A descriptive study on epidemiological profile of patients presenting with animal bites at a rural health facility in Uttarakhand, India

ABSTRACT

Background:

Rabies is a viral disease caused by Lyssavirus type 1, primarily affecting warm-blooded animals, especially carnivores like dogs and cats. It is classified as a neglected tropical disease and is almost always fatal once symptoms appear. Rabies spreads through saliva, typically via bites or scratches from infected animals, and 95% of global rabies deaths occur in Africa and Asia. In India, around 6-7 million animal bites are reported annually, with dogs responsible for 95% of rabies cases.

Aims and Objectives:

The aim of the present study was to assess the clinical − social profile of animal bite cases attending outpatient departments at a rural health facility in a northern hilly state of India. The objective of the study was to study the epidemiological characteristics of animal bite cases attending the outpatient department.

Material and Methods:

This descriptive cross-sectional study was conducted at a rural health facility under the Department of Community and Family Medicine in a northern hilly state of India. All cases of animal bites who were presented at the health care facility were enumerated and were contacted by telephone to obtain information after obtaining verbal consent.

Results:

A total of 63 cases of animal bites presented to the outpatient clinic at a rural health facility were included in the study. Most animal bite victims (58.8%) had category III bites. 76.2% had taken a full course of anti-rabies vaccination as suggested by the healthcare provider at the facility, while 22.2% had left the vaccination in between.

Conclusion:

The findings indicate that while rabies is preventable with appropriate medical intervention, gaps in knowledge regarding rabies transmission and PEP protocols persist among the local population.

Introduction

Rabies is a vaccine-preventable, viral disease caused by Lyssavirus type 1 (other serotypes like 2,3,4 are rabies-related but antigenically distant viruses). It is also classified as a neglected tropical disease. It is a primarily zoonotic disease of warm-blooded animals, particularly carnivorous such as dogs, cats, jackals, and wolves. It can be transmitted from infected animals to humans, so it is classified as a zoonotic disease. The disease is almost always fatal.[1] It spreads to people and animals via saliva, usually through bites, scratches, or direct contact with mucosa (e.g. eyes, mouth, or open wounds). Out of total global deaths caused by rabies, 95% of deaths occur in Africa and Asia.[2] In India, it is a major public health problem and approximately 6-7 million animal bites are reported annually under the Integrated Health Information Program (IHIP, previously known as IDSP). 95% of rabies cases in India occur as a result of a bite by dogs followed by cats (2%), jackals, mongoose, and others (1%).[3] Rabies is prevalent in the whole country except for the islands of Andaman, Nicobar, and Lakshadweep.[4] With a target of zero deaths by rabies by 2030,[5] it is important to assess the epidemiology of animal bites for the prevention of human deaths due to rabies and formulation of effective rabies control strategies. Even though rabies is 100% fatal disease, it is also preventable with comprehensive postexposure prophylaxis, which involves proper wound management at the site of an animal bite, administration of anti-rabies immunoglobulin (in cases indicated), and a complete course of anti-rabies immunization in the individuals involved. Therefore, the present study was conducted at a rural health facility in a northern hilly state of India with the objective of studying the clinical − social profile of patients presenting with animal bites at the facility.

Aims and Objectives

The aim of the present study was to assess the clinical − social profile of animal bite cases attending outpatient departments at a rural health facility in a northern hilly state of India. The objective of the study was to study the epidemiological characteristics of animal bite cases attending the outpatient department.

Materials and Methods

Study design and settings

The present study was conducted at a rural health facility under the Department of Community and Family Medicine in a northern hilly state of India. It was a descriptive cross-sectional study, and the method of data collection was retrospective for the duration of 1 year from 1 April 2022 to 31 March 2023 at the outpatient clinic department of the facility.

Inclusion Criteria: All individuals with any animal bite who have reported to the health facility between 1 April 2022 and 31 March 2023.

Exclusion Criteria: Individuals who did not answer the phone after three attempts were excluded from the study.

Data collection and ethics

All cases of animal bites who were presented at the health care facility were enumerated and were contacted by telephone to obtain information after obtaining verbal consent. All patients fulfilling inclusion criteria and giving verbal consent were included in the study.

