Abstract

Research Question:
What is the profile of animal bite cases at ARC of MKCG Medical College, Berhampur, Orissa?

Objectives:

1. To study the epidemiological characteristics of animal bites (Including the monthly trend).
    

2. To know the attitude & practices regarding animal bites including First aid measures & reporting time to ARC.

Setting :
Anti Rabies Clinic of MKCG Medical College.

Participants:
4458 animal bite cases who attended the ARC to seek post exposure treatment.

Result:
Of the 4458 cases, 69.6% were males & 30.4% were females; 59.8% were from rural areas & 40.2% from urban. Majorities (46.4%) were in the age group of 15 - 45 yrs & children below 14 yrs of age accounted for 38.9%. Category III animal bite cases accounted for 95.6% & only a few (0.5%) were Category I who didn't require treatment. Lower limb was the most common site of bite but in case of children upper limb was the most common site. The monthly trend of animal bites showed a rise of incidence during winter & summer months and even the nature of biting animal i.e. unprovoked bite & abnormal behavior was also on rise during the same seasons. Nearly two third of the cases (73.8%) reported within 48 hrs of exposure & 7.5% reported after one week. Only 4.8% of cases practiced some form of first aid measures & majority (53%) followed some religious practices. Among the cases receiving ARV from Gp, majority had received the ARV over gluteal region & only 0.1 % had been administered RIG.

Key Words:
Animal bite; Dog bite; Monthly trend of animal bites; Attitude & Religious practices.  

Introduction

Rabies is a zoonotic disease, transmitted to human by animal bites mainly dogs. It is invariably fatal if proper treatment is not received after exposure. About 99% of all deaths occur in the developing nations. Out of the total 55,000 deaths reported annually in the Afro-Asian countries, 56% are from Asian nations. 20,000 deaths are reported annually only in India. Also the management of Post Exposure Prophylaxis after animal bite is costly, and in India the patient has to bear nearly half of the financial burden for this purpose.

Studies had also showed that there is a particular seasonal pattern in animal bite cases. These studies had also shown that younger age populations were usually exposed to animal bites. The present study was carried out with the objectives of knowing the profile of animal bite cases, the monthly trend of animal bites and attitude & practices adopted by the patients after exposure to animal bites.

Materials & Methods

The present study was conducted at the Anti Rabies Clinic (ARC) under the Community Medicine department of M.K.C.G. Medical College Hospital Berhampur (Orissa) over a period of one year from 151 April 2005 to 31st March 2006.

During the study period a total number of 4458 cases were reported at the ARC which was taken as study population. Cases reported with exposure to rat, bat or human bites were excluded from study population. Study variables included were age; sex; habitation of the patients; type of animal involved; profile of the involved animal like, stray I pet, provoked lunprovoked bite, abnormal behavior shown by the animal, whether that animal was killed; category of exposure; site of bite; time of reporting at ARC; treatment received prior to reporting at ARC etc.

The data collected were analyzed using statistical tools like percentage, proportions at the department of Community Medicine ofM.K.C.G. Medical College & Hospital, Berhampur.

Results

Table I : Age, Sex and Area wise Distribution  

Out of total 4458 cases 3103 (69.6%) were male and 2666 (59.8%) were from rural areas. Maximum number of cases i.e. 2069 (46.4%) were from the economically productive age group 15 to 45 yrs. Children from 0-14 yrs age group accounted for 38.9%. Children from rural areas accounted 42.7% of total rural population.

Table-II: Type of Animal Bites  

*   Excluded from Total.
**  Includes animals like Mongoose, Cow, Pig, Buffalo, Bear, Lamb, Hyena etc.

9 Clinical rabies cases had been diagnosed during the study period.

Dog was the most common (84.5%) animal associated with overall bite cases. Out of 3764 dog bite cases 82.6% were stray & 17.4% were pet.1393 (43.4%) stray dog bites were provoked & rest 1716 (56.6%) were unprovoked bites. 380 (12.5%) stray dogs were showing either abnormal behavior or were killed I died. Other animals involved were cat (3.4%), jackal (3.6%) and monkey (7.9%).

Table -III: Categorization of Cases  

Majority of cases (95.6%) were having category III exposure (According to WHO categorization). Only 0.5% were Category I exposure which did not require any treatment.

