Zoonoses and Public Health
ORIGINAL ARTICLE
Knowledge, Attitudes and Practices of Primary Care Physicians in the Franche-Comte Region (France) Regarding the Risk of Rabies R. Jeanpetit1, A.-P. Bellanger2,3, E. Piotte1, C. Haffner-Mauvais4 and P. Marguet1,5 1 2 3 4 5
Emergency Department, Regional Hospital of Pontarlier, Pontarlier, France Department of Parasitology-Mycology, University Hospital of Besancßon, Besancßon, France CNRS-University of Franche-Comte/UMR 6249 Chrono-environnement, Besancßon, France University Hospital of Besancßon, Clinical Investigation Center (Inserm CIT 808), Besancßon, France Rabies Center, Pontarlier, France
Impacts
• Primary care physicians (PCPs) have some knowledge of the basic • •
information about the risk of rabies (type of animal transmitting the disease, severity criteria for bites). PCPs are not familiar with the indications for the rabies vaccine and rabies immunoglobulin. PCPs’ knowledge of how to manage and prevent rabies exposure often requires updating.
Keywords: Primary care physician; advice; knowledge; risk of rabies Correspondence: A.-P. Bellanger. Department of ParasitologyMycology, University Hospital Jean Minjoz, 25030 Besancßon, France. Tel.: +33 3 81 66 91 65; Fax: +33 3 81 66 89 14; E-mail: [email protected] Received for publication January 30, 2013 doi: 10.1111/zph.12082
Summary Rabies remains a public health concern and is associated with a mortality rate of nearly 100%. An observational survey was undertaken in 2010 to assess the knowledge, attitudes and practices of primary care physicians (PCPs) in our area regarding the risk of rabies. Standardized questionnaires were sent to a random sample of 400 PCPs practicing in the Franche-Comte region (eastern France), requesting their voluntary and anonymous participation. The questionnaires requested socio-demographic details and self-evaluation. Seven clinical situations were selected to assess the attitudes of physicians. The response rate was 38.5%. Most of the PCPs were based in rural and semi-rural areas, 76% knew where their nearest rabies centre was located and 75% of them claimed their knowledge of the risk of rabies was poor. While most of them (>80%) knew which animals transmitted the disease as well as the severity criteria for bites, only 12% knew that there was no contraindication for the rabies vaccine in the event of exposure to the disease. Responses to the seven clinical situations showed that most of them did not know the precise indication for the rabies vaccine and rabies immunoglobulin. Primary care physicians are usually aware of the risk of rabies, but their knowledge of how to manage rabies exposure and prevention often requires updating. The health authorities should provide more detailed information to PCPs and to the general population about the risk of rabies.
Rabies remains a public health concern and is associated with a mortality rate of nearly 100% (Gautret and Parola, 2011). Estimates indicate that more than 50 000 people worldwide die from this disease every year. Around 500 000 suspected rabies-infected animal bites are treated each year.
The last case of human rabies acquired in mainland France was reported in 1924 and the last case of fox rabies in 1998 (Gautret et al., 2013). In France, data from 2007 showed that 47% of all people who sought medical care in anti-rabies centres received post-exposures prophylaxis (PEP) treatment with 11% of them receiving rabies immunoglobulin (RIG; Bourhy et al., 2009). Rabies was officially
© 2013 Blackwell Verlag GmbH Zoonoses and Public Health, 2014, 61, 371–376
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Introduction
Rabies Risk and Primary Care Physicians
eradicated in non-flying mammals in metropolitan France between 2001 and 2008 according to the World Organization for Animal Health (Gautret et al., 2011). However, rabies has remained a threat, as the disease was reported in imported animals from rabies endemic countries and bats during this period (Gautret et al., 2011, 2013). Between 2000 and 2008, seven rabid dogs were illegally imported into France from Africa. For each imported rabid dog, between 2 and 187 people with direct contact received post-exposure vaccination and 15% received RIG (Bourhy et al., 2009). The number of reported human exposures to bats in Europe has also increased in recent years. In these cases, patients received RIG together with the vaccine in accordance with national and WHO guidelines. In France alone, an average of 100 people receive PEP including RIG after exposure to bats every year (Bourhy et al., 2009). Few publications can be found in the scientific literature investigating the attitudes and practices of primary care physicians (PCPs) concerning rabies, but they all tend to show that PCPs have insufficient knowledge of how to manage the risk of rabies (Ichhpujani et al., 2006; Ross et al., 2006; Shah et al., 2009; Mai et al., 2010; Pavli et al., 2011). Rabies is taught once and only briefly in French medical schools, as part of the ‘animal and insect bites’ section. Therefore, an observational survey was undertaken in 2010 to investigate the knowledge, attitudes and practices of PCPs in our area regarding the risk of rabies.
