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A Multicentric Community Survey on Animal Exposures among Humans in India


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OrigBackground: Rabies is a 100% fatal disease. There are inadequate data on animal exposures and rabies postexposure prophylaxis (PEP) from community‑based field surveys in India. Objectives: The main objective of the study is to estimate the incidence of animal exposures (bite, scratch, or lick) in the study population and to describe the rabies PEP among the cases. Methods: A descriptive survey was conducted in seven states of India between July and November, 2017. In each state, multistage sampling methodology was followed for selection of district, taluka/ tehsil, block, and clusters within the block. The primary sampling unit was a household (HH). A case was a patient with animal exposure (bite, scratch, or lick) in the last 1 year from the date of survey. The animal exposure was categorized based on the WHO guidelines (Category‑I, Category‑II, and Category‑III). The patients with the history of multiple animal exposures any time during the survey period was considered as a single case. Results: A total of 1012 HHs were surveyed covering a population of 4294. 3016 (70.2%) participants were from rural settings and 1278 (29.8%) were living in urban settings. 2181 (50.8%) participants were male and 2113 (49.2%) were female. The annual incidence of animal exposure was 1.26% (confidence interval [CI]: 0.93%–1.59%). The annual incidence in urban setting was 1.33% (0.70 - 1.96) and rural settings were 1.23% (CI: 0.84 - 1.62). Majority (68.5%) of the cases were from rural settings, 61.2% of the cases were in the age group of 15–60 years. Among the 43 cases who had received PEP, 21 had Category‑II exposures, of whom 66.7% had completed vaccination with either five doses intramuscular or four doses intradermal route. Similarly, 22 had Category‑III exposures and only 4 (18.2%) cases had received rabies immunoglobulin and completed rabies vaccination. Six (11.1%) cases did not receive PEP. There was no report of human rabies case. Conclusion: The incidence of animal exposure was 1.26%. Rabies PEP in the cases was not satisfactoryinal Article
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© 2019 Indian Journal of Public Health | Published by Wolters Kluwer - Medknow S9
Original Article
Rabies is an acute progressive encephalitis caused by RNA
viruses in the Genus Lyssavirus. The major global reservoir is
the dog. Rabies has a case fatality ratio approaching 100%, the
highest of any conventional infectious disease.[1] An estimated
20,000 human rabies death and 17.4 million animal bites were
reported from India in 2004.[2]
Surveillance for human and animal rabies has been
inadequate throughout the world, which has contributed to
minimal awareness, public health prioritization, and resource
allocation for rabies prevention and control.[3-7] The WHO
states that information on the frequency of animal bite cases
associated with dog/animal bite injuries are needed for
more effective risk modeling assessments and inform about
strategies for rabies prevention and control.[6] Domestic dogs
are the principal reservoir and vector of rabies. There has
been no systematic evaluation of animal bites in the entire
A lot of changes have taken place since the Indian Rabies
Survey of 2004, such as availability of modern rabies
postexposure prophylaxis (PEP), introduction of intradermal
rabies vaccination, withdrawal of nerve tissue vaccines, Animal
Birth Control Programme, and implementation of National
Rabies Control Programme. More and more people have
access to modern rabies PEP (rabies immunoglobulin [RIG]
and rabies vaccination).
Background: Rabies is a 100% fatal disease. There are inadequate data on animal exposures and rabies postexposure prophylaxis (PEP) from
community-based eld surveys in India. Objectives: The main objective of the study is to estimate the incidence of animal exposures (bite,
scratch, or lick) in the study population and to describe the rabies PEP among the cases. Methods: A descriptive survey was conducted in seven
states of India between July and November, 2017. In each state, multistage sampling methodology was followed for selection of district, taluka/
tehsil, block, and clusters within the block. The primary sampling unit was a household (HH). A case was a patient with animal exposure (bite,
scratch, or lick) in the last 1 year from the date of survey. The animal exposure was categorized based on the WHO guidelines (Category-I,
Category-II, and Category-III). The patients with the history of multiple animal exposures any time during the survey period was considered as
a single case. Results: A total of 1012 HHs were surveyed covering a population of 4294. 3016 (70.2%) participants were from rural settings
and 1278 (29.8%) were living in urban settings. 2181 (50.8%) participants were male and 2113 (49.2%) were female. The annual incidence
of animal exposure was 1.26% (condence interval [CI]: 0.93%–1.59%). The annual incidence in urban setting was 1.33% (0.70 - 1.96) and
rural settings were 1.23% (CI: 0.84 - 1.62). Majority (68.5%) of the cases were from rural settings, 61.2% of the cases were in the age group
of 15–60 years. Among the 43 cases who had received PEP, 21 had Category-II exposures, of whom 66.7% had completed vaccination with
either ve doses intramuscular or four doses intradermal route. Similarly, 22 had Category-III exposures and only 4 (18.2%) cases had received
rabies immunoglobulin and completed rabies vaccination. Six (11.1%) cases did not receive PEP. There was no report of human rabies case.
Conclusion: The incidence of animal exposure was 1.26%. Rabies PEP in the cases was not satisfactory.
Key words: Animal exposure, human rabies, India, postexposure prophylaxis
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How to cite this article: Ramesh Masthi NR, Pradeep BS, Bilagumba G.
A multicentric community survey on animal exposures among humans in
India. Indian J Public Health 2019;63:S9-14.
A Multicentric Community Survey on Animal Exposures among
Humans in India
Ramesh Masthi NR1, Pradeep BS2, Gangaboraiah Bilagumba3
1Professor and 3Former Professor, Department of Community Medicine, Kempegowda Institute of Medical Sciences,
2Additional Professor, Department of Epidemiology, Centre for Public Health, NIMHANS, Bengaluru, Karnataka, India
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Masthi, et al.: A multicentric community survey on animal exposures
Indian Journal of Public Health ¦ Volume 63 ¦ Issue Supplement 1 ¦ September 2019
By evaluating the health-seeking practices of persons exposed
to dog/animal bites, we hope to discover possible weaknesses
in rabies PEP in local communities. The availability of medical
care personnel, facilities, and appropriate medicines for PEP
administration can also be known. This data will be used to
develop effective risk communication materials.
In this background, an estimation on the dog/animal bite
injuries in selected states of India was done with the objectives,
to estimate the incidence of animal exposure (Bite, scratch or
lick) in the study population along with coverage of rabies
PEP among them.
MateRIals and Methods
A descriptive epidemiological study was conducted across
seven representative states (Himachal Pradesh, Bihar, West
Bengal, Manipur, Kerala, Madhya Pradesh, and Gujarat)
in India between July and November, 2017. In each state,
multistage sampling methodology was followed for selection
of district, taluka/tehsil, block, and clusters within the block.
