were not aware of the proper method for cleaning wounds as a first-line treatment in ... Committee on Immunization Practices for the treatment of rabies caused by animal bites. ..... likely to be inadequately prepared in terms of rabies.
Jpn. J. Infect. Dis., 64, 382-390, 2011
Original Article
Clinical Knowledge and Attitudes of Turkish Physicians toward Rabies Caused by Animal Bites I_ smail G äonen, Ahmet Soysal*, Ahmet Topuzo ¾glu1, and Mustafa Bakir
Division of Pediatric Infectious Diseases, Department of Pediatrics and of Epidemiology and Biostatistics, Marmara University Hospital, Istanbul, Turkey
1Department
(Received January 28, 2011. Accepted July 6, 2011) SUMMARY: Rabies is an endemic infectious disease and one of the most important causes of human mortality in both underdeveloped and developing countries. In Turkey, 167,000 individuals are believed to be victims of animal bites annually. In this study, we investigated Turkish physicians' knowledge and clinical awareness of rabies caused by animal bites. This was a cross-sectional, analytical study. We used questionnaires that collected demographic information and assessed the physicians' basic knowledge of rabies as well as the management of animal bites suspected of causing rabies. The questionnaires were completed in person with physicians who work in Istanbul. A total of 890 physicians responded to our cross-sectional questionnaires. The maximum possible scores for basic and clinical rabies-related knowledge was 100 points each. The average score for basic rabies knowledge was 64.5 ± 16, while the average score for clinical rabies knowledge was 62.8 ± 12. However, 68z of the physicians in the study were not aware of the proper method for cleaning wounds as a first-line treatment in postexposure prophylaxis. In addition, 38.4z of the physicians in the study did not understand the administration of vaccines together with immunoglobulin as part of postexposure prophylaxis. We also found that 79z of the physicians did not know the correct doses of vaccines, while 37.6z did not know the correct sites and routes of vaccine administration. Finally, 30z of the physicians were not aware of the correct vaccine schedules in postexposure prophylaxis. Our data indicate that Turkish physicians' basic and clinical knowledge of rabies was insufficient. Rabies prophylaxis educational programs should be designed to educate physicians on the guidelines provided by the World Health Organization and the Advisory Committee on Immunization Practices for the treatment of rabies caused by animal bites. prophylaxis each year (1). The administration of prophylaxis is important after suspected exposure to rabies. In this study, we surveyed Turkish physicians working in different health centers to assess their clinical approaches toward bites from suspected rabies-infected animals, and their knowledge about the disease.
INTRODUCTION Rabies is one of the most important zoonotic diseases transmitted to humans by bites or scratches from infected animals. According to the latest World Health Organization (WHO) report, human mortality from endemic canine rabies is estimated at approximately 55,000 deaths annually worldwide (1,2). According to unpublished data received from the Turkish Health Ministry, the average number of bites from animals suspected to be infected with rabies were nearly 167,000 in the last 5 years, and 190,000 suspected rabies-infected animal bites were reported in 2009. The majority (97z) of these patients receive postexposure rabies prophylaxis (3). After admission of these patients to healthcare centers, 1–3 human rabies cases occur, and unfortunately, 1–3 human deaths from rabies are documented annually due to missed postexposure prophylaxis. There is no comprehensive treatment possible after the clinical occurrence of rabies, which can result in mortality. After an animal bite, postexposure rabies prophylaxis is the only way to prevent rabies disease (4). An average of 10 million people worldwide receive postexposure rabies
MATERIALS AND METHODS A cross-sectional survey was conducted between June and September of 2009 in 55 hospitals in Istanbul, Turkey. In Istanbul, there are nearly 22,000 doctors working in either private practices or governmental health centers. Among these doctors, 66z work in private health care centers. Therefore, the sample size was calculated according to the following formula: n ＝ Nt2pq/d2(N － 1) ＋ t2pq, where N ＝ universe or population stratum size, n ＝ required sample size, p ＝ posibility or incidence of an event happened, q ＝ posibility or incidence of an event not happening, t ＝ the theoretical value determined with a confidence level at a particular t table, d ＝ standard deviation. The required sample size was calculated to be 744 doctors, including the design effect. The study questionnaire consisted of 39 multiple-choice questions divided into three sections (see Appendix). The first part of the questionnaire requested demographic information, including age, sex, experience (years), status of having a child or pet, professional specialty, and type of hospital in which the respondent worked. The second part consisted of
