CMPH Journal

Results

Socio-demographic characteristics

50.2% of the respondents lived in Dabou town, in the wrood (25.1%) and old Dabou (25.1%) districts, and 53% had secondary education, 20.5% primary education and 15% illiteracy.

Table 2: Distribution of subjects according to reasons for not using PEP (N=322).

Obstacles to PEP consultation

29.55% did not know that in the event of exposure they had to go to the RAC to be vaccinated, 14.33% had a transport problem, 13.46% mentioned the refusal of the owner of the biting animal and 20.32% gave various reasons (Table 3).

Table 3: Répartition of subjects according to the determinants of consultation time (N=322).

The existence of statistically significant links

Statistical relationships between consultation time and assessment of vaccine cost. There was a statistically significant relationship between the assessment of the cost of the vaccine and the delay in consultation. Our study showed that the more expensive patients thought the vaccine was, the less likely they were to be vaccinated (Table 4).

Table 4: Distribution of subjects according to the relationship between consultation time and assessment of the cost of the vaccine.

Relationship between level of education and health centre attendance

There is a statistically significant link between the level of education and the health centre. The more educated the subjects, the more they consulted the health centres (Table 5).

Table 5: Distribution of subjects according to the relationship between level of education and health centre attendance.

Statistical links between the different “use and negligence”, “use and lack of financial means” and “use and injury considered minimal” complexes

The different complexes “Use and negligence” (Fisher exact; 0.009; Significant), “Use and lack of financial means” (Fisher exact: 0.028, Significant), “Use and injury considered minimal” (Fisher exact: 0.004, Significant) show that there is firstly a statistically significant link between use of the PEP and negligence, i.e. the more negligent the subjects are, the less they use the PEP. Secondly, there is a statistically significant link between use and lack of financial means. In other words, the more subjects lacked financial means, the less they used a health centre. Finally, there was a statistically significant link between use of a health centre and an injury judged to be minor. The more the subjects judged the injury to be minor, the less they used a health centre.

Discussion

Limitations of the study

This study has a number of limitations, in particular: the fact that the respondents had to use their memory to find the notion of a bite could have caused information bias, and the parents who answered the questionnaire in place of their children could have given inaccurate answers about the circumstances and the date because they were not always present at the time of the bite. Despite these limitations, the study remains relevant and could contribute to improving compliance with post-exposure prophylaxis in Côte d’Ivoire. Despite these limitations, the study remains relevant and could contribute to improving compliance with post-exposure prophylaxis in Côte d’Ivoire.

Socio-demographic characteristics

Age

In this study, the age group most exposed to the risk of rabies infection was the 10-19 age group, which accounted for 58.8%. The results are in line with those of Tiembré [22] in 2009, who found 62.3%, Lezou [25] in 2012 and Noufé [33] in 2015, who found proportions of 57.5% and 51% respectively in the 10-19 age group. Furthermore, in 2001, Chevalier [7] in France stated that more than 50% of all dog bites in the general population occurred between the ages of 0 and 18. This predominance can be explained by children and adolescents playing with dogs.

Gender

The subjects surveyed were male in 67.1% of cases. These results corroborate those of Dao (66%) and Mfupa (60%) in Mali [34,35] in relation to sex.

In Côte d’Ivoire, this male predominance is usual and has been described by several authors, including Aké [37] who found 57%, Detchi [37] with 56.3%, and Lezou [25] with 62.3%. In our context, this situation could be explained by a difference in lifestyle and professional activities, which would expose male subjects more.

Level of education

In the present study, 53% of subjects had secondary education. These results are much higher than those of Noufé [33], who found a rate of 24.4% in Abidjan in 2015. This difference can be explained by the fact that Noufé’s study was limited to subjects who came for a post-bite consultation. Younger subjects may not have sought medical attention because they were negligent, and their parents may not have referred them.

Place of residence

The risk of exposure to rabies infection is greatest in two districts of the town of Dabou, which together account for half of all victims (50.2%). This predominance in the Ancien Dabou and Wrood neighbourhoods could be due to their precarious nature, with a high child population and many stray dogs.

Conversely, the low rates observed in the Mermeville (1.7%) and Cité CIE (1.4%) neighbourhoods, which are residential areas, could be explained by the low number of stray dogs and, above all, the population’s level of education. The better educated people are, the more aware they are of the risk of rabies infection.

Occupation

In 64.8% of cases, schoolchildren were the most exposed. According to Tiembré et al [22], students and housewives were the occupations most affected. Ouattara et al [38] found that the majority of students and workers were of low socio-economic status. The results are also similar to those of Diehi [39] in 2012 (36.3%) and Noufé [33] in 2015 (43.7%). This predominance could be explained by the fact that the majority of victims were young people. It should also be noted that schoolchildren are more mobile and like to play with animals [25].

