Economic costs of rabies post-exposure prophylaxis and healthcare utilization patterns post animal bites: An experience from a private healthcare facility in Bhubaneswar, Odisha, India

ABSTRACT

Introduction:

Rabies remains a public health challenge in many parts of the world, particularly in countries like India, where it is responsible for a significant number of human fatalities. Despite being a preventable disease, rabies continues to exert a heavy toll on the population, largely due to delays in seeking post-exposure prophylaxis (PEP) and the economic burden associated with treatment.

Objective:

1. To address this gap by assessing the economic costs of rabies PEP and healthcare utilization patterns among individuals treated at a private healthcare facility in Bhubaneswar 2. To assess patient’s awareness on rabies prevention and reason for non-adherence to PEP and their psychological status and behavioral change post-bite incident.

Methods:

Longitudinal mixed-method study among patients who received anti-rabies vaccination in the study centre from April, 2024-July, 2024, using pre-tested questionnaire.

Results:

133 animal bite exposure cases were reported. Dog bite was most common (67.86%) followed by cat bite (30.03%). 72.8% were self-motivated to seek health care. Overall, the total direct medical cost (Rs.2968 ± 1095) was higher than the total indirect cost (Rs.2160 ± 994). Those fully vaccinated spent more towards ARV (Rs.4750 ± 152, P = 0.02) and consultation (Rs.450 ± 189, P = 0.04), while participants partially vaccinated had higher lost wages (Rs.3532 ± 440, P = 0.05).72.8% reported being scared of animals post-incident 5% participants adopted preventive measures against animal bites in future. 63.5% were aware of before or to counseling at health-care facility. The association between vaccination status against rabies and awareness of the potential consequences of rabies was statistically significant (P = 0.04). 41.36% adhered to the recommended PEP doses as per schedule. PEP Non-adherence was mostly due to the high cost of treatment (88.5%).

Conclusion:

Financial strain was compounded by psychological and behavioral stress experienced by patients post-bite, indicating a multifaceted impact on individuals affected by animal bites. Awareness of rabies and its management was significantly better among those completing the vaccination regimen suggesting that comprehensive education ensures adherence to vaccination.

Introduction

Rabies, an acute viral encephalitis caused by a member of the Rhabdoviridae family, occurs through broken skin or mucosa exposed to saliva or neural tissue of a rabid animal.[1] Globally, fatality due to rabies is estimated to be 40,000–70,000 per year, with more than half the deaths occurring in India.[1] However, approximately 10 million individuals receive rabies post-exposure prophylaxis (PEP) each year after being exposed to suspected rabies-infected animals.[1] Treatment options for rabies include primary wound cleaning, rabies immunoglobulin, and vaccine administration. As the disease is fatal, there are no contraindications to the rabies PEP vaccine due to its life-saving potential.[2]

Rabies remains a critical public health challenge in many parts of the world, particularly in countries like India, where it is responsible for a significant number of human fatalities each year. Despite being a preventable disease, rabies continues to exert a heavy toll on the population, largely due to delays in seeking PEP and the economic burden associated with treatment. In India, the financial strain imposed by the need for PEP after an animal bite can be substantial, especially for individuals from lower socio-economic backgrounds.[3] This cost includes not only direct medical expenses but also indirect costs such as lost wages and travel expenses, which further exacerbate the economic impact.

The magnitude of the epidemiological, humanistic, and economic burden of animal bites and dog-mediated rabies in India is still unexplored, with a wide variation in the PEP treatment cost.[4] The city of Bhubaneswar in Odisha, like many urban centers in India, has seen a rise in cases of rabies exposure, necessitating a better understanding of healthcare utilization patterns and the associated economic costs.[5,6] The interplay between healthcare accessibility, patient behavior, and economic burden plays a crucial role in the outcomes of rabies prevention and control efforts.[6] Yet, there is limited data on the comprehensive economic impact of rabies PEP and the healthcare utilization patterns following animal bites, particularly in the context of tertiary care institutes. This study aims to address this gap by examining the economic costs of rabies PEP and healthcare utilization patterns among individuals treated at a private healthcare facility in Bhubaneswar, Odisha. It also assesses the patient’s awareness of rabies prevention and reason for non-adherence to PEP and their psychological status and behavioral change post-bite incident.

