An Epidemiological Study on Dog Bite and Its Management in Bellary, Karnataka.

J. Commun. Dis. 44(1) 2012 : 15-23 An Epidemiological Study on Dog Bite and Its Management in Bellary, Karnataka. Hemagiri K*, Someshwar GM*, Karinagannanavar Aravind* (Received for publication Nov 2011) Abstract Animal bites are common childhood occurrences. Dog bites remain constant problem in our country because of the increasing dog population. To know the pattern of dog bites in children, the morbidity Pattern, the circumstances of dog bites, ascertain the first aid measures and Vaccination practiced by people after dog bites and the compliance with vaccination and adverse reactions due to vaccination, this cross sectional descriptive study was carried put on children who were dog bite victims attending VIMS hospital, Bellary during Feb 2011 to Nov 2011. Out of 536 participants 71% were males and 29% were females. 35% of the participants belongs to 10-12yr age group. Majority of the victims belongs to upper lower and lower class of socio economic group. 42% of children were bitten over lower limbs and 43.8% of the victims had some local treatment immediately. 77% of the victims were received antirabies vaccine and only 11% of the dogs were vaccinated against rabies. Key words: Dog bite, wounds, local treatment, anti-rabies vaccines INTRODUCTION In India dogs are the principal reservoir of rabies and as many as 96% of the persons undergoing antirabies treatment in this country are bitten by dogs. Though the dogs are only moderately susceptible to this infection their large population (80 million as per census by Agriculture Ministry) makes 1 them chief reservoir of infection. Children are at great risk because of their small stature 2 and lack of caution. * Dept of Community Medicine & MCH, VIMS, Bellary. Correspondence to : Dr. Hemagiri. K, Associate Professor, Dept of Community Medicine, VIMS, Bellary, Karnataka, 583104. Mob: 09845459468, e-mail: k.hemagiri@gmail.com

16 Hemagiri K et al Every year approximately 1.1 to 1.5 million people receive post- exposure treatment with either nerve tissue or cell culture rabies vaccine. More than 95% of these 3 cases are bitten by dogs. Dog bites remain a constant problem in our country mainly because of the increasing dog population. The dog population in India is estimated to be around 25 million and most of them are not 3 protected against rabies. Dog to human ratio is 1:35 most of these dogs are the so called 'stray dogs'. The dog densities are higher in densely populated areas inhabited by lower 4 income groups. A study of 4475 cases of animal bites by the Pasteur Institute of India, 4 Coonoor, showed 94.48% to be dog bites. Rabies is responsible for extensive morbidity and mortality in India. It is estimated that more than 25,000 persons die of hydrophobia every year and approximately 5,00,000 undergo antirabies treatment. This results in a loss of 4.2 million man days per year and incalculable loss to the state exchequer which provides vaccine free of cost to the persons bitten by suspected rabid 1 animals. A study of hydrophobia deaths in different states/union territories of India during 1971 to 1981 by the Central Research Institute, Kasauli, showed that the maximum numbers of cases were recorded during 1971 with gradual fall in the deaths during successive years. Maharashtra is the state where maximum numbers of hydrophobia cases are recorded every year, in comparison to other states. This may not only be due to the high incidence of rabies, but possible because of better reporting. The numbers of cases reported in Maharashtra during 1971 to 1981 were 6169. Karnataka State reported a total of 4 646 hydrophobia deaths during 1971 1981. In India rabies occurs in all parts of the with the exception of Lakshadweep and Andaman 1,5 & Nicobar Islands. Hence this study is undertaken to highlight the type of dog bite, morbidity, behavior and practices regarding dog bites. MATERIALS AND METHODS The present descriptive, cross sectional, hospital