Rabies is a preventable viral zoonotic disease with a near 100% case fatality rate once clinical symptoms appear. In Sudan, rabies remains a significant public health concern, exacerbated by limited resources and the ongoing armed conflict. Physicians play a critical role in rabies prevention and management, yet their knowledge and adherence to updated clinical guidelines remain poorly understood. This study assesses physicians’ knowledge, and awareness of rabies disease, adherence to updated rabies prophylaxis guidelines, and clinical practices in Sudan.

A cross-sectional study was conducted in June 2024, targeting licensed physicians actively practicing in Sudan. Data were collected using a self-administered, structured questionnaire distributed via social media platforms. The questionnaire evaluated demographic characteristics, general rabies knowledge, familiarity with updated guidelines, and clinical practices. Descriptive and inferential statistical analyses were performed using SPSS version 28, with significance set at p < 0.05.

A total of 468 physicians participated, with (52%) demonstrating adequate general rabies knowledge and only (7.1%) showing good knowledge of updated guidelines. Awareness of critical aspects, such as the intradermal route of vaccine administration (20.1%) and the appropriate use of post-exposure prophylaxis (PEP) (25.5%), was limited. Clinical practice scores indicated moderate knowledge, with 56.2% demonstrating good practice in rabies management. Correlation analysis revealed a positive association between knowledge of updated guidelines and clinical practice (r = 0.230, p < 0.001). No significant associations were found between knowledge levels and demographic or professional characteristics.

The study reveals significant gaps in rabies knowledge, updated rabies prophylaxis guidelines awareness, and clinical practices among Sudanese physicians, highlighting the need for targeted training and resource allocation. Strengthening healthcare systems, particularly in conflict-affected regions, and promoting adherence to WHO rabies guidelines are critical to improving rabies prevention and management in Sudan.

Rabies is a highly fatal viral zoonotic disease responsible for an estimated 59,000 deaths annually worldwide, with the greatest impact on children in rural areas of Asia and Africa [1, 2]. However effective prevention of rabies relies on post-exposure prophylaxis (PEP) measurements, which include thorough wound care, administration of rabies immunoglobulin (RIG), and vaccination [3]. Recent World Health Organization (WHO) clinical guidelines emphasize the importance of local wound infiltration with RIG as the primary protective measure while discouraging intramuscular injection due to its inefficiency [4]. Studies have shown that small volumes of RIG directly infiltrated into wound sites are effective, whereas intramuscular administration is considered wasteful and less impactful [5].

Despite its critical role in rabies prevention, the availability of RIG remains limited in many countries, primarily due to high costs [6]. Regrettably, access to vaccines is also uneven, with only 39% of surveyed countries offering free and consistent public-sector vaccine programs [6]. Consequently, to address these challenges, global health authorities advocate for intra-dermal vaccination protocols and standardized systems for monitoring and reporting vaccine utilization, aiming to enhance accessibility and optimize the use of rabies vaccination, particularly in resource-constrained settings [6].

Sudan has long struggled with rabies as an endemic disease, with documented cases dating back to 1904 [7]. Historically, between 1992 and 2002, over 2,600 animal rabies cases were reported, with Khartoum alone accounting for more than half [8]. During the same period, approximately 108,957 individuals received PEP, and 253 human deaths from rabies were reported [8]. Furthermore, in 2015, global partners established the Pan-African Rabies Control Network (PARACON) to foster collaboration, enhance scientific capacity, and develop strategies for canine rabies elimination using a One Health approach [9]. However, progress in Sudan -as in many African countries- has been limited due to inconsistent veterinary systems, insufficient funding, political instability, and limited vaccine availability for humans and animals [10]. The Stepwise Approach towards Rabies Elimination (SARE) framework, which evaluates rabies control efforts, rated Sudan at 1.5 out of 5 in 2017, indicating the presence of small-scale rabies control programs but the absence of a comprehensive national rabies control plan [9, 11].

