ABSTRACT
Aim
Rabies is a universally fatal yet preventable disease when post‐exposure prophylaxis (PEP) is administered promptly and appropriately. To describe exposure characteristics, risk categorization and real‐world PEP practices among children in an endemic urban setting.
Methods
We conducted a retrospective study of children (< 18 years) presenting with rabies‐risk contact between January 2013 and October 2023. Data were extracted from the provincial (İzmir) rabies surveillance system and included demographics, exposure type, time to presentation, animal species, risk category, wound care, rabies vaccination, rabies immunoglobulin (RIG) and tetanus prophylaxis.
Results
A total of 3732 children were included (median age 9 years, IQR 5–13), with 63.3% being male. Most exposures involved dogs (49.8%) and cats (44.8%) and occurred in İzmir. Same‐day presentation occurred in 48.8% of cases, while 0.9% presented after more than 30 days. Risk categorization was documented in only 33.6% of patients, most commonly Category II (61.5%) and Category III (30.5%). RIG was administered to 2.6% of patients and more frequently after wild animal exposures.
Conclusion
Substantial gaps in risk documentation and variability in pediatric rabies PEP practices were observed, highlighting the need for standardized risk assessment and improved clinical guidance.
Keywords: animal bites, children, post‐exposure prophylaxis, rabies, rabies immunoglobulin
Summary
This study was needed because real‐world data on rabies post‐exposure prophylaxis in children in endemic urban settings is limited.
It found that although many children presented early, risk categorization was often undocumented and variability existed in prophylaxis practices, including low use of rabies immunoglobulin.
These findings highlight the need for standardized risk assessment, improved documentation and decision‐support systems to optimize clinical management.
Abbreviations
- IQR
interquartile range
- PEP
post‐exposure prophylaxis
- RIG
rabies immunoglobulin
- SPSS
statistical package for the social sciences
- WHO
World Health Organization
1. Introduction
Rabies is a severe and progressive viral encephalitis that remains almost uniformly fatal once clinical symptoms develop [1]. Despite this, rabies is entirely preventable through timely and appropriate post‐exposure prophylaxis (PEP), which constitutes one of the most effective public health interventions in infectious diseases [2]. Standard PEP includes immediate and thorough wound care, administration of rabies vaccine, and, when indicated, rabies immunoglobulin (RIG). Depending on the nature of the exposure, additional interventions such as tetanus prophylaxis and antibiotic therapy may also be required [2, 3].
Clinical decision‐making regarding rabies PEP is guided by exposure risk categories defined by the World Health Organization (Categories I–III) and, in some countries, by national guidelines that include additional subcategories. These categories are based on the type of contact, the animal involved and the integrity of the skin or mucosal surfaces, and they determine the need for vaccination and RIG administration [3]. Accurate risk classification is essential to ensure adequate protection against rabies while avoiding unnecessary use of vaccines and immunoglobulin, which may contribute to increased healthcare costs and strain on limited resources [4].
Children represent a particularly vulnerable population in the context of rabies exposure. They are more likely to sustain severe bites to the head and upper extremities, may have difficulty providing a reliable exposure history, and can experience delays in seeking medical care due to caregiver‐related factors. In addition, inappropriate or delayed prophylaxis in paediatric patients may have devastating consequences given the almost universally fatal outcome of untreated rabies.
Türkiye remains endemic for rabies, with the majority of human exposures attributed to dogs and cats [5, 6]. Large metropolitan areas experience a substantial burden of rabies‐risk contacts each year, creating significant workload for emergency departments and public health surveillance systems. Although national guidelines for rabies prophylaxis are well established, real‐world data evaluating the implementation of these recommendations in paediatric populations are limited. In particular, long‐term data on exposure characteristics, timeliness of presentation, completeness of risk documentation and adherence to recommended prophylaxis strategies are scarce.
Understanding local epidemiological patterns and real‐life prophylaxis practices is critical for identifying gaps in rabies prevention strategies and for improving both clinical management and public health planning [7]. Large‐scale, long‐term paediatric data can provide valuable insights into system‐level challenges, including documentation practices, risk stratification and resource utilization.