The primary sampling unit was a household (HH). The Census
of India, 2011 database was used as sampling frame for clusters
selection and clusters were dened as villages for rural areas
and wards for urban areas.[8]
Sample size calculation
The incidence of animal/dog bites was considered to be around
0.9%.[9] Precision taken was 0.4%.[6,9] Design effect considered
for the study was 2. The nal sample size was 4282 persons.
Assuming a nonresponse rate of about 15%, net sample size
calculated was 4924 persons. The number of individuals in
each state = 4924/7 states = 703 persons/state. The number of
HHs to be surveyed in each state (703/5) = 141 HH (average
of 5persons per HH) and number of HHs to be surveyed in
each cluster = 141 HH/6 cluster = 24 HH per cluster.
Random numbers were generated using the “Randbetween”
function of Microsoft Excel software for selecting one district
within the state, one taluka/tehsil, or block within the selected
district and within each block, a minimum of 6 clusters were
selected randomly. The number of rural and urban clusters
selected was based on the rural–urban demography of that
particular state (probability proportional to size sampling).
Selection of households for community survey
The WHO-EPI cluster evaluation survey methodology was
followed.[10] The teams surveyed every adjacent HH in a
counting series along mapped routes until 24 HHs per cluster
were covered. The head of HH was the preferred respondent,
but any adult responsible respondent living in the HH, female
or male, was also considered as an alternative. Inclusion criteria
consisted of: (i) respondent should have been a resident of
the HH for a minimum of 6 months in the last 1 year and
(ii) respondents who gave informed consent for participation.
Data collection
Data were collected by a community survey team from the
respective states. The faculty of the Department of Community
Medicine of a Medical College situated in the selected district
or the nearest Medical College in the neighboring district
within the state formed the community survey team. The
surveyors in selected states were trained for 1 day on the survey
methodology. Surveyors conducting eldwork used a handheld
Table 1: Sociodemographic characteristics of the cases (n=4294)
Characteristics Details Urban (n=1278),
n (%)
Rural (n=3016),
n (%)
Total (n=4294),
n (%)
Total number of cases 17 (1.33) 37 (1.23) 54 (1.26)
Age (years) ≤14 (children) 4/256 (1.56) 13/704 (1.84) 17/960 (1.77)
15-60 13/919 (1.41) 20/2066 (0.96) 33/2985 (1.10)
>60 -/103 4/246 (1.62) 4/349 (1.14)
Gender Male 9/645 (1.39) 28/1537 (1.82) 37/2182 (1.69)
Female 8/633 (1.26) 9/1479 (0.61) 17/2112 (0.80)
Religion Hindu 10/780 (1.28) 29/2266 (1.28) 39/3046 (1.28)
Christian 7/307 (2.28) 5/524 (0.95) 12/831 (1.44)
Muslim -/191 3/226 (1.33) 3/417 (0.72)
Education Illiterate 1/176 (0.57) 9/828 (1.09) 10/1004 (0.99)
Primary/middle/high school/preuniversity college 13/831 (1.56) 25/1891 (1.32) 38/2722 (1.39)
Degree/diploma/postgraduation 3/271 (1.11) 3/297 (1.01) 6/568 (1.06)
Occupation Cultivator/laborer (agricultural/nonagricultural) 4/62 (6.45) 10/674 (1.48) 14/736 (1.90)
Salaried employment/business 5/386 (1.29) 6/483 (1.24) 11/869 (1.27)
Housework 3/356 (0.84) 5/835 (0.59) 8/1191 (0.67)
Unemployed -/98 2/126 (1.59) 2/224 (0.89)
Student 5/376 (1.33) 14/898 (1.56) 19/1274 (1.49)
Marital Status Currently married 10/712 (1.40) 21/1666 (1.26) 31/2378 (1.30)
Never married 6/496 (1.21) 16/1211 (1.32) 22/1707 (1.29)
Divorced/separated/widowed 1/70 (1.43) -/139 1/209 (0.48)
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Indian Journal of Public Health ¦ Volume 63 ¦ Issue Supplement 1 ¦ September 2019 S11
personal digital assistance/device (PDA) that included a GPS
receiver or a smartphone (Android) and software application
specially developed by WHO India ofce, New Delhi, for
the survey.
The study tool consisted of details on sociodemographic
characteristics of populations surveyed. A case was a subject
with animal exposure (bite, scratch, or lick) in the last 1 year
from the date of survey. The animal exposure was categorized
based on the WHO guidelines (Category-I, Category-II,
and Category-III). The patients with the history of multiple
animal exposures any time during the survey period was
considered as a single case. Rabies PEP consisted of wound
wash, administration of RIG, and rabies vaccination. Suspect,
probable, and conrmed rabid animal bites were classied as
per the WHO guidelines.[11] Bites from dogs, cat, cow, and
monkeys were considered as domestic animal bites; bites
from fox and jackal were considered as wild animal bites.
Information was collected from the respondents of the surveyed
population on any deaths due to rabies that they may have
come across as an additional information and was not part of
the main study. A case presenting with one or more than one
of the following symptoms: hydrophobia, aerophobia, and
photophobia during the study period of 1 year was dened as
human rabies case for the purpose of the survey.
Statistical analysis
Data were entered into the PDA at the place of data collection
using the digital platform developed for the study. The excel
sheet was imported from the digital platform and analyzed.
Appropriate descriptive statistics, such as frequencies and
proportions were generated.
Ethical aspects
Ethics committee reference number and date of approval was
KIMS/IEC/S15-2016. Informed signed consent (or thumb
impression from the illiterates with witness) was obtained from
all respondents. Condentiality of the data was maintained.
A total of 1012 HHs were surveyed covering a population
of 4294. 3016 (70.2%) persons were from rural settings and
1278 (29.8%) were living in urban settings. The median age
with interquartile range was 30 (16,45) years. 2181 (50.8%)
persons were male and 2113 (49.2%) were female.
Animal exposure incidence
The annual incidence of animal exposure was 1.26%
(condence interval [CI]: 0.93%–1.59%), i.e., 54 cases out
of 4294 population surveyed. The annual incidence in urban
and rural settings were 1.33% (CI: 0.70 - 1.96), i.e., 17 cases
out of 1278 and 1.23% (CI: 0.84 - 1.62), i.e., 37 cases out of
3016, respectively [Table 1].
Sociodemographic characteristic of the cases
Among the 54 cases, majority (37 [68.5%]) of the cases were
from rural settings. 61.2% cases were in the age group of
15–60 years. The youngest case was 3 years old and oldest case
was 82 years old. The median age with interquartile range of the
cases was 35 (12, 48) years. 72.2% cases were Hindu by religion,
70.4% cases were school and preuniversity educated, 25.9%
cases were laborer (agricultural/nonagricultural) by occupation,
and 19 (35.2%) cases were students [Table 1]. The median income
with interquartile range was Rs. 78,000 (1217$) (Rs. 32,250–Rs.
240,000).The minimum and maximum income of the cases was
Rs. 5000 (78$) and Rs. 500,000 (7808$) per annum.
