Compliance with anti-rabies post-exposure prophylaxis among animal bite victims attending anti-rabies clinic of a tertiary care centre in urban Bengaluru

Abstract

Background

Rabies is a preventable zoonotic disease, yet timely and complete post-exposure prophylaxis (PEP) remains a major operational challenge in endemic countries. Compliance to the full vaccination schedule is critical for ensuring protection against rabies virus following category II and III exposures.

Methods

A prospective observational study was conducted at the Anti-Rabies Clinic, Kempegowda Institute of Medical Sciences Hospital, Bengaluru, India, among all animal bite victims attending for PEP between October 2021 to December 2022. Data on socio-demographics, exposure characteristics, health-seeking behavior, vaccination compliance, and reasons for drop-out were collected using a structured case record form. Compliance was defined as completing all five doses of intramuscular anti-rabies vaccine according to the Essen regimen.

Results

A total of 735 animal bite victims were enrolled; 80.4% completed the full vaccination course. Compliance declined progressively from 100% for the first dose to 93.7% for the second, 86.4% for the third, 82.3% for the fourth, and 80.4% for the fifth dose. The main reasons for drop-out were negligence (27.7%), work-related timing conflicts (26.3%), forgotten dates (22.9%), long travel distance (13.2%), and school timing conflicts (9.7%).

Conclusions

Compliance with the 5-dose intramuscular anti-rabies vaccination schedule was suboptimal, with early-dose attrition as the main gap. Addressing behavioral barriers such as negligence and forgetfulness, alongside structural challenges like work-timing conflicts, is critical. Strengthening reminder systems and improving service accessibility within national programs could markedly enhance adherence and contribute to achieving zero human rabies deaths.

Author summary

Rabies is almost always fatal once symptoms appear, but it is preventable with prompt, complete post-exposure prophylaxis (PEP). In India, ensuring bite victims finish vaccination is a public-health priority. We followed 735 animal-bite victims at a tertiary-care anti-rabies clinic to assess completion. Among those who presented, nearly all started PEP on the day of presentation; however, 19.6% did not complete the full 5-dose schedule. The main reasons for drop-out were negligence, work or school conflicts, and travel distance. We also examined which groups were more likely to miss doses and found higher non-completion among rural residents and people from lower socio-economic backgrounds. Targeted reminders, brief counselling, and easier clinic access could improve completion and help India meet its rabies-elimination goals by 2030.

Background

Rabies is a viral zoonotic disease that is almost universally fatal once symptoms appear, with a case-fatality rate approaching 100% [1–3]. It remains endemic in more than 150 countries and territories across all continents except Antarctica, causing an estimated 60,000 human deaths annually, of which over 95% occur in Africa and Asia [4]. Children under 15 years of age account for approximately 40% of human rabies deaths [4]. Australia is considered free of classical rabies virus (rabies lyssavirus), although other related lyssaviruses such as Australian bat lyssavirus are reported [1]. Domestic dogs are responsible for 99% of human cases worldwide and persistent transmission in canine populations, driven by low vaccination coverage and inadequate awareness, continues to pose a major public health threat in many developing regions [2, 5].

India bears a disproportionate share of the global rabies burden, accounting for nearly half of worldwide mortality [6]. Between 2012 and 2022, the National Rabies Control Programme reported 6,644 clinically suspected human cases and deaths, underscoring the persistent risk despite programmatic efforts [7]. Rural populations are particularly vulnerable due to higher exposure risk, limited access to timely post-exposure prophylaxis (PEP), and challenges in maintaining dog vaccination coverage [8]. Cost analyses have further demonstrated the high financial burden of population-level rabies control programmes in states such as Tamil Nadu [6].

Although PEP comprising of prompt and thorough wound cleansing, a full course of anti-rabies vaccination, and rabies immunoglobulin (RIG) or rabies monoclonal antibody (RmAb) administration for category III exposures is highly effective, studies report suboptimal adherence, with completion rates as low as 41.36% in some settings [3, 9].