R. Jeanpetit et al.
Table 1. Geographical and demographical distribution of the participating physicians in comparison with the Regional Health Agency (RHA) data
Department Doubs Jura Haute Saone Belfort area No Answer Age 56 years old No Answer
Number
%
RHA, %
64 30 32 17 11
41.56 19.48 20.78 11.04 7.14
49.5 21.25 18 11.25 –
22 34 43 54 1
14.29 22.08 27.92 35.06 0.65
6 17 37.3 39.7 –
were asked about which animals can transmit the disease, contraindications for administration of rabies biologicals after exposure to the disease (Table 2), and PCPs were requested to provide the criteria for bite severity. Seven clinical situations were selected to assess the attitudes of PCPs, which included information on a variety of patient situations (Table 3). The software package STATA v10 (StataCorp LP, College Station, TX, USA) was used for statistical analysis using chi-squared and Fisher’s exact tests with a significance threshold of 5%. Results
Materials and Methods An observational survey was conducted in February 2010 as follows: standardized questionnaires were sent to a random sample of 400 PCPs practicing in the Franche-Comte region (eastern France), requesting their voluntary and anonymous participation. Franche-Comte is divided into four geographical areas (Doubs, Jura, Belfort and Haute Saone), and the number of PCPs to the population is 110/ 100 000 inhabitants. The addresses of PCPs were obtained from the French Medical Association. Primary care physicians having declared a specialty such as sports medicine, geriatrics or osteopathy were excluded. Of the 400 questionnaires mailed, 198 were sent to PCPs in the Doubs, 72 in Haute Saone, 85 in the Jura and 45 in the Belfort area (Table 1). The distribution of participating PCPs was compared with the distribution of PCPs in the Franche-Comte region using data from the Regional Health Agency (RHA). The questionnaire requested socio-demographic details and practice-related characteristics as well as a self-evaluation of the knowledge that each participating PCPs had about rabies (Table 2). Multiple choice questions (MCQ)
The response rate of the PCPs was 38.5% (154 questionnaires were returned completed and were analysable). The number of completed questionnaires obtained from each geographical area is presented in Table 1. The geographical distribution of the practices of participating PCPs in the four geographical areas of the Franche-Comte region (Doubs, Jura, Haute Saone and Belfort area) was proportional to the distribution of PCPs in the Franche-Comte region (RHA data, Table 1). In contrast, the demographical distribution of the participating PCPs did not exactly match the demographical data provided by the RHA: PCPs aged between 46 and 55 were under-represented (27.92% in our sample versus 37.3% according to the RHA), and PCPs aged under 45 were over-represented (36.37% in our sample versus 23% according to the RHA; Table 1). The socio-demographic details, practice-related characteristics of the participating PCPs and self-evaluation of knowledge of the risk of rabies are presented in Table 2. We observed that physicians’ initial medical training remains their main source of information (cited in 69% of the questionnaires). We also noted that the highest
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© 2013 Blackwell Verlag GmbH Zoonoses and Public Health, 2014, 61, 371–376
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Table 2. Socio-demographic details and practice-related characteristics of the participating primary care physicians (PCPs) Socio-demographic details
%
% Male 67 Age 55 years old 35 Practice-related information Rural 43 Semirural 39 Urban 17 Working alone 46 In association 39 Medical facility 14 Main sources of information used Initial medical training 37 Health instances 10 Medical review 10 Initial medical training + Health instances 10 Initial medical training + Medical review 14 Health instances + Medical review 3 Initial medical training + Health instances + Medical review 8 Frequency of rabies risk consultation Never 27 3 per year 8 Frequency of rabies risk consultation depending on the localization of the practice Rural Never 18 3 per year 12 Semi-rural Never 30 3 per year 5 Urban Never 38 3 per year 4 Does the PCP know where their Nearest Rabies Centre (NRC) is located? Yes 76 No 12 Distance between the PCP practice and the NRC 30 km 40 Self-evaluation of PCP about risk of rabies Up to date 23 Not up to date 75 Does the PCP know the pre-exposure vaccine procedure? Yes 27 No 69
Table 3. Description of responses to the multiple choice questions in percentages Yes (%)
No (%)
Animals that can transmit rabies Dog 90 8 Cat 75 23 Fox 92 6 Crow 11 87 Bat 84 14 Ferret 73 25 Horse 67 31 Weasel 66 33 Viper 4 93 Chamois 23 75 Snake 6 92 Contraindication for rabies vaccine after exposure Diabetes 1 58 Splenectomy 10 49 Pregnancy 27 32 Renal deficiency 8 50 Immunodeficiency 27 31 Over 75 years old 0 58 Autoimmune disease 16 42 None 12 0
Unanswered (%)
2 2 2 2 2 2 2 1 3 2 2 41 41 41 42 42 42 42 88
percentage of PCPs declaring more than three rabiesrelated consultations per year was from rural areas (12%; with 5% from semirural areas and 4% from urban areas). Most of the PCPs (75%) recognized that they were not up to date on rabies knowledge and PEP procedures (Table 2). Primary care physicians responses to the MCQs are presented in Table 3. The participating PCPs generally knew which types of animal transmitted rabies. The correct responses to these MCQs were dog, cat, fox, bat, ferret, horse, weasel and chamois. The highest percentages were obtained for fox (92%), dog (90%) and bat (84%). In contrast, only 12% knew that there was no contraindication for the rabies vaccine after exposure to the disease. We also found a high percentage of PCPs who did not answer this question (41–42%). The PCPs were also asked to indicate the criteria for bite severity. Depth, localization of the bite and behaviour of the biting animal were the most frequently chosen (respectively 55%, 40% and 36% of responses) compared with early management: 7%, clinical monitoring of the patient/animal: 3% and age of the patient: 1%. Analysis of the clinical situations The seven clinical cases and the participating physicians’ responses are listed in Table 2.
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Clinical case (CC) 1: a 7-year-old girl consults at your practice. She was just scratched by the neighbour’s cat. The scratch is very deep and on the forearm The expected answer was ‘no’ for each item proposed, mainly because the cat involved is a domestic cat. So neither RIG administration nor monitoring of the cat by a veterinarian would have been required in this situation in France. (However, French requirements for the administration of RIG may differ in this case from those of the US.) The PCPs largely chose not to request an expert opinion (67%), and many of them did not answer the question on whether there was an indication for the rabies vaccine or RIG (64% and 69%, respectively). Most PCPs recommended monitoring both the cat (80%) and the patient (89%). In practice, a simple surveillance of the cat at home by the owner could have been sufficient and reassuring both for the patient and the physician. CC2: a pregnant woman (8 weeks) consults because she was scratched by a fox that she was trying to stroke in the forest The expected answers were expert advice from the rabies centre + vaccine rabies + monitoring of the patient. Rabies immunoglobulin administration would have been postponed here because of the pregnancy. An expert opinion from the rabies centre was requested by 89% of the PCPs. Both rabies vaccine and RIG were recommended by the PCPs, with a response rate of 45% and 42%, respectively. CC3: You see in consultation a 3-year-old boy brought by his parents after a trip to Morocco; they were staying with family there, but one day a dog in the street jumped on the boy and licked him all over the face The expected answers were ‘yes’ to all the items proposed: expert advice from rabies centre + rabies vaccine + RIG + monitoring of the patient; a non-domestic dog from a rabies endemic country is indeed involved as well as clear saliva-mucous contact. Only 55% of the participating PCPs would have requested an expert opinion while 73% did recommend monitoring the patient. A large proportion of the PCPs did not know whether administration of rabies vaccine and RIG was required, with 49% and 56%, respectively, responding ‘no answer’. CC4: a 6-month-old boy is brought to your practice. The parents found a bat in a corner of his bedroom
