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 Table of Contents  
Year : 2022  |  Volume : 8  |  Issue : 4  |  Page : 199-204

Compliance rate of anti-rabies vaccination in patients presenting with an animal bite

Department of Emergency Medicine, Christian Medical College, Vellore, Tamil Nadu, India

Date of Submission16-Jun-2022
Date of Acceptance01-Sep-2022
Date of Web Publication28-Dec-2022

Correspondence Address:
Dr. Darpanarayan Hazra
Department of Emergency Medicine, Christian Medical College, Vellore - 632 004, Tamil Nadu
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Source of Support: None, Conflict of Interest: None

DOI: 10.4103/ijam.ijam_54_22

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Introduction: To prevent rabies in animal bite victims, complete postexposure prophylaxis (PEP) with an anti-rabies vaccination (ARV) is essential. This study was done to determine the compliance rate of ARV in patients with animal bites who presented to the emergency department (ED) during the COVID-19 pandemic.
Materials and Methods: This was a prospective observational study done on patients presenting to the ED with a history of animal bites over 1 year (May 2020–June 2021). Categorical variables were presented as percentages, and quantitative variables were summarized using mean and standard deviation (SD).
Results: A total of 122 animal bite (World Health Organization [WHO] Category II and III) victims presented to the ED during the study. The mean age of the cohort was 38.12 (SD: 16.4) years with a male (n = 67: 54.9%) preponderance. Based on the physiological stability, a majority were triaged as priority III (n = 119; 97.5%). Most patients presented with dog bites (n = 88; 72.1%), followed by cat (n = 14; 11.5%) and rat bites (n = 13; 10.7%). Two-thirds were unprovoked (n = 82; 67.2%) and were caused by stray animals (n = 62; 50.8%). More than half (n = 65; 53.3%) of the bites were WHO Category III bites. All Category II and III patients had received the first dose of ARV at our center and category III patients received immunoglobulin local injection as well. Noncompliance to ARV was seen in almost a quarter (n = 32; 26.2%) of patients of which forgotten dates (n = 11; 34.4%) were the most common cause. There was no significant statistical variable to determine the cause of noncompliance.
Conclusion: Unprovoked bites by stray dogs were the cause of a majority of the animal bites. Compliance with PEP remains low at two-thirds of the total. The most common cause of noncompliance to ARV was due to forgotten dates.
The following core competencies are addressed in this article: Medical knowledge, Systems-based practice, Practice-based learning and improvement.

Keywords: Anti-rabies vaccination, compliance rate, dog bite, postexposure prophylaxis

How to cite this article:
Pal R, Vegiraju V, Hazra D, Nekkanti AC, Abhilash KP. Compliance rate of anti-rabies vaccination in patients presenting with an animal bite. Int J Acad Med 2022;8:199-204

How to cite this URL:
Pal R, Vegiraju V, Hazra D, Nekkanti AC, Abhilash KP. Compliance rate of anti-rabies vaccination in patients presenting with an animal bite. Int J Acad Med [serial online] 2022 [cited 2023 Jan 31];8:199-204. Available from: https://www.ijam-web.org/text.asp?2022/8/4/199/365556

  Introduction Top

Rabies is a viral infection of the neurological system that is spread by the bite of rabid animals such as dogs, rats, cats, bats, racoons, and foxes.[1],[2] It is also one of the deadliest viruses, with a near 100% case-fatality rate once symptoms appear.[1] Dogs are the most common cause of human rabies mortality (domestic or stray) in India.[3] According to the latest World Health Organization (WHO) statistics, India has between 18,000 and 20,000 cases of human rabies per year, making it a common occurrence in both rural and urban areas.[3],[4] In the last decade, there has been a steady decline in the admission rates and deaths due to human rabies in urban areas, thanks to largely improved vaccination rates for postexposure prophylaxis (PEP).[5],[6] However, because a large proportion of the cases come from rural areas, the majority of which are not recorded, these statistics do not reflect the full picture.

Patients usually present to the emergency department (ED) immediately following the bite and are managed with thorough wound wash, antibiotics, diphtheria toxoid, anti-rabies vaccination (ARV), and local administration of immunoglobulin as per established guidelines for the different types of bites.[7],[8] ARV is administered as an intensive five-dose intramuscular regimen, on days 0, 3, 7, 14, and 28. Alternatively, a 2-1-1 regimen can be followed with two doses administered on day 0, and one dose each on days 7 and 21.[7],[8] If the dose or subsequent booster doses are missed, it can lead to catastrophic disease, whereas with the use of PEP, this sickness can be completely avoided. The importance of following this strict schedule should be particularly emphasized to and by the doctors working in the ED, and in primary health-care centers. Despite best efforts, compliance with the full regimen remains a concern in most places. This prospective observational study was conducted in the ED of a large tertiary care referral center to study the rate of ARV compliance and the barriers to ARV noncompliance.