Furthermore, since April 2023, armed conflict in Sudan has exacerbated the challenges of rabies prevention and control. The humanitarian crisis has displaced millions, devastated healthcare infrastructure, and created conditions conducive to the spread of infectious diseases, including rabies [12]. In East Darfur, healthcare facilities have reported a sharp rise in demand for rabies serum following increased dog bite cases, particularly among children [13]. Regrettably, this rise is linked to the proliferation of stray dogs, cats, and rats feeding on human remains in conflict zones such as Khartoum, Darfur, and Omdurman [13]. Currently, over 65% of the population lacks access to healthcare, and many hospitals remain non-functional, compounding the difficulty of managing rabies outbreaks [14].

Physicians play a critical role in managing rabies cases, particularly in Sudan, where the risk of outbreaks has increased due to conflict-induced displacement, healthcare system collapse, and the growing number of stray animals. Adequate knowledge of rabies prophylaxis guidelines and effective management of animal bites are essential to preventing disease transmission and reducing mortality. However, physicians’ awareness and practices regarding rabies in Sudan remain poorly understood, leaving significant gaps in the country’s rabies control strategy. This study aims to assess physicians’ knowledge, and awareness of rabies disease, adherence to updated rabies prophylaxis guidelines, and clinical practices in Sudan. By identifying gaps and training needs, this research seeks to inform strategies for strengthening rabies control measures, particularly during the ongoing conflict and associated healthcare crisis.

This cross-sectional study, conducted in June 2024, aimed to assess physicians’ knowledge, and awareness of rabies disease, adherence to updated rabies prophylaxis guidelines, and clinical practices across various hospitals in Sudan.

Sudan’s healthcare system faces profound challenges, primarily due to the ongoing conflict that has severely strained its infrastructure [12, 14]. The system comprises government, private, military, and university-affiliated hospitals, with the majority of healthcare providers concentrated in urban areas [15]. In 2019, the health sector in Sudan was critically under-resourced, with only one skilled health worker per 1,000 population—this included 0.2 physicians and 0.3 nurses per 1,000 population [16]. Currently, over 70% of hospitals and medical centers are non-functional due to ongoing army conflict, and 20% of these facilities are severely impacted, even in regions distant from active conflict zones [17]. Most physicians work in government hospitals; the rest are in private clinics and university hospitals. Additionally, the unequal distribution of health professionals between rural and urban areas exacerbates disparities in healthcare access, further limiting the population’s ability to obtain necessary medical care [18].

The study targeted physicians defined as licensed medical practitioners actively engaged in clinical practice in Sudanese hospitals during the study period. Participants were eligible if they confirmed their active clinical practice in a hospital. Individuals not practicing medicine or engaged in non-clinical roles were excluded.

The sample size for this study was determined using a formula for proportions, assuming an unknown population size. Following the onset of the conflict on April 15, 2023, accurate documentation of the number of physicians in Sudan has been challenging due to significant migration and displacement. Additionally, many official Sudanese health professional websites, including those of the Ministry of Health and the Sudan Medical Council, are either non-functional or lack updated data on physician numbers. Consequently, a formula for an unknown population was employed to estimate the sample size [19].

The sample size calculation was based on the following parameters: 𝑛= (𝑍². 𝑝. (1−𝑝))/m².

Where: Z is the Z-value corresponding to a 95% confidence level (1.96), p represents the estimated proportion of the population with adequate knowledge (assumed to be 0.5 to maximize variability), and m is the margin of error (set at 0.05).

Using these parameters, the initial sample size was 384 participants. To address the limitations associated with convenience sampling and potential non-response, a 20% increase was applied, resulting in a final target size of 461 participants. Ultimately, 468 responses were successfully collected for analysis.

A convenience sampling approach was employed, leveraging the widespread use of social media platforms such as Facebook and WhatsApp among Sudanese physicians. This method was deemed appropriate due to the unique challenges posed by Sudan’s healthcare system in the aftermath of the April 15, 2023, conflict. The conflict significantly disrupted healthcare infrastructure and displaced many physicians, rendering traditional recruitment methods, such as hospital-based sampling, impractical. Moreover, the lack of a centralized, updated database of practicing physicians further limited the feasibility of probability-based sampling techniques.

