Post Exposure Treatment - Patients and Practices

Dr. G. Sampath
Medical Officer, Rabies Clinic, Institute of Preventive Medicine, HYDERABAD

Introduction

Rabies is an important public health problem in India. The maximum number of deaths due to Human Rabies are reported from our country. The WHO – APCRI National Survey1 has revealed that annually about (a) 20,000 people are dying of Rabies and (b) 18 million people are being exposed to animal bites in India.

Out of these 18 million people less than 50% are seeking post-exposure treatment from government and private clinics.

Various attitudes, practices and prejudices of the lay people hamper the administration of timely and proper post-exposure treatment to the animal bite victims.

An animal bite clinic (Rabies Clinic) is functioning at ‘The Institute of Preventive Medicine’, Hyderabad for the past many decades. On an average 130 to 150 new patients attend the clinic everyday for post-exposure treatment. Patients from rural areas and neighbouring states also seek treatment at the clinic.

Study and Results

A small study was undertaken with the help of an independent and unbiased person to collect details about the patient profile.

The following data was collected :-

1) Age Group, 2) Sex, 3) Urban / Rural, 4) Type of biting animal, 5) Status of the Animal, 6) Site of Bite, 7) Time elapsed between animal bite and patient attending the clinic and 8) Local wound treatment received prior to attending the clinic.

A total of 1000 patients attending the Rabies Clinic at I.P.M. were selected randomly during July and August 2005 and data was collected by individually interviewing the patients and the results are given below.

Table-1
Age/Sex of Patients

  Biting Animal Dog Monkey Cat
  Sex of patient M F M F M F
  Age group of patients

  0 - 5 years

  6 - 10 years

  11 - 20 yers

  21 - 30 years

  31 - 40 years

  41 - 50 years

  51 - 60 years

  > 60 years

  

63

95

187

146

99

68

32

13

  

28

36

29

42

40

37

12

5

  

3

3

8

4

3

3

1

0

  

2

3

1

5

0

3

0

0

  

0

3

1

5

2

0

1

0

  

2

1

2

4

3

4

0

1

Total

 703 229 25 14 12 17

 

  1. Age and Sex
    Maximum number of patients were children and young adults. 74% of the patients were males and 26% female.
     

  2. Urban and Rural
    72 % of the patients were from urban areas and 28 % were from rural areas.
     

  3. Biting Animals (Fig.1)
    Majority of the patients were exposed to dogs bites (93.2%). Next in order of frequency were monkey bites (3.9%) and cat bites (2.9%). Bites due to other animals (wild and domestic) were rare and not included in the study.

Fig. 1

EXPOSURES
Animal Number
Dog 932
Cat 29
Monkey 39
Total 1000
 

 

 

 

 Fig. 2
 
STATUS OF THE DOGS AND CATS CAUSING THE EXPOSURES
Dogs and Cats Alive Un obs Dead Killed Caught Abandoned Total
Pet 366 0 6 15 0 4 391
Stray 340 165 7 57 12 0 570
Total 706 165 13 72 12 4 961

 

  1. Status of the Animal (Fig. 2)

    In case of exposures to dogs and cats, the status of the animal was recorded.

Fig. 3(a)
 

Exposures caused by Dogs in different sites
Site of Bite (Dogs) Number
   Head of Neck

   Upper Limbs

   Back and Shoulder

   Lower Limbs

   Gluteal Region

   Groin

25

198

45

625

64

4
Total 961
  Fig. 3(b)
 

Exposures caused by Cats and Monkeys in different sites
Cats and Monkeys Number of Patients with bites
   Head of Neck

   Upper Limbs

   Back and Shoulder

   Lower Limbs

   Gluteal Region

   Groin

 1

26

12

33

1

1
Total 74

  1. Site of Bites (Fig. 3(a) and 3(b))
    The most common site of bite was the lower limbs ( 65.8% ).
    2.6 % of the bites were in the head and neck region.
     

  2. Time Elapsed between Bite and Visit to Clinic (Table 2)
    Majority of the patients reported to the clinic within 24 hours of exposure. As the Rabies clinic functions between 8 AM to 2 PM, patients bitten in the evening report on the next day. Some patients reported within few hours of being bitten by the animal.

Table-2
Time Interval between Exposure and Visit to Rabies Clinic

Time Interval Urban Patients Rural Patients
   <1 hr

   2 hrs

   4 hrs

   12 hrs

   24 hrs

   2 days

   3 days

   4 to 7 days

   8 to 15 days

   >15 days

 19

43

36

79

302

86

59

72

19

5

 0

4

9

14

106

34

26

57

16

14
Total 720 280
 
Fig. 4

 

Management of the wound after the Exposure
Wound Management Number of Patients
   Soap water

   Water only

   Antiseptics only

   Household medicaments

   No local Wound Treatment

472

88

57

52

331
Total 1000

  1. Local Wound Treatment ( Fig. 4 )
    Majority (62%) of the patients applied first aid measures before reporting to the clinic. Similar observation was previously reported2. 5% of the patients applied local irritants/medicaments only (like turmeric, chilli powder, seeds). Some patients applied turmeric first and later washed the wounds with soap/ water. 33% of the patients did not take any local wound treatment.