*Corresponding author: Mailing address: T.C. Sa ¾glƒk Bakanlƒ ¾gƒ Marmara Universitesi Hastanesi, Fevzi Çakmak mah. Mimar Sinan Caddesi No:41 Ust Ä Kaynarca-Pendik, Istanbul, Turkey. Tel: ＋90-216-6254725, E-mail: asoysal ＠marmara.edu.tr 382
Table 1. Demographic characteristics of participitants
questions related to basic rabies knowledge, including etiology, incubation period, prodromal signs of rabies, transmission routes, and types of available vaccines. The last section of the questionnaire consisted of questions related to three different scenarios that aimed to assess the clinical practices of the responding doctors, including wound care and postexposure prophylaxis after rabies suspected animal bites. The readability, internal consistency, and reliability of the questionnaire were assessed in a pilot study of 20 doctors working in the Emergency Department of Marmara University Hospital. Answers to the questions were categorized as either true or false, and each true answer added a point to the participant's score. Basic rabies knowledge and clinical practice scores were calculated as sums of individual answer scores, and presented on a scale of 100 possible points. For each section, participants with scores above 69 points were assumed to have sufficient knowledge about the care of patients bitten by a suspected rabies-infected animal. Knowledge and clinical practice attitude scores among different groups were compared using non-parametric tests. To determine the factors associated with basic rabies knowledge and clinical practice attitudes, multivariate analyses were performed with the statistical analysis program SPSS (statistical package for social sciences) v.11.0. Statistical significance was set at P º 0.05.
Characteristic Gender Male Female Age (y) Ã33 À33 Specialty area General practitioner General surgery Internal medicine Pediatrician Emergency medicine Family medicine Infectious disease Other internal medicine Other surgery Institution Goverment university hospital Goverment research and education hospital Goverment hospital Private university hospital Private hospital Work in rabies center Yes No Child owner Yes No Pet owner Yes No Intervention to suspected rabid animal bites before Yes No
RESULTS A total of 890 doctors participated and their mean age was 33.1 ± 6.9 years. Table 1 shows the demographic characteristics of the participants. Of the 890 doctors, 456 (51.5z) were male. The mean professional experience of the doctors was 2.06 ± 0.8 years. Of the 890 doctors, 56 (6.3z) were general practitioners, 85 (9.6z) were general surgeons, 127 (14.3z) were internal medicine specialists, 150 (16.9z) were pediatricians, 113 (12.7z) were emergency medicine specialists, 103 (11.6z) were family practitioners, 81 (9.1z) were infectious disease specialists, 75 (8.4z) were specialists in fields other than internal medicine (e.g., dermatology or neurology), and 98 (11.1z) were surgeons other than general surgeons. Among those participating, 111 (12.5z) worked in government university hospitals, 175 (19.7z) in government research and education hospitals, 145 (16.3z) in government hospitals, 416 (46.8z) in private hospitals, and 42 (4.7z) in private university hospitals. Of the 890 total doctors, 234 (26.3z) worked in hospitals to which patients bitten by suspected rabies-infected animals are referred. Knowledge of rabies: Among the participants, 98z knew that rabies must be reported to national health authority services. The etiologic agents of rabies were known by 92z of the doctors, though 68z did not know that the incubation period of rabies is between 3 weeks and 3 months. Moreover, 41z did not know the prodromal signs of rabies. Of the participants, 73z did not know that animals such as rats, rodents, and guinea pigs are assumed to be at low risk for rabies transmission. Moreover, 42z of the participants failed to accurately understand the transmission routes of rabies. Factors affecting basic rabies knowledge: The average score for basic rabies knowledge was 64.5 ± 16 over 100
No. (z) 456 (51.5) 434 (48.5) 512 (58.2) 368 (41.8) 56 85 127 150 113 103 81 75 98
(6.3) (9.6) (14.3) (16.9) (12.7) (11.6) (9.1) (8.4) (11.1)
111 175 145 42 416
(12.5) (19.7) (16.3) (4.7) (46.8)
234 (26.3) 656 (73.7) 362 (40.8) 526 (59.2) 114 (12.8) 775 (87.2) 534 (60.1) 354 (39.9)
