Rabies encephalitis, both human and animal continue plague this country even after introduction of preventive vaccines more than a century ago. According to a latest WHO estimate about 50,000 human deaths due to rabies is reported from every year world wide, out of which 30,000 are from India alone2. At the dawn of 21st century we have achieved treatments progress in many spheres including science and technology, information technology, agriculture, satellite communication, etc. Unfortunately we still have highest number of deaths due to rabies, ironically a disease preventable by modern prophylactic measures.
General practitioner's (GP's) constitute an important source of medical care in Jamnagar city and approached for antirabies treatment by the victims of animal bites. The antirabies treatment viz., postexposure prophylaxis is a life saving treatment in definite rabid animal bite. It has three main components viz., wound treatment (1/3), antirabies vaccine (1/3), antirabies serum+advice (1/3) and it should be timely and appropriately given. Hence we conducted our study with the following objectives to document the knowledge of general practitioners in treatment of animal bite patients to know the preventive measures used by general practitioners in cases of animal bite.
The study was done in Jamnagar city in April 2001.The study population composed of 100 GP's comprising of 40 M.B.B.S. doctors & 60 others (B.A.M.S., RMP). They were randomly selected from the Jamnagar city, having a population of 3.5 lacs.
The GP's were approached at their clinics or nursing homes by PG.s in Community Medicine and Pharmacology at the end of their practice hours to minimize interruption to their practice. They were provided with a questionnaire to fill up after proper briefing, subsequently they were interviewed for some additional information where ever required.
Profile of GP's: Mean age of GP's was 40 yrs (range 30-70 yrs); the average duration of practice was 19 yrs for M.B.B.S. (range 2-40) and all of them were males.The average duration of practice for others (B.A.M.S., RMP) was 19.34 yrs and all of them were males. On an average each of them examined about 5 cases of animal bites per month.The most common animal bites were of dogs, pigs and rarely jackals & horses.
Knowledge about various aspects of rabies was comparatively better amongst M.B.B.S. doctors. (Table 1)
|What is rabies (infection)||38||95%||26||43.3%||64||64%||7.12||<0.01|
|Causative organism of rabies (virus,||34||85%||28||16.7%||62||62%||4.5||<0.01|
|System affected in rabies (CNS)||38||95%||50||83.3%||88||88%||1.976||<0.05|
On being asked if rabies could be transmitted by other than dog bite, 58% of the total doctors were of the view that it can be transmitted by blood transfusion also, 24%- STD, 34% Contact, 22%- Faeco-oral, 26%- Sputum, 38% Perinatal.
Most (95%) of M.B.B.S., and 66.6% of others practiced cleaning of wound as FIRST AID for animal bite.The difference between the two was statistically significant. 15% of M.B.B.S. and 50% of others 'dressed the wound'.
Dettol and Savlon were the most preferred antiseptics used by the general practitioners (30%), followed by Betadine (19%). TT was used by 30% M.B.B.S. doctors as compared to 50% other doctors.
Knowledge ragarding scientific concepts of NTV (Nervous tissue vaccine) and CCV (Cell culture vaccine) was very poor among general practitioners. Almost all preferred Rabipur (Purified Chick Embryo Vaccine) or Verorab (Purified Vero cell Vaccine). After explaining them that Verorab and Rabipur were cell culture vaccine we got only 45% M.B.B.S. and 10% from others the correct schedule of CCV-Post exposure probhylaxis. The difference was statistically significant. Their knowledge regarding schedule of NTV and CCV pre-exposure prophylaxis was very poor.Though they knew that vaccine that is given at Govt. hospitals, CHC.s & PHC.s running antirabies clinics is given on anterior abdominal wall but they did not know that it is 5% BPL inactivated nervous tissue vaccine.
Their knowledge ragarding categorization of animal bites in different classes was very poor. Nobody knew about immunoglobulin or sera and they are not at all using them for treating patients.
|Route of admn. of CCV||M.B.B.S. N=(40)||Others N=(60)||Total N=(100)|
|Site of Adm. of CCV|
|Lat. aspect of thigh||0||0||0||0||0||0|
|Ant. abd. wall||0||0||0||0||0||0|
|**z=3.79, p<0.01, ***z=2.72, p<0.01.|
Table-2 reveals that M.B.B.S. Doctors (90%) were more knowledgeable about intramuscular (I.M.) as correct route compared to others (60%) for administration of CCV (Verorab, Rabipur), the difference between two was statistically significant.