Rabies Immunoglobulins (RIGs) Administration

WHO recommends administration of RIGs to all patients with category III exposures. Majority (>90%) of the patients attending the Rabies Clinic come with category III exposures. As in most parts of our country and other Asian countries, very few patients with category III exposure receive RIGs.

This is due to various factors like

  1. Lack of awareness about the existence and importance of RIGs.

  2. Inability to afford RIGs.

  3. Reluctance to purchase RIGs especially when the patient attends a government clinic, where vaccines are administered free of cost.

  4. Lack of awareness about and reluctance to use RIGs by majority of private practitioners whom the patients consult prior to attending the Rabies Clinic.

Presently RIGs are not given free of cost to the patients at our centre. Moreover it becomes a herculean task to administer ERIGs to more than 100 patients every day if all category III patients have to be given RIGs as per WHO recommendations. In this scenario, it is important to prioritise the administration of RIGs. RIG administration is compulsorily advocated in the following situations at our centre:

  1. Bites due to dogs likely to be rabid -
    a) Where the dog bites many people and animals.
    b) Dog is killed by the people.

  2. Bites due to stray dogs which are not available for observation.

  3. Bites on head, face, neck and fingers.

  4. Wounds (lacerated / bleeding) where suturing is unavoidable.

  5. Bites where wounds have already been sutured elsewhere.

  6. Bites due to wild animals.

In spite of appropriate advice given to the patients many refuse to take RIGs. In the present study of 1000 patients, out of 144 patients advised to compulsorily take RIGs, only 53 consented to take RIGs.

Table-3
Patients Receiving Rabies Immunoglobulines

Status of Biting Animal Number of Patients
   Dog Killed

   Dog Died

   Unobservable Stray Dog

   Observable Stray Dog

   Monkey

   Pet Dog

54

6

19

23

4

4
Total 110
 

Table-4
Patients Receiving Rabies Immunoglobulines

Time Interval between Day of Starting TCV & Day on which RIG was taken

 Number of Patients
   0 day
   1 day
   2 days
   3 days
   4 days
   5 days
   6 days
   7 days

22
21
8
21
8
8
7
15
Total 110

 

Data was collected from another group of 110 patients who were administered RIGs at our centre. Out of these only one received HRIG and the remaining ERIG. The status of the animal to which the patients were exposed is given in Table No. 3. The time interval between starting the first dose of the vaccine (TCV) and the day on which RIGs were administrated is given in Table No. 4. The patients have to purchase RIGs at their own expense.They also take their own time to understand the importance of taking RIGs.Hence they do not always receive RIGs on day 0 of exposure/vaccination.

Vaccine Administration

Since February 2005 patients attending our centre are being administered TCVs. The number of patients attending the clinic has increased as TCVs are being given free of cost.

Maximum importance is given by both patients and physicians to Vaccine Administration, when compared to local wound treatment and RIG administration.

Conclusion :

Proper and timely treatment of animal bites victims is important in our country due to

  1. The burden of disease being high

  2. No National Rabies Control Programme existing in India.

  3. Huge reservoir of infection i.e. stray dog population with no effective dog population control programmes.

  4. Lack of awareness among the public regarding proper and timely treatment (including local wound treatment, RIGs and full course of Vaccine administration).

  5. Private practitioners adopting their own ways of treating animal bite victims.

An effective way of giving the best possible post exposure treatment is by educating the patients and the public. Animal bite victims are treated by a variety of doctors (G.Ps. and Specialists ) in our country and awareness has to be brought among some of these doctors also, about appropriate measures to be taken for prevention of Rabies.

As far as local wound treatment is concerned, the proportion of patients who have already taken some useful local wound treatment has increased from 25% ten years back to about 65% now. This has been possible due to educative measures to bring awareness among the public. However more efforts have to be made to see that more patients adopt the cheap and effective prophylactic measure of washing the wounds with soap and water immediately after exposure.

As far as RIG administration is concerned, a concerted effort is needed to educate both the patients and the primary care physicians so that RIGs are administered as early as possible after exposure, at least in high risk cases.

Acknowledgements :

The author sincerely thanks Dr. Amol Deshpande, B.D.S., for interviewing the patients, collecting the data and also for preparing the Tables and Figures.

References :

  1. Assessing the burden of rabies in India WHO sponsored National Multi-Centric Rabies Survey, August 2003, Bangalore APCRI.

  2. Vaccine Asian, Hong Kong, Issue 8, 2005

  3. WHO Expert consultation on Rabies First report 2004, WHO Geneva. (WHO TRS 931)