Epidemiology of Animal Bites and Factors Associated With Delays in Initiating Post-exposure Prophylaxis for Rabies Prevention Among Animal Bite Cases: A Population-based Study

  • Esmaeilzadeh, Firooz (Department of Health Economic, School of Nursing and Midwifery, Maragheh University of Medical Sciences) ;
  • Rajabi, Abdolhalim (Department of Epidemiology, Golestan University of Medical Sciences) ;
  • Vahedi, Sajad (Department of Health Economic, Student Research Committee, Zabol University of Medical Sciences) ;
  • Shamsadiny, Mohammad (Department of Research and Technology, Hormozgan University of Medical Sciences) ;
  • Ghojogh, Mousa Ghelichi (Department of Urima University of Medical Sciences) ;
  • Hatam, Nahid (Department of Health Services Management, School of Management and Medical Information, Shiraz University of Medical Sciences)
  • Received : 2017.02.15
  • Accepted : 2017.04.28
  • Published : 2017.05.31


Objectives: One way to prevent deaths due to rabies is the timely utilization of post-exposure prophylaxis (PEP). Therefore, in addition to an understanding of the epidemiological distribution of animal bites, it is necessary to explore the factors leading to delays in PEP initiation. Methods: This cross-sectional study was conducted in Iran in 2011, and included 7097 cases of animal bites recorded at the Rabies Treatment Center of the Shiraz University of Medical Sciences using the census method. Logistic regression was used to identify factors associated with delays in PEP. Results: Among the patients studied, 5387 (75.9%) were males. The prevalence of animal bites in Fars province was 154.4 per 100 000 people. Dogs were the most frequent source of exposure (67.1%), and the most common bitten part of the body was the hands (45.5%). A delay in the initiation of PEP was found among 6.8% of the studied subjects. This delay was more likely in housewives (odds ratio [OR], 4.66; 95% confidence interval [CI], 2.12 to 10.23) and less likely in people with deep wounds (OR, 0.65; 95% CI, 0.43 to 0.97). Conclusions: Although all animal bite victims received complete PEP, in some cases, there were delays. Further, the type of animal involved, the depth of the bite, and the patient's occupation were the major factors associated with a delay in the initiation of PEP for rabies prevention.


