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
Developed
and thither, tears his flesh vaccines
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.
Courtesy of
Prof Ananda Jayasinghe
Global incidence of human rabies 2000-2005*

Bangladesh China
1,550 cases (2003) 2,009 cases (2003)

Myanmar
1,100 cases (2003)

Pakistan Philippines
Annual death 2,490 cases (2000) 248 cases (2004)
toll 55,000
Cost burden Uganda
$580M 105 cases (2003)
Sri
SriLanka
Lanka †
55
55cases
cases(2005)
(2005)†
India
17,000 cases (2004)
Africa 24,000
$20M Indonesia Thailand
109 cases (2004) 18 cases (2003)
44% 56% * - WHO
Asia 31,000
†
- Ministry of Health Sri Lanka
$560M
Important reservoirs of rabies in the world

FOX
BAT
BAT 、 RACCOON 、 SKUNK 、
COYOTE 、 FOX

DOG DOG
MONGOOSE WOLF
FOX

BAT
BAT
DOG
MONGOOSE 、 DOG 、 BAT
FOX 、 JACKAL

LTCZ/DVS/NIID
Neglected diseases:
Rabies’ health burden with intervention

10000

8000
DALYs x 1000*

5600
6000 4700

4000 2400 1940 1800 1600

2000 1000 700 600 200
0
s

sis

es

as
si s
sis

y
si

is
ns

os
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bi

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ia

ia

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pr
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Ra
ar

an

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om

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om

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ic

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In

* - Disability-adjusted life years WHO, 2004

Neglected diseases:
Rabies’ health burden without intervention

9600
10000

8000
DALYs x 1000*

5600
6000 4700
4000 2400
1800 1600
2000 1000 700 600 200
0
s

sis

es

as
si s

y
e
is
si

is
ns

gu

os
s
bi

ag
ia
ia

as
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an
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ci
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* - 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 Dog rabies

1,000 1 Imported case from Nepal

(1970)
No. of cases

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 Rabies Chronic renal

disease
KAP survey National workshop for laboratory Etiological studies
diagnosis of rabies
•College students
•Educators Rabies Control Unit
•Construction workers KAP survey
HIV testing & Educational campaigns among
counseling school children Japan Bank for International Cooperation

Health-seeking behavior survey

Post-exposure prophylaxis study
Partnership with
Development of models for intervention strategies &NGOs
WHO academe
government
Animal birth control & Cost analysis of
vaccination intervention
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

400 4
350 Human rabies

Incidence per 100,000

No. of human rabies

300 Incidence 3
250
200 2
150
100 1
50
0 0
1988

2004
1964

1968

1972

1976

1980

1984

1992

1996

2000
* - 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）

1200

1000
No. of rabid animals

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）

400 900
National Rabies Control Program Human rabies

No. of vaccinated & eliminated dogs x 1,000

Dogs vaccinated
Dogs eliminated
300
No. of human rabies

600

200

300
100

0 0
1978

1981

1984

1987

1990

1993

1996

1999

2002
1975

* - Rabies Control Program, Ministry of Health Sri Lanka

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
2001 Population
 Logistic regression
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 15.04
Rural 90.22 87.82 84.96
Religion
Buddhism 73.14 86.29 76.70
Hinduism/Islam/Christianity 26.81 13.71 23.30
Ethnicity
Sinhalese 74.03 87.55 82.00
Tamil 12.23 8.74 9.40
Moor/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 % Urban % Rural % p
The main reservoir of rabies in Sri Lanka is
Dog 1400 89.6 178 92.7 1222 89.1 0.097
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 0.002
No 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 0.195
No 96 6.2 8 4.2 88 6.5
Uncertain 88 5.7 15 7.9 73 5.4
Knows that dog rabies vaccines could be obtained from authorized government offices
Yes 1376 90.6 170 90.9 1206 90.5 1.000
No 143 9.4 17 9.1 126 9.5
Table 2B: Knowledge of rabies
Total % Urban % Rural % p
Sources of information
Multiple sources 934 60.7 137 72.1 797 59.1 0.000
Government rabies 237 15.4 10 5.3 227 16.8
vaccination campaign
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 % Urban % Rural % p

Would seek treatment first if bitten by dogs
Doctor/hospital 1490 95.5 191 99.5 1299 94.9 0.017
Native/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

Total % Urban % Rural % 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
* - Medical Research Institute
Table 3C: Health attitude and practice
Total % Urban % Rural % p
Willing to register pets
Yes 1163 85.3 140 85.4 1023 85.3 0.980
No 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 0.710
No 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 0.042
No 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 72 5.1 18 10.1 54 4.4
control & disposal
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 0.023
Dog 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 0.002
No 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 0.016
No 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 0.018
No/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*

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 0.009
No/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
* - 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

MI
IM
A
6-12
62-3
2-3
mo mo
yr
yr
0-6 mo

II
M
A
A
M
M
I 0-6
6-12 mo
2-3mo
6
yr
6 mo
2-3
2-3
6-12
0-6 mo
yr
mo
moyr

Intensive
Maintenance
Intensive
Advance vaccination
phase
vaccination
Maintenance phase
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