Assessment on Human Rabies Exposure and Treatment at Karamara Hospital of Ethiopian Somali Regional State
- 1. Ethiopian Public Health Institute (EPHI), Ethiopia
Abstract
Objectives: to investigate the incidences of human rabies exposures among individuals that encountered animal bites and post exposure prophylaxis /PEP/ administered in Karamara hospital from November 2017- March 2018.
Methodology: A cross sectional study was conducted in Karamara Hospital, Jigjiga city, Ethiopian Somali Regional State (ESRS). A semi structured questioner was used to collect the data. The data was entered and analyzed using SPSS version 20 statistical software. A descriptive analysis was performed for categorical variables.
Result: Adult victims accounted the largest proportion (65.6%). The fact that the majority of the community in the study area were Muslim religion followers (74%), Different species were identified as potentially responsible animal for transmitting rabies. Almost all part of the body had the chance of being bitten despite part of the thigh (23.4%), leg (48.1%) and hand (7.8%) took the largest proportion respectively. Among 192 domestic dogs and cats, 172 (89.6) were stray while 20 (10.4) of them were owned and controlled. Both provoked (15.4%) and unprovoked (84.6%) attacks were recorded in the present study. The type of vaccine administered to the victims was both tissue culture (50.6%) and local vaccine (49.4%) produced in the Ethiopian Public Health Institute /EPHI/ There was no any tendency to use traditional treatment as a means of therapy by the victims.
Conclusion: Poor collaboration between sectors shortage of anti-rabies vaccines especially, the modern cell culture vaccine and low level of community awareness have been traced as a major challenge in the prevention and control of the disease in the study area. On the basis of the above facts, awareness of the disease should be created through the use of different media and other tools for the community, health professionals and policy makers.
Keywords
• Rabies Exposure; Karamara Hospital; ESRS; PEP
Citation
Birhanu E, Aklilu M (2021) Assessment on Human Rabies Exposure and Treatment at Karamara Hospital of Ethiopian Somali Regional State. J Vet Med Res 8(4): 1223.
INTRODUCTION
Rabies, from the Latin word for madness, is a viral disease that causes deadly maladies such as encephalitis in animals (1). Infection of humans usually follows bites by rabid animals and is almost invariably fatal once signs of disease occur. More than 3.3 billion people live in regions where there is a risk of rabies. Approximately 55 000 people die from rabies each year, the vast majority of these deaths occurring in Asia and Africa. Children are at particular risk (2).
Prompt administration of post exposure prophylaxis (PEP), consisting of rabies vaccine and immunoglobulin, immediately after exposure effectively prevents the disease (3). Further-more, the continued existence of traditional medicine practitioners in the various parts of the country to date is a testimony for the significance of the disease in Ethiopia (4).
Rabies is a prime example of a neglected tropical disease that mostly affects poor communities, children and elderly people suffering from inequitable health care (5). In Africa, the highest recorded human death due to the disease for the year 1998 was reported from Ethiopia (6).The magnitude of the problem is higher in big cities like Addis Ababa linked with the presence of large population of stray dogs and associated factors (7).
In Ethiopia especially In Addis Ababa where dogs are the commonest domestic animal, the total dog population and the number of stray dogs are estimated to be 250,000 and 120,000 respectively according to the Urban Agriculture Extension Core process (8).
However, all mammals are susceptible to infection by the rabies virus (RABV), Transmission of RABV by dogs is responsible for up to 99% of human rabies cases in rabies-endemic regions, with a small proportion due to transmission via wildlife (9).
Increasing accessibility of quality health services in pastoral areas is the second Policy issue that focuses on expanding social and economic infrastructure and urban areas together with industry to modernize the life of pastoralists in Ethiopia (10).
Pastoralists are one of the most researched yet least understood groups in the world. Despite decades of empirical research, many policymakers, government staff, NGO personnel, and the broader public do not fully understand or appreciate the rationale and dynamics of pastoral livelihood systems. This poor understanding has often resulted in inappropriate policies and development interventions, which might institutions and their strategies for responding to environmental variability, particularly in arid and semi-arid environments (11).
Although there are fewer segments of Somali pastoralists that normally keep dogs in house, it is known that rural communities grow up dogs for the security of their animals. Moreover, hospital reports from the ESRS indicate that wild canids (particularly foxes) pose significant threat to the public especially during scarce feed sources and at common watering foci for the fox populations and livestock that expose the animals and keepers themselves. Thus, it is common to find frequent foci of outbreaks of both cycles in many towns and rural communities of the Somali Regional State (ESRS).
