Determinants of health seeking behavior of animal bite victims in rabies endemic South Bhutan: a community-based contact-tracing survey

Rabies control in Bangladesh and prediction of human rabies cases by 2030: a One Health approach

Background

Bangladesh is making progress toward achieving zero dog-mediated rabies deaths by 2030, a global goal set in 2015.

Methods

Drawing from multiple datasets, including patient immunisation record books and mass dog vaccination (MDV) databases, we conducted a comprehensive analysis between 2011 and 2023 to understand the effectiveness of rabies control programmes and predict human rabies cases in Bangladesh by 2030 using time-series forecasting models. We also compared rabies virus sequences from GenBank in Bangladesh and other South Asian countries.

Findings

The estimated dog population in Bangladesh was determined to be 1,668,140, with an average dog population density of 12.83 dogs/km2 (95% CI 11.14-14.53) and a human-to-dog ratio of 86.70 (95% CI 76.60-96.80). The MDV campaign has led to the vaccination of an average of 21,295 dogs (95% CI 18,654-23,935) per district annually out of an estimated 26,065 dogs (95% CI 22,898-29,230). A declining trend in predicted and observed human rabies cases has been identified, suggesting that Bangladesh is poised to make substantial progress towards achieving the 'Zero by 30' goal, provided the current trajectory continues. The phylogenetic analysis shows that rabies viruses in Bangladesh belong to the Arctic-like-1 group, which differs from those in Bhutan despite sharing a common ancestor.

Interpretation

Bangladesh's One Health approach demonstrated that an increase in MDV and anti-rabies vaccine (ARV) resulted in a decline in the relative risk of human rabies cases, indicating that eliminating dog-mediated human rabies could be achievable.

Funding

The study was supported by the Communicable Disease Control (CDC) Division of the Directorate General of Health Services (DGHS) of the People's Republic of Bangladesh.

Tracking lethal threat: in-depth review of rabies

An infectious disease known as rabies (family Rhabdoviridae, genus Lyssavirus) causes severe damage to mammals' central nervous systems (CNS). This illness has been around for a very long time. The majority of human cases of rabies take place in underdeveloped regions of Africa and Asia. Following viral transmission, the Rhabdovirus enters the peripheral nervous system and proceeds to the CNS, where it targets the encephalon and produces encephalomyelitis. Postbite prophylaxis requires laboratory confirmation of rabies in both people and animals. All warm-blooded animals can transmit the Lyssavirus infection, while the virus can also develop in the cells of cold-blooded animals. In the 21st century, more than 3 billion people are in danger of contracting the rabies virus in more than 100 different nations, resulting in an annual death toll of 50,000-59,000. There are three important elements in handling rabies disease in post exposure prophylaxis (PEP), namely wound care, administration of anti-rabies serum, and anti-rabies vaccine. Social costs include death, lost productivity as a result of early death, illness as a result of vaccination side effects, and the psychological toll that exposure to these deadly diseases has on people. Humans are most frequently exposed to canine rabies, especially youngsters and the poor, and there are few resources available to treat or prevent exposure, making prevention of human rabies challenging.

An exploratory study on the perceptions of rabies and ill-health causations and health seeking behaviours of school children and local communities in southern Bhutan

BACKGROUND

The perception of illness and health-seeking behaviours, including rabies differ from one culture to another. Depending on the cultural setting of the society in which people live, the definition of the causal factors of illness may range from natural biological causes to supernational causes which greatly influence subsequent health-seeking behaviour. To ensure best health practices and plan effective health interventions for the control of dog-mediated-human rabies, we explored how school children and adult communities perceive and respond to illnesses, including rabies in southern Bhutan.

METHODS

We collected quantitative data related to the causes of illness and health-seeking practices of school children using a questionnaire survey (QS). Qualitative data were collected through focus group discussions (FGDs) and in-depth interviews (IDIs) with older members of communities (≥ 18 years) that work closely with school children. Descriptive analysis was performed for the quantitative data and thematic analysis was performed for the qualitative data.

