Knowledge, Attitude And Practice Survey On Rabies In A Community In Sri Lanka

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 Matibag 6 February 2007

Rabbas: to do violence Painting of a rabid dog biting a man. Arabic (Mesopotamia). AD 1224

Girolamo Fracastoro, 1546

Louis Pasteur, 1885

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 Developed vaccines 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. Courtesy of Prof Ananda Jayasinghe

Global incidence of human rabies 2000-2005*

Bangladesh 1,550 cases (2003)

China 2,009 cases (2003) Myanmar 1,100 cases (2003)

Annual death toll 55,000 Cost burden $580M

Pakistan 2,490 cases (2000) Uganda 105 cases (2003) India 17,000 cases (2004)

Africa 24,000 $20M

44%

56%

Philippines 248 cases (2004)

Sri SriLanka Lanka † 55 55cases cases(2005) (2005)† Thailand Indonesia 109 cases (2004) 18 cases (2003)

Asia 31,000 $560M

* - WHO †

- Ministry of Health Sri Lanka

Important reservoirs of rabies in the world

BAT 、 RACCOON 、 SKUNK 、 COYOTE 、 FOX MONGOOSE

BAT DOG

FOX BAT DOG WOLF FOX

DOG

BAT MONGOOSE 、 DOG 、 FOX 、 JACKAL

BAT

LTCZ/DVS/NIID

Neglected diseases: Rabies’ health burden with intervention 10000 DALYs x 1000*

8000 5600

6000

4700

4000

2400

1940

1800

2000

1600

1000

700

600

200

pr os y Le

Ch ag as

gu e De n

ia sis yp an os om ia On si s ch oc er ci as is

om

Tr

Sc

hi s

to s

Ra bi es

m an ia sis

Le

ish

ti o ns in fe c

e at od

In t

es t

in al n

em

Ly

m

ph at ic

fil

ar ia si

s

0

* - Disability-adjusted life years

WHO, 2004

Neglected diseases: Rabies’ health burden without intervention 9600

10000 DALYs x 1000*

8000 6000

5600

4700

4000

2400

1800

2000

1600

1000

700

600

200

pr os y Le

Ch ag as

gu e De n

is yp an os om ia On si s ch oc er ci as is

om ia s

Tr

Sc

hi s

to s

Ra bi es

m an ia sis

Le

ish

ti o ns in fe c

e

In t

es t

in al n

Ly m

em at od

ph at ic

fil

ar ia si

s

0

* - Disability-adjusted life years

WHO, 2004

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







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, Geneva

Pathogenesis

100% fatality once symptoms manifest

Photo courtesy of Dr Elizabeth Miranda

LTCZ/DVS/NIID

Rabies in Japan 1897-2006* 10,000 Human rabies 1 Imported case from Nepal (1970)

1,000 No. of cases

Dog rabies

2 Imported cases from the Philippines (2006)

100

10

1 1890

1910

1930

1950

1970

1990

2010

* - Ministry of Health, Labour and Welfare

Tsunami 26 Dec 2004

Projects of Hokkaido University in Sri Lanka

HIV/AIDS KAP survey •College students •Educators

Rabies

Chronic renal disease

Etiological studies

National workshop for laboratory diagnosis of rabies

Rabies Control Unit

•Construction workers

KAP survey

HIV testing & counseling

Educational campaigns among school children

Japan Bank for International Cooperation

Health-seeking behavior survey Post-exposure prophylaxis study Development of models for intervention strategies Animal birth control & vaccination

Cost analysis of intervention

Partnership with WHO academe &NGOs government

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

Human rabies

300

Incidence

3

250 200

2

150 100

1

50

* - Ministry of Health Sri Lanka

2004

2000

1996

1992

1988

1984

1980

1976

1972

0 1968

0

Incidence per 100,000

4

350

1964

No. of human rabies

400

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

1200

No. of rabid animals

1000 800 600 Others

400

Cat 200

Dog

0 1995 1996 1997 1998 1999 2000 2001 2002 2003 * - 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（１９７３－２００ ４年）

National Rabies Control Program

900

Human rabies Dogs eliminated

300

600 200 300 100

* - Rabies Control Program, Ministry of Health Sri Lanka

2002

1999

1996

1993

1990

1987

1984

1981

0 1978

0 1975

No. of human rabies

Dogs vaccinated

No. of vaccinated & eliminated dogs x 1,000

400

Cost of rabies treatment in Sri Lanka* 

Annual expenditure by the Health Ministry Over

150 million rupees ($1.38 million)

 84%

- post-exposure prophylaxis  13% - 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://www.spur.asn.au/LTTE_Atrocities_Suic ide_Bomb_Attack_on_General_Sarath_Fonseka .htm http://news.bbc.co.uk/2/hi/in_pictures/4753509.stm

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*

0.98

1.02

0.94

90.50

89.20

91.00

9.78

12.28

15.04

90.22

87.82

84.96

Buddhism

73.14

86.29

76.70

Hinduism/Islam/Christianity

26.81

13.71

23.30

Sinhalese

74.03

87.55

82.00

Tamil

12.23

8.74

9.40

Moor/Burgher/Malay

13.61

3.72

8.40

4.30

4.54

4.90

Monthly income (SLRupees)

12672†

8429

12804†

Monthly income (JPYen)