Cases exposure details
Out of the 54 cases, 59.3% exposures had occurred outside
home. Majority (44 [81.5%]) of the cases had single wound.
The median number of bite wounds with interquartile range
was 1 (1, 3). One case had a maximum of >10 bite wounds.
In 61.1% cases, site of bite was the leg and feet, followed by
the arms, forearms, and hand. Majority (57.4%) of the cases
had abrasion, 29 (53.7%) cases had Category-II bites and
25 (46.3%) cases had Category-III bites [Table 2].
Biting animal and vaccination
Dog (74.1%) was the main biting animal followed by cats
12 (22.3%), monkey (1.8%), and Ox (1.8%). Among dogs,
55.0% exposures were by pet dogs, 47.5% dogs were
unvaccinated, and 65.0% dogs were available for 10 days
observation. Five (45.4%) dogs in urban and 9 (31.0%) dogs
in rural areas were classied as suspected rabid animals.[12]
Thirty-one (57.4%) cases mentioned that the animal had not
bitten anyone else besides them, whereas 10 (25.0%) of the
cases had mentioned that in addition to them, others were also
bitten by the same animal and the remaining did not know.
Postexposure prophylaxis of cases
Among 54 cases, 19 (35.2%) had washed the wounds with
water and soap and 8 (14.8%) had applied irritants [Table 3].
Forty-eight (88.9%) cases had sought PEP at the health
centre. Six ( 11.1%) cases had not taken PEP and the common
reasons attributed were 3(50.0%) were not aware/do not
know and 2(33.3%) gave reasons such as no need to go to
hospital. Among the cases who had sought PEP at the health
facility, 5 (10.4%) were not advised PEP by the health-care
provider and for calculation of PEP coverage, n = 43 was
Among the 43 (79.6%) cases, 21 had Category-II exposures,
of whom 14 (66.7%) had completed with either ve doses
intramuscular or four doses intradermal vaccination. Majority
(40 [93.0%]) had taken vaccine in the deltoid region [Table 3].
The median duration (interquartile range) in days between bite
and rabies vaccination was 2 (2, 3).
Similarly, 22 cases had Category-III exposures, only 4 (18.2%)
had received both RIG and completed the rabies vaccination.
Three (75.0%) had received equine RIG and one (25.0%) had
received human RIG.
Health‑care accessibility
About 53.5% cases had to travel 0–5 km to seek rabies PEP
and 12.9% had to travel >15 km. The median distance traveled
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was 5 (2, 12) km, urban area was 1 (1, 2) km, and rural area
was 7 (3, 15) km. 45.4% cases, mode of transport was by
bike/car/jeep/auto-rickshaw, etc., 35.8% traveled by bus,
18.4% mentioned by walk, and least 0.3% said ambulance.
There was no mention of having come across a human rabies
case by the surveyed respondents during the study period of
1 year.
A cross-sectional survey on the incidence of animal exposure
was conducted in seven states of India in 2017. The animal
exposures were categorized based on the WHO guidelines.
The annual incidence of animal exposure was 1.26%
(CI: 0.93%–1.59%). Majority of the cases were from rural
settings, 15–60 years of age, 14 (66.7%) cases had completed
Table 2: Details of exposure of the bite victims
Characteristics Details Urban (n=17), n (%) Rural (n=37), n (%) Total (n=54), n (%)
Place of bite Home 9 (52.9) 13 (35.1) 22 (40.7)
Outside home 8 (47.1) 24 (64.9) 32 (59.3)
Nature of bite Provoked bite 10 (58.8) 17 (45.9) 27 (50.0)
Unprovoked bite 7 (41.2) 20 (54.1) 27 (50.0)
Number of bite wounds One 11 (64.7) 33 (89.2) 44 (81.5)
Two 5 (29.4) 2 (5.4) 7 (13.0)
More than two 1 (5.9) 2 (5.4) 3 (5.5)
Site of bite* Leg/feet 9 (52.9) 24 (64.9) 33 (61.1)
Arm/forearm/hand 8 (47.1) 12 (32.4) 20 (37.0)
Head/face - 1 (2.7) 1 (1.8)
Buttock - 1 (2.7) 1 (1.8)
Type of wound* Abrasion 11 (64.7) 20 (54.0) 31 (57.4)
Puncture wound 4 (23.5) 12 (32.4) 16 (29.6)
Laceration 2 (11.8) 7 (18.9) 9 (16.7)
Category of bites Category-II 11 (64.7) 18 (48.6) 29 (53.7)
Category-III 6 (35.3) 19 (51.4) 25 (46.3)
*Multiple response possible
Table 3: Postexposure prophylaxis of the cases
Characteristic Details Urban (n=17), n (%) Rural (n=37), n (%) Total (n=54), n (%)
Wound care* Water and soap 9 (52.9) 10 (27) 19 (35.2)
Water 3 (17.6) 5 (13.5) 8 (14.8)
Nothing 1 (5.9) 7 (18.9) 8 (14.8)
Applied irritants/consulted traditional healer 1 (5.9) 7 (18.9) 8 (14.8)
Sought PEP at health
Yes 15 (88.2) 33 (89.2) 48 (88.9)
No 2 (11.8) 4 (10.8) 6 (11.1)
Time gap for PEP
(n=48) (days)
<1 13/15 (86.6) 24/33 (72.8) 37 (77.1)
1-2 2/15 (13.4) 5/33 (15.1) 7 (14.6)
3+ - 4/33(12.1) 4 (8.3)
Rabies Vaccination (n=43) Yes 13 30 43
Site of vaccination Deltoid 13 (100.0) 27 (90.0) 40 (93.0)
Gluteal - 3 (10.0) 3 (7.0)
Number of doses 1 - 4 (13.3) 4 (9.3)
3 2 (15.4) 6 (20.0) 8 (18.6)
4 6 (46.1) 12 (40.0) 18 (41.9)
5 5 (38.5) 8 (26.7) 13 (30.2)
Health facility visited Government 9 (69.2) 26 (86.7) 35 (81.4)
Private 4 (30.8) 4 (13.3) 8 (18.6)
Category-III wounds (n=22) 6 16 22
Rabies immunoglobulin
Administered 1 (16.7) 3 (18.7) 4 (18.2)
ERIG 1 (100.0) 2 (66.7) 3 (75.0)
HRIG - 1 (33.3) 1 (25.0)
Site of administration
Into the wound 1 (100.0) 1 (33.3) 2 (50.0)
Deltoid - 2 (66.7) 2 (50.0)
*Multiple response possible and nonresponders, ERIG: Equine rabies immunoglobulin, HRIG: Human rabies immunoglobulin
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PEP in Category-II exposures and 4 (18.2%) had received RIG
and completed the rabies vaccination schedule in Category-III
Survey coverage
In the present study, 7 states (28 rural and 14 urban communities)
were covered compared to the Indian rabies survey 2004, where
18 states (21 urban and 63 rural communities) were covered.[12]
Hence, the comparison between the two studies is not ideal,
and the results cannot be generalized to the entire country.