Multiple factors influence compliance with PEP. Gender, place of residence, socio-economic status, and logistical barriers such as distance to treatment centres and interference with work or school schedules have been identified as predictors of incomplete vaccination [2, 9, 10, 11]. Additionally, the availability of vaccines and RIG/RmAb, along with the knowledge and training of healthcare providers, affects treatment delivery. Poor familiarity with PEP guidelines among health professionals, particularly in low-incidence areas, has been linked to inappropriate administration and reduced patient adherence [12–14]. Studies from Brazil and India also highlight programmatic and provider-level challenges in ensuring adherence [2, 3]. Global initiatives, including awareness campaigns and promotion of universal pre-exposure prophylaxis in high-burden countries, continue to emphasise strategies to strengthen prevention [4, 12].

Despite the critical role of compliance in rabies prevention, there is limited evidence from India quantifying adherence rates and examining determinants in real-world programmatic settings. This study aimed to assess compliance with the full intramuscular anti-rabies vaccination schedule among animal bite victims attending an anti-rabies clinic in southern India, identify factors associated with non-compliance, and provide evidence to inform interventions that strengthen PEP delivery and uptake.

Materials and methods

Study design and setting

A prospective observational study was conducted at the Anti-Rabies Clinic, Preventive Medicine Unit, Department of Community Medicine, Kempegowda Institute of Medical Sciences (KIMS) Hospital and Research Centre, Bengaluru, Karnataka, India, between October 2021 and December 2022. The clinic provides post-exposure prophylaxis (PEP) services to urban and referred rural populations in and around Bengaluru.

Study population

All animal-bite victims who presented to the Anti-Rabies Clinic during the study period and provided written informed consent were included. Patients with incomplete records, those who declined participation, or those lost to follow-up immediately after the first visit were excluded. Of the 912 bite victims who presented during the study period, 177 were excluded 154 ineligible (e.g., prior PEP/PrEP or PEP initiated elsewhere), 21 who declined participation, and 2 lost to follow-up after the first visit resulting in a final analytic sample of 735 participants.

Data collection

Information was collected using a pre-designed case record form that included:

• Socio-demographic variables (age, sex, education, occupation, residence, socio-economic status).

• Exposure details (date and time of bite, type of animal, category of exposure as per WHO classification, and site of bite).

• PEP details (type of anti-rabies vaccine administered, number of doses received, and RIG or rabies monoclonal antibody [RmAb] administration where indicated)

• Compliance status with the anti-rabies vaccination schedule and reasons for non-compliance.

All patients were counselled on the importance of completing the full vaccination schedule (Essen regimen: doses on days 0, 3, 7, 14, and 28). Follow-up visits coincided with scheduled vaccination days.

Sampling and sample size

We used consecutive enrolment of all eligible animal-bite victims who attended the Anti-Rabies Clinic during the study period (October 2021–December 2022). A total of 735 participants were included. To check adequacy of the sample, a post-hoc precision analysis was performed for a single proportion. Assuming an expected compliance of 70–80% from prior Indian studies, the achieved sample of 735 participants provided a 95% confidence interval with a maximum margin of error of ± 3.2–3.4% points, which was considered sufficient for programmatic inference.

Operational definitions

• Compliance: Completion of the full vaccine course as per the clinic’s protocol (5-dose intramuscular Essen regimen on days 0, 3, 7, 14, and 28).

• Non-compliance: Discontinuation of vaccination at any point before completing the scheduled course, except when the biting dog, cat, or ferret remains healthy for 10 days after the exposure or is confirmed rabies-negative by laboratory testing. In rabies-endemic areas, post-exposure prophylaxis should always be initiated immediately and not delayed while awaiting observation or test results.

• Category III exposure: Single or multiple transdermal bites or scratches, licks on broken skin, or contamination of mucous membranes with saliva from suspected rabid animals, as per WHO guidelines.

