Trend Analysis of Animal Bite Cases and Utilization of Rabies Biologicals at an Anti-Rabies Clinic in Bengaluru

Rabies is a neglected zoonotic disease caused by the rabies virus, belonging to the genus Lyssavirus under the family Rhabdoviridae. It remains a major public health concern, particularly in developing countries, where it primarily affects poor and vulnerable populations living in remote rural areas and urban slums.¹ Rabies is present in more than 150 countries and territories across all continents except Antarctica and continues to pose a risk to over 3.3 billion people worldwide.² The disease is almost invariably fatal once clinical symptoms develop; however, it is entirely preventable through timely and appropriate post-exposure prophylaxis.³

Globally, rabies causes substantial health and economic burden, particularly in Asia and Africa, where the majority of cases occur. It is estimated that around 12 million people in Asia receive PEP annually following suspected rabid animal exposures. In the absence of PEP, approximately 327,000 rabies deaths would occur each year in Asia and Africa.4 Rabies also contributes to significant psychological trauma and economic burden due to the high cost of treatment and preventive measures.5

India bears a substantial share of the global rabies burden. It is estimated that approximately 17.4 million animal bites occur annually in the country, with an incidence of about 1.7%.6 Dogs are responsible for about 96% of these bites, and the large population of unvaccinated stray dogs contributes to ongoing transmission. Despite the availability of effective preventive measures, rabies deaths continue to occur due to delayed or incomplete post-exposure prophylaxis.7

Post-exposure prophylaxis is the cornerstone of rabies prevention and includes immediate and thorough wound washing, administration of anti-rabies vaccines, and rabies immunoglobulin or monoclonal antibodies for category III exposures.8 Modern cell culture vaccines are safe, effective, and widely used for both pre-exposure and post-exposure prophylaxis.9 The World Health Organization has targeted rabies for global elimination by 2030, emphasizing improved access to PEP, dog vaccination, and strengthened surveillance.

The Government of India has implemented the National Rabies Control Programme to reduce rabies mortality and improve access to PEP services.10 Monitoring trends in animal bite cases and usage of rabies biologicals is essential for planning resource allocation, ensuring uninterrupted supply of vaccines and immunoglobulin, and strengthening rabies prevention strategies.

Tertiary care anti-rabies clinics play an important role in providing PEP services and serve as valuable sources of epidemiological data on animal bite cases. Trend analysis of such data provides insights into disease burden and healthcare utilization patterns.

However, limited data are available regarding long-term trends of animal bite cases and usage of rabies biologicals in tertiary care settings in Bengaluru. Therefore, the present study was conducted to describe the trends of animal bite cases and usage of rabies biologicals at an anti-rabies clinic in a tertiary care hospital.

The study was conducted at the Anti-Rabies Clinic (ARC) of the Preventive Medicine Unit, Kempegowda Institute of Medical Sciences (KIMS) Hospital and Research Centre, Bengaluru, after obtaining approval from the Institutional Ethics Committee. The Anti-Rabies Clinic is a tertiary care facility providing comprehensive post-exposure prophylaxis (PEP) services for animal bite victims, including wound management, anti-rabies vaccination, and administration of rabies immunoglobulin. The study was carried out over a period of one and a half years, from January 2017 to June 2018, with the objective of assessing the trends of animal bite cases and utilization of rabies biologicals among victims.

A descriptive study design was adopted, incorporating both retrospective and prospective components. The retrospective component involved collection of data from case records of animal bite victims who reported to the Anti-Rabies Clinic between January 2012 and December 2016. The prospective component included all animal bite victims who reported to the clinic between January 2017 and December 2017 and who provided written informed consent to participate in the study.

Purposive sampling was used. Inclusion criteria comprised all cases with complete records during the retrospective period and animal bite victims willing to provide informed consent and available for follow-up during the prospective period. Cases with incomplete records and re-exposure cases were excluded. Data were collected using structured case record forms maintained at the clinic. The data collected included socio-demographic information such as age, gender, address, education, and occupation; relevant past and present medical history; details of the biting animal including species and ownership status; type and category of exposure; wound characteristics; wound washing practices; rabies vaccination details including dates and route of administration; and rabies immunoglobulin administration details. Information on adverse drug reactions following vaccination and immunoglobulin administration was also recorded.

All study participants underwent detailed history taking and clinical examination to identify any pre-existing illness, history of previous rabies vaccination, or drug allergies. Post-exposure prophylaxis was provided according to World Health Organization (WHO) guidelines, which included immediate wound washing with soap and water, administration of anti-rabies vaccine, and rabies immunoglobulin for category III exposures.