Methods

This longitudinal mixed-method study was done in the Department of Community Medicine, of a private healthcare facility in Bhubaneswar from April 2024 to July 2024 after approval from the Institutional Ethics Committee (KIMS/KIIT/1880/2024).

Any person above 18 years of age with a history of any animal bite reporting to the Emergency department of the facility for vaccination was taken up while those cases reported as Category-I by the treating doctor and were not residents of Bhubaneswar were excluded. Uncooperative patients not willing to participate were also excluded from the study [Figure 1]. With these considerations, on purposive sampling, 135 participants were taken up in the study. Two participants neither visited the center for follow-up after the first dose of the Anti-rabies vaccine (ARV), nor could be contacted telephonically.

Figure 1.

Sample size of the study population with methodology

Data collection and research tool

The 133 study participants were interviewed after written informed consent using a semi-structured questionnaire, regarding the socio-demography, characteristics of animal bite and healthcare-seeking behavior, direct and indirect costs incurred for PEP, psychological impact, and behavioral change post-incident. It also included questions to assess knowledge, attitudes, and practices related to rabies prevention and PEP among patients. In the study, there were four follow-up visits to complete the PEP regimen. Above mentioned information from the participants was collected on the first follow-up visit. Whereas, during every follow-up, information regarding direct and indirect costs incurred for PEP was recorded. In the case where the participant was found to be non-adherent to completion of the vaccination series i.e. participant was partially vaccinated, the reason for the same was recorded. If the follow-up could not be done in the Emergency Department where participants were called for follow-up, they were followed up telephonically. Data was self-reported by participants but the vaccination status was cross-verified with a doctor’s prescription on each visit or over WhatsApp if followed up telephonically.

Socioeconomic status was calculated by a modified B.G. Prasad scale.[7] The economic cost of PEP included direct medical costs for immunoglobin, vaccination, medical consultations, and wound care, and indirect costs incurred by patients such as transportation expenses, loss of wage due to missed working days, and other out-of-pocket expenses. Behavioral change post-bite incident on patient was assessed by their response regarding: precautions to prevent animal bite, changed attitude towards pet (if any), intention to pet an animal in future, and if the incident affected daily work. For the purpose of the study, the researcher explored the immediate mental and/or emotional state of the participant post-animal bite. This psychological impact was determined by their response to: Feeling post-bite event, anxiety on thinking of the event, scared of animals after the event, and anxiety going to the hospital or doctor for consultation irrespective of PEP. The responses to behavior change and psychological impact could be multiple. Both had provision for open-ended response as well which was noted by the interviewer.

This tool was also translated to the local language Odia, for the ease of elucidating the patient’s correct response and was back translated. Participants who were found to be experiencing stress and/or anxiety were referred to the Psychiatry department for counseling.

Data analysis

Data was entered in a Microsoft Excel sheet and analyzed using STATA version 17. It was checked for completeness and distribution. Participants who completed the ARV-Essen regimen i.e. five ARV doses, were “full vaccinated” while those who did not complete were “partially vaccinated”. Distance of the vaccination center from the residence was continuous data which was categorized into “near (≤5 km)” and “far (>5 km)”. This was done to facilitate a more straightforward analysis and interpretation of the distance data, examining whether proximity significantly impacts vaccination uptake or adherence to PEP and follow-up. Education status was categorized into “formal” and “non-formal” wherein formal education refers to structured education that usually takes place within a school system, following a set curriculum and leading to recognized qualifications. This includes primary, secondary, and tertiary education. Whereas, non-formal refers to the type of education which is flexible, not necessarily following a curriculum such as educational activities taking place in community centers or workplaces like adult literacy workshops. The occupation was categorized into a “Professional” occupation characterized by higher educational requirements and formal training, and a “Non-professional” meaning an occupation involving skills acquired through on-job training, or vocational programs and not requiring educational certification.

Mean and standard deviation for continuous variable while, frequency and percentages for categorical variables for descriptive statistics. The Chi-square test and t-test were applied for significance in determining association as appropriate, and a P value <0.05 was considered statistically significant.

