Study area
The study was conducted in five catchment areas of government hospitals located in southern Bhutan where rabies is endemic - Phuentsholing hospital (Chukha district), Samtse hospital (Samtse district), Gelephu hospital (Sarpang district), Deothang hospital and Samdrup Jongkhar hospital (Samdrup Jongkhar district) (Fig. 1). These hospitals are the main healthcare facilities in their respective districts in southern parts of the country, where majority of the rabies outbreaks in dogs and the highest use of rabies vaccine in people occurs in the country [15,16,17,18].
These hospitals provides health care services including PEP to approximately 57,341 catchment population (Phuentsholing hospital: 27,658 people, Samtse hospital: 10,500, Gelephu hospital: 9858, Deothang hospital and Samdrup Jongkhar hospital: 9325). Therefore, only a very negligible number of rabies exposed people within these hospital catchment area might have seek PEP from village level Basic Health Unit (BHU) clinics when situation demand for their travel on business or due to other emergencies.
Bhutan is a Buddhist country located in South Asia and is administratively divided into 20 districts and 205 sub-districts. It has a population of about 0.73 million with an overall literacy rate of 71.4%. In Bhutan, all healthcare services including anti-rabies vaccine is provided free of costs to the population through a network of 30 hospitals and 210 BHUs. Typically, there is at least one hospital in each district and a BHU in each sub-district that provides healthcare services to the communities. All animal-bite victims that visit the hospitals/BHU to seek medical care are provided wound care and PEP for rabies if necessary after careful assessment by the clinical staff. An Updated Thai Red Cross Intradermal regimen (2–2–2-0-2) which requires four visits on day 0, 3, 7 and 28 post-exposure is being adopted in Bhutan. All types of vaccines including rabies vaccine are procured centrally by the health ministry and distributed to the hospitals and BHUs in the country. Thus, there are no parallel private healthcare facilities in Bhutan and private pharmacies are not allowed to sell rabies or any other vaccines [11, 15, 19,20,21].
Data collection
A community-based questionnaire survey was conducted between April and June 2017. The following information was included in the questionnaire (see Additional file 1): socio-demographic characteristics of patients, awareness about rabies (including knowledge about susceptible animals, routes of transmission, signs of rabies in animal and rabies prevention and control measures), details on the nature of the exposure and PEP administration (vaccination status of biting dog/cats determined by review of vaccination card), additional people bitten by the same animal, dates of exposure and PEP administration, reasons for delay or not seeking PEP) and the costs incurred for visiting the hospitals for PEP treatment. If the circumstances of bite was associated with playing, feeding, touching its offspring, running in close proximity and handling injured animals, this was referred to as “provoked bite”. The questionnaire was piloted with 10 dog-bite patients and modified to improve clarity. PEP registers maintained in each hospital were used as the primary source of patient data. Using information from the PEP registers, animal-exposed victims that had visited hospitals between January and March 2017 were traced back and followed up in the community by telephone and personal visit for interview. Data about animal exposure and PEP details were retrieved from the PEP registers. The exclusion criteria used for data collection were: 1) any victims who could not be traced after 3 attempts to contact and interview; 2) any victims who declined consent to be interviewed, and 3) any victims who had died prior to follow-up. Interviewers were selected from the respective hospitals and trained on study protocol, questionnaires and data collection methods prior to administering the survey. The investigators supervised and coordinated the conduct of the field survey.
A snowballing technique was used to identify/trace people from the index patients for interview who had animal exposure but had not visited health centre for treatment. This is a non-probability sampling method in which dog-bite victims who had visited the hospitals for PEP recruited other bite victims who had not visited the hospitals within their community from among their acquaintances [22]. This was done to obtain comparative information related to socio-demographic factors that influenced the PEP-seeking behaviours of the individual.
For each patient contacted, the selected person was informed about the purpose of the study, that the participation was voluntary and data collected would be kept confidential. The interview was conducted with the victim himself/herself or with a supervising adult in the case of children less than 18 years of age, after obtaining written informed consent. The study was approved by Research Ethics Board of Health (REBH) vide approval letter No. REBH/Approval/2017/005.
Data analysis
The data management and analysis was conducted using EpiInfo™ version 7.1.2.0 (Centers for Disease Control and Prevention (CDC), Atlanta, GA, USA) and Stata, version 14. Descriptive analysis was performed by calculating frequencies and percentages of variables of interest to investigate patterns of exposure. The factors associated with reporting to hospitals (PEP seeking) and completing the PEP regimen (PEP compliance) were assessed using logistic regression analysis. The risk factors investigated included: age group and gender, educational qualification, occupation, income level of the family, knowledge about rabies of the respondents, type of exposure (animal bite versus non-bite), ownership of the animal responsible for exposure (pet, stray and wild animal), vaccination status of biting animals (vaccinated vs non-vaccinated), location (rural vs urban), circumstances of exposure (provoked vs unprovoked), category of exposure (category I, II, III), rabies status of biting animal (normal, suspected, confirmed rabid) and distance in kilometers from the victims residence to the nearest hospital. Continuous (age of the respondents) and categorical variables (education, occupation, household income level, circumstances of animal exposures) were re-categorized for regression analysis. First a univariable logistic regression was conducted with “PEP sought vs PEP not sought” and “PEP completed vs PEP not completed” as an outcome with the above mentioned variables as predictors. Any variables with p < 0.25 were selected for the multivariable logistic regression model. The final models were built using forward stepwise elimination approach based on likelihood ratio tests and any variables with p-value of < 0.05 were considered significant and retained in the final model.