Data collectors, who were physicians themselves, shared the survey link within professional WhatsApp groups, which are widely used among Sudanese physicians to share knowledge, prepare for exams, and discuss clinical cases. These groups included active medical practitioners from diverse specialties and geographic regions, ensuring broad representation despite the non-probabilistic nature of the sampling.

To enhance the accessibility and reliability of data collection, the survey was distributed via Google Forms, which restricted responses to one per participant by requiring Gmail login credentials. This approach mitigated the risk of duplicate submissions and ensured data integrity. Additionally, the data collection team directly disseminated the link to known physicians to maximize participation and reach those who might not actively engage in professional groups.

By adapting the sampling strategy to the constraints of the Sudanese healthcare system, this study ensured feasible and timely data collection, while acknowledging the inherent limitations of a convenience sampling approach.

Data were collected using a structured, self-administered questionnaire adapted from validated tools used in previous studies by Gönen et al. (2011) and Pradhan et al. (2024) [20, 21]. The questionnaire was modified to include context-specific questions relevant to the Sudanese healthcare system and rabies management. A pilot study with 74 physicians tested its reliability and validity.

The study instrument showed acceptable reliability, with an overall Cronbach’s α of 0.757, indicating good internal consistency. Principal Component Analysis (PCA) with varimax rotation identified a single dominant component explaining 68% of the variance, with strong loadings for knowledge (0.876), guidelines knowledge (0.859), and practice (0.732) scores. Furthermore, Bartlett’s Test of Sphericity (χ² = 61.5, df = 3, p < 0.001) and a Kaiser-Meyer-Olkin (KMO) measure of 0.650 confirmed data suitability for factor analysis. Exploratory Factor Analysis (EFA) supported a single-factor structure accounting for 54.5% of the variance, validating the instrument’s design for assessing knowledge, adherence to guidelines, and practices.

The questionnaire covered demographics, rabies knowledge, guidelines familiarity, and clinical practices. Participants were informed that completing the questionnaire implied consent to participate in the study.

Knowledge scores were categorized as “Adequate” or “Inadequate” based on predefined thresholds. General rabies knowledge was classified as “Adequate” for scores of 4 or higher out of 6. Guideline-specific knowledge was classified as “Adequate” for scores of 9 or higher out of 18. Clinical practice scores ranged from 0 to 7, with scores of 4 or higher categorized as “Good” and scores below 4 categorized as “Bad”.

Ethical approval for this study was obtained from the Alazhari Health Research Center. The study adhered to the ethical principles outlined in the Declaration of Helsinki and Sudan’s National Ministry of Health’s National Guidelines for Ethical Conduct of Research Involving Human Subjects (2008) [22, 23]. Participation in the study was entirely voluntary. Electronic informed consent was obtained from all participants before completing the survey, which included a clear description of the study’s objectives and assurances of anonymity and confidentiality. Participants indicated their consent by selecting “Yes” in a mandatory consent question before completing the survey.

Data were analyzed using IBM SPSS Statistics version 28. Descriptive statistics, including frequencies and percentages, summarized demographic and knowledge variables. Inferential statistics, such as the chi-square test, examined associations between demographic factors and knowledge levels. A p-value of less than 0.05 was considered statistically significant. Correlation analyses explored relationships between knowledge of guidelines and clinical practice scores. Results were presented in tables and prose for clarity and comprehensiveness.

A total of 468 physicians participated in the study. The majority (69%, n = 322) were aged between 25 and 30. Female participants comprised 56% (n = 261) of the sample, and nearly all respondents were Sudanese (99%, n = 464). Regarding residence, most participants were from the Central region (41%, n = 192), followed by the Northern region (38%, n = 180). Governmental hospitals were the most common workplace (62%, n = 288), while 27% (n = 127) worked in university hospitals. The majority were interns (64%, n = 299), followed by general practitioners (23%, n = 109), and only 2.1% (n = 10) were specialists. Most respondents (58%, n = 271) had less than one year of medical practice experience, and only 17% (n = 80) reported receiving rabies-related training or attending workshops in the past year (Table 1).