No sample size was calculated as this study was a retrospective study. Any patient who did not respond to a telephonic call even after three (3) attempts was excluded from the study. Approval to conduct the study was obtained from the Institutional Ethics Committee (IEC) before the start of the study (Ref No. AIIMS/IEC/23/160).

In the case of children (<15 years), information was obtained from their attendants. A bite was considered provoked due to patient initiating interactions, such as annoying the animal or playing with it. The animal bite wound was classified as per National Guidelines on Rabies Prophylaxis [Table 1].

Table 1.

Category and type of exposure*

Category of Exposure	Type of Exposure
I	Touching or feeding animals, licking on intact skin.
II	Nibbling of uncovered skin, minor scratches, or abrasions without bleeding.
III	Single or multiple transdermal bites or scratches, contamination of mucous membrane with saliva from licks, licks on broken skin.

* Source: National Guidelines for Rabies Prophylaxis, 2019[3]

Statistical analysis

The data was collected and entered in Microsoft Excel 2016 and was analyzed using Statistical Package for the Social Sciences (SPSS for Windows, Version 25.0, IBM Corporation, Armonk, New York, United States). Results were expressed in frequency and proportions for categorical variables, and mean and standard deviation for continuous variables.

Results

A total of 63 cases of animal bites presented to the outpatient clinic at a rural health facility were included in the study.

Table 2 shows the sociodemographic characteristics of the study population. Around two-thirds (66.7%) of study participants were males and the remaining one-third (33.3%) were females. Most of the participants (52.4%) were in the age group of 19-60 years followed by those belonging to the age group of 1-18 years (39.7%). The mean age for the study population was found to be 29.51 ± 20.17 years. Most of the participants in the study belonged to rural areas (96.8%) and only 3.2% were from urban areas.

Table 2.

Sociodemographic characteristics of the study population (n=63)

Sociodemographic Characteristics	Frequency	Percentage
Gender
Males	42	66.7
Females	21	33.3
Age (in years)
01−18	25	39.7
19−60	33	52.4
>60	05	7.9
Residence
Rural	61	96.8
Urban	02	3.2

Most animal bite victims (58.8%) had category III bites, 39.6% had category II bites, and 1.6% had category I bites as per the classification of animal bite wounds for postexposure prophylaxis based on national guidelines. A large proportion (74.2%) of patients had a single number of wounds in comparison to those with multiple number of wounds (25.8%). Similarly, 68.2% of patients had lacerated wounds, and the remaining patients (31.8%) had abrasions [Table 3].

Table 3.

Characteristics of wound

Characteristics of Wound	Frequency	Percentage
Category of Wound
Category I	01	1.6
Category II	25	39.6
Category III	37	58.8
Number of Wounds (n=62)
Single	46	74.2
Multiple	16	25.8
Type of Wound (n=62)
Lacerations	43	68.2
Abrasions	19	31.8

Figure 1 shows the distribution of different sites of animal bites. More than half (58.7%) of study participants had bites on their upper limbs. 34.9% of victims were found to have bite site on their lower limb while the remaining 7.9% had bite of sites as others which included face, neck, thorax, and abdomen.

Figure 1.

Site of bites

Table 4 shows that 76.1% of bites occurred because of bites by pet animals as compared to 23.9% by those with wild or stray animals. 90.5% of animal bites were unprovoked in nature while only 9.5% had a history of provocation. When asked about the vaccination status of animals, 50.8% of animals were vaccinated, while the vaccination status of remaining animals was either unknown (28.6%) or not vaccinated (20.6%). Most bites were caused by dogs (85.7%) followed by cats (11.1%).

Table 4.

Nature of animal bite

Nature of Bite	Frequency	Percentage
Category of biting animals
Pet	48	76.1
Stray/Wild	15	23.9
Provocation
Unprovoked	57	90.5
Provoked	06	9.5
Vaccination status of animal
Vaccinated	32	50.8
Not vaccinated	13	20.6
Unknown status	18	28.6
Animal involved
Dogs	54	85.7
Cats	07	11.1
Others	02	3.2

Table 5 shows that 57.1% of the victims had washed the wound with soap and water for a short duration of time. 23.8% did nothing postanimal bite, while 14.3% washed the wound with antiseptics. No one among the study participants had washed the wound thoroughly with soap and water for at least 15 min as recommended. Wrong practices like applying mirchi and vicks were also practiced by 4.8% of individuals.