Incidence of animal exposure
The annual incidence of animal exposure was lower in the
present study compared to 1.74% (CI: 1.63%–1.85%) observed
in the Indian Rabies Survey.[2] Studies from other urban and
rural settings had observed the incidence of animal exposure
varied from 1.6% to 2.6%.[12,13]
Profile of cases
The mean age of the cases in Bhutan was 21.2 years and Babol,
Iran, was 33.68 ± 17.23 similar to the present study.[14,15] The
incidence of animal exposure was nearly twice in children than
adults in 2004 study, 47.5% in multicentric study of 2008, 65%
in Haiti, and 45% in a region endemic to rabies in difference
to the observation of the present ndings.[15-18] From studies
across different settings, it was observed that majority of cases
were male (68%–82%) similar to the ndings of the present
study.[13-15,17] Females had the highest rate of cat bites.[5] In the
multicentric study of 2008, 63% had Category-III exposure,
when compared to the present study, where Category-II
exposures were more in number.[16]
Body part involved
In the studies done in Bhutan and Babol, 73% had exposure
on the legs and 18% on the hand/arms, 46.9% on the shoulder
and upper organs, and 41% lower extremities similar to the
observation of the present study.[14,15]
Biting animal
In the Indian Rabies Survey, the biting animals were mainly
dogs (91%), stray (63%) compared to the 22% exposures due
to cats in the present study.[12] Low- and middle-income country
data reveal that dogs account for 76%–94% of animal bite
injuries. Worldwide, cat bites account for 2%–50% of injuries
and monkey bites account for 2%–21% of animal bite injuries.[5]
A small proportion of transmission was via wildlife.[19]
Surveillance status of animals
On the basis of descriptive case histories, 48.1% of animals
were noncases and 51.9% were suspect rabies in the current
study compared to 60% suspect rabies in regions endemic to
rabies.[19] In Bhutan, majority (59%) of the victims mentioned
that the rabies status was unknown, 32% mentioned normal
and 9% suspect rabies.[15]
Wound wash
In the Indian Rabies Survey and multicentric study of 2008
about 39% and 58% had washed wounds with soap and water
in concordance to ndings observed in the present study.[12,16]
Antirabies vaccination and rabies immunoglobulin
88.2% had received three doses of rabies vaccine and 2.8%
had received ve doses of rabies vaccine in Babol similar to
the present study.[15] The interesting observation was that the
coverage of ARV in rural area was better compared to urban
areas. The cases usage of RIG was 18.4% compared to 2.1%
usage in 2004.[12] However, the RIG usage continues to be
poor and needs to be strengthened along with introduction and
scaling up of human rabies monoclonal antibodies. In a region
endemic to rabies, it was observed that the cost of PEP varied
depending on the health facility and the date of presentation.[17]
Majority preferred government hospitals (59%) for rabies PEP
than private hospitals (36%) similar to the present study.[11]
The incidence of animal exposure was 1.26% in the surveyed
population. Postexposure rabies vaccination and RIG coverage
were not satisfactory.
Limitation of the study
The sample size of 4924 was calculated based on the
assumption of ve persons per HH with 1008 HHs to be
surveyed. However, a total of 1012 HHs were surveyed and
only 4294 persons were available (4.24 persons per HHs).
Resurvey was done in 50 HHs. (Gujarat [n = 2], Madhya
Pradesh [n = 34], Himachal Pradesh [n = 6], and Kerala
[n = 8]), as there was technical error in uploading data on to
PDA. The study involved only selected states in India and
generalization of the results for the country was not attempted.
Recall Bias There may be a possibility of recall bias in
remembering the bite/exposure, time taken between bite and
wound wash, wound wash and vaccination. The information
bias in the categorization of animal exposure and rabies PEP
was minimized by prior training of surveyors, in data collection
and asking leading questions to verify the type of exposures.
The authors would like to thank Dr. Bernadette Abela-Ridder,
Team Leader, Neglected Tropical Diseases, World Health
Organization (WHO), Geneva, Switzerland; Dr. Lea G
Knopf, Neglected Tropical Diseases, WHO, Geneva,
Switzerland; Dr. Ritu Singh Chauhan, National Professional
Ofcer–IHR, WHO Country Ofce for India, New Delhi; and
Mr. Avijit Chaudhury, WHO Country Ofce.
The authors gratefully acknowledge the help and support of
Dr. Anmol Gupta, Professor and HOD of Community Medicine,
Indira Gandhi Medical College, Shimla, Himachal Pradesh;
Dr. Chittaranjan Roy, Professor and HOD of Community
Medicine, Darbhanga Medical College, Darbhanga, Bihar;
Dr. Longjam Usharani Devi, Professor and HOD of
Community Medicine, Jawaharlal Nehru Institute of Medical
Sciences, Imphal, Manipur; Dr. Dipankar Mukherjee, Assistant
Professor, KPC Medical College, Kolkata, West Bengal;
Dr. M Geetadevi, Associate Professor, Government Medical
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Masthi, et al.: A multicentric community survey on animal exposures
Indian Journal of Public Health ¦ Volume 63 ¦ Issue Supplement 1 ¦ September 2019
College, Kottayam, Kerala; Dr. Arun Kokane, Professor and
HOD of Community Medicine, AIIMS, Bhopal, Madhya
Pradesh; and Dr. Abhay Kavishvar, Associate Professor,
Government Medical College, Surat, Gujarat, for conducting
the community survey in the respective states. We would
like to thank with gratitude the staff, postgraduates/interns of
community medicine departments from all the surveyed states
for their cooperation in the study.
The authors also thank Dr.M K Sudarshan,Former Dean and
Principal; Dr.D H Ashwath Narayana,Professor and Head;Dr.T
V Sanjay and Dr. Ravish H S, Professor; Dr. Anwith H S,
Assistant Professor; and Dr. Manasa AR and Dr. Afraz Jahan,
Postgraduates, Department of Community Medicine, KIMS,
Bengaluru, for data management and assistance in the project.
Financial support and sponsorship
The study was nancially supported by the WHO India Country
Ofce, New Delhi.
Conflicts of interest
There are no conicts of interest.
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Fellowship Award to Life Members
Nominations are invited from Life Members of Indian Public Health Association for the Award of
The prescribed Fellowship application form is available at the IPHA website
The nominations should reach the IPHA HQ Office, at 110, C.R. Avenue, Kolkata – 700073 by 30th
September 2019.
Nominations should be accompanied by relevant supporting documents (details available at
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Secretary General, IPHA
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... More than half (52.5%) were triaged as priority 3 at ED arrival with only 8.2% triaged as priority 1 requiring immediate The seasonal variation of various bites was charted, and it was found that the incidence of bites saw a surge around the months of July to September, which happen to be part of the monsoon season in our geographical locality [ Figure 2]. The monthly variation in the number of cases was greater for snake bites (range 6-21) than for dog bites (range [10][11][12][13][14][15][16][17][18][19][20]. ...
