Older Adults Delay Seeking Rabies Treatment After Animal Bites, Hangzhou Study Finds

Rabies remains one of the deadliest infectious diseases known to medicine, with a case fatality rate that approaches 100 percent once clinical symptoms appear. Yet the disease is almost entirely preventable if exposed individuals receive timely post-exposure prophylaxis, a regimen of vaccination and, in higher-risk cases, immunoglobulin administration that can stop the virus before it reaches the nervous system. A new retrospective study from Hangzhou, China, published in BMC Infectious Diseases, has now added an important piece to the puzzle of why some people fail to access this lifesaving care promptly, and the answer points squarely at age.

Researchers led by Zheng Yang of the Emergency Department at Tongde Hospital of Zhejiang Province, affiliated with Zhejiang Chinese Medical University, analyzed 3,327 exposure-related clinic presentations recorded between October 2022 and October 2025. The team began with a larger pool of records and applied rigorous exclusion criteria, removing seven system-test entries, fifteen exposures classified as World Health Organization Category I, thirteen confirmed continuation visits, ten records with contradictory dates, and two unresolved duplicates. What remained was a clean hospital-based cohort suitable for examining two distinct questions: how quickly patients presented after a potential rabies exposure, and whether they had attempted any wound care on their own before arriving at the clinic.

The central finding concerns timing. Of the 3,327 presentations, 218, or 6.6 percent, occurred on a calendar day after the day of injury. Because the study relied on electronic medical records rather than precise timestamps, the researchers used a date-based operational proxy for delay: presenting on a subsequent calendar day rather than the same day. This is a conservative measure, and the authors are careful to frame it as such, but it captures a meaningful gap in access to care. Rabies virus travels along peripheral nerves at a relatively slow rate, and every hour of delay before prophylaxis begins extends the window during which the virus could, in principle, establish itself at the wound site and begin its ascent.

When the researchers fitted multivariable logistic regression models adjusting for other characteristics, patients aged 65 and older had significantly higher adjusted odds of subsequent-calendar-day presentation compared with the reference group aged 15 to 44 years. The adjusted odds ratio was 2.28, with a 95 percent confidence interval of 1.31 to 3.96 and a P value of 0.003. In practical terms, older adults in this cohort were more than twice as likely to show up at the clinic only after the calendar day of their exposure had passed. This age-related pattern persisted even after accounting for other variables in the model, suggesting that advancing age itself, or factors closely tied to it, creates a genuine barrier to prompt care-seeking after an animal bite or scratch.

The study also examined pre-hospital wound management, the self-directed cleaning or treatment that patients perform before reaching professional care. Guidelines from the World Health Organization emphasize immediate and thorough washing of bite wounds with soap and running water for at least fifteen minutes, a simple intervention that mechanically reduces viral load at the exposure site. The researchers modeled any pre-hospital wound self-treatment as a separate binary outcome. Interestingly, the estimate for the oldest age group pointed in the opposite direction: patients aged 65 and older appeared less likely to report any self-treatment, with an adjusted odds ratio of 0.71 and a confidence interval of 0.50 to 1.01. However, this estimate did not reach the conventional threshold of statistical significance, with a P value of 0.056, and the authors explicitly caution that it is imprecise and requires confirmation in future work.

A methodologically important point in the paper is that the two outcomes were modeled separately. The authors stress that their analysis does not establish a combined individual-level outcome linking delay and self-treatment within the same patient. In other words, the data cannot tell us whether an older adult who delays presentation is also the same person who skips wound washing, or whether these behaviors occur independently across the cohort. This distinction matters for intervention design: if delay and inadequate wound care cluster in the same individuals, targeted outreach could address both at once, whereas independent patterns might require broader, population-level messaging.