Therefore, the aim of this study was to retrospectively evaluate the demographic characteristics, exposure patterns, risk categorization and post‐exposure prophylaxis practices among children who received rabies PEP at a tertiary referral centre in İzmir, Türkiye, over an 11‐year period.
2. Materials and Methods
2.1. Study Design and Setting
This retrospective observational study was conducted at İzmir Tepecik Training and Research Hospital, a tertiary referral centre serving a large metropolitan population in western Türkiye. The study included paediatric patients evaluated for rabies‐risk exposure over an 11‐year period, from January 2013 to October 2023.
2.2. Study Population
Children younger than 18 years of age who presented with suspected rabies exposure and received post‐exposure prophylaxis were eligible for inclusion. Patients with incomplete demographic data were excluded. All cases were identified through the İzmir Provincial Directorate of Health Rabies Suspected Contact Notification System.
2.3. Data Collection
Data were extracted from the provincial surveillance database and included age, sex, city of residence, location of exposure, time between exposure and hospital presentation, animal species involved, animal vaccination and ownership status, documented rabies risk category, wound care, planned rabies vaccination schedule, rabies immunoglobulin administration and tetanus prophylaxis.
Vaccination status was based on caregiver report and surveillance records and was frequently unknown or undocumented.
Exposure Categories (I–IV) Were Defined According to the 2019 Turkish Ministry of Health Rabies Prophylaxis Guideline (Table S1) [8].
Rabies Vaccination Schedule a Total of Four Doses Are Administered in PEP: One Dose on Days 0, 3 and 7, and a Fourth Dose Between Days 14 and 28.
2.4. Outcome Measures
The primary outcomes were patterns of rabies exposure and post‐exposure prophylaxis practices, including wound care, vaccination schedules, RIG administration and tetanus prophylaxis. Secondary outcomes included associations between animal type and prophylactic interventions.
2.5. Statistical Analysis
Data Were Analyzed Using IBM SPSS Statistics Version 26.0 (IBM Corp., Armonk, NY, USA). Categorical Variables Were Summarized as Frequencies and Percentages, and Continuous Variables Were Expressed as Medians With Interquartile Ranges (IQR) and Ranges. Associations Between Categorical Variables Were Assessed Using Pearson's Chi‐Square Test or Fisher's Exact Test, as Appropriate. A p‐Value < 0.05 Was Considered Statistically Significant.
2.6. Ethical Approval
The study was conducted according to the guidelines of the Declaration of Helsinki and approved by the Institutional Ethics Committee of İzmir Tepecik Education and Research Hospital (Protocol number: 2023/10–29 and Date of approval: 20 November 2023). Verbal informed consent was obtained from all participants and their legal guardians.
3. Results
3.1. Demographic Characteristics
A total of 3732 paediatric patients were included in the study. The median age was 9 years (IQR: 5–13; range: 0–18). Children aged ≤ 1 year constituted 2.5% (n = 91) of the cohort. Male patients predominated (63.3%, n = 2362), while 36.7% (n = 1368) were female. Almost all patients (99.0%) resided in İzmir, and exposure occurred within İzmir in 99.9% of cases. Only three exposures were reported outside the city (Table 1).
TABLE 1.
Demographic and exposure characteristics of paediatric rabies cases (N = 3732).
| Characteristic | n (%) or median (IQR) |
|---|---|
| Age, years | 9 (5–13) |
| Age ≤ 1 year | 91 (2.5) |
| Sex | |
| Male | 2362 (63.3) |
| Female | 1368 (36.7) |
| Residence city | |
| İzmir | 3695 (99.0) |
| Other | 37 (1.0) |
| Location of exposure | |
| İzmir | 3729 (99.9) |
| Outside İzmir | 3 (0.1) |
| Time from exposure to presentation | |
| Same day | 1821 (48.8) |
| ≥ 30 days | 29 (0.9) |
| Animal involved | |
| Dog | 1858 (49.8) |
| Cat | 1672 (44.8) |
| Other | 182 (4.9) |
| Wild animal | 20 (0.5) |
| Animal vaccinated | |
| Yes | 46 (1.2) |
| No | 3686 (98.8) |
| Animal owned | |
| Yes | 38 (1.0) |
| No | 3694 (99.0) |
Note: Data are presented as n (%) or median (interquartile range, IQR).