The majority of participants (83%, n = 390) correctly identified the causative pathogen of rabies as a virus. However, only 29% (n = 137) were aware of the typical incubation period of rabies (3 weeks–3 months), and 62% (n = 290) correctly excluded priapism as a prodromal symptom. Awareness regarding the importance of bite location, such as the head and neck, was noted in 45% (n = 211) of respondents, while 24% (n = 111) correctly identified fluid and mucous as the transmission route. Knowledge about the 10-day observation period being valid for dogs and cats was noted in 40% (n = 188). Overall, knowledge classification revealed that 52% (n = 243) of respondents had adequate knowledge (Table 2)

Knowledge of the updated rabies guidelines was low among participants. Only 34.3% (n = 159) correctly identified the anterolateral thigh as the ideal site for administering the rabies vaccine in infants and young children, while 20.7% (n = 96) understood that PEP should be administered only when the vaccination status of the biting animal is unknown or outdated. Awareness of the recommendation to provide PEP for provoked dog bites was observed in 25.5% (n = 118). Furthermore, 41.3% (n = 191) accurately recognized that neither pregnancy nor lactation contraindicates PEP administration

Regarding vaccine administration practices, 59.4% (n = 275) correctly identified the intramuscular route as the preferred method for modifying PEP to Pre-Exposure Prophylaxis (PrEP). Additionally, 47.7% (n = 221) were aware that the intramuscular route is recommended for immunocompromised individuals. Knowledge of the updated Thai Red Cross regimen for PEP using the intradermal route was accurate among 23.5% (n = 109), while only 20.1% (n = 93) correctly identified the intradermal route as a safe, efficacious, and cost-effective approach for PEP. Adequate knowledge regarding serum antibody titers post-vaccination was demonstrated by 28.3% (n = 131) of participants

Overall, only 7.1% (n = 33) of the participants were classified as having adequate knowledge of the updated guidelines [Table 3]

A clinical scenario involving a 7-year-old boy bitten by a stray dog was presented to assess participants’ clinical practice knowledge. The majority of participants (72.4%, n = 335) identified cleaning the wound area as the most appropriate first-line treatment for rabies exposure. Tetanus prophylaxis was recommended by 63.9% (n = 296), and 61.8% (n = 286) correctly described the cleaning method as washing with water and soap followed by povidone-iodine application. Antibiotic prophylaxis, based on the depth and location of the bite, was suggested by 42.5% (n = 197), and 44.1% (n = 204) recommended administering both the rabies vaccine and HRIG as the next step in management. Nearly half (49.2%, n = 228) understood that suturing is not recommended for animal bite wounds, while 47.1% (n = 218) correctly stated that HRIG should be administered in suspected rabies exposures when not previously given. Overall, 56.2% (n = 263) of participants demonstrated good practice in managing rabies cases [Table 4]

The results of the binomial logistic regression analyses are summarized in Table 5, which examines the factors associated with knowledge, awareness of updated guidelines, and practices related to rabies management

Knowledge classification

Age, gender, health facility type, and medical practice experience did not show statistically significant associations with knowledge classification. However, rabies training/workshop attendance in the past year was marginally significant (OR = 0.61, 95% CI = 0.37–1.01, p = 0.052), suggesting that those who did not attend training had higher odds of inadequate knowledge compared to those who did

New guidelines knowledge classification

Participants under 25 years of age had lower odds of inadequate new guidelines knowledge compared to those aged 25–30, although this association was marginally significant (OR = 0.40, 95% CI = 0.16–1.02, p = 0.055). Gender, health facility type, level of work, and medical practice experience did not exhibit significant associations with new guidelines knowledge. Similarly, rabies training/workshop attendance was not significantly associated with knowledge of the new guidelines (p > 0.05)

Practice classification

None of the predictors showed statistically significant associations with poor practice classification. Gender, health facility type, level of work, and medical practice experience all had wide confidence intervals and non-significant p-values. Rabies training/workshop attendance also did not exhibit a significant effect on practice classification (OR = 0.72, 95% CI = 0.44–1.19, p = 0.197)

Overall, the results suggest that training or workshop attendance in the past year had a marginal effect on knowledge classification but was not significantly associated with new guidelines for knowledge or practice classification