  Materials and Methods Top

This was a prospective observational study conducted in a 49-bed ED of a large tertiary care referral center in South India that caters to almost 75,000 emergencies per year. The study population were recruited over 12 months from May 2020 to April 2021. All adult patients more than 18 years old presenting to the ED with a history of animal bites requiring PEP, i.e., WHO Category II and III bites, were included in the study after obtaining informed written consent. Patients with Category I bites were excluded as ARV was not administered to them. Patients who could not be contacted over the phone or were not willing to participate in the study were excluded. After the first visit, patients were followed up by a phone call, at the end of 1 month to determine compliance with the advised ARV schedule and the reason for noncompliance.

The following variables were collected in a standard data abstraction sheet at enrollment: demographic details, socio-economic details of the victim, animal bite-related details, and the treatment administered in the ED. The outcome variables included compliance with ARV on scheduled dates and the reason for noncompliance with the same. Data were summarized using mean along with standard deviation (SD) for continuous variables and frequencies along with percentages for categorical variables. Data analysis was done using Statistical Package for Social Sciences (SPSS) for Windows (IBM Corp. Released 2017. IBM SPSS Statistics for Windows, Version 25.0, Armonk, NY, USA). Dichotomous variables were compared using Chi-square tests. The factors associated with noncompliant of ARV in these victims were determined by univariable analysis and their 95% confidence intervals were calculated. A two-sided P < 0.05 was considered statistically significant.

This study was approved by the Institution Review Board (IRB) and Ethics committee (IRB Min no: 12909 dated June 8, 2020). Informed and written consent was obtained from each of the study participants. Patient confidentiality was maintained using unique identifiers and password-protected data entry software with restricted users.

  Results Top

During the 12-month study, a total of 122 animal bite victims presented to the ED [Figure 1]. The mean age was 38.12 (SD: 16.4) years with a male (n = 67: 54.9%) preponderance. Baseline characteristics, comorbidities, and socio-economic status of the victims are shown in [Table 1]. Based on the physiological assessment of vital signs at presentation to the ED, the majority were triaged as priority III (n = 119; 97.5%). Most patients presented with dog bites (n-88; 72.1%), followed by cat (n = 14; 11.5%) and rat bites (n = 13, 10.7%). Two-thirds were unprovoked (n = 82; 67.2%) and were caused by stray animals (n = 62; 50.8%); these details are summarized in [Table 2]. The clinical features, WHO classification of bites, and surgical classification of bites are given in [Table 3]. Based on WHO wound classification for animal bites, majority (n = 65; 53.3%) were category III bites, remaining (n = 57; 46.7%) had category II bites. As per guidelines, all patients (WHO category II and III bites) were treated with wound wash, antibiotics, and diphtheria toxoid. In addition, all Category II and III patients received the first dose of ARV at our center while all Category III patients were prescribed local immunoglobulin administration. At 1-month follow-up, three-fourths (n = 90; 73.8%) of the patients were compliant with the 5-dose regimen of ARV. On enquiry, common reasons for noncompliance included forgotten dates (n = 11; 34.4%) day-to-day busy schedule (n = 9; 28.1%), logistical constraints (n = 2; 6.3%), other health-related issues (n = 3; 9.4%) or were stopped by other physicians (n = 7; 21.8%); these details are shown in [Figure 2]. We performed univariate analysis to correlate factors such as mean age, gender, socio-economic determinants like education, occupation and income, and severity of the wound with noncompliance to ARV [Table 4]. However, none of the above factors had a significant association with noncompliance to ARV.
Figure 1: STROBE diagram. ARV = Anti-rabies vaccination, WHO = World Health Organization

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Table 1: Baseline characteristics, occupation, vital signs at presentation and socioeconomic class (n=122)

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Table 2: Animal bite related details (n=122)

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Table 3: Clinical features/World Health Organization classification/surgical classification of animal bites (n=122)

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Figure 2: Reasons of noncompliance to ARV. ARV = Anti-rabies vaccination

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Table 4: Univariate analysis to predict factors associated with noncompliance to anti-rabies vaccine

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  Discussion Top

Our study population showed a distressing and significant rate of noncompliance with ARV, predominantly due to an inability to keep track of the complicated rabies schedule, and this complacency must be tackled. We conducted this study to also assess compliance in a world where the pandemic made travel and hospital visits extremely challenging. ARV is particularly susceptible to missed appointments due to a multiple-dose regimen, lack of external symptoms until the disease develops, and a poor understanding of the disease process and its lethality. In addition, bites by household animals, unless severe, are treated with a somewhat carefree attitude as owners tend to be more forgiving of their pets.

The male predominance seen in our study was similar to other studies such as those by Dhaduk et al., and Sudarshan et al.[5],[9] A possible reason for this could be cultural factors in India, wherein the males tend to work outdoors, whereas the women tend to stay at home. As per national data, dog bites are the most common cause of rabies by a huge margin at 96% of the cases.[3] This is reflected in the findings of our study and a multi-centric study in India.[5],[10] This highlights the importance of identifying rabid dogs, controlling the stray population, and neutering them to prevent breeding and adoption of rehabilitated strays. These are massive undertakings that would require the collaboration of multiple levels of government and other nonprofit organizations.

All Category II and III patients that presented to us received the first dose of ARV, and category III patients received local immunoglobulin injection as well. Immunoglobulin is a vital part of PEP and should be made as widely available as the vaccine, even to remote parts of the country. Health-care workers in rural areas should also be educated regarding the correct method of administration of immunoglobulin for it to be beneficial.