R. Jeanpetit et al.
The correct answers were expert opinion + rabies vaccine + RIG + monitoring the patient, because of the risk from both drops of saliva from an infected bat and the very young age of the patient. Only 40% of the participating PCPs would have requested an expert opinion while 71% did recommend monitoring the patient. Concerning PEP procedures, only 10% recommended rabies vaccine and 9% RIG administration. Moreover, a large proportion of the PCPs did not know whether administering rabies vaccine and RIG was required, with 62% and 64%, respectively, responding ‘no answer’. CC5: You see in consultation a 7-year-old boy. He was bitten by a ferret bought 48 h before from a neighbour who has a breeding farm. The bite is superficial The correct answers were expert opinion + monitoring the ferret + monitoring the patient. The animal was considered as domestic because it comes from the neighbour’s breeding farm, so both rabies vaccine and RIG administration could have been postponed. PCPs were 61% to request an expert opinion. Again, many of them did not know whether administering rabies vaccine and RIG was required, with 48% and 54%, respectively, responding ‘no answer’. A large majority recommended monitoring both the patient (83%) and the ferret (87%). CC6: You examined a 48-year-old HIV-positive patient who has a deep bite on his right calf. He was bitten by the dog of a farmer’s friend. The latter killed the dog immediately because it had already attacked a boy on a bike the same day The correct answers were ‘yes’ to all the items proposed: expert opinion + rabies vaccine + RIG+ monitoring the patient + examination of the dog’s body. Responses were more uniform in this case, with 80% requesting an expert opinion, 81% requesting an examination of the dog’s body, 93% monitoring the patient, 43% recommended rabies vaccine and 44% RIG administration. CC7: a 34-year-old man comes to your practice. He is an engineer leaving for Mauritania on a humanitarian mission. He is worried about the risk of rabies because a colleague reported that many stray dogs were present on the site Most of the PCPs (70%) recommended the preventive rabies vaccine, which was the correct answer, but 72% would not agree to administer the vaccine at their practice. Discussion
This was a very unusual situation, and many PCPs added individual remarks to explain or comment on their answers.
The aim of this observational survey was to investigate the knowledge, attitudes and practices of PCPs in our area concerning rabies risk management.
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In general, this study shows that PCPs had correct knowledge of the basic information about the disease (types of animals transmitting the disease, severity criteria for bites), but were not familiar with the indications for PEP procedures. Primary care physicians did not always suspect rabies exposure in all the situations considered at-risk (only 39% in the case of a bat found in the bedroom of a child and 55% in the case of a boy’s face licked by a stray dog in a rabies endemic country). The contrast between the low frequency of suspected exposure to rabies declared (rare to
Rabies Risk and Primary Care Physicians
exceptional) at their practice and the mean number of bites per year in France (around 500 000) leads to the same conclusion. However, it is essential that PCPs consider the risk of rabies when treating patients subjected to animal-tohuman contact (bite, scratch, etc.) and that they assess the risk of rabies exposure by discussing the clinical situation with their nearest rabies centre. Human rabies is almost entirely preventable if patients exposed to rabies are correctly identified and receive appropriate and prompt PEP (Table 4).
Table 4. Evaluation of the knowledge of and attitudes towards rabies of the participating primary care physicians using seven clinical situations Yes (%)
No (%)
No answer (%)
Clinical Case (CC) 1: A 7-year-old girl consults at your practice. She was just scratched by the neighbour’s cat. The scratch is very deep and on the forearm Expert opinion from the rabies centre 25 67 8 Indication for rabies vaccine 6 30 64 Indication for rabies Ig 6 25 69 Monitoring of the cat 80 16 4 Monitoring of the patient 89 6 5 CC 2: A pregnant woman (8 weeks) consults because she was scratched by a fox that she was trying to stroke in the forest Expert advice from the rabies centre 89 7 4 Indication for rabies vaccine 45 21 34 Indication for rabies Ig 42 22 36 Monitoring of the patient 90 2 8 CC 3: You see in consultation a 3-year-old boy, brought by his parents after a trip to Morocco; they were staying with family there, but one day a dog in the street jumped on the boy and licked him all over the face Expert opinion from the rabies centre 55 43 2 Indication for rabies vaccine 32 19 49 Indication for rabies Ig 19 25 56 Monitoring of the patient 73 21 6 CC 4: A 6-month-old boy is brought to your practice. The parents found a bat in a corner of his bedroom Expert opinion from the rabies centre 40 56 4 Indication for rabies vaccine 10 28 62 Indication for rabies Ig 9 27 64 Monitoring of the patient 71 19 10 CC 5: You see in consultation a 7-year-old boy. He was bitten by a ferret, bought 48 h before from a neighbour who has a breeding farm. The bite is superficial Expert opinion from the rabies centre 61 36 3 Indication for rabies vaccine 26 26 48 Indication for rabies Ig 15 31 54 Monitoring of the ferret 87 8 5 Monitoring of the patient 83 7 10 CC 6: You examined a 48-year-old HIV-positive patient who has a deep bite on the right calf. He was bitten the same day by the dog of a farmer’s friend. The latter killed the dog immediately because it had already attacked a boy on a bike the same day Expert opinion from the rabies centre 80 16 4 Indication for rabies vaccine 43 30 27 Indication for rabies Ig 44 23 33 Examination of the dog’s body 81 12 7 Monitoring of the patient 93 1 6 CC 7: A 34-year-old man comes to your practice. He is an engineer leaving for Mauritania on a humanitarian mission. He is worried about the risk of rabies because a colleague reported that many stray dogs were present on the site Expert opinion from the rabies centre 86 10 4 Indication for rabies vaccine 70 8 22 Indication for rabies Ig 2 53 45 Would you agree to administer the preventive vaccine at your practice? 21 72 7
