Primary local wound management practices and initiation of post-exposure prophylaxis among animal bite victims in a teaching institution hospital of Central India

ABSTRACT

Context:

Rabies is associated with sociocultural practices and myths leading to ineffective management of wound due to animal bite among the victims making it prime importance in the field of primary health care. As per World Health Organization (WHO), 79% do not receive anti-rabies vaccination (ARV) with lacunae of number requiring post-exposure prophylaxis (PEP).

Aim:

To identify the primary local wound management practices, initiation of PEP and association of various factors with the local wound management practices among the animal bite victims.

Settings and Design:

A cross-sectional study was conducted in a teaching institution hospital, Jabalpur.

Materials and Methods:

This study was conducted among animal bite victims for a period of 6 months, till the completion of sample size of 515. Data collection was done by means of pre-tested, self-structured questionnaire by face-to-face interview technique after obtaining informed consent from them.

Statistical Analysis Used:

Data entered in MS-Excel, descriptive and inferential statistical analysis was done using IBM SPSS v27.0 software.

Results:

Majority of the victims did local primary management of wound by application of antiseptic without washing 126 (24.47%), and maximum adopted improper primary local wound management 506 (98.25%) and majority were initiated PEP. Those did improper management maximum were educated till school level 321 (84.47%); odds ratio = 7.25 (1.58–33.25); P = 0.003.

Conclusions:

Maximum of the victims reported adopted improper local primary management of wound practices, and majority were initiated PEP. The victims with better education level did proper management of wound than that of illiterate ones and school level education, due to better awareness level.

Introduction

Rabies is considered as one of the most dreaded viral zoonotic diseases which is 100% fatal but 100% preventable. As per recent reports of World Health Organization (WHO), the low middle income countries (LMICs) <2% of Category-III bites of animal bite victims are deprived from immunoglobulin.[1] Rabies is a preventable disease but a neglected public health problem which is associated with multiple cultural, religious, and social practices and myths in India, where there is more faith in Indigenous practices of wound management and not washing the wound due to bite making it prime importance in the field of primary health care. As per WHO, around 79% of the animal bite victims do not receive any anti-rabies vaccination (ARV).[2]

In February 2015, WHO, Food and Agriculture Organization of the United Nations, World Organization for Animal Health, along with Global Alliance for Rabies Control united together and launched the End Rabies Now campaign with the goal of worldwide zero human Rabies deaths by 2030.[2] By seeing the burden of Rabies on global scale, a plan of “Zero by 30” was launched in 2017. WHO targeted elimination of human Rabies by dogs in South-East Asia by 2021–2030.[3] Here 5^th year plan (FYP, 2012–2016) was aimed to reduce the burden of death due to human Rabies by half to that of current estimation number in endemic countries. In India, as per the 12^th, FYP of National Rabies Control Programme has implemented both human and animal component.[4] Human health is being implemented throughout the country where National Centre for Disease Control focused on human health component by providing appropriate animal bite management in time.[5]

The wound due to animal bites are not managed effectively due to myths and multiple sociocultural practices associated with Rabies. The sociocultural practices include application of oil, herbs, mustard, kerosene, mud, and red chilies upon wound. Along with this on addition, less financial resources, negligence, lack of awareness, poor healthcare infrastructure leads to failure of proper management with complications among the victims at primary healthcare level/facility. So, this study was undertaken to identify the primary local wound management practices, initiation of PEP, and association with various factors among the animal bite victims reported to the hospital.

Aim and objectives

1. To identify the various primary local wound management practices and initiation of post-exposure prophylaxis (PEP) among the animal bite victims

2. To find the association between primary local wound management practices with various factors among the animal bite victims.

Materials and Methods

This was a cross-sectional study conducted in a teaching institution hospital, Jabalpur for a period of 6 months (August 2022 to January 2023) among the animal bite victims reported to hospital.

Sample size and sampling technique

The animal bite victims reported to the hospital during the study period were taken by means of convenient sampling technique, and the sample size was found to be 515.

Inclusion criteria

Animal bite victims those who gave willingness for consent to participate in study.

Exclusion criteria

Victims with mental illness.

