One Health 9 (2020) 100126 Contents lists available at ScienceDirect One Health journal homepage: www.elsevier.com/locate/onehlt Knowledge and attitudes about rabies in dog-bite victims in Bangladesh T a,1 b c,d,⁎ Ahmed Nawsher Alam , Mahmuda Siddiqua , Jordi Casal a Institute of Public Health, Mohakhali, Dhaka 1212, Bangladesh b Ibn Sina Medical College, Kallyanpur, Dhaka 1215, Bangladesh c Departament de Sanitat i Anatomia Animals, Facultat de Veterinària, Universitat Autònoma de Barcelona, Bellaterra, Barcelona, Spain d IRTA, Centre de Recerca en Sanitat Animal (CReSA, IRTA-UAB), Bellaterra, Spain A R T I C LE I N FO A B S T R A C T Keywords: Rabies is an important zoonotic disease that causes several thousand deaths in Asian countries. Bangladesh Rabies launched an elimination programme in 2010 based on the mass vaccination of dogs, management of dog bites, Bangladesh application of post-exposure prophylaxis and communication and social mobilization. The aim of this study is to Dog bites ascertain the behaviour of and knowledge about dog-bite victims. Attitudes A cross-sectional descriptive study was performed on 885 dog-bite victims who presented themselves for post- Post-exposure prophylaxis 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. 1. Introduction Bangladesh is located in the Indian subcontinent, a hotspot for rabies, with an estimated canine population of 1.6 million (83% considered to Rabies is a zoonotic disease caused by a virus belonging to be free-roaming dogs). Annual incidence of humans bitten by dogs is Rhabdoviridae family and Lyssavirus Genus. Humans become infected greater than 300,000 [6]. Before the start of the program, more than after a bite or scratch from a rabid animal, usually a dog [1,2]. Rabies is 2000 people died annually from rabies. In 3 years, human death from almost always fatal once symptoms have started, but can easily be rabies decreased by 50%, with the number of reported rabies-related prevented with pre- and post-exposure prophylaxis. According to the deaths being 52 in 2016. World Health Organization [3], more than 15 million people worldwide The program is based on the mass vaccination of dogs, management receive a post-exposure prophylaxis (PEP) annually. Despite the vast of dog bites, increased availability of PEP, and communication and number of treatments, rabies is still the cause of about 59,000 deaths social mobilization [7]. This last point includes promoting awareness annually (95% Confidence Intervals: 25,000-159,000), 60% of these in and increasing people's knowledge about the transmission and pre- Asia [4]. In 2015, the WHO, the Food and Agriculture Organization vention of rabies. Knowing the circumstances in which dog bites have (FAO), the International Organization for Animal Health (OIE) and the occurred, as well as a clear understanding of people's level of knowl- Global Alliance for Rabies Control (GARC) launched a program to edge and of their beliefs is important for planning communication achieve “zero human deaths from dog-transmitted rabies by 2030” [5]. strategies aimed at increasing the awareness of rabies and what mea- Prior to this program, certain countries in South-East Asia had sures can be taken against it, particularly in rural areas [8]. begun rabies-elimination campaigns. Bangladesh launched an elimina- As in other countries, dog bites are common in Bangladesh; how- tion program in 2010 with the target of regional elimination by 2020. ever, there are misconceptions and false beliefs about such incidents ⁎ Corresponding author at: Departament de Sanitat i Anatomia Animals, Facultat de Veterinària, Universitat Autònoma de Barcelona, Bellaterra, Barcelona, Spain. E-mail address: Jordi.casal@uab.cat (J. Casal). 1 Current address: Institute of Epidemiology, Disease Control & Research. Mohakhal, Dhaka-1212, Bangladesh. https://doi.org/10.1016/j.onehlt.2020.100126 Received 30 October 2019; Received in revised form 6 March 2020; Accepted 8 March 2020 Available online 09 March 2020 2352-7714/ © 2020 The Authors. Published by Elsevier B.V. This is an open access article under the CC BY license (http://creativecommons.org/licenses/BY/4.0/). A.N. Alam, et al. One Health 9 (2020) 100126 Fig. 1. Geographic distribution of the seven districts in which data were collected. among the general population, and there is also a lack of awareness making a total of 7 sites (Fig. 1). about rabies. The aim of this study is to characterize dog-bite victims, to know ascertain their behavior and knowledge and to determine the 2.2. Data collection and analysis factors associated with a failure to complete full PEP. A cross-sectional descriptive study was performed based on ev- 2. Materials and methods eryone that went for an initial dose of rabies post-exposure vaccination to the seven selected vaccination centers between 31 March 2013 and 2.1. Study area 11 July 2013. All patients residing in the study areas were asked to complete a questionnaire; those