This study highlights substantial gaps in awareness, knowledge, and clinical practices regarding rabies and updated prophylaxis guidelines among Sudanese physicians. These findings reflect broader challenges observed in low-resource and conflict-affected settings, emphasizing the critical need for systemic improvements and targeted interventions

A significant majority of respondents (84%) correctly identified rabies as a viral infection, with a higher proportion among house officers. This finding aligns with a study by Gönen et al. [20], where 92% of Turkish physicians recognized the viral etiology of rabies. Similarly high levels of awareness have been documented in India, Pakistan, and Chad, indicating strong baseline knowledge in identifying rabies’ pathological origin [21, 24, 25]

In contrast, only 29% of respondents identified the rabies incubation period as between 3 weeks and 3 months. This is markedly lower than the 32% observed in Turkey [20] and the 51.7% documented in Pakistan [24]. Understanding the incubation period is vital for transitioning PEP to PrEP, which can reduce costs and optimize resources [26]

Knowledge of rabies transmission pathways revealed critical gaps. Only 45% of respondents recognized the head and neck as key areas for rabies transmission, and 25% accurately identified the transmission route. These figures parallel findings from Turkey, where 42% of physicians struggled with similar concepts [20]. Such gaps may lead to delayed or inappropriate clinical responses, exacerbating patient outcomes

The limited knowledge of rabies prophylaxis guidelines among Sudanese physicians is a pressing concern. Only 7.1% of participants demonstrated an adequate understanding of updated guidelines, particularly regarding the intradermal vaccination route (20.1%) —recommended by WHO for its safety, efficacy, and cost-effectiveness — [27]. While this figure is higher than the 3% reported in a Kenyan study [26], it falls significantly below the rates observed in two Indian studies, which reported awareness levels of 43.2% and 66.6%, respectively [21, 28]. The implementation of the ID route in Sudan could significantly reduce costs and improve vaccine accessibility, particularly in resource-limited settings, underscoring the importance of incorporating this knowledge into training programs

A positive correlation between guideline knowledge and clinical practices (r = 0.230, p < 0.001) underscores the importance of adequate training. Studies in Uganda and Kenya have shown that better-informed healthcare workers are more effective in managing rabies cases, leading to improved patient outcomes [26, 29]. Conversely, inadequate knowledge risks poor clinical decisions, which can exacerbate morbidity and mortality rates associated with rabies

Although 56.2% of participants demonstrated good clinical practices, significant deficiencies were observed. For instance, only 47.1% of physicians correctly identified the need for RIG in category III exposures. This finding aligns with research in Kenya, where gaps in RIG knowledge and accessibility were prominent [26]. Similarly, Wambura et al. [30] reported limited awareness of cost-effective prophylaxis approaches, such as the intradermal route, among rural healthcare workers

Basic wound care practices also revealed gaps. While cleaning bite wounds with soap, water, and virucidal agents is a cornerstone of rabies prevention, this knowledge was inconsistent among participants. Koruk et al. [31] found similar deficiencies in Turkey, where nearly 67% of physicians were unaware of proper wound care protocols. Effective first-line interventions are crucial to preventing rabies transmission, highlighting the need for hands-on training to standardize practices

Clinical practice scores revealed additional challenges. While 72.4% of respondents identified wound cleaning as the initial step in rabies management, only 61.8% were aware of the correct cleaning protocol involving soap, water, and povidone-iodine. This aligns with Turkish studies, where 95% recognized wound cleaning as critical, but 66.9% lacked knowledge of proper techniques [31]

Administration of PEP remains a significant challenge. Only 20.7% of respondents knew that PEP should be administered when the vaccination status of the biting animal is unknown, and just 25.5% recognized its necessity in provoked dog bites. By contrast, 95.1% of Indian physicians demonstrated correct knowledge of PEP in such cases [21]. Similarly, while 41.3% of Sudanese physicians understood that pregnancy and lactation are not contraindications for PEP, awareness of the WHO-recommended route for PEP administration was strikingly low at 20.1%