The data collected were entered into Microsoft Excel and analysed using Stata version 12.1 statistical software. Statistical analysis included calculation of median, interquartile range, proportions, and percentages.

A total of 8171 cases of animal bites had been reported to anti rabies clinic during the study period of 6 years, from 2012 to 2017 for availing post exposure prophylaxis. The intra-annual trend of animal bite cases reported to anti rabies clinic during this period showed that, most of the cases had reported during the months of December to April (table-1),(graph-1).

Table 1: Intra-annual trend of animal bite cases during 2012-2017

 Figures in parenthesis indicate percentages

Graph 1: Intra-annual trend of animal bite cases during 2012-2017

In the study majority of the animal bite victims were adults & children.  Most of the bite victims were males had studied above primary school education and were employed. As anti-rabies clinic is in the urban locality majority of them were from urban areas (table-2).

Table 2: Socio-demographic profile of animal bite victims

   Figures in parenthesis indicate percentages

During the study period in majority the biting animal was dog (table-3), only 10-15% of were vaccinated, 50-55% healthy & alive and the remaining others were either non-traceable, sick, died or killed; which may be suspected rabid and pose a potential threat to the bite victim.

Table 3: Details of the biting animal

Figures in parenthesis indicate percentages

Majority of the exposures were abrasions, lacerations and punctured wounds (table-4). The commonest site of bite was on lower limb (50-52%); followed by upper limb, head, neck and face, trunk and genitals(graph-2) and most of the animal bites were unprovoked (70-75%), which may be suspected rabid animals.

Table 4: Type of animal exposure

Figures in parenthesis indicate percentages

Graph 2: Trend of site of animal exposure          

Most of the individuals washed their wounds with either water only (25-30%) or with soap and water (65-70%), to remove the virus which might have deposited locally at the wound site. The trend of wound washing practices has been gradually improving over the study period from 2102 to 2017, but is still inadequate; since it is the first step of post exposure prophylaxis to remove the virus present on the surface/ wound site.

Application of local antiseptics to neutralize the virus, if deposited was practiced by only few of them (1-3%). Irritants such as turmeric powder, calcium carbonate (lime), plant extract, coffee powder, jack fruit, calotropis sap were used.

All the animal bite victims reported to anti-rabies clinic were provided complete post exposure prophylaxis as per WHO guidelines and the details are as follows (tabie-5).

Table 5: Distribution of animal bite victims according to category of exposure

Figures in parenthesis indicate percentages

Most of the animal bite victims during the study period had received rabies vaccination through intramuscular route. The trends of the usage of different vaccines are as follows:(graph-3) The most commonly used brands of vaccines during the period of 2012 – 2017 were Rabipur, Abhayrab, Vaxirab N and Zoonovac V.

Graph 3: Trend of anti-rabies vaccines used during 2012-2017

All category III exposures were given rabies immunoglobulin as per WHO guidelines and majority of them received equine rabies immunoglobulin (ERIG) followed by human rabies immunoglobulin (graph-4). The common brands of equine rabies immunoglobulin used were Equirab and Premirab and human rabies immunoglobulin brands were Berirab P and Plasmarab.

Graph 4: Trend of types of rabies immunoglobulins used

Rabies remains a major public health problem in India despite the availability of effective preventive measures. The present study assessed trends in animal bite cases and usage of rabies biologicals at a tertiary care anti-rabies clinic over a six-year period.

The present study reported a total of 8171 animal bite cases over a six-year period (2012–2017), with relatively consistent reporting throughout the study period. The intra-annual distribution showed that most animal bite cases were reported during the winter months from December to April. This seasonal trend may be attributed to increased aggressiveness of animals during their breeding season and increased human–animal interaction during this period.Similar findings were reported in a retrospective study conducted at M.K.C.G. Medical College, Berhampur, which observed higher reporting of animal bite cases during winter months, with peak incidence in February and lower incidence during summer and rainy seasons. This pattern was attributed to breeding behaviour of dogs and increased protective aggression, along with greater outdoor exposure of humans.11 Likewise, a retrospective study at G.C.S. Hospital, Jamnagar reported higher incidence of animal bite cases during winter months, which was attributed to breeding season, poor visibility during early morning and evening hours, and increased vulnerability of humans.12A study conducted at Dr. S.C.G. Medical College, Nanded reported increasing trends in animal bite cases over a five-year period, with peak incidence during pre-monsoon months from February to April.13 These findings suggest that seasonal variation in animal bite incidence is influenced by animal breeding patterns, climatic conditions, and human outdoor activities.