Data collection procedure

Data collection was conducted by means of a pre-tested, self-structured questionnaire consisting of information such as socio-demographic characteristics (age, gender, education, and occupation as per Modified Kuppuswamy Scale 2021,[6] family type, socioeconomic status of the family as per Modified B.G. Prasad 2021[7]), type of animal bite, wound characteristics (type and depth of wound, number of bite marks, site of bite, and category of wound, which was identified by treating physician’s opinion), type of primary local management of the wound (in this study, the terminologies for categorization of primary local wound management were defined as per WHO guidelines for time of washing of wound after bite for interpretation of results as follows: (a) proper local wound management – washing under running water with soap/detergent for ≥15 min, (b) improper local wound management – these include washing under only running water without application of soap, application of antiseptics (solution/ointment), application of Indigenous substances, did nothing and application of multiple options among these[1] and initiation of PEP (Td injection, initiation of 1st dose of ARV and immunoglobulin administered as per treating physician’s opinion).

It was performed by means of face-to-face interview technique from the animal bite victims those visited the hospital for the first time, but not on follow-up. Data collection was conducted daily in a week. A pilot study was conducted among 30 animal bite victims those attended the hospital prior to main data collection procedure for validation of the questionnaire. Confidentiality of the identity of the victims was maintained, and data was used only for research purpose.

Ethical clearance and consent

The study was conducted after taking prior permission from the Medical Superintendent of the Hospital and after taking clearance regarding ethical ground from Institutional Ethical Committee (IEC) from author’s institution (No. IEC/2022/8629-77, Jabalpur dated 05-09-2022). Data collection from the victims was performed after taking informed consent from them in the local language. In case the victim was of the age group ≤15 years, the interview was taken from his/her attendant/guardian after taking prior consent.

Data analysis

Data entered in MS-EXCEL with descriptive and inferential statistical analysis was performed by using IBM SPSS v27.0 (IBM Corp. Released 2015. IBM SPSS Statistics for Windows, v27.0. Armonk, NY, USA: IBM Corp. by taking help of a Statistician). Results were interpreted by means of frequencies and percentages in tables and cross-tables along with calculation of Chi-square tests and odds ratios at 95% confidence interval to find the strength of association and P values (significant at P < 0.05).

Results

In this study, among 515 animal bite victims reported to the hospital, the mean age among them was observed to be 29.06 ± 16.44 years. It was noted that the majority of them belonged to age group of 21 to 30 years, 115 (22.33%), while the least age group belonged to >70 years, 5 (0.97%), with males predominant, 386 (74.95%). Majority of them had education level of high school 132 (25.63%), while minimum had education level till post-graduation 17 (3.30%) with maximum unemployed ones 245 (47.57%) and least were semi-professional by occupation 3 (0.58%). It was noted that the majority of victims belonged to the upper-lower class 218 (42.33%), while the minimum, 20 (3.88%), belonged to the upper class.

It was observed that maximum number of victims were bitten by dogs, 465 (90.29%), while the minimum reported as tiger 1 (0.18%) as a referral. In the study, among dog bites, majority bite victims reported were of stray dog bites 270 (58.06%), while rest due to pet ones 195 (41.94%).

It was observed that maximum victims reported with lacerated type of wound 165 (32.04%) followed by scratch/abrasion without bleeding, 158 (30.68%), and minimum with lick on intact/unabraided skin, 29 (5.63%). This study revealed that majority of the victims reported with Category-III type of wound 328 (63.69%), Category-II 158 (30.68%), while least Category-I type 29 (5.63%).

In the study, majority of the victims reported to the hospital have applied antiseptic (solution/ointment) over the wound without washing followed by application of Indigenous substances, while only few washed with soap/detergent under running water as primary local wound management measures after bite. It was noted that some of the victims adopted multiple measures for primary local wound management due to bite. Among them majority washed under running water and applied antiseptic, while the least of them applied Indigenous substances over the wound and antiseptic without washing [Table 1].

Table 1.