Monthly income in CFA Francs

In this study, 47.6% of the subjects had no income. Most were pupils and students. These results are similar to those of Tiembré in Côte d’Ivoire [22] in 2009, who found a proportion of 57%. Our results are also consistent with those of Ouattara et al. in Côte d’Ivoire [38], who found that the majority of students and workers were of low socio-economic status.

Pet ownership

The subjects surveyed owned a pet at home in 54.8% of cases. These figures are similar to those of Diehi [39] and Tiembré [1] in 2001, who found 56% and 76.9% respectively of exposure at home. This could be explained by the fact that growing insecurity is prompting residents to own guard animals and pets [25].

Distribution of animals

Dogs were the most common type of animal in the home, accounting for 65.3%. These results are comparable to those of Kayali in N’Djamena, where 85% of exposures were related to family dogs [40] and 85% of bites were caused by pet dogs [40]. The same is true of Dao [14] in his 2006 study in Mali, who noted that in 97.1% of cases, the biting animal was the dog. Tiembré [1] in 2007 found 94.8% while Noufé [33] in 2015 found 69.6%.

These figures could be explained by the fact that dogs are, for several reasons, man’s best companions and guardians.

Respondents’ knowledge and attitudes about rabies

Respondents’ knowledge of rabies

Most of those exposed were unaware of the symptoms of rabies and how long it takes for signs to appear. Hydrophobia was mentioned in only 9.9% of cases, and 72.6% did not know how long it took for signs to appear. These results show how little this population knows about rabies. Diehi [39] in 2002 found that 61.1% of people were unaware of the disease. According to Tiembré [22], rabies is one of the neglected diseases, which explains the population’s lack of awareness of the disease. This general lack of awareness leads to neglect of post-exposure prophylaxis. In addition, 8.6% of people surveyed were unaware that rabies is 100% fatal once reported. The results corroborate those of Noufé in 2015 who found 8.5% [33]. On the other hand, Lezou [25] found 19.9% in his 2012 study. Despite the decrease in the proportion of people unaware of rabies, the situation remains worrying because people who are unaware of the fatal state of rabies lag behind in starting PEP. In 1999, Aké [36] pointed out that ignorance of rabies was one of the reasons for the low rate of vaccination of domestic animals. The mode of transmission was dominated by bites (76.9%) and scratches (34.9%). A study carried out by Diallo [41] in 2009 showed that 94.5% of cases involved bites and 3.8% of scratches. These results could be explained by the fact that animals use either their mouths or their claws to attack or to defend themselves.

In terms of rabies vectors, dogs (93.4%) and cats (54.2%) were the main animals that transmit rabies. These results corroborate those of Detchi [37] in 2000, who found 87.8%, as well as those of N’Guessan [42] in 2002, who noted 93.5%, and Aké [36] in 1999, who showed that 90.6% of dogs were mainly responsible for rabies exposure. Whatever the study, the dog is the animal most frequently implicated because of its proximity to humans, either as a pet or for protection [38, 1, 22].

With regard to the cost of the vaccine, respondents reported that it cost 8,000 CFA francs, and 65% thought it was expensive. Noufé [33] noted in his study that 74.5% found the vaccine expensive. In fact, whatever the protocol used, the total cost of a complete treatment varied between 32,000 and 40,000 FCFA. It should be noted that Diehi [39] in 2001 noted that the cost of treating an exposed subject varied between 9,100F and 53,875F CFA. This excessive cost could lead to delay or abandonment of PEP.

Information on exposure

The vast majority of exposures occurred in the morning and afternoon, and 91.1% of exposures occurred in the street. In Côte d’Ivoire, canine or urban rabies is the main source of human rabies, with almost 90% of cases secondary to a stray dog bite [43]. In Chad, on the other hand, 85% of bites are caused by pet dogs [40]. Our results are at odds with those of Noufé [33] in 2015 and Diehi [37] in 2002, who found respectively that in 78.0% and 56% of cases exposure occurred at home.

The type of exposure most frequently encountered in this study is comparable to that of Tiembré [22] in 2009, Detchi [37] in 2000, Diop et al [35] in 2007 and Fadwa [44] in 2006, who found (63%), (90.6%),(98%) and (50.53%) respectively. This study shows that bites occurred preferentially on the lower limbs, as in the studies by Tiembré [1], Mfupa [35], Dao [14] and Fadwa [44]. This preferential location could be explained by the fact that these parts of the body are easily accessible to the animal. On the other hand, in another study, Ouattara [38] found that the upper limb was the most affected because it is put forward by the victims to protect themselves from the attack.