RESULTS

The participants during the FDGsand IDIshave linked the illnesses to past actions, spirits, energy channels, planetary movement, sorcery, black magic, food, physical or environmental factors, individual habits and social factors. The survey of the school children reported microorganisms (75%), past actions (16.8%), spirits (9.6%) and black magic (9.1%) as causal factors for illnesses. Health seeking behaviours reported by the participants included visiting hospitals, performing spiritual or religious rituals and local treatments. Similarly, school children also mentioned that illnesses can be treated by visiting hospitals (98%), performing rituals (59.1%), and seeking traditional treatments practices (18.8%). Both school children and adult members of the communities that we interviewed were well aware on the causes of rabies and need for allopathic treatments rather than seeking spiritual or local treatments.

CONCLUSION

There is a need for the consideration of the socio-cultural context in the planning and implementation of health-related policies, including the rabies prevention programs in Bhutan, by involving traditional healers and religious entities with "One Health" public health sectors.

Assessment of the rabies education among middle secondary school students of southeastern Bhutan

Rabies is one of the most important zoonotic diseases that mostly affect children. We conducted a rabies education among 129 secondary school children (intervention group = 94 students, control group = 35 students) in two schools in southeast Bhutan and evaluated the effectiveness of the lesson by comparing the knowledge, perception and safety behaviour score about rabies before and after education. We also assessed the knowledge retention capacity of the students at three months post intervention. Our findings indicated that short rabies lesson significantly (P<0.001) improved the mean knowledge score from 19.98(±2.72) to 26.96(±2.24) in the intervention group. Similarly, mean scores for perception and safety behaviour improved significantly (P<0.001) from 10.77 (±1.89) to 13.95 (±1.36) and 9.809 (±1.85) to 12.97 (±1.54), respectively. Although the scores have reduced significantly (P<0.001) at three months post intervention, most of the rabies information was largely retained by the students. In control group, significant increase in mean scores were also observed for perception from 10.17 (±2.38) to 11.2 (±2.44) and safety behaviour from 9.14(±1.44) to 10.74 (±1.95) after 3 months of education. The finding demonstrate that a short rabies lesson is effective in improving knowledge, perceptions and understanding of dog bites safety behaviour among the school children. However, there is a need for a frequent awareness program, at least quarterly or half yearly. Rabies education should focus on critical points such as dog bites being the main source of rabies and the importance washing a dog/animal bite wound with soap and water, and visiting the hospital for medical advice following animal bites.

Delays in initiating rabies post-exposure prophylaxis among dog bite victims in Wakiso and Kampala districts, Uganda

Background   Although rabies in dog bite patients is preventable through timely initiation of post-exposure prophylaxis (PEP), a number of barriers to achieving PEP exist. This study investigated the delays to initiation of PEP among dog bite patients in the emergency departments of two PEP centers in Uganda. Methods A cross-sectional study was conducted among dog-bite patients that presented to two selected rabies PEP centers. A semi-structured questionnaire was used to collect data. Delay to receive PEP was defined as reporting for PEP beyond 24 hours after the bite event. Generalized linear models were used to calculate prevalence ratios and the 95% confidence intervals as a measure of association between delay and patient factors. Results Out of 376 participants, just over half (53.5%) were males. The majority of participants (54.0%) were 15 years or older and 28.5% had no formal education. Just over three-quarters (77.9%) had category II dog bite wounds. Nearly 40% delayed to receive PEP, and median (inter quartile range) lag time between bite event and seeking medical care of 18 (41) hours. Compared to education level of secondary or above, patients with no formal education (adj. PR=4.06, 95% CI: 2.69 -  6.10) or primary education (adj.PR=2.15, 95% CI: 1.37 -  3.35), belonging to the lowest socio-economic tertile as compared to the highest (adj.PR=1.58, 95% CI: 1.10 - 2.28), knowing the owner of the biting dog (adj.PR=1.30, 95% CI: 1.02 - 1.65) and having category II wounds (adj.PR=2.31, 95% CI: 1.43 - 3.71) were all associated with delayed presentation for PEP. Conclusions and recommendations Delays to receive PEP are common and are associated with poor level of education or low socio-economic status, knowledge of who the dog owner is and less severity of bite wounds. Seeking care irrespective of wound severity or knowledge of dog owner should be promoted.

