A survey of Knowledge, Attitude and Practices of persons bitten by suspected rabid animals

Vida Fallahian (1) Ahmad Fayaz (3) Susan Simani (3) Ali Eslamifar (2) Hooman Fazlalizadeh (4) Mahboob Hazrati (1) Ebrahim Elmi (1) Akbar Zaheri (1) 1-Vida Fallahian MSc, Mahboob Hazrati MD, Ebrahim Elmi B.S, Akbar Zaheri B.S: Prevention and treatment of rabies center Department of vaccination. Pasteur Institute of Iran, Tehran 2-Ali Eslamifar MD Department of Clinical Reaserch. Pasteur Institute of Iran, Tehran 3-Ahmad Fayaz D.V.M., Susan Simani Ph.D: WHO Collaborating Center for Reference and Research on Rabies, Pasteur Institute of Iran, Tehran 4-Hooman Fazlalizadeh MD, General physician Correspondence: Vida Fallahia: MSc, Prevention and treatment of rabies center. Department of vaccination Pasteur Institute of Iran, Tehran, Tel: +982166465147, Fax: +982166409467, Email: vida.1333@yahoo.com

ABSTRACT Background: Rabies is associated with high case fatality rate and is reported in Iran, especially in the North, North-West, and North-East provinces. Objective: The survey was carried out to assess the general knowledge, attitudes, and practices (KAP) of subjects who had been bitten by a suspected rabid animal, about rabies, during 2007-2008. Methods: One-hundred and two subjects bitten by a suspected rabid animal and who were admitted to the Pasteur Institute of Iran, completed the questionnaire. Results: In assessing the knowledge, 64.7% of participants hadgood knowledge , 21.5% poor and 13.7% had very good knowledge about rabies. In assessing the attitudes toward rabies, most of the cases had a good attitude (74.5%) and 12.8% had a poor attitude and 12.7% had an acceptable attitude. For practices, 75 out of 102 subjects performed washing the bite site with soap and water, versus 25 (25.5%) subjects did not. Conclusion: General knowledge, attitudes, and practices of participants were adequate in this study. More public awareness about prevention and prompt post exposure treatment is needed. Keywords: Rabies, Knowledge, Attitudes, Practices, Assessment, Iran

INTRODUCTION

Rabies is an acute fatal infection. Rabies is a fatal neurological pathogen that is a persistent problem throughout the developing world where it is spread primarily by domestic dogs (1). Every year at least 55,000 people die from rabies and more than 7 million are treated for exposure to the virus (2). More than 99% of these deaths occur in the developing world where the disease is a much greater problem, chiefly because rabies is endemic in domestic dog populations (3). Rabies is a preventable zoonotic disease (4). The etiologic agents are neurotropic RNA viruses belonging to the Family Rhabdoviridae, Genus Lyssavirus (5).

In Iran, rabies has been reported in all provinces especially in North, North-West, and North-East of the country and has a significant role in economic loss and social disruption (6). According to a study in Tehran Province, the offending animals were dogs 65.9%, cats 25.44%, squirrels 3.89%, monkeys 1.52%, hamsters 1.41%, and other animals in 1.84% of cases. Bites were most frequent among the 20 - 29 years old age group (30.1%), followed by >40 (26.9%), 10 - 19 (19.9%), and 30 - 39 years (14.7%). Those aged <9 years had the least frequency of animal bite (8.4%) (7).

The objective of this survey is assessing the general knowledge, attitudes, and practices about rabies by the people who has been exposed directly to a suspected rabid animal.

PATIENTS AND METHODS
This survey has been carried out on 102 persons who had been bitten by a suspected rabid animal and admitted to the Institute Pasteur of Iran during 2007-2008. We prepared a questionnaire for each participant who agreed to complete it and on the first part included the demographic information and past previews of their rabies exposure and also questioned about having home pets. On the second part, there were questions assessing the general knowledge and rabies prevention, - is rabies treatable, about the nature of rabies, and duration of immunity. On the third part the questions were targeted to determine the attitudes towards rabies by asking participants do they recognize rabies signs and symptoms in rabid animals and humans. On the last part, practices regarding rabies were evaluated and questioned about wound suture, referring to rabies care center after exposure, cleaning the wound and how they were admitted after exposure to the institute and whether they were able to guide others about prevention and treatment of rabies.

Statistical analysis
One score to correct answers and no score to incorrect answers was designated. Proportions were compared by chi-square tests, and differences were regarded to be significant at P value <0.05. For data analysis, the Statistical Package for Social Sciences, version 16 (SPSS Inc) was applied.

RESULTS

Table 1: The knowledge of participants about rabies in the studied population

Table 2: The attitude of participants about rabies in the studied population

Of 102 participants, 36 cases were female and 66 cases were male (35% female, 65% male). The mean age of participants was 31.4 years with a minimum of 12 and a maximum of 76 years of age, and most of the cases were between 20 to 30 years of age. 81% of participants had no previous bite compared to 18% with such an experience, while only 10% of the patients had a history of previous rabies vaccination and Rabies immune globulin (RIG). 31% of participants had home pets. Suspected rabid animal of exposure in the studied population were: dog 48 (47.1%), cat 42 (41.2%), hamsters 5 (4.9%), squirrel 2 (2%), horse 1(1%), monkey 1 (1%). In 3 (2.9%) of cases the suspected rabid animal was unknown.