The Ethiopian Somali Regional Health Bureau received report on 19/11/2013 from kebribeyah District about the dog bite situation in which 10 people was bitten by dog. Following the report, regional PHEM (Public Health Emergency management) sends the teams composed of Field Epidemiologist & Health Officer to the site having the objectives verify the existence of dog bites, provide technical support for District, and characterize the situation by time, place, & person and to recommend for the future based on the findings (12).
Regardless of the number of rabies cases reported from each region, all have got a lot of doses of rabies post exposure vaccine every year. No or only few cases of rabies were reported from Afar, Somali, Gambela, Harari and Dire Dawa in the last six years (2007-september2012). However, a lot of doses of human vaccine were distributed to these regions. This indicates that there had been many but unreported rabies exposure cases (13).
One of the major factors that affect rabies distribution is improper dog management. Currently, in our country, Ethiopia, the management of dog is conducted by using vaccination of dog, killing/destroying of stray dog and surgical sterilization technique. Among the above stated techniques Amhara, Oromia and SNNP regions are used killing/destroying of stray dog, where as in Tigray region vaccination of dog was highly utilized. Regarding surgical sterilization technique only Amhara, Addis Ababa and Oromia were used in a very low number (13).
A versatile one health strategy for canine rabies elimination should aim to create sustainable herd immunity in dogs, using proven vaccination strategies at the local level, coupled with community education and human population management. Such strategies have succeeded in both developed and developing countries, and can be adapted to any locality (14).
Thus, the aim of the present study was to assess the risks of rabies exposure and PEP administration in individuals that encountered animal bites and visited Karamara hospital from November 2017- March 2018.
MATERIALS AND METHODS
Study Area
The study was conducted in Karamara Hospital, Jigjiga city, ESRS (Figure 1). Geographically, the region occupies a large area and falls in the eastern and southeastern part of the country with land mass area of about 350,000 km2 and an estimated total population of 4,445,219 people Its health service infrastructure is organized by one counsel health department, one referral hospital, one general hospitals and tree health centers which offer ANC, PIHTC and PMTCT services in the town and ten health posts. In addition, there is one private hospital, clinics and drug vendors in the town. The potential health coverage of the area is about 82% (SRHB, 2014).
The study zones for this study were: Fafan, Jarar, Korahey, Fiiq and Shebelle zones. The list of woredas involved were: Ararso, Aware, Awbare, Birqod, Degehabour, Fafan, Fiiq, Gode, Gursum, Hamero, Jigjiga, Kebribeyah, Mersin, Shegosh.
Study Design
A cross sectional, institution based cross sectional study design was implemented from November 2017 – march 2018.
Study Population
All victims who had a fellow up at Karamara hospital following animal bites during the seven month of the present study.
Data Collection
A structured questioner was used to assess about the occurrence of rabies by interviewing exposed individuals directly. A semi structured questioner prepared in English was translated in to Somali (native language) for appropriateness and easiness in approaching the study participants.
Data analysis
Data of human rabies exposure cases was collected by interviewing rabies exposed Individuals. From direct patient interview. The data was entered and analyzed using SPSS version 20 statistical software. A descriptive analysis was performed for categorical variables.
RESULTS
A total of 308 respondents from five words who were exposed to rabies suspected animal visited the hospital and interviewed. The result showed that male participants accounted for the largest proportion. Level of education ranges from primary to degree holders (Table 1a).
A total of 14 different Woredas was traced as a study area during the study period in the five zones of Fafan, Jarar, Korahey, Fiiq and Shebelle (Figure 2).
Various ranges of occupational status were recorded among the study participants. Adult victims accounted the largest proportion. Both children and adults age group were exposed.
The fact that the majority of the community in the study area were Muslim religion followers, Muslims respondents accounted the largest number. (Table 1b).
Different species were identified as potentially responsible animal for transmitting rabies. Almost all part of the body had the chance of being bitten despite part of the thigh, leg and hand took the largest proportion respectively. Among 192 domestic dogs and cats, 172 (89.6) were stray while 20 (10.4) of them were owned and controlled (Table 2).
Both provoked and unprovoked attacks were recorded in the present study. The type of vaccine administered to the victims was both tissue culture and local vaccine (NTV) produced in the Ethiopian Public Health Institute /EPHI/ There was no any tendency to use traditional treatment as a means of therapy by the victims (Table 3).