14400

9560

14520

Male:female Literacy rate % Socio-economic sector % Urban Rural

Religion

Ethnicity

Household size

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

- Dept of Census and Statistics Sri Lanka, 2002

Table 2A: Knowledge of rabies Total

%

Urban

%

Rural

%

p 0.097

The main reservoir of rabies in Sri Lanka is Dog

1400

89.6

178

92.7

1222

89.1

Cat

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

No

219

14.1

43

22.5

176

12.9

Uncertain

112

7.2

11

5.8

101

7.4

0.002

Knows that rabies could be prevented by vaccination Yes

1364

88.1

166

87.8

1198

88.2

No

96

6.2

8

4.2

88

6.5

Uncertain

88

5.7

15

7.9

73

5.4

0.195

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

Yes

1376

90.6

170

90.9

1206

90.5

No

143

9.4

17

9.1

126

9.5

1.000

Table 2B: Knowledge of rabies Total

%

Urban

%

Rural

%

p

Multiple sources

934

60.7

137

72.1

797

59.1

0.000

Government 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

Sources of information

Table 3A: Health attitude and practice Total

%

Urban

%

Rural

%

p 0.017

Would seek treatment first if bitten by dogs 1490

95.5

191

99.5

1299

94.9

Native/traditional healer

59

3.8

1

0.5

58

4.2

None/Uncertain

12

0.8

0

0.0

12

0.9

Doctor/hospital

Would inform authorities if bitten by dog Yes

859

55.6

85

45.0

774

57.0

No

687

44.4

104

55.0

583

43.0

0.002

Table 3B: Health attitude and practice Total

%

Urban

%

Rural

%

p 0.102

Would destroy pet if rabid Yes

1013

71.1

129

76.8

884

70.4

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

No

849

57.0

73

39.9

776

59.4

0.000

Would send the head of the animal for laboratory confirmation Yes

825

58.0

113

68.9

712

56.6

No

598

42.0

51

31.1

547

43.4

* - Medical Research Institute

0.002

Table 3C: Health attitude and practice Total

%

Urban

%

Rural

%

p

85.3 5.9 8.9

140 10 14

85.4 6.1 8.5

1023 70 107

85.3 5.8 8.9

0.980

1161 137 61

85.4 10.1 4.5

0.710

Willing to register pets Yes No Undecided

1163 80 121

In favor of animal birth control (ABC) program Yes No Undecided

1324 153 71

85.5 9.9 4.6

163 16 10

86.2 8.5 5.3

Would want authorities to destroy stray dogs Yes No

1289 218

85.5 14.5

165 17

90.7 9.3

1124 201

84.8 15.2

0.042

0.001

Actions preferred to control stray dogs Animal birth control Animal disposal Combined birth control & disposal Others

893 318 72

63.6 22.7 5.1

97 50 18

54.5 28.1 10.1

796 268 54

65.0 21.9 4.4

120

8.6

13

7.3

107

8.7

Table 4: Pet care Total

%

Urban

%

Rural

%

p

322 281 160 72 10

38.1 33.3 18.9 8.5 1.2

47 24 20 16 1

43.5 22.2 18.5 14.8 0.9

275 257 140 56 9

37.3 34.9 19.0 7.6 1.2

0.023

Pet dogs are housed in Cage Dog is free to roam around

Tied outside the house

Cohabit with owner Cage & free to roam sometimes

Pet has been vaccinated one year prior to survey Yes No Uncertain

750 229 7

76.1 23.2 0.7

108 13 1

88.5 10.7 0.8

642 216 6

74.3 25.0 0.7

0.002

63 44

58.9 41.1

292 339

46.3 53.7

0.016

Dog vaccination certificate was shown Yes No

355 383

48.1 51.9

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

No

143

9.4

63

7.1

80

12.7

1.91

1.35-2.71

0.000

1.34

1.05-1.72

0.020

1.43

1.06-1.93

0.018

0.71

0.43-1.16

0.446

Attitude Would destroy pet if rabid Yes

1013

71.1

643

73.2

370

67.8

No

411

28.9

235

26.8

176

32.2

In favor of the animal birth control (ABC) program Yes No/Undecided

1324

85.5

785

87.5

539

82.8

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

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* 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

No

143

9.4

63

7.1

80

12.7

1.97

1.38-2.81

0.000

1.30

1.03-1.64

0.027

1.46

1.10-1.93

0.009

0.82

0.48-1.38

0.446

Attitude Would destroy pet if rabid Yes

1013

71.1

643

73.2

370

67.8

No

411

28.9

235

26.8

176

32.2

In favor of the animal birth control (ABC) program Yes No/Undecided

1324

85.5

785

87.5

539

82.8

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

TH‡

73

4.7

48

5.3

25

3.8

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

- Doctor/hospital

‡

- Native/traditional healer/None/Uncertain

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. 

Recommendations 

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.

Zero grazing of human rabies in 2008

I M A IM

6-12 mo 2-3 yr yr 62-3 mo 0-6 mo

A M M I

6 mo 2-3 2-3 6-12 0-6 yr yr mo mo

M II A

0-6 mo 6-12 2-3mo yr 6 mo

Intensive Maintenance vaccination phase Intensive vaccination Maintenance phase Advance preparation Rabies Control Unit in the University of Peradeniya

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