K Apoline Sondo*, Caroline Yonaba and Emeline Kaboré
Centre Hospitalier Universitaire Yalgado Ouedraogo, Kadiogo, Burkina Faso
Received Date: July 01, 2015; Accepted Date: July 21, 2015; Published Date: July 28, 2015
Citation: Sondo KA, Yonaba C, Kaboré E (2015) Rabies in Children: Report of 24 Cases at the Yalgado Ouedraogo University Hospital Center of Ouagadougou in Burkina Faso. J Trop Dis 3:168. doi:10.4172/2329-891X.1000168
Copyright: © 2015 Sondo KA. This is an open-access article distributed under the terms of the Creative Commons Attribution License, which permits unrestricted use, distribution, and reproduction in any medium, provided the original author and source are credited.
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Introduction/Objectives: Rabies is responsible for more than annual 55000 deaths in the world including 24000 in Africa. This study aims to study the epidemiological and clinical aspects of rabies in children at the University Hospital Center Yalgado Ouedraogo on 11 years. Patients and Methods: This was a retrospective descriptive study of rabies cases in children who were received at CHUYO (University Hospital Center Yalgado Ouedraogo) from 1st January 2003 to 31 December 2014. The diagnosis was clinical, associated with a notion of suspect animal bite; data were collected from medical files and analyzed with Epi Info version 6. Results: During the study period, 60 rabies cases were reported, including 24 children. Children average age was 08.5 ± 4 years with a sex ratio of 07. In 47.6% of cases, children were referred from other provinces of the country and 58.3% case lived in rural areas. In all cases, the animal aggressor was a dog, and in 62.5% of cases, it was a stray dog. Upper limbs were the most common site followed by the lower limbs; nevertheless, the head represented 12.5% of the reported injuries. The main clinical signs were agitation (70.8%), hydrophobia (58.3%), and fever (50%). In 30% of cases, the parents left the hospital with their child without or against medical opinion. Conclusion: Rabies frequency is significant in children and is probably under-diagnosed because of clinical signs most often confused with other diseases. Pre-exposure prevention through vaccination is the best way to fight against rabies in children.
Juvenile rabies; Dog; Pre-exposure prevention
Rabies is an anthropozoonosis responsible for an acute, primitive, and viral encelophalomyelitis. All warm-blooded animals are the pathogenic agent’s reservoir . According to the World Health Organization (WHO) information on rabies, this disease is enzootically present in more than one hundred and fifty (150) countries; and it even is estimated that rabies is responsible for more than fifty five thousand (55.000) deaths all the world over. This disease is especially raging in Asian, Africa, and South American countries [2-4]. After Asia, Africa is the second continent that is most affected by this zoonosis and counts for over twenty-four thousand (24.000) deaths a year, that is 44% in the world. WHO estimates that every twenty (20) minutes, a person dies due to the infection by this disease in Africa [2,5,6]. In Western Africa, rabies is still a permanent threat to the populations. Rabies has a very heavy and socioeconomic impact on the populations’ lives, because the post exposition management is enormously costly . Burkina Faso is not an exception to this rule. The population, children above, live together with their dogs and their dogs and other animals that are not vaccinated. A dog has many roles in a family, for it is the housekeeper and a good companion which children play with. It helps hunt for game animals and rarely is a company animal that is well taken care of and well fed, as can be observed in developed countries. Very few studies are devoted to rabies with children, now children are the most threatened persons that are also infected by this disease as is pointed out by WHO  that is why this works to study epidemiological and clinical aspects of rabies with children in Burkina Faso.
Patients and Methods
Study design and population
This retrospective study with a descriptive aim in mind was conducted from 1st January 2003 to 31st December 2014, which concerned all children less than 15 who are hospitalized because of rabies in the department of infectious diseases of CHU-YO. This University Hospital (CHU) is a national reference for all those patients coming from all the provinces of the country. It‘s composed of specialized services including infectious diseases. Burkina Faso has two other CHU and nine regional hospitals. In the study we are interested in the cases referred to our hospital. The following variables were studied: children’s and parents’ epidemiological characteristics (age, gender, residency, origin, parents’ profession, level of literacy); aggressor animal’s characteristics (nature, qualification, future, vaccinal status, animal’s outcome), the preventive aspects realized by parents, clinical characteristics (time between animal bite and 1st sign, bite location, the clinical signs), and the output mode of the hospital.
