CLINICAL PRACTICE ARTICLE

Post-exposure Rabies Prophylaxis for Children in

Southern Turkey
Can Celiloglu, Ulas Özdemİr, Orkun Tolunay, Asena Sucu and Umit Celik
Department of Pediatrics, University of Medical Sciences, Adana City Training and Research Hospital, Adana, Turkey

ABSTRACT
Objective: To evaluate the prophylaxis practices used on children with animal exposures in a major southern city of Turkey,
close to the Syrian border.
Study Design: Cross-sectional study.
Place and Duration of Study: Emergency and Outpatient departments, Adana City Training and Research Hospital, Turkey
between September 2017 and September 2018.
Methodology: The demographic data of the patients, who presented due to animal contact; the interval between animal
contact and hospital presentation; species of exposed animals, type, and apparent condition of the animals; risk categories
based on national assessment scale; the number of rabies vaccines and anti-rabies immunoglobulin (RIG) administrations;
administration of tetanus prophylaxis; adherence of patients to the follow-up schedule; vaccine refusals; and development of
rabies disease (if any), were recorded.
Results: Of the 2,068 presentations after animal exposure, 906 (43.8%) were children, mostly boys (62%), and the mean age
was 97.15 ± 57.68 months. Risky contact was most frequently caused by cats (52.8%) and dogs (45.6%). Exposure to stray
animals was the most common (58.5%). For serial prophylaxis vaccinations, 761 (83.99%) families were in full compliance and
145 (16%) families had discontinued vaccinations. The discontinuation rate of the immigrant population was significantly higher
(p = 0.001).
Conclusion: Risky contacts were mostly due to stray animals. Efforts to minimise the stray animal population should be
increased. The rate of discontinuation of rabies prophylaxis follow-ups was 16%. Significantly higher prophylaxis discontinuation
among the immigrant population was noted.

Key Words: Rabies, Vaccines, Prophylaxis, Turkey.

How to cite this article: Celiloglu C, Özdemİr U, Tolunay O, Sucu A, Celik U. Post-exposure Rabies Prophylaxis for Children in Southern
Turkey. J Coll Physicians Surg Pak 2021; 31(10):1219-1223.

INTRODUCTION Dogs are the most important reservoir for rabies virus, and dog
bites account for up to 99% of human rabies cases.6 Turkey
Rabies is an acute, rapidly progressive encephalitis, and is one
remains an endemic country in terms of rabies.7 Approximately
of the oldest known zoonotic diseases. The causative agent is
180,000 rabies risk-posing animal contacts are reported; and
the rabies virus, which is an enveloped, single-stranded RNA
virus from the rhabdoviridae family under the genus of 1-2 human rabies cases are seen annually in Turkey.7 Turkey is
lyssavirus.1 Despite medical developments, rabies almost unique in that it is the only European country in which the prin-
invariably progresses to death.2 Rabies continues to be a cipal vector for rabies is the domestic dog (canis familiaris),
serious public health problem due to the high mortality rate; and rather than the fox (vulpes vulpes).8 The stray animal popula-
medical care costs of post-exposure prophylaxis practices.3 It is tion is a major concern in Turkey. Municipalities are responsible
estimated that around 59,000 people die of rabies each year for the treatment of stray animals in Turkey. According to
worldwide.4 According to data of the World Health Organization current law, animals are vaccinated, kept temporarily in shel-
(WHO), around 15 million post-exposure prophylaxis applica- ters, and released into nature. There are no data on the total
tions are performed worldwide, annually.5 number of stray animals and the vaccinated percentage of
these animals.
Correspondence to: Dr. Can Celiloğlu, Department of Pedi-
It is well known that no cases of documented rabies develop
atrics, University of Medical Sciences, Adana City
Training and Research Hospital, Adana, Turkey
when strict adherence to post-exposure prophylaxis rules is
E-mail: canceliloglu@yahoo.com established.5 A comprehensive field prophylaxis programme is
..................................................... ongoing within Turkey's health system, because rabies disease
Received: February 13, 2020; Revised: March 06, 2021; is lethal and a potentially preventable health problem. The
Accepted: March 30, 2021 rabies vaccine prophylaxis cost is funded by the Government
DOI: https://doi.org/10.29271/jcpsp.2021.10.1219
Health System. The vaccine type used in Turkey is “purified vero