points, which is below the previously defined proficiency limit. The results of the univariate logistic analysis are shown in Table 2. There were no significant differences between doctor's basic knowledge of rabies with respect to gender, age, parenthood status, workplace setting (e.g., a rabies referral hospital), and job experiences. On the other hand, basic rabies knowledge showed significant differences with respect to the doctors' professional specialty areas (P º 0.01). When physicians participating in the study were classified according to area of expertise, infectious disease specialists received the highest scores for basic knowledge of rabies, with 83z meeting the proficiency limit in basic knowledge scores. In addition, physicians who had intervened previously in suspected rabiesinfected animal bites showed higher rates of sufficient basic rabies knowledge than those who had not previously intervened (P ＝ 0.002). In terms of hospital settings, physicians working in private university hospitals showed the highest rates (66z) of basic knowledge of rabies. When multivariate logistic analysis was performed (Table 3), significant differences were found only with regard to practice fields and hospital settings. Because infectious disease specialists had the highest proficiency 383
Table 2. The sufficiency of basic rabies knowledge in univariate analysis
Gender Male Female Age (y) Ã33 À33 Specialty area Infectious disease Family medicine Pediatrician Internal medicine Other internal medicine Emergency medicine General surgery General practitioner Other surgery Institution Private university hospital Goverment hospital University hospital Goverment research and education hospital Private hospital Work in rabies center Yes No Child owner Yes No Pet owner Yes No Intervention to suspected rabid animal bites before Yes No 1):
Insufficient No. (z)
Sufficient No. (z)
201 (52.9) 179 (51.7)
179 (47.1) 167 (48.3)
0.75
220 (53) 161 (53)
195 (47) 143 (47)
0.98
11 37 65 61 35 52 40 26 56
(16.9) (48.1) (50.4) (54.5) (54.7) (57.8) (58.8) (63.4) (68.3)
54 40 64 51 29 38 28 15 26
(83.1) (51.9) (49.6) (45.5) (45.3) (42.2) (41.2) (36.6) (31.7)
14 53 44 77 194
(34.1) (43.8) (50) (52.7) (58.4)
27 68 44 69 138
(65.9) (56.2) (50) (47.3) (41.6)
P
101 (52.1) 282 (52.7)
93 (47.9) 253 (47.3)
0.87
154 (51.2) 227 (53.3)
147 (48.8) 199 (46.7)
0.57
66 (66.7) 317 (50.3)
33 (33.3) 313 (49.7)
0.0021)
217 (48.1) 166 (60.1)
234 (51.9) 110 (39.9)
0.0021)
There is a significant difference between groups (P º 0.05).
veyed understood the necessity of tetanus prophylaxis after bites from animals suspected of being rabies-infected. The use of antimicrobial agents was understood by 79z of the physicians, and 94z were aware of unnecessary wound suturing. While 74z of the physicians were aware of the different types of rabies vaccines, 79z did not know the correct doses of the vaccines. Of the physicians, 31z did not fully understand the correct sites and routes of vaccine administration, and 38z did not know the correct vaccine schedules in postexposure prophylaxis. Moreover, 38.4z of the physicians in the study did not know the regimen for the administration of vaccine with immunoglobulin in postexposure prophylaxis. The correct doses of human rabies immune globulin (HRIG), intervening frequencies, and routes of administration were insufficiently understood by 64z, 41z, and 94z of the physicians in the study, respectively. When they were tested using clinical case scenarios, 35z of the physicians were unaware of the 10-day observation period for dogs suspected of being rabiesinfected. When physicians were asked to identify the correct postexposure treatment to the patient if the dog develops rabies symptoms during the observation
rate, the average score from that specialty was set as a reference point. Surgical specialists displayed a 2.9-fold greater likelihood of having insufficient basic rabies knowledge than infectious disease specialists (P ＝ 0.02). Physicians working in private university hospitals had the highest competence in terms of their basic knowledge of rabies. Therefore, the average score from private university hospitals was taken as the reference for these groups. Private hospital physicians were 3 times more likely to possess insufficient basic rabies knowledge than those from private university hospitals (P ＝ 0.002). Clinical attitude towards suspected rabies-infected animal bites: The average clinical rabies knowledge score of the physicians participating in the study was 62.86 ± 12 over 100 points, which is below the previously defined proficiency limit. The results of the univariate logistic analysis are shown in Table 4. A total of 95z of the physicians participating in the study knew that it is necessary to first clean the wound area in a suspected rabies-infected animal bite. However, 67z of these physicians did not know the proper wound-cleaning techniques. In addition, 89z of the physicians sur384
