Preliminary survey on knowledge , attitudes and practices regarding rabies

Introduction: The Ministry of Health’s goal is to reduce the number of human deaths from rabies to zero by 2020. Community awareness and responsible behaviour of pet owners are key factors to achieve this goal. Knowledge, attitude and practices (KAP) regarding rabies has been reported only from the Kandy district. We describe a preliminary survey among outpatients in Colombo, to supplement existing knowledge. Methods: A convenience sample (n = 200) was selected from 26 March to 8 April 2016, from outpatients of the National Hospital of Sri Lanka. Data was collected using a selfadministered questionnaire. Results: The majority were females (66.5%), Buddhist (80.5%) and from the Colombo District (58.5%). More than 75% of the subjects knew that dogs were the main reservoir of rabies, transmission was by biting, that washing the wound was important and that rabies could be prevented by vaccinating dogs and humans. However, only 22.5% were aware that rabies was fatal after development of disease. There was a lack of knowledge regarding other animal reservoirs, other modes of transmission and clinical features of rabid animals. Pet owners were more likely to have been bitten by a dog than those who did not own pets (p<0.05). However, only half of the respondents admitted that their pets had been vaccinated during the last year. Conclusion: Future health educational programs should highlight the risks of rabies transmission by animals other than dogs and methods of transmission other than bites as well as the clinical features of rabies for easy identification of rabid animals. The message that vaccination after developing the disease does not change the outcome needs to be clearly presented. Reasons for non compliance of dog vaccination needs to be investigated and rectified.


Introduction
Rabies is a fatal animal disease of significant public health importance globally. 1Although it is a vaccine preventable disease, it is responsible for tens of thousands of deaths annually, mostly in Asia and Africa. 1 Domestic and wild animals are reservoirs for rabies. 2 Exposures recorded in Sri Lanka are mainly from domestic or stray animals with very little exposure from wild animals. 2 Therefore, elimination of rabies in the domestic and stray animal population would lead to a marked decline in the number of cases in Sri Lanka.
The policy goal of the Ministry of Health, Sri Lanka is to reduce the number of human deaths from rabies to zero by 2020. 3 This appears feasible as only five cases of human rabies were recorded in the first half of 2016 compared with 24 in all of 2015. 3 In 2015, the Colombo district had the second highest recorded number of deaths (4 deaths) due to rabies. 4mmunity awareness of rabies and responsible behaviour of pet owners are key components for prevention.Studies on this subject have been conducted in the Kandy district in 2006. 5owever, these findings do not necessarily apply to other districts in the country.The current study was therefore designed to ascertain the knowledge, attitudes and practices of a sample population attending the outpatient department at the National Hospital of Sri Lanka (NHSL) in order to identify areas that need to be addressed through future health educational programs.

Methods
A preliminary survey was conducted from 26 th March to 8 th April 2016 among outpatients attending the NHSL.A pre-tested self-administered structured questionnaire was used to collect data from 200 respondents.Every fifth patient was selected to be part of the survey.Those over 12 years of age were recruited following informed written consent.For those who were illiterate, the questionnaire was read out and the responses given marked by the data collector.
The questionnaire was formulated in a similar structure to the previously reported survey in Kandy, to enable comparison. 5Chi square test or Fisher's exact test (2 tailed) was used as appropriate to evaluate statistical differences in responses between pet owners and non-pet owners and those who had been previously bitten.A p value <0.05 was considered as significant.