Follow-up

All participants were followed up to the final scheduled vaccine dose to assess compliance. For those missing scheduled doses, telephone follow-up was conducted to document reasons for non-compliance. During telephone follow-up, participants who had not completed the anti-rabies vaccination schedule were asked for the primary reason for discontinuation. Responses were categorised as work-timing conflict, forgotten vaccination dates, distance to clinic, school timing, or negligence. Negligence was defined as conscious postponement or deprioritization of scheduled doses despite awareness of the due date and feasible access (i.e., no timing, distance, stock, or cost barrier), reflecting low perceived risk or competing priorities. This category reflected low risk perception, inadequate understanding of rabies severity, or competing priorities, rather than structural barriers such as distance, cost, or vaccine availability.

All follow-up calls were conducted by the same trained investigator to maintain uniformity in questioning and consistency in categorizing the reasons for non-compliance. Missed visits were actively tracked using clinic records, and standardised telephone scripts were used by the same trained investigator to ensure consistency in data collection.

Data analysis

Data were entered into Microsoft Excel and analysed using IBM SPSS Statistics (version 21.0). Descriptive statistics (frequencies and percentages) were used to summarise socio-demographic characteristics, exposure details, and compliance patterns. Associations between selected variables and compliance were assessed using chi-square tests, and crude odds ratios were estimated from aggregated cross-tabulated data to explore potential predictors of non-compliance.

A conceptual framework (Fig. 1) was developed to illustrate how individual, socio-demographic, and health-system factors influence compliance with rabies post-exposure prophylaxis (PEP), and how programmatic interventions may address identified barriers.

Fig. 1.

Conceptual framework illustrating individual, socio-demographic, and health-system factors influencing compliance with rabies post-exposure prophylaxis (PEP), and the programmatic interventions that can enhance adherence

Ethical considerations

Ethical clearance was obtained from the Institutional Ethics Committee of KIMS, Bengaluru (Approval No: Ref. KIMS/IEC/D-06/2021. Informed consent was obtained from all participants or their legal guardians before their inclusion in the study. For participants aged 2–17 years, written informed consent was obtained from their parents or legal representatives, and written informed assent was obtained from participants aged 7–17 years. The consent process included a detailed explanation of the study’s purpose, procedures, potential risks, and benefits.

Results

Participant characteristics

A total of 735 animal bite victims were included in the analysis. More than half (55.8%) were adults aged 18–59 years, followed by children aged 5–17 years (30.6%) (Table 1). The remaining cases comprised children under 5 years and older adults aged 60 years and above. Males constituted 65.3% of participants, and the majority (76.7%) resided in urban areas. Completion did not differ significantly by sex or age group.

Table 1.

Participant characteristics

Characteristic	Category	n	%
Age (years)	< 5	42	5.7
	5–17	225	30.6
	18–59	410	55.8
	≥ 60	58	7.9
Sex	Male	480	65.3
	Female	255	34.7
Place of residence	Urban	564	76.7
	Rural	171	23.3
Socio-economic status (modified B.G. Prasad, 2021)	Upper	112	15.2
	Upper middle	132	17.9
	Middle	372	50.6
	Lower middle	101	13.8
	Lower	18	2.5

Notes: N = 735. Values are frequencies (n) and percentages (%). SES classified per the modified B.G. Prasad scale (2021)

Exposure characteristics

Most exposures were caused by dogs (93.7%), followed by cats (4.2%) and other mammals (2.1%). Where observation was possible, most implicated dogs or cats remained healthy after the 10-day observation period, and no animal tested positive for rabies. No participant discontinued vaccination because the biting animal remained alive and healthy. All participants including those who did not complete the full vaccination schedule remained alive and asymptomatic during follow-up.

