UNIVERSITY OF

GONDAR

COLLEGE OF MEDICINE AND HEALTH SCIENCES

SCHOOL OF BIOMEDICAL AND LABORATORY SCIENCES

Incidence of human rabies exposure and its associated risk

factors at Gondar Health Center, Gondar, North west

Ethiopia: A three years retrospective study.

By: Meseret Yibrah

Advisor: Debasu Damtie(BSc., MSc.)

A research paper to be submitted to the School of

Biomedical and Laboratory Sciences, College of

Medicine and Health Sciences, University of Gondar

for partial fulfilment of the requirements for the

degree of Bachelor of Science in Medical Laboratory

Sciencei

June, 2014

Gondar, Ethiopia

ii

Acknowledgement

I sincerely appreciate my advisor Mr. Debasu Damtie for his

invaluable support and advice during this research work. I

also would like to acknowledge School of Biomedical and

Laboratory Sciences for selecting my topic of interest.

Lastly, my deepest gratitude goes to Gondar Health Centre for

allowing me to use the rabies post exposure data for this

study.

I

Table of contents

Contents

page

Acknowledgement..............................................I

Table of contents...........................................II

List of

tables .......................................................

..............................................................

.......IV

List of

figures.......................................................

..............................................................

.......V

Acronyms......................................................

..............................................................

.............VI

II

Abstract......................................................

..............................................................

...............VII

1. Introduction.............................................1

1.1.

Background....................................................

..............................................................

...1

1.2. Statement of the problem...............................3

2. Literature review....................................................................................................................4

3. Justification of the study................................5

4.Objectives.................................................6

4.1. General objective......................................6

4.2. Specific objectives....................................6

5. Materials and methods.....................................7

5.1. Study area.............................................7

5.2. Study design and period................................7

5.3. Population.............................................7

5.3.1. Source population..................................7

5.3.2. Study population...................................7

5.4. Inclusion and Exclusion criteria………………………………………………………...7

5.5. Variables...........................................7

III

5.5.1. Independent variables..............................7

5.5.2. Dependent variables................................7

5.6. Sample size and sampling technique.....................8

5.7. Data collection methods................................8

5.8. Quality control........................................8

5.9. Data analysis and interpretation.......................8

5.10. Result dissemination..................................8

5.11. Ethical consideration.................................8

6.

Result........................................................

..............................................................

................9

7.Discussion..................................................

..............................................................

.............14

8. Conclusion and recommendations

.........................................................

.............................16

8.1. Conclusion............................................16

8.2. Recommendations.......................................16

9.Limitation of the

study.........................................................

.................................................17

10. References..............................................18

11. Annex...................................................20

IV

Annex I....................................................20

List of tables

Table1. Socio-demographic and seasonal distribution of human

rabies exposure cases between 2011-2013 at Gondar Health

Centre ………………………………………………10

Table2. Time of arrival to health centre for post exposure

prophylaxis after human rabies exposure at Gondar Health

Centre from 2011-

2013..........................................................

......11

Table3. Incidence of human rabies exposure cases in Gondar

Health Center by sex from 2011-

2013…………………………………………………………………………………....12

V

Table4. Incidence of human rabies exposure cases in North

Gondar Administrative Zone by residence from 2011-

2013…………………………………………………………………...13

List of figures

Fig 1. Human rabies exposure cases by year between 2011–2013

at Gondar Health Center………………………………………………………………………………………….9

VI

Fig 2. Dog statuses at the time of health centre visit for

post exposure prophylaxis Gondar Health Center from 2011-

2013..........................................................

......................................11.

VII

Acronyms

CDC- Centre for Disease Control

EHNRI -Ethiopian Health and Nutrition Research Institute

OR-odds ratio

PEP-Post Exposure Prophylaxis

RIG-Rabies Immune Globulin

WHO-World Health Organization

VIII

Abstract

Back ground: Rabies is one of the oldest known and most feared

human diseases recognized since the early period of

civilization. It is one of the main zoonotic diseases caused

by a virus and death nearly always follows once an animal or

human has been clinically ill with the disease.

Epidemiological studies provide basic information about the

burden of the disease and enhance prevention and control

interventions.