Diagnosis of rabies
The diagnosis of rabies was based upon an animal bite history and children clinical examination: basis of antecedents of non-vaccinated dogs’ bites or having an unknown vaccinal status (stray dog) associated to clinical signs similar to hydrophobia, psychomotor restlessness, hypersialhoroea. No child benefitted from diagnostic test for rabies because there was no available medical technical equipment.
Post-exposure prophylaxis by animal bite
After the bite, the wound must be cleaned with water and soap and the patient then goes to a health care center. Depending on the animal’s vaccinal status, the anti-rabies vaccine was administrated. As regards the management of the post exposition of rabies, the protocol that is used in Burkina Faso, is that of ESSEN. It’s applied in 5 doses on D1, D3, D7, D14, D28 which costs about 76 Euros. Depending on the location of the bite (areas near the brain) and condition of the injury, rabies immunoglobulins should be administered but they are not available.
Data management and statistical analysis
The data from each patient were entered anonymous from the patients’ medical files and analyzed with Epi Info version 6 software by descriptive statistics such as frequency distribution.
Ethics approval was not requested for this outbreak investigation; The permission to use data was approved by local authorities of Yalgado Ouedraogo University Hospital (CHUYO).
Sixty (60) cases of human rabies were reordered in the department of infectious diseases, classified as clinical human rabies-compatible cases. Twenty-four (24) of which were under 15 (40%) and included in the study. The annual average was 4 ± 2.9 cases. The average age was 8.5 ± 4. They were 21 boys (87.5%) and 3 girls (12.5%) with a sex ratio=7, they were children of primary school (37.5) and preschool (33.3%) mostly. Children lived in rural areas in 58.3%. They came from Ouagadougou and it’s peri urban areas (58.3) and from other provinces across the country in 41.7% (Figure 1). Table 1 represents the children épidémiologicals characteristics.
|Socio-epidemiological Characteristics||Numbers N=24||(%)|
|Level of literacy||Pre school||8||33.3|
|Area of living||Urban||10||41.7|
Other regions: West Central, North, East Central, Sahel, Central
**Ouagadougou and its peri urban areas
***Other provinces: Zoudweogo,
Bazega, Boulkiemdé, Passoré, Boulgou, Ganzourgou, Kourweogo
Table 1: Rabies in children: distribution according to the socio epidémiological characteristics.
Characteristics of the children’s parents
The father was illiterate in 86.3% of the cases, and the mother in 90.9% of the cases. The mothers were all housewives and their fathers were farmers in 81.8% of the cases, traders in 9.1% of the cases and civil servants or drivers in 4.5% of the cases.
Characteristics of the children’s aggressor animals
The aggressor animals were mostly dogs (100%). They were stray dogs in 62.5% and these animals would have been killed (58.3%). The vaccinal status was unknown (66.7%) and no animal was kept under observation, nor vaccinated. The aggressor animal’s characteristics are presented on Table 2.
|Animal’s qualification||Stray dog||15||62.5|
|Animal’s vaccinal status||Unknown||16||66.7|
Table 2: Distribution according to the aggressor animal’s characteristics.
Clinical characteristics of the child infected with rabies
That concerned lesions from bites in 91.5% of the cases and from claws in 8.5%. The lesions were mostly found at the level of the upper limbs (66.6%) especially the hands in 58.3%. However, the head represented 12.5% of the notified lesions The main signs of rabies were agitation 70.8%, hydrophobia (58.3) and fever (50%). The children all presented a spastic form of rabies. The average duration of incubation was 47days ±32 with extremes ranging from 15 to 120 days. Table 3 shows the clinical findings of children. In this study, 30% of the children left hospital with no permission from the doctor and they died afterwards.
|Location of the bite|
|Clinical forms||Spastic rabies||24||100|
Sweating, dyspnea, aggressiveness, skin rash, pruritus, insomnia
Table 3: Distribution of rabies cases according to clinical characteristics.
Practices after exposition
After the child’s aggression by an animal, five (5) parents (20.8%) went to a health center and among them three (3) children received two doses of anti-rabies vaccine before the disease broke out. No patient had received rabies immunoglobulin. Thirteen (13) parents (54.1%) sent their child to the traditional healer and five (5) children (20.8) benefitted from local care, consisting of cleaning of the lesion with water a soap at home. Five (5) children (20.8%) had not informed their parents of the animal’s bite. Table 4 represents the distribution of the children according to the post exposition practices realized by their parents.
|Post exposure practices realized by children parents||Numbers (n=24)||(%)|
|Consultation at the traditional healer|
|Consultation in a health care center|
|Local care at home|
|Parents ‘information afteranimal ’s bite|
*= two doses of vaccine in three children with bite in the head (eye, ear)
**= Washing the lesion with water and soap at home
Table 4: Distribution of the cases according to the post exposure realized by the parents.
