Key Findings
Although static point (SP) vaccination campaigns are less expensive to conduct, they are less likely to achieve the 70% vaccination coverage necessary to prevent a rabies outbreak due to various barriers.
Seventy-five percent of SP campaign attendees walked up to 1.5 km, with those from impoverished areas showing a greater willingness to participate. However, participation rates decrease more sharply for this group as the distance increases.
Young puppies, lactating females, and dogs that are difficult to handle were less likely to be brought to SPs, highlighting the need for increased education to dispel misconceptions and provide guidance on dog handling.
Summary
Mass dog vaccination campaigns are the most effective strategy to eliminate rabies in humans and dogs, requiring at least 70% vaccination coverage to prevent outbreaks, as recommended by the World Health Organization.
Yet, achieving over 70% coverage is challenging, particularly in Sub-Saharan Africa, where no country is rabies-free despite healthcare interventions. Strategies include door-to-door (D2D) and static point (SP) campaigns. D2D campaigns secure high coverage but are labor-intensive and costly, while SP campaigns are more feasible but often fail to reach necessary coverage levels. Most Sub-Saharan Africa programs use SP campaigns, which can vaccinate more dogs with the same budget but typically achieve lower coverage in each area.
Improving SP attendance could eliminate the trade-off between coverage and numbers vaccinated. Understanding and overcoming barriers to SP attendance is crucial for the success of rabies elimination programs, allowing for high vaccination coverage without resorting to expensive D2D campaigns. Previous studies pointed to common reasons for low attendance by dog owners, including a lack of information about the campaign, difficulty handling dogs, dogs being too young or lactating, and financial barriers.
Understanding these barriers is critical in Blantyre, Malawi, where rabies significantly impacts child mortality. As such, this study aimed to explore barriers to SP attendance using a multi-faceted approach, including modeling the relationship between travel distance and attendance as well as dog owner questionnaires. It represents the first large-scale, city-wide investigation into why people do not attend SPs in Sub-Saharan Africa.
The study was conducted in Blantyre, the second-largest city in Malawi, with a human population of 881,074 and an estimated dog population of 45,526 in 2015. An annual mass dog vaccination campaign occurred across the entire city from April 30 to May 25, 2016, using two approaches: static point (SP) and door-to-door (D2D). Only 53% of the overall 79% vaccination coverage was achieved through SPs, with the rest via D2D vaccination.
During the D2D campaign, data were collected on every dog encountered. Relevant data included the dog’s age, sex, pregnancy and lactation status, confinement level, GPS location, vaccination status, and reasons for not attending SP clinics.
Key Barriers Identified
Distance Matters
The study found that the distance from households to SPs significantly affected attendance. The regression model indicated that for every kilometer closer a household was to an SP, the odds of taking a dog for vaccination increased by 3.3 times. Distance was also a primary reason cited by owners (17%) for not attending SPs.
To improve future vaccination campaign planning, the study estimated how far people were willing to walk to an SP in both straight-line and path-based distances. Data showed that people were willing to walk an average of 1.22 km to an SP, with 75% walking up to 1.5 km. The mean straight-line distance was 0.812 km. The researchers highlighted the differences between straight-line and path distances, noting that while straight-line distance is easier to estimate for mass campaigns, path distance is more accurate for estimating travel costs. On average, the path distance was 50% greater than the straight-line distance in this context.
Socioeconomic Barriers
The study found that socio-economic status affects attendance at static point (SP) vaccinations. Dogs from areas with higher poverty levels were more likely to be brought for vaccination. The study also revealed that the impact of distance on attendance was more pronounced in impoverished areas, indicating a greater drop in attendance with increasing distance in these regions. In Blantyre, dogs are often brought to SPs by younger family members, and middle- and high-income parents may be less inclined to send their children alone or spend time waiting in line for dog vaccinations.
Pups, Lactating Females & Difficult To Handle Dogs
The likelihood of attending a static point (SP) vaccination was also influenced by the characteristics of the dogs. Young dogs and pregnant or lactating females were less likely to be brought to SPs. Puppies under three months are often excluded from vaccination campaigns due to misconceptions about their ability to mount an immune response or because it requires off-label vaccine use. Since puppies make up to 30% of the dog population in Sub-Saharan Africa, they are crucial for maintaining vaccination coverage above the 70% threshold. Misconceptions need to be addressed through better advertising and education to ensure all dogs are brought to SPs for vaccination.
The study also found a relationship between dog confinement levels and attendance at static point (SP) vaccinations. Dogs that never roamed were less likely to be taken to an SP compared to those that always roamed, possibly due to owners believing confined dogs are not at risk of rabies. However, dogs kept on a leash or in gardens can still be exposed to rabies. Dogs that roamed daily but were restrained part-time had higher odds of being taken to an SP compared to dogs that roamed constantly. This may indicate that owners who interact more with their dogs are more likely to seek healthcare for them or are better able to handle them for SP visits. It should be noted that 19% of owners cited difficulty in handling their dogs as the reason for not bringing them to SPs. To improve SP coverage, promotional campaigns and rabies education should include year-round guidance on safely handling and walking dogs.
Lack Of Awareness
Lastly, the study found that a lack of awareness of the vaccination program was a significant issue, despite extensive local advertising efforts through posters, local radio, and loudspeakers. The most common reason for not attending a static point vaccination was a lack of awareness, cited by 27% of owners, especially those further from SPs. This aligns with findings from other developing countries like Chad, Mali, Tanzania, and Peru. Improving information dissemination about SP locations and schedules could enhance participation and be cost-effective for future campaigns.
Miscellaneous
Data From Study:
Rabies: Vaccination Campaign / Barriers / Blantyre, Malawi, 2015 Campaign Barriers
Year of Publication:
2018
External Link:
Mazeri S, Gibson AD, Meunier N, Bronsvoort BM, Handel IG, Mellanby RJ, et al. (2018) Barriers of attendance to dog rabies static point vaccination clinics in Blantyre, Malawi. PLoS Negl Trop Dis 12(1): e0006159. https://doi.org/10.1371/journal.pntd.0006159