Objective: To assess the incidence of human rabies exposure

and associated risk factors at Gondar Health Centre from 2011

up to 2013, Gondar, North west Ethiopia.

Methods: A retrospective cross sectional study was conducted

at Gondar Health Centre where post exposure prophylaxis for

rabies was available for the whole population in the North

Gondar Zone catchment area. Data of human rabies exposure

cases between 2011 and 2013 was collected from rabies post

exposure prophylaxis registration book using data abstraction

sheets. The data was entered and analyzed using SPSS version

16 statistical software. A descriptive analysis was performed

for categorical variables. Bivariate analysis was used to

IX

determine association of explanatory variables and outcome

variable.

Result: A total of 261 human rabies exposures were reported to

Gondar Health Centre from 2011 up to 2013 with a decreasing

trend. The sex and age specific distribution showed that the

majority of rabies exposure cases were among males (142/226,

62.8%) and children less than 14 years old (87/261, 38.5%).

Also Predominant numbers of rabies exposure cases (161/220,

73.2%) were observed from rural area and during fall and

winter with the same proportion (67/222, 30.18%). Significant

number of human rabies exposure cases (23.2%) came to health

centre beyond 2 weeks time after injury for PEP and The

incidence of human rabies exposure cases was 4.6, 2.61 and

1.27 per 100, 000 population in 2011, 2012 and 2013

respectively. Being male and living in urban setting was found

to be risk factors for human rabies exposure from bivariate

analysis.

Conclusion: Significant number of human rabies exposure was

reported at Gondar Health Centre and being male and living in

urban area was found to be associated with rabies exposure. A

community based follow up study is recommended to accurately

estimate the incidence of human rabies exposure. There is a

need for deliberate efforts to educate the public about the

risks of rabies and where to go in case of rabies exposure.

Key words: Exposure, Incidence, Rabies, Risk factors

X

1. Introduction

1.1. BackgroundRabies is one of the very dangerous viral zoonoses and all

mammals can be infected by the virus. The cause of rabies is a

neurotrop virus belonging to the class Mononegavirales, the

family Rhabdoviridae, and the genus Lyssavirus[1]. The disease

mainly is transferable through biting and sometimes through

mucous tissues, respiration, placenta, contaminated instruments

and plantation of organs. This disease is endemic in tropical

areas and more cases are observed in developing countries [2].

Almost 99.9% of mortalities caused by human rabies as well as

98.5% of animal bite cases are related to tropical areas [3].

According to WHO report, worldwide human deaths from endemic

canine rabies were estimated to be 55000 per annum [4], with 56%

share from South East Asia Region [5].

An effective rabies vaccine was developed over a century ago

making rabies a preventable disease. When human diploid cell

vaccine in combination with rabies immune globulin is

administered promptly to rabies-exposed patients following

appropriate wound care, it is virtually 100% effective in

preventing human death [6]. Although rabies can infect and be

maintained by several different host species, domestic dogs are

by far the most important source of infection to humans with more

than 95% of human cases caused by bite from rabid dogs [7].

1

Rabies has the highest case fatality rate of any conventional

infectious disease, approaching 100%. The likelihood of a

productive rabies infection after exposure to a lyssa virus is

known to depend on a variety of factors, including but not

limited to dose, route of exposure, site of exposure, variant,

host genetic makeup, pre- and/or post-exposure prophylaxis

etc[8]. All mammals are susceptible to lyssa virus infection, but

species-level variation in susceptibility has long been

recognized [9].

Rabies in Africa constitutes a serious public health problem [10-

12]. In Ethiopia it is an important disease that has been

recognized for many centuries. The treatments recommended for

people bitten by rabid animals mainly dogs have been recorded in

many Ethiopian medical books since the early 17th century

(Sterleyn 1968) cited by Fekadu [13]. Rabies satisfies all the

World Health Organization (WHO) criteria for diseases that are a

priority for control [14] and, unlike many other emerging

zoonosis (such as West Nile virus), safe and effective animal and

human vaccines are widely available for its prevention and

control. Despite this, rabies remains a neglected disease that is

poorly controlled throughout much of the developing world,

particularly Africa and Asia, where most human rabies deaths

occur [14, 15]. A major factor in the failure of rabies control

is the low level of political commitment, partly arising from a

lack of quantitative data on the true public health impact of the

2

disease [14] and the cost-effectiveness and cost benefits of

controlling it [16].