Limits and constraints
The inundation of the CHU-YO that took place on 1st September 2009 made it impossible to exploit some files, which reduced the size of the sample. The retrospective aspect of the study explained the reason why some files were missing, but did not affected the quality of our results.
The frequency of children rabies in the department of infectious diseases was 40%. This result confirms the frequency of rabies estimated by WHO with children under 15 in the world ranging from 30% to 60% of the cases . Some other, African authors share in this view: Diop in Senegal reported in 2007 a frequency of 53.7% rabies cases with children from 5 to 15; In Mali, Dao in 2006 noticed 6 children out of 10 cases of rabies. On the contrary, in Ivory Coast, Ouattara in 2007 reported a frequency lower than 2 children out 7 cases of rabies in a study conducted and carried out on 7 years [8,9,7]. In the Democratic Replublic of ghe Congo, Muyila in 2014 had a very high frequency, because he recorded twenty-one (21) cases of rabies with children in seven (7) months . We estimate that there is not enough notification as regards cases of rabies with children in particular and as regards rabies in Burkina Faso in general. So, in other developing countries such as in Madagascar, Rakotomala had noticed, after a retrospective national investigation, a proportion of one notified case for two non-notified cases from 1985 to 2006 . This insufficient notification is multisectorial: the frequency of the clinical signs with children in relation to other diseases such as meningitis, malaria, and typhoid fever. In addition, if the health care worker fails orientating the interview towards finding out a notion of an animal’s bite, the long period of incubation of the disease may also make the child or the parents forget about this notion of bite. Very often, some parents are not well informed about their child having been bitten, which may make the diagnosis improbable. Finally, poverty, ignorance combined with cultural habits such as consultation at the traditional healer may result in a notification that is not well orientated as regards the cases. All these reasons we believe that many cases of rabies have gone unnoticed.
Young persons could possibly be risk factors of rabies in so far as children like playing with dogs, the main animals which are the vectors of rabies . Indeed we found mostly children of the pre-school and primary school in our study. It is they who are most at risk for the disease, because it ignores the severity of a bite by a dog. Therefore, it is necessary to maintain a constant prophylactic treatment in children. The males predominated (87.5%) with a higher frequency than in the study of Muyila in Congo (51.7%). This male predominance had been reported by the authors who worked on human rabies in Ivory Coast, Senegal, and Mali [7-9]. The sex ratio is higher in our study probably because little boys are mostly exposed to the disease. They provoke dogs by throwing stones at them; they also like playing outdoors, sometimes far from their houses where they can meet stray dogs
More than half of the children were from Ouagadougou and it’s peri urban areas; however a non-negligible proportion (41.7%) came from other regions across the country such as the West Central, North, East Central, and Sahel. These regions are often remote places at 100 km away from the CHU-YO and even further; and taking these children infected with rabies from these remote places to the CHU-YO costs much for the parents as regards transportation, hospitalization, and mortuary expenses. This situation is all the more dramatic as the medical care that is administrated to the patient is just palliative. To face such a situation it is recommended to train the health care workers in the different sanitary center of the regions on how to manage the disease, in order to avoid useless sanitary evacuations of rabies cases to a recommended sanitary center. In this study, 58.8% of the children lived in rural areas. This observation of the vulnerability in the rural areas as regards rabies was pointed out by some authors in Africa, Diop in Dakar (88%) and Dao in Bamako for all the cases of his study [8,9]. Promiscuity is frequent near the rural areas, which explains why animals and men are living together, which leads to the frequency of zoonoses with men. It has demonstrated that rabies is a disease of poor and needy populations . In actual fact, most of these children’s parents were illiterate, their fathers were mainly farmers and their mothers were all housewives and jobless. In such a country as Burkina Faso, in which agriculture is still precarious, limited just to subsistence farming, most of the farmers are needy persons and are unable to pay anti rabies vaccine to 76 Euros. Which explains the absence of post exposure prevention child after the bite noted in our study.
