Key Findings
In rural areas, vaccination was not prioritized due to significant barriers such as distance and cost. It was often perceived as a luxury for wealthier families, although some recognized its benefits in preventing social and financial repercussions if a dog were to bite someone.
The study revealed a lack of knowledge on handling dog bites, with only 45% of victims opting to wash the wound and just 65% seeking medical care.
Social cohesion played a major role in decisions following a dog bite, as seen in the reluctance to confront the dog’s owner and the greater likelihood of killing a known dog that had bitten someone.
Summary
Rabies continues to pose a serious threat to public health in Madagascar. Despite the availability of free post-exposure prophylaxis (PEP) at 31 treatment centers nationwide, a significant number of cases likely go unreported due to factors such as limited awareness, inadequate surveillance, and difficulties in reaching health facilities. The country’s poor road infrastructure, particularly in remote areas, hinders access to these centers, contributing to a high mortality rate in remote areas. While efforts to vaccinate dogs have been made through occasional mass campaigns, low vaccination rates, especially in rural regions, due to logistical challenges impede their effectiveness.
Despite the increasing number of studies on knowledge, attitudes, and practices (KAP) towards rabies in Africa and other regions, research on this topic in Madagascar remains scarce and unpublished in scientific journals. Awareness campaigns in Madagascar have been infrequent and localized, with no national initiatives in the past decade. The human-dog relationship and perceptions of dogs also influence rabies-related practices and require further study. Understanding KAP towards rabies is crucial for designing effective awareness campaigns that address the specific needs and barriers in different communities. To this end, a study explored human-dog interactions, dog bite management, and care-seeking behaviors to identify the right target communities and messages to deliver during awareness campaigns.
Study Methods
The study, titled “Mixed methods to evaluate knowledge, attitudes, and practices (KAP) towards rabies in central and remote communities of Moramanga district, Madagascar,” was conducted in Moramanga district, a medium-sized provincial city in the middle-eastern part of Madagascar, with a population of 350,724 as of 2018. Moramanga was selected due to its endemic rabies situation, the presence of an anti-rabies treatment center (ARTC), and previous demographic data from the Moramanga Health Survey. The study aimed to assess KAP towards rabies in households located close to (<5 km) and further from (>15 km) the ARTC. It hypothesized that most people would travel by foot to the ARTC due to poverty and poor road conditions, and that even small distances would significantly impact KAP.
The research used a two-pronged approach. First, a quantitative survey was conducted to assess rabies knowledge and practices among households near and far from the ARTC. Second, a qualitative interview focused on individuals who were bitten by a dog or scratched by a cat and treated at the Moramanga ARTC in 2017, owners of biting dogs, biomedical managers at the ARTC, and local community authorities.
Survey Results
Dog Ownership
In the study, 15.6% of households owned dogs, with an average of 1.6 dogs per household, and a dog-to-human ratio of 1 dog for every 17.6 people. Vaccination rates were significantly lower in remote areas (2.4%) compared to central areas (62.5%). Key barriers to dog vaccination included the distance to veterinary services (41%), which was cited exclusively by rural respondents, lack of awareness that dogs could be vaccinated (15%), and the cost of vaccination (11%).
The qualitative survey revealed that many dog owners, particularly in remote areas, did not prioritize vaccination, often viewing their dogs as harmless and considering dog vaccination a low household budget priority. Vaccination was perceived as something primarily for wealthier families who are closely connected with their dogs. The interviews indicated that the main perceived benefit of rabies vaccination was avoiding social disruption and financial burdens if a dog were to bite someone, as social pressure would likely compel the owner to cover healthcare costs.
Even though vaccination coverage in urban Moramanga city improved due to a 2018 campaign by the non-governmental organization Mad Dog Initiative, it still remained below the 70% threshold necessary for effective rabies control. Given the barriers of distance and cost, the study underscores the need for free mass dog vaccination campaigns with extensive reach. These efforts should be paired with awareness campaigns to educate communities on the effectiveness and importance of dog vaccination.
Rabies Knowledge
Most respondents (91.9%) were aware of rabies, both in remote and central areas. While the majority knew that rabies is fatal and transmitted by animals, knowledge about specific animal carriers, such as cats (75.7%) and ruminants (29.4%), was lower. Most respondents were aware of transmission through bites, scratches, and licks on wounds, and recognized symptoms like aggressive behavior and drooling. However, misconceptions persisted, with many incorrectly believing that rabies could be transmitted through consuming meat or milk from a rabid animal.
A significant knowledge gap was identified regarding Anti-Rabies Treatment Centers (ARTCs). Only 14.7% of respondents knew about them, hindering the goal of eliminating rabies due to the lack of awareness about free Post-Exposure Prophylaxis (PEP).