Journal of the College of Physicians and Surgeons Pakistan 2021, Vol. 31(10): 1219-1223 1219
Can Celiloglu, Ulas Özdemİr, Orkun Tolunay, Asena Sucu and Umit Celik

cell vaccine.” However, despite the efforts of the health adminis- group met the assumption of normal distribution. Descriptive
tration on rabies prophylaxis measures, both the enormous statistics of the numerical parametric variables were calculated
immigrant flow that occurred from Syria and the emerging as mean ± standard deviation; non-parametric variables were
vaccine hesitancy among different socioeconomic levels of the calculated in the median and interquartile range (IQR) and cate-
population poses new challenges to Turkey’s health system. gorical variables were given as a percentage (%). A Chi-square
The rate of adherence of families to rabies post-exposure test was performed for the comparison of categorical variables
prophylaxis measures is of importance.
9
between groups. A p value of <0.05 was considered statistically
significant.
The aim of the present study was to investigate the total number
of admittance to our hospital for post-exposure rabies prophy- Ethical approval regarding the study was obtained from the
laxis between September 2017 and September 2018, the rate Adana City Education and Research Hospital Clinical Research
of pediatric cases among all hospital presentations, the species Ethics Committee (Meeting No. 26; Date 05.02.2018; Decision
of animals and types of human exposure, the number of devel- number: 350.
oped rabies diseases if any, and the rate of adherence of
patients to the follow-up process among Turkish and immigrant
populations.

METHODOLOGY
The study was conducted in Adana City Training and Research
Hospital, Turkey. Medical records of patients, who presented
due to risky animal contacts between September 2017 and
September 2018, were evaluated retrospectively, based on
electronic records of the hospital. Patients aged under 18 years
of all nationalities were included. Cases with record errors and
missing data were excluded from the study (Figure 1). The
Figure 1: Flow diagram of the study group.
demographic data of the patients; the interval between animal
contact and hospital presentation; species of exposed animals,
type of animal contacts, and apparent condition of the animals;
risk categories based on the national assessment scale (Table
I); the number of rabies vaccines and anti-rabies immunoglob-
ulin (RIG) administrations, administration of tetanus prophy-
laxis, adherence of patients to follow-up schedules; vaccine
refusals; and development of rabies disease (if any) were
recorded.
(1) If the exposed animal presents any kind of rabies symptoms,
dies or escapes, then rabies vaccination is to be commenced.
(2) If the exposed animal presents any kind of rabies symptoms
or dies; rabies vaccination should be commenced anti-rabies Ig Figure 2: Seasonal and monthly distribution of hospital presentations
due to animal contacts with suspicion of rabies.
should be administered.
(3) If the exposed animal (dog or cat) is healthy for 10 days after RESULTS
the incident, vaccination should be stopped. Within one year from September 2017 to September 2018, 906
(4) If the exposed animal (dog or cat) presents any kind of rabies children were enrolled in the study (Table II). The median age of
symptoms, dies or escapes, anti-rabies Ig should be adminis- the children was 91 months (47-142.2). The day of presentation
tered within 7 days following the first dose of rabies vaccination. was termed as day 0, if presentation occurred < 24 hours after
If more than 7 days have passed, anti-rabies Ig should not be the animal contact. Seven hundred and twenty (79.4%) of the
children presented to our clinic within 24 hours, and the latest
administered instead; 5th dose of rabies vaccination should be
presentation was 12 days after the contact. The mean interval
added to the scheme.
between animal contact and hospital admission was 0.41 ±
(5) If anti-rabies Ig is not immediately available, it should be 1.15 days.
administered within the following 7 days.
When the cases were aligned, according to the months of
The statistical analysis was performed using the Statistical hospital presentation, the lowest number of presentations were
Package for Social Sciences version 20 (IBM Corp., Armonk, NY, in January (n=53, 5.8%) and February (n=56, 6.2%); and the
USA) software package. The Kolmogorov–Smirnov test was highest numbers of presentations were in May (n=99, 10.9%)
used to evaluate whether the numeric variables of the study and June (n=99, 10.9%) (Figure 2).