Table 3. The insufficiency of basic rabies knowledge in multivariate analysis OR (95z CI) Gender Male1) Female Age (y) Ã33 À331) Specialty area Infectious disease1) General practitioner General surgery Internal medicine Pediatrician Emergency medicine Family medicine Other internal medicine Other surgery Institution Private university hospital1) University hospital Government research and educatioan hospital Government hospital Private hospital Work in rabies center Yes1) No Child owner Yes1) No Pet owner Yes No1) Intervention to suspected rabid animal bites before Yes1) No
P
0.9 (0.6–1.3)
0.7
0.8 (0.4–1.3)
0.4
2.7 2.2 2.1 1.6 1.8 1.5 2.9 2.9
0.05 0.09 0.09 0.26 0.18 0.38 0.05 0.022)
(0.9–7.6) (0.8–5.7) (0.8–5.2) (0.6–3.9) (0.7–4.6) (0.5–3.8) (0.9–8.5) (1.1–7.5)
2.3 (1–5.4) 2.5 (0.9–6.5) 2.2 (0.8–5.6) 3 (1.4–6.2)
0.03 0.05 0.08 0.0022)
0.9 (0.4–1.9)
0.94
1.1 (0.7–1.7)
0.47
2 (1.2–3.4)
0.0082)
1.3 (0.9–1.9)
0.08
1):
Group accepted for reference. There is a significant difference between groups (P º 0.05). OR, odds ratio; CI, confidence interval.
2):
period, 35.6z suggested the administration of the rabies vaccine alone, while 2.8z suggested administration of HRIG alone. The correct treatment, the rabies vaccine in combination with HRIG, was proposed by only 61.6z of the physicians. In addition, 94z did not know the correct administration of postexposure rabies prophylaxis in patients bitten a second time within a year after initial exposure. Factors affecting clinical practice attitudes toward suspected rabies-infected animal bites: Possible factors affecting insufficient clinical rabies knowledge were evaluated by univariate analysis. Work status in rabies centers, parenthood status, and past experiences with suspected rabies-infected animal bites were statistically unrelated to the levels of clinical rabies knowledge. Male physicians had lower rates of sufficient clinical rabies knowledge than females. Young physicians displayed a higher proportion of clinical rabies knowledge proficiency than older physicians. Physicians working in governmental state hospitals had the highest rates of knowledge sufficiency (Table 4). Multivariate analysis revealed significant differences
in clinical rabies knowledge according to the age and specialty of the physician (Table 5). General practitioners were 31-fold more likely to possess insufficient clinical rabies knowledge than infectious disease specialists. Further, the likelihood of insufficient clinical rabies knowledge was 22.9-fold higher in general surgery physicians, 11-fold higher in internal medicine specialists, 12.6-fold higher in pediatric physicians, 25.1-fold higher in emergency physicians, 33.1-fold higher in family physicians, 35.8-fold higher in other internal medicine specialists, and 30.6-fold-higher in other surgical physicians, compared to infectious disease specialists (Table 5). Physicians older than 33 years had a 2.3-fold higher rate of insufficient clinical rabies knowledge than younger physicians (Table 5). DISCUSSION The diagnosis, treatment and reporting behaviors associated with rabies are usually proportional to physicians' knowledge of the disease. Rabies has the highest mortality rate (100z) among all infectious diseases (4). 385
Table 4. The sufficiency of clinical rabies knowledge in univariate analysis
Gender Male Female Age (y) Ã33 À33 Specialty area Infectious disease Internal medicine Pediatrician Other internal medicine Emergency medicine General surgery Family medicine Other general surgery General practitioners Institution Government hospital Goverment research and education hospital Private university hospital University hospital Private hospital Work in rabies center Yes No Child owner Yes No Pet owner Yes No Intervention to suspected rabid animal bites before Yes No 1):
Insufficient No. (z)
Sufficient No. (z)
189 (66.3) 123 (53.9)
96 (33.7) 105 (46.1)
0.0041)
163 (57.4) 152 (67.6)
121 (42.6) 73 (32.4)
0.0191)
7 40 46 35 44 31 38 47 27
(13.2) (51.9) (57.5) (62.5) (68.8) (72.1) (77.6) (78.3) (79.4)
46 37 34 21 20 12 11 13 7
(86.8) (48.1) (42.5) (37.5) (31.2) (27.9) (22.4) (21.7) (20.6)
49 47 22 45 152
(51.6) (52.2) (59.5) (64.3) (67.9)
46 43 15 25 72
(48.4) (47.8) (40.5) (35.7) (32.1)
P
0.0241)
75 (57.3) 240 (62.3)
56 (42.7) 145 (37.7)
0.30
130 (62.2) 185 (60.3)
79 (37.8) 122 (39.7)
0.65
40 (62.5) 275 (60.8)
24 (37.5) 177 (39.2)
0.79
194 (60.1) 119 (62.3)
129 (39.9) 72 (37.7)
0.61
There is a significant difference between groups (P º 0.05).