Knowledge, Attitude and Practices of rabies during an outbreak in Samtse Municipality, Bhutan: A cross-sectional study

Background

A rabies outbreak in dogs occurred on February 22, 2021, in the Samtse Municipality, Bhutan. A rapid response team (RRT) was activated comprising of human and animal health teams to investigate and contain this outbreak. An assessment of the knowledge, attitude, and practice (KAP) on rabies was elicited during this period to develop evidence-based education material.

Methods

A face-to-face KAP questionnaire was administered to a volunteer member of 55 households in two communities (Norbuling and Xing Workshop areas) following the rabies outbreak in the Samtse Municipality from March 15 to 22, 2021. Descriptive statistics were used to describe the demographic characteristics. The associations between the KAP scores were assessed using the Pearson correlation coefficient.

Results

Of the 55 respondents, 63.6% (35) had poor knowledge, 90.9% (50) and 63.6% (35) reported good attitude and practice toward rabies. Three (5.5%) participants had not heard about rabies. The other misconceptions were that rabies can be prevented with antibiotics (67.3%, 37), dressing the bite wounds (20.0%, 11), and seeking treatment from the local healer (5.5%, 3). Correct knowledge was reported on excessive salivation as the sign of the rabid animal (58.2% 32), rabies prevention through vaccination (81.8%, 45), and seeking medical care on the same day (94.5%, 52). Eighty-nine percent (49) vaccinated their dogs and domestic animals annually, 100% received post-exposure prophylaxis (PEP) after an animal bite, 78.2% (43) washed the animal bite wounds with soap and water, and 9.1% (5) would consult the local healer for animal bites. A majority (78.2%, 43) of them agreed that rabies is a serious public health problem in the Samtse Municipality and 49.1% (27) agreed that the public was adequately informed about rabies. A positive correlation was observed between the knowledge-practice scores (r = 0.3983, P value = 0.0026), and attitude-practice scores (r = 0.4684, P value < 0.001).

Conclusion

The poor knowledge of rabies in this study needs to be addressed urgently. The main misconceptions included were that rabies is not fatal, dressing animal bite wounds, and seeking dog and animal bite care from local healers. Health education should focus on these misconceptions.

Knowledge, attitudes, and practices toward rabies in three provinces of Indonesia

Background and Aim:

Rabies is an important viral zoonotic disease that is mostly transmitted through the bite of a rabid dog. Despite serious efforts regarding its control, rabies is still endemic in many provinces of Indonesia. The study aims to assess the knowledge, attitudes, and practices (KAP) related to rabies in urban and rural areas in three provinces of Indonesia.

Materials and Method:

s: A total of 432 respondents of different age groups, educational levels, geographical areas, and occupations participated in this study. Data were collected using a pre-designed questionnaire with online and offline modes to assess the KAP of rabies among the respondents. A series of Chi-square tests and frequency distribution analyses were performed to determine associations between response variables.

Results:

Of the 432 participants, 56.9% were aware of the clinical signs of rabies. Excepting for people at high risk of contracting the disease (e.g., veterinarians), most respondents (83.1%) were not vaccinated against rabies. Surprisingly, 79.4 % of those who were bitten by an infected dog did not seek medical care from the doctor and approximately 71.8% had poor knowledge of rabies control and vaccine campaigns. Of all respondents, 64% (p<0.05, odds ratio=1.63) were vaccinated after an infected dog bite. Similarly, 32% (p<0.05, odds ratio=1.59) were aware of surveys and vaccinations in their areas. In contrast, 20.7% (p<0.05, odds ratio=0.593) reported that rabid dogs were killed in their areas. The majority (89.60%) of the respondents were aware of the fact that rabies can cause death. Most of the respondents (93%) knew that rabies is caused by an infected dog bite. The overall levels of KAP among the respondents were good.

Conclusion:

The findings of the current study generally show that participants had good knowledge about clinical signs based on their frequency percentage, but lacked knowledge regarding medical treatment and surveys for awareness and vaccination of rabies. Overall, a significant (p<0.05, odds ratio>1) relationship was found among the KAP of participants. This depicts that the majority of the population is aware of rabies and factors involved in its transmission.