that consented to be interviewed were Bangladesh is divided into 8 administrative divisions and 64 dis- then eligible, with a total of 885 cases finally being included in the tricts. For this study, three divisions (Dhaka, Sylhet, and Rajshahi) were study. A structured questionnaire with a small number of open ques- randomly selected, with two districts from each division (Narshingdi, tions was used. Interviewers were hired in each center and were trained Mymenshing, Sylhet, Habigonj, Sirajgonj and Rajshahi) then also being before start the study by the project team with respect to dog bites and randomly selected. Finally, a tertiary-level hospital (the Infectious rabies in people and animals. For children aged under 15, the corre- Disease Hospital, Dhaka city) was also included as a referral hospital, sponding parents or guardians were interviewed. 2 A.N. Alam, et al. One Health 9 (2020) 100126 Each individual was followed up until the whole PEP protocol was Table 2 completed. Those who did not attend the vaccination center for entire Characterization of circumstances of bite in 885 dog-bite victims. treatment protocol were interviewed by telephone or, if necessary, Number Proportion visited at home to obtain information on the discontinuation of vacci- nation. The questionnaire was pre-tested by the project team on sub- Ownership of the dogs Own (pet Dog) 72 8.1% Neighbour's Dog 181 20.5% jects who had attended a vaccination center for PEP before the start of Community Dog 245 27.7% the study. Stray Dog 291 32.9% Data were entered into an Epi Info database (Epi Info version −7) Unknown 96 10.8% and descriptive analyses (proportions and chi-square test) were per- Place At street 440 49.7% formed with this software. Multivariable analysis to evaluate the effect At home 361 40.8% At market 48 5.4% of the different variables on knowledge and attitudes was conducted At school 13 1.5% with Stata. Briefly, a bivariate chi-square test was performed between Others 23 2.6% these variables and the explanatory variables. All variables with a p- Activity when bitten Walking 629 71.1% value < .25 were selected and tested to detect co-linearity. For vari- Stepping over 95 10.7% Playing with 37 4.2% ables that presented strong co-linearity (p < .05), only the variable Feeding 22 2.5% with the stronger initial association was retained and included in the Provocating 9 1.0% logistic regression analysis. Using a backward selection, all variables Others 93 10.5% with a nonsignificant p-value biological association were sequentially Anatomic region Leg 705 79.7% deleted from the model. Hand 114 12.9% Body / neck 74 8.4% Head 6 0.7% 3. Results 3.1. Demographic characteristics of dog-bite victims education qualification (662, 75%), and only 41 (8%) finished sec- ondary education or had a higher-education degree. This study included 885 cases of dog-bite victims who attended a PEP vaccination center in the seven study areas. Table 1 shows the main 3.2. Epidemiology of dog bites characteristics of the affected subjects. Males (617 out of 885, 70%) were more common in the study population than females. Ages ranged All victims were bitten by dogs, usually free-roaming animals such from 1 year to 95 years with a median age of 20 years. Due to the high as community dogs (245, 27.7%) or stray dogs (291, 32.9%). Two proportion of young people (386–43.6%- were younger than 18 years); hundred fifty-three (29%) were bitten by their own dog (72 people) or the number of students is high (284, 32%). This was the most frequent by the neighbors' dog (181), and 96 (10.8%) did not know the own- occupation of the patients, followed by housewives (139, 16%) and pre- ership of the animal. The highest proportion of people were bitten school children (101, 11%). Most dog-bite victims had very few or no outside their home, most of them (440, 50%) in the street (Table 2). Most dog bites occurred without provocation (629, 71.1%); how- Table 1 Characterization of the 885 dog-bite victims attended to in the PEP vaccination ever, some cases were caused by accidentally stepping on a dog (95, centres. 10.7%) or by children irritating a dog (9 cases). Very few cases hap- pened when either feeding dogs or playing with them. Almost 80% of Variable Categories All population 18 years or older the bites (705 cases) were on the leg (Table 2), but this aspect shows Gender Males 617 (70%) 330 (66%) differences between ages: 65% of children under 10 years were bitten Females 268 (30%) 169 (34%) on the leg, while the proportion was 85% for older people (chi Age < 10 218 (25%) – squared = 40.1, p < .0001). 