of rabies (5). In another study conducted by Bhalla et al. in India, 85z of 100 general practitioners correctly identified the cause of rabies (6). In addition, we found that the incubation period for rabies, which is between 3 weeks and 3 months, was not known by 68.3z of the physicians in our study. Similarly, 48.3z of the physicians in the Pakistan study did not know the correct incubation period (5). The knowledge that animal bites are associated with the risk of rabies is the most important element in postexposure rabies prophylaxis. In our study, 72.9z of the physicians had an incorrect understanding of the animals associated with rabies risk. It is interesting that physicians chose rodents, mice, guinea pigs, and rabbits as pets with a rabies risk and recommended postexposure rabies prophylaxis in cases where it was not needed. According to our data, the majority of Turkish doctors showed a deficiency in basic rabies knowledge, falling short of the minimum levels required for postexposure rabies prophylaxis following bites from suspected rabies-infected animals. In recently published national and international guides, the first line of treatment of rabies involves the cleaning of bitten areas with soap, water, and virucidal
After a bite from a suspected rabies-infected animal, the development of the disease can be prevented with appropriate postexposure prophylaxis. In Turkey, approximately 167,000 suspected rabies-infected animal bites are seen in health clinics each year, and an average of 1–3 rabies-related deaths occur annually. Appropriate postexposure rabies prophylaxis is very important. This study was conducted to correct much of the misguided information propagated by physicians by identifying their knowledge of basic rabies-related information and clinical approaches toward patients bitten by animals suspected to be infected with rabies. In our study, age was not a significant factor in basic rabies knowledge adequacy. In fact, physicians with an average age of 33 years and over had a 2.4-fold lower rate of clinical rabies knowledge adequacy. This finding indicates that with increasing age, physicians are more likely to be inadequately prepared in terms of rabies knowledge and treatment guidelines. A total of 92.4z of the physicians in our study knew that rabies is caused by a virus. Similarly, a study conducted in Pakistan, another developing country, found that 77.5z of 151 general practitioners correctly identified the viral cause 386
Table 5. The sufficiency of clinical rabies knowledge in multivariate analysis OR (95z CI) Gender Male1) Female Age (y) Ã331) À33 Specialty area Infectious disease1) General practitioner General surgery Internal medicine Pediatrician Emergency medicine Family medicine Other internal medicine Other urgery Institution Government hospital1) University hospital Government research and education hospital Private university hospital Private hospital Rabies Center Yes1) No Child owner Yes No1) Pet owner Yes No1) Intervention to rabies suspected animal bites Yes1) No
P
1.3 (0.8–2.1)
0.2
2.3 (1.1–4.7)
0.0172)
31 (5.3–181.8) 22.9 (4.2–124.2) 11 (2.2–55.2) 12.6 (2.5–62.5) 25.1 (4.8–130.9) 33.1 (6.1–179.4) 35.8 (6–211.2) 30.6 (5.6–165.6)
0.0012) 0.0012) 0.0032) 0.0022) 0.0012) 0.0012) 0.0012) 0.0012)
1.2 0.4 0.8 1.1
(0.4–3.4) (0.1–1.1) (0.2–2.5) (0.4–2.7)
0.72 0.10 0.75 0.83
1.3 (0.5–3.6)
0.35
1.3 (0.7–2.3)
0.50
1 (0.5–1.9)
0.95
1.4 (0.8–2.2)
0.16
1):
Group accepted for reference. There is a significant difference between groups (P º 0.05). OR, odds ratio; CI, confidence interval.