based study was conducted in the out patient department (OPD) of surgery, pediatrics of Vijayanagara Institute of Medical sciences, Bellary situated in Karnataka state. The children who were dog bite victims and came to VIMS Hospital seeking medical advice were chosen as study subjects. The children (below 15 years) who came to the pediatric and surgical outpatient departments during Feb 2011 to Nov 2011 were chosen. The technique followed were interview of the patient and attending parent. A pre-tested, pre-designed, semistructured questionnaire was used to collect the information and it was validated during the pilot study. The questionnaire consists of demographic profile, site of bite, type and number of wound, time interval between bite and treatment, fate of the dog, factor for bite, treatment taken prior to coming to the hospital, vaccination and compliance. The data was analyzed by using epi-info software version 3.4.3. RESULTS Our study included 536 dog victims among them 382 (71%) were males and 154 (29%) were females. Majority of the boys 134 (35%) belongs to 10-12 age group and only 19 (5%) belongs to 13-15 age group. Among females majority of the victims 46 (30%) belongs to 4-6

An Epidemiological Study on Dog Bite and Its Management in Bellary, Karnataka 17 Table 1 : Demographic characters of children Age and Sex distribution age (yrs) male (n%) female (n%) total (536) 1 3 38 (59.3) 26 (40.6) 64 (12) 4 6 69 (60) 46 (40) 115 (21) 7 9 122 (73) 45 (27) 167 (31) 10 12 134 (83) 28 (17) 162 (30) 13 15 19 (68) 9 (32) 28 (5) Total 382 (71) 154 (29) 536 (100) SE Class No % Upper 11 2 Upper middle 18 3.4 Lower middle 39 7.3 Upper lower 248 46.3 lower 220 41 age group. The males were found to be more commonly bitten than females (2.5:1). Most of the cases 468 (87.3%) belonged to upper lower and lower class of socio-economic groups, according to Modified B G Prasad's 6 classification. Regarding the wounds, site of the wound, numbers, types of wounds and classification of wounds are described in Table 2. In our study majority had bite at the lower limb 225 (42%) followed by upper limb 93 (17.4%) and least was genital region 5 (1%). Majority had 2-4 wounds 311 (58%), followed by one 198 (37%) and more than five 27 (5%) and most of them had Superficial Lacerations 351 (65%) and Class II bite (moderate risk) 351 (65.5%). In this study, 235 (43.8%) of children had local treatment of the wound immediately, and 196 (36.6%) after 4 hours and 36 (6.7%) after 24 hrs but 69 (12.9%) of them no local treatment was given. The local treatment given varies from cleansing with soap and water and antiseptic to application of traditional treatment. In our study 467 victims have done some local treatment, out of it 101 (21.6%) received antiseptic application, 119 (25.5%) applied lime stone paste, 85 (18.2%) applied turmeric ointment and 59 (12.6%) cleaned with soap and water and none of the wounds were sutured or cauterized. None of our patients were given local antirabies serum. Regarding time taken by a patient to report to the hospital after being bitten by a dog, majority of the victims 273 (51%) of the patients came to the hospital between 1 to 3 days after the dog bite but only 175 (32.6 %) of patients came within one day of being bitten, 76 (14.2%) came between 3 to 7 days of being bitten and only 2.2% came after 7 days of being bitten. After coming to the hospital the patients were given local treatment and vaccination. 415 (77.4%) of the patients received Purified 5 Vero Cell Vaccine (PVRV) and rest of them