10–20 200 (23%) 37 (7%) Subjects were also asked about previous cases of dog bites in the 20–29 153 (17%) 153 (31%) 30–39 104 (12%) 104 (21%) family: 77 respondents (8.7%) informed that a relative had been bitten 40–49 88 (10%) 88 (18%) by a dog within the last 12 months, mainly by non-pet dogs (58), 50–59 76 (9%) 76 (15%) neighbors' dogs in 12 cases, with only 7 bitten by their own dog. Of > 60 46 (5%) 46 (9%) these bite victims, only 28 undertook treatment after the bite; 29 un- Occupation Student 284 (32%) 32 (6%) detook no treatment and the remaining 20 did not know whether House wife 139 (16%) 120 (24%) Pre school 101 (11%) – treatment had been undertaken. Farmer 88 (10%) 84 (17%) Business 70 (8%) 70 (14%) Service 57 (6%) 54 (11%) 3.3. Knowledge and attitudes about rabies Employee 30 (3%) 28 (6%) Beggar/ Do nothing 26 (3%) 15 (3%) Five hundred sixteen (58%) of the subjects interviewed were una- Other 76 (9%) 83 (17%) ware of the consequences of a dog bite. Only 219 (25%) were able to Unknown 14 (2%) 13 (3%) name the disease (176 termed it “hydrophobia”, 43 “rabies”); other Education No Education 267 (30%) 150 (30%) Primary school 395 (45%) 176 (35%) responses were less specific, indicating that bites can lead to madness Secondary school 145 (16%) 101 (20%) (48), death (44) or disease (23). According to a local belief, 35 re- High school 43 (5%) 41 (8%) spondents answered that they could become pregnant, and in some Graduate 28 (3%) 28 (6%) cases that such a pregnancy will produce a puppy (13 respondents). Other 7 (1%) 3 (1%) Type of house House /apartment 163 (18%) 92 (18%) Regarding their knowledge about the clinical signs of rabies in dogs, Tin shed 661 (75%) 371 (74%) 460 (52%) did not know any signs, 262 (30%) mentioned salivation, Hut 55 (6%) 32 (6%) 163 (18%) indicated aggressive behavior and 106 (12%) referred to Other 6 (1%) 4 (1%) restlessness (Table 3). Location Rural 545 (62%) 302 (61%) When asked directly about rabies, respondents showed slightly City 327 (37%) 190 (38%) Slumps 13 (1%) 7 (1%) better knowledge about the disease, with 467 (53%) knowing that the disease could be transmitted from dogs to humans. Most respondents 3 A.N. Alam, et al. One Health 9 (2020) 100126 Table 3 the treatment; 4 left the city; 3 said that their wound was not a real bite; Knowledge about rabies in the surveyed dog-bite victims. and 7 could not be traced. Failure to complete the full vaccination Knowledge about rabies Number Proportion protocol could not be related to level of education or any of the other studied variables. Name of the disease Hydrophobia 176 19.9% Rabies 43 4.9% Death 44 5.0% 4. Discussion Become mad 48 5.4% Become pregnant 35 4.0% Dog-bite injuries are an important health problem worldwide. In pregnant with a puppy 13 countries where rabies is endemic, in addition to the importance of the Disease 23 2.6% Do not know 516 58.3% bites themselves, they become still more important because they are the Clinical signs (dogs) Salivation 262 29.6% principal route of transmission of this disease. Aggressive 163 18.4% From 2013, between March and July, 883 people were surveyed Restless 106 12.0% when they attended seven vaccination centres in Bangladesh to receive Paralysed 31 3.5% the initial dose of rabies PEP. A high proportion of the patients (70%) Do not take food 21 2.4% Sleepy 10 1.1% were male. This is much higher than subjects described in Bhutan [9], Others 13 1.5% but is similar to the 72% obtained in two Indian studies [10,11] and Mad 7 0.8% slightly lower than in other Asian countries, such as the 78% and 79% Do not know 460 52.0% observed in Iran [12] and Pakistan [13], respectively. Most of the victims were children or young people under 20. These findings are highly similar to those described in several studies con- knew that rabies in humans can be prevented after a dog bite, but up to ducted both in developed [14,15] and developing [16,17] countries, 70% gave an incorrect answer to other questions regarding the pre- including previous studies from Bangladesh [18,19]. Increased dog-bite vention and treatment of rabies (Table 4). incidence in children is considered a behavioural risk because of chil- dren's curiosity, lack of understanding as regards dog behaviour and 3.4. Measures taken after a dog bite their inability to protect themselves from attack [20]. Almost three quarters (71.6%) of the dog bites occurred without any Most of the victims took no measures to treat the bite wound before previous provocation or interaction by the victim, as has been pre- coming to hospital for vaccination (279, 31.5%). 198 (22.4%) applied viously reported [20,21]. In most cases, victims were attacked by free- antiseptic; 192 (21.7%) applied plain water and 125 (14.1%) applied roaming dogs (71.3%). This is a consequence of the high number of soap and water. Application of indigenous products such as lime, soda, stray dogs in Bangladesh, as commonly observed in developing coun- salt and kerosene oil was also carried out by 129 patients (14.6%). tries [22,23]. In 601 cases (67.9%), no action was taken against the dog; in 214 As previously mentioned, dog bites represent a considerable pro- cases (24.2%) the animals could not be traced and in 42 cases (4.8%) blem in rabies-endemic countries. Rabies is a neglected disease re- the dogs were killed. Only 19 dogs (2.2%) were observed in order to sponsible for several thousands deaths annually, and has an important check for rabies. Most of the subjects surveyed (681, 77.0%) did not cost deriving from the 15 million people who receive a post-exposure know the vaccination status of the dog that had bitten them; 193 prophylaxis [3], particularly in developing countries. In 2015, the (21.8%) said that the dogs were not vaccinated and only 10 (1.1%) said Global Alliance for Rabies Control was launched to change this situa- that the dogs in question were vaccinated. tion, with the objective of eradicating rabies transmitted by terrestrial animals by 2030. One of the bases of Global Alliance program is the 3.5. Level of education: effect implementation of rabies-awareness campaigns adapted to the local situation of the countries in question, in order to motivate dog owners Level of education had an important effect on knowledge of and to vaccinate against rabies, to prevent dog bites and to administer first attitudes about rabies. A clear gradient can be observed, running from aid for bite victims, including wound washing and post-exposure rabies people without education through to graduates having a knowledge of injections [3]. the name and clinical signs of the disease, and those who cleaned the This program faces considerable challenges in countries where wound with soap and water (Table 5). people's level of knowledge about rabies and the role of dog bites in the virus transmission is low, as is the case of the subjects surveyed here: 3.6. Subjects who did not complete PEP correctly 58% of the patients interviewed in this study did not know the name of this disease, and only 25% could provide the term hydrophobia or ra- Fifty-eight people did not complete PEP correctly (6.4% of all bies. As regards the clinical signs of rabies in dogs, the most cited treatments: 10 people took only 1 dose, 23 took 2 and 20 took 3 but did symptoms were salivation, and aggressive or restless behaviour; half of not complete the entire treatment. The other 5 people completed the 4 the subjects in the study were unable to name any symptom of rabies. doses, but they did not follow the schedule. Of these 58 people, 25 These results are lower than two other studies carried out in thought they did not need the full protocol for protection; 2 changed to Bangladesh, where 64% and 73% of the people had heard about rabies “another treatment”; 7 were too busy; 6 said that they could not afford [24,25]. This difference may be due to a distinct formulation of the Table 4 Knowledge about rabies transmission, prevention and evolution of the disease in humans and dogs in the dog-bite victims. Questions related to knowledge about rabies Yes No Don't know Rabies can be transmitted from dogs to humans 467 (53%) 418 (47%) Rabies in dogs can be prevented 117 (13%) 90 (10%) 678 (77%) Rabies in dogs can be cure after they become sick 17 (2%) 238 (27%) 630 (71%) Rabies in humans can be prevented before dog bite 179 (20%) 89 (10%) 617 (70%) Rabies in humans can be prevented after dog bite 569 (64%) 65 (7%) 251 (28%) Rabies in humans can be cured after they get sick 72 (8%) 231 (26%) 575 (66%) 4 A.N. Alam, et al. One Health 9 (2020) 100126 Table 5 Effect of education on knowledge of and attitudes regarding rabies. Dependent variable Independent variables Beta SE Beta Odds ratio 95% IC Significance Know the name of the disease No Education 1 Primary 0.0352 0.2166 1.036 0.678–1.584 0.8709 SSC 1.3016 0.2384 3.675 2.303–5.864 > 0.0001 HSc 2.1032 0.3543 8.193 4.091–16.407 > 0.0001 Graduate 3.7984 0.6336 44.631 12.891–154.523 > 0.0001 Constant −1.6784 0.1681 > 0.0001 Know the clinical signs No Education 1 Primary 0.3408 0.222 1.406 0.910–2.173 0.1247 SSC 0.3841 0.2786 1.468 0.850–2.535 0.168 HSc 0.665 0.403 1.944 0.883–4.284 0.0989 Graduate 1.5712 0.4218 4.813 2.105–11.00 0.0002 Constant −1.8589 0.1792 > 0.0001 Clean with soap No Education 1 Primary 0.1082 0.2584 1.114 0.672–1.849 0.6754 SSC 0.8826 0.2868 2.417 1.378–4.240 0.0021 HSc 0.8557 0.4263 2.353 1.020–5.426 0.0447 Graduate 2.0428 0.4299 7.712 3.321–17.909 > 0.0001 Constant −2.1848 0.203 > 0.0001 Significances lower than .05 are underlined question, we can assume that most subjects probably know about ra- can be carried out immediately at home in order to remove the rabies bies, but do not relate it directly to dog bites). virus from the wound and to reduce the chance of being infected by The question on the name of the disease was responded to by 35 rabies from a rabid dog [3]. In this study, we found that only 14% of people as “becoming pregnant”. Of these, 13 further specified “preg- dog-bite victims used soap and water to wash the wound, which is nant with a puppy”. This reflects a strong cultural belief in rural areas of much lower than studies carried out in India (31.1%) and Bhutan (45%) Bengal, that people bitten by a dog may develop an asexual puppy [10,30]. pregnancy, and this includes males [26]. This is a