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Very few similar studies can be found in the scientific literature, but they all tend to show that PCP knowledge of rabies risk management is often insufficient. Two studies previously conducted to assess the knowledge of the risk of rabies in India and Vietnam highlighted a lack of information among the local population (Ichhpujani et al., 2006; Mai et al., 2010). Other studies have investigated the knowledge of the risk of rabies for travellers and health advisors (Ross et al., 2006; Altmann et al., 2009; Shah et al., 2009; Pavli et al., 2011). A German study conducted in 2006 (Ross et al., 2006) investigated the attitudes after rabies exposure of 496 PCPs and pharmacists, and 60% described the post-exposure protocol correctly. Another study, carried out in Pakistan (Shah et al., 2009), demonstrated that more than 80% of PCPs were well aware of rabies transmission, the incubation period and symptoms, but only approximately 20% knew the correct patient management procedures in the event of exposure. In 2011, a Turkish study (Koruk et al., 2011) involving a survey conducted on 84 PCPs demonstrated that while 65% knew how to manage the risk of rabies after exposure, only 18% knew the preventive protocol. Another recent Turkish study (Gonen et al., 2011) interviewed 890 physicians (specialist physicians and PCPs) using MCQs on general knowledge of rabies and management protocols. In their study, 41% of the participating physicians did not know which animals transmit rabies. By focusing on PCPs only, they concluded that 63% had insufficient knowledge of rabies and 80% did not know the management procedures. We observe a contrast between the gravity of the disease (100% mortality once the symptoms appear) and the lack of updates in PCP knowledge of rabies since their early training. Rabies is rare in France, but animals from rabies endemic countries are regularly (and sometimes illegally) imported. Furthermore, the risk of rabies is still present and constantly evolving, as new or previously unidentified rabies virus variants are identified in rabies-free areas (Gautret et al., 2011). French health authorities should provide primary care physicians with more detailed information about the risk of rabies. Conclusion While cases of rabies infection in humans are rare in France, exposure to the virus is still possible via domestic and wild animals, especially bats. Primary care physicians are usually aware of the risk of rabies but their knowledge of how to manage and prevent rabies exposure often requires updating. Health authorities should provide PCPs and the general population with more detailed information about the risk of rabies. 376
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Acknowledgements We thank Pamela Albert for her editorial assistance. Conflict of Interest The authors have no conflict of interest to declare. References Altmann, M., P. Parola, J. Delmont, P. Brouqui, and P. Gautret, 2009: Knowledge, attitudes, and practices of French travelers from Marseille regarding rabies risk and prevention. J. Travel Med. 16, 107–111. Bourhy, H., M. Goudal, A. Mailles, M. Sadkowska-Todys, L. Dacheux, and H. Zeller, 2009: Is there a need for anti-rabies vaccine and immunoglobulins rationing in Europe? Euro. Surveill. 14, 19166. Gautret, P., and P. Parola, 2011: Rabies vaccination for international travelers. Vaccine 30, 126–133. Gautret, P., C. Labreuil, M. Seyni, J. Delmont, P. Parola, and P. Brouqui, 2011: Effect of media warnings on rabies postexposure prophylaxis, France. Emerg. Infect. Dis. 17, 1131–1132. Gautret, P., S. Le Roux, B. Faucher, J. Gaudart, P. Brouqui, and P. Parola, 2013: Epidemiology of urban dog-related injuries requiring rabies post-exposure prophylaxis in Marseille, France. Int. J. Infect. Dis. 17, e164–e167. Gonen, I., A. Soysal, A. Topuzoglu, and M. Bakir, 2011: Clinical knowledge and attitudes of Turkish physicians toward rabies caused by animal bites. Jpn. J. Infect. Dis. 64, 382–390. Ichhpujani, R., M. Chahabra, V. Mittal, D. Bhattacharya, J. Singh, and S. Lal, 2006: Knowledge, attitude and practices about animal bites and rabies in general community-a multicentric study. J. Commun. Dis. 38, 355–361. Koruk, S. T., I. Koruk, and S. Kutlu, 2011: Where do we stand in the control of rabies? Knowledge and practices among physicians in a health district in Turkey. Wilderness Environ. Med. 22, 151–155. Mai, T., L. Dung, N. Tho, N. Quyet, P. Than, and N. Mai, 2010: Community knowledge, attitudes and practices toward rabies prevention in North Vietnam. Int. Q. Community Health Educ. 31, 21–31. Pavli, A., G. Saroglou, S. Hadjianastasiou, S. Patrinos, A. Vakali, Z. Ouzounidou, and H. C. Maltezou, 2011: Knowledge and practices about rabies among travel medicine consultants in Greece. Travel Med. Infect. Dis. 9, 32–36. Ross, R. S., B. Wolters, S. O. Viazov, and M. Roggendorf, 2006: Awareness of rabies risks and knowledge about preventive measures among experienced German travel health advisors. J. Travel Med. 13, 261–267. Shah, S. F., M. Jawed, S. Nooruddin, S. Afzal, F. Sajid, S. Majeed, M. Naveed, K. Mustafa, and M. Azhar, 2009: Knowledge and practices among the general practitioners of Karachi regarding dog bite management. J. Pak. Med. Assoc. 59, 861–864.