... In a multicentric community survey on animal exposures among humans in India in 2017, 80% received postexposure prophylaxis while only 18.2% of those with category three exposure were administered rabies postexposure prophylaxis. [13] Another study comparing the practices of people in response to dog bites in the urban and rural slums of Delhi showed that one-fifth of patients did not receive rabies vaccine. [14] This calls for increasing awareness and stricter exercising of protocol when it comes to postexposure prophylaxis for rabies. ...
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Context: Animal bites including insect, reptile, and mammalian bites are common presentations to the emergency department (ED). Although profile and outcome of individual bites are described in detail, the literature on comprehensive overall clinical spectrum and seasonal variation of all animal bites is scant. Aims: To describe the spectrum, seasonal variation, clinical features, and outcomes of all patients presenting as emergencies due to animal bites. Methods: All the patients who presented to the ED of a large tertiary care hospital in South India with bites from January 2017 to December 2018 were retrospectively included in the analysis. Results: During the 2-year study period, animal bites constituted 0.83% of all ED admissions with 1145 incidents included in our analysis. The various animal bites/stings were classified as follows: mammal bites (480: 41.9%), arthropod bites (275: 24%), reptile bites (290: 25.3%), and unknown bites (100: 8.6%). We found an increase in the incidence of bites during the monsoon months of July to September (average: 58 cases per month) in our geographical locality. More than half (46: 58%) of scorpion stings had features of envenomation while a quarter (19: 24%) had the signs of autonomic storm. Snake bites constituted a quarter (25.2%: 289/1145) of all animal bites with 66% (191/289) showing features of envenomation. Dog bites constituted the majority of mammalian bites with 73% (352/480), followed by rat bites (14%: 68/480), cat bites (7.5%: 37/480), human bites (2.5%: 12/480), and monkey bites (1.9%: 9/480). The World Health Organization rabies exposure Category 3 bites were seen in 48%, 12%, and 27% of dog, rat, and cat bites, respectively. Conclusion: Snake and dog bites comprised the majority of all animal bites. There was a clear seasonal pattern with increased prevalence of bites during the rainy season.
... Another study estimated that 12700 human deaths from symptomatically identifiable furious rabies occurred in India in 2005 [60]. Most recently, a multicentric survey conducted in 2017 across seven Indian states estimated an annual incidence of animal exposures (bite, scratch or lick from an animal irrespective of its rabies status) of 1.26%, which was reportedly lower than previous estimates from India [61]. However, the authors acknowledged that, owing to the limited scale of their study, results could not be used to generate a country-level burden of potential rabies exposures. ...
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The ‘Zero by 30’ campaign aims to globally eliminate dog-mediated human rabies deaths by 2030. Theoretical and empirical studies have shown that annual mass rabies vaccination (MRV) campaigns that vaccinate at least 70% of the dog population in an area can effectively control canine rabies outbreaks and eventually eliminate it. Achieving such coverages in free-ranging dog (FRD) populations, the main source of human infections in rabies-endemic regions, can be a major challenge where most FRDs are unowned and so not easily accessible for vaccination. Despite bearing the largest burden of human rabies deaths globally, few studies have explored the population characteristics of FRDs in India in the context of rabies elimination, particularly accessibility for vaccination. Similarly, there are limited studies of dog ownership practices (DOP) relevant to rabies control in India. We conducted a longitudinal field study over 16 months in a cohort of unowned dogs (UDs), semi-owned dogs (SODs) and ODs at an urban (human population of 240991 individuals) and a semi-urban (25861 individuals) site each in Kerala, south India. The study gathered data on dog population characteristics, DOP and pre- and post-vaccination rabies virus neutralizing antibody (RVNA) dynamics. In round 1 (R1) pre-vaccination blood samples were collected from all dogs, after which they were vaccinated against rabies, collared and microchipped where necessary and released. Data on demographic characteristics (sex, age, body condition etc.) and DOP were also collected. As many dogs as possible from this cohort were recaptured at approximately ~30 days (R2), ~150 – 180 days (R3) and ~365 days (R4) after first capture to collect post-vaccination blood samples. All serum samples were tested to assess post-vaccination RVNA titre dynamics and rates of decline. These data were used to parameterise an age-structured deterministic compartmental Susceptible-Exposed-Infectious-Vaccinated (SEIV) model incorporating assumptions about accessibility for vaccination. The model was used to assess the impacts of varying various demographic, immunological and MRV campaign parameters on prospects of rabies elimination within 20 years of campaign implementation. In R1, 577 dogs across all ownership categories were captured. Only 12% of FRDs were owned, with about 60% of ODs in R1 being free-ranging. Only 29% of ODs were vaccinated against rabies. Approximately 26% (95% CIs: 22 – 31%) of all dogs sampled in R1 had RVNA titres ≥ 0.23 IU/ml. Mixed-effects logistic regression models found higher recapture probabilities for sterilised dogs and lower probabilities for UDs, dogs from the semi-urban site and those with pre-vaccination RVNA titres ≤ 0.5 IU/ml or no detectable titres. Over 80% of dogs recaptured in R2 had titres > 0.5 IU/ml, irrespective of age or vaccination history. Mixed-effects linear regression models identified significant associations between post-vaccination RVNA titres and age at vaccination, sterilisation status and RVNA titre levels in R1. Titres were estimated to drop below 0.5 IU/ml approximately 200 days (95% CI: 167 – 256 days) after achieving post-vaccination peak levels. However, titres declined at a faster rate for ODs and completely/partially confined dogs compared to dogs without owners and completely FRDs. We also found evidence suggesting the occurrence of non-lethal rabies infections in FRDs. The SEIV model indicated that as accessibility for vaccination increased, rabies elimination was possible in a wider range of scenarios within shorter timeframes, generally within 10 years of implementation of vaccination campaigns, and required lower vaccination coverages. Where ≤ 20% of dogs were accessible, campaigns needed to consistently vaccinate > 95% of dogs for > 20 years to eliminate rabies. Rabies elimination was possible in most scenarios, typically with annual campaigns, even with < 70% effective vaccination coverages in the total dog population. The model also highlighted the complex interplay of demographic factors and disease transmission, with high birth rates resulting in higher rabies cases, irrespective of juvenile mortality or adult lifespan. Mass rabies vaccination continues to be the most effective rabies control method; however, the implementation and frequency of MRV campaigns must account for varying accessibility of FRD populations and consider variations in demography and immunological dynamics. Rabies control in India will require a multi-pronged approach incorporating more responsible dog ownership, access to veterinary care, effective MRV and dog population and waste management, while ensuring the use of properly stored, high-quality vaccines and where necessary, the use of alternative vaccination methods such as oral vaccines to access as many dogs as possible.