18 Hemagiri K et al Table 2 : Descriptions of the wounds 1. Site of wounds (n=536) (%) a. Head & Neck 32 5.9 b. Upper limb 93 17.4 c. Hand 84 15.7 d. Trunk 32 5.9 e. Genital area 5 1.0 f. Gluteal region 65 12.1 g. Lower limb 225 42.0 2. Number of wounds (n= 536) (%) a. 1 198 37.0 b. 2-4 311 58.0 c. > 5 27 5.0 3. Type of wounds (n= 536) % a. Superficial abrasions 72 13 b. Skin not broken 45 08 c. Superficial Laceration 351 65 d. Deep. Laceration/Puncture 68 13 4. 7 Classification of wounds (n= 536) (%) a. Class I (slight risk) 117 21.8 b. Class II (moderate risk) 351 65.5 c. Class III (severe risk) 68 12.7 5. Local treatment a. Immediately 235 43.8 b. After 4 hrs 196 36.6 c. After 24 hrs 36 6.7 d. No local treatment 69 12.9 were asked to observe the dogs for 10 days but 514 (95.9%) of the victims received Tetanus Toxoid from VIMS hospital 471 (91.63%) as well as in private clinic 43 (8.34%). The main reasons for dog bite was provoking like feeding, teasing, throwing stones in 331 (61.8%) cases compare to unprovoked bites 205 (38.2%). Majority 305 (57%) of the dogs were of the mixed breed, the pure breeds encountered in our study were Pomeranians 16 (3%), German shepherds 4 (0.7%) and Great Dane 8 (1.5%), but breed of 203 dogs were not known. Regarding the owner, stray dogs accounted for 272 (50.7%) of the total compared to only 88 (16.4%) bitten by their own dogs. However, it was interesting to note that the neighbors dog accounted for 176 (32.8%) of the total bites. The status of the dog at the time of bite, fate of the dog after bite, bitten any one else

An Epidemiological Study on Dog Bite and Its Management in Bellary, Karnataka 19 Table 3 : PVRV Vaccination 1. PVRV given (n= 415) (%) a. Class I 57 13.7 b. Class II 299 72.1 c. Class III 59 14.2 2. 8 Duration of Vaccination a. I ( n = 57) Complete 30 52.6 Incomplete 27 47.4 b. II (n = 299) Complete 97 32.4 Incomplete 202 67.6 c. III (n = 59) Complete 46 78.0 Incomplete 13 22.0 3. Complications of PVRV n=366 (%) d. Local redness 188 51.37 e. Swelling 173 47.27 f. Pain 314 85.79 g. Fever 32 8.7 Table 4 : Status of the dog 1. Status of the dog at the time of bite (N=536) (%) a. Rabid 18 3.4 b. Normal 276 51.5 c. Not Known 242 45.1 2. Fate of the dog after bite a. Killed 29 5.4 5 b. Under observation 268 50.0 c. Unknown 239 44.0 3. Bitten any one else a. None 106 19.8 b. 1-2 134 25.0 c. 3-4 87 16.2 d. > 5 39 7.3 4. Vaccine status of the dog a. Vaccinated 59 11.0 b. Not Vaccinated 197 36.8 c. Unknown 280 52.2

20 Hemagiri K et al and vaccination status of the dog is shown in the table 4. Our study shows that majority dogs were normal, bitten one or two persons and 59(11%) were vaccinated. DISCUSSION Dog bites are a common but neglected pediatric problem. It is a common cause of traumatic injury and tends to be a greater source of morbidity and mortality in children than in adults. In our study, of the 536 dog bite victims majority 382 (71%) of the victims were males and 154 (29%) were females. Majority of the boys 134 (35%) belongs to 10-12yr age group and only 19 (5%) belongs to 13-15 age group. Among females majority 46 (30%) belongs to 4-6yr age group. The males were found to be more commonly bitten than females (2.5:1). According to a study conducted in United Kingdom, over 2,000 cases in 22 hospitals showed that children between 5-15 years were most commonly involved (73%) 9 and the male female ratio was 1.4:1. Another study by Gershman et al in Denver showed that children below 12 years were victims in 51% of cases and 64.7% of bite victims were 10 male. Similar study of 120 cases by Lillington and Ross in Sunderland showed 73% of cases were in the 1 to 10 years age group, the male 11 female ratio was 2.3:1. Our study shows that most of the cases 468 (87.3%) belonged to upper lower and lower class socio economic groups, of Modified Prasad's classification. In India, the dog to human ratio is 1:35; the dog densities are higher in densely populated areas inhabited by the lower socio economic groups, therefore making them more 4 susceptible to dog bites. In the present study, 27 (5%) had 5 or more wounds, therefore exposed to severe risk. Children are more susceptible to dog bites and also thought to be more susceptible to rabies. Bites in densely innervated areas such as face, neck, hand and arm also 12 increases the risk of rabies. In present study the maximum number 225 (42%) of children were bitten in the lower limbs followed by upper limb 93 (17.4%), hand 84 (15.7%) and