Results

The study included 133 animal bite cases, all category-II (84.21%, 112/133) and III (15.79%, 21/133) exposures visiting the hospital for Rabies PEP. Dog bites were most common (67.86%,91/133) followed by cats (30.03%,40/133). The time of the incident for the majority (59.69%) was during the evening hours (5–7 pm) [Figure 2]. The majority (33.8%) reported the lower limb to be body site exposed to bite. 2.1% of participants reported extensive surgical wound care.

Figure 2.

Description of suspected rabies exposure, N = 133

A total of 72.8% of participants reported being self-motivated to seek healthcare post-animal bite incidents. All participants received intramuscular rabies vaccination by the Essen Regimen. Sociodemographic characteristics of participants by vaccination status i.e. fully vaccinated (n₁ = 55, 40.4% participants) or partially vaccinated (n₂ = 78, 59.6% participants) as shown in Table 1, indicates disparities in vaccination adherence being influenced by sociodemographic factors. Age, gender, and socioeconomic status (SES) of the participant significantly influenced vaccination status [Table 1]. Among those partially vaccinated, the majority were female (65%), aged more than 25 years (72%), and belonged to upper-lower class (51%).

Table 1.

Sociodemographic characteristics of participants by vaccination status, n=133

Variables	Vaccination status		P*
	Fully Vaccinated (n1=55) (%)	Partially Vaccinated (n2=78) (%)
Age (in years)
<25	23 (42%)	22 (28%)	0.04
25–40	12 (22%)	26 (34%)
>40	20 (36%)	30 (38%)
Sex
Male	39 (71%)	27 (35%)	<0.001
Female	16 (29%)	51 (65%)
Education
Formal education	43 (78%)	21 (27%)	0.12
No formal education	12 (22%)	57 (73%)
Occupation
Professional	28 (51%)	48 (62%)	0.36
Non-professional	27 (49%)	30 (38%)
Residence
Near vaccination centre (within 5 kms)	31 (56%)	25 (32%)	0.09
Far from vaccination centre (>5 kms)	24 (44%)	53 (68%)
Socioeconomic status
Upper middle class	38 (69%)	16 (21%)	0.04
Lower middle class	15 (27%)	22 (28%)
Upper lower class	2 (4%)	40 (51%)

*Using Chi-square test as test of association

Further analysis was done to find the association of selected patient variables with the vaccination status and total PEP cost. It was seen that the mean healthcare cost related to PEP was higher among those who were fully vaccinated and aged more than 40 years (P = 0.007) and fully vaccinated females (P = 0.003) [Table 2].

Table 2.

Association of selected variables with the vaccination status and total PEP cost, n=133

Variables	Healthcare costs related to PEP		P*
	Fully vaccinated (cost in mean±SD rupees)	Partially vaccinated (cost in mean±SD rupees)
Age group (in years)
<25	4545±1371	3794±1583	0.110
25-40	4583±2098	3953±1728	0.082
>40	4631±1387	4244±1380	0.007
Gender
Male	4747±1575	4259±1755	0.071
Female	5295±1899	3562±1247	0.003
Educational status
Formal education/Graduate & above	5209±1742	4442±1523	0.214
No formal education/Secondary & below	4510±1586	3086±1311	0.343
Occupation
Professional	4200±1349	3989±1218	0.441
Non-professional	4186±1151	3799±1067	0.121
Residence
Near vaccination centre (within 5 kms)	4843±1537	3713±1540	0.246
Far from vaccination centre (> 5 kms)	5257±2152	4500±1576	0.331
Socioeconomic status†
Upper-Middle Class	4386±2188	3998±1722	0.152
Lower-Middle Class	4231±1485	3008±1080	0.097
Upper-Lower Class	4233±1411	2446±1121	0.072

*t-test applied. P<0.05 is statistically significant. ^†Modified BG Prasad scale[7]

A total of 15.79% (21/133) of participants received immunoglobulin post-Category III animal bite. Among the sample, 18.5% (24/133) reported a loss of wages in incurring PEP. Table 3 represents the economic costs incurred for Rabies PEP wherein the total direct medical cost mean (Rs.2968 ± 1095) was higher than the total indirect cost (Rs.2160 ± 994). Expenditure toward vaccines, doctor consultation fees, and lost wages were found to be associated with the vaccination status of participants [Table 3]. Those fully vaccinated had spent more towards incurring ARV (Rs.4750 ± 152, P = 0.02) and consultation (Rs.450 ± 189, P = 0.04) while participants partially vaccinated had higher lost wages (Rs.3532 ± 440, P = 0.05).

