 2].
Head, neck and face
21 (5.9)
Upper extremities (Hands, fingers, etc.)
64 (18.0)
Lower extremities (Foot, leg, thigh, etc.)
260 (73.3)
On the basis of WHO wound classification, 4.2% animal bites were placed in grade I, 88.2% in grade II and 7.6% in grade III. Regarding wound location majority of injuries (73.3%) were in the lower extremities including foot, legs, /thigh and buttock. Only 5.9% of patients had wound located on head, neck and face [Table 3].
Table 4: Immunization in animal bite patients (n = 380)
65.0% of patients received a complete rabies vaccine course (Essen intramuscular 5 dose schedule). All
Table 3: Type of animal bite (n = 355) Type of Bite (WHO category)
No. (%)
Grade I
15 (4.2)
Grade II
313 (88.2)
Grade III
27 (7.6)
Wound location
Others (Grade I)
10 (2.8)
Anti-rabies vaccination
No. (%)
Only 1st dose
28 (7.4)
Up to 2nd dose
12 (3.2)
Up to 3rd dose
24 (6.3)
Up to 4th dose
69 (18.2)
Up to 5th dose (complete vaccination)
247 (65.0)
Human rabies immune globulin Tetanus immunization
Journal of Global Infectious Diseases / Jan-Mar 2015 / Vol-7 / Issue-1
3 (11.1) 390 (100.0)
31
Sahu, et al.: Epidemiological characteristics of patients attending post-exposure prophylaxis at IDH
DISCUSSION
In the present study children and adult were commonly affected by animals bite. It is probably due to outdoor activity. Similar findings were observed in other studies.[6-9] The overall male/female ratio of animal bite victims among Asian countries was 1.6:1.[10] In a WHO survey conducted in India male and female ratio was 2.19:1.[11] In our study, the male/female ratio was slightly higher. It is important for the effectiveness of rabies PEP that treatment should be as early as possible after animal bite. In our study approximate two-third animal bite patients received rabies PEP within 24 hours. In this study main biting animal was dog followed by monkey, cat and other animals which confirm previous studies.[7,8] However, the proportion of injuries caused by monkeys in our survey was higher than in a national multicentre survey conducted in 2007.[11] This may be related to a recent increase in monkey population in the urban area, due to deforestation. About 7.6% of animal bite patients belonged to grade III bite. These types of bites require the use of both the vaccine and human rabies immunoglobulin. Completion of full course of vaccination was poor (65.0%) when it should be 100%. In a multi-centre study in India, completion of full course of vaccination was 42%. The use of life-saving human rabies immunoglobulin was very poor. It was due to the high cost of immune globulin. Similar findings were seen in another study.[11] CONCLUSION
Our study provides strong evidence that the problem of rabies exposure is widespread in our region, dog being the main culprit and lack of compliance due to ignorance among the patients as reflected by the failure to take the complete
32
course of vaccination. In order to increase compliance, awareness campaigns along with the use of electronic media highlighting the severity of disease and availability of highly effective vaccination should be emphasized upon. REFERENCES 1.
Prevention and control of rabies in South-East Asia Region. World Health Organization, Regional Office for South East Asia. New Delhi: SEA-Rabies 23; 2004. p.1-17. 2. Ichhpujani RL, Bhardwaj M, Chhabra Mala, Datta KK. Rabies in India. Country report, 4th International Symposium on Rabies Control in Asia. Vietnam: John Libbey Eurotext Paris 2001. p. 35. 3. PSMD Task Force Recommendation for Rabies Pre and Post exposure prophylaxis. Phil J Microbiol Infect Dis 1997;26:25-9. 4. ANON. Assessing the Burden of Rabies in India. WHO Sponsored National Mult-Icentric Rabies Survey 2003. Bangalore, Association for Prevention and Control of Rabies in India. 2004. http://rabies.org.in/rabiesjournal/ rabies-06/SpecialArticle1.htm. [Last accessed on 2014 Feb 07]. 5. WHO Technical Report Series. WHO Expert Consultation on Rabies. Geneva: World Health Organization; 2005. http://apps.who.int/iris/ bitstream/10665/85346/1/9789241209823_eng.pdf. [Last accessed on 2014 Feb 07]. 6. Sudarshan MK, Nagaraj S, Savitha B, Veena SG. An epidemiological study of rabies in Bangalore city. J Indian Med Assoc 1995:93:14-7. 7. Singh J, Jain DC, Bhatia R, Ichhpujani RL, Harit AK, Panda RC, et al. Epidemiological characteristics of rabies in Delhi and surrounding areas, 1998. Indian Pediatr 2001;38:1354-60. 8. Sudarshan MK, Mahendra BJ, Narayan DH. A community survey of dog bites, anti-rabies treatment, rabies and dog population management in Bangalore city. J Commun Dis 2001;33:245-51. 9. Agrawal N, Reddaiah VP. Knowledge, attitude and practice following dog bite: A community based epidemiological study. Health and Promotion. Perspective and issue 2002;26:154-61. 10. Dodet B, Goswami A, Gunasekera A, de Guzman F, Jamali S, Montalban C, et al. Rabies awareness in eight Asian countries. Vaccine 2008;26:6344-8. 11. Sudarshan MK, Madhusudana SN, Mahendra BJ, Rao NS, Ashwath Narayana DH, Abdul Rahman S, et al. Assessing the burden of human rabies in India: Results of a national multi-centre epidemiological survey. Int J Infect Dis 2007;11:29-35. How to cite this article: Sahu KK, Manar MK, Singh SK, Singh H. Epidemiological characteristics of patients attending for rabies postexposure prophylaxis at the infectious diseases hospital of Lucknow, India. J Global Infect Dis 2015;7:30-2. Source of Support: Nil. Conflict of Interest: None declared.
Journal of Global Infectious Diseases / Jan-Mar 2015 / Vol-7 / Issue-1
Copyright of Journal of Global Infectious Diseases is the property of Medknow Publications & Media Pvt. Ltd. and its content may not be copied or emailed to multiple sites or posted to a listserv without the copyright holder's express written permission. However, users may print, download, or email articles for individual use.