2):
agents such as povidone-iodine. In our study, 96.6z of the physicians understood that wound cleaning was the first required step, though 66.9z of them did not know that the appropriate treatment of the wound involved water, soap, and povidone-iodine. Overall, 64.3z of the physicians suggested cleaning such wounds with only water and soap. On the other hand, 94.4z of the physicians knew that suturing the bitten area is not a necessary part of wound cleaning, except in unusual cases where it is absolutely necessary. In the Pakistan study, 80.5z of the physicians did not know the firstline treatment for rabies bites (5). Another study conducted by Dodet et al. involved eight Asian countries where 4,377 patients bitten by animals suspected of being rabies-infected were seen at rabies health centers. In this study, 38z of the patients did not receive appropriate wound treatment, with 49z receiving a wound cleaning with only water and soap/detergent, and 12z receiving a cleaning with only water (7). The second important point involves the administration of the rabies vaccine together with rabies immunoglobulin as part of the postexposure prophylaxis following con-
tact with an animal suspected of being infected with rabies; this is recommended in guides published by the Turkish Ministry of Health (3), WHO (1), and the Advisory Committee on Immunization Practices (ACIP) (8). In our study, 38.4z of the physicians were not aware of this recommendation. In our study, 23.7z of the physicians did not know what types of rabies vaccines were used in Turkey, whereas 45.1z of them thought that the vaccine was contraindicated in cases involving pregnancy, alcoholism, immune deficiencies or immune suppression among drug users, and vaccinations for viral or bacterial infections. The rabies vaccine is not contraindicated in these patients; in fact, it is absolutely necessary, as recommended by both national and international guides (1,3,8). More than one-third of the physicians studied displayed a lack of proper understanding about the contraindications for rabies vaccination. We found that the majority of physicians did not know the correct dose schedules, sites, or routes of vaccine administration in postexposure prophylaxis. In the Pakistan study, 56.3z of the physicians did not know the routes of rabies vaccination, 76.2z did not know 387
the application area of the vaccine, and 89.4z did not know the vaccine immunization schedule. Similarly, in the Indian study, 25z of the physicians did not know the correct vaccine administration routes, 66z did not know the application area of the vaccine, and 76z did not know the correct vaccine schedule. In addition, physicians in the current study did not fully understand HRIG dosages, frequency of administration, or correct methods of administration. Rabies guides published in recent years indicate that as much as possible, the majority of the HRIG dose should be applied to bite areas, while the rest of the HRIG should be applied to the extremities, where the vaccine was not applied. In our study, 63.3z of the physicians suggested applying half of the HRIG dose to wound areas and the other half to other areas that did not receive the vaccine, as recommended by outdated rabies guidelines. In the Pakistan study, anti-rabies serum practices were not understood by 88.8z of the physicians (5). In this study, we provide evidence that infectious disease specialists display the highest proficiency regarding both basic and clinical knowledge of rabies. The data suggest that, because infectious disease specialists follow and treat bites from suspected rabies-infected animals more often than other specialists, they have a
more up-to-date knowledge of rabies. The observation that other specialists displayed different rates of basic and clinical knowledge regarding rabies suggests that they may not be updating their knowledge after finishing their training. Rabies is still an important public health problem in Turkey, as it is in many other developing countries. Although the reduction of animal bites is a major protective measure, the appropriate treatment of bites from suspected rabies-infected animals can save lives. Overall, the physicians who participated in our study did not have sufficient knowledge of rabies. Rabies prophylaxis educational programs should be designed to educate physicians about the WHO and ACIP guidelines for the treatment of bites from suspected rabies-infected animals. Our findings provide important information to government officials. We also recommend professional postgraduate training for physicians in rabies care and management. Acknowledgments The authors wish to thank Istanbul Health Director's Office, Turkey and Turkish Medical Association for their help in data gathering.
Conflict of interest None to declare.
