Knowledge and practices towards rabies and determinants of dog rabies vaccination in households: a cross sectional study in an area with high dog bite incidents in Kakamega County, Kenya, 2013

Introduction An estimated 55,000 people die from rabies annually. Factors promoting dog vaccination, estimates of vaccination coverage and knowledge on rabies are important for effective rabies control. We sought to establish these estimates at household (HH) level and whether rabies knowledge is associated with proper control practices. Methods Cross-sectional cluster survey with two-stage sampling was employed in Kakamega County to enroll HH members above 18 years. A set of questions related to rabies knowledge and practice were used to score participant response. Score above the sample mean was equated to adequate knowledge and proper practices respectively. Independent t-test was used to evaluate the differences of sample mean scores based on dog vaccination status. Bivariate analysis was used to associate knowledge to practices. Results Three hundred and ninety HHs enrolled and had a population of 754 dogs with 35% (n = 119) HH having vaccinated dogs within past 12 months. Overall mean score for knowledge was 7.0 (±2.8) with range (0-11) and 6.3 (±1.2) for practice with range (0-8). There was a statistically significant difference in mean knowledge (DF = 288, p < 0.01) and practice (DF = 283, p = 0.001) of HH with vaccinated dogs compared to ones with unvaccinated dogs. Participants with adequate rabies knowledge were more likely to have proper health seeking practices 139 (80%) (OR = 3.0, 95% CI = 1.4-6.8) and proper handling practices of suspected rabid dog 327 (88%) (OR = 5.4, 95% CI = 2.7-10.6). Conclusion Rabies vaccination below the 80% recommended for herd immunity. Mass vaccination campaign needed. More innovative ways of translating knowledge into proper rabies control practice are warranted.


Introduction
Rabies is acute viral encephalitis affecting mainly carnivores and insectivorous bats but can affect any mammal. Case fatality rate is nearly always 100% once clinical signs appear. Rabies has a worldwide distribution in continental regions of Africa, Asia and the Americas but a few countries (e.g. Japan, Australia, New Zealand and The British Isles) are free of the disease due to successful eradication programs or their island status and enforcement of rigorous quarantine regulations [1]. In Africa, high rabies risk countries include Zambia, Angola, Namibia, Mozambique and Zimbabwe among others [2]. Globally, more than 15 million people receive rabies post exposure prophylaxis treatment [3] with an estimated that 55,000 people dying from rabies annually [4]. Africa and Asia record the highest human rabies deaths worldwide with an estimated 24,500 annual human deaths [5].
The first case of rabies in Kenya was diagnosed in 1912 and it was not until 1982 that the annual number of cases diagnosed rose to 200 [6]. The department of Livestock Development in Kenya has listed rabies as a notifiable disease with the zoonotic disease unit and the integrated disease surveillance and response strategy listing it as a priority disease. Determinant factors for dog vaccination, estimates of vaccination coverage and knowledge of rabies in households are useful elements for determining herd immunity and building effective control strategies. These estimates are lacking in most countries recording high dog bite and rabies cases including Kenya. In countries where domestic animals are not vaccinated against rabies, dogs are a source of 99% of human rabies deaths [7]. Adequate dog vaccination campaigns have been successful in causing dog rabies decline in high-density urban and rural areas of Kenya and Tanzania [8]. Despite numerous government and private rabies vaccination campaigns, rabies remains endemic in some parts of Kenya due to inadequate coverage and high dog turnover rates.
Dog registration and vaccination against rabies is a legal requirement and compulsory especially for dogs kept in urban areas under the revised rabies act chapter 365 [9]. Therefore, evaluation of vaccination coverage is vital to assessing adequacy of the vaccination programs. Studies on Vaccination coverage, dog ecology and models on dog vaccination done in Machakos District predicted that for rabies control to be effective, 59% of the dog population has to be vaccinated at any one time. For an annual vaccination cycle, at least 70% of the dog population needs to be vaccinated but for a bi-annual cycle, coverage of 60% would be adequate [10]. Therefore, with this herd immunity, the stray dog population ceases to be a major concern. Studies carried out in Eastern and Southern Africa has shown that for effective rabies control, dog ecological/demographic data are vital. These include the dog population density, dog population structure (age and sex) and the population characteristics of dogs which are mainly dog movements, restriction and dependency [10]. Apart from the occasional government vaccination clinics, no major steps have been taken by the government to promote awareness, proper dog handling and appropriate health seeking behavior in the event of dog bites in the community [11]. Lack of baseline data on knowledge, attitudes and practices regarding rabies could possibly be one of the reasons for delayed action.The objective of this study was to determine the rabies vaccination coverage among dogs at the household level, and establish whether the level of knowledge on rabies disease influences dog vaccination practices in Kakamega County of Kenya.  [11].

Sample size
a minimum sample size of 384 households calculated using the Cochran formula of 1977 [12]. The sample size required was estimated assuming an expected prevalence of 50% to achieve maximum sample size, a 95% CI and desired accuracy of 5% [12].

Sampling scheme
A two-stage systematic random sampling method was done to recruit study participants.

