KAP survey on rabies in a community in Sri Lanka

スリランカにおける狂犬病に対する地域住民の KAP 調査

北　海　道　大　学大学院医学研究科　国際保健医学分野

Gino Cuarto Matibag6 February 2007

Rabbas: to do violence

Courtesy of Prof Ananda Jayasinghe

Painting of a rabid dog biting a man. Arabic (Mesopotamia). AD 1224

Louis Pasteur, 1885

Developed vaccines

Girolamo Fracastoro, 1546

The patient can neither stand nor lie down, like a mad man he flings himself hither and thither, tears his flesh with his hands, and feels

intolerable thirst. This is the most distressing symptom, for he so shrinks from water and all liquids that he would rather die than drink or be brought near to water. It is then they bite other persons, foam at the mouth, their eyes look twisted, and finally they are exhausted and painfully breathe

their last.

Global incidence of human rabies 2000-2005*

* - WHO

† - Ministry of Health Sri Lanka

Sri Lanka55 cases (2005)†

Myanmar1,100 cases (2003)

China2,009 cases (2003)

India17,000 cases (2004)

Philippines248 cases (2004)

Indonesia109 cases (2004)

Pakistan2,490 cases (2000)

Uganda105 cases (2003)

Thailand18 cases (2003)

Bangladesh1,550 cases (2003)

Asia 31,000$560M

Annual death toll

55,000Cost

burden $580M

Africa 24,000$20M

56%44%* - WHO

† - Ministry of Health Sri Lanka

Sri Lanka55 cases (2005)†

DOG

FOX

BAT

DOGWOLFFOX

BAT

MONGOOSE 、 DOG 、FOX 、 JACKAL

BAT

BATDOG

BAT 、 RACCOON 、 SKUNK 、COYOTE 、 FOX

MONGOOSE

Important reservoirs of rabies in the world

LTCZ/DVS/NIID

56004700

2400 1940 1800 16001000 700 600 200

0

2000

4000

6000

8000

10000

Lymph

atic fi

laria

sis

Inte

stinal nem

atod

e infe

ctions

Leish

maniasis

Rabies

Schisto

somiasis

Tryp

anos

omiasis

Onch

ocer

ciasis

Deng

ue

Chag

as

Lepr

osy

DALY

s x

1000

*

Neglected diseases:Rabies’ health burden with intervention

* - Disability-adjusted life years WHO, 2004

56004700

2400

9600

1800 16001000 700 600 200

0

2000

4000

6000

8000

10000

Lymph

atic fi

laria

sis

Inte

stinal nem

atod

e infe

ctions

Leish

maniasis

Rabies

Schisto

somiasis

Tryp

anos

omiasis

Onch

ocer

ciasis

Deng

ue

Chag

as

Lepr

osy

DALY

s x

1000

*

Neglected diseases:Rabies’ health burden without intervention

* - Disability-adjusted life years WHO, 2004

Define a global standard for the production, quality control, & regulation of therapeutic sera

Train inspectors & manufacturers on critical parameters of the production of therapeutic sera

Facilitate transfer of technology to developing countries

Etc.

WHO to increase treatment access for victims of rabies & snake bites*

* - WHO, Geneva

LTCZ/DVS/NIID

Pathogenesis

100% fatalityonce symptoms manifest

Photo courtesy of Dr Elizabeth Miranda

1

10

100

1,000

10,000

1890 1910 1930 1950 1970 1990 2010

No.

of

case

s

Human rabies Dog rabies

1 Imported case from Nepal (1970)

2 Imported cases from the Philippines (2006)

Rabies in Japan 1897-2006*

* - Ministry of Health, Labour and Welfare

Tsunami 26 Dec 2004

Projects of Hokkaido University in Sri Lanka

Chronic renal

disease

Chronic renal

diseaseEtiological

studies

HIV/AIDSHIV/AIDS

KAP survey•College students

•Educators

•Construction workersHIV testing &

counseling

RabiesRabies

Health-seeking behavior survey

Post-exposure prophylaxis study

Development of models for intervention strategies

Animal birth control & vaccination

Cost analysis of intervention

Educational campaigns among school children

KAP survey

National workshop for laboratory diagnosis of

rabiesRabies Control Unit

Japan Bank for International Cooperation

Partnership with WHO &

government

Partnership with academe

Partnership with NGOs

0

50

100

150

200

250

300

350

400

1964

1968

1972

1976

1980

1984

1988

1992

1996

2000

2004

No.