Delays in initiating rabies post-exposure prophylaxis among dog bite victims in Wakiso and Kampala districts, Uganda

Background: Although rabies in dog bite patients is preventable through timely initiation of post-exposure prophylaxis (PEP), a number of barriers to achieving PEP exist. This study investigated the delays to initiation of PEP among dog bite patients in the emergency departments of two PEP centers in Uganda. Methods: A cross-sectional study was conducted among dog-bite patients that presented to two selected rabies PEP centers. A semi-structured questionnaire was used to collect data. Delay to receive PEP was defined as reporting for PEP beyond 24 hours after the bite event. Generalized linear models were used to calculate prevalence ratios and the 95% confidence intervals as a measure of association between delay and patient factors. Results: Out of 376 participants, just over half (53.5%) were males. The majority of participants (54.0%) were 15 years or older and 28.5% had no formal education. Just over three-quarters (77.9%) had category II dog bite wounds. Nearly 40% delayed to receive PEP, and median (inter quartile range) lag time between bite event and seeking medical care of 18 (41) hours. Compared to education level of secondary or above, patients with no formal education (adj. PR=4.06, 95% CI: 2.69 -  6.10) or primary education (adj.PR=2.15, 95% CI: 1.37 -  3.35), belonging to the lowest socio-economic tertile as compared to the highest (adj.PR=1.58, 95% CI: 1.10 - 2.28), knowing the owner of the biting dog (adj.PR=1.30, 95% CI: 1.02 - 1.65) and having category II wounds (adj.PR=2.31, 95% CI: 1.43 - 3.71) were all associated with delayed presentation for PEP. Conclusions and recommendations: Delays to receive PEP are common and are associated with poor level of education or low socio-economic status, knowledge of who the dog owner is and less severity of bite wounds. Seeking care irrespective of wound severity or knowledge of dog owner should be promoted.

Delays in initiating rabies post-exposure prophylaxis among dog bite victims in Wakiso and Kampala districts, Uganda

Background: Although rabies in dog bite patients is preventable through timely initiation of post-exposure prophylaxis (PEP), a number of barriers to achieving PEP exist. This study investigated the delays to initiation of PEP among dog bite patients in the emergency departments of two PEP centers in Uganda. Methods: A cross-sectional study was conducted among dog-bite patients that presented to two selected rabies PEP centers. A semi-structured questionnaire was used to collect data. Delay to receive PEP was defined as reporting for PEP beyond 24 hours after the bite event. Generalized linear models were used to calculate prevalence ratios and the 95% confidence intervals as a measure of association between delay and patient factors. Results: Out of 376 participants, just over half (53.5%) were males. The majority of participants (54.0%) were 15 years or older and 28.5% had no formal education. Just over three-quarters (77.9%) had category II dog bite wounds. Nearly 40% delayed to receive PEP, and median (IQR) lag time between bite event and seeking medical care of 18 (41) hours. Compared to education level of secondary or above, patients with no formal education (adj. PR=4.06, 95% CI: 2.69 -  6.10) or primary education (adj.PR=2.15, 95% CI: 1.37 -  3.35), belonging to the lowest socio-economic tertile as compared to the highest (adj.PR=1.58, 95% CI: 1.10 - 2.28), knowing the owner of the biting dog (adj.PR=1.30, 95% CI: 1.02 - 1.65) and having category II wounds (adj.PR=2.31, 95% CI: 1.43 - 3.71) were all associated with delayed presentation for PEP. Conclusions and recommendations: Delays to receive PEP are common and are associated with poor level of education or low socio-economic status, knowledge of who the dog owner is and less severity of bite wounds. Seeking care irrespective of wound severity or knowledge of dog owner should be promoted.

Knowledge, attitude, and practices associated with rabies in villages with different dog vaccination statuses in Cambodia

Background and Aim

Rabies is a highly infectious but neglected zoonotic disease. Almost 99% of rabies-related human deaths are caused by dog-mediated rabies. Although canine rabies vaccination is highly effective and provides protection, nationwide rabies vaccination campaigns have been insufficient in Cambodia, resulting in a limited number of rabies vaccinated dogs. This study aimed to explore the rabies knowledge, attitude, and practices (KAP) among participants from both dog rabies vaccinated (DRV) and dog rabies unvaccinated (DRUV) villages located in the Kandal and Prey Veng Provinces, Cambodia.