Table - IV : Category of Bite in different Age Group  

In all age groups category III exposure was highest Category I exposure was highest (0.9%) in 46 - 60 yrs. of age followed by <5 yrs. and >60 yrs of age. Similarly Category II exposure was highest in 15 - 45 yrs. age followed by >60 yrs. of age.

Table -V : Site of Bite in different Age Groups  

Lower limb was the most common site (66.7%) exposed to animal bite followed by upper limb (24.7%). But in younger age group «5 yrs. of age), exposure of upper limb (46.7%) was more. Head & face was common site in children < 14 years of age & above 45 yrs. of age.

Table - VI: Site of animal bites in different categories.

Maximum number (15) of Category I exposures were seen on Lower Limb, while most of the Category II bites were found to be present over the trunk {41 (19.1 %)}. All the injuries (100.0%) inflicted over Head & Face were found to be of Category III exposure. Animal bite cases were higher during month of December (9.9%), January (11.7%), February (9.2%),

Table - VII : Month Wise Distribution of Cases

Fig-I: Month wise Distribution of Abnormal dog bite cases

Fig-II: Month wise Distribution animal bite cases

March (9.6%) & April (9.8%). Similarly exposures to abnormal dog bite cases were higher during the same period.

Table-VIII: Time of Reporting to ARC

After exposure, majority cases (61.2%) reported to tt,e ARC between 24 hrs. to 48 hrs. Only a few (12.6 patients came to ARC within 24 hrs. after exposure. Still some cases (2.4%) reported to the ARC after -; days of exposure that too after getting some traditiona treatment and only a few cases (0.5%) reported after one month of exposure.

Tab-X: Treatment Received prior to Reporting at ARC  

1.2% of cases had received ARV prior to attending ARC & among them one third had took the vaccine over gluteal area. Only 0.1 % of cases reported at ARC after taking both anti rabies vaccine & rabies immunoglobulin before reporting at the ARC. 39.5% of cases had applied traditional substances like juice of bitter gourd leaf or calotropis leaf, turmeric or chilly powder, oil over the bite area while 11.6% cases had tied the affected limb thinking that it will prevent dissemination of the poison. 2.8% patients had cut the wound & surrounding area to remove the poison. 30.3% cases had adopted traditional methods like ~har Phoonk' for treating the animal bites cases before reporting at ARC. Only 0.7% of cases had washed the injury site with soap & water while 3.6% cases had applied antiseptic ointment. 56.4% cases had received T.T. injection before coming to ARC.

Discussion

Animal bites (Mainly dog bites, 95%) still pose a public health problem in the country. Our study showed that more than two third (84.5%) were victims of dog bites. In a Study by Renu Bedi & et al in Ajmer found that 90.7% of animal bites were due to dogs2.

In the present study majority (59.8%) were from rural areas and 69.6% were males. From both the urban & rural areas males were more victims of dog bites because of their mobile nature than females. This finding corroborates with other studies by Jairaj Singh Hanspal at Jamnagar3 & Sudarshan et al4 in Bangalore. Among the dogs as biting animal, majorities (82.6%) were stray dogs & 17.4% werepet dogs. Among the stray dogs more than half (56.6%) had biting without provocation and interestingly 12.5% stray dogs showed abnormal behaviour or were killed. This finding was similar to other studies by Renu Bedi & et al.

In our study nearly half (46.5%) were in the age group of 15 - 45 years and children < 15 years were 38.9%. In other studies by Renu Bedi & et aF and Jairaj Singh Hanspal (3) have found that more than half of the animal bite victims were in children < 10 years of age. As with the finding of the other studies, Category III animal bite cases accounted for 95% of cases.

The most common site of bite was lower limb (66.7%) as it is the most easily approachable part of body for an animal. Upper extremity was the next common site of bite. Sampath5, Shetty et a16, Agarwal et aJ7, Renu Bedi et aF & Jairaj Singh Hanspal et al3 also found lower extremities as the most common site of bite in their studies.

In our study there is a seasonal variation of animal bite cases being highest during the winter i.e. November, December & January and again during the summer there is rise of animal bite cases during March, April & May. This finding is similar with the study by Jairaj Singh Hanspal et al3 who reported higher incidence during winter and similar with the study by Agarwal et aJ7 who found higher incidence in summer. This may be due to the fact that during winter the female dogs are lactating and in fear of hurting their puppies they might be biting the humans.

The abnormal behaviour of biting dogs for which they are even killed is most commonly seen from December to May.