In assessment of knowledge: 91.2% of participants believed that rabies is a preventable disease and 52.9% thought rabies is treatable. 65.7% of participants had a correct answer about the golden time for prevention after exposure. 33.3% of participants had no idea that rabies is a virus, and 88.2% had no idea or a wrong idea about the duration of immunity caused by rabies vaccine. 13.7% of subjects had very good, 64.7% good, and 21.5% had poor general knowledge. Table 1 shows the knowledge of participants about rabies in the studied population.
In assessment of attitudes toward rabies: 36.3% of participants were wrong about suturing the wound, and 70.6% had enough information about signs of rabies in a rabid animal. 75.5% of participants had no idea about rabies signs and symptoms in humans and 90.2% said they should be referred to a rabies care center. Most of the cases had a good attitude (74.5%), 12.8% had a poor attitude and 12.7% had an acceptable attitude. Table 2 shows the attitude of participants about rabies, in the studied population.

In assessing the practices, 75 of 102 (76.5%) subjects performed washing the bite site with soap and water, versus 25 (25.5%) subjects who did not. Forty-two subjects (42.8%) were referred to Pasteur institute by health care personnel, 28 cases (28.5%) were aware of visiting by themselves, and the rest by their friends and families.

All subjects except 7 (7.1%), believed data regarding necessity of serum and vaccine registration by personnel of Pasteur institute was sufficient. All cases except 6 (6.1%), believed after training by personnel of Pasteur institute, they found the capability to recommend others about rabies post exposure treatment.
By chi-square test, association between the history of previous bite and knowing rabies signs in animal was significant (P value: 0.45). Also association between previous bite and practice of transfer of pet home for visit was significant (P value: 0.028).

DISCUSSION
Rabies is endemic in Iran. It is the most important zoonotic disease in the country. Based on studies undertaken during the past few decades, there is evidence that the main reservoir for rabies is wolves. The incidence of rabies in humans and animals is increasing each year. In 2006, more than 130,000 people received post-exposure prophylaxis. Similar figures apply regarding preventive vaccination in animals. Official data suggests that the majority of human exposures are due to biting episodes caused by dogs. However, investigations performed by this team showed that in many cases wolves were responsible for rabies transmission to humans (8). According to the present study, dogs were the most suspected rabid animal that exposed the studied subjects to rabies post-exposure treatment. Domestic dogs are the principal reservoir of rabies throughout most of Africa and Asia (9). Dogs and cats still are our most exposed animal subjects at risk of rabies and concern must be focused on collecting or vaccinating these animals.

In assessing knowledge, attitudes, and practices about animal bites and rabies in the general community, in a study of 1129 persons in India, only 360 (31.9%) of people felt that washing the wound with soap and water was the best option. Application of indigenous products like chillies (11.4%), turmeric (5.6%), lime (6.8%), kerosene oil (2.3%), herbal paste (4.2%) was suggested along with a visit to an occult medicine practitioner (1.5%) as part of the bite wound management. People were not aware of the number of injections needed for treatment of animal bites (10). Every year, millions of people travel to countries where rabies is enzootic. In a study of 496 German physicians and pharmacists who completed the questionnaire for evaluating the quality of rabies-specific information provided by travel health advisors and the extent of their knowledge about pre and post exposure prophylaxis, almost all respondents indicated that they would mention the risk of rabies and appropriate preventive measures to long-term travelers and tourists planning to visit rural areas (11). With the establishment of rabies as a disease that is endemic among wildlife species in North Carolina, educational efforts directed at a subpopulation of residents potentially at high risk of rabies virus infection would have public health benefits (12). In a cross-sectional study of a rural community, the dog bite rate was 25.7/1000 population per year. The rate for males was higher than for females; half of the bites were in summer; 40% did not go for any prophylaxis. Most knew that injections were available to prevent rabies. Only half said they would visit a hospital for treatment (13).

As other studies in Iran the most common range of age affected by the rabid animal was 20-29 years as in the present study. In our study, knowledge, attitude and practices were good. However, many of the subjects were living in Tehran where referring is much easier there. Nearly half of them (42%) were referred by health care personnel who may have been informed somehow by health providers before post-exposure treatment. Both media and training at schools has important roles to educate the people in our country.

More than 29,000 human deaths were reported in 2006 in Far East Asia, representing more than 50% of all human rabies cases around the globe. Although there are many factors that contribute to the epidemic or endemic nature of rabies in these countries, the single most important factor is the failure to immunize domestic dogs, which transmit rabies to humans. Dog vaccination is at or below 5% in many of these countries, and cannot stop the transmission of rabies from dogs to dogs, thus to humans. It is thus most important for these countries to initiate mass vaccination campaigns in dog populations in order to stop the occurrence of human rabies in Far East Asia (14). The development of integrated control measures involving public health, veterinary, wildlife conservation and animal welfare agencies is needed to ensure that control of canine diseases becomes a reality in Africa and Asia (9).

CONCLUSION
Despite adequate general knowledge, attitudes, and practices of participants in this study, more awareness about prevention and prompt post exposure treatment is needed. Regarding number of bitten cases, there was not any case of rabies after receiving post exposure treatment in our center. Rabies prevention education especially in rural areas may decrease the financial burden of vaccines and consequences of infection.

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