Data collection method
A household (eating from the same pot) member above 18 years was interviewed using a structured questionnaire. For purposes of assessing and scoring participants knowledge on rabies, six questions were used and covered a description of rabies, its mode of transmission and the outcome of disease, the range of species affected and how it can be either prevented or controlled. The highest mark achievable for knowledge was eleven and all respondents who got a score of seven and above were classified as being knowledgeable while those who scored below seven were

Knowledge of rabies:
Study participants who knew of rabies as a disease were 351 (90%) and out of these, 191 (49%) correctly described rabies as a disease while 127 (33%) described rabies as a change in the behavior of dog/animal.

Determinant factors
Some of the factors that were significantly associated with vaccinated dogs in households on bivariate analysis are summarized in Table 2. On multivariate analysis, Factors that were independently and significantly associatedwith having a vaccinated dog at the household level are summarized in Table 3. They included having formal employment, knowledge of rabies as a disease including its fatal nature and knowledge of frequency of government sponsored vaccination clinics.

Discussion
The rabies vaccination coverage for this study was below the WHO recommended coverage of 80% required to achieve herd immunity.
There was a statistically significant difference in the mean  [17]. Households that reported their dog had at some point been implicated to have bitten someone were three times more likely to have a vaccinated dog probably due to awareness that post exposure prophylaxis is expensive after being charged for the victim's treatment.
Households that knew of a disease called rabies were three times more likely to have a vaccinated dog due to awareness of its fatal nature if left untreated. this was consistent with studies in Sri Lanka (89%) and New Delhi (84%) on the fatal nature of rabies [17,18].
The response on rabies knowledge is also consistent with the study by Sambo in Tanzania where 96% of respondents knew of rabies, the study by Kongkaew in Thailand where 93% of respondents knew of rabies and in Sri Lanka where 95% of respondents knew of rabies as a disease [12,15,17]. In this study, the respondents' source of knowledge on rabies was from family, friends, neighbors and colleagues which was consistent with the study done in Tanzania where 70% of respondents reported neighbors, parents and friends as their main source of rabies knowledge [15]. Only 56% and 29% in Pakistan and Sri Lanka respectively reported friends and neighbors as their source [16,17] with 36% of respondents in Thailand study reporting verbal propaganda as their source of knowledge on rabies [12]. Radio and TV had low response rates in this study compared to17% in Pakistan and 37% in Thailand [12,16]. This shows that the media (Radio and TV) which is more accessible to a wider population has not been well utilized as a source of dispersing knowledge and awareness of rabies.
Respondents who had a secondary/tertiary education were two times more likely to have a vaccinated dog in the household which isconsistent with a study done in Tanzania [15] and Pakistan [16] where respondents with secondary education were associated with having better knowledge of rabies. This is probably due to Page number not for citation purposes 6 awareness and access to information on rabies and the importance of dog vaccination.Respondents who were formally employed were three times more likely to have a vaccinated dog in the household.
Having a stable income might be contributing to the ability to pay for vaccination services.In terms of dog acquisition and ownership, the results are different from a study on dog ecology and demography done in Machakos District in Kenya where 56% of the owned dogs were acquired as gifts given by friends or neighbors and only 9% had been bought [13]. In this study, owned dogs that had been adopted from the stray population were 9% which was similar to that of a study done in Thailand where 11% of the owned dogs had been adopted from the strays [12]. Respondents who thought rabies was mainly transmitted through animal bites were two and a half times more likely to have a vaccinated dog. This is probably due to the awareness that if their dog was unvaccinated and ended up biting someone, they would have to pay for the victims treatment. These findings are consistent with study in Ethiopia where 73% reported animal bites as main mode of rabies transmission with the study in Tanzania having 81% of these report [14,15].
In terms of prevention, household respondents who thought annual vaccination of dogs, seeking medical attention immediately after dog bite incident, and that the treatment for dog bite was antirabies, were two times more likely to have a vaccinated dog.
Knowledge of rabies prevention could stem from having experienced a dog bite incident either in the household or neighbors. The finding is consistent with one in Tanzania where 67% of respondents reported vaccination of dogs as the major mode of rabies prevention with 88% reporting the same in Sri Lanka. However more respondents (83%) in Tanzania reported they would seek medical attention immediately after dog bite incident [15]. For this study, awareness of the WHO recommended first aid measure of washing the bite wound with soap and water was the lowest compared to respondents from Sri Lanka 8%, respondents from the New Delhi community based study 32% and respondents from Thailand 70% [12,17,18]. The high response on these preferred first aid measure recommended by the WHO is possibly due to the fact that the studies were done in regions that had received some awareness campaigns prior to the studies.
Respondents who said that they would report a rabid dog to the veterinary officerswere two times more likely to have a vaccinated dog. This was different from the study in Tanzania where only 7% would report rabid case to livestock officer. In this study, there was no difference in the description of rabies between the urban and rural populations. This was consistent with the study in Tanzania which also found no difference in the description of rabies between urban and rural populations.

Conclusion
Rabies vaccination is below the recommended 80% for achievement

Competing interests
The authors declare no competing interests.