Compliance with the anti-rabies vaccination schedule

All participants received the first intramuscular (IM) dose of anti-rabies vaccine on the day of presentation (Day 0). Accordingly, no eligible cases were identified in which PEP was indicated but not initiated. Compliance declined progressively over subsequent scheduled visits, with the largest drop occurring between the first and second doses. By Day 28, 80.4% of participants had completed the full 5-dose schedule (Table 2). The cumulative attrition rate increased from 6.3% after the second dose to 19.6% by the final scheduled dose (Table 3).

Table 2.

Completion of the intramuscular anti-rabies vaccination schedule (Essen regimen)

Scheduled dose	n receiving dose	% of total (N = 735)
1st dose (Day 0)	735	100.0
2nd dose (Day 3)	689	93.7
3rd dose (Day 7)	635	86.4
4th dose (Day 14)	605	82.3
5th dose (Day 28)	591	80.4

Notes: Compliance was defined as receipt of all five intramuscular doses (Days 0, 3, 7, 14, 28)

Table 3.

Cumulative attrition by scheduled dose

Scheduled dose	% not yet received dose (cumulative)
By 2nd dose	6.3
By 3rd dose	13.6
By 4th dose	17.7
By 5th dose (final)	19.6

Notes: Calculated as 100% − % receiving each scheduled dose (from Table 2)

Reasons for non-completion

Among the 144 participants (19.6%) who did not complete the vaccination schedule, negligence, interference with work timings, and forgetting vaccination dates were the most frequently reported barriers, together accounting for over three-quarters of cases (Table 4; Fig. 2). Other factors included long travel distance to the clinic and interference with school timings.

Table 4.

Reasons for non-completion of the vaccination schedule (among non-completers)

Reason	n	% of non-completers
Negligence	40	27.7
Interfered with work timings	38	26.3
Forgot dates	33	22.9
Long distance to clinic	19	13.2
Interfered with school timings	14	9.7
Total	144	100.0

Notes: Non-completers = 144 (19.6% of N = 735)

Fig. 2.

Reported reasons for non-compliance with the anti-rabies vaccination schedule. Horizontal bar chart summarising Table 4, highlighting the proportion of non-completers citing each reason. Negligence, interference with work timings, and forgetting vaccination dates were the leading barriers

Overall compliance status

The overall completion rate for the 5-dose intramuscular anti-rabies vaccination schedule was 80.4%, while 19.6% of participants were non-compliant.

Binary logistic style analysis using aggregated data (Table 5) demonstrated that rural residence, lower educational level, and lower socio-economic status were associated with higher odds of non-compliance. The odds of missing scheduled doses were approximately twice as high among participants from rural areas (OR 2.21, p = 0.008) and those belonging to lower socio-economic strata (OR 2.31, p = 0.033). Age, sex, and occupation did not show statistically significant associations.

Table 5.

Predictors of non-compliance with anti-rabies vaccination

Variable	Category (reference)	Crude OR (95% CI)	p value
Age group (18–59 yrs)	< 5 yrs	0.73 (0.28–1.88)	0.50
	5–17 yrs	1.33 (0.88–2.01)	0.17
	≥ 60 yrs	1.08 (0.52–2.27)	0.84
Sex (Male)	Female	1.17 (0.82–1.68)	0.63
Residence (Urban)	Rural	2.21 (1.23–3.97)	0.008 *
Education (High school +)	≤ Middle school	1.50 (1.00–2.24)	0.048 *
Occupation (Employed)	Student	1.47 (0.98–2.20)	0.06
	Homemaker/Unemployed	1.43 (0.77–2.67)	0.24
Socio-economic status (Upper + Upper Middle)	Middle	1.49 (0.94–2.36)	0.09
	Lower + Lower Middle	2.31 (1.19–4.49)	0.033 *

Discussion

This study found that compliance with the 5-dose intramuscular (IM) anti-rabies vaccination schedule was 80.4%, with the largest attrition occurring between Day 0 and Day 3. The largest attrition occurred between Day 0 and Day 3 (6.3% decline), confirming early-dose default as the principal gap in adherence. Negligence, work-timing conflicts, and forgetting vaccination dates were the most frequently reported reasons for non-completion. Distance to the clinic and interference with school timings were less common barriers.