Table 5.

Postexposure prophylactic measures (by the patient)

Postexposure Prophylactic Measures	Frequency	Percentage
Practices after bite
Washed with soap and water	36	57.1
Did nothing	15	23.8
Washed with antiseptics	09	14.3
Applied chili powder/vicks	03	4.8
Postexposure prophylaxis (anti-rabies vaccine)
Full course	48	76.2
Left in between	14	22.2
Not applicable	01	1.6
Anti-rabies immunoglobulin (n=37)
Yes	08	21.6
No	29	78.4
Source of anti-rabies vaccine (ARV) (n=62)
Health center	23	37.1
Self	29	46.8
Mixed (health center plus self)	08	12.9
Did not take	02	3.2

Out of a total of 63 study participants, around three-fourths (76.2%) had taken a full course of anti-rabies vaccination as suggested by a healthcare provider at the facility, while 22.2% had left the vaccination in between. Since one (1) patient belonged to category I, and hence, the course of anti-rabies vaccination was not applicable.

Out of the total victims with category III bite, only 21.6% took the anti-rabies immunoglobulin, and the remaining (78.4%) did not take prescribed anti-rabies immunoglobulin from higher centers.

Out of those who required the administration of an anti-rabies vaccine (ARV), 46.8% of patients brought their ARV along with them, while 37.1% of patients received the ARV from the health center itself. 12.9% of participants had mixed sources for the administration of ARV while 3.2% of patients did not take ARV at all.

Discussion

Animal bites pose a public health problem in our country. In the present study, males were found to be more affected as compared to females. Similar findings have been reported by Panda et al.,[6] Wadde et al.,[7] Salve et al.,[8] and Wankhede et al.[9] in whom males were found to be more affected when compared to females.

The mean age for the study population was found to be 29.51 ± 20.17 years which was quite comparable to findings reported by Panda et al.[6] who reported a mean age of 29.3 ± 15.2 years different from those reported by Laishram et al.[10] and Chandan et al.[11] who reported a mean age of 32.97 ± 13.02 years and 34.95 ± 13.49 years, respectively.

In the present study, 96.8% of participants were from rural areas, which was also seen in the study done by Singh et al.[12] and Wankhede et al.[9] in which a maximum number of cases were from rural areas. This finding was in contrast to the study done by Ain et al.[13] in which most of the cases were from urban areas.

In the present study, most animal bite victims (58.8%) had category III bites, 39.6% had category II bites, and 1.6% had category I bites as per the classification of animal bite wounds for postexposure prophylaxis based on national guidelines. Our results are in concordance with a previous study conducted by Singh et al. in Gorakhpur[12] where 77.43% had category III wounds and Panda et al. in Delhi[6] where 80.8% of cases had category III wounds.

In our study, we found that a large proportion (74.2%) of patients had a single number of wounds. Our findings are in contrast with Panda et al.[6] in which 60.3% of patients had a single number of wounds and Singh et al.[12] in which they found that 56.13% of participants with multiple wounds.

In our study, 68.2% of patients had lacerated wounds, which was similar to those reported by Singh et al.[12] in which 65.81% of participants had lacerated wounds. However, this finding differed from the study by Panda et al.,[6] who reported that 36.9% of participants had lacerated wounds.

In the present study, 58.7% of participants had bites on upper limbs followed by 34.9% of participants with bites on lower limbs. This finding was in contrast to findings reported by Sachdeva et al.[14] and Umrigar et al.[15] in which 67.9% and 81.7% of patients had lower limbs as the most common site of animal bite. This could be attributed to a higher proportion of bites as a result of pet animals in the present study.

In our study, we found that 76.1% of bites occurred as a result of bites by pet animals as compared to 23.9% by those with wild or stray animals. However, findings as reported by Panda et al.[6] and Umrigar et al.[15] in which the majority of participants (85.3%) and (94.7%) reported being bitten by stray animals.