Primary wound management practices and time of initiation of post-exposure prophylaxis among animal bite victims (n=515)

Primary wound management practices	Frequency, n (%)
Washed with soap/detergent under running water	42 (8.16)
Washed under running water without application of soap/detergents	61 (11.84)
Application of only antiseptic (solution/ointment) without washing	126 (24.47)
Application of Indigenous substances	120 (23.30)
Did nothing	80 (15.53)
Washed under running water and applied antiseptic	36 (6.99)
Washed under running water but applied Indigenous substances	31 (6.02)
Application of Indigenous substances and antiseptics without washing	19 (3.69)
Td injection
Yes	459a (89.13)
No	56 (10.87)
1st dose of ARV/initiation of ARV
Yes	515b (100)
Immunoglobulin received (only for Category-III type wounds) (n=328)
Yes	6 (1.83)
No	322 (98.17)

^aOut of 515 animal bite victims, only 459 of them received Td, due to reasons like: (1) victims belonging to age group of ≤10 years they have already received as per NIS. (2) Those victims who recently received Td within 6 months, ^bAll the animal bite victims were given 1^st dose of ARV injection as it is a tertiary care setting, for safe side, and sometimes they come for delayed treatment, the wound characteristics cannot be distinguished. Sometimes wounds, such as scratches, remain unnoticed among children, so as a precautionary, it was given to all children age group. NIS=National Immunization schedule, ARV=Anti-rabies vaccination

The victims those applied Indigenous substances over the wound, maximum applied turmeric powder paste 56 (33.73%), followed by chilli paste 44 (26.51%), 22 (13.25%) paste of quick-lime, 14 (8.43%) paste of plant extract/product, 10 (6.02%) oil, 4 (2.41%) ghee, while least 1 (0.60%) mud/soil.

It was noted that among the victims, those who washed the wound under running water, the majority washed for <15 mins [Figure 1]. In this study, 81 (46.29%) of them washed for 5–9 min followed by 0–4 min 30 (17.14%) while least for ≥15 min 16 (9.14%).

Figure 1.

Approximate time of wound washing under running water among the victims reported (n = 175)

It was observed that the majority of the victims adopted improper primary local wound management practices before reporting to the hospital for PEP [Figure 2].

Figure 2.

Categorization of type of primary local wound management among the victims reported (n = 515)

It was observed that majority of the victims received Td vaccination, rest of them received Td within 6 months prior of bite and children were already under National Immunization Schedule. All the victims reported received the first dose of ARV vaccination as active immunization. In the present study, victims with WHO Category-III type of wound, majority did not receive immunoglobulin (equine Rabies immunoglobulin/human Rabies immunoglobulin) [Table 1].

In the present study, the victims those who did proper primary local management of wounds majority were educated till Graduation and above, while those who did improper management majority were educated till the school level, with moderate association and highly significant results. Again, those who did proper management of wounds maximum were educated till graduation, while those who did improper management maximum were illiterate with moderate association but insignificant result [Table 2].

Table 2.

Association of categorization of local primary wound management practice with various factors among animal bite victims reported (n=515)

	Proper (n=9), n (%)	Improper (n=506), n (%)	OR (at 95% CI); χ2	P
Education level
Graduation and above and school education (n=387)
Graduation and above (n=63)	4 (57.14)	59 (15.53)	OR=7.254 (1.582–33.251)* χ2=8.734	0.003**
School education (n=324)a	3 (42.86)	321 (84.47)
Graduation and above and illiterate (n=128)
Graduation and above (n=63)	4 (66.67)	59 (48.36)	OR=2.135 (0.377–12.069)* χ2=0.766	0.381
Illiterate (n=65)	2 (33.33)	63 (51.64)
Occupation type
Employed (n=270)b	5 (55.56)	265 (52.37)	OR=1.136 (0.301–4.282)* χ2=0.036	0.849
Unemployed (n=245)	4 (44.44)	241 (47.63)
Socioeconomic status
Above lower middle class (n=74)	3 (33.33)	71 (14.03)	OR=3.063 (0.749–12.528)* χ2=2.677	0.101
Lower middle class and below (n=441)	6 (66.67)	435 (85.97)

^aVictims with education from primary to high school were considered as school education, ^bUnskilled workers to Professional ones were considered as employed. *OR ≥1=Association present, **p value significant at P<0.05. χ²=Chi-square test, OR=Odds ratio, CI=Confidence interval.

It was noted that the victims, who did improper primary management of wounds were majority employed ones with association present but insignificant result. It was observed that those who did improper management of wounds the majority belonged to the lower middle class and below, with moderate association but insignificant result [Table 2].

Discussion

The present study conducted in a teaching institution hospital of Jabalpur district among 515 animal bite victims, it was observed that majority adopted improper measures of primary local wound management and received Td and initiated PEP, clearly indicating a failure in primary health care level/facility.