Aggressor animals’ characteristics
The dog was the children’s animal aggressor (100%) which was a stray dog in most of the cases (62.5%). Muyila  in his study with the child, found out a higher frequency for the stray dog (90.5%). Some other authors have noted the stray dog’s place in their study on rabies in general in developing country [7-9,14]. Indeed, the dog is the main vector of human rabies in developing countries. Nevertheless, domestic dogs did play a non-negligible role in the unexpected arrival of rabies in our study (37.5%). these so-called domestic animals, are actually occasional stray dogs which keep wandering particularly around dustbins and dumps for their food; that is the places they come across the very stray dogs they get infected from. The surrounding persons, especially the children, become easy victims for their virulent bites. These dogs are most of the time neither vaccinated nor cared. After biting, whether stray dog or domestic dog had disappeared or were killed by the population; most of the time it is eaten; which situation makes it impossible for a veterinary doctor to examine the dog. Muyila in Congo has also found out the same situation as we have in regard to the slaughtering of the dog after its aggression .
Clinical aspects of rabies
The lesion is most of the time found at the level of the upper limbs (66.6%), frequently on the hand (58.3%). Most of the studies that were conducted on rabies show a predominance of the lower limbs as frequent localizations whether with adults or children [8,9]. Muyila has noted a higher frequency in the legs (66.7%), then the arms (23.8%) in his study in children; probably because he had a frequency of big children higher than in our study . The three most signs were agitation (70,8%), hydrophobia (58.3) and fever (50%); followed by headaches, fever, and vomiting. Our results confirm Muyali’s at higher frequencies. The frequency of the clinical signs with children in relation to other diseases such as meningitis, malaria, and typhoid fever; these signs are found in most infectious diseases in children; and thus may mislead the diagnosis of rabies. On the other hand, whereas in the study all the children got a spastic form of rabies. All the patients developed spastic rabies in this report. No case of paralytic and furious rabies was noted. In Muyali’s study, all the children got furious rabies. This is the most commonly seen form bound to hyperexcitability .
The study showed that 30% of the children had left hospital with or without a doctor’s telling them to do so. The risk of interhuman transmission was not still described, but the virus is present in the saliva [16,17] and the parents permanently in contact with their child are exposed to their bites. Once rabies diagnosis established, patients should be isolated and treated in a health center; should minimize close contact with the family to avoid contamination.The management of the cases of rabies must be and still is utterly under the health care workers’ responsibility. A psycho-medical management of the parents should also be considered because rabies inevitably evolves towards death.
The post exposure practices realized by the children’s parents
No children received appropriate post-exposure prophylaxis. The local care was not realized by the parents after exposure. So, in this study, 86.9% patients had not consulted health care center after being bitten by an animal; Diop in Senegal had found a lower frequency to ours (77.8%) . Agreeing on the same point as Tiembre in Ivory Coast, who had found out that 56% of the patients exposed to an animal’s bite, did not benefit from local care . This care is the first basic step in the post-exposure management . The low use of health care center for the benefit of traditional healers is an outstanding obstacle to the management of rabies as it is well illustrated by our results . In our study, no patient had received rabies immunoglobulin. Only three children (12.5%) received an anti-rabies vaccine (ARV) after the bite and it is those with a bite to the head (eye and ear); as they have not received immunoglobulin and they made rabies. Some children do not inform their parents after the bite; but they were numerous those parents who were informed about their child’s exposure yet, still were numerous those parents who had not consulted a health care center after the exposure. Probably either out of sheer negligence, ignorance of the seriousness of the disease, or for lack of means, the disease evolved and became worse with the children. The major reason for this is resource deficiency. Most of the parents are poor and they cannot buy the five regimen of antirabies vaccine. Muyali in Congo has found the same results in his study . The antirabic vaccine should therefore be imperatively subsidized and made available in all the regions of Burkina Faso. More than the rabies immunoglobulin essential, when the bite is located in the region of the head or richly innervated area.The primary prevention is indispensable and the vaccination of the domestic animals and the slaughtering of stray dogs will have to be made obligatory in Burkina Faso.
The frequency of rabies in children in the department of infectious diseases was 40% of all the rabies cases. It was probably not diagnosed well enough in our context. The dog was the aggressor animal and because the children were too close to the animal, pre-exposure should be recommended and subsidized in the child. So, it is necessary for the health care workers to be retrained in regard to rabies in order to avoid useless sanitary evacuations. Burkina Faso’s needs to develop a technical medical tray for confirmation of human rabies; especially make available and accessible anti-rabic vaccine and rabies immunoglobulin to the population.
All authors participated in the writing of this article and gave their consent to its submission