1220 Journal of the College of Physicians and Surgeons Pakistan 2021, Vol. 31(10): 1219-1223
Rabies prophylaxis

Table I: Risk categories of animal exposures according to the T.R. Ministry of Health, National Rabies Field Guide.

-Touching/feeding the animal

1 No intervention warranted
-Intact skin exposure to animal's saliva

Wound care
If the exposed animal was vaccinated within the last year
Evaluation for tetanus prophylaxis
Observation of animal for 10 days1
-Slight scratching of skin (injuries not Wound care
If the animal is healthy
extending to subcutaneous tissue) If the exposed animal was not Evaluation for tetanus prophylaxis
2 and can be observed
vaccinated within the last year properly Observation of animal for 10 days1
-Minor injuries without bleeding or vaccination status is
unknown Wound care
If the animal cannot be
Evaluation for tetanus prophylaxis
observed
Initiation of rabies vaccination

Wound care
If the exposed animal was vaccinated within the last year Evaluation for tetanus prophylaxis
Observation of animal for 10 days2
-Bites/scratches penetrating the skin
-Exposure of open wounds/mucosa to Wound care
animal's saliva If the animal is healthy Ovaluation for tetanus prophylaxis
and can be observed Commencement of rabies vaccination3
3
-Lesions localised to head, fingertips properly Observation of animal for 10 days3
(areas of dense innervation) If the exposed animal was not Administration of anti-rabies Ig4
vaccinated within the last year
or vaccination status is Wound care
unknown If the animal cannot be Ovaluation for tetanus prophylaxis
observed Commencement of rabies vaccination
Administration of anti-rabies Ig5

Wound care
Ovaluation for tetanus prophylaxis
4 Exposure to wild animals with a risk of rabies
Commencement of rabies vaccination
Administration of anti-rabies Ig5

Table II: Demographic and clinical characteristics of the study group. (RIG), and rates of compliance of families with follow-up.

Parameter n (%) Number of administered rabies vaccine

Age (median) 91 months No vaccine administered 22 (2.4%)
Male 565 (62.4%) 1 dose 95 (10.4%)
Sex 2 doses 51 (5.6%)
Female 341 (37.6%).
T.R. 876 (96.7%) 3 doses 108 (11.9%)
Nationality 4 doses 526 (58%)
Immigrant 30 (3.3%)
5 doses 104 (11.4%)
Cat 478 (52.8%)
Dog 413 (45.6%) RIG administration
The exposed animal species Administered
Bat 4 (0.4%) 447 (49.3%)
Other species 11 (1.2%) Not administered 459 (50.7%)
Scratch 428 (47.2%) Prior full dose anti-rabies vaccination within a year
Bite 388 (42.8%) Administered 11 (1.2%)
The type of animal contact Open wound contact 11 (1.2%) Not administered 895 (98.8%)
Other types of trauma 79 (8.7%)
Compliance of families with follow-up
(e.g. abrasions) Full compliance 761 (84%)
Discontinuation 122 (13.5%)
Vaccine refusal 23 (2.5%)
The exposed animals were stray animals in 530 (58.5%) Compliance of Prophylaxis Applications to National Guideline
cases that could not be observed after the contact. In 11 Full compliance 716 (79.1%)
Inappropriate 190 (20.9%
(1.2%) cases, the animals were reported to be deceased.
Only 94 (25.7%) of 365 owned animals were reported to be
vaccinated properly. Besides local wound care and animal observation, for 22
children (2.4%), no procedures were performed, intramus-
When post-exposure procedures were categorised cular (im) RIG and a 4-dose scheme of rabies vaccinations
according to the Rabies Field Guide of the T.C. Ministry of were performed for 456 (50.3%) children, a 4-dose scheme
Health in 2014 (Table I), 19 (2.1%) cases were classified as of rabies vaccinations was performed for 224 (24.7%) chil-
category I, 210 (23.2%) were classified as category II, 673 dren, and a 5-dose scheme of rabies vaccinations (0.3.7.14,
(74.2%) cases were classified as category III, and four 28 days) was planned for post-exposure prophylaxis for 204
(0.4%) were classified as category IV. (22.5%) children (Table III). The mean number of rabies
vaccines administered per child was 3.54±1.17.