head & neck 32 (5.9%). Similar study in Bangkok revealed that the lower extremities were involved in 54%, upper extremities in 20% and face & head in 13 9% of cases. Lillington and Ross reported the anatomical distribution of dog bites in their study to be as follows: Lower limbs 34.1%; face 17.5%, trunk 12.5%; of the children aged 5 years or less, 80% were bitten in the 11 face, hand or arm. Injuries caused by dog bites can result in significant morbidity. It can range from superficial abrasions to deep lacerations/ puncture wounds with injury to the underlying structures. A single patient can have two to three types of wounds. In our study, majority 376 of the children sustained superficial lacerations, 68 deep lacerated and 72 with superficial abrasions compared to a study by Robinson, among the 136 cases, 48% had superficial abrasions; skin was not 14 broken in 24% of the cases. Tuggle et al reported that out of 13 children with serious injuries due to dog bites, 5 patients had bony injuries, 2 had tracheal injuries, 2 had nerve 15 injuries and 4 patients had intestinal injuries. Dog bites are classified into 3 groups; Class 1 (Slight risk), class II (Moderate risk) and Class-III (Severe risk), depending upon the degree of risk of rabies, anti-rabies

An Epidemiological Study on Dog Bite and Its Management in Bellary, Karnataka 21 5 treatment is given. In our study majority 351(65.5%) of patients came under class-ii. However, a significant number 117 (21.8%) belonged to class-i, suggesting that a large number of patients were in sever risk of developing rabies. Shewell and Nancarrow reported the severity of wounds in 59 children. 3% minor, 36% - moderate and 61%- 16 severe. In this study, 235 (43.8%)% of children had local treatment of the wound immediately but for 69 (12.9%) no local treatment was given. This suggests that most people are aware that there is some danger due to dog bites. Local treatment of the wound following a dog bite is essential however severity of the wound. The suggested simple local treatment immediately after the bite is cleansing of the wound with plenty of soap and running water, this can bring the risk of infection 17 down from 50-60% to almost 20%. The local treatment given varies from cleansing with soap and water and antiseptic to application of traditional treatment. In this study of 467 patients, 101 (21.6%) received antiseptic application, 119 (25.5%) applied lime stone paste, 85 (18.2%) applied turmeric ointment and 59 (12.6%) cleaned with soap and water, this group grossly represents the number of patients aware of dog bites and its consequences. N.M. Gandhi reports that the usual traditional treatment includes application of root powder, Chilli powder or turmeric powder on the wound, the use of holistic amulets and even cauterization of the 18 wound by fire. Lackmann and Tollner studied 16 children aged 18 months to 14 years with facial dog bite injuries, all injuries were treated surgically by primary closure of the wounds. The clinical course did not show any complications, therefore, they recommended that all facial injuries should 19 be treated by primary closure. In our study, majority 273 (51%) patients came for medical advice 1-3 days after being bitten by a dog were as 175 (32.6%) within 24 hrs and only 12 ( 2.2%) came after 7 days for the treatment were as according to a survey conducted in one of the semi-urban towns of Maharashtra revealed that only 20% of the patients reported for treatment within 24 hours, 35% between 24 and 48 hours, 18% beyond 48 hours and 27% did not report at 18 all. In the hospital the patients were given local treatment and vaccination. 