© 2013 Blackwell Verlag GmbH Zoonoses and Public Health, 2014, 61, 371–376
ORIGINAL ARTICLE
Knowledge, Attitudes and Practices of Primary Care Physicians in the Franche-Comte Region (France) Regarding the Risk of Rabies R. Jeanpetit1, A.-P. Bellanger2,3, E. Piotte1, C. Haffner-Mauvais4 and P. Marguet1,5 1 2 3 4 5
Emergency Department, Regional Hospital of Pontarlier, Pontarlier, France Department of Parasitology-Mycology, University Hospital of Besancßon, Besancßon, France CNRS-University of Franche-Comte/UMR 6249 Chrono-environnement, Besancßon, France University Hospital of Besancßon, Clinical Investigation Center (Inserm CIT 808), Besancßon, France Rabies Center, Pontarlier, France
Impacts
• Primary care physicians (PCPs) have some knowledge of the basic • •
information about the risk of rabies (type of animal transmitting the disease, severity criteria for bites). PCPs are not familiar with the indications for the rabies vaccine and rabies immunoglobulin. PCPs’ knowledge of how to manage and prevent rabies exposure often requires updating.
Keywords: Primary care physician; advice; knowledge; risk of rabies Correspondence: A.-P. Bellanger. Department of ParasitologyMycology, University Hospital Jean Minjoz, 25030 Besancßon, France. Tel.: +33 3 81 66 91 65; Fax: +33 3 81 66 89 14; E-mail: [email protected] Received for publication January 30, 2013 doi: 10.1111/zph.12082
Summary Rabies remains a public health concern and is associated with a mortality rate of nearly 100%. An observational survey was undertaken in 2010 to assess the knowledge, attitudes and practices of primary care physicians (PCPs) in our area regarding the risk of rabies. Standardized questionnaires were sent to a random sample of 400 PCPs practicing in the Franche-Comte region (eastern France), requesting their voluntary and anonymous participation. The questionnaires requested socio-demographic details and self-evaluation. Seven clinical situations were selected to assess the attitudes of physicians. The response rate was 38.5%. Most of the PCPs were based in rural and semi-rural areas, 76% knew where their nearest rabies centre was located and 75% of them claimed their knowledge of the risk of rabies was poor. While most of them (>80%) knew which animals transmitted the disease as well as the severity criteria for bites, only 12% knew that there was no contraindication for the rabies vaccine in the event of exposure to the disease. Responses to the seven clinical situations showed that most of them did not know the precise indication for the rabies vaccine and rabies immunoglobulin. Primary care physicians are usually aware of the risk of rabies, but their knowledge of how to manage rabies exposure and prevention often requires updating. The health authorities should provide more detailed information to PCPs and to the general population about the risk of rabies.
Rabies remains a public health concern and is associated with a mortality rate of nearly 100% (Gautret and Parola, 2011). Estimates indicate that more than 50 000 people worldwide die from this disease every year. Around 500 000 suspected rabies-infected animal bites are treated each year.
The last case of human rabies acquired in mainland France was reported in 1924 and the last case of fox rabies in 1998 (Gautret et al., 2013). In France, data from 2007 showed that 47% of all people who sought medical care in anti-rabies centres received post-exposures prophylaxis (PEP) treatment with 11% of them receiving rabies immunoglobulin (RIG; Bourhy et al., 2009). Rabies was officially
© 2013 Blackwell Verlag GmbH Zoonoses and Public Health, 2014, 61, 371–376
371
Introduction
Rabies Risk and Primary Care Physicians
eradicated in non-flying mammals in metropolitan France between 2001 and 2008 according to the World Organization for Animal Health (Gautret et al., 2011). However, rabies has remained a threat, as the disease was reported in imported animals from rabies endemic countries and bats during this period (Gautret et al., 2011, 2013). Between 2000 and 2008, seven rabid dogs were illegally imported into France from Africa. For each imported rabid dog, between 2 and 187 people with direct contact received post-exposure vaccination and 15% received RIG (Bourhy et al., 2009). The number of reported human exposures to bats in Europe has also increased in recent years. In these cases, patients received RIG together with the vaccine in accordance with national and WHO guidelines. In France alone, an average of 100 people receive PEP including RIG after exposure to bats every year (Bourhy et al., 2009). Few publications can be found in the scientific literature investigating the attitudes and practices of primary care physicians (PCPs) concerning rabies, but they all tend to show that PCPs have insufficient knowledge of how to manage the risk of rabies (Ichhpujani et al., 2006; Ross et al., 2006; Shah et al., 2009; Mai et al., 2010; Pavli et al., 2011). Rabies is taught once and only briefly in French medical schools, as part of the ‘animal and insect bites’ section. Therefore, an observational survey was undertaken in 2010 to investigate the knowledge, attitudes and practices of PCPs in our area regarding the risk of rabies.