Two other associations emerged from the models. Patients who reported any pre-hospital wound self-treatment had higher adjusted odds of subsequent-calendar-day presentation, with an adjusted odds ratio of 2.72 and a 95 percent confidence interval of 2.00 to 3.69. One plausible interpretation is that people who attempt self-care may believe they have managed the problem adequately and therefore postpone professional evaluation, though the observational design of the study prevents any firm causal claim. The temporal pattern of the data also revealed that presentations during the clinic-opening calendar period of October through December 2022 were associated with subsequent-calendar-day presentation, with an adjusted odds ratio of 2.54. The authors interpret this finding as exploratory, noting that it may reflect the establishment phase of the clinic itself, shifts in case mix, seasonality of animal exposures, or unmeasured access factors rather than any stable behavioral pattern.

The implications for rabies control programs, particularly in China where dog-mediated rabies persists at low but nonzero levels, are significant. Older adults represent a vulnerable population on multiple fronts. They may have reduced mobility, limited awareness of modern PEP protocols, greater reliance on traditional remedies, or fewer social contacts who can urge them to seek care quickly. Sensory and cognitive changes can also affect how seriously a minor bite wound is perceived. Because the incubation period of rabies can range from weeks to months depending on the site and severity of exposure, a delay of even one day is unlikely to be decisive in every case, but the cumulative effect of late presentation across a population contributes to preventable deaths. Public health campaigns that specifically target older adults, perhaps through community health workers, primary care touchpoints, or family-centered messaging, could help close this gap.

The study’s design has limitations that the authors acknowledge. As a retrospective, single-center, hospital-based analysis, it captures only people who eventually reached the clinic, leaving unexamined the experiences of exposed individuals who never sought care at all. The date-based proxy for delay is coarser than exact time-to-presentation measurements, and self-reported wound treatment is subject to recall bias. The clinic-opening period association is explicitly flagged as potentially confounded by factors the data cannot disentangle. Nevertheless, the large cohort size, careful data cleaning, and transparent statistical reporting give the findings credibility, and the consistency of the age effect with prior studies cited in the paper’s supplementary comparisons, including work from Hangzhou and Wuhan, strengthens the case that delayed presentation among older adults is a reproducible phenomenon rather than a local artifact.

Funded by the Zhejiang Provincial Bureau of Disease Control and Prevention Science and Technology Program, the study received ethics approval from Tongde Hospital of Zhejiang Province and was conducted on de-identified electronic medical record data with a waiver of informed consent, in accordance with the 2013 Declaration of Helsinki. As rabies continues to kill an estimated tens of thousands of people worldwide each year, most of them in Asia and Africa, research of this kind translates a grim global statistic into actionable local insight. The message for clinicians and health communicators is clear: when it comes to rabies post-exposure prophylaxis, age is not just a demographic variable but a risk factor for the behaviors that allow a preventable disease to claim lives. Ensuring that older adults recognize exposures as emergencies, wash wounds immediately, and reach prophylaxis clinics without delay may prove one of the most cost-effective interventions available in the ongoing effort to eliminate rabies deaths.

Subject of Research: Age-related delays in seeking rabies post-exposure prophylaxis and pre-hospital wound care after animal exposures

Article Title: Age-related patterns in delayed presentation and pre-hospital wound management for rabies post-exposure prophylaxis: a retrospective hospital-based study in Hangzhou, China, 2022–2025

Article References: Yang, Z., Zhu, Y., Cao, K., Yi, X., Tian, S., Yan, B., & Zhao, Z. (2026). Age-related patterns in delayed presentation and pre-hospital wound management for rabies post-exposure prophylaxis: a retrospective hospital-based study in Hangzhou, China, 2022–2025. BMC Infectious Diseases. https://doi.org/10.1186/s12879-026-14571-1

Image Credits: AI Generated

DOI: 10.1186/s12879-026-14571-1

Keywords: rabies, post-exposure prophylaxis, older adults, wound management, delayed presentation, China, Hangzhou, retrospective study, public health, geriatrics, animal bites, BMC Infectious Diseases