77.4% of the patients received PVRV and rest asked to observe the dog for 10 days but 95.9% of the victims received Tetanus Toxoid. It's appreciated that more than 50% of all the 3 category patients completed the full course of vaccination, it means remaining did not turn up for succeeding doses. In a study of 80 cases of human rabies by Madhusudana and Aggarwal, full course of vaccination was taken by 2.5% of cases and partial course of vaccination was administered in 31% of cases. About 37.5% of cases were not aware of vaccination and 7% of cases had applied some indigenous herbal medicine over the local wound. In almost all cases, Local treatment of wound was found to be either completely neglected or application of chilli powder was 20 Considered sufficient. In our study majority 366 (88.2%) of the victims developed one or the other complication to PVRV. Some of them had more than one complication, i.e pain 314 (85.79%), redness188 (51.37%), 173 (47.27%) swelling at the site of injection and only

22 Hemagiri K et al 32 (8.7%) complained of fever. One study in India, reported the incidence of neuroparalytic accidents to vary from 1:220 to 1:12, 21 000, another study reported the incidence to 22 vary from 1:1756 to 1:4000. The main reason for dog bite was provoking 61.8% in our study. Lauer et al reported 48% of attacks were unprovoked. Playing or feeding was cited as a provocation in 26.3%, teasing was cited in 18.6% and prior 23 circumstances were unknown in 7.2%. She well and Nancarrow reported that in half of children's bites and almost a third of adults bites the attacks were judged to be 16 'Unprovoked'. Avner and Baker reported that children aged 5 years or younger were more likely to provoke the dog prior to injury 14 than older children. Regarding the breed 57% of the dogs were of the mixed breed, but pure breeds were Pomeranians 3%, German shepherds 0.7% and Great Dane 1.5%, but breed of 203 dogs were not known. In a study by Avner and Baker in Pennsylvania, 62.6% of dogs were pure breeds out of which 20 (8%) were German shepherds, 36.3% were of mixed 14 breeds and 1.2% unknown. Lauer et al reported that German shepherds account for 23 30% of bites and large mixed breeds for 41%. Regarding the owner, stray dogs accounted for 50.7% of the total compared to only 16.4% bitten by their own dogs and the neighbors dog accounted for 32.8%. but in another study, 19.1% of the dogs were owned by a friend or relative, and 3.6% were owned by other persons. Stray dogs were seldom 23 involved in attacks (6.2%). According to our study 3.4% of the dogs were rabid were as 51.5% were normal and of 45.1% status at the time of bite was unknown but 50% of dogs were under observation. However, in a significant number 44 % the fate was unknown and 5.4% of the dogs in our study were killed due to abnormal behavior. A complicating factor is that in our country the observation of dogs is difficult. The stray dogs usually escape after the bite, and most victims do not know that the animal should be traced or impounded. She well and Nancarrow reported that in 36 (68%) of 53 children and 24 (56%) of 43 adult victims the dog was subsequently destroyed by the 16 owners. The present study says that 25% of dogs had bitten 1-2 people other than the victim, 16.2% had bitten 3-4 patients and 7.3% of the dogs had bitten more than 5 people, which may suggest abnormal behavior. Joshi et al reported an incident of a stray dog biting 8 school children randomly in a short period of time, postmortem examination of the dog's 24 brain revealed Negri bodies. Another study reported a single rabid dog having bitten 118 17 people in Central Delhi in four hours. A single rabid dog is capable of biting a large number of human beings and animals and the number of victims can be up to 60-100 and can cover up to 45 km in a short span of clinical 17 illness. It is important to note that only 11% of the dogs were vaccinated in our study and 197 (36.8%) were not vaccinated and 280 (52.2%) status was unknown. The Department of Animal husbandry initiated a canine rabies control programme in Coimbatore city in 1985. The programme comprised of intensive antirabies vaccination of dogs at their door step, in addition to public education and stray dog control. The operation has clearly reduced the occurrence of rabies in both dogs 5 and man over the period of time.