  1. Franka R, Wu X, Jackson FR, Velasco-Villa A, Palmer DP, Henderson H, et al. Rabies virus pathogenesis in relationship to intervention with inactivated and attenuated rabies vaccines. Vaccine 2009;27(51):7149-7155.
  2. World Health Organization. Animal bites; 2013 [cited 2017 Apr 29]. Available from:
  3. World Health Organization. Rabies; 2017 [cited 2017 Apr 30]. Available from:
  4. Hemachudha T, Ugolini G, Wacharapluesadee S, Sungkarat W, Shuangshoti S, Laothamatas J. Human rabies: neuropathogenesis, diagnosis, and management. Lancet Neurol 2013;12(5):498-513.
  5. World Health Organization. Investing to overcome the global impact of neglected tropical diseases: third WHO report on neglected diseases 2015 [cited 2017 Apr 30]. Available from:
  6. Esmaeilzadeh F, Hatam N, Esmaeilzadeh Z, Rajabi A, Anami M, Vahedi S, et al. Effectiveness of post-exposure rabies prophylaxis. Tehran Univ Med J 2014;72(9):630-637 (Persian).
  7. Hatam N, Esmaelzade F, Mirahmadizadeh A, Keshavarz K, Rajabi A, Afsar Kazerooni P, et al. Cost-effectiveness of rabies post exposure prophylaxis in Iran. J Res Health Sci 2014;14(2):122-127.
  8. Dalfardi B, Esnaashary MH, Yarmohammadi H. Rabies in medieval Persian literature: the Canon of Avicenna (980-1037 AD). Infect Dis Poverty 2014;3(1):7.
  9. Quiambao BP, Dy-Tioco HZ, Dizon RM, Crisostomo ME, Teuwen DE. Rabies post-exposure prophylaxis with purified equine rabies immunoglobulin: one-year follow-up of patients with laboratory-confirmed category III rabies exposure in the Philippines. Vaccine 2009;27(51):7162-7166.
  10. Gholami A, Fayaz A, Farahtaj F. Rabies in Iran: past, present and future. J Med Microbiol Infect Dis 2014;2(1):1-10.
  11. World Health Organization. WHO guide for rabies pre and post exposure prophylaxis in humans; 2014 [cited 2017 May 20]. Available from:
  12. Sabouri Ghannad M, Roshanaei G, Rostampour F, Fallahi A. An epidemiologic study of animal bites in Ilam Province, Iran. Arch Iran Med 2012;15(6):356-360.
  13. Iran Data Portal. Iran statistical yearbook: population; 2013 [cited 2017 May 20]. Available from:
  14. Joseph J, N S, Khan AM, Rajoura OP. Determinants of delay in initiating post-exposure prophylaxis for rabies prevention among animal bite cases: hospital based study. Vaccine 2013;32(1):74-77.
  15. Jha S, Khan WS, Siddiqui NA. Mammalian bite injuries to the hand and their management. Open Orthop J 2014;8(Suppl 1):194-198.
  16. Kassiri H, Kassiri A, Mosavi R, Jashireh A, Lotfi M. Prevalence rate and epidemiological determinants of animal bite in Ahvaz County, Khuzestan Province, Southwestern Iran. J Acute Dis 2014;3(1):51-55.
  17. Dadypour M, Salahi R, Ghezelsofla F. Epidemiological survey of animal bites in Kalaleh district, North of Iran (2003-05). J Gorgan Univ Med Sci 2009;11(1):pe76-pe79 (Persian).
  18. Matter HC, Sentinella Arbeitsgemeinschaft. The epidemiology of bite and scratch injuries by vertebrate animals in Switzerland. Eur J Epidemiol 1998;14(5):483-490.
  19. Khazaei S, Rezaeian S, Soheylizad M, Gholamaliee B. Factors associated with delay in post-exposure prophylaxis in bitten people. Med J Islam Repub Iran 2014;28:158.
  20. Gautret P, Le Roux S, Faucher B, Gaudart J, Brouqui P, Parola P. Epidemiology of urban dog-related injuries requiring rabies post-exposure prophylaxis in Marseille, France. Int J Infect Dis 2013;17(3):e164-e167.
  21. Pandey P, Shlim DR, Cave W, Springer MF. Risk of possible exposure to rabies among tourists and foreign residents in Nepal. J Travel Med 2002;9(3):127-131.
  22. Lyu C, Jewell MP, Piron J, Ehnert K, Beeler E, Swanson A, et al. Burden of bites by dogs and other animals in Los Angeles County, California, 2009-2011. Public Health Rep 2016;131(6):800-808.
  23. Kassiri H, Kassiri A, Lotfi M, Shahkarami B, Hosseini SS. Animal bite incidence in the County of Shush, Iran. J Acute Dis 2014;3(1):26-30.
  24. Bahonar AR, Bokaee S, Khodaverdi KH, Nikbakht-Broogeni GhR, Rad MA. Epidemiology of rabies and animal biting in Ilam State. Iran J Epidemiol 2008;4(1):47-51 (Persian).
  25. Majidpour A, Arshi S, Sadeghi H, Shamshirgaran S, Habibzadeh S. Animal bites: epidemiological considerations in Ardabil province, 2000. J Ardabil Univ Med Sci 2003;3(4):39-43 (Persian).
  26. Poorolajal J, Babaee I, Yoosefi R, Farnoosh F. Animal bite and deficiencies in rabies post-exposure prophylaxis in Tehran, Iran. Arch Iran Med 2015;18(12):822-826.
  27. Gongal G, Wright AE. Human rabies in the WHO southeast Asia region: forward steps for elimination. Adv Prev Med 2011;2011:383870.
  28. Sheetal V, Kinnari G, Gneyaa B, Hemant T. Animal bite management practices: study at three municipal corporation hospitals of Ahmedabad. Natl J Community Med 2010;1(2):75-78.
  29. World Health Organization. WHO expert consultation on rabies: first report. Geneva: World Health Organization; 2005, p. 2-10.
  30. Verma R, Khanna P, Prinja S, Rajput M. Intra-dermal administration of rabies vaccines in developing countries: at an affordable cost. Hum Vaccin 2011;7(7):792-794.
  31. Knobel DL, Cleaveland S, Coleman PG, Fevre EM, Meltzer MI, Miranda ME, et al. Re-evaluating the burden of rabies in Africa and Asia. Bull World Health Organ 2005;83(5):360-368.
  32. Sudarshan MK, Madhusudana SN, Mahendra BJ, Rao NS, Ashwath Narayana DH, Abdul Rahman S, et al. Assessing the burden of human rabies in India: results of a national multi-center epidemiological survey. Int J Infect Dis 2007;11(1):29-35.
  33. Hampson K, Dobson A, Kaare M, Dushoff J, Magoto M, Sindoya E, et al. Rabies exposures, post-exposure prophylaxis and deaths in a region of endemic canine rabies. PLoS Negl Trop Dis 2008;2(11):e339.
  34. Si H, Guo ZM, Hao YT, Liu YG, Zhang DM, Rao SQ, et al. Rabies trend in China (1990-2007) and post-exposure prophylaxis in the Guangdong province. BMC Infect Dis 2008;8:113.
  35. Sengoz G, Yasar KK, Karabela SN, Yildirim F, Vardarman FT, Nazlican O. Evaluation of cases admitted to a center in Istanbul, Turkey in 2003 for rabies vaccination and three rabies cases followed up in the last 15 years. Jpn J Infect Dis 2006;59(4):254-257.
  36. Riahi M, Latifi A, Bakhtiyari M, Yavari P, Khezeli M, Hatami H, et al. Epidemiologic survey of animal bites and causes of delay in getting preventive treatment in Tabbas during 2005-2010. Tolooebehdasht 2012;11(1):20-31 (Persian).