Table III: Administration of rabies vaccine, rabies immunoglobulin When evaluated according to the Rabies Field Guideline, anti-

Journal of the College of Physicians and Surgeons Pakistan 2021, Vol. 31(10): 1219-1223 1221
Can Celiloglu, Ulas Özdemİr, Orkun Tolunay, Asena Sucu and Umit Celik

3
rabies post-exposure prophylaxis practices were properly under-treated. In this analysis, 79% of post-exposure prophy-
performed in 716 (79%) children. Non-compliance with the laxis was performed in accordance with the guidelines struc-
guidelines was found in 190 (21%) cases. When the factors of tured for Turkey. Turkey’s ongoing health policies include
the non-compliance were examined, parents of 122 (13.5%) completely unrestricted, free-of-charge emergency health
children discontinued the follow-ups without declaring any services, regardless of nationality or insurance coverage, and
reason, the parents of 23 (2.5%) children signed that they this may play a role in this relatively successful rate of proper
refused for their child to be vaccinated, and in 45 cases, other prophylaxis compared with the other developing countries.
types of non-compliance with the guideline were observed.
The mean age of patients, who discontinued prophylaxis Studies have shown that compliance of the population with
follow-up and those who were continuing follow-up, were the post-exposure rabies follow-ups may be low in developing
compared and no significant difference was found. countries. In a study from the Ivory Coast, the rate of discont-
inuation of follow-ups was reported as 52.7%, it was 22.6% in
When compared in terms of the rate of discontinuation of Thailand.17,18 In this study, the follow-up rate was lower (16%)
rabies prophylaxis vaccination follow-ups, this rate was than those. However, studies from Turkey and Europe with
higher in immigrant patients (15.3% vs. 36.7%). Fortunately, vaccine doses administered at 100% and no discontinuation
14,16
no human rabies case was observed in the region of the during follow-ups have also been reported in the literature.
authors during the one year within the scope of the present This high dropout rate in this study may be due to the high
study. rate of rural presentations with a low economic-educational
level and a high number of presentations from the immigrant
DISCUSSION population (almost all from Syria).19 Increasing knowledge
levels of both local and refugee families regarding the impor-
Prophylaxis after risky contact is of great importance during
tance of rabies vaccination may increase the compliance
the struggle against rabies 2 . In the current literature, rates with the rabies vaccination scheme.
41.9-49.6% of all patients, who present to hospitals for
rabies prophylaxis after animal contact, are children and this The progress made by some developed countries regarding
study results are consistent with the literature. 10,11 Males rabies is inspiring. In Singapore, for instance, rabies has not
presented more frequently with rabies-risk contacts, which is been seen since 1953. In Turkey, 1-2 rabies cases are seen
consistent with the literature.10-12 In the literature, animal annually. In this study, we observed that the animals causing
contacts evaluated for rabies prophylaxis have been rabies-risk contact were predominantly stray. Reducing the
reported to increase during school holiday periods.13 In this stray animal population by preventing further abandonment
study, the most frequent presentations were in May and of animals to the streets may lower the risk of rabies posing
June. The increase in presentations during these warm through animal contact with children.20
months may be attributed to the increased time spent in
The retrospective nature of this study is one of the major limi-
outdoor areas, thus raising the possibility of exposure to
tations. Although the time between contact and presentation
animals.
has been reported as hours in some publications, the authors
In this study, the most common species of exposed animals could not obtain these data, thus reported this interval in
were found as cats and dogs, respectively. In the literature, days. The authors even could not obtain data about the level
the leading species that caused post-exposure rabies prophy- of education of the parents, monthly income or language/fi-
laxis was reported as dogs. 10,12,14 In most studies, it was nancial/geographic difficulties causing difficulties in accessing
reported that stray dogs were the most common cause of hospitals for vaccinations. In the present study, it was not
post-exposure rabies prophylaxis presentations.12,15 In this possible to question the extent to which the immigrant popu-
study, 58.5% of the animals were stray animals. We found lation gained information about rabies and the importance of
cats as the most frequently exposed animals and these data prophylaxis vaccinations. In the forthcoming studies, it may
be examined whether the high dropout rate of these families
were not consistent with the literature, but consistent with
of foreign nationalities is due to lack of information about
another study conducted in Turkey.16
rabies and the importance of serial vaccinations.
When post-exposure prophylaxis against rabies studies are
examined, the most frequently reported risk categories were CONCLUSION
as follows: category II in Poland,14 category I in India,15 and A higher proportion of discontinuation of post-exposure
category III in Greece12 and Turkey.16 Risk category III was prophylaxis vaccinations was observed among the immi-
found here as the leading risk level and this result is in agree- grant population; and efforts to raise the awareness about
ment with the literature. rabies and prophylaxis practices of this disadvantaged popu-
lation should be increased. This study emphasised the impor-
In terms of post-exposure prophylaxis against rabies, serious
tance of developing administrative mechanisms to reduce
insufficiencies have been reported, especially in developing
countries. In a study conducted in Brazil, it was reported that the number of stray animals and increase compliance with
95.8% of patients, who presented with risky contact, were post-exposure prophylaxis.