Epidemiological studies provide basic information about the

burden of the disease and enhance prevention and control

interventions. To this regard, there are limited studies

conducted regarding incidence of rabies and associated factors in

Ethiopia in general and the study area in particular. Therefore,

this study was aimed to assess the incidence of human rabies

exposure cases and associated factors at Gondar Health Center.

3

1.2. Statement of the problemRabies is widely distributed across the globe. More than 55,000

people die of rabies each year [17]. About 95% of human deaths

occur in Asia and Africa. India is the most severely affected,

and China is the next [18]. Rabies is endemic in developing

countries of Africa and Asia, and most human deaths from the

disease occur in these endemic countries [19]. More than 99% of

all human deaths from rabies occur in the developing world [19].

Ethiopia being one of the developing countries is highly endemic

for rabies. Approximately 10, 000 people were estimated to die of

rabies annually in Ethiopia which makes it to be one of the worst

affected countries in the world [20]. Dogs are the principal

source of infection for humans and livestock [21]. However

incidence of human rabies exposure and its associated factors has

not been assessed at Gondar Health Center, Gondar. Hence, this

study was aimed to avail information required in combating the

disease.

4

2. Literature review

There are studies conducted about rabies anywhere else in the

globe. A retrospective study conducted in New York reported a

total of 2,216 PEP cases from 1995 to 2000, with 317–469 cases

each year. Annual PEP incidence was 23–34 cases/100,000 during

the 6-year period with 6-year average incidence of 27/100,000

reported higher mean annual incidence of PEP in rural areas and

during early spring/late summer, but no significant differences

were observed among sex or age distributions and PEP [23]. On the

other hand Chinese Centre for Disease Control and prevention5

(CDC) , reported 19,806 human rabies cases between 1996 and 2008

with an average of 1,524 cases each year, and the incidence

almost was rising rapidly, with the peak in 2007 (3,300 cases)

[24].

A community-based active surveillance for rabies in Machakos

District, Kenya showed 234 per 100 000 people annual incidence of

animal-bites of humans and the point estimate of human-rabies

incidence per year was 25 per million people. Almost all (97%)

animal-bites of humans were due to dogs [25].

Another study conducted in Zaria, Nigeria reported that males are

significantly more affected and incidence of dog bite was highest

during the hot season (April-June) and low during the wet season

(July-October) [26].

A 5-year (2002-2006) retrospective study conducted in Tanzania at

Bugando Hospital reported a total of 767 bite injuries by rabies-

suspected animals giving a mean annual incidence of ~58 cases per

100,000. A Tanzanian study revealed majority of human exposure

cases in each year were recorded during the period between June

and October and unlike the New York study children less than 18

were the most affected group [27]. A retrospective record review

study conducted in Ethiopia between 2001 and 2009 at EHNRI using

the rabies record book reported annual post exposure prophylaxis

for human rabies ranges between 1026 and 1580 every year for the

last nine years in Addis Ababa. It ranged from 300 to 1922 for

areas outside Addis Ababa. This study determined fatal human

6

rabies cases in 2001-2009 reported that children under 14 years

of age and males were highly affected segments of the community

[28]. A one year follow up of rabies incidence in humans and

domestic animals in North Gondar zone depicted an estimated human

rabies incidence of 2.33 cases per 100, 000 populations per year

[29].

3. Justification of the studyMany households own dogs usually for guarding property. Although

there are no formal studies, it is estimated that there is one

owned dog per five household nationally [20]. Dog management is

often poor and dog vaccination is limited to few dogs in urban

centres. High population of dogs with poor management contributes

for high endemicity of canine rabies in Ethiopia. In canine

rabies endemic countries like Ethiopia, rabies has also

significant economic importance by its effect on livestock [22],

so need to be investigated still. Local data are limited and old

regarding the incidence and associated factors of rabies exposure

in the study area. Hence, the findings of this study will be

useful to health service providers, planners, policy makers and

community at large for planning interventions targeting

prevention and control of rabies in the study area and beyond.

Moreover the findings of this study will serve as baseline

information for the further studies.