APPENDIX Questionnaire 1. What is your specialty? □ General Practitioner □ General Surgery □ Other Surgery □ Internal Medicine □ Other Internal Medicine □ Pediatrician □ Emergency Medicine □ Family Medicine □ Infectious Disease 2. What is your institution? □ University Hospital □ Government Research and Education Hospital □ Government Hospital □ Private University Hospital □ Private Hospital □ Yes □ No 3. Is your institution a rabies center? 4. How long have you been working in your profession? 5. Age: □ Female □ Male 6. Gender: □ Yes □ No 7. Do you have a child? □ Yes □ No 8. Do you have a pet? 9. Is the rabies a disease which must be reported to national health services? □ Yes □ No 10. Did you intervene a rabies suspected animal bites? □ Yes □ No 11. What is the cause of rabies? □ Fungus □ Bacteria □ Protozon □ Virus □ Prion 12. What is the incubation period of rabies? □ 1–3 days □ 3–7 days □ 7–10 days □ 10–21 days □ 3 weeks–3 months 13. What is/are the prodromal signs of rabies? (you can fill more than one choice). □ Pain around the wound □ Fever (39–419 C) □ Headache and vertigo □ Vomiting □ Delirium □ Convulsion □ Fatigue □ Hydrophobia 14. Which of the following animals are out of the risk of rabies in Turkey when it bites? □ Cow, Sheep, farm animals □ Bats □ Wolf, jackal, fox, and other carnivorous animals □ Rodents, rats, and guinea pigs □ Cat, dog, and other domestic animals 15. Do you recommend rabies prophylaxis to a person whose hand, which has not injured skin, was licked by a dog or a cat? □ Yes □ No 16. Which of the followings areas are important areas in the term of occurrence time of the disease in rabies suspected animal bites? □ Head and neck □ Arm and forearm □ Body and abdomen □ Thigh □ Feet and legs 17. Which is the correct transmission route in rabies disease? □ Pinprick contact with blood of the patient □ Direct contact with body fluids or mucous membranes of the patient □ The bites by patient □ Sexual relationship in prodramal term
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□ All Seven-year-old boy, his leg had been bitten by a stray dog while he was coming from school and the dog escaped. After 2 hours, the patient applied the emergency department. (The following 5 questions will be answered according to the above situation.) 18. What do you do to patient above as first line treatment? □ The cleaning of wound area. □ Doing rabies vaccine. □ Intervene to patient the human rabies immune globulin (HRIG). □ Recommending to go to a rabies center. 19. Do you recommend tetanus prophylaxis to the patient above? □ Tetanus prophylaxis is not recommended for animal bites. □ Recommend the tetanus prophylaxis according to the last dose of tetanus vaccination's schedule. 20. How do you clear the animal bite area? □ Washing with water and soap. □ Washing with alcohol. □ Washing with povidone iodine. □ After cleaning with water and soap, apply the povidone iodine. □ After cleaning with water and soap, apply a bandage wrap. 21. Do you recommend antibiotics to the patient above? □ The use of antibiotics have no place in animal bites. □ I suggest antibiotics according to the depth of animal bite and bite area, 22. Do you recommend to suture the wound in the patient's bite area? □ Yes □ No 23. What do you apply secondly to the patient above? □ Rabies vaccine alone □ Rabies vaccine and HRIG □ HRIG alone 24. What kind of rabies vaccine is used in Turkey? □ Live-virus vaccine □ Inactive virus vaccine 25. What is the dose of human diploid cell vaccine (HDCV) administered by intramuscularly? □ 0.05 cc □ 0.1 cc □ 0.5 cc □ 1 cc □ 2 cc 26. Which region and route of HDCV should be applied? □ Deltoid region, intramuscularly □ Deltoid region, subcutaneously □ Gluteal region, intramuscularly □ Anterolateral region of thigh for adults, intramuscularly □ Abdominal region for children, subcutaneously 27. What scheudule of HDCV should be applied in postexposure prophylaxis of previously unvaccinated people? □ On days 0, 7, 21, or 28 □ On days 0, 7, 14, or 28 □ On days 0, 3, 7, 14, and 28 □ On days 0, 3, 7, 14, 28, and 56 □ On days 0, 3, 7, 14, 28, and 60 28. In what conditions would you recommend HRIG? □ Should be applied in every rabies suspected animal bites if not given before the PEP □ There is no need to do if you could not find rabies vaccine. □ Apply for treatment after rabies signs have occured. □ Apply if patient is immunocompromised. □ Apply people vaccinated as preexposure prophylaxis. 