1222 Journal of the College of Physicians and Surgeons Pakistan 2021, Vol. 31(10): 1219-1223
Rabies prophylaxis

ETHICAL APPROVAL: doi: 10.1017/S0950268805005017.

This study was approved by the Clinical Research Ethics
9. Bozkurt HB. An overview of vaccine rejection and review of
Committee of the Adana City Training and Research Hospital literature. Kafkas J Med Sci 2018; 8:71-6. doi: 10.5505/kjm-
(Meeting No. 26; Date 05.02.2018; Decision No. 350) prior to s.2018.12754.
the initiation of the research. 10. De Paula NS, Saraiva EA, Araújo IM, Nascimento KKG, Xavier
DA, Santos KS, et al. Characterisation of rabies post-exposure
PATIENTS’ CONSENT: prophylaxis in a region of the eastern Amazon, state of Pará,
Informed consents were not obtained from patients due to Brazil, between 2000 and 2014. Zoonoses Public Health 2018;
the retrospective nature of the study. 65(4):395-403. doi: 10.1111/zph
11. Karadaş MA, Yılmaz F, Demir TA, Okudan RN, Çalışkan G. Eval-
CONFLICT OF INTEREST:
uation of animal contacted patients with rabies suspected.
The authors declared no conflict of interest. Exposures presented to antalya training and research
hospital emergency service. Acta Medica Alanya 2018;
AUTHORS’ CONTRIBUTION: 2:163-9. doi: 10.30565/medalanya.413956.
CC: Design of the study.
12. Dougas G, Konte V, Mitrou K, Georgakopoulou T, Baka A,
CC, UÖ, AS: Data acquisition. Liona A, et al. Surveillance of rabies postexposure prophylaxis
OT, ÜÇ: Substantial contributions to the conception and in greece: 4 Years’ Experience. Vector Borne Zoonotic Dis
design of the work. 2019; 19(4):295-301. doi: 10.1089/vbz.2018.2344.
CC, OT, ÜÇ: Final approval of the version to be published and 13. Kularatne SA, Ralapanawa DM, Weerakoon K, Bokalamulla
revising it critically for important intellectual content. UK, Abagaspitiya N. Pattern of animal bites and post expo-
sure prophylaxis in rabies: A five-year study in a tertiary care
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