7

4. Objectives

4.1. General objective To assess incidence of human rabies exposure and associated

factors at Gondar Health Center.

4.2. Specific objectives To determine incidence of human rabies exposure at Gondar

Health Centre.

8

To identify associated risk factors of human rabies exposure

at Gondar Health Centre.

5. Materials and methods

5.1. Study areaThe study was conducted at Gondar Health Center, Gondar town.

Gondar town is located in the North Gondar zone of the Amhara

9

regional state, Northwest Ethiopia, at 748 km away from the

capital Addis Ababa. The town has a latitude and longitude

of 12°36′N 37°28′E with an elevation of 2133 meters above sea

level. Based on figures from the Central Statistical Agency in

2008, Gondar has an estimated total population of 231,977. Gondar

Health Center is one of the governmental health centers in

Gondar. This Health center is the only health center providing

rabies post exposure prophylaxis in the zone.

5.2. Study design and period

A retrospective cross sectional study was conducted to assess

incidence of human rabies exposure and associated risk factors

from 2011 up to 2013.

5.3. Population

5.3.1. Source populationAll population in Gondar health center who lived between 2011 and

2013 was source population of this study.

5.3.2. Study populationAll rabies exposure cases who visited Gondar Health Center for post exposure prophylaxis (PEP) between 2011 and 2013 were study population.

5.4. Inclusion and Exclusion criteria

5. 4.1. Inclusion criteria

Human rabies exposure cases who visited Gondar health center

for post exposure proph ylaxis (PEP) from 2011 up to 2013

were included in this study.10

5. 4.1. Exclusion criteria

Human rabies exposure cases who didn’t visit Gondar health

center for post exposure prophylaxis (PEP) from 2011 up to

2013 were excluded from this study.

5.5. Variables

5.5.1. Independent variableso Ageo Sexo Seasono Residenceo Dog status

5.5.2. Dependent variableso Human rabies exposure

5.6. Sample size and sampling techniqueAll human exposure cases visiting Gondar Health Centre between2011 and 2013 was included in the study.

5.7. Data collection methodsData of human rabies exposure cases between 2011 and 2013 will becollected from rabies post exposure prophylaxis registration bookusing data abstraction sheets.

5.8. Quality controlTraining regarding data entry and analysis using SPSS version 16was given to the principal investigator of the study to make surethat the data collected from the PEP log book is properly enteredand analyzed.

11

5.9. Data analysis and interpretationThe data was entered and analysed using SPSS version 16statistical software. A descriptive analysis was performed forcategorical variables. Bivariate analysis was performed toexamine possible risk factors of human rabies exposure. Oddsratio has been used to assess the presence and strength ofassociation between the outcome variable and explanatoryvariables. To obtain adjusted estimates of the odds ratio whileaccounting for all possible risk factors, multivariate analysiswill be used. In all cases, P-value less than 0.05 wereconsidered statistically significant. The findings of the studyare presented in narratives, tables and graphs.

5.10. Result disseminationAfter the completion of this study, a copy of the document willbe given to Gondar Health Centre, North Gondar Zone Health Deskand to the School of Biomedical and Laboratory Sciences each.Moreover efforts will be made to publish on one of the peerreviewed journals.

5.11. Ethical considerationEthical approval was obtained from the School of Biomedical andLaboratory Sciences Research and Ethical Review Committee,College of Medicine and Health Sciences, University of Gondar.Moreover, the Health Centre was communicated through officialletter for smooth conduct of the study.

6. Result

1. Human rabies exposure

A total of 261 human rabies exposures were reported to Gondar

health centre from 2011 up to 2013. The distribution of human

rabies exposure cases from year to year was observed to decrease

(Fig 1).

12

2011 2012 2013

87

52

25

53

2915

140

81

40

Male Female Total

Fig 1. Human rabies exposure cases by year between 2011 – 2013 atGondar Health Center

The sex and age specific distribution showed that the majority of

rabies exposure cases were among males (142/226, 62.8%) and among

children less than14 years old (87/261, 38.5%) (Table 1). This

study showed that, more rabies exposure cases (161/220, 73.2%)

were observed from rural area. In contrast human rabies exposure

in urban area were low which accounts (59/220, 26.8%). The higher

numbers of rabies exposure cases were reported from fall and

winter, with the same proportion (67/222, 30.18%). Similar lower

proportion of rabies exposure cases were reported during spring

and summer seasons (44/222, 19.91%) (Table1).