Rabies knowledge scores, as calculated by the researchers, were higher among individuals with higher socioeconomic status, those living in central areas, those with prior rabies awareness, and former dog owners. Despite awareness campaigns, knowledge gaps persisted, with the qualitative survey finding that acquaintances were the primary source of information on how to respond to a bite. The study emphasized the importance of raising awareness about rabies transmission, the role of ARTCs, and correcting misconceptions to improve prevention and control efforts.
Bite Management Practice
Quantitative Survey
The quantitative survey revealed both how people handle bites and the actions taken by bite victims. Only 45.5% of respondents would wash a bite wound, and more people in central areas sought medical care than those in remote areas. Most relied on conventional medicine, with 87.7% preferring doctors or medical centers, though few (6.6%) sought PEP. Traditional treatments were less common, with some using oil on wounds.
For a bite from an unknown dog, 24.9% thought the dog should be killed. However, for a known dog, 48.8% would consider killing it. Only 5.7% would restrain and observe the dog. Central area respondents were more likely to call or consult a doctor than those in remote areas.
In this study, 42.5% of respondents knew someone bitten by an animal, but only 7.5% of households reported a member had been bitten in the last five years. Central areas had a higher bite incidence (0.53 per 100 person-years) than remote areas (0.22). The average age of bite victims was 22, with 13% being children under five. Most bites happened outside the home and were unprovoked.
After a bite, 65% of victims sought medical care, and 52% received PEP. Reasons for not seeking care included cost, minor wounds, work, and distance. Four victims had complications, and one died, likely due to not seeking medical care.
Analysis showed that living in a central area, having prior rabies awareness, and having a higher socioeconomic status were associated with better rabies prevention practices. However, dog ownership did not correlate with improved practices. Awareness campaigns need to emphasize immediate wound washing, seeking PEP, and the benefits of observing the dog post-bite. The population, including dog owners, should be aware that PEP is available and free at ARTCs. Increasing access to veterinarians and animal health services, especially in remote areas, could improve practices and surveillance.
Interviews of Bite Victims
Interviews with 28 bite victims, as part of the qualitative survey, revealed that most (19) were bitten by free-roaming dogs. Only 7 were bitten by guard dogs, and 2 by pet dogs. No bites were attributed to feral dogs, despite interviewees considering them the most threatening. Rabies was confirmed in the biting dog for 7 victims, including three bitten by another person’s dog and four by their own. Most rabies cases were suspected due to abnormal behavior or multiple bites. Rabies confirmation occurred only after victims sought vaccination at the ARTC, with post-mortem analysis on the dogs.
Regarding bite management, most respondents believed wounds should be washed with soap. If the dog was not perceived as rabid, applying hair oil or animal fat was deemed sufficient. Superficial bites were often disregarded. Many respondents (54%) thought the bite victim should contact the dog’s owner for vaccination and treatment cost support. Only later would the victim consult a health center, which would refer them to an ARTC. If bitten by a free-roaming or feral dog, victims were advised to seek medical care at a health center.
Social conflicts were a major concern. Bite victims often avoided confronting the owner to maintain community harmony. This cultural practice, “fihavanana,” emphasizes strong social links and moral obligations. It can slow down PEP delivery and reduce survival chances.
Despite common beliefs, biting dogs were rarely killed after a single bite, and confinement for rabies observation was infrequent. If the dog was known, the victim could more easily decide to kill it to maintain social cohesion. However, when the dog was unknown, victims often left the owners to take their responsibilities and decide what to do with the dog. This highlights the importance of social pressure in maintaining community relations and the weak attachment to dogs.
The decision to seek medical care was influenced by advice from family or community members, the dog owner’s willingness to cover costs, and whether the dog was suspected of having rabies. If rabies was suspected, victims sought medical care more quickly, often under family pressure.
Awareness campaigns should promote the practice of confinement for rabies observation, adapting it to the context. In poor or remote rural households, this might mean isolating the dog at home due to cost and limited access to veterinarians. Alongside awareness campaigns, increasing access to veterinarians and animal health workers would contribute to improved practices, surveillance, and overall animal health.
Miscellaneous
Data From Study:
Rabies / Knowledge, Attitude & Practices / Moramanga district, Madagascar
Year of Publication:
2024
External Link:
Leblanc C, Kassié D, Ranaivoharimina M, Rakotomanana EFN, Mangahasimbola RT, Randrianarijaona A, et al. (2024) Mixed methods to evaluate knowledge, attitudes and practices (KAP) towards rabies in central and remote communities of Moramanga district, Madagascar. PLoS Negl Trop Dis 18(3): e0012064.
https://doi.org/10.1371/journal.pntd.0012064