In the present study, the majority of animal bite victims were adults and children, with fewer elderly individuals affected. Males constituted the majority of victims. This finding is consistent with studies conducted at Bangalore Medical College and Research Institute, which reported that males accounted for 78% of bite victims, with most belonging to the young adult age group.14 Similarly, a study conducted at an urban health training centre in Bangalore reported that 72.4% of bite victims were males, with a significant proportion among children.15These findings indicate that males and economically productive age groups are at greater risk of animal bite exposure.

The present study also showed that most bite victims were literate and belonged to urban areas. This may be due to better healthcare access and reporting patterns, as the anti-rabies clinic was located in an urban tertiary care centre. Similar findings were reported in studies conducted in Madhya Pradesh and Karnataka, where most victims were educated and belonged to working age groups.¹6,17 A study conducted in South Karnataka reported that most victims belonged to unskilled and semi-skilled occupations.18 These findings suggest that animal bite exposure is common among urban populations and economically active individuals.

In the present study, dogs were responsible for the majority (>92%) of animal bite cases. Similar findings have been reported in multiple studies conducted across India, where dogs accounted for more than 90% of animal bite cases.19,20 This confirms that dogs remain the primary reservoir and source of rabies transmission in India.Most bites were unprovoked, which is consistent with studies conducted in Madhya Pradesh and Rajasthan, where unprovoked bites constituted the majority of cases.21,22 This may be attributed to aggressive behaviour of stray dogs and increased human–animal interaction. The most common types of injury included abrasions, lacerations, and puncture wounds. The lower limb was the most frequently affected site, followed by upper limb and other body parts. Similar findings were reported in studies conducted in Surat and Lucknow where lower limbs were the most commonly affected site.23,24 This may be due to greater accessibility of lower limbs during animal attacks and the natural defensive posture of humans.

Appropriate wound washing is a critical step in rabies prevention, as it reduces viral load at the exposure site. In the present study, most victims reported washing their wounds with water or soap and water. However, only a few applied antiseptics, and some applied harmful traditional substances such as turmeric, lime, and plant extracts. Similar practices were reported in studies conducted in Haryana and Pune where victims applied substances such as turmeric powder, oil, and ash to wounds.25,26 These findings indicate gaps in awareness regarding appropriate wound care practices.

The majority of cases in the present study were Category III exposures, indicating severe exposure and high risk of rabies transmission. Similar findings were reported in studies conducted in Maharashtra and Mumbai, where Category III exposures constituted the majority of cases.27,28 This may be due to increased exposure to stray animals and delayed healthcare seeking behaviour. Most Category III exposure cases received rabies immunoglobulin as per WHO guidelines, with ERIG being the most commonly used due to its availability and affordability. Proper local infiltration of immunoglobulin was performed in most cases. Rabies vaccination was administered predominantly through the intramuscular route, although intradermal vaccination was also used.

The study revealed a substantial burden of animal bite cases and an increasing trend in utilization of rabies biologicals. Continuous surveillance, adequate supply of rabies vaccines and immunoglobulin, and strengthening rabies prevention programmes are essential to achieve rabies elimination goals.

1.             WHO Expert Consultation on Rabies. Third Report, Technical Report Series 1012.World Health Organization, Geneva, 2018.

2.             World Health Organization. Weekly Epidemiological Record. Rabies vaccines: WHO position paper - April 2018, No.16;93:21-210.

3.             Tarantola A. Four Thousand Years of Concepts Relating to Rabies in Animals and Humans, Its Prevention and Its Cure. Trop Med Infect Dis. 2017; 2:5.

4.             Knobel DL, Cleaveland S, Coleman PG, Fèvre EM, Meltzer MI, Miranda ME, et al.  Re-evaluatingthe burden of rabies in Africa and Asia.Bulletin of the World Health Organization. 2005;83(5):360−368.

5.             WHO South East Asia region: Strategic Framework for Elimination of Human Rabies Transmitted by Dogs in the South-East Asia Region: World Health Organization, Regional office for South East Asia; 2012.

6.             Sudarshan MK, Madhusudana SN, Mahendra BJ, Rao NSN, Ashwath Narayana DH, Abdul Rahman, et al. Assessing the burden of human rabies in India: results of a national multi-center epidemiological survey. Int J Infect Dis 2007;11(1):29-35.

7.             Sudarshan MK, Mahendra BJ, Madhusudana SN, Ashwath Narayana DH, Abdul R, Rao NSN, et al. An epidemiological study of animal bites in India: results of a WHO sponsored national multi-centric rabies survey. J Commun Dis 2006;38(1):32-9.

8.             WHO Expert Consultation on Rabies. First report, Technical Report Series 931. World Health Organization, Geneva, 2005.