further example of A small but significant proportion of the subjects surveyed (6.4%) the importance of education in reducing false beliefs about rabies. did not follow the protocol correctly. At all events, this proportion is far In contrast to other studies, only 52.8% of dog-bite victims knew lower than the 17% observed in Bhutan [9] or the 40% and 23% de- that rabies could be transmitted from dogs to humans, a proportion that scribed in India [31] for intramuscular and intradermal rabies vacci- is much lower than the 90% to 99% described for Sri Lanka, Pakistan, nation, respectively. The most cited explanation for non-completion of India and Bhutan [9,27–29]. Knowledge about prevention of rabies in treatment was the belief that the full vaccination course was not needed dogs as well as in humans was also low in the subjects included in this for protection. Other reasons given for non-completion indicate a lack study. Between 66% and 77% answered “don't know” to these ques- of knowledge about rabies and about the risk implied by such non- tions. The only exception to this was that 64% of dog-bite victims knew completion. Other authors [9,31] have also cited the difficulties ex- that rabies in humans can be prevented after a dog bite. Nevertheless, pressed by patients with regard to the vaccination itself (loss of wages, 7% answered indicated that, in their opinion, that this was not the case, forgotten appointments, interference with work obligations, etc.) and despite going to the centre for treatment. the lack of information from clinicians about the need for treatment A strong relationship was observed between knowledge about rabies follow-up. Patients' motivation through better communication and in- prevention and level of education; similar conclusions were obtained by formation is therefore crucial in increasing their completion of the full distinct authors [9,24,28]. This knowledge was also related to an urban course of vaccination. population and to people living in houses or apartments; but these A One Health approach should be applied to overcoming the lack of variables are strongly correlated with the level of education and, in our knowledge about rabies shown by Bangladeshi citizens. In addition to opinion, the true cause of lack of knowledge is actually education. reinforcing the application of vaccines and PEP, public awareness All these findings indicate that both general education and knowl- should also be increased. it is important to develop an intensive and edge about rabies was low among dog-bite victims, a fact that could coordinated plan comprising governmental departments and agencies hamper the national rabies-control program. that involves health, education and livestock, non-government organi- As children are an important proportion of the population who have zations, international institutions and academia to inform and educate been bitten, it is important to include education activities within the people about dog bites, about the risk of becoming infected from the school curriculum in order to provide information about dog behaviour rabies virus and most especially about the measures to adopt in order to and wound management, so as to reduce the risk of rabies in the young reduce risk, including the need to complete PEP treatment [32]. population [11,16]. At the same time, practical information on rabies There are certain limitations to our study; the most important is the prevention and control should be particularly addressed to people with representativeness of the population attending the district vaccination a low economic and cultural level. Additionally, health authorities and centre. We assume that they are different from the general population hospital personnel should be aware of the important role they play in and particularly from people bitten by dogs who did not attend a vac- educating about rabies prevention and control, and most especially the cination centre. We additionally assume that the knowledge and atti- influence they have in ensuring the completion of PEP treatment. tudes in this latter group, and perhaps also in the general population, is Another important constraint for rabies control is the high propor- lower than or—at the most—equal to the subjects in our study. tion of people bitten by free-roaming dogs, as well as the low number of Two other circumstance may have an influence on responses, the vaccinated dogs. A reduction in stray dogs and a significant reinforce- first being the low level of education of most of participants. This ment of vaccination would reduce rabies transmission among dogs and, plausibly plays a role in certain participants' lack of understanding consequently, lower the risk for people. particular questions and in providing the response “don't know” (which Cleaning the dog-bite wound with soap and water is an important may be true for them but which is also a ‘safe’ option). 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