Animal Bite Management Facilities in aRural Area Near Bangalore

Introduction

Rabies also known as hydrophobia is an acute, progressive encephalitis or meningoencephalitis due to Lyssavirus, the most dreaded and lethal disease in man with highest case fatality rate for any infectious disease. Rabies being one of the oldest diseases known to mankind continues to kill thousands of people every year till today, despite the availability of effective vaccines and sera to prevent it.¹ About 35,172 human deaths and roughly 2.2 million DALYs loss occur per year in Asia due to dog-mediated rabies. India accounts for the most rabies deaths in Asia (59.9% of human rabies deaths) and globally (35% of human rabies deaths). Despite widespread underreporting and uncertain estimates, rabies is a major burden in Asia, particularly for the rural poor.²

After suspected or proven exposure to rabies virus, WHO in TRS-1012 recommends the prompt use of cell culture and embryonated egg-based rabies vaccines (CCEEVs) with proper wound management and simultaneous administration of rabies immunoglobulin for effective prevention of rabies, even after severe exposure. Post-exposure prophylaxis (PEP) consists of: local treatment of the wound promptly after exposure, a course of potent, effective rabies vaccine that meets WHO recommendations and administration of rabies immunoglobulin, if indicated.²

The vast majority of rabies deaths (84%) occur in rural areas. There are various reasons contributing to it, and difficulty in availability of health care facilities for animal bite management in these areas is one among them.³

Hence the present study was undertaken with an objective of assessing the availability of health care services for management of animal bites / exposure in rural areas.

Materials and methods

The study was conducted in the villages coming under field practice area of Rural Health Training Centre (RHTC), Kempegowda Institute of Medical Sciences (KIMS), Bangalore over a period of six months. A total of 56 villages covered by three primary health centre areas with a total of 46291 population were selected for the study.

The study began after being approved by institution ethics committee. All the health care facilities accessed by the local community for animal bite treatment in the study area were visited. The health care provider at the facility was contacted, explained the purpose of study and the data was collected after obtaining written informed consent. A total of three primary health centres, five subcentres, four private clinics and four pharmacies present in the study area were visited. The information regarding availability and storage of rabies biological (anti-rabies vaccine and rabies immunoglobulin) was collected by face-to-face interview of the health personnel in charge of these health centres using a check list, and also by observation of the storage of rabies biological in these health care facilities.

Results

The government health care facilities (primary health centres and sub centres) in the study area lacked the resources for animal bite management as observed during the visit to these facilities. Only two out of three primary health centres (PHC) had anti-rabies vaccine (ARV) at the time of study visit. Among the two PHCs which had ARVs only one PHC had regular supply of vaccine, whereas it was irregular in the other PHC (verified with stock book). Among the PHCs having ARV, in one of PHC, ARV was administered by a pharmacist, who was not trained in animal bite management/anti-rabies vaccine (ARV) administration. None of the PHCs had rabies immunoglobulin (RIG), and referred the case of animal bite to higher centre if wound was perceived as severe by the health care staff of PHCs.

Cold storage was available in all PHCs but none of the PHCs had temperature monitoring chart for the refrigerator which stored anti-rabies vaccines. It was also observed that food items and drinking water bottles were stored along with ARVs in the refrigerator. None of the sub-centres in the study area had anti-rabies vaccines (probably due to the non-storage of vaccines at SC level as per the norm). None of SCs had been practicing vaccination following animal bite, but referring the cases to PHC/ higher centres. All the PHCs and SCs referred the animal bite cases to higher centres, which are situated at a distance of 15-20 kilometers requiring 1.5-2 hours of travel time. (Table 1)

The private health care facilities (private clinics and pharmacies) too lacked in many aspects as follows: Three out of four private clinics available in the study area had facility of administering ARV and were practicing correct regimen of 5 doses of ARV to animal bite cases. However, discussion with the practitioners of these clinics revealed that though the practitioners prescribed and advised to complete 5 doses of ARV, hardly any animal bite cases completed the schedule. The dog bite/exposure case load for private practitioners in these clinics ranged from 1-2 per month in one clinic to 4-5 per month in the other clinic. Interestingly, it was revealed that the practitioners were advising RIG only for animal bite cases having multiple wounds of severe nature (practitioners never considered transdermal bites with minimal bleed/licks over mucosa as severe and potential threat for rabies), but advised full course of ARV for all animal bite cases consulting them. Another reason for avoiding RIG administration was the fear of anaphylaxis.