A quarter of the patients in our study were noncompliant with their vaccination schedule, a finding that is echoed in other Indian studies.[11],[12],[13] The main reasons for noncompliance, as obtained by telephonic interviews of the participants, were forgotten dates, interfering day-to-day activities, logistical constraints, and other health-related issues which were inconsistent with other studies.[11],[12],[13] While a reasonable assumption can be made that the rates of noncompliance would be higher among the lower socio-economic groups due to lack of education, inaccessibility of healthcare, and the restrictions of daily wage labor, our study did not find any such statistical difference. We can be sceptical of this finding, due to the relatively small sample size of our study. It is unsure whether the rates of compliance in our study were affected by the pandemic itself, though there was a fall in the number of patients presenting to our ED with animal bites compared to prepandemic levels, suggesting that patients may have found it difficult to access adequate treatment on the first visit itself.[14]

We can make several suggestions for improving compliance rates among the population, the most important of which is widespread education to both health-care workers and the general population regarding the disease and its outcomes and the need for strict adherence to the vaccination schedule. Equally vital is ensuring an adequate supply of vaccines and immunoglobulin to all areas of the country, rural and urban, providing treatment free of cost, and administering doses at a local center to prevent interfering with the daily activities of patients. Reminders to patients regarding dates through phone calls or mobile applications can help improve rates of compliance. The role of community health workers cannot be underestimated in this situation, as they are frequently the point of contact between patients in remote areas and their health-care team.


No statistically significant conclusions could be drawn on the factors of noncompliance from our study. In addition, this study was done at a single referral tertiary center, creating the potential for referral bias. Finally, this study was conducted purely on adults, shedding no light on the rates of compliance in the pediatric population.

  Conclusion Top

Unprovoked bites by stray dogs were the cause of a majority of the animal bites in our study population. Most patients were in the upper-lower socioeconomic class. The most common cause of noncompliance was forgotten dates, which underlines the importance of proper education, adequate social support, and regular reminders.

Financial support and sponsorship


Conflicts of interest

There are no conflicts of interest.

Research quality and ethics statement

This study was approved by the Institutional Review Board/Ethics Committee at Christian Medical College and Hospital, Vellore, Tamil Nadu (IRB Min no: 13781 dated 27th January 2021). The authors followed the applicable EQUATOR Network (http://www.equator-network.org/) guidelines, specifically the STROBE guidelines, during the conduct of this research project. We also certify that we have not plagiarized the contents in this submission and have done a plagiarism check.

  References Top

Hemachudha T, Ugolini G, Wacharapluesadee S, Sungkarat W, Shuangshoti S, Laothamatas J. Human rabies: Neuropathogenesis, diagnosis, and management. Lancet Neurol 2013;12:498-513.  Back to cited text no. 1
Banyard AC, Tordo N. Rabies pathogenesis and immunology. Rev Sci Tech 2018;37:323-30.  Back to cited text no. 2
Rabies. Available from: https://www.who.int/news-room/fact-sheets/detail/rabies. [Last accessed on 2022 February 17].  Back to cited text no. 3
Rabies – India. Available from: https://www.who.int/westernpacific/health-topics/rabies. [Last accessed on 2022 February 17].  Back to cited text no. 4
Sudarshan MK, Madhusudana SN, Mahendra BJ, Rao NS, Ashwath Narayana DH, Abdul Rahman S, et al. Assessing the burden of human rabies in India: Results of a national multi-center epidemiological survey. Int J Infect Dis 2007;11:29-35.  Back to cited text no. 5
Radhakrishnan S, Vanak AT, Nouvellet P, Donnelly CA. Rabies as a public health concern in India-a historical perspective. Trop Med Infect Dis 2020;5:162.  Back to cited text no. 6
Desai AN. Dog bites. JAMA 2020;323:2535.  Back to cited text no. 7
Rabies Vaccines and Immunoglobulins: WHO Position April 2018. Available from: https://www.who.int ' pp_rabies_summary_2018. [Last accessed on 2022 February 17].  Back to cited text no. 8
Dhaduk KM, Unadkat SV, Katharotiya PR, Mer AR, Chaudhary MC, Prajapati MM. Case profile, volume analysis, and dropout rate of antirabies vaccination regimens among animal bite victims in Gujarat. Indian J Public Health 2016;60:268-72.  Back to cited text no. 9
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Domple V, Doibale M, Sonkar V, Aswar N, Khadilkar H, Jain S. Treatment compliance of self-reported dog bite cases attending outpatient department of Tertiary Care Hospital, Maharashtra. Int J Med Public Health. 2015;5(4):297–300.  Back to cited text no. 12
Wadde SK, Edake SS, Dixit JV, Nagaonkar AS. Non-compliance of post exposure prophylaxis amongst dog bite cases attending antirabies clinic of a tertiary care hospital-A record based study. Natl J Community Med 2018;9:643.  Back to cited text no. 13
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  [Figure 1], [Figure 2]

  [Table 1], [Table 2], [Table 3], [Table 4]


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