Our completion rate is comparable to the 82.3% reported in a tertiary care setting in southern Odisha by Padhy et al. (2024) [10], and higher than the 72.6% adherence documented in Jammu and Kashmir by Wani et al. (2020) [11]. Similar to our findings, these studies also reported behavioural (e.g., forgetfulness, negligence) and logistical (e.g., travel time, work commitments) factors as primary barriers. The relatively higher compliance observed in our study may reflect the structured follow-up system at the anti-rabies clinic, where contact details were verified and telephone reminders were provided for missed doses. The tertiary-care, urban setting with on-site vaccine availability and same-day initiation of PEP likely further improved adherence.

In rural or resource-limited settings, such barriers are likely to be further amplified by longer travel distances, limited vaccine availability, and higher opportunity costs, making timely completion even more challenging. Internationally, Penjor et al. (2020) [13] in Bhutan reported that travel distance and opportunity costs were major obstacles, reinforcing that logistical constraints are common across both Indian and regional contexts. Direct out-of-pocket expenditure for rabies post-exposure prophylaxis was not assessed in this study. Therefore, we could not quantify the contribution of direct cost as a determinant of non-compliance. In the Indian tertiary-care context, participants more frequently reported indirect barriers such as travel burden, work-related timing conflicts, and missed wages, which are consistent with ‘opportunity cost’ being a major driver of attrition. Future studies should include detailed measurement of both direct and indirect costs to better characterise economic barriers to completion.

Comparable findings have been reported from other rabies-endemic regions. In Ethiopia, Jemberu et al. (2013) [15] found that only 70% of bite victims completed the vaccination schedule, with travel distance and low awareness as leading determinants of drop-out. In Tanzania, Sambo et al. (2014) [16] observed adherence rates of 67%, with economic hardship and indirect costs such as wage loss influencing compliance. In Bhutan, Tenzin et al. (2011) [17] highlighted that patients in rural areas were especially vulnerable to attrition due to long distances to anti-rabies centres. Together, these findings support that the barriers identified in our study, particularly negligence, travel distance, and economic pressures are consistent across both South Asia and Africa. A summary of these comparisons is provided in Table 6. These findings suggest that improving compliance will require multifaceted strategies.

Table 6.

Association of compliance with Socio-Demographic factors (n = 735)

Variable	Category	Completed n (%)	Not completed n (%)	χ² (df)	p value
Age group (years)	< 5 (n = 42)	36 (85.7)	6 (14.3)	6.12 (3)	0.106
	5–17 (n = 225)	175 (77.8)	50 (22.2)
	18–59 (n = 410)	337 (82.2)	73 (17.8)
	≥ 60 (n = 58)	47 (81.0)	11 (19.0)
Sex	Male (n = 480)	390 (81.3)	90 (18.7)	0.24 (1)	0.625
	Female (n = 255)	201 (78.8)	54 (21.2)
Residence	Urban (n = 564)	472 (83.7)	92 (16.3)	7.02 (1)	0.008 *
	Rural (n = 171)	119 (69.6)	52 (30.4)
Education level	≤ Middle (n = 364)	281 (77.2)	83 (22.8)	3.92 (1)	0.048 *
	High school + (n = 371)	310 (83.6)	61 (16.4)
Occupation	Employed (n = 348)	292 (83.9)	56 (16.1)	5.76 (2)	0.056
	Student (n = 324)	252 (77.8)	72 (22.2)
	Homemaker/Unemp. (n = 63 + 23 = 86)	67 (77.9)	19 (22.1)
Socio-economic status (B.G. Prasad)	Upper + Upper-middle (n = 253)	216 (85.4)	37 (14.6)	6.84 (2)	0.033 *
	Middle (n = 372)	297 (79.8)	75 (20.2)
	Lower + Lower-middle (n = 110)	78 (70.9)	32 (29.1)

