Psychological effects of rabies on the relatives of people who died from human rabies in Côte d'Ivoire between 2023 and 2025: Qualitative Observational Study

Technical Summary: Psychological Effects of Rabies on Relatives in Côte d'Ivoire

Problem Statement
Rabies is a nearly 100% fatal zoonosis with a profound epidemiological impact, particularly in Africa where approximately 24,000 deaths occur annually. While the clinical and epidemiological aspects of human rabies are well-documented, the psychological burden on the relatives of victims remains largely unexplored. The rapid, inevitable, and often traumatic progression of the disease, characterized by severe neurological symptoms and a fatal prognosis, exposes families to intense emotional shock. Furthermore, existing rabies response activities in Côte d'Ivoire and globally focus on post-exposure prophylaxis and surveillance, with virtually no formal psychological support provided to bereaved families. This study addresses the gap in understanding the specific psychological consequences for relatives of individuals who died from confirmed or suspected human rabies.

Methodology
This research employed a single-center, descriptive qualitative study design conducted between January and June 2026 at the Anti-Rabies Center (CAR) of the National Institute of Public Hygiene (INHP) in Treichville, Abidjan.

• Population: The study included close relatives (spouses, parents, siblings, adult children, or cohabitants) of individuals who died from laboratory-confirmed or suspected human rabies between 2023 and 2025.
• Sampling: From a database of 128 deaths and 837 listed contacts, 37 participants were selected based on their relationship to the deceased, ability to articulate emotional experiences, and accessibility. Inclusion required participants to be at least 18 years old and fluent in French.
• Data Collection: Researchers conducted individual semi-structured interviews until data saturation was achieved. Interviews lasted 30 to 60 minutes, were audio-recorded, and transcribed verbatim.
• Analysis: Data were analyzed using MAXQDA 2026 software through thematic analysis.
• Ethics: The study received approval from the INHP Ethics Committee (No. 00087/07/01/26/MSHPCMU/INHP/EKD/FC). Participation was voluntary, with verbal informed consent obtained. Measures were taken to protect participant anonymity and offer referrals for psychological distress.

Key Results
The study included 37 relatives (mean age 39.8 years; 59.5% male). The majority were farmers or individuals with no formal education, reflecting the rural and socioeconomically vulnerable demographic typically affected by rabies.

1. Care Pathway and Risk Perception: Most exposures were dog bites (32/37), often from stray dogs. A recurrent theme was the underestimation of risk, where families initially sought traditional remedies or delayed medical care due to lack of awareness or organizational barriers (e.g., vaccination centers closed on holidays).
2. Diagnostic Experience: The announcement of the rabies diagnosis and its fatal prognosis was universally described as abrupt and traumatic, inducing immediate shock, surprise, and confusion.
3. Emotional Responses:
   • Pre-death: Dominant emotions included sadness (18/37), helplessness (15/37), shock (9/37), anger (8/37), and guilt (7/37). Witnessing the patient's agony and the inability to provide curative treatment were cited as highly distressing.
   • Post-death: Participants reported profound grief, often exacerbated by public health restrictions that prevented traditional funeral practices (e.g., viewing the body or performing customary rites), leading to feelings of abandonment and injustice.
4. Persistent Psychological Manifestations: All participants (37/37) reported intrusive memories. Other symptoms included sleep disturbances/insomnia (24/37), nightmares (15/37), and avoidance of animals (11/37). These symptoms suggest post-traumatic psychological distress and prolonged grief.
5. Coping and Support: Coping strategies relied almost exclusively on informal resources: prayer/faith (28/37) and family/community support (18/37). No participant reported receiving formal psychological support.
6. Unmet Needs: The primary unmet need identified was psychological support (28/37), followed by financial assistance and better information on rabies prevention.

Key Contributions

• First Local Study: This is the first study in Côte d'Ivoire to specifically investigate the psychological impact of rabies on bereaved relatives.
• Identification of Trauma Patterns: The study documents that the psychological sequelae of rabies bereavement include symptoms consistent with Post-Traumatic Stress Disorder (PTSD) and prolonged grief disorder, driven by the sudden nature of the death, the horrific clinical progression, and the preventable nature of the outcome.
• Gap in Care: It highlights a critical gap in the current rabies management framework, which lacks a psychosocial component for families, despite the high prevalence of unmet emotional needs.
• Constructive Adaptation: The study notes that some relatives transformed their grief into preventive actions (e.g., community awareness, vaccinating other animals), suggesting that bereaved families could serve as effective advocates if supported.

Significance and Claims
The paper claims that the burden of rabies extends beyond mortality to include profound and lasting psychological suffering for families. It argues that the current absence of psychological support exacerbates trauma and hinders the potential for families to become agents of change in rabies prevention.

The author concludes that integrating a culturally appropriate psychosocial component into rabies management is essential. Such integration would not only alleviate the suffering of bereaved relatives but also strengthen community awareness and engagement, thereby contributing to the global goal of eliminating human rabies deaths by 2030. The study emphasizes that addressing the psychological needs of families is a necessary step toward a holistic and effective rabies elimination strategy.