An Epidemiological Study on Dog Bite and Its Management in Bellary, Karnataka 23 From our study we conclude that health education regarding the seriousness of dog bites and the importance of proper vaccination will go a long way in the prevention of this tragedy. ACKNOWLEDGEMENT The authors would like to thank all the participants, all the undergraduate and post graduate students of the department for their co-operation & assistance. Authors also thankful to the heads of the department of Community Medicine, Surgery & Pediatrics and Medical Superintendent for their cooperation and valuable guidance. REFERENCES 1. Saraljit Sehgal, Rajesh Bhatia, Rabies Epidemiology, principles of control and treatment, National Institute of Communicable Diseases, 1987: 1-4. 2. Eng TR, Fishbein DB, Talamanti HE, Hall BD, Chanez GF, Dobbins JG. Et al. Urban epizootic of rabies in Mexico: Epidemiology and impact of animal bite injuries. Bull WHO 1993, 71: 615-624. 3. WHO (1999) Health situation in South east Asia region 1994-1997, Regional office for SEAR, New Delhi. 4. Rao AR. Occurrence of rabies in human beings in Tamilnadu, National workshop on strategies to control rebies in Tamil Nadu, 1993, 35-41. 5. Park K. Rabies. In Park's text book of th preventive and social medicine, 20 Edn. Eds Park K. Jabalpur, M/s Banarasidas Bhanot, 1995, pp 239-245. 6. Prasad BG. Changes proposed in the social classification of Indian families. Journal of Indian Medical Association. 1970; 55(16): 198-199. 7. WHO (2005) Tech Rep. Ser No 931. 8. WHO (1997), WHO recommendations on Rabies Post- Exposure treatment and correct technique of Intradermal Immunisation against Rabies, Division of emerging and other Communicable Diseases Surveillance and control. 9. Leuene S. Dog bites to children. BMJ 1991; 303: 466. 10. Gershman KA, Sacks JJ, Wright JC. Which dogs bite? A case control study of risk factors. Pediatr 1994, 93: 913-916. 11. Lillington AW, Ross MS. Dog bites in children. Lancet 1976, 2: 98-99. 12. Wilberger JE, Pang D. Carniocerebral Injuries from Dog bites. JAMA 1983, 249: 2685-2688. 13. Bhanganada K, Wilde H, Sakolsataydorn P, Donsombat. Dog bite injuries at a Bangkok teaching hospital. Acta- Trop 1993; 55: 249-55. 14. Avner JR, Baker MD. Dog bites in urban children. Pediatr 1991; 88: 55-57. 15. Tuggle DW, Taylor DV, Stevens RJ. Dog bites in children. J Pediatr Sur 1993; 28: 912-914 16. Shewell PC, Nancarrow JD. Dogs that bite. BMJ 1991, 303: 1512-1513. 17. Sehgal S. Rabies in India- Epidemiology and prophylaxis. Indian J Int Med 1993, 3: 11-15. 18. Gandhi NM. The role of education in rabies control in India. Indian J Int Med 1994; 5: 2-6. 19. lackmann GM, Tollner U, More on dog bite injuries. Pediatr 1992, 89: 356-7. 20. Madhusudhana SN, Aggarwal P. Human rabies: Epidemilogical and Laboratory studies in 80 cases. J Indian Medical Association 1992; 90 : 169-171. 21. Dutta JK, Dutta TK. Rabies in endemic countries. BMJ 1994; 308: 488-489. 22. Thraenhart O. Newer trends in global rabies eradication and their relevance for India. Indian J Int Med 1993; 3: 5-10. 23. Lauer EA, White WC, Lauer BA. Dog bites- A neglected problem in accident prevention. 24. Joshi MV, Prasad SR, Shaikh N, D' Lima LV, Sreenivasan MA. Exposure to rabies in school precincts : History repeats itself. Indian Pediatr 1993; 30 : 820-1.