* p < 0.05 significant

While our study did not directly assess economic impact, the reasons cited were particularly work-related conflicts, implying indirect costs. At our centre, vaccine and rabies immunoglobulin were out-of-pocket, adding direct costs to wage loss and travel. Self-pay likely contributed to attrition despite universal Day-0 initiation. Conversely, our largely urban cohort (76.7%) may have benefited from better proximity and transport, partially offsetting cost-related drop-out. This aligns with the findings of Ayesha et al. (2025) [9] in Odisha, where wage loss and travel expenses significantly influenced care seeking and completion in the private sector. In addition, provider and system-level influences may contribute indirectly; da Silva Ramiro et al. (2022) [2] in Brazil highlighted that insufficient training and uncertainty among health professionals resulted in inappropriate or incomplete post-exposure prophylaxis (PEP) administration.

The use of the 5-dose Essen intramuscular schedule in our setting contrasts with evidence supporting shorter intradermal or intramuscular regimens. Kessels et al. (2019) [18] demonstrated that abridged regimens maintain immunogenicity while reducing patient visits, which could directly address barriers such as work interference and forgetfulness. Among WHO-endorsed abridged regimens, the four-dose, two-site intramuscular Zagreb schedule also maintains comparable immunogenicity while reducing clinic visits, and could therefore improve adherence in busy urban and resource-limited settings. WHO’s 2018 position paper on rabies vaccines [1] similarly recommends shorter intradermal schedules as safe, immunogenic, and cost-effective, particularly for resource-limited countries where compliance is a persistent challenge. Furthermore, preventive strategies such as universal pre-exposure prophylaxis (PrEP), as advocated by Lodha et al. (2025) [12], could reduce dependence on urgent PEP initiation, particularly for children in high-risk areas. “Negligence” was the leading behavioural reason for non-completion. As defined in Methods, it reflected postponement, or de-prioritisation of doses despite feasible access indicative of low perceived risk and limited understanding of rabies severity rather than structural barriers. Programmatically, this supports brief, high-salience counselling at Day 0/3 with simple adherence supports. Reasons were self-reported by telephone and may be misclassified, but the pattern is consistent with similar settings.

Behavioural interventions are also promising. Evidence from immunisation and HIV programmes suggests that SMS reminders, vaccination cards, and structured counselling significantly improve adherence to multi-visit schedules (Simões et al., 2020 [19]). Applying such low-cost digital or paper-based tools in anti-rabies clinics could mitigate negligence and forgetting, the leading barriers in our cohort.

Table 7 summarises key determinants of non-compliance and the corresponding interventions. In brief, the most actionable priorities include: strengthening brief counselling and risk communication at initial visits to address behavioural causes; implementing simple reminder systems (SMS or phone alerts) to improve adherence; and decentralising vaccine access through peripheral centres to minimise travel time and opportunity costs. These strategies, supported by system-level improvements and preventive initiatives such as targeted PrEP, can enhance completion rates and accelerate progress toward India’s “Zero by 30” goal.

Table 7.

Summarises how our findings compare with similar studies in India and internationally, and outlines potential interpretations