9.             World Health Organization. Weekly Epidemiological Record. Rabies vaccines: WHO position paper No. 32, 2010, 85, 309–320.

10.           National Rabies Control Programme, National guidelines for rabies prophylaxis, National Centre for Diseases Control, Ministry of Health and Family Welfare, New Delhi, India. 2015. p. 7-12.

11.           Pratap AK, Behera TR, Satapathy DM, Sethi S, Tripathy RM. Seasonal trend of animal bite cases reporting at anti rabies clinic of M.K.C.G. Medical College, Berhampur, Orissa. APCRI Journal 2011;13(1):24-9.

12.           Hanspal JS, Bhanderi D, Nagar S. A review of attendance trend of animal bite cases in anti-rabies clinic of G.C.S Hospital, Jamnagar (Gujarat). APCRI Journal 2007;8(2):16-18.

13.           Kulkarni S.K. Trend of animal bite victims reported to anti rabies vaccination clinic at a tertiary care hospital, Nanded, Maharashtra. IOSR Journal of Dental and Medical Sciences 2016;15(2):36-39.

14.           Navya S Sreenivas, Saraswathi Sakranaik, Ranganath T Sobagiah, Anil Kumar. An epidemiology of animal bite cases attending tertiary care centre of Bangalore Medical College and Research Institute, Bengaluru. International Journal of Community Medicine and Public Health 2017;4(7):2538-42.

15.           Karthik C, Viswanantha PG, Shobha, Ranganath TS, Sushmitha P. Profile of dog bite cases attending the outpatient department of an urban health training centre in Bangalore city, India. Int J Community Med Public Health 2016;3:1765-68.

16.           Choudhary K, Shekhawat K, Kumawat R. Trend analysis of animal bite cases in a tertiary care center from the last six years hospital registry. IJSAR.2014;1(2):81-85.

17.           Trivedi R, Kumar S, Saxena M et al. Epidemiological trends and practices of animal bite victims presenting to the OPD, district & medical college hospital, India. Int J Health Sci Res. 2015;5(12):14-20.

18.           Jahnavi R, Vinay M, Manuja LM, Harish BR. Profile of patients attending anti rabies clinic in a government tertiary care hospital in South Karnataka and their compliance to 4 dose intra dermal rabies vaccine. APCRI Journal 2015;17(1):12-15.

19.           Marathe N, Kumar S. Epidemiological study of animal bite victims in Central India: a cross sectional institutional study. Int J Community Med Public Health 2016;3(1):78-82.

20.           Patel S, Toppo M, Lodha R. An epidemiological study of animal bite cases in a tertiary care center of Bhopal city: A cross-sectional study. Int J Med Sci Public Health 2017;6(3):539-543.

21.           T Rajana, M Neera, Srivastava DK. A retrospective analysis of the patient attending anti rabies clinic at JA group of hospitals, Gwalior. APCRI Journal 2009;11(1):27-28.

22.           Jain M, Prakash R, Garg K, Jain R, Choudhary M. Epidemiology of animal bite cases attending anti-rabies clinic of a tertiary care centre in Southern Rajasthan.      J Res Med Dent Sci. 2015;3(1):79.

23.           Umrigar P, Parmar GB, Patel PB, Bansal RK. Epidemiology of animal bite cases attending Municipal Tertiary Care Centres in Surat City: A cross sectional study. Natl J Community Med 2013;4(1):153-7.

24.           Sahu KK, Manar MK, Singh SK, Singh H. Epidemiological characteristics of patients attending for rabies post-exposure prophylaxis at the infectious diseases hospital of Lucknow, India. J Global Infect Dis 2015;7(1):30-32.

25.           Majra JP, Verma R. Epidemiology of animal bite cases attending the anti rabies clinic of a rural tertiary care hospital of Haryana. APCRI Journal 2016;17(2):27-30.

26.           Shelke SC, Kamble MS, Niwal A. Epidemiological determinants of animal bite cases attending the anti-rabies immunization OPD in Sassoon hospital, Pune. Int J Basic Appl Sci. 2015;5(2):98-101.

27.           Vishwanath GR, Rajderkar SS, Sangrulkar TV, Sharma SK, Gajbhiye RI. Animal bite cases in western Maharashtra, India: a retrospective study 2010-2015. Int J Community Med Public Health 2018;5(4):1610-2.

28.           Gogtay NJ, Nagpal A, Mallad A, Patel K, Stimpson SJ, Belur A, et.al. Demographics of animal bite victims & management practices in a tertiary care institute in Mumbai, Maharashtra, India. Indian J Med Res. 2014;139:459-62.