Journal of Infection and Public Health (2012) 5, 374—380

Community perception regarding rabiesprevention and stray dog control inurban slums in India

Mrudu Herbert ∗, Riyaz Basha S, Selvi Thangaraj

Department of Community Medicine, Bangalore Medical College and Research Institute, Fort Road,Bangalore, Karnataka 560002, India

Received 6 February 2012; received in revised form 30 March 2012; accepted 25 May 2012

KEYWORDSRabies;First aid;Stray dog;Animal control

SummaryBackground: The lack of community awareness about rabies control is a major issuethat thwarts efforts to prevent human deaths caused by rabies.

The objectives of this study were (1) to assess community knowledge and attitudesabout rabies, rabies prevention and stray dog control in an urban slum communityand (2) to determine the factors that influence rabies awareness in urban slums.Methodology: Using a systematic random sampling strategy, 185 participants wereselected from 8 urban slums. The data were collected by direct interview using apre-tested, structured questionnaire.Results: In the study population, 74.1% of the participants had heard about rabies,and 54.1% knew that rabies is a fatal disease. Only 33.5% of the interviewees feltthat people in the community had a role to play in controlling the stray dog popu-lation. Gender, age and educational status were significantly associated with rabiesawareness.Conclusions: Our study indicates that there are gaps in the knowledge and attitudes

of individuals living in urban slums regarding rabies prevention and control. Effortsto promote awareness should be targeted at men, older people and uneducatedindividuals.© 2012 King Saud Bin Abdulaziz University for Health Sciences. Published by ElsevierLtd. All rights reserved.

∗ Corresponding author. Tel.: +91 0966 330 4861.E-mail addresses: mrudu.h@gmail.com (M. Herbert),

drriyaz@gmail.com (R. Basha S), selangel 2006@yahoo.co.in(S. Thangaraj).

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1876-0341/$ — see front matter © 2012 King Saud Bin Abdulaziz University for Health

http://dx.doi.org/10.1016/j.jiph.2012.05.002

ntroduction

abies is a zoonotic disease that is almost alwaysatal. Globally, 55,000 people die from rabies eachear [1]. The majority of these deaths occur insia and Africa, with the South-East Asian Region

Sciences. Published by Elsevier Ltd. All rights reserved.

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SEAR) accounting for 60% of global rabies deaths2]. India is one of the SEAR countries in whichabies is endemic. A WHO-sponsored multi-centertudy estimated that at least 20,000 rabies deathsccur every year in India [3]. Dogs are responsibleor 99% of human rabies deaths. Children are par-icularly susceptible to exposure to rabid dogs [4];0% of individuals bitten by suspected rabid animalsre children under 15 years of age [1].

While human rabies is largely controlled in devel-ped countries, primarily due to the successfulontrol of animal rabies, developing countries withcarce resources are still battling this scourge [5].s a result, the WHO has classified rabies as aeglected tropical disease because the major bur-en of the disease is borne by Asia and Africa. Its a matter of global concern that rabies remains aeglected disease 125 years after the discovery ofhe rabies vaccine by Louis Pasteur [6]. The reasonsor this neglect lie at various levels. Insufficienturveillance systems, limited access to and supplyf the modern rabies vaccine, lack of awarenessmong policymakers and the public and insufficientolitical commitment all impede efforts to controlabies [7].

The availability of safe and effective vaccines foruman rabies has prevented many human deaths.ögel and Meslin state that the most cost-effectivepproach for human rabies control is a combina-ion of post-exposure prophylaxis and canine rabieslimination [8]. The WHO has stated that pre-enting human rabies by controlling rabies amongomestic dogs is a realistic goal for large partsf Africa and Asia and is financially justified byhe future savings resulting from discontinuation ofost-exposure prophylaxis for residents [1].

