Paolo Dela Rosa, MD Lawrence Allen Tria, MD Ariel Valones , MD Department of Medicine PGH

Animal Bite Surveillance Report in a Government Hospital – The Philippine General Hospital Anti-Rabies Unit Experience: A 10 year Retrospective Review Paolo Dela Rosa, MD Lawrence Allen Tria, MD Ariel Valones, MD Department of Medicine PGH

2.29 per million 5th FATAL 100% Preventable

US$ 40 in Africa US$ 49 in Asia PhP1705-4470

Objectives The study described the epidemiological characteristics of animal bite cases consulting at the Anti-Rabies Unit of Philippine General Hospital from 2001-2011. • It described the clinical and demographic profile (age distribution, sex, area of residence, area of injury) of patients who sought consult at the Anti-Rabies Unit • of the Philippine General Hospital • It compared the compliance on ERIG/ Post-exposure Prophylaxis to the Category of Animal bite.

Methodology Retrospective Descriptive Cohort Medical records/ registry at the Anti-Rabies Unit of the Philippine General Hospital from its inception in 2002 to 2011. Demographic Data were extracted such as age, sex, area of residence, place of injury, initial wound management done before consult, patient’s immunization history and status, bite to consult time interval, animal profile (biting animal, ownership status, animal status at the time of bite and consult, animal vaccination status), immunization status, compliance to PEP regimen).

Outcome Variables Primary Outcome Variable • Epidemiologic characteristics of animal bite patients who sought consult at the Anti-Rabies Unit of the Philippine General Hospital from 2001-2011 Secondary Outcome Variables • Demographic profile of patients who sought consult at the Anti-Rabies Unit of the Philippine General Hospital. • Proportion of animal bites at the Anti-Rabies Unit’s Ten-Year existence at the Philippine General Hospital, and • Compliance on ERIG/ Post-exposure Prophylaxis to the Category of Animal bite.

Operational definition Category of Animal Bite Category I: touching or feeding animals, licks on intact skin (i.e. no exposure) Category II – nibbling of uncovered skin, minor scratches or abrasions without bleeding Category III – single or multiple transdermal bites or scratches, licks on broken skin; contamination of mucous membrane with saliva from licks, exposures to bats

Results

Table 1. Demographics and Baseline Characteristics of Patients at Philippine General Hospital - Anti Rabies Unit (PGH-ARU) from 2002 to 2011 (n=10,146)

Figure 1. Animal Bite Consult per year N=10, 146

Figure 2. Proportion Distribution of Animal Bite Patients According to Age Group at PGH-ARU for 2002-2011 (n=10,146)

Figure 3. Top Ten Places of Animal Bite occurrence as to Place of Injury, PGH ARU 2002 to 2011 (n= 9,889)

Map of Philippines showing the frequency of animal bite occurrence

Figure 4. Three Dimensional Relationship among the Time in years ( X axis), Proportion of Animal Bites ( Y axis) and the Age Group

Table 2. Characteristic of Domestic Animal bites at the Philippine General Hospital Anti Rabies Unit from 2002 to 2011

Figure 5. WHO Wound Category

Figure 6. Animal Bite to Consult time Interval

Figure 7. Frequency of Initial Wound Management

Figure 8. Percentage distribution of herbal and traditional animal bite wound management

Figure 9. Percent distribution of ancillary animal bite wound management

Figure 10. Proportion Distribution of Post Exposure Prophylaxis (PEP) vaccine Administered as to Category ( n= 9,541)

Table 3. Association of Wound category with the compliance with PEP

Table 4. Cost of vaccination depending on WHO Wound Category

Conclusion • Children and reproductive age-group are vulnerable to domestic animal bite. • Most of the animals are owned/ unleashed • 13% are vaccinated which is below the national vaccination coverage. • Barangays and non-government organizations played a role in a majority of canine vaccination, which can be further tapped to increase vaccination. • Herbal and traditional remedies account for 13.9%, of these 88% used garlic. • Completion of PEP is a function of the category of animal bite and the health awareness of the patient to comply with the recommended vaccination.

Conclusion There is a need for a multi-sectoral approach to strengthen mass advocacy campaign, accessibility of rabies unit and affordability of rabies vaccine. These revelations and public’s ability to recognize a potential rabies exposure and the appropriate management of the case by healthcare professionals are critical in rabies advocacy.

Recommendation The researchers recommend doing a biomedical research on the herbal and traditional practices, as well as surveillance on the clinical outcome of animal bite patients, and the various reasons for noncompletion of recommended post-exposure prophylaxis

Paolo Dela Rosa, MD Lawrence Allen Tria, MD Ariel Valones , MD Department of Medicine PGH