Results
Outpatient attendees resident in the Colombo district consisted of 58.5% of the sample.Ages ranged from 12-76 years (median age 36 years) and 66.5% were females.The majority were Buddhists (80.5%) and Sinhalese (88.5%).Fifty six percent were educated up to the GCE Ordinary Level.Sixty-four percent of our convenience sample were pet owners (Table 1 More than 75% of our convenience sample knew that dogs were the main animal reservoir, were aware that rabies was transmitted through bite wounds and that washing the bite wound was an important first aid measure (Table 2).They were also aware that rabies could be prevented by vaccination of dogs and post exposure vaccination of humans and that vaccines were available free of charge from government centres.The majority of study participants had gained this information from health care officials (Table 2).
Knowledge was lacking regarding other animals that could transmit rabies and modes of transmission other than bites (Table 2).Foaming was identified as a sign of rabies but knowledge of other signs, especially of the paralytic type was lacking in most participants (Table 2).Only 22.5% were aware that rabies could not be cured once humans develop the disease (Table 2).
There was no difference in gender, hometown or knowledge of rabies between those who had or had not previously experienced a dog bite (p > 0.05) except for two instances (Table 3).There was a higher level of awareness that cats could also be a reservoir of infection in those who had been previously bitten by dogs (p < 0.05).Most of those with no previous exposure to bites, correctly answered the question on prevention of dog rabies by vaccination (p<0.05).

Attitudes
Most considered rabies a major problem and stray dogs a nuisance (Table 4).The majority (94%) were willing to take post exposure treatment if bitten by an animal (Table 4).However, most people were not willing to kill their pets if suspected of having rabies (Table 4).A large group of participants (40.5%) had no knowledge of stray dog control (Table 4).A few (19%) suggested the use of dog pounds, killing of strays (17.5%), vaccination (14%) and sterilization of dogs (9%) as measures for controlling the stray dog population.On direct questioning, 78% were in favour of sterilization of dogs as a control measure (Table 4).

Practices
Most participants (97%) responded that they would seek treatment from a doctor or hospital after exposure and that they would go immediately following an exposure (Table 4).Most pet owners had dogs (Table 4) and pet owners were more likely to have been bitten by a dog than those who didn't have pets (p<0.05)(Table 5).Only half the respondents admitted that their pets had been vaccinated during the past year (Table 4).However, those who had been previously bitten were more likely to have had their pet dogs vaccinated during the previous year (p < 0.05) (Table 5).cured once symptoms developed and 30% were unsure of the outcome of human rabies.The previous study in Kandy 5 reported a high level of awareness of the fatal nature of rabies, but it is not clear how the question was phrased in that survey. 5In our questionnaire, we did not ask "Is rabies fatal?"Our question was phrased as "can you be cured after developing symptoms and signs of rabies".Future surveys should include questions to find out if respondents clearly understand the need for seeking treatment without delay and that the vaccine is for prevention and not as a cure.
Knowledge and attitudes of the use of post exposure vaccination was satisfactory in the current study.Vaccination and sterilization of dogs are key strategies to control rabies in the stray dog population.However, a small group of respondents (17.5%) still considered killing of dogs as a suitable strategy.People need to be made aware that more humane measures are equally effective and that responsible pet ownership is the most important factor.
Although many were aware that vaccination of dogs could prevent rabies, only half admitted that they had vaccinated their pet during the previous year.The survey done in Kandy showed a similar pattern. 5As shown in our study, pet owners are more likely to be bitten.The fact that pet owners are most likely to require post exposure vaccination needs to be conveyed to the public, in order to encourage people to vaccinate their pet animals.Reasons for non-compliance with dog vaccination need to be studied, and corrective measures should be taken in future mass dog vaccination campaigns.
More detailed questions on attitudes and practices regarding responsible pet ownership need to be included in future surveys.More information is needed on the reasons for dogs being allowed to roam freely on roads, willingness of owners to sterilize pets and what they would do with unwanted puppies.The media should be utilized to a greater extent for educating the public and making them aware about dog adoption agencies.

Ethical considerations
Approval was obtained from the Ethics Review Committee of the Faculty of Medicine, Kotelawala Defence University (EC-11-121).Administrative approval was obtained from all relevant authorities.

Table 3 (ct). Association between knowledge and previous exposure to dog bite
* Fisher's exact test † Rat rabies has not been reported in Sri Lanka.Therefore, those who said NO were taken as correct SLJID • www.http://sljol.info/index.php/SLJID• Vol. 7, No. 1, April 2017