There are three practical methods of dog popu-ation management: movement restriction, habitatontrol and reproduction control [9]. In Asia, animalirth control (ABC) programs and rabies vaccina-ion have been advocated as methods to controlale and female urban street dog populations

nd, ultimately, human rabies. Animal rabies con-rol interventions in Sri Lanka and Thailand haveemonstrated considerable success in controllinguman rabies in an area in which canine rabies isndemic [10,11].

The dog population in India is estimated atpproximately 25 million [12]. In India, initialttempts to control rabies have included programso exterminate the stray dog population. However,his method has proven ineffective because stray

og population is so large that new packs of dogsuickly moved into the areas in which dogs hadreviously been eliminated. Thus, a combination ofBC and mass vaccination that covers at least 70% of

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he dog population in a short period of time shoulde utilized as the primary method to control rabiesn dogs [13].

The lack of community awareness about theisease is a major hurdle in fighting rabies [14].ommunity participation is one of the major com-onents of any successful public health program.ommunity-based surveillance systems have beenuccessful and cost-effective for rabies control inther areas [15,16]. Awareness of simple preventiveeasures, such as washing bite wounds with soap

nd water, can be a decisive factor in preventingabies deaths in at-risk human populations.

Slum communities have a unique convergence ofisk factors for human rabies. First, they attract

large number of stray dogs because of thenplanned dumping of garbage. Additionally, therere often many unsupervised children in slums,hich creates a potentially dangerous scenario, ashildren are more likely than adults to be victimsf dog bites. In this environment, the knowledgend attitudes of the community are crucial factorsn averting the morbidity and mortality caused byuman rabies.

Community participation in rabies control effortsan be multi-faceted. Community members canelp participate in rabies control programs, enactocal by-laws, enforce anti-rabies laws and plannd publicize and implement dog vaccination cam-aigns, dog registration and stray dog control.ndividuals in the community can also report rabiesases and ensure that dog bite victims receive firstid and treatment. Educating the public about thepidemiological features of rabies, as well as sim-le preventive and precautionary measures, mayelp protect them and reduce the incidence ofabies.

Previously available data from Indian studiesere primarily collected from patients seekingost-exposure treatment for animal bites in hos-ital settings. These studies may present biasedesults about community attitudes and knowledgehat fail to reflect those of the broader population.hus, this study was conducted to ascertain thenowledge and attitudes about rabies preventionnd control in a selected urban slum community.

aterials and methods

tudy design

his descriptive cross-sectional study was carriedut from July 2010 to October 2010 in Bangalore, arominent south Indian city and the capital of the

M. Herbert et al.

Table 1 Socio-demographic characteristics of thestudy population.

Variable FrequencyN = 185

Percentage

GenderMale 86 46.5Female 99 53.5ReligionHindu 161 87.0Muslim 20 10.8Christian 4 2.2Type of familyNuclear 98 53Jointa 87 47Educational levelIlliterate 24 18.4Primary or middle school 84 38.4High school or higher 77 43.2Average per capita income in household (in Rupees)675—2024 24 13.02025—3374 26 14.13375—5049 44 23.85050—6749 8 4.36750—13,499 54 29.2>13,500 29 15.6

a Joint family in India is one in which a number of married

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state of Karnataka, India. The population of Ban-galore is well over 6 million, according to the 2011Census conducted by the government of India. Esti-mates suggest that one in every three people inBangalore lives in slums in the city, often in sub-human conditions [17]. This study was conductedin urban slums near the H. Siddiah Road ReferralHospital in Bangalore, which is in the practice areacovered by Bangalore Medical College and ResearchInstitute There are eight slums in this area, com-prising a total of 5540 houses and a population of38,426.

Sample size and sampling technique

The sample size was determined using the followingformula: n = Z2pq/d2 (where Z = the normal varia-tion estimated at 4, p = prevalence of awarenessabout rabies, estimated at 68.7% using the datafrom a previous study, q = 1 − p and d = 10% of p,6.87) [18]. The total sample size was 182, with a 5%level of significance and 95% confidence limits. Thesample size was rounded up to 185. The householdincluded in the study was selected by systematicsampling with a sampling interval of 30. One adultmember from each household was selected ran-domly using the KISH method [19]. If the residentsof the selected house were unavailable at the timeof the first visit, the house was re-visited two addi-tional times. If the residents were still unavailableafter the third visit, the next house was visited asan alternative.