Materials and Methods

A cross-sectional survey was conducted with dog owners in Kandal and Prey Veng Provinces, Cambodia, during August and September 2020. The structural questionnaire collected general sociodemographic information and the KAP associated with rabies transmission, clinical signs, management, and control. The data were then analyzed using Wilcoxon rank-sum test and Chi-square statistics.

Results

In total, 312 participants were interviewed: 137 participants from DRV villages and 175 from DRUV villages. Among them, 99.4% (310/312) had previously heard about rabies. Out of these 310, 93.5% (290/310) were aware that rabies is a fatal disease, while 96.5% (299/310) were willing to vaccinate their dog against rabies if the vaccination was provided for free. However, 32.9% (102/310) indicated that they would be willing to sell their own dog if it bit someone or showed aggression. More than one-third (115/310) of all the respondents had poor overall KAP regarding rabies. The respondents from DRV villages had significantly higher overall scores with regard to rabies KAP than those from DRUV villages (p<0.0001). According to the factors related to overall KAP, village type and education level were significantly associated with overall KAP of the respondents (p<0.0001).

Conclusion

The rabies disease is recognized in Cambodia, and dog owners are willing to vaccinate their dogs if the vaccination is provided for free. The overall rabies-related KAP were poor among 30% of the respondents, and higher KAP scores were obtained for the DRV villages. The village type and education level were found to be associated with the different overall KAP of the participants.

Evaluation of rabies immunoglobulin administration status in China: a retrospective, cross-sectional study at a tertiary hospital in Beijing

This retrospective cross-sectional study included patients with category Ⅲ exposure to the rabies virus at a single center between January and December 2019. Exposure characteristics and clinical data were compared and statistically analyzed among groups willing and unwilling to receive RIG injection, and determinants of its administration were identified by stepwise multivariate logistic regression analyses. In total, 1,757 patients with category Ⅲ exposure were enrolled: 845 males (48.1%) and 912 females (51.9%; median age: 28 [9-50] years). Among them, 1,297 (73.8%) received RIG injection (median age: 28 [8-50] years) and 460 (26.2%) refused to receive the injection (median age: 25 [15-48] years). Patients aged 16-25 years (odds ratio [OR]=3.006, 95% confidence interval [CI]=1.957-4.619), 26-45years (OR=2.940, 95% CI=2.011-4.298), 46-55 years (OR=3.647, 95% CI=2.233-5.959) and over 56 years (OR=6.660, 95% CI=4.009-11.062); those with injuries caused by cats (OR=1.937, 95% CI=1.476- 2.542); and people with scratch (OR=3.319, 95% CI= 2.510-4.390), minor (OR=35.281, 95% CI=18.524-64.198), and moderate (OR=12.711, 95% CI=7.221-22.375) injuries were more likely to refuse injection. The RIG administration level in the settings studied herein is insufficient. Educational and awareness programs should be considered for rabies prevention, especially those targeted at people not injured by dogs, people with minor injuries, and the elderly.

Rabies control in South Asia requires a One Health approach

Rabies is a vaccine-preventable viral disease present in more than 150 countries around the world. Globally, almost 60,000 people die each year from rabies, of which more than 58% are in Asia and around 45% in South Asia with especially high incidence in India, Pakistan and Bangladesh. Vaccination coverage of both people and stray dogs is low in the region and in general people are not given enough protection and information about pre- and post-exposure prophylaxis. Engagement of multiple sectors and One Health collaboration including community education, awareness programmes and vaccination campaigns are critical to control and elimination of rabies.