The ongoing armed conflict in Sudan compounds the challenges of rabies prevention and control. Displacement, the collapse of healthcare infrastructure, and increased stray animal populations have created conditions conducive to rabies outbreaks. Such scenarios are not unique to Sudan; conflict-affected regions like East Darfur and South Sudan face comparable issues, where healthcare systems struggle to manage zoonotic diseases [26, 29]

Turkey’s rabies control efforts offer valuable lessons. Despite initial setbacks, Turkey’s national program achieved significant progress through mass dog vaccinations and public education campaigns [30]. These systemic interventions underscore the potential of coordinated efforts to mitigate the impact of rabies, even in resource-limited contexts

The challenges identified in Sudan align with findings from other rabies-endemic countries. In Sri Lanka and India, healthcare workers displayed limited knowledge of observation periods for rabies-susceptible bites and vaccine schedules [21, 32]. Similar barriers—including inconsistent vaccine supplies and inadequate training—have been reported in Pakistan and Kenya [24, 26]

Globally, mass dog vaccination and accessible PEP are recognized as cornerstone strategies for rabies elimination. Success stories from Latin America, where coordinated efforts have nearly eradicated human rabies, demonstrate the transformative impact of such initiatives [33]. These examples highlight the critical importance of sustained investments and multi-sectoral collaboration in achieving rabies control

Addressing the significant gaps in rabies awareness, knowledge, and clinical practices among Sudanese physicians requires a comprehensive approach. Priority should be given to the development and implementation of targeted training programs that focus on rabies prevention, management, and adherence to updated WHO guidelines. These programs should emphasize essential practices such as proper wound care techniques, including the use of soap, water, and povidone-iodine. Additionally, they should highlight the benefits of the intradermal vaccination route, which is both cost-effective and efficient, as well as the appropriate use of rabies RIG in high-risk exposures

Policymakers must ensure the consistent availability of essential resources, particularly vaccines and RIG, in underserved and conflict-affected regions. Integrating these resources into public health strategies will help standardize care across healthcare facilities. Alongside this, it is crucial to raise awareness both among healthcare providers and the public. Professional education campaigns should focus on enhancing physicians’ adherence to updated rabies guidelines, while community outreach programs can educate the population about preventive measures and the importance of seeking timely medical care for potential rabies exposures

ARVs:

Anti-rabies vaccines

HRIG:

Human rabies immunoglobulin

ID:

Intradermal

IM:

Intramuscular

PARACON:

Pan-African Rabies Control Network

PEP:

Post-exposure prophylaxis

PrEP:

Pre-exposure prophylaxis

RIG:

Rabies immunoglobulin

TRS:

Technical Report Series

WHO:

World Health Organization

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M.A.A.S. conceived the study, designed the study, supervised the project, coordinated data curation, and wrote the original draft. T.S.M.S. developed the methodology and contributed to data analysis and interpretation. H.E.S.E. conducted the literature review, validated the data, and reviewed and edited the manuscript. M.M.E.O. carried out the investigation, performed a formal analysis, and visualized the results. A.A.A.Y. collected the data, applied software tools, and conducted statistical analysis. A.M.K.E. acquired the data, managed resources, and handled data management. M.F.A.Y. reviewed and edited the manuscript and coordinated with co-authors. H.E.M.A. reviewed and edited the manuscript, validated the findings, and ensured quality control. F.A.M.A. contributed to methodology development, performed formal analysis, and assisted in manuscript preparation. O.E.M.A. reviewed and edited the manuscript and coordinated with co-authors.

Correspondence to Mohannad Abdalfdeel Almahie Shaban.

Ethical approval for this study was obtained from the Alazhari Health Research Center. The study adhered to the ethical principles outlined in the Declaration of Helsinki and Sudan’s National Ministry of Health’s National Guidelines for Ethical Conduct of Research Involving Human Subjects (2008) [22, 23]. Participation in the study was entirely voluntary. Electronic informed consent was obtained from all participants before completing the survey, which included a clear description of the study’s objectives and assurances of anonymity and confidentiality. Participants indicated their consent by selecting “Yes” in a mandatory consent question before completing the survey.

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The authors declare no competing interests.

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