29. What is the correct dose of HRIG? □ 20 IU/kg □ 40 IU/kg □ 50 IU/kg □ 60 IU/kg □ 80 IU/kg 30. How many doses of HRIG should be recommended? □1 □2 □3 □ Single dose together with every rabies vaccinations □5 31. How do you applied the HRIG intramuscularly? □ All dose should be infiltrated into deltoid muscle. □ Half dose should be infiltrated into wounds, the other half dose into deltoid muscle. □ Half dose should be infiltrated into wounds, the rest into unvaccinated deltoid muscle. □ All dose should be infiltrated into and around the wounds. 32. What would you recommend to a doctor whose hand was cut with knife, while making post-mortem autopsy to a patient who died from rabies? □ Only tetanus vaccine □ Only rabies vaccine □ Rabies vaccine together with HRIG □ Hepatitis vaccine □ Only cleaning the wound 33. What would you recommend to a nurse bitten by a patient kept under observation with predetermined rabies? □ Only tetanus vaccine □ Only rabies vaccine □ Rabies vaccine together with HRIG □ Hepatitis vaccine □ Only cleaning of wound 34. What would you recommend a nurse to wear who aspirated to patient kept under observation with predetermined rabies? □ Gloves □ Coat □ Mask □ Glasses □ All 35. Seven-year-old boy had been bitten by the dog in the foot and the dog was caught. In this case, which treatment approach do you do? □ Only rabies vaccine □ Rabies vaccine together with HRIG □ If the dog shows rabies symptoms under observation period, only rabies vaccine. □ If the dog shows rabies symptoms under observation period, rabies vaccine together with HRIG.
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36. How many days rabies suspected domestic animals should be keep under observetion? □ 10 □ 15 □ 20 □ 25 □ 30 37. One year ago, seven-year-old boy bitten by a dog and received rabies prophylaxis. Now he was bitten by rabies suspected dog and it could not be caught. What would you recommend for this patient? □ Nothing □ Only rabies vaccine □ Rabies vaccine together with HRIG □ Only tetanus vaccine □ Rabies and tetanus vaccines 38. If you recommend the rabies vaccine, which scheudule should you apply? □ On days 0, 3, 7, 14, and 28 □ On days 0. 3. 7, and 28 □ On days 0 and 3 □ On days 0, 14, and 28 □ On days 0, 3, and 7 39. What condition is contraindication for HDCV? □ Pregnancy □ Patient with alcohol □ Immunocompromised patient or taking immonodepressive medicine □ Patient has viral or bacterial infection while vaccination. □ None of above
REFERENCES 1. World Health Organization (2005): Expert consultation on rabies. WHO Technical Rep. Ser., 931, 1–106. 2. Baer, G.M. (1991): The Natural History of Rabies. 2nd ed. CRC Press, Florida. 3. Ministry of Health of Turkey (2001): The Prevention and Control Rules of Rabies. Essential Health Care General Manager. p. 1–22 (in Turkish). 4. Bassin, S.L., Rupprecht, C.E. and Bleck, T.P. (2010): Rhabdoviruses. p. 2249–2258. In Mandell, Doglas and Bennett's Principles and Practice of Infectious Diseases. 7th ed. Churchill Livingstone, New York. 5. Hassam Shah, F.S., Jawed, M., Nouruddin, S., et al. (2009):
Knowledge and practices among the general practitioners of Karachi regarding dog bite management. J. Pak. Med. Assoc., 59, 861. 6. Bhalla, S., Mehta, J.P. and Singh, A. (2005): Knowledge and practice among general practitioners of Jamnagar city regarding animal bite. Indian J. Commun. Med., 30, 94–96. 7. Dodet, B., Goswami, A., Gunasekera, A., et al. (2008): Rabies awareness in eight Asian countries. Vaccine, 26, 6344–6348. 8. Manning, S.E., Rupprecht, C.E., Fishbein, D., et al. (2008): Human rabies prevention—United States, 2008: recommendations of the Advisory Committee on Immunization Practices. Morbid. Mortal. Wkly. Rep., 57(RR-3), 1–28.
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