3.2. Time From Exposure to Hospital Admission
The median time between exposure and hospital admission was 1 day (min‐max: 0–51). Nearly half of the patients (48.8%) presented to the hospital on the same day as exposure. An additional 13.0% presented within 1 day. Delayed presentation was uncommon; 29 patients (0.9%) sought medical care more than 1 month after exposure (Table 1).
3.3. Characteristics of Animal Exposure
The most common animals involved were dogs (49.8%) and cats (44.8%), followed by other animals (4.9%) and wild animals (0.5%). The vast majority of animals were unvaccinated (98.8%) and unowned (99.0%) (Table 1).
3.4. Risk Categorization and Prophylaxis
Risk categorization was documented in 1254 patients (33.6%). The distribution of rabies risk categories is shown in Table 2.
TABLE 2.
Distribution of rabies risk categories (n = 1254).
| Risk category | n | % |
|---|---|---|
| Category I | 84 | 6.7 |
| Category II | 771 | 61.5 |
| Category III | 383 | 30.5 |
| Category IV | 16 | 1.3 |
Note: Only patients with documented risk categorization. Category IV represents exposures classified according to the national guideline and is not included in the WHO classification.
Wound care was performed in 57.9% of patients. The standard 4‐dose rabies vaccination schedule was planned in 77.0% of cases. Rabies immunoglobulin was administered to 2.6% (n = 98) of patients, while 35.7% received tetanus vaccination.
3.5. Associations Between Animal Type and Prophylactic Interventions
3.5.1. Wound Care
Wound care was performed significantly more often following dog‐related injuries compared with other animal exposures (p = 0.041) (Table 3).
TABLE 3.
Association between animal type and wound care.
| Animal type | Wound care performed n (%) | No wound care n (%) | p |
|---|---|---|---|
| Dog | 1119 (60.2) | 739 (39.8) | 0.041 |
| Cat | 956 (57.2) | 716 (42.8) | |
| Wild animal | 9 (45.0) | 11 (55.0) | |
| Other | 78 (42.9) | 104 (57.1) |
Note: Percentages are calculated within animal type. p value derived from Pearson's chi‐square test.
3.5.2. Rabies Immunoglobulin
Rabies immunoglobulin administration was significantly higher in exposures involving wild animals compared with domestic animals (p < 0.001) (Table 4).
TABLE 4.
Association between animal type and rabies immunoglobulin (RIG) administration.
| Animal type | RIG administered n (%) | No RIG n (%) | p |
|---|---|---|---|
| Dog | 74 (4.0) | 1784 (96.0) | < 0.001 |
| Cat | 15 (0.9) | 1657 (99.1) | |
| Wild animal | 2 (10.0) | 18 (90.0) | |
| Other | 7 (3.8) | 175 (96.2) |
Note: Percentages are calculated within animal type. p value derived from Pearson's chi‐square test.
3.5.3. Tetanus Vaccination
Similarly, tetanus vaccination was administered at a significantly higher rate in wild animal–related injuries (p = 0.011) (Table 5).
TABLE 5.
Association between animal type and tetanus prophylaxis.
| Animal type | Tetanus prophylaxis n (%) | No tetanus prophylaxis n (%) | p |
|---|---|---|---|
| Dog | 776 (41.8) | 1082 (58.2) | 0.011 |
| Cat | 504 (30.1) | 1168 (69.9) | |
| Wild animal | 10 (50.0) | 10 (50.0) | |
| Other | 44 (24.2) | 138 (75.8) |
Note: Percentages are calculated within animal type. p value derived from Pearson's chi‐square test.
4. Discussion
In this large, long‐term retrospective study, we evaluated rabies exposure characteristics and PEP practices among children presenting to a tertiary centre in Türkiye over an 11‐year period. Our findings provide comprehensive real‐world data from a high‐volume urban setting and highlight both strengths and critical gaps in paediatric rabies prevention practices.