... [3] This is reflected in the findings of our study and a multi-centric study in India. [5,10] This highlights the importance of identifying rabid dogs, controlling the stray population, and neutering them to prevent breeding and adoption of rehabilitated strays. These are massive undertakings that would require the collaboration of multiple levels of government and other nonprofit organizations. ...
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Introduction: To prevent rabies in animal bite victims, complete postexposure prophylaxis (PEP) with an anti-rabies vaccination (ARV) is essential. This study was done to determine the compliance rate of ARV in patients with animal bites who presented to the emergency department (ED) during the COVID-19 pandemic. Materials and Methods: This was a prospective observational study done on patients presenting to the ED with a history of animal bites over 1 year (May 2020-June 2021). Categorical variables were presented as percentages, and quantitative variables were summarized using mean and standard deviation (SD). Results: A total of 122 animal bite (World Health Organization [WHO] Category II and III) victims presented to the ED during the study. The mean age of the cohort was 38.12 (SD: 16.4) years with a male (n = 67: 54.9%) preponderance. Based on the physiological stability, a majority were triaged as priority III (n = 119; 97.5%). Most patients presented with dog bites (n = 88; 72.1%), followed by cat (n = 14; 11.5%) and rat bites (n = 13; 10.7%). Two-thirds were unprovoked (n = 82; 67.2%) and were caused by stray animals (n = 62; 50.8%). More than half (n = 65; 53.3%) of the bites were WHO Category III bites. All Category II and III patients had received the first dose of ARV at our center and category III patients received immunoglobulin local injection as well. Noncompliance to ARV was seen in almost a quarter (n = 32; 26.2%) of patients of which forgotten dates (n = 11; 34.4%) were the most common cause. There was no significant statistical variable to determine the cause of noncompliance. Conclusion: Unprovoked bites by stray dogs were the cause of a majority of the animal bites. Compliance with PEP remains low at two-thirds of the total. The most common cause of noncompliance to ARV was due to forgotten dates. The following core competencies are addressed in this article: Medical knowledge, Systems-based practice, Practice-based learning and improvement.
... 34 Rabies infections following dog bites are most commonly cited in lower extremity injuries and associated with residence in developing countries, residence in rural areas, male gender, warm weather, and dry season. [34][35][36][37] Other common sequelae include lacerations, fractures, arterial injuries, amputations, and arthritis. 38,39 Most sequelae are of cosmetic nature and associated with female gender, larger dog weight, and severity of dog bite injury. ...
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Animal bites are common worldwide. Due to the plethora of animals, there are diverse pathogens with specific associated risks and treatment algorithms. It is crucial to understand these to develop and execute appropriate management plans. This practical review was designed to amalgamate the most common bites worldwide and synthesize data to help guide treatment plans. Methods: A PubMed literature search was performed focusing on the major animal bites. High-level studies were preferred and analyzed but lower-level studies were also used if high-level studies did not exist. Results: The tables presented in this article cover the pertinent information regarding the incidence, common presentation, initial treatment, and potential complications associated with bites from dogs, cats, horses, rodents, snakes, marine life, and spiders. Many of the pathogens associated with the bites are treatable with various and somewhat common antimicrobials, though some are less easy to access. Basic irrigation, debridement, and wound culture are common to almost every animal and should be the first step in treatment. Conclusions: Based on the current studies, the most important factor in treating animal bites is timely presentation to a medical facility and/or physician. It is critical that the offending animal be accurately identified to help guide medical and surgical algorithms, including specific antimicrobial treatment guided by the most commonly presenting pathogens specific to certain animals.
... Rabies is acute progressive encephalitis, caused by a virus that enters the body after the bite of an infected animal, and migrates to the brain [1,2]. Rabies is caused by a group of antigen-related viruses in the genus Lyssavirus [3]. ...
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Rabies is acute progressive encephalitis, caused by a virus that enters the body after the bite of an infected animal, and migrates to the brain. Management of rabies animal bite transmission (GHPR) with post-exposure prophylaxis (PEP) is the most important strategy for preventing rabies-related mortality. GHPR victims need the right PEP. Effective post-exposure provision depends on good individual awareness about rabies and access to health services. To find out the efforts made by the community in raising public awareness to get PEP by doing initial handling after GHPR appropriately. This systematic review begins by identifying the literature on scientific articles that have been published in 2014-2019 in international databases namely Proquest, ScienceDirect, Springer and Ebsco. Selection is done by systematic reviews and meta-analyses (PRISMA) flow diagram and selected using the Joanna Briggs Institute (JBI) checklist format tools. The nine relevant articles were obtained to be analyzed into a systematic review, namely four articles from the Proquest database, two articles from the ScienceDirect database and three articles from the Ebsco database. Community efforts in initial treatment of victims exposed to GHPR are immediately carried out by applying wound washing, providing antiseptics and immediately to health care facilities to get further treatment. The community should understand important information about handling practices in GHPR wound management appropriately. PEP was an immediate action for early relief when victims are exposed to GHPR. PEP was conducted as an effort to prevent the virus from developing into dangerous stages that could result in death
... Annually, approximately 15 million dog bite cases occur in India [6]. This considerable burden of dog bite cases is attributable to the stray dog population. ...
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Background Annually, in India, millions of dog bite cases occur; most of them are inflicted by a stray dog. There are over 25 million dogs in the country. The rate of stray dog vaccination is suboptimal in India. This study aims to develop an intervention strategy, using Intervention Mapping framework, tailored for the target community to achieve canine rabies controlled zone. Methodology This is an exploratory, cross-sectional study conducted at a tertiary care Medical Institute at Jodhpur, Rajasthan, India, from 2018–2019. The semi-structured, In-Depth Discussion was conducted with a multidisciplinary planning group comprising of members from veterinary, health, and administrative sectors. The In-Depth Discussion focused on knowledge regarding complete stray dog vaccination schedule, self-efficacy (to prevent dog bites), challenges, and barriers faced by residents to achieve canine rabies controlled zone. Further, discussion with veterinary stakeholders focused on challenges faced for rigorous implementation of stray dog vaccination and sterilization. Results In-Depth Discussion revealed the following challenges: Lack of participation by the study population for canine vaccination, incomplete knowledge about annual canine vaccination schedule, lack of understanding of dog gestures, lack of infrastructure and resources at veterinary hospitals. The majority of the dogs in the study area were stray dogs that were partially or non-vaccinated and non-sterilized. An intersectoral collaboration was achieved between the community members, veterinary stakeholders both private and Non-Governmental organisations, and heath sector. Following which 35 (76.0%) stray dogs were vaccinated, and 17 (35.4%) were sterilized with community support. Burden of dog bite cases also decreased. The stray dog density map was prepared, and community engagement activity on dog gestures was conducted. Conclusion The present study demonstrates the feasibility of achieving canine rabies controlled zone. When implemented in a phase-wise manner across all Medical and Residential complex, this strategy would ensure achieving canine rabies controlled zone through multi-stakeholder engagement.