In the present study, 90.5% of animal bites were unprovoked in nature while only 9.5% had a history of provocation. Similar findings have been reported in a study conducted by Jain et al.[16] in which 86.2% of cases were unprovoked in nature. Behera et al.[17] reported that only 54.7% of bites were unprovoked in nature in their study.

In our study, 50.8% of animals were vaccinated while the vaccination status of the remaining animals was either unknown (28.6%) or not vaccinated (20.6%). This was in contrast with findings in a study done by Sachdeva et al.[14] in which they found that the vaccination status of 80.5% of animals was unknown. This could be implied by the fact that a higher proportion of animals in the present study were pet animals in nature.

In our study, the majority of bites were caused by dogs (85.7%). Studies by Dhaduk et al.,[18] Lilare et al.,[19] and Panda et al.[6] also reported dogs to be the main biting animal in their studies, that is, 98.8%, 91.2%, and 88.1%, respectively.

In our study, 57.1% of the victims had washed the wound with soap and water for a short duration of time. 23.8% did nothing post animal bite while 14.3% washed the wound with antiseptics. Noone among study participants had washed the wound thoroughly with soap and water for at least 15 min as recommended. In a study by Singh et al.,[12] 39.35% had washed the wound with soap and water for a short duration of time. 35.48% had washed the wound with water only and nobody had washed the wound thoroughly with soap and water for at least 15 min as recommended. The findings were in contrast to findings of study by Jain et al.[16] and Shah et al.[20] in which only 18.7% and 24.9% of cases, respectively, washed the wounds with running water or water with soap before attending the ARV clinic.

In the present study, the application of indigenous products like mirchi and vicks was seen in 4.8% of individuals, which was comparatively lower than reported by Singh et al.[12] 11.63% of cases applied indigenous substances like lime and chili powder over wounds. In another study by Jain et al.,[16] 56.2% of cases reported applying indigenous substances like lime and chili powder applied over wounds.

In the present study, three-fourths (76.2%) had taken a full course of anti-rabies vaccination as suggested by the healthcare provider at the facility, while 22.2% had left the vaccination in between. In a study by Sachdeva et al.,[14] 97.7% of cases took ARV. The findings were also similar to a study by Gogtay et al.,[21] in which 32% did not complete the full Essen regime.

In our study, in patients with category III bite, only 21.6% took the anti-rabies immunoglobulin.

This was similar to the findings in a study by Sachdeva et al.[14] and Sahu et al.,[22] in which only 46% and 11.1% of patients with category III bite took anti-rabies immunoglobulin. The unavailability of rabies immunoglobulin on most occasions and unaffordability could be cited as the main reason for the failure to administer RIG to all category III cases.

In the present study, 46.8% of patients brought their ARV along with them while 37.1% of patients received the ARV from the healthcare center itself. 12.9% of participants had mixed sources for administration of ARV while 3.2% of patients did not take ARV at all. In a study by Gogtay et al.,[21] all patients received ARV free of cost at the center. This can be due to variability in the availability of ARV at healthcare centers.

Conclusion

There are a few limitations of the present study. One of the limitations was that this study was conducted only at a single center and of limited duration. Another limitation was reliance on self-reported exposure incidents as the source of data for the classification of exposures.

This study on the epidemiological profile of rabies at our healthcare center highlights the critical need for enhanced awareness and timely administration of postexposure prophylaxis (PEP) among animal bite victims. The findings indicate that while rabies is preventable with appropriate medical intervention, gaps in knowledge regarding rabies transmission and PEP protocols persist among the local population. Recommendations can be implementing community education programs to raise awareness about rabies prevention, emphasizing the importance of immediate wound care and timely vaccination following animal bites. Additionally, establishing a standardized protocol for assessing rabies risk based on regional epidemiological data can guide healthcare providers in making informed decisions about PEP administration, thereby reducing unnecessary healthcare costs and improving patient outcomes. Enhanced collaboration between public health officials and local healthcare providers is essential to ensure that effective rabies prevention strategies are accessible and consistently applied within the community.

Conflicts of interest

There are no conflicts of interest.

Funding Statement

Nil.