R. Jeanpetit et al.
Table 1. Geographical and demographical distribution of the participating physicians in comparison with the Regional Health Agency (RHA) data
Department Doubs Jura Haute Saone Belfort area No Answer Age 56 years old No Answer
Number
%
RHA, %
64 30 32 17 11
41.56 19.48 20.78 11.04 7.14
49.5 21.25 18 11.25 –
22 34 43 54 1
14.29 22.08 27.92 35.06 0.65
6 17 37.3 39.7 –
were asked about which animals can transmit the disease, contraindications for administration of rabies biologicals after exposure to the disease (Table 2), and PCPs were requested to provide the criteria for bite severity. Seven clinical situations were selected to assess the attitudes of PCPs, which included information on a variety of patient situations (Table 3). The software package STATA v10 (StataCorp LP, College Station, TX, USA) was used for statistical analysis using chi-squared and Fisher’s exact tests with a significance threshold of 5%. Results
Materials and Methods An observational survey was conducted in February 2010 as follows: standardized questionnaires were sent to a random sample of 400 PCPs practicing in the Franche-Comte region (eastern France), requesting their voluntary and anonymous participation. Franche-Comte is divided into four geographical areas (Doubs, Jura, Belfort and Haute Saone), and the number of PCPs to the population is 110/ 100 000 inhabitants. The addresses of PCPs were obtained from the French Medical Association. Primary care physicians having declared a specialty such as sports medicine, geriatrics or osteopathy were excluded. Of the 400 questionnaires mailed, 198 were sent to PCPs in the Doubs, 72 in Haute Saone, 85 in the Jura and 45 in the Belfort area (Table 1). The distribution of participating PCPs was compared with the distribution of PCPs in the Franche-Comte region using data from the Regional Health Agency (RHA). The questionnaire requested socio-demographic details and practice-related characteristics as well as a self-evaluation of the knowledge that each participating PCPs had about rabies (Table 2). Multiple choice questions (MCQ)
The response rate of the PCPs was 38.5% (154 questionnaires were returned completed and were analysable). The number of completed questionnaires obtained from each geographical area is presented in Table 1. The geographical distribution of the practices of participating PCPs in the four geographical areas of the Franche-Comte region (Doubs, Jura, Haute Saone and Belfort area) was proportional to the distribution of PCPs in the Franche-Comte region (RHA data, Table 1). In contrast, the demographical distribution of the participating PCPs did not exactly match the demographical data provided by the RHA: PCPs aged between 46 and 55 were under-represented (27.92% in our sample versus 37.3% according to the RHA), and PCPs aged under 45 were over-represented (36.37% in our sample versus 23% according to the RHA; Table 1). The socio-demographic details, practice-related characteristics of the participating PCPs and self-evaluation of knowledge of the risk of rabies are presented in Table 2. We observed that physicians’ initial medical training remains their main source of information (cited in 69% of the questionnaires). We also noted that the highest
372
© 2013 Blackwell Verlag GmbH Zoonoses and Public Health, 2014, 61, 371–376
R. Jeanpetit et al.
Rabies Risk and Primary Care Physicians
Table 2. Socio-demographic details and practice-related characteristics of the participating primary care physicians (PCPs) Socio-demographic details
%
% Male 67 Age 55 years old 35 Practice-related information Rural 43 Semirural 39 Urban 17 Working alone 46 In association 39 Medical facility 14 Main sources of information used Initial medical training 37 Health instances 10 Medical review 10 Initial medical training + Health instances 10 Initial medical training + Medical review 14 Health instances + Medical review 3 Initial medical training + Health instances + Medical review 8 Frequency of rabies risk consultation Never 27 3 per year 8 Frequency of rabies risk consultation depending on the localization of the practice Rural Never 18 3 per year 12 Semi-rural Never 30 3 per year 5 Urban Never 38 3 per year 4 Does the PCP know where their Nearest Rabies Centre (NRC) is located? Yes 76 No 12 Distance between the PCP practice and the NRC 30 km 40 Self-evaluation of PCP about risk of rabies Up to date 23 Not up to date 75 Does the PCP know the pre-exposure vaccine procedure? Yes 27 No 69
Table 3. Description of responses to the multiple choice questions in percentages Yes (%)
No (%)
Animals that can transmit rabies Dog 90 8 Cat 75 23 Fox 92 6 Crow 11 87 Bat 84 14 Ferret 73 25 Horse 67 31 Weasel 66 33 Viper 4 93 Chamois 23 75 Snake 6 92 Contraindication for rabies vaccine after exposure Diabetes 1 58 Splenectomy 10 49 Pregnancy 27 32 Renal deficiency 8 50 Immunodeficiency 27 31 Over 75 years old 0 58 Autoimmune disease 16 42 None 12 0
Unanswered (%)
2 2 2 2 2 2 2 1 3 2 2 41 41 41 42 42 42 42 88
percentage of PCPs declaring more than three rabiesrelated consultations per year was from rural areas (12%; with 5% from semirural areas and 4% from urban areas). Most of the PCPs (75%) recognized that they were not up to date on rabies knowledge and PEP procedures (Table 2). Primary care physicians responses to the MCQs are presented in Table 3. The participating PCPs generally knew which types of animal transmitted rabies. The correct responses to these MCQs were dog, cat, fox, bat, ferret, horse, weasel and chamois. The highest percentages were obtained for fox (92%), dog (90%) and bat (84%). In contrast, only 12% knew that there was no contraindication for the rabies vaccine after exposure to the disease. We also found a high percentage of PCPs who did not answer this question (41–42%). The PCPs were also asked to indicate the criteria for bite severity. Depth, localization of the bite and behaviour of the biting animal were the most frequently chosen (respectively 55%, 40% and 36% of responses) compared with early management: 7%, clinical monitoring of the patient/animal: 3% and age of the patient: 1%. Analysis of the clinical situations The seven clinical cases and the participating physicians’ responses are listed in Table 2.