13

Table 1. Socio-demographic and seasonal distribution of human rabies exposure cases between 2011-2013 at Gondar Health Center.

14

Sex Residence Season

Agegroup Male

# (%)Female # (%)

Total# (%)

Urban# (%)

Rural # (%)

Total# (%)

Fall# (%)

Winter# (%)

Spring# (%)

Summer

Total# (%)

# (%)<5 10(7.0

)8(9.5) 18(8) 5(2.3) 13(5.9) 18(8.2) 7(3.2) 3(1.4) 4(1.8

)4(1.8)

18(8.1)

5-14 43(30.3)

26(31) 69(30.5)

12(5.5) 53(24.1)

65(29.5)

13(5.9) 22(9.9)

15(6.8)

19(8.6)

69(31.1)

15-24 25(17.6)

19(22.6)

44(19.5)

15(6.8) 29(13.2)

44(20) 15(6.8) 11(5.0)

7(3.2)

9(4.1)

42(18.9)

25-34 26(18.3)

11(13.1)

37(16.4)

11(5) 25(11.4)

36(16.4)

12(5.4) 15(6.8)

7(3.2)

2(0.9)

36(16.2)

35-44 15(10.6)

4(4.8) 19(8.4)

6(2.7) 13(5.9) 19(8.6) 6(2.7) 6(2.7) 4(1.8)

3(1.4)

19(8.6)

45-54 10(7) 9(10.7) 19(8.4)

3(1.4) 15(6.8) 18(8.2) 6(2.7) 6(2.7) 3(1.4)

3(1.4)

18(8.1)

55-64 5(3.5) 3(3.6) 8(3.5) 3(1.4) 5(2.3) 8(3.7) 2(0.9) 2(0.9) 2(0.9)

2(0.9)

8(3.6)

>/=65 8(5.6) 4(4.8) 12(5.3)

4(1.8) 8(3.6) 12(5.4) 6(2.7) 2(0.9) 2(0.9)

2(0.9)

12(5.4)

Total 142(62.8)

84(37.2)

226(100)

59(26.8)

161(73.2)

220(100)

67(30.2)

67(30.2)

44(19.8)

44(19.8)

222(100)

The time of arrival to the health centre after rabies exposure

was variable. Most of the rabies exposed cases visited to the

health centre within a week and from 1-2weeks after time of

exposure. On the other hand significant number of human rabies

exposure cases came late to health centre for PEP which

accounted 23.2% of human exposure cases (table 2).

Table 2. Time of arrival to health centre for post exposure

prophylaxis after human rabies exposure at Gondar Health Centr

from 2011-2013.

Variables Immediat

ely N(%)

Within

a week

N(%)

From 1-

2 weeks

N(%)

From 2-

4 weeks

N(%)

>4

weeks

N(%)Sex Male 27(16.9) 44(27.5

)

46(28.8

)

29(18.1

)

14(8.8)

Female 16(17.6) 32(35.2

)

24(26.4

)

14(15.4

)

5(5.5)

Total 43(17.1) 76(30.3

)

70(27.9

)

43(17.1

)

19(7.6)

Residen

ce

Urban 13(22.0) 19(32.2

)

15(25.4

)

10(16.9

)

2(3.4)

Rural 30(16.9) 54(30.3

)

51(28.7

)

27(15.2

)

16(9.0)

Total 43(18.1) 73(30.8

)

66(27.8

)

37(15.6

)

18(7.6)

The types of animals involved as a source of exposure to humans

were all in all through the bite of dogs and majority of the

11

dogs have died at the time of health centre visit and the rest

were with unknown status.

45

2011 2012 2013 Overall050100150200250300

9762

28

187

4319 12

74

140

8140

261

Died Unknown Total

Fig 2. Dog statuses at the time of health centre visit for post

exposure prophylaxis Gondar Health Centre from 2011-2013.