Probable rabies in a child in a Bhutanese town bordering India, 2020

Rabies is a neglected tropical disease that causes mortality and high economic burden in many developing countries. Rabies is a vaccine-preventable disease if timely post-exposure prophylaxis is available after animal exposure. The control of rabies requires limiting the transmission of the virus in the animal reservoir, effective public health measures to control outbreaks and increasing accessibility and uptake of rabies post-exposure prophylaxis. Bhutan is a small Himalayan country where rabies is endemic. In this article, we describe the death of a 3-year-old female child due to probable rabies in a Bhutanese village located along the border with India. The child had a furious form of rabies with encephalitic syndrome developing 57 days after a category III dog bite on the chest. The child was managed at a district hospital with the available resources. This is the first rabies death in Bhutan in the last 5 years and the 18^th since 2006. This case report focuses on the efforts required to increase the timely uptake of post-exposure prophylaxis in a free healthcare system in Bhutan.

Knowledge and Perception of Rabies among School Children in Rabies Endemic Areas of South Bhutan

Rabies is endemic in southern Bhutan and children are the frequent victims of dog bites. We surveyed the knowledge, attitude, and practices on rabies among school children in three schools located in southern Bhutan. A total of 701 students (57.9% female, 42.1% male) with an age range of 12–21 years (mean: 15 years) participated in the survey, of which 98.2% had heard about rabies. Most of the students demonstrated a good level of knowledge (59.7%) and a favorable perception towards rabies (57.7%). Multivariable logistic analysis revealed the relation between knowledge and the awareness campaign (OR:1.5, 95% CI: 1.1–2.1). Similarly, higher grades of students (OR:1.9, 95%CI: 1.3–2.9) and employed mothers of the students (OR: 1.6, 95% CI: 1.0–2.7) were associated with more favorable perceptions. However, some knowledge gaps were identified in this study, such as students not being able to clearly mention the susceptible hosts of rabies, transmission routes, clinical signs, and prevention and control options. Therefore, regular awareness programs on rabies are necessary among school children in Bhutan.

Epidemiological study of human rabies cases in Bangladesh through verbal autopsy

Identification of risk factors is crucial to find ways to reduce rabies deaths. We investigated the hospital records of rabies deceased through contact tracing of the relatives of the victims using enhanced verbal autopsies (VA) to identify why the people had to die from rabies in recent years in Bangladesh. Patients whose deaths were confirmed by physicians based on the history of animal exposure and clinical signs were taken into account for VA. Socio-demographic profile of the deceased, animal exposure, nature of the wound, and history of post-exposure prophylaxis (PEP) data were obtained and analysed. The study found 256 cases in which the cause of death was attributed to rabies, most of the victims were male (71.88%), resided in the rural community (80.47%), dependent (49.22%), and children below the age of 15 years (47.27%). Dogs were the single most responsible (81.64%); however, cats (12.11%), jackals (3.91%) and mongoose (2.34%) were also found accountable for rabies incidence (P < 0.05). Significantly, limbs were the most common (67.97%) site of exposure, and the shortest incubation period was identified in the case of bites to head and face (P < 0.05). The majority (86.72%) of the deceased did not receive any PEP; whereas, 66.80% sought treatment from traditional healers. Among the deceased (13.28%, n = 34) who had received PEP, only 8.82% of them completed the full course of the vaccination regimen (P < 0.01); however, none of them had history of taking rabies immunoglobulin (RIG). The study recommends extensive public health awareness programs in the rural community and establishing methods to improve healthcare-seeking behaviours, including receiving PEP instead of visiting traditional healers. Moreover, the availability and accessibility of PEP in the government hospital facilities are desirable, and laboratory-based surveillance with compatible rapid data reporting may be incorporated in the existing policy.

Incidence of Animal-Bite Injuries Registered in Public Hospitals of Post-Conflict Swat District, Pakistan in 2014