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Clinical case (CC) 1: a 7-year-old girl consults at your practice. She was just scratched by the neighbour’s cat. The scratch is very deep and on the forearm The expected answer was ‘no’ for each item proposed, mainly because the cat involved is a domestic cat. So neither RIG administration nor monitoring of the cat by a veterinarian would have been required in this situation in France. (However, French requirements for the administration of RIG may differ in this case from those of the US.) The PCPs largely chose not to request an expert opinion (67%), and many of them did not answer the question on whether there was an indication for the rabies vaccine or RIG (64% and 69%, respectively). Most PCPs recommended monitoring both the cat (80%) and the patient (89%). In practice, a simple surveillance of the cat at home by the owner could have been sufficient and reassuring both for the patient and the physician. CC2: a pregnant woman (8 weeks) consults because she was scratched by a fox that she was trying to stroke in the forest The expected answers were expert advice from the rabies centre + vaccine rabies + monitoring of the patient. Rabies immunoglobulin administration would have been postponed here because of the pregnancy. An expert opinion from the rabies centre was requested by 89% of the PCPs. Both rabies vaccine and RIG were recommended by the PCPs, with a response rate of 45% and 42%, respectively. CC3: You see in consultation a 3-year-old boy brought by his parents after a trip to Morocco; they were staying with family there, but one day a dog in the street jumped on the boy and licked him all over the face The expected answers were ‘yes’ to all the items proposed: expert advice from rabies centre + rabies vaccine + RIG + monitoring of the patient; a non-domestic dog from a rabies endemic country is indeed involved as well as clear saliva-mucous contact. Only 55% of the participating PCPs would have requested an expert opinion while 73% did recommend monitoring the patient. A large proportion of the PCPs did not know whether administration of rabies vaccine and RIG was required, with 49% and 56%, respectively, responding ‘no answer’. CC4: a 6-month-old boy is brought to your practice. The parents found a bat in a corner of his bedroom
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The correct answers were expert opinion + rabies vaccine + RIG + monitoring the patient, because of the risk from both drops of saliva from an infected bat and the very young age of the patient. Only 40% of the participating PCPs would have requested an expert opinion while 71% did recommend monitoring the patient. Concerning PEP procedures, only 10% recommended rabies vaccine and 9% RIG administration. Moreover, a large proportion of the PCPs did not know whether administering rabies vaccine and RIG was required, with 62% and 64%, respectively, responding ‘no answer’. CC5: You see in consultation a 7-year-old boy. He was bitten by a ferret bought 48 h before from a neighbour who has a breeding farm. The bite is superficial The correct answers were expert opinion + monitoring the ferret + monitoring the patient. The animal was considered as domestic because it comes from the neighbour’s breeding farm, so both rabies vaccine and RIG administration could have been postponed. PCPs were 61% to request an expert opinion. Again, many of them did not know whether administering rabies vaccine and RIG was required, with 48% and 54%, respectively, responding ‘no answer’. A large majority recommended monitoring both the patient (83%) and the ferret (87%). CC6: You examined a 48-year-old HIV-positive patient who has a deep bite on his right calf. He was bitten by the dog of a farmer’s friend. The latter killed the dog immediately because it had already attacked a boy on a bike the same day The correct answers were ‘yes’ to all the items proposed: expert opinion + rabies vaccine + RIG+ monitoring the patient + examination of the dog’s body. Responses were more uniform in this case, with 80% requesting an expert opinion, 81% requesting an examination of the dog’s body, 93% monitoring the patient, 43% recommended rabies vaccine and 44% RIG administration. CC7: a 34-year-old man comes to your practice. He is an engineer leaving for Mauritania on a humanitarian mission. He is worried about the risk of rabies because a colleague reported that many stray dogs were present on the site Most of the PCPs (70%) recommended the preventive rabies vaccine, which was the correct answer, but 72% would not agree to administer the vaccine at their practice. Discussion
This was a very unusual situation, and many PCPs added individual remarks to explain or comment on their answers.
The aim of this observational survey was to investigate the knowledge, attitudes and practices of PCPs in our area concerning rabies risk management.
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In general, this study shows that PCPs had correct knowledge of the basic information about the disease (types of animals transmitting the disease, severity criteria for bites), but were not familiar with the indications for PEP procedures. Primary care physicians did not always suspect rabies exposure in all the situations considered at-risk (only 39% in the case of a bat found in the bedroom of a child and 55% in the case of a boy’s face licked by a stray dog in a rabies endemic country). The contrast between the low frequency of suspected exposure to rabies declared (rare to
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exceptional) at their practice and the mean number of bites per year in France (around 500 000) leads to the same conclusion. However, it is essential that PCPs consider the risk of rabies when treating patients subjected to animal-tohuman contact (bite, scratch, etc.) and that they assess the risk of rabies exposure by discussing the clinical situation with their nearest rabies centre. Human rabies is almost entirely preventable if patients exposed to rabies are correctly identified and receive appropriate and prompt PEP (Table 4).
Table 4. Evaluation of the knowledge of and attitudes towards rabies of the participating primary care physicians using seven clinical situations Yes (%)
No (%)
No answer (%)