2. Incidence of human rabies exposure

The incidence of human rabies exposure cases as it was

calculated from the midyear population of the respective year

revealed 4.6, 2.61 and 1.27 per 100, 000 population in 2011,

2012 and 2013 respectively. In all the three years that the

study included, males were more exposed to rabies. In addition

the incidence of human rabies exposure in case of residence was

4.14, 2.61 and1.23 respectively and urban area was shown to be

observed with high incidence for human rabies exposure (Table

3).

3. Risk factor analysis for human rabies exposure

Though we didn’t exhaustively assess all possible risk factors

for human rabies exposure due to limited data available on the

log book, being male and living in urban setting was found to12

be risk factors for human rabies exposure from bivariate

analysis [COR=1.5967(95%CI=1.1347-2.2467) and

COR=2.6328(95%CI=1.8092-3.8311)] respectively for the year

2011.

Table 3. Incidence of human rabies exposure cases in North

Gondar Administrative Zone by sex from 2011- 2013.

Year Sex Populat

ion

Report

ed

cases

Incidence per

100,000

population

COR (95% CI)

2009 Male 1542518 87 5.64 1.5967(1.1347-

2.2467)*Female 1500347 53 3.53 1Total 3042865 140 4.6

2010 Male 1571760 52 3.30 1.4752(1.1081-

2.7488)*Female 1529784 29 1.90 1Total 3101544 81 2.61

2011 Male 1601699 25 1.56 1.6232(0.8558-

3.0789)Female 1559956 15 0.96 1

Total 3161655 40 1.27COR=Crude odds ratio, CI=confidence interval, *statistically

significant association

Table 4. Incidence of human rabies exposure cases in North

Gondar Administrative Zone by residence from 2011- 2013.

13

Year Sex Populat

ion

Reporte

d casesIncidence per

100,000

population

COR (95% CI)

2011 Urban 456879 40 8.76 2.6328(1.8092-

3.8311)*Rural 2585986 86 3.32 1Total 3042865 126 4.14

2012 Urban 476476 13 2.73 1.0533(0.5819-

1.9064)Rural 2625068 68 2.59 1Total 3101544 81 2.61

2013 Urban 496914 10 2.01 1.8492(0.9012-

3.7944)Rural 2664741 29 1.09 1Total 3161655 39 1.23

COR=Crude odds ratio, CI=confidence interval, *statistically

significant association

14

7. Discussion

In the present study, animal bite cases during 2011-2013 were

140, 81 and 40 respectively. Also, the Incidence cases per

100,000 were respectively 4.6, 2.61 and 1.27.This finding is by

far lower than a report from New York (23-34/100,000), Kenyan

active surveillance report (234/100,000) and Tanzanian study

which reported 58/100,000 population [23, 25, 27]. These

discrepancies might be explained by multiple socio-cultural

factors and methodological differences. In Ethiopia many people

prefer to go to traditional and faith healers than getting

modern medical care after exposure. Hence vast majority of

human exposure cases might not be reported to the health

facilities as a result it falsely reduces the incidence of

human rabies exposure.

The distribution of human rabies exposure cases from year to

year was observed to decrease. This might be explained by the

fact that dog vaccination services are being common practices

from time to time particularity in urban settings thereby

reducing possibility of dog bite.

The sex specific distribution showed that the majority (62.8%)

of rabies exposure cases were among males. This finding was

supported by a previous Ethiopian study conducted at the former

15

EHNRI and a Nigerian study which showed higher proportion of

males being exposed to rabies [26, 28]. This might be explained

by the day and night outdoor activities males are frequently

involved in and females are more likely to remain in-doors for

cultural and religious reasons. On the other hand majority of

human rabies exposure cases were reported among children less

than 14 years old (38.5%). This finding is in line with the

study done in Tanzania and Ethiopian study which reported

higher incidence of human rabies exposure among under 18 and

under 14 years old children respectively [27, 28]. This could

be probably due to children are more likely to have the dogs

provoked and are also less likely to defend themselves thereby

sustaining dog bite injuries. Unlike the present study a study

in New York reported no significant differences among sex or

age distributions and rabies exposure [23].

This study showed that, more rabies exposure cases (161/220,

73.2%) were observed from rural area. This finding is

concurrent with the study done in New York [23]. This might

possibly be explained by the large population being residing in

rural areas compared to urban settings.