At the national level, a substantial number of animal rabies cases continue to be reported; however, only a few human rabies cases were reported during the study period, underscoring the low incidence of the disease in humans [8, 9, 10]. This epidemiological context highlights the effectiveness of existing rabies control strategies while emphasizing the critical role of timely and appropriate post‐exposure prophylaxis in maintaining this favourable outcome [2, 3, 7, 8].
Timely initiation of rabies PEP is critical, as delayed prophylaxis may compromise its effectiveness, particularly in severe exposures involving deep wounds or high‐risk anatomical sites. In our cohort, nearly half of the children presented on the same day as exposure, which is comparable to rates reported from other middle‐income countries with established rabies control programs [5, 6, 11]. However, a considerable proportion of patients sought medical care after the first 24 h, and a small but clinically relevant subset presented more than 30 days after exposure.
Delayed presentation following rabies‐risk contact has been consistently reported in paediatric populations and is often influenced by caregiver‐related factors, misperception of risk, or underestimation of minor animal bites or scratches [12]. Children may be particularly vulnerable to such delays, as exposures are not always witnessed, and symptoms at the exposure site may appear minimal. These findings emphasize the continued need for community‐based education programs targeting caregivers and school‐aged children, even in urban settings with good healthcare accessibility.
Dogs and cats accounted for the vast majority of rabies‐risk contacts in our study, consistent with national surveillance data from Türkiye and reports from other rabies‐endemic countries [1, 13]. While dog‐related exposures slightly predominated in our cohort, other paediatric series from Türkiye and Europe have reported higher proportions of cat‐related contacts [5, 6, 11]. Such discrepancies likely reflect regional differences in animal population dynamics, urban stray control policies and cultural attitudes toward domestic animals. These variations underline the importance of locally tailored rabies prevention strategies rather than reliance on uniform national or international assumptions. Urban endemic settings, in particular, may require different public health approaches compared with rural or peri‐urban regions, where dog‐mediated transmission remains the dominant concern [1, 14].
Interpretation of animal vaccination status should be cautious, as this information was frequently based on caregiver reports and incomplete surveillance records.
Accurate rabies exposure risk categorization is fundamental to appropriate PEP decision‐making, ensuring that vaccination and RIG are used judiciously and in accordance with established guidelines [2, 3]. In our study, formal risk categorization was documented in only one‐third of patients. This finding should not be interpreted merely as missing data, but rather as an indicator of real‐life clinical practice in high‐volume paediatric emergency departments.
Similar gaps between guideline recommendations and routine documentation have been reported in both adult and paediatric rabies studies from diverse healthcare systems [11, 15, 16]. In busy emergency settings, clinicians may initiate PEP based on clinical judgement without explicitly recording exposure categories, potentially leading to defensive medical practices, including unnecessary vaccination or omission of RIG in high‐risk cases. The absence of standardized documentation may also hinder surveillance accuracy and public health planning.
Appropriate wound care is a cornerstone of rabies prevention and has been shown to significantly reduce viral load at the exposure site [2]. In our cohort, wound care was more frequently performed following dog‐related injuries, likely reflecting the higher severity and contamination associated with dog bites. Similar patterns have been observed in paediatric studies from Asia and Eastern Europe [5, 11].
RIG and tetanus prophylaxis were administered significantly more often in wild animal exposures, consistent with guideline‐based risk perception. Nevertheless, the overall rate of RIG administration in our study was low. Underuse of RIG has been repeatedly documented in endemic countries and is often attributed to limited availability, cost concerns, or uncertainty regarding indications [11, 17]. Given the potentially fatal consequences of inadequate prophylaxis, improving adherence to RIG recommendations remains a critical priority in paediatric rabies management. Since our centre is a tertiary hospital, there are no issues regarding the availability of RIG.