None of the private clinics stored anti-rabies vaccine. In the clinics where ARV was administered, the animal bite cases were advised to purchase ARV from the nearest pharmacy. Hence all the pharmacies available in the study area were visited and checked for the availability. Three out of four pharmacies had stock of antirabies vaccines (XP-RAB in one, VERORAB in two pharmacies). But discussion with pharmacist revealed that only two pharmacies out of four had regular supply of ARVs. None of the clinics and pharmacies had rabies immunoglobulin, and referred the case of animal bite to higher centre if the practitioners perceived wound is severe. None of the private practitioners have been trained in animal bite management and three of them were Bachelor of Ayurvedic Medicine and Surgery (BAMS) graduates and one was Bachelor of Medicine and Bachelor of Surgery (MBBS) graduate. Thus in three of clinics, ARV was administered by the BAMS graduates and only in one clinic ARV was administered by a MBBS graduate.

Cold storage was available in all the pharmacies but none of them had temperature monitoring chart for the refrigerator which stored anti-rabies vaccines. Also none of the refrigerators in which ARV had been stored had power backup and when asked specifically for the same, the pharmacists perceived that there is no harm for vaccines during power failure, indicating their lack of awareness and wrong perception. All the private practitioners referred only the animal bite cases which they perceived as severe to higher centres for rabies immunoglobulin, which are around 15-20 kilometers away requiring 1.5-2 hours of travel time.

Discussion

In poor, rural communities of Asia and Africa, the vast majority of human rabies deaths occur due to high incidence of dog-mediated rabies and difficulty in accessing timely, affordable, adequate post-exposure prophylaxis (PEP).²

Anti-rabies vaccine (ARV)

In the present study, it was observed that only two out of three primary health centres had anti-rabies vaccines and only one among them had regular supply of ARV. This shows that maintenance of adequate stock of anti-rabies vaccines at PHC is much needed. Studies in over 20 countries conducted to characterize PEP distribution and delivery systems showed that stock-outs were frequent, due to low budget allocation for rabies biologicals at central level, ineffective use of PEP at treatment centres and/or lack of accurate vaccine forecasting.² Also the animal bite victims are burdened to travel to referral centres which may increase the cost of treatment, travel time, loss of wages which in turn might result in failure of completion of post-exposure prophylaxis (PEP) schedule (drop outs). The ARVs if made available at all the PHCs may enhance compliance to PEP as well as reduce the aforesaid burden of bite victims.

Rabies immunoglobulin (RIG)

The present study revealed that none of the PHCs had rabies immunoglobulin. Similar was the situation in urban area as observed by Sudarshan MK et al. in 1995, who reported that the lifesaving anti-rabies serum (ARS)/ rabies immunoglobulin (RIG) was not available in any of the four state run government hospitals or at any of 86 ARV centres run by Bangalore City Corporation separately for treating animal bite patients.⁴ This shows that situation has remained the same in the rural areas near Bangalore. A technical stakeholders meeting held under the chairmanship of the Drug Controller General of India at New Delhi in December 2017 has identified the following problems and dilemmas related to rabies biologicals (ARV & RIG) in India: frequent shortages of life-saving rabies vaccines and rabies immunoglobulin for PEP because rabies biologicals are mostly procured by the state governments that often face resource crunch and hurdles in logistics within the states, low production levels of rabies biologicals in the public sector and the export of rabies biologicals from the private sector.⁵ There is an urgent need to scale up the production of rabies biologicals and make lifesaving RIG available in the rural areas for preventing human deaths due to rabies.⁶

Cold storage and temperature monitoring

All the primary health centres in the study area had cold storage facility with power backup, but none of them had temperature monitoring chart for the refrigerator in which anti-rabies vaccines (ARVs) were stored. Interestingly, the PHCs had monitoring chart for the ice lined refrigerators (ILRs) which stored vaccines under universal immunization programme (UIP). It was also noted that food items and water bottles were stored along with ARVs in the refrigerator, which is a wrong practice. This indicates lack of awareness among the staff of health centres regarding the storage of ARVs.