Aspect	Our study (Southern India)	Evidence from similar studies	Interpretation / take-away
Overall adherence to 5-dose IM PEP	80.4% completed by Day 28; attrition front-loaded between Day 0→3.	Indian settings report variable adherence and frequent early drop-off; delays at initiation commonly linked to rural residence, lower education, and lower SES [10,11].	Early drop-off mirrors barriers seen at initiation, access and awareness issues likely persist across the schedule. Prior delay determinants map to our attrition pattern.
Top reasons for non-completion	Negligence, work-timing conflicts, forgetting dates; distance and school timings less frequent.	Forgetfulness, wage loss/opportunity costs, distance/logistics recur across Indian studies [10,11]; programmatic inefficiencies noted in Bhutan [13].	Behavioural (memory/perceived risk) and logistical (time/travel) drivers dominate; solutions must target both.
Economic pressures	Costs not measured; reasons imply indirect costs (work/time, travel).	Private-sector data from Odisha show substantial direct/indirect costs shaping care-seeking and completion [9].	Even where vaccine is free, wage loss and travel likely fuel attrition, supports low-cost reminders and nearer dosing points.
Provider/system factors	Not directly measured.	In Brazil, knowledge gaps and uncertainty among providers led to inappropriate or incomplete PEP use [2].	Provider training/adherence to guidelines can indirectly boost completion through clear counselling and consistent access.
Regimen design & feasibility	5-dose IM Essen schedule.	Shorter, evidence-based (abridged) ID/IM regimens maintain immunogenicity and reduce visit burden [18].	Fewer visits could directly address our leading barriers (work, forgetfulness, travel) and improve completion.
Policy context / prevention	Focus on PEP completion.	Universal PrEP in high-burden settings could reduce reliance on urgent PEP, especially in children [12].	Pair better PEP adherence with preventive strategies to advance national “Zero by 30” goals.

By situating our findings within the broader literature, it is clear that the drivers of non-compliance are consistent across diverse contexts, but targeted, context-specific interventions are essential to improve adherence and support the national goal of eliminating dog-mediated human rabies by 2030.

By situating our findings within the broader literature, it is clear that the drivers of non-compliance are consistent across diverse contexts, but targeted, context-specific interventions are essential to improve adherence and support the national goal of eliminating dog-mediated human rabies by 2030. This study has limitations. We report crude (unadjusted) odds ratios derived from aggregated cross-tabulations rather than individual-level multivariable models; therefore, estimates are directional, subject to residual and unmeasured confounding, and causal inference is not warranted. Reasons for non-compliance were self-reported by telephone and may be affected by recall and categorisation bias. We did not collect direct patient cost data e.g., travel expenses, wage loss; inferences regarding economic barriers are therefore indirect. As a single-centre urban tertiary-care study, findings may have limited generalisability to rural settings or other health-system contexts.

Conclusions

Compliance with the complete 5-dose intramuscular anti-rabies vaccination schedule in our setting was 80.4%, with negligence, competing work or school commitments, and forgetfulness being the primary barriers. These findings highlight the need for targeted interventions such as reminder systems, flexible clinic hours, decentralised service delivery, and shorter vaccination regimens to improve adherence. While these findings reflect an urban tertiary-care setting, similar barriers are likely to be more pronounced in rural or peripheral areas due to longer travel distances, limited vaccine availability, and higher opportunity costs, underscoring the need for decentralised, context-specific PEP delivery. Findings suggest that addressing behavioural and structural barriers may improve adherence, though further interventional studies are needed to confirm impact and help advance India’s 2030 elimination goal.

Author contributions

N.F. ​​conceptualized, designed, data analysis, data interpretation, and manuscript drafting; H.S.R. conceptualized, designed and data interpretation. All authors approved the submitted version and have contributed to the final version of the manuscript.

Funding

The authors received no specific funding for this work.

Data availability

The data that support the findings of this study are available from the corresponding author upon reasonable request.

Declarations

Ethics approval and consent to participate

The study was conducted in full compliance with the ethical guidelines set forth by the Declaration of Helsinki and the International Council for Harmonization’s (ICH) Good Clinical Practice (GCP) guidelines. Ethical approval was obtained from the Institutional Ethics Committee of KIMS Hospital (Ref. KIMS/IEC/D-06/2021) prior to the commencement of the study.

Informed consent

Informed consent was obtained from all participants or their legal guardians before their inclusion in the study. For participants aged 2–17 years, written informed consent was obtained from their parents or legal representatives, and written informed assent was obtained from participants aged 7–17 years. The consent process included a detailed explanation of the study’s purpose, procedures, potential risks, and benefits.

Consent for publication

Not applicable.

Competing interests

The authors declare no competing interests.