Awareness regarding animal bite management among resident doctors of tertiary care institute of Northern India
Correspondence Address: Source of Support: None, Conflict of Interest: None DOI: 10.4103/0975-2870.213928
Background: According to the WHO, rabies incidence in India has been constant for a decade, without any obvious declining trend. It has been seen that there is a lack of awareness among health professionals about animal bite management. Therefore, for success of National Rabies control programs, it is of utmost importance to assess their training needs. Objectives: The objective of this study was to assess knowledge and practice regarding animal bite management among resident doctors of the Government Rajindra Hospital Patiala, Punjab. Materials and Methods: A cross-sectional survey using a self-administered pretested questionnaire. The overall knowledge and practices were assessed using sum score of each outcome based on Bloom's cutoff point 60%–80%). Analysis of variance was used and P < 0.05 was considered statistically significant. Results: Out of 386 residents, government doctors (junior resident/senior resident [JR/SR]) constitute 30% (116) and fresh doctors 70% (270). Government doctors (SRs) have mean age of 40 ± 6.2 years and 13.23 ± 7.6 years of service. JRs from government cadre are comparatively young with 5.4 ± 3.1 years of government service. Overall, there are many gaps in the knowledge and practice of all the residents. Government cadre SRs and JRs have shown slightly better knowledge and practices than fresh residents. It is surprising that majority (63.7%) of experienced government doctor have shown moderate knowledge and 30% of them have poor K-P score with just 5% of them have high score. Similar trend was seen in JR of government cadre. Awareness was even less in fresh JRs and least in fresh SRs. Conclusion: The knowledge and practice is inadequate in all the residents. State health department and medical colleges must collaborate and start reorientation programs and continued medical education. Keywords: Awareness, government cadre, K-P score, residents
Human rabies is present in 150 countries and territories and on all continents, except for Antarctica. Globally, estimates indicate that human mortality (due to endemic canine-mediated rabies) is highest in Asia, with the highest incidence and deaths reported in India, closely followed by Africa, more investigation into the scale of the burden of rabies in the Middle East and Central Asia is required, where minimal information is available.[1] The situation is especially pronounced in India, where 20,000 of an estimated global annual 55,000 rabies deaths occur, three-quarters of them in rural areas. One of the reasons the disease has been neglected is because “deaths are scattered” and never amount to the kind of crisis that get epidemics top billing.[2] Rabies incidence in India has been constant for a decade, without any obvious declining trend, and reported incidence is probably an underestimation of true incidence because in India, rabies is still not a notifiable.[3],[4] There was no comprehensive national program for rabies control in India, so under twelfth 5-year plan, the National Rabies program was implemented. One of the strategies for human health component adopted in this program is training of health professionals, use of intradermal route of cell culture vaccines, and strengthening surveillance.[5] According to the WHO, it has been seen that there is a lack of awareness among medical doctors and health professionals about animal bite management.[6] While private doctors are concentrated in urban areas, public doctors cater to rural population at large. Animal bite cases are frequently referred to Government Rajindra Hospital by medical officers posted in peripheral health facilities, due to lack of resources and training, even private practitioners in urban areas are unable to provide treatment to Class III bite cases particularly. Medical colleges have very important role to play by providing interns/junior resident/senior residents (JR/SRs) with sufficient training and exposure to animal bite management, so that when these doctors join government/private practices in rural and urban areas, they have required confident and competence to manage, educate, and counsel animal bite cases effectively. Government Rajindra Hospital is a large tertiary care institute and every year approximately three thousand cases of animal bite come here for treatment. KAP studies have been done on private practitioners and general public about rabies/animal bite management, but so far none has been done on government doctors. Therefore, the present study is designed for assessing the knowledge and practice of doctors of the Government Rajindra Hospital which includes residents (JR and SR), both fresh residents without any clinical experience in the rural settings, and government cadre doctors who have already served for many years in rural areas before joining tenured post of 3 years in tertiary care facility. This pilot study will provide baseline information about the level of awareness in government doctors who have already served the health department at various levels of healthcare delivery system ranging from dispensary, primary health center, community health center, sub-divisional and district level hospitals. Also, a comparative analysis with fresh residents will help in finding gaps in their level of awareness and in assessing training needs which can later be provided to all the residents.
This is descriptive cross-sectional study done in Government Rajindra Hospital, Patiala and was done from April 2016 to June 2016. There are approximately 420 residents (JRs (330) and SRs (90)) in Government Rajindra Hospital. The entire sampling frame of 420 residents was taken to decrease sampling bias and error. As 34 residents did not give informed consent, finally 386 residents participated in the study. All residents were given equal chance to participate in the study, keeping a nonresponse rate below 10%, to increase power and precision of the study. The study was conducted after taking approval from the Institutional Ethical Committee. Trained interns and senior residents in the Department of Community Medicine were assigned the task to get pretested questionnaire filled by residents (JR/SR) of all the departments of the Government Medical College, Patiala. Interns in teams of two visited the residents of different specialties during their ward days; verbal informed consent was taken from all the residents after explaining them the purpose of study. Residents were requested to fill the questionnaire in the presence of interns without discussing with each other in 10–15 min, and in case, the resident was busy with patients he was visited again in the ward to get the pro forma filled. No pro formas were left with any resident in their wards/units. SRs from Community Medicine Department supervised the teams. The questionnaire was pretested on twenty residents and was validated by experts from other Departments of Medical College and after making required corrections the questionnaire was used for assessment. There were 22 questions on basic and clinical knowledge about rabies and animal bite management with one correct answer to each question. The overall knowledge of the studied participants was assessed using the sum score of each outcome based on Bloom's cutoff point (60%–80%).[7],[8],[9] Scores descriptions:
Having a score above the cutoff point was equated with having high levels of knowledge and good practice. Data from dually filled pro formas were analyzed using Epi-Info and Microsoft Excel 2010.