In the present study, majority of the bite victims did primary management of wound by application of antiseptic (ointment/solution) without washing, followed by application of Indigenous substances, followed by doing nothing and then washing under running water without application of soap [Table 1]. The reason behind this may be due to the education level and lack of awareness and knowledge regarding proper wound management after an animal bite among the study participants. A similar result was noted in a study done by Venkatesan et. al.[8] A dissimilar result was noted in a study by Bharathy and Gunaseelan where 51% washed their wound and 12% applied Indigenous substances, which is much higher than that of the present study.[9] This may be due to a better education level among victims reporting to the tertiary care setup. Again study by Kinge and Supe revealed that 16.6% of the victims applied only antiseptic, 6.7% with soap and water and 3.3% washed under only water which may be due to lack of awareness among the victims reporting to anti-Rabies clinic of a tertiary care health setup at Nagpur.[10]

In the present study, 175 (33.98%) of the animal bite victims reported to the hospital overall washed the wound under water. A dissimilar result was noted in a study conducted by Venkatesan et al. where 64% of the victims washed their wounds and 36% used soap and water.[8] It was observed that victims those washed their wound under running water majority did for <15 min, while the rest washed for ≥15 min, which is as per the proper guidelines of WHO for washing of wounds [Figure 1].[1] In the present study, 30 (17.14%) of the victims washed the wound for <5 min. A dissimilar result was noted in a study conducted by Wankhede et. al. in Panvel, Raigad district, Maharashtra, where 70.5% of the victims washed for <5 min, which may be due to a difference in study setting.[11]

In the current study, it was observed that the victims reported to the hospital for wound management, 100% of them were given ARV vaccination irrespective of WHO Category of bite [Table 1]. The reason behind this may be due to the study setting. Sometimes victims make a delay in visiting hospital for treatment, due to which the wound characteristics cannot be distinguished and often bites among children remains unnoticed. So, for precautionary measures all the victims were administered ARV. Similar results were noted in the studies conducted by Khan et. al. and Sachdeva et al., while a dissimilar result was noted in study conducted by Julka et al., which may be due to the fact that the study participants comprise of families owning pet dogs with less nature of severity of wound due to bite and better vaccination status among them.[12,13,14]

It was noted that the victims reported with Category-III type of wound, only 6 (1.83%) received immunoglobulin, while the rest did not, which is similar to recent reports of WHO, in LMICs < 2% of Category-III bites of animal bite victims are deprived from immunoglobulin [Table 1].[1] A dissimilar result was noted in a study by Khan et. al. in a hospital at Karachi, Pakistan, where 99% of the patients with Category-III type of wound received immunoglobulin.[12]

It was observed that, majority of the victims adopted improper primary local wound management practices before reporting to the hospital for PEP [Figure 2]. This may be due to the study setting and study population, as maximum victims reported to the hospital had lower level of education with unskilled and semi-skilled type workers belonging to lower middle class and below socioeconomic status. The victims those did proper primary local management of wound majority were educated till Graduation and above, while those did improper management majority were educated till school level with moderate association and highly significant result [Table 2]. Again, those did proper management of wound maximum were educated till graduation and above, while those did improper management maximum were illiterate ones, with moderate association but insignificant result [Table 2]. This is similar to the study conducted by Lu et al.[15] It was noted that the victims who did improper primary management of wounds maximum were employed ones. The result is found to have an association present but an insignificant result [Table 2]. These findings are suggestive of the fact that with better education level along with employment among the victims, they are much aware regarding the primary local wound management practices than that of illiterate, poor education and unemployed victims. Moreover, the illiterate and poorly educated victims rely more on Indigenous substance use along with traditional practices due to social beliefs, taboos, and stigma.

Conclusions

This study concluded that maximum of the victims reported did primary wound management by application of only antiseptic (solution/ointment) without proper washing of wound with majority adopting improper primary local wound management practices and also initiated PEP. Those with a better education level, occupation type, and socioeconomic status did proper management of wounds than those of illiterate ones, school level education with poor occupation type belonging to lower socioeconomic status, due to better awareness level. The illiterates, school education level with poor occupation type relied more upon Indigenous substance use due to social beliefs, taboos, stigma, remote place of work and poor health care facilities.

Limitations

In the present study, the time for washing of wound is taken as approximate values, so there may be a chance of information bias. In this study, the outcome (death/survival/complications) of the victims along with treatment completion were not included in the study, so a follow-up study is required.

Conflicts of interest

There are no conflicts of interest.

Funding Statement

Nil.