A study in a district of Karnataka showed that only 54.2% PHC’s had maintained temperature book till date. Around 87.5% PHCs had kept unused vaccines separately. All PHC’s had technical support when there is power cut for more than 48 hours; among them four had generator facility and remaining PHC’s used to shift the vaccine to the nearest PHC. Storage of food and laboratory specimens in vaccine refrigerators and the storage of vaccines on refrigerator door shelves was also observed. Similar was the state for anti-rabies vaccines in our study as none had maintained temperature book for the vaccines.⁷

The main problem is lack of orientation to the health personnel which was also reported in a study where out of the 40 respondents, only 16 were aware of the appropriate storage conditions for the vaccines. Eight had minimum and maximum thermometers but only one of these was monitored daily.⁸ A study conducted by Berhane Y et al. showed that vaccine storage in the refrigerator was not proper in three fourth of the centres.⁹ Grasso M et al., reported that out of 52 primary vaccination offices inspected, around three fourth centres had a refrigerator for vaccine storage and faulty procedures such as the storage of food and laboratory specimens in vaccine refrigerators and the storage of vaccines on refrigerator door shelves were noted.¹⁰ Pai HH et al. pointed that majority stored articles other than vaccines in their vaccine refrigerators. Twentyfive clinics (39.7%) equipped their refrigerators with UPS (uninterruptable power system). But in our study, only four PHCs had this facility. Also, they discovered inappropriately high temperatures (> 8 degrees C) in 22% of all the refrigerators.¹¹

The problem exists worldwide, but most affected are the rural areas of tropical countries like India. The irregular maintenance of cold chain for anti-rabies vaccines can lead to failure in development of adequate immune response against rabies virus in the vaccinated exposed victim that may prove fatal.

Training in animal bite management

The study revealed that none of the primary health centre staff including medical officers or sub-centre staff were trained in animal bite management. In fact in few health centres, it was observed that the pharmacist prescribes or administers the anti-rabies vaccine without a formal training in animal bite management. Also in private clinics, ARVs were administered by non-MBBS graduates who were not trained to do so. None of the staff were advising or administering RIGs, a lifesaving drug for Category III exposures. Instead, they were referring only the cases which they perceived as severe leading to misclassification of many Category III exposures as Category II exposures and not advising RIG for such cases. Such practices might prove fatal for an animal bite victim as he may contract rabies with inadequate post-exposure prophylaxis. Risk assessment of potential rabies exposure can be complex and confusing. Hence the attending physicians should be trained in animal bite management as well as when in doubt, PEP should be initiated and the attending physician should consult a specialist at Anti Rabies Clinic (ARC). Also in the present study, the health centre staff feared of anaphylactic reactions for RIG, which are in fact extremely rare.¹²

A network of specialized animal bite centres should be set up where staffs are trained in provision of PrEP and PEP and management of adverse reactions, where the supply of adequate quantities of rabies biological (antirabies vaccine and rabies immunoglobulin) is ensured. There needs to be a referral system to maximize the benefit of the ID regimen and reduce the amount of leftover vaccine. A quality assurance system should also be established, with set standards that will be followed by all the centres. Importantly, provincial and municipal governments should be involved in order to support the establishment of new centres, to ensure sustainability of the supply of vaccines/RIG and other immunization products, and to guarantee reporting, investigation of human rabies cases and monitoring of the rabies programme.¹³

Majority (84%) of rabies deaths occur in rural areas.² With such a skewed distribution of rabies deaths towards rural areas, the non-availability or inadequate availability of health care services for animal bite management in these areas pose a great challenge in the path of rabies prevention and elimination.

Conclusion

The study showed that the health care facilities lacked the training and resources for animal bite management in the rural area near Bangalore. Recommendation There is an urgent need to train the staff of health care facilities in animal bite management and make the rabies biological (ARV and RIG) available round the clock in adequate quantity.

Limitation of the study

The study was limited to health care facilities situated in the rural field practice area of the medical college. Traditional healers, whom the animal bite victims’ approach in the villages, could not be reached due to their non-availability during the study period. The study was limited to the observations and in-depth analysis for the results obtained needs to be carried out in further studies, preferably by qualitative methods.

Acknowledgments

Medical Officers and other staff of PHCs, Junior Health Assistant Females (JHAF) of sub-centres, Private practitioners of private clinics, Pharmacists of pharmacies in the study area for providing the data and allowing the authors to inspect their facilities. Dr. Rachana AR for assisting in data collection.

Conflict of interest

None.