The Swat district, a conflict-hit territory due to Taliban militancy, had a damaged local health infrastructure. Animal-bite injuries leading to rabies is one of the major health concerns in developing countries, especially within conflict zones. The current prospective epidemiological study was conducted to estimate the cumulative incidence of animal-bite injuries, to summarize characteristics of bite victims and biting animals, and to collect information about post-exposure prophylaxis (PEP) practices in Swat district, Pakistan, during 2014. A questionnaire was designed to collect data about the sociodemography of the patients, bite incident situation (provoked or unprovoked), injury pattern, animal type, PEP, and vaccination. Descriptive analyses were conducted using bar graphs, frequency tables, and chi-square tests were used to determine associations. The cumulative incidence of animal-bite injuries was 39 per 100,000 people during the study period (May-August 2014). The majority of incidents were reported from rural regions (77.7%) and were males (76.6%) younger than 10 years (37.3%). Dogs were the most frequent biting animal (86.8%) followed by rats (4.7%). About 77.7% patients washed their wound before arrival at hospital. After an eclipse phase of 10 days, 44 (10.1%) animals developed sign of rabies. The current study has highlighted a topic of interest for health, education, veterinary, and local government policy makers regarding prevention of animal bites, benefits of PEP, vaccination of human and domestic animals, control of stray dogs, and eradication of rabies in developing countries with damaged healthcare structures.

Epidemiology and preclinical management of dog bites among humans in Wakiso and Kampala districts, Uganda: Implications for prevention of dog bites and rabies

In rabies endemic areas, appropriate management of dog bites is critical in human rabies prevention. Victims must immediately wash bite wound for 15 minutes with water, soap, and a disinfectant before seeking medical care. This study investigated the epidemiology of dog bites and the determinants of compliance to these pre-clinical guidelines requirements among dog bite victims from high rabies-burden areas of Wakiso and Kampala, Uganda. An explanatory sequential mixed-methods study design was used. Quantitative data were collected from 376 dog-bite patients at two healthcare facilities. Qualitative data were also collected through 13 in-depth interviews with patients, healthcare workers, herbalists, and veterinarians. Qualitative data were analyzed using a deductive thematic approach. Generalized linear models were used to determine factors associated with compliance. Nearly half (190, 51%) of the patients were from Wakiso District and 293 (77.9%) had grade II wounds. Most of the wounds (171, 45.5%) were on the legs. Two-thirds of the bites occurred in public places. Only 70 (19%) of the bite patients had complied with pre-clinical guidelines. Nearly half of the patients had applied substances that were not recommended e.g. herbs (47/193), antiseptics (46/193), "black stone" (25/193), and unknown creams (10/193). Factors negatively associated with compliance included: being aged 15 years or older, adjPR = 0.70 (0.47-0.92) and knowing the dog owner, adjPR = 0.65 (0.36-0.93). However, attainment of secondary or higher education, adjPR = 1.76 (1.24-3.79), being in employment, adjPR = 1.48 (1.09-2.31), perception that the dog was sick, adjPR = 1.47 (1.02-2.72) and knowledge about the dog's subsequent victim(s) adjPR = 0.35 (0.17-0.70) were positively associated with compliance. High occurrence of dog bites in public places by free-roaming dogs suggests the need for deliberate promotion of responsible dog ownership. Additionally, targeted health education may be required to improve the low compliance to pre-clinical guidelines.

Knowledge, attitude and practice (KAP) survey of canine rabies in Khyber Pakhtunkhwa and Punjab Province of Pakistan

BACKGROUND

This study aimed to assess the extent of knowledge and understanding of rabies disease in rural and urban communities of Pakistan. It also identified malpractices after suspected dog bite that might pose a risk for humans contracting rabies.

METHODS

A cross-sectional study was conducted (n = 1466) on people having different age groups and educational levels in four different geographic regions of Punjab and Khyber Pakhtunkhwa provinces in Pakistan. Knowledge, attitude, and practices of people were assessed using a structured questionnaire. We used a bivariate and multivariate analysis to study the association between rabies related mortalities in near or extended family members and different risk behaviors.

RESULTS

Our results demonstrate that the majority of the juvenile population (less than 18 years of age) were not aware of the clinical signs of rabies in animals. 75% of the total respondents were not vaccinated against rabies, 60% did not seek a doctor's advice after a suspected animal bite, and 55% had inadequate health care facilities for rabies patients in local hospitals. Respondents that had pets at home had not vaccinated (38%; p < 0.05; odds ratio 1.58) themselves against rabies due to lack of knowledge and awareness of pre-exposure prophylaxis for rabies (51%; p < 0.05; odds ratio 1.25). They also tend to not visit doctor after suspected bite (52%; p < 0.05; odds ratio 1.97), which may had resulted in more deaths (65%; p < 0.05; odds ratio 1.73) of someone in their near or extended family due to rabies.