DISCUSSION
In the present study, dogs were the main animals that had bitten the patients which is 62% followed by Ethiopian genet (locally called Ama) that was 29.9%.
Likewise, in a study conducted in Asella hospital, Among individuals exposed to rabies suspected animals, dogs were the most and primary responsible animals (49%) for maintaining as well as disseminating of rabies in the study area (15).
This might be due to the reason in our study that the high number of stray dogs from abattoirs, deserted military camps to major towns in the region and that too low level of eradication programs of these stray dogs due to the lack of collaboration between municipalities of towns, health office and agriculture offices of seen in the region. A study in Addis Ababa and the surrounding areas also shows that no emphasis has been given to rabies by the relevant veterinary, medical and public authorities in contrast to European and American countries where rabies due to domestic carnivores has been controlled and wildlife rabies is a problem (16).
In Jigjiga city, about 86.8% of dogs that inflicted bite damage on patients were stray dogs; 10.5% were controlled dogs, while 2.6% were controlled but suspects. The figure is in contrast to a study done in Addis Ababa pertaining patients that reported to have been bitten by suspects (7). Post-exposure anti rabies treatment was given to 53.2% of people bitten by dogs that bite and escaped, as indicated by the study participants, which is lower than our study. This could be associated with the presence of a large number of stray dogs in the streets of Jigjiga which showed that people in the city have the risk of being attacked and developing rabies by free-roaming dogs unless they get early medical treatment. Hence, controlling free-roaming dogs in the regional capital Jigjiga requires very serious attention.
Regarding, traditional medicine use in rabies exposure cases, we found that no single respondent had ever visited a traditional healer and all had directly sought the vaccine at health facilities around. In many studies done elsewhere in Ethiopia, most victims of dog bites in rural Ethiopia have access to traditional healers prior to the rabies diagnosis facility in modern health institutions (17). The deep-rooted traditional practice of pretending to treat rabies in Ethiopia interferes with getting the real magnitude of the problem. The existing experience indicates that most human rabies victims who came to the EPHI laboratory are either manifesting the clinical sign of the disease or after exhausting the traditional medicinal intervention. By the time the victim arrives, since the symptoms have already developed, there will be no hope to reverse the condition by medical care. Most fatal human rabies cases recoded at EPHI during the last nine years were associated with herbal remedies whereby the majority of human rabies cases were helped exhaustively by traditional healers (17).
In a survey conducted in Addis Ababa, rabies clinical observation and quarantine of animal data revealed that 90% of clinically observed animals were certified as provisionally free from rabies after 10 days quarantine period. Ten percent of them were positive during the observation period which was also confirmed by laboratory findings. This clinical observation showed that all responsible dogs were not infected by rabies.at the time of inflicting (17). Similarly, other studies also demonstrated that the majority of the PEP (78%) was given to humans bitten by animals in which their rabies status was unknown while 28% of the PEP was given to humans bitten by animals in which rabies was confirmed by a laboratory (16). Sometimes, under the Ethiopian situation, people move door-to-door and from one house to another for cultural holidays and other religious festivals which can trigger owned dogs to bark and bite visiting guests in its compound under normal conditions. Even though the WHO guideline has a special procedure, practicalities in the area coupled with the resistance of patients not to avoid taking the PEP immediately have borne this condition. The hospital’s assessment to date tells that there is essentially no default in patients that start the vaccination. We confirmed this information to be true from nurses and physicians working in the Emergency OPD of Karamara hospital, ESRS.
Another important finding in the study was a provocation. We found that only about 15% of patients had reported having provoked the animals involved, the remaining 85% have said that they were bitten even without a knowledge that there was a biting danger around. The dogs were diagnosed clinically as stated in the Standard Treatment Guidelines for General Hospitals that unvaccinated dogs that cause unprovoked bites must be suspected to be rabid (19). The underlying principle is that rabies virus-infected animals could only transmit the virus shortly before and after clinical signs have developed. After quarantine, the dog might have either displayed a significant change in behavior or signs of illness suggestive of rabies and/or died during the observation period.
CONCLUSION
Poor collaboration between sectors shortage of anti-rabies vaccines especially, the modern cell culture vaccine and low level of community awareness have been traced as a major challenge in the prevention and control of the disease in the study area. On the basis of the above facts, awareness of the disease should be created through the use of different media and other tools for the community, health professionals and policy makers.