M.B.B.S. Doctors (60%) knew about Deltoid as a correct site for administration of CCV as compared to Others (33%) and the difference between the two was statistically significant. While majority, 56% preferred gluteus as a site of administration of CCV that is not generally advisable. Majority of the doctors were of the view that there is no need to re-vaccinate in previously vaccinated patient within three months, if he or she gets an animal bite.
In our study the average duration of private practice was 19 yrs for M.B.B.S. and 19-34 yrs for others. All of them were males. Overall knowledge about antirabic treatment and practice by GP's in Jamnagar city was very poor. All the doctors were aware that dog is the major source for spread of rabies in human population which was 98.3% in another study in Amritsar Medical College5. The most commonly biting animals were dogs, pigs in our study while in another study they were dogs, rats, cats, monkeys and horses in Karnataka1.
Regarding knowledge about wild animals like mongoose, jackals being reservoirs of infection of rabies only 24.3% of the total doctors had this in our study. This was comparatively better than the study done in Amritsar city only 11% of total doctors knew about reservoirs of rabies5.
About 58% of the total doctors were of the view that it can also be transmitted by blood transfusion, 38%-perinatal, 34% contact, 24%- STD, and 22% by faeco-oral route in our study, while in another study in north India about 21.6% doctors were of the view that oro-faecal route is also one of the routes of transmission5.
Majority of the M.B.B.S. (95%) and only 66.6% of others preferred wound toilet as first aid for animal bite. Dettol and Savlon (38%) were most preferred antiseptics being used by GP's followed by Betadine (19%), while is study done in Bangalore city dettol was again the most preferred antiseptic used by private practitioner.s1. In our study 36% of GP's 'dressed the wound' as compared to 20% in study done in Bangalore city1 while in another study in Amritsar6 16.5% of total doctors were in favour of bandaging the wound which is contraindicated as this may facilitate entry of the virus.
Knowledge of respond NTV and CCV was very poor amongst both groups. All preferred Rabipur (PCEV) or Verorab (PVRV) nobody is using HDCV1 and NTV. While in another study in Bangalore city though widely preferred ARB was Verorab but some of them were also using HDCV. In another study done by Depts. of Pharmacology and Anaesthesia in Amritsar Medical College widely preferred ARV was Rabipur6.
Only 24% of the total doctors gave us the correct schedule of post-exposure prophylaxis only after explaining to them that Verorab or Rabipur which they were prescribing is cell culture vaccine where as in another study done in Bangalore city, only 11% of the PMP's knew about the correct schedule of CCV post-exposure prophylaxis1. In our study only 4% of total doctors knew about correct pre-exposure prophylaxis of CCV while in another study done in Haryana by Community Medicine dept. P.G.I. Chandigarh 18.8% of health care providers were aware of it7.
Regarding route and site of administration of CCV (Rabipur or Verorab) in our study 72% of the total doctors were aware of the correct route of administration (I.M.) and 44% of total were aware of correct site of administration (Deltoid) while in another study done at Medical College, Amritsar only 43.7% of total doctors knew about the correct route and site of administration of CCV6.
In our study 56% of the total doctors had administered the vaccine in gluteal region while in another study done at M.K.C.G. Medical college Behrampur 68% had administered the vaccine in gluteal region4. In our study nobody knew about the serum administration in class III bites while in another study done by Community medicine dept. Amritsar 38.3% of the total were aware about the serum administration in class III bites5. Regarding vaccination practice in previously vaccinated patients within three months. 46% of total opined of no vaccination while 26% of total opined of again complete course of CCV in animal bite patients.
No doubt, knowledge and practice regarding animal bites are comparatively better amongst M.B.B.S. doctors than others (RMP, BAMS) but there is an apparent lack of awareness among doctors regarding the appropriate management of animal bite wound and vaccine administration. CMEs and reorientation programmes should be designed to highlight the guidelines given by WHO regarding treatment of animal bites. Persistence in following these guidelines by the doctors will go a long way in prevention of human rabies.