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Background: Rabies is 100% fatal disease and till date only 4 victims had survived following intensive life support and nursing care. It is said to be preventable only using modern vaccines and artificial immunoglobulins. Rabies is preventable through wound care and correct rabies prophylaxis. Objective: The main objective of this study is to assess the knowledge attitude and behaviour towards rabies prevention and control. Methodology: This cross-sectional descriptive study was carried out among 131 people aged above 18 years and above residing in Anakaputhur, an urban area in Kanchipuram district, Tamil Nadu selected by purposive sampling method. Results: Among the study participants, most of them were in the age group between 15 to 40 years. Around 70% of the study population had good knowledge about the first aid and vaccination methods after bit by a stray animal and 76% of the study population felt that they should report to the government in case they see an aggressive stray dog suspected of rabies. Around 92% of the dog owners vaccinate their pet dogs as per schedule. Conclusion: Different areas showed different knowledge towards rabies prevention and control. Mass media awareness or other health posters, awareness camp conduction will help in creating common knowledge, awareness and there by good practise towards rabies prevention and control.
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India bears the highest burden of global dog-mediated human rabies deaths. Despite this, rabies is not notifiable in India and continues to be underprioritised in public health discussions. This review examines the historical treatment of rabies in British India, a disease which has received relatively less attention in the literature on Indian medical history. Human and animal rabies was widespread in British India, and treatment of bite victims imposed a major financial burden on the colonial Government of India. It subsequently became a driver of Pasteurism in India and globally and a key component of British colonial scientific enterprise. Efforts to combat rabies led to the establishment of a wide network of research institutes in India and important breakthroughs in development of rabies vaccines. As a result of these efforts, rabies no longer posed a significant threat to the British, and it declined in administrative and public health priorities in India towards the end of colonial rule-a decline that has yet to be reversed in modern-day India. The review also highlights features of the administrative, scientific and societal approaches to dealing with this disease in British India that persist to this day.
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Objective: To describe the current situation of animal bites in the Babol County, North of Iran. Methods: This was a cross-sectional study based on recently collected data of 3798 victims bitten (656 females and 3142 males) from 2010 to 2014 in the Health Center of Babol, Iran. The interest variables in the study included demographic variables, characteristics of animal, some of the time patterns, and some clinical patterns provided to victims. Results: The average age of victims was (33.68 ± 17.23) years. The age group with the max proportion (for males, 32.1%; for females, 26.2%) of bites occurred in 18–30 years old group for males and 30–45 years for females. The ratio of male victims to female ones was 4.78. In terms of place of incident, 2502 (65.9%) cases of animal bites occurred in rural areas. Dogs and cats were the most dominant biters with 3340 (87.9%) and 395 (10.4%) bites, respectively. For the kinds of biters, 3643 (95.9%) were pets, 133 (3.5%) were strays and 22 (0.6%) were wild animals. Most of the lesions were on shoulder as well as upper organs (46.9%) and lower organs (41.0%), respectively. Conclusions: Since the average age of the subjects with injuries on the head and upper organs was lower than that of victims with other organs injured and since that pet dogs were the major biter, structured monitoring programs that focus on specified target groups in collaboration with other organizations are essential to control the animal bites.
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Current passive surveillance data for canine rabies, particularly for the regions where the burden is highest, are inadequate for appropriate decision making on control efforts. Poor enforcement of existing legislation and poor implementation of international guidance reduce the effectiveness of surveillance systems, but another set of problems relates to the fact that canine rabies is an untreatable condition which affects very poor sectors of society. This results in an unknown, but potentially large proportion of rabies victims dying outside the health system, deaths that are unlikely to be recorded by surveillance systems based on health centre records. This article critically evaluates the potential sources of information on the number of human deaths attributable to canine rabies, and how we might improve the estimates required to move towards the goal of global canine rabies elimination.
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Rabies is a notoriously underreported and neglected disease of low-income countries. This study aims to estimate the public health and economic burden of rabies circulating in domestic dog populations, globally and on a country-by-country basis, allowing an objective assessment of how much this preventable disease costs endemic countries. We established relationships between rabies mortality and rabies prevention and control measures, which we incorporated into a model framework. We used data derived from extensive literature searches and questionnaires on disease incidence, control interventions and preventative measures within this framework to estimate the disease burden. The burden of rabies impacts on public health sector budgets, local communities and livestock economies, with the highest risk of rabies in the poorest regions of the world. This study estimates that globally canine rabies causes approximately 59,000 (95% Confidence Intervals: 25-159,000) human deaths, over 3.7 million (95% CIs: 1.6-10.4 million) disability-adjusted life years (DALYs) and 8.6 billion USD (95% CIs: 2.9-21.5 billion) economic losses annually. The largest component of the economic burden is due to premature death (55%), followed by direct costs of post-exposure prophylaxis (PEP, 20%) and lost income whilst seeking PEP (15.5%), with only limited costs to the veterinary sector due to dog vaccination (1.5%), and additional costs to communities from livestock losses (6%). This study demonstrates that investment in dog vaccination, the single most effective way of reducing the disease burden, has been inadequate and that the availability and affordability of PEP needs improving. Collaborative investments by medical and veterinary sectors could dramatically reduce the current large, and unnecessary, burden of rabies on affected communities. Improved surveillance is needed to reduce uncertainty in burden estimates and to monitor the impacts of control efforts.
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Dog bites in humans are a public health problem worldwide. The issues of increasing stray dog populations, rabies outbreaks, and the risk of dogs biting humans have been frequently reported by the media in Bhutan. This study aimed to estimate the bite incidence and identify the risk factors for dog bites in humans, and to estimate human deaths from rabies in rabies endemic south Bhutan. A hospital-based questionnaire survey was conducted during 2009-2010 among dog bites victims who visited three hospitals in Bhutan for anti-rabies vaccine injection. Decision tree modeling was used to estimate human deaths from rabies following dog bite injuries in two rabies endemic areas of south Bhutan. Three hundred and twenty four dog bite victims were interviewed. The annual incidence of dog bites differed between the hospital catchment areas: 869.8 (95% CI: 722.8-1022.5), 293.8 (240-358.2) and 284.8 (251.2-323) per 100,000 people in Gelephu, Phuentsholing and Thimphu, respectively. Males (62%) were more at risk than females (P<0.001). Children aged 5-9 years were bitten more than other age groups. The majority of victims (71%) were bitten by stray dogs. No direct fatal injury was reported. In two hospital areas (Gelephu and Phuentsholing) in south Bhutan the annual incidence of death from rabies was 3.14 (95% CI: 1.57-6.29) per 100,000 population. The decision tree model predicted an equivalent annual incidence of 4.67 (95% CI: 2.53-7.53) deaths/100,000 population at risk. In the absence of post exposure prophylaxis, the model predicted 19.24 (95% CI: 13.69-25.14) deaths/year in these two areas. Increased educational awareness of people about the risk of dog bites and rabies is necessary, particularly for children in rabies endemic areas of Bhutan.