CONCLUSIONS

Lack of knowledge about the nature of rabies disease and prophylaxis has contributed to increase of rabies related deaths. Inadequate health care facilities and poor attitude of not seeking medical attention after suspected dog bite are the major reasons of rabies related deaths. These findings could help in devising a targeted management strategy and awareness program to control and reduce the incidence of human rabies related deaths in Pakistan.

Evaluation of a rapid immunochromatographic test kit to the gold standard fluorescent antibody test for diagnosis of rabies in animals in Bhutan

Background

Rabies kills approximately 59,000 people each year worldwide. Rapid and accurate diagnosis of rabies is important for instituting rapid containment measures and for advising the exposed people for postexposure treatment. The application of a rapid diagnostic tests in the field can greatly enhance disease surveillance and diagnostic activities, especially in resource poor settings. In this study, a total of 179 brain tissue samples collected from different rabies suspect animal species (113 dogs, 50 cattle, 10 cats, 3 goats, 2 horses, and 1 bear) were selected and tested using both rapid immunochromatographic kit and the reference standard fluorescent antibody test (FAT). We evaluated the sensitivity, specificity, positive predictive value (PPV) and negative predictive value (NPV) of a rapid antigen detection test kit produced by BioNote, Inc. (Hwaseong-si, Korea) relative to a FAT for its fit-for-purpose for confirmation of clinical cases of rabies for early response and enhancing rabies surveillance.

Results

Among 179 samples examined in this study, there was a concordance in results by the rapid test and FAT in 115 positive samples and 54 negative samples. Test results were discordant in 10 samples which were positive by FAT, but negative (false negative) by rapid kit. The rapid test kit showed a sensitivity of 92% (95% CI: 85.9–95.6) and specificity of 100% (95% CI: 93.4–100) using FAT as the reference standard. The positive and negative predictive values were found to be 100% (95% CI:96.7–100) and 84.4% (95% CI: 73.6–91.3), respectively. Overall, there was 94.4% (95% CI: 90–96.9) test agreement between rapid test and FAT (Kappa value = 0.874) with a positive percent agreement and negative percent agreement of 92 and 100%, respectively.

Conclusions

Our finding demonstrated that the rapid test kit (BioNote) can be used for rabies surveillance and confirming clinical case of rabies in animals for making rapid decisions particularly controlling rabies outbreaks in resource poor settings.

Knowledge and attitudes about rabies in dog-bite victims in Bangladesh

Rabies is an important zoonotic disease that causes several thousand deaths in Asian countries. Bangladesh launched an elimination programme in 2010 based on the mass vaccination of dogs, management of dog bites, application of post-exposure prophylaxis and communication and social mobilization. The aim of this study is to ascertain the behaviour of and knowledge about dog-bite victims.

A cross-sectional descriptive study was performed on 885 dog-bite victims who presented themselves for post-exposure rabies vaccination to six randomly selected vaccination centers, in addition to a tertiary-level hospital in Bangladesh. Most dog-bite victims were male (70%) and with very low or no education qualifications (75%). Respondents' knowledge of rabies was low: 58% were unaware of the consequences of a dog bite and 52% did not know about any indication of rabies. Most knew that rabies in humans can be prevented after dog bites, but up to 70% did not give a correct answer for other questions related to the prevention and treatment of rabies. Knowledge and attitudes about rabies is closely related to level of education. Finally, 58 of those surveyed (6.4%) did not complete the post-exposure prophylaxis correctly.

In conclusion, knowledge about rabies among Bangladeshi citizens is low. An intensive plan to inform and educate people about dog bites, the risk of rabies and measures to adopt for preventing the disease should be implemented in order to reduce risk, including the need to complete post-exposure treatment.

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Knowledge about rabies in victims of dog bites in Bangladesh was low (58% were unaware of the consequences of a dog bite).

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Up to 70% of bite victims did not give a correct answer to some questions related to prevention and treatment of rabies.

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A small but significant proportion of dog-bite victims (6.4%) did not complete the Post-Exposure prophylaxis correctly.