Respondents’ attitudes towards exposure to rabies

Biting animals were alive in 40.5% of cases in our study. These results are much lower than those of Tiembré [1], Diehi [39], N’guessan [42] and Detchi [37] who reported respectively that in (74.9%), (81.7%), (85.8%) and (86.6%) of cases, the animal was still alive.

In addition, more than half the population (58.5%) had no idea of the vaccination status of the biting animal. Our figures are similar to those of Noufé [33] in 2015, who found 43.4% compared with 82.3% in Diehi [39] in 2001, Morvan [45] with 79% in 1992, and Jamshid [16] with 79.2% in 1992. This situation is worrying because it may increase the risk of exposure to rabies infection.

In addition, the delay between the bite and the consultation was 24 to 48 hours after exposure in 42.6% of cases. Our results are similar to those of Fadwa [44] who, in her study, found a delay depending on the type of animal and the site, extent and nature of exposure. For dogs, she found a mean delay of 2.67 ± 4.08 days. Del Valle [46] in his study in Nancy found 2.4 days ± 21 days. On the other hand, Dao [34] and Traoré [47] in Mali found respectively that in (18.8%) and (17%) of cases, the subjects were presented on the same day. The emphasis should be on raising awareness to encourage people to seek medical advice as soon as possible.

Types of care sought

This study reveals that 46% of exposed subjects stated that they had washed the wound after exposure. Our results corroborate those of Tiembré [48] in 2009 and Noufé [33] in 2015, who found rates of 44% and 61% respectively. It should be noted that the rabies virus is very fragile. Cleaning must therefore always be undertaken. It is therefore advisable to consult a health centre after exposure.

In addition, the respondents stated that they had undertaken SAT in 20.2% of cases. Del Valle [46] in his study found isolated serotherapy in 9 cases, i.e. 0.8%. On the other hand, Fadwa [44] in his study in Mali found that 89% of people exposed to rabies had not received anti-tetanus prophylaxis. This situation is seen in almost all bite cases. Although SAT is not the specific treatment for rabies, it is still indicated because the wound is an entry point for the telluric bacillus.

In addition, only 12% of subjects used PEP. These results are contrary to those of Tiembré [22] in Côte d’Ivoire in 2009, who found 92%, and those of Fadwa [44] in Morocco, who found that 86.38% had undergone PEP. In a sense, the majority of the subjects surveyed did not undertake PEP. The reasons for this were ignorance, negligence, lack of financial resources and the remoteness of Rabies Control Centres (RACs). In fact, 21.90% (71/322) of subjects consulted a RAC for more than 48 hours. This situation is similar to the observations of Ouattara [40], where nonuse of PEP appears to be the result of human ignorance, negligence and unawareness. According to Tiembré et al [1], rabies is a disease that is often poorly understood. In addition, the low economic level of the population is a major obstacle to seeking care [39]. Other factors, such as geographical accessibility of the rabies centre by users and conflicts between victims and pet owners, are thought to contribute to further delays in consultations [37].

With regard to the cost of the vaccine, it has been observed that there is a distribution of subjects according to the relationship between the assessment of the cost of the vaccine by the subjects surveyed and the delay in consultation. The higher the cost was considered by the subjects surveyed, the less they were vaccinated. Our results are in line with those of Fadwa [50] and Dao [35] in Mali and Tiembré [22] and Diehi [41] in Côte d’Ivoire. On the other hand, sex, age, knowledge of rabies, vaccination status of the animal, number of lesions and monthly income had no influence on the delay in consultation. Contrary to the study by Aké in Côte d’Ivoire in 1996 (36), which showed that that the level of education had an influence on consultation times. The more educated the patients, the shorter the consultation time.

Conclusion

This study has shown that exposure to rabies is very common in the town of Dabou, particularly in the densely populated districts of Ancien Dabou and Wrood (50.2%). The biting animal is mainly a stray dog, and the victims are generally young people (20 ±10 years), most of whom have secondary education (53%). The place of bite was generally the street (91%). Despite the lethal nature of rabies, there is a lack of awareness of the disease. The services involved in the fight against rabies must therefore step up their efforts to educate the public about the risks associated with rabies infection, placing particular emphasis on the importance of postexposure prophylaxis. The Ministry of Health must introduce a policy of subsidizing rabies vaccines, given the lethal nature of the disease and, above all, with a view to eliminating it by 2030.

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