Table 3.

Economic Costs of Rabies Post-Exposure Prophylaxis (PEP)

Cost category	Expenditure (Mean±SD) (INR)		P*
	Partial vaccination	Full vaccination
Direct cost
Immunoglobulin (n=21)	2834±200	2860±110	0.54
Vaccine (n=133)	3121±133	4750±152	0.02
Consultation fees (n=133)	330±96	450±189	0.04
Others (Admission/medicines) (n=133)	902±343	1192±625	0.75
	Total direct cost (INR) 2968±1095
Indirect cost
Transportation (n=133)	488±150	588±160	0.70
Lost wages (n=24)	3532±440	3400±553	0.05
	Total indirect cost (INR) 2160±994

*t-test applied. P<0.05 is statistically significant

Anxiety, fear, and discomfort experienced by individuals following an animal bite incident were assessed. Post-event, the majority reported experiencing stress regarding contracting rabies after the bite (58.5%), feeling anxious thinking of the bite event (50.5%), and being scared of animals post-incident (72.8%) [Figure 3].

Figure 3.

Psychological impact of patient post animal bite, N = 133

On behavior change assessment post animal bite incident, 55% of participants didn’t want to pet animals, and 58% reported a changed attitude towards existing pets [Figure 4]. Furthermore, 64.5% of participants reported adopting preventive measures such as avoiding streets where they usually find dogs (29.8%), avoiding parks with monkeys and/or dogs in and around (15%), not entering a friend’s house who pets an animal (15%) against animal bites in future.

Figure 4.

Behaviour change of patient post animal bite, N = 133

The awareness of ARV and knowledge regarding rabies and its management are crucial factors influencing appropriate responses to potential rabies exposure. It was noted that 63.5% of participants were aware of ARV before counseling at a healthcare facility. Awareness regarding rabies and its management was better among those fully vaccinated [Figure 5]. There was evidence of an association between the vaccination status of participants against rabies and awareness of the potential consequence of rabies disease (P = 0.045).

Figure 5.

Awareness regarding rabies and its management, N = 133

Adherence to the PEP treatment regimen for rabies, including completion of vaccination series and follow-up visits was assessed. 41.36% of participants were found to have adhered to the recommended PEP doses on time i.e. as per schedule. However, there were many (58.64%) who did not adhere to the PEP which was attributable to various reasons such as the high cost of treatment (88.5%), longer distance to healthcare facility from home (71.8%), and lack of awareness regarding PEP (53.8%) [Figure 6].

Figure 6.

Reasons for non-adherence to Post-exposure prophylaxis, N = 78

Discussion

Rabies remains a public health concern because of its high fatality rate.[1,2] Globally, to reduce the incidence of rabies cases, timely and complete vaccination against it post-exposure has been introduced.[2] This cross-sectional study among adults exposed to animal bites reports the expenditure towards the direct medical cost, to access healthcare post-exposure to animal bites was higher and that there was a significant impact on the psychology and behavior of the patient post-incident. Also, those found to be fully vaccinated with ARV were more aware of rabies as a disease and its management was better among for non-adherence to PEP.

Socio-demography

Our study reports the majority (65%) being females among those partially vaccinated females. Studies from Tamil Nadu and Uttar Pradesh reported similar findings where 62% and 68% of partially vaccinated individuals respectively, were females, indicating potential gender bias in health-seeking behavior.[8,9] It points towards a pattern where women are less likely to complete vaccination, possibly due to prioritization of male health within the family, and lower autonomy.

SES too plays a crucial role in vaccination completion. In the present study, participants from the upper-lower class formed the majority (51%) of those partially vaccinated. A similar trend was observed in a study from Odisha which suggested economic barriers such as transportation costs and loss of wages contributed to incomplete vaccination.[10] Age also appeared to be a determining factor, with participants aged above 25 years being more likely to be partially vaccinated in our study which is consistent with findings from another study in West Bengal, where older age groups had a higher likelihood of being partially vaccinated compared to younger groups.[11] The reasons for this could include a lower perceived risk of disease or competing work commitments.