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Thousands of human deaths from rabies occur annually despite the availability of effective vaccines following exposure, and for disease control in the animal reservoir. Our aim was to assess risk factors associated with exposure and to determine why human deaths from endemic canine rabies still occur. Contact tracing was used to gather data on rabies exposures, post-exposure prophylaxis (PEP) delivered and deaths in two rural districts in northwestern Tanzania from 2002 to 2006. Data on risk factors and the propensity to seek and complete courses of PEP was collected using questionnaires. Exposures varied from 6-141/100,000 per year. Risk of exposure to rabies was greater in an area with agropastoralist communities (and larger domestic dog populations) than an area with pastoralist communities. Children were at greater risk than adults of being exposed to rabies and of developing clinical signs. PEP dramatically reduced the risk of developing rabies (odds ratio [OR] 17.33, 95% confidence interval [CI] 6.39-60.83) and when PEP was not delivered the risks were higher in the pastoralist than the agro-pastoralist area (OR 6.12, 95% CI 2.60-14.58). Low socioeconomic class and distance to medical facilities lengthened delays before PEP delivery. Over 20% of rabies-exposed individuals did not seek medical treatment and were not documented in official records and <65% received PEP. Animal bite injury records were an accurate indicator of rabies exposure incidence. Insufficient knowledge about rabies dangers and prevention, particularly prompt PEP, but also wound management, was the main cause of rabies deaths. Education, particularly in poor and marginalized communities, but also for medical and veterinary workers, would prevent future deaths.
Human rabies remains a significant problem in many developing countries, where canine rabies is the most common means of transmission. Although vaccination of dogs has been shown to be the most effective method of prevention in humans, dog vaccination is often lacking. This systematic review examined dog rabies vaccination coverage achieved following mass vaccination campaigns and dog ecology/management factors relevant to rabies control in the developing world. We searched a variety of electronic databases for published articles pertaining to dog rabies vaccination or dog ecology where data were collected utilizing a household cluster survey. We reviewed studies published between January 1, 1980 and present and identified 29 articles for inclusion. We found the majority of vaccination campaigns were able to achieve the WHO recommended vaccination coverage of ≥ 70% and calculated weighted mean post-campaign vaccination coverage of 76.5% in urban areas and 73.7% in rural areas. However, we found an absence of studies related to dog vaccination/dog ecology from countries with the greatest burden of rabies such as India, China, and Pakistan. In addition, the majority of dogs in the developing world are very young and short-lived, reducing the effectiveness of vaccination campaigns. Future studies on canine ecology should be undertaken in countries with high endemic canine rabies. New methods for improving the longevity of dogs and reducing high dog population turnover need to be investigated. Programs which encourage good dog management and promote responsible pet ownership are essential to eliminating canine and human rabies.
As a follow-up to the first AfroREB (Africa Rabies Expert Bureau) meeting, held in Grand-Bassam (Côte-d'Ivoire) in March 2008, African rabies experts of the Afro-REB network met a second time to complete the evaluation of the rabies situation in Africa and define specific action plans. About forty French speaking rabies specialists from Northern, Western and Central Africa and Madagascar met in Dakar (Senegal), from March 16th to 19th, 2009. With the participation of delegates from Tunisia, who joined the AfroREB network this year, 15 French speaking African countries were represented. Experts from the Institut Pasteur in Paris, the Alliance for Rabies Control, and the Southern and Eastern African Rabies Group (SEARG, a network of rabies experts from 19 English speaking Southern and Eastern African countries) were in attendance, to participate in the discussion and share their experiences. AfroREB members documented 146 known human rabies cases in all represented countries combined for 2008, for a total population of 209.3 million, or an incidence of 0.07 cases per 100,000 people. Even admitting that the experts do not have access to all reported cases, this is far from the WHO estimation of 2 rabies deaths per 100,000 people in urban areas and 3.6 per 100,000 in rural Africa. It was unanimously agreed that the priority is to break the vicious cycle of indifference and lack of information which is the main barrier to human rabies prevention.
Rabies, a disease of antiquity continues to be a major public health problem in India. Multiple factors contribute to high mortality and morbidity due to animal bites. An effective strategy for control of rabies takes into account the epidemiology of animal bites, rabies and factors influencing post exposure treatment. The study was carried out as a part of Agreement for Performance of Work (APW) from World Health Organization (WHO) during the period April 2001 to September 2002. Two sets of proformae were developed and used after field testing to interview cases of animal bites and get retrospective information about rabies cases. The study was carried out at six selected centres across the country viz. Delhi, Hyderabad, Raipur, Jamnagar, Coonoor and Rajahmundry and was co-ordinated by National Institute of Communicable Diseases (NICD), Delhi. The officials engaged in the study work were thoroughly trained in the study methodology before the start of the study itself. To maintain quality and uniformity supervisory checks were done during the survey. A total of 1357 fresh animal bite victims were interviewed (exit interview) from the anti-rabies centres (ARCs). Dog bites caused maximum morbidity (92%). Second most common biting animal was monkey (3.2%), followed by cat (1.8%), fox (0.4%) etc. Most bites (64.3%) were unprovoked bites by stray (64.7%) animals. In this study 72.4% animal bite victims were males and 47.5% were children in age group of 2-18 years. 63% had Category III exposure as per the WHO classification. Before coming to ARCs 58.5% people had washed the wound with water/soap or water alone. Some of the bite victims (10.8%) had also applied chillies, salt, turmeric powder, lime, snuff powder, paste of leaves, acid, ash given by Peer Baba (magician) etc. These practices varied from one region to another. The practice of wound washing at the ARC which is an important component of animal bite management was being practiced at only one of the six centres. Of the six centres, Rabies Immunoglobulin (RIG) was available and was being used at only two centres. The study was conducted in public sector ARCs where Nervous Tissue Vaccine (NTV) was available free of cost. All the centres were using NTV except Coonoor, which is using indigenously produced Tissue Culture Vaccine along with NTV. Analysis of 192 case records of rabies cases, from two centres, revealed that dog bites caused maximum mortality (96.9%). Nearly 40% were children below 15 years of age and 78.6% were males indicating that it is an exposure related disease. In all cases, failure to seek timely and appropriate treatment led to development of disease. This paper provides an overview of epidemiology of animal bites and retrospective information about rabies patients. There is a need to strengthen Information, Education and Communication (IEC) programme regarding merits of local wound management including "do's and don'ts". ARCs should be strengthened in terms of facilities and availability of safe and effective anti rabies immunobiologicals. There is a need to create awareness regarding epidemiology and at-home and hospital management of animal bites among the service providers and general community.