Clinical Case (CC) 1: A 7-year-old girl consults at your practice. She was just scratched by the neighbour’s cat. The scratch is very deep and on the forearm Expert opinion from the rabies centre 25 67 8 Indication for rabies vaccine 6 30 64 Indication for rabies Ig 6 25 69 Monitoring of the cat 80 16 4 Monitoring of the patient 89 6 5 CC 2: A pregnant woman (8 weeks) consults because she was scratched by a fox that she was trying to stroke in the forest Expert advice from the rabies centre 89 7 4 Indication for rabies vaccine 45 21 34 Indication for rabies Ig 42 22 36 Monitoring of the patient 90 2 8 CC 3: You see in consultation a 3-year-old boy, brought by his parents after a trip to Morocco; they were staying with family there, but one day a dog in the street jumped on the boy and licked him all over the face Expert opinion from the rabies centre 55 43 2 Indication for rabies vaccine 32 19 49 Indication for rabies Ig 19 25 56 Monitoring of the patient 73 21 6 CC 4: A 6-month-old boy is brought to your practice. The parents found a bat in a corner of his bedroom Expert opinion from the rabies centre 40 56 4 Indication for rabies vaccine 10 28 62 Indication for rabies Ig 9 27 64 Monitoring of the patient 71 19 10 CC 5: You see in consultation a 7-year-old boy. He was bitten by a ferret, bought 48 h before from a neighbour who has a breeding farm. The bite is superficial Expert opinion from the rabies centre 61 36 3 Indication for rabies vaccine 26 26 48 Indication for rabies Ig 15 31 54 Monitoring of the ferret 87 8 5 Monitoring of the patient 83 7 10 CC 6: You examined a 48-year-old HIV-positive patient who has a deep bite on the right calf. He was bitten the same day by the dog of a farmer’s friend. The latter killed the dog immediately because it had already attacked a boy on a bike the same day Expert opinion from the rabies centre 80 16 4 Indication for rabies vaccine 43 30 27 Indication for rabies Ig 44 23 33 Examination of the dog’s body 81 12 7 Monitoring of the patient 93 1 6 CC 7: A 34-year-old man comes to your practice. He is an engineer leaving for Mauritania on a humanitarian mission. He is worried about the risk of rabies because a colleague reported that many stray dogs were present on the site Expert opinion from the rabies centre 86 10 4 Indication for rabies vaccine 70 8 22 Indication for rabies Ig 2 53 45 Would you agree to administer the preventive vaccine at your practice? 21 72 7
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Very few similar studies can be found in the scientific literature, but they all tend to show that PCP knowledge of rabies risk management is often insufficient. Two studies previously conducted to assess the knowledge of the risk of rabies in India and Vietnam highlighted a lack of information among the local population (Ichhpujani et al., 2006; Mai et al., 2010). Other studies have investigated the knowledge of the risk of rabies for travellers and health advisors (Ross et al., 2006; Altmann et al., 2009; Shah et al., 2009; Pavli et al., 2011). A German study conducted in 2006 (Ross et al., 2006) investigated the attitudes after rabies exposure of 496 PCPs and pharmacists, and 60% described the post-exposure protocol correctly. Another study, carried out in Pakistan (Shah et al., 2009), demonstrated that more than 80% of PCPs were well aware of rabies transmission, the incubation period and symptoms, but only approximately 20% knew the correct patient management procedures in the event of exposure. In 2011, a Turkish study (Koruk et al., 2011) involving a survey conducted on 84 PCPs demonstrated that while 65% knew how to manage the risk of rabies after exposure, only 18% knew the preventive protocol. Another recent Turkish study (Gonen et al., 2011) interviewed 890 physicians (specialist physicians and PCPs) using MCQs on general knowledge of rabies and management protocols. In their study, 41% of the participating physicians did not know which animals transmit rabies. By focusing on PCPs only, they concluded that 63% had insufficient knowledge of rabies and 80% did not know the management procedures. We observe a contrast between the gravity of the disease (100% mortality once the symptoms appear) and the lack of updates in PCP knowledge of rabies since their early training. Rabies is rare in France, but animals from rabies endemic countries are regularly (and sometimes illegally) imported. Furthermore, the risk of rabies is still present and constantly evolving, as new or previously unidentified rabies virus variants are identified in rabies-free areas (Gautret et al., 2011). French health authorities should provide primary care physicians with more detailed information about the risk of rabies. Conclusion While cases of rabies infection in humans are rare in France, exposure to the virus is still possible via domestic and wild animals, especially bats. Primary care physicians are usually aware of the risk of rabies but their knowledge of how to manage and prevent rabies exposure often requires updating. Health authorities should provide PCPs and the general population with more detailed information about the risk of rabies. 376
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Acknowledgements We thank Pamela Albert for her editorial assistance. Conflict of Interest The authors have no conflict of interest to declare. References Altmann, M., P. Parola, J. Delmont, P. Brouqui, and P. Gautret, 2009: Knowledge, attitudes, and practices of French travelers from Marseille regarding rabies risk and prevention. J. Travel Med. 16, 107–111. Bourhy, H., M. Goudal, A. Mailles, M. Sadkowska-Todys, L. Dacheux, and H. Zeller, 2009: Is there a need for anti-rabies vaccine and immunoglobulins rationing in Europe? Euro. Surveill. 14, 19166. Gautret, P., and P. Parola, 2011: Rabies vaccination for international travelers. Vaccine 30, 126–133. Gautret, P., C. Labreuil, M. Seyni, J. Delmont, P. Parola, and P. Brouqui, 2011: Effect of media warnings on rabies postexposure prophylaxis, France. Emerg. Infect. Dis. 17, 1131–1132. Gautret, P., S. Le Roux, B. Faucher, J. Gaudart, P. Brouqui, and P. Parola, 2013: Epidemiology of urban dog-related injuries requiring rabies post-exposure prophylaxis in Marseille, France. Int. J. Infect. Dis. 17, e164–e167. Gonen, I., A. Soysal, A. Topuzoglu, and M. Bakir, 2011: Clinical knowledge and attitudes of Turkish physicians toward rabies caused by animal bites. Jpn. J. Infect. Dis. 64, 382–390. Ichhpujani, R., M. Chahabra, V. Mittal, D. Bhattacharya, J. Singh, and S. Lal, 2006: Knowledge, attitude and practices about animal bites and rabies in general community-a multicentric study. J. Commun. Dis. 38, 355–361. Koruk, S. T., I. Koruk, and S. Kutlu, 2011: Where do we stand in the control of rabies? Knowledge and practices among physicians in a health district in Turkey. Wilderness Environ. Med. 22, 151–155. Mai, T., L. Dung, N. Tho, N. Quyet, P. Than, and N. Mai, 2010: Community knowledge, attitudes and practices toward rabies prevention in North Vietnam. Int. Q. Community Health Educ. 31, 21–31. Pavli, A., G. Saroglou, S. Hadjianastasiou, S. Patrinos, A. Vakali, Z. Ouzounidou, and H. C. Maltezou, 2011: Knowledge and practices about rabies among travel medicine consultants in Greece. Travel Med. Infect. Dis. 9, 32–36. Ross, R. S., B. Wolters, S. O. Viazov, and M. Roggendorf, 2006: Awareness of rabies risks and knowledge about preventive measures among experienced German travel health advisors. J. Travel Med. 13, 261–267. Shah, S. F., M. Jawed, S. Nooruddin, S. Afzal, F. Sajid, S. Majeed, M. Naveed, K. Mustafa, and M. Azhar, 2009: Knowledge and practices among the general practitioners of Karachi regarding dog bite management. J. Pak. Med. Assoc. 59, 861–864.
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