of

hum

an r

abie

s

0

1

2

3

4

Inci

denc

e pe

r 10

0,00

0

Human rabies

Incidence

Human rabies in Sri Lanka, 1964-2005*スリランカにおける狂犬病の年次別発生数と症例数（１９６４－２００５年）

National Rabies Control Program

* - Ministry of Health Sri Lanka

Animal rabies in Sri Lanka, 1995-2003*動物の種類別狂犬病発生件数（ 1995 ～ 2003 年）

* - Ministry of Health Sri Lanka

0

200

400

600

800

1000

1200

No.

of

rabi

d an

imal

s

1995 1996 1997 1998 1999 2000 2001 2002 2003

Others

Cat

Dog

0

100

200

300

40019

75

1978

1981

1984

1987

1990

1993

1996

1999

2002

No.

of

hum

an r

abie

s

0

300

600

900

No.

of

vacc

inat

ed &

elim

inat

ed d

ogs

x 1,

000

Human rabies

Dogs vaccinated

Dogs eliminated

National Rabies Control Program

* - Rabies Control Program, Ministry of Health Sri Lanka

Human rabies, vaccinated & eliminated dogs in Sri Lanka, 1973-2004*ヒトの狂犬病の発生件数とワクチン接種および処分された犬数（１９７３－２００４年）

Cost of rabies treatment in Sri Lanka*

Annual expenditure by the Health Ministry Over 150 million rupees ($1.38 million)

84% - post-exposure prophylaxis13% - dog vaccination & sterilization 3% - dog elimination

Out-of-pocket spending Cost of vaccination with rabies immunoglobulin is 30-40,000 rupees

($280-370)

* - Prof Ananda Jayasinghe, University of Peradeniya

Objectives

To determine the level of knowledge, attitude and practice (KAP) on rabies in selected communities.

To compare the KAP on rabies of Urban and rural areas Pet owners and non-pet owners.

地域における狂犬病に対する「 KAP 」（ Knowledge 、 Attitude 、 Practice ）のレベルを調査すること

都市部・農村部別およびペットの有無別によって KAP調査結果を比較すること

http://news.bbc.co.uk/2/hi/in_pictures/4753509.stm

http://www.spur.asn.au/LTTE_Atrocities_Suicide_Bomb_Attack_on_General_Sarath_Fonseka.htm

Methods Design: cross-sectional study Venue: Kandy District, Sri Lanka Period: May 2006 Sample population: 1570 household heads Respondents: Household heads (≥15 years old) Survey tool: in-person

interview by questionnaire Statistical analysis:

Descriptive statistics (frequency distribution)

& Chi-square/Fisher’s exact test Logistic regression

2001 Population

Central Province: 2.43M

Kandy District: 1.28M

Table 1: Household profile

Characteristics Kandy* Sample Sri Lanka*

Male:female 0.98 1.02 0.94

Literacy rate % 90.50 89.20 91.00

Socio-economic sector %

Urban 9.78 12.28 15.04Rural 90.22 87.82 84.96

ReligionBuddhism 73.14 86.29 76.70Hinduism/Islam/Christianity

26.81 13.71 23.30

EthnicitySinhalese 74.03 87.55 82.00Tamil 12.23 8.74 9.40Moor/Burgher/Malay 13.61 3.72 8.40

Household size 4.30 4.54 4.90

Monthly income (SLRupees)

12672† 8429 12804†

Monthly income (JPYen) 14400 9560 14520

* - Dept of Census and Statistics Sri Lanka, 2005† - Dept of Census and Statistics Sri Lanka, 2002