Economic cost of PEP of rabies

The current study showed that a large portion of participants (72.8%) were self-motivated to seek healthcare after an animal bite which is in contrast to a similar study done among individuals with animal bites in Murad Nagar that showed 80% of patients used non-recommended treatments such as chili and oil to clean their wounds, while only 0.8% washed with soap water.[12] Our study highlights higher direct medical costs during PEP of rabies which might be attributed to the finding of 59.6% of cases being partially vaccinated. Delayed treatment and incomplete vaccination may be due to high expenditure and logistical challenges.

A study from Srinagar among patients exposed to animal bites reported a median cost of Rs.2,430 for PEP, with direct costs averaging Rs.1,700 and greater than the indirect costs which stands lower than the mean direct cost of Rs.2,968 and indirect cost of Rs. 2,160 in current study.[13] Behera et al.[14] in their study reported fully vaccinated individuals spending an average of Rs. 4800 on ARV, which aligns with our findings. They noted transportation costs and lost wages usually exceeded direct medical costs, particularly for individuals who did not complete the vaccination regimen.[14] This supports the notion that indirect costs, such as lost wages are crucial in determining adherence to vaccination, as seen in the partially vaccinated group in our study as the financial burden of PEP was found to vary between fully and partially vaccinated participants. Only 41.36% of participants in the present study adhered to the full PEP vaccination regimen which is in line with results of a study in Vietnam, where 41.4% completed the five-dose intramuscular vaccine series and a significant portion of patients did not complete their schedule due to financial constraints.[15] Participants in this study, who were fully vaccinated spent more on ARV and doctor consultations, whereas partially vaccinated participants faced more indirect costs, like lost wages. This is similar to the cost analysis in Tamil Nadu, where ARV programs had significant financial burdens.[16] Thus, both studies emphasize the need for a cost-effective vaccination program for greater vaccine coverage among those experiencing animal bites. In a study in Nepal, vaccine production and distribution were highlighted as critical issues in adhering to PEP, with the need for increased local vaccine production to reduce expenses and drop-outs.[17]

Psychological impact and behavioral changes

When analyzing our data on the psychological impact of the bite incident, stress regarding contracting rabies, feeling anxious thinking of the incident, and being scared of animals were found to be common among the patients, suggesting that emotional responses to bites should also be considered in future interventions. It aligns with the findings of a study from Maharashtra, where 65% patients of with animal bites reported anxiety regarding contracting rabies infection.[18] Also, a study in West Bengal noted about 58% of bite victims experienced severe anxiety and were preoccupied with the thought of developing rabies symptoms.[19] This might disrupt daily routine, attributing to decreased quality of life.[19] Madhusudana et al.[20] noted that nearly 45% of animal bite victims reported post-traumatic stress, including having persistent nightmares. Singh et al.[21] in Odisha revealed 72% of victims had stress and fear of death even after completing PEP due to a belief that rabies could develop at any time thus, suggesting that inadequate health education and misinformation play a critical role in shaping the psychological response to bite incidents, particularly in resource-limited settings.

Animal bite incidents have a significant impact on human behavior, resulting in a noticeable change in interactions with animals, especially pets.[21,22] The change in attitude towards existing pets and a reluctance to adopt new pets post-bite was also highlighted in a study conducted in Karnataka where 62% of victims reported fear of interacting with their pets after the incident, citing concerns about potential future attacks or rabies exposure while a study from West Bengal showed 25% giving up their pets altogether.[19,23] Such findings suggest that animal bite not only causes immediate trauma but also affects the long-term perception and relationship between victim, their pets or other animals, potentially leading to abandonment of pet or avoidance of other animals. Our study found 64.5% participants adopted preventive measures to avoid future animal bites which is in accordance to the findings of study conducted in Gujarat, where 68% victims implemented behavioural changes, like avoiding areas with the presence of stray dogs or carrying sticks/stones as a precautionary measure.[24] Another found that 54% of victims altered their daily routine to minimize chances of encountering animals, such as choosing different roads and restricting outdoor activity.[19] This indicates that animal bite incidents can result in persistent behavioral changes aimed at mitigating perceived risks, even when the actual threat of a repeat incident might be minimal. Also impact on social behavior was evident when individuals avoided visiting friends’ houses who had pets, which aligns with a study from Tamil Nadu where 35% of respondents reported social isolation after a bite incident due to an aversion to pets at friends’ houses.[25] This behavior was compounded by the belief that any dog, regardless of its vaccination status, could potentially be rabid.[25]