In our study, the reporting time to ARC varied from within 24 hrs. to one month and majority (61.2%) reported after one day & within two days. Only a few reported within 24 hrs. and still a few nearly 8% reported after a week.

The reporting varied with educational status of the patients. More number of patients who reported within 24 hrs. were educated and those who reported after 1 week were not educated. Those who reported late, they had some type of traditional treatment by the quacks like Jhar phoonk, cutting the affected limb with blade, applying a stone over the affected site of bite. In a study by U.S. Singh et al (8) in the rural community of Gujarat, only 36.4% people would like to visit the doctor & 19.2% did some religious customs and 13.3% did nothing.

In our study only 4.8% did some type of first aid measures like washing with soap/water & applying antiseptics. More than two third i.e. 39.5% applied some sort of traditional substances such as bitter gourd leaf or turmeric powder. A few (14.4%) of them either tied the limb/ finger with a thread or applied a stone over bite site and more than half (30.3%) did some Jhar phoonk. A similar type of observation was found in a study by U.S. Singh et al8 in the rural community of Gujarat.

Interestingly a very few patients took ARV (CCV) before coming to the ARC and those who took ARV, out of them majority being administered ARV over the gluteal region. In a study by S. Bhalla et al9 in Jamnagar city more than half (56%) of General Practitioners opted the route of administration of CCV as gluteal and a similar finding was observed previously in Berhampur in astudy by RM Panda et al.

In our study more than half of the patients were administered Tetanus Toxoid injection before reporting the ARC and only 1 % of patients took ARV & RIG. This shows a very low knowledge on use of RIG by the GPs which is similar to the finding of U.S. Singh et al8but on contrary in another study by Jasleen et apl in Amritsar found that 38.3% were aware of use of RIG in Category III animal bite cases.

References

1. WHO Expert Consultation on Rabies, First Report. Geneva World Health Organization, 2005, WHO Technical Report Series, No. 931.
    

2. Renu Bedi & et ai, Profile of animal bite cases attending Anti Rabies Clinic of JLN Medical College & Hospital, Ajmer; APCRI Journal, Vol-VIlI, Issue I, July 2006: 28-30.
    

3. Jairaj Singh Hanspal & et ai, A review of attendance trend of animal bite cases in the Anti Rabies Clinic of GGS Hospital, Jamnagar (Gujarat); APCRJJournal, Vol-VIII, Issue II, January 2007: 16-18.
    

4. Sudarshan MK, Mahendra BJ, Narayan DH -A Community survey of dog bites, anti - rabies treatment, rabies & dog population management in Bangalore city - J Commun Dis, 2001 Dec; 33 (4): 245-51.
    

5. Sampath G. Post Exposure treatment - Patients & practices. APCRI Journal 2004 - 2005; 1&2 (7): 30 - 33.
    

6. Shetty PA, Chaturvedi S, Singh Z, Profile of animal bite cases in Pune. J Commun Dis, 2005; 37 (1): 66 - 72.
    

7. Agarwal N, Reddajah VP Epidemiology of dog bites: A community based study in India. Trap Dod. 2004; 34 (2): 76 - 8.
    

8. US Singh, SK Choudhary. Knowledge, Attitude, Behavior and Practice Study on Dog Bites and Its Management in The context of Prevention of Rabies in Rural Community of Gujarat; Indian Journal of Community Medicine, Vol-30, No.3, July - September, 2005: 81 - 83.
    

9. S. Bhalla, JP Meheta, A Singh. Knowledge and Practices among General Practitioners of Jamnagar city regarding Animal Bite. IJCM, Vol-30, No.3, July - September, 2005: 94 - 96.
    

10. Satapathy OM, Pradhan S, Panda RM, Tripathy RM, Das BC; Realities and Perceptions concerning Rabies prophylaxis among General Practitioners in Berhampur, Orissa; Indian Journal of Internal Medicine, Vol II, No.3, 2001; p 21- 22.
     

11. Jasleen, Padda AS et ai, A study of the assessment of training needs of the doctors, working in various Health facilities in Amritsar Disst., Regarding management of animal bite cases. (From souvenir APCRICON 2001 - 3m National Conference on Rabies)

1. Lecturer, 2. Assistant Professor, 3. Associate Professor, 4. PG Student.
Department of Community Medicine, MKCG Medical College, Berhampur.