Table 2A: Knowledge of rabies

Total % Urba

n

% Rura

l

% p

The main reservoir of rabies in Sri Lanka is

Dog 1400 89.6 178 92.7 1222 89.1 0.097Cat 40 2.6 7 3.6 33 2.4

Cattle/Rat/Bat 45 2.9 2 1.0 43 3.1

Uncertain 78 5.0 5 2.6 73 5.3

Knows the fatal nature of rabies

Yes 1220 78.7 137 71.7 1083 79.6 0.002No 219 14.1 43 22.5 176 12.9

Uncertain 112 7.2 11 5.8 101 7.4

Knows that rabies could be prevented by vaccination

Yes 1364 88.1 166 87.8 1198 88.2 0.195No 96 6.2 8 4.2 88 6.5

Uncertain 88 5.7 15 7.9 73 5.4Knows that dog rabies vaccines could be obtained from authorized government offices

Yes 1376 90.6 170 90.9 1206 90.5 1.000No 143 9.4 17 9.1 126 9.5

Table 2B: Knowledge of rabies

Total % Urba

n

% Rura

l

% p

Sources of informationMultiple sources 934 60.7 137 72.1 797 59.1 0.000Government rabies vaccination campaign

237 15.4 10 5.3 227 16.8

Newspaper/TV/Radio 173 11.2 24 12.6 149 11.0

Others 195 12.7 19 10.0 176 13.0

Table 3A: Health attitude and practice

Total % Urba

n

% Rura

l

% p

Would seek treatment first if bitten by dogs

Doctor/hospital 1490 95.5 191 99.5 1299 94.9 0.017Native/traditional healer

59 3.8 1 0.5 58 4.2

None/Uncertain 12 0.8 0 0.0 12 0.9

Would inform authorities if bitten by dog

Yes 859 55.6 85 45.0 774 57.0 0.002

No 687 44.4 104 55.0 583 43.0

Table 3B: Health attitude and practice

* - Medical Research Institute

Total % Urba

n

% Rura

l

% p

Would destroy pet if rabid

Yes 1013 71.1 129 76.8 884 70.4 0.102

No 411 28.9 39 23.2 372 29.6

Knows that the head of suspected animal be submitted to MRI for confirmation*

Yes 641 43.0 110 60.1 531 40.6 0.000

No 849 57.0 73 39.9 776 59.4

Would send the head of the animal for laboratory confirmation

Yes 825 58.0 113 68.9 712 56.6 0.002

No 598 42.0 51 31.1 547 43.4

Table 3C: Health attitude and practice

Total % Urban

% Rural

% p

Willing to register petsYes 1163 85.3 140 85.4 1023 85.3 0.980No 80 5.9 10 6.1 70 5.8

Undecided 121 8.9 14 8.5 107 8.9

In favor of animal birth control (ABC) program

Yes 1324 85.5 163 86.2 1161 85.4 0.710No 153 9.9 16 8.5 137 10.1

Undecided 71 4.6 10 5.3 61 4.5

Would want authorities to destroy stray dogs

Yes 1289 85.5 165 90.7 1124 84.8 0.042No 218 14.5 17 9.3 201 15.2

Actions preferred to control stray dogs

Animal birth control

893 63.6 97 54.5 796 65.0 0.001

Animal disposal 318 22.7 50 28.1 268 21.9

Combined birth control & disposal

72 5.1 18 10.1 54 4.4

Others 120 8.6 13 7.3 107 8.7

Table 4: Pet care

Total % Urban

% Rural

% p

Pet dogs are housed in

Cage 322 38.1 47 43.5 275 37.3 0.023Dog is free to roam around

281 33.3 24 22.2 257 34.9

Tied outside the house

160 18.9 20 18.5 140 19.0

Cohabit with owner

72 8.5 16 14.8 56 7.6

Cage & free to roam sometimes 10 1.2 1 0.9 9 1.2

Pet has been vaccinated one year prior to survey

Yes 750 76.1 108 88.5 642 74.3 0.002No 229 23.2 13 10.7 216 25.0

Uncertain 7 0.7 1 0.8 6 0.7

Dog vaccination certificate was shown

Yes 355 48.1 63 58.9 292 46.3 0.016No 383 51.9 44 41.1 339 53.7

Table 5A: KAP odds ratios by pet ownership

Total % With pet % Without pet % OR 95% CI p

Knowledge

Knows that dog rabies vaccine could be obtained from authorized government offices