Awareness of rabies and its management

Kishore et al.[26] reported that 50% of bite victims were aware of the existence of an ARV before seeking treatment, which is notably lower than our findings. A significant association was found between participants’ vaccination status and their awareness of the consequences of rabies in the present study which is supported by findings from a study from West Bengal.[27] These findings align with similar studies done, hinting at prior vaccination and awareness campaigns enhancing awareness and preventive practices against rabies. A community-based study conducted in tribal Odisha revealed knowledge on rabies being higher among patients who had a history of receiving full-course ARV, compared to those who did not.[28] Their study showed that 40% of non-vaccinated participants were aware of the fatal consequences of untreated rabies, while 80% of vaccinated participants had a good understanding of the need for immediate vaccination post-bite and the consequence of not adhering to a complete vaccination regimen.[28] These findings highlight the importance of comprehensive education and awareness programs being an integral part of the rabies vaccination campaign. Improving knowledge of rabies, particularly among those at higher risk, it is possible to increase vaccine uptake and adherence, ultimately decreasing the burden of this preventable disease.

Adherence to PEP

Regarding barriers that impede completion of rabies PEP regimen, factors like the financial burden of treatment (88.5%), healthcare facility far from home (71.8%), and lack of awareness regarding PEP (53.8%) were found to be evident. The financial burden emerged as the most prominent barrier, with 88.5% of participants reporting difficulties in bearing the cost of the complete regimen. This finding is consistent with studies conducted in rural India, where out-of-pocket expenditure for PEP has been cited as a significant deterrent to compliance.[29] A similar study from Tamil Nadu reports that 65% of participants found it challenging to afford PEP leading to discontinuation.[30] Moreover, in a community-based survey from Kerala, almost 70% of respondents highlighted expensive PEP as the primary barrier to its completion.[31]

A study from Chhattisgarh noted that 82% of patients find it difficult to reach designated ARV centers due to long travel distances, which is in accordance with our findings.[32] Similarly, in Madhya Pradesh, about 75% of rural residents cited travel distance as a reason for not adhering to and completing PEP, suggesting geographical inaccessibility remains a pervasive barrier to PEP adherence across different regions of India.[33]

Lack of awareness regarding PEP was reported by most participants in our study which is in line with findings from a multi-centric study by ICMR in Uttar Pradesh and Bihar, which reported less than 60% of the general population being aware of the importance of completing PEP regimen.[34] A community-based study conducted in tribal districts of Odisha found awareness about rabies and PEP to be notably low (40%).[35] These findings underscore the need for targeted awareness campaigns in underserved regions to improve PEP compliance. A study from Srinagar on patients attending ARV clinic showed that 72.36% of participants delayed seeking treatment for more than 6 hours after the incident.[36] Our study didn’t specifically report delays in seeking treatment, but 58.64% of participants didn’t adhere to the full PEP regimen, indicating a possible delay in treatment completion.

Limitation

Being a single-centre study and it being a private hospital, current study findings with regard to healthcare cost may not be generalizable to the entire population. However, it might be suitable for other private hospital settings.

Conclusion and Recommendation

Direct medical costs were found to be higher in this study. Financial strain was compounded by psychological and behavioral stress experienced by patients post-bite, indicating a multifaceted impact on individuals affected by animal bites. Cautious behavior is likely reinforced by the lack of awareness regarding appropriate rabies prevention measures and information on animal behavior and safety. Adoption of avoidance strategies highlights the need for targeted educational interventions addressing misconceptions and promoting safe interactions with animals. Adherence to PEP was poor, with reasons for non-adherence being a lack of knowledge regarding disease fatality and a lack of proper counseling. Awareness of rabies and its management was significantly better among those who completed the vaccination regimen suggesting that comprehensive education ensures adherence to vaccination schedules. Subsidization of rabies vaccines is essential to reduce the PEP non-adherence rate. Policymakers and healthcare providers to focus on strategies to alleviate the economic impact on patients and improve the effectiveness of rabies prevention and management programs.

Conflicts of interest

There are no conflicts of interest.

Funding Statement

Nil.