There were 386 residents who participated in the study, out of them government doctors (JR/SR), who were currently serving in Punjab Civil Medical Services constitute 30% (116) and fresh doctors (JR/SR) who have no service experience in government cadre were 70% (270). JRs from government cadre were comparatively young with less experience [Table 1].
[Table 2] shows the comparative analysis of basic and clinical knowledge between government and fresh SRs. Government SRs have overall more knowledge about epidemiological determinants of rabies. Although majority of SRs know about causative agent of rabies but still nearly one-third of them do not know about the reservoir of rabies. Statistically significant difference was seen regarding knowledge of rabies transmission by body fluids between two groups. Rabies is a 100% fatal disease, this fact was not known to 40% of fresh SRs. There were residents in both groups who lack clinical knowledge about rabies and animal bite management. Questions on common miscellaneous clinical scenarios such as consumption of raw milk of rabid cattle and bite by animals such as donkey/mongoose were found statistically significant. Government cadre residents have better awareness about importance of 10-day observation period and correct dosage of rabies immunoglobulin. Astonishingly, majority of SRs do not know that rabies immunoglobulin can be given with 7 days of animal bite and vaccination regimen in case of reexposure after full vaccination. Nearly, 50% of SRs do not know about preexposure regimen.
[Table 3] shows comparative analysis of knowledge of JRs from government cadre and fresh JRs. Government cadre JRs have slightly better knowledge about epidemiological determinants of rabies. Most JRs know about causative agent of rabies but about one-third do not know about reservoir of rabies. Majority of them do not know about correct incubation period, possibility of rabies transmission through body secretions, minimum duration of wound washing after animal bite. Almost 30% recommended immediate wound suturing. Just like SRs, questions on management of common miscellaneous clinical scenarios were not answered correctly by majority of JRs. There was statistically significant difference about reexposure vaccine regimen between government JRs (26%) and fresh JRs (12%).
[Table 4] and [Table 5] show the mean K-P score and level of knowledge using the sum score of each outcome based on Bloom's cutoff point (60%–80%). Overall government cadre doctors (SR/JR) have better mean K-P score than fresh doctors. However, the difference in means of four groups of doctors is not statistically significant. Among SRs, 31% of government SRs and 45% of fresh SRs have low K-P score of 13 and have poor knowledge. Similar trend can be seen in JRs but in contrast to SRs, 7% fresh JRs have high K-P score than government cadre JRs.
Overall, there are many gaps in the knowledge of all the residents working in Government Medical College, Patiala, one of the oldest and largest tertiary care institute in North India. Although government cadre doctors who have worked in rural areas and peripheral health facilities for many years before joining Government Medical College on 3 years tenured post have shown slightly better knowledge of animal bite management than fresh residents, but it is not statistically significant. It was very surprising that majority (63.7%) of most experienced government doctor (mean years of service, 13.23 ± 7.6) have shown moderate knowledge while 30% of them have poor K-P score and just 5% of them have high score. Similar trend was seen in JR of government cadre. Awareness was even less in fresh JRs. Worst performance was shown by fresh SRs where 45% have poor score and none have high score. Almost all residents were aware of causative agent of rabies in current study, but reservoir of rabies other than dog was known to 60%–70% of them as against 92% in study done at Rohtak.[10] In contrast to this, studies done in Belgaum [11] and Jamnagar [12] reported 11% and 24% awareness in doctors about other animal reservoirs, respectively. It was very surprising and unfortunate that 55%–70% of residents were not aware that rabies can be transmitted by body fluids of case of rabies in our study, which is comparatively higher than study done on private practitioners in Ambala district of Haryana.[13] In our study, 60%–70% residents were aware of minimum duration of wound washing, in contrast to study,[13] where only 47% knew this fact. Immediate wound suturing was recommended by 10%–35% of residents which is similar to studies done in Jamnagar [12] and Bangalore [14] which reported 36 and 20%, respectively. In the present study, 60%–80% of the residents knew about postexposure and more than 50% about preexposure prophylaxis, in concordance with studies done in Rohtak [10] and Delhi,[15] whereas studies done in Ambala [13] and Bangalore [14] reported lesser knowledge. Almost 15%–30% of the residents in current study did not know about correct route and site of vaccination, in contrast to 45% doctors in study done by Bhalla et al.[12] It was very unfortunate that about 80% of the residents recommended rabies immunoglobulin after 7 days of animal bite, in concordance with results of study done in Ambala.[13] Almost 20%–40%, of residents do not know about correct dosage of human and equine rabies immunoglobulin in our study. Even though government cadre residents have worked in rural areas for many years, it is astonishing that most residents in the current study did not have adequate knowledge about the management of animal bite cases frequently encounter in rural areas such as donkey, mongoose bites, and consumption of raw milk of rabid milch animals. More than 80% residents did not know about reexposure vaccine schedule in our study as against study done by Garg et al. in Delhi,[10] which reported 40.4%.
The knowledge and practice is inadequate in all the residents. Even experienced government cadre resident's knowledge and practice skills need to be updated despite having many years of rural service at different levels of healthcare delivery system. State health department and medical colleges must collaborate to assess the training needs of fresh residents and government cadre doctors and start reorientation programs and continued medical education, for success of national antirabies program. Financial support and sponsorship Nil. Conflicts of interest There are no conflicts of interest.
[Table 1], [Table 2], [Table 3], [Table 4], [Table 5]
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