Recent studies have demonstrated that system‐level interventions, including clinical decision‐support tools integrated into emergency department workflows, can significantly improve guideline adherence and optimize RIG use. Mobile health applications and structured educational programs targeting healthcare professionals have also shown promise in enhancing risk assessment accuracy and reducing unnecessary vaccination [18, 19].
Our findings support the implementation of such interventions in high‐burden urban centres. Standardized electronic documentation, mandatory risk categorization fields and clinician‐facing decision‐support systems may help bridge the gap between guidelines and real‐world practice, ultimately improving the effectiveness and efficiency of paediatric rabies prevention strategies.
4.1. Strengths and Limitations
This study has several notable strengths. First, it represents one of the largest paediatric rabies post‐exposure prophylaxis series reported from Türkiye, encompassing 3732 children over an 11‐year period, which provides substantial statistical power and temporal depth. Second, the use of a provincial‐level rabies surveillance and notification system allowed for comprehensive capture of real‐world clinical practice across a high‐volume urban setting, rather than a narrowly defined clinical cohort. This enhances the generalizability of our findings to similar metropolitan areas in endemic countries.
Another important strength is the detailed evaluation of multiple components of post‐exposure management, including wound care, vaccination schedules, rabies immunoglobulin and tetanus prophylaxis. The availability of these data enabled us to explore clinically meaningful associations between animal type and prophylactic interventions, which are often underreported in paediatric rabies studies. Finally, the long observation period allowed us to identify persistent practice patterns and system‐level challenges that may not be apparent in short‐term or single‐year analyses.
Several limitations should be acknowledged. The retrospective design of the study precluded assessment of clinical outcomes beyond prophylaxis administration and limited our ability to evaluate causality. Risk category documentation was incomplete, limiting formal assessment of guideline adherence; however, this also highlights an important real‐world challenge in routine paediatric emergency care.
Furthermore, information on animal follow‐up, laboratory confirmation of rabies and patient adherence to the full vaccination schedule was not consistently available through the surveillance system. Finally, as this was a single‐centre study conducted in a large urban area, regional differences in animal ecology and healthcare access may limit extrapolation of our findings to rural settings.
5. Conclusion
In high‐burden urban settings, improving rabies prevention in children requires not only access to vaccines and immunoglobulin, but also structured documentation, standardized risk assessment and clinician‐facing decision‐support tools integrated into routine emergency care.
Author Contributions
Selin Taşar Karabulut: writing – original draft, validation, visualization, methodology, formal analysis, data curation, supervision. Dilek Yılmaz: conceptualization, investigation, methodology, validation, writing – review and editing, resources, supervision. Nilay Lemay: visualization, software, formal analysis, project administration, data curation. Ahu Kara‐Aksay: conceptualization, investigation, writing – original draft, methodology, validation, visualization, writing – review and editing, software, project administration, resources, supervision, formal analysis, data curation, funding acquisition. Ayşegül Elvan‐Tüz: writing – original draft, validation, methodology, formal analysis, software, data curation, resources. Gizem Avcı Demirciler: visualization, software, formal analysis, project administration, data curation. Aslıhan Arslan Maden: writing – original draft, visualization, validation, formal analysis, software, data curation. Nesli Ağralı Eröz: writing – original draft, methodology, validation, software, formal analysis, supervision.
Funding
The authors have nothing to report.
Ethics Statement
The study was conducted according to the guidelines of the Declaration of Helsinki and approved by the Institutional Ethics Committee of İzmir Tepecik Education and Research Hospital (Protocol number: 2023/10‐29 and Date of approval: 20 November 2023). Verbal informed consent was obtained from all participants and their legal guardians.
Conflicts of Interest
The authors declare no conflicts of interest.
Supporting information
Table S1: Prophylaxis in rabies risk exposures.
Acknowledgements
The authors have nothing to report.
Data Availability Statement
The data that support the findings of this study are available from the corresponding author upon reasonable request.
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Associated Data
This section collects any data citations, data availability statements, or supplementary materials included in this article.
Supplementary Materials
Table S1: Prophylaxis in rabies risk exposures.
Data Availability Statement
The data that support the findings of this study are available from the corresponding author upon reasonable request.