Yes 1376 90.6 827 92.9 549 87.3 1.91 1.35-2.71 0.000

No 143 9.4 63 7.1 80 12.7

Attitude

Would destroy pet if rabid

Yes 1013 71.1 643 73.2 370 67.8 1.34 1.05-1.72 0.020

No 411 28.9 235 26.8 176 32.2

In favor of the animal birth control (ABC) program

Yes 1324 85.5 785 87.5 539 82.8 1.43 1.06-1.93 0.018No/Undecided 224 14.5 112 12.5 112 17.2

Practice

Would seek treatment first if bitten by dogs

MD* 1490

95.3 860 94.7 630 96.2 0.71 0.43-1.16 0.446

TH‡ 73 4.7 48 5.3 25 3.8* - Doctor/hospital

‡ - Native/traditional healer/None/Uncertain

Table 5B: KAP adjusted odds ratios by pet ownership*

* - Adjusted odds ratios for urban or rural areas, gender, education, religion, ethnicity & pet ownership

† - Doctor/hospital

‡ - Native/traditional healer/None/Uncertain

Total % With pet % Without pet % OR* 95% CI p

Knowledge

Knows that dog rabies vaccine could be obtained from authorized government offices

Yes 1376 90.6 827 92.9 549 87.3 1.97 1.38-2.81 0.000

No 143 9.4 63 7.1 80 12.7

Attitude

Would destroy pet if rabid

Yes 1013 71.1 643 73.2 370 67.8 1.30 1.03-1.64 0.027

No 411 28.9 235 26.8 176 32.2

In favor of the animal birth control (ABC) program

Yes 1324 85.5 785 87.5 539 82.8 1.46 1.10-1.93 0.009No/Undecided 224 14.5 112 12.5 112 17.2

Practice

Would seek treatment first if bitten by dogs

MD† 1490

95.3 860 94.7 630 96.2 0.82 0.48-1.38 0.446

TH‡ 73 4.7 48 5.3 25 3.8

Discussion

There is a high level of awareness (source of rabies, its fatal nature, prevention by vaccination & where to obtain dog vaccines.)

High level of knowledge may be due to availability of information from various sources.

Rural respondents were more aware of the fatal nature of rabies probably because they are more receptive to government vaccination campaigns.

Discussion

Respondents seem to be cooperative to rabies control program due to their positive attitude toward pet registration, animal birth control, & destruction of rabid pets & stray animals.

Health practices are not consistent with knowledge & attitude. Few would report animal bite incidents, send animal specimen,

& poor pet care practices such as low vaccination rate & more dogs are allowed to roam freely.

Due to free health care from government hospitals, majority would seek medical care.

Study limitation

Non-random selection of respondents Topography & distribution of houses Weather condition Interviewers’ security

Conclusions

The level of awareness about rabies & the acceptability of control measures are high.

There is a significant difference in the attitudes and practices to rabies control between urban & rural areas.

Poor practices may reflect the inaccessibility to facilities & services that would enable community participation in rabies control.

To increase accessibility to rabies control facilities: Local authorities could facilitate the transfer

of specimens to laboratory. Decentralization or establishment of

satellite laboratories is another option.

Recommendations

Regular vaccination of animals is an acceptable measure. Increased access to vaccination sites especially in

remote areas & intensified oral vaccination for inaccessible animals would complement parenteral vaccination measures.

Rabies control program should give close attention to rural areas & non-pet owners who may perceive that animal bite is a remote possibility.

Recommendations

Rabies Control Unit in the University of Peradeniya

Zero grazing of human rabies in 2008

A6 mo

Advance preparation

I0-6 mo

A6 mo

Intensive vaccination

A6

mo

I0-6 mo

I6-12 mo

Intensive vaccination

M

I6-12 mo

I0-6 mo

Maintenance phaseMaintenance phase

M2-3 yr

I6-12 mo

M2-3 yr

Maintenance phase

M2-3 yr

M2-3 yr

M2-3 yr

Acknowledgment All respondents & local government officials of the 26 survey

areas Students & staff members of the University of Peradeniya Ethics Committees of Hokudai & the University of

Peradeniya Dr Rosanna A Ditangco Prof H Abeygunawardena Hokudai’s 21st Century COE Program Japan Health Sciences Foundation

Global Health Risk Management Network Project

Doomo arigatoo gozaimashita