The majority of rabies exposure cases were reported from fall

and winter, with the same proportion (67/222, 30.18%). In

contrary to this finding, studies from New York, Tanzania and

Nigeria reported high incidence of rabies exposure during

spring and summer seasons [23, 27, and 26]. This seasonal

16

variation could be due to variation in geographical locations

which determine the weather condition of each season.

Significant number of human rabies exposure cases came late to

health centre for PEP which accounted 23.2% of human exposure

cases while only 17.1% of victims have visited the health

centre immediately after bite. Unlike our finding, a Nigerian

retrospective study revealed that most (87.7%) of the victims

afflicted with dog bite injuries presented within 24 hours of

the bite which is quite commendable [26]. This might be due to

inaccessibility of the health centre in terms of distance for

majority of the rural catchment area since Gondar Health Centre

is the only facility providing PEP service. Therefore, the

efficacy of the PEP would be hampered by late arrival of the

victims at health facility.

The types of animals involved as a source of exposure to humans

were all in all through the bite of dogs. The present study

finding is consistent with another community based active

surveillance study conducted in Kenya which revealed 97% of

animal bites of humans were attributed to dogs [25]. Among dogs

responsible for human rabies exposure, majority (72.8%) have

died at the time of health centre visit by the victim and the

rest was with unknown status. This implies that dogs were

potential sources of rabies infection to humans.

Though we didn’t exhaustively assess all possible risk factors

for human rabies exposure due to limited data available on the

log book, being male was found to be risk factors for human

rabies exposure from bivariate analysis respectively for the

17

year 2011. This was supported by studies from Nigeria, Tanzania

and Ethiopia [26, 27, 28]. The present study also found out

that and living in urban setting is also a risk factor unlike

the report from New York which reported living in rural setting

as a risk factor. This might be due to the fact that in

Ethiopia people in rural settings settle very far apart in

contrary to urban area where people live in crowded conditions

which may favour dog bite exposure. On other hand in urban

settings stray dogs are abundant which may contribute for human

rabies exposure.

8. Conclusion and recommendations

8.1. Conclusion Significant number of human rabies exposure was reported at

Gondar Health Centre despite the fact that majority of victims

would prefer traditional healers for post exposure management

of rabies which probably may reduce the actual figure. Majority

of human rabies exposure cases were reported among children and

males. Human rabies exposure was common during fall and winter

seasons. Dog bite was the only source of exposure reported.

Significant number of rabies exposed cases came late to the

Health Centre to seek medical attention. Being male and living

in urban seating was found to be risk factors for rabies

exposure in humans.

18

8.2. RecommendationsBased on this study the following recommendations are made:

A community based follow up study is recommended to

accurately estimate the incidence of human rabies

exposure.

There is a need for deliberate efforts to educate the

public about the risks of rabies and where to go in case

of rabies exposure.

It is vital to vaccinate dogs for rabies in North Gondar

Zone.

Human diploid cell vaccine together with human rabies immune

globulin should be made available in every health care

facility.

19

9. Limitation of the study

Since the data for this study was from secondary sources

(document review), it was not complete and difficult to get

important variables. All the rabies cases reported to Gondar

health centre was considered treated with anti rabies vaccine

but the number of cases completed PEP regime and the status of

exposed cases after PEP was not documented. Moreover, this

study compiled data of exposure cases who did report to the

health centre. Hence those victims who didn’t come to the

health centre were not considered in the study which may

underestimate the true incidence of rabies exposure.

20

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11. Annex

Annex I. Data abstraction sheet for Human rabies exposure cases at Gondar Health Centre, 2014

S. no.

Variables Responses

1. Age

2. Sex 1. Male 2. Female

3. Occupation 1. Peasants 2. Students 3. Unattended children 4. Others

4. Residence 1. Urban 2. Rural

5. District 24

6. Season 1. Spring 2. Summer 3. Fall 4. Winter

7. Type of animal 1. Dog 2. Cat 3. Other specify __________

8. Time of arrival to thehealth center after bitten

1. Immediately 2. Within one week3. Within two weeks 4. After two weeks

9. PEP status 1. Completed 2. Discontinued 3. Status unknown

25