Data collection

One adult member of each household was selectedand interviewed to collect the data. A pre-tested structured questionnaire that had beenvalidated in a pilot study was used to collect theinformation. The study variables included the fol-lowing: the socio-demographic characteristics ofthe respondents; awareness about rabies (includingits transmission and symptoms), first aid measuresused to treat animal bites and the anti-rabies vac-cine; and attitudes toward stray dog control.

Statistical analysis

The data were analyzed using Epi Info, version 3.5.1(CDC, Atlanta, Georgia, USA). The means, percent-ages and standard deviations were calculated todescribe the profiles of the respondents. Chi-square

tests or Fisher’s exact tests were used, as appropri-ate, to evaluate the statistical significance of thedifferences between the responses of the partici-pants. Logistic regression models were used, with

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couples and their children live together in the same house.All the men are related by blood.

wareness about rabies as the dependant variablend age, gender and education as the independentariables. A P-value < 0.05 was considered signifi-ant.

esults

he mean age of the study population was 35.4±11.4) years. Of the 185 people interviewed,3.5% were female (Table 1) with a mean age of4.6 (±11.3) years. Males comprised 46.5% of theespondents, and their mean age was 36.5 (±11.5)ears.

Of the respondents, 74.1% (137) were aware ofabies. The most common sources of informationere mass media (television/radio/newspaper) and

amily members.Our data indicated that only 54.1% of the respon-

ents knew that rabies is a fatal disease (Table 2).ale gender, belonging to an older age group (>25ears) and having no education were found to beredictors of low awareness about rabies (Table 3).

Of the study subjects, 67% understood that dogs

re responsible for transmitting rabies. Approxi-ately one half of the residents did not know toash the wound from an animal bite with water, and

Community perceptions regarding rabies prevention and stray dog control 377

Table 2 Awareness regarding transmission, symptoms and treatment of rabies among the study population.

Variable Frequencyn = 185

Percentage(100%)

Heard about rabiesYes 137 74.1No 48 25.9Source of informationMass media (television/radio/newspaper) 58 31.4Friends/family members 62 33.5Health personnel 13 7.0Don’t know 52 28.1Awareness about animals transmitting rabiesDog only 124 67.0Dog + cat 8 4.3Dog + cow/monkey 5 2.7Don’t know 48 25.9Mode of transmissionBites only 96 51.9Bite + scratch/licks 28 15.1Scratch only 48 4.9Licks only 9 2.2Don’t know 4 25.9Symptoms of human rabiesHydrophobia/convulsions/paraesthesia/fever 124 67.0Others (dementia, behaving like a dog) 9 4.9Don’t know 52 28.1Is rabies fatal?Yes 100 54.1No 21 11.3Don’t know 64 34.6First aid after animal biteWash the wound with water 95 51.4Tie a cloth around the wound 12 6.5Apply turmeric or other powders 13 7.0Don’t know 65 35.1Practice after an animal biteConsult a doctor 137 74.1No response 48 25.9Aware about anti rabies vaccineYes 79 42.7No 106 57.3Aware about a health facility for treatment of animal bitesYes 70 37.8No 115 62.2Type of health facility where treatment will be sought for animal biteGovernment health facility 120 64.9Private health facility 17 9.2Don’t know 48 25.9

Table 3 Predictors of low awareness about rabies.

Variable Univariate analysis Multivariate analysis

OR 95% CI P OR 95% CI P

Age > 25 years 6.32 2.14—18.63 <0.01 5.3 1.77—16.01 0.03Male gender 3.07 1.54—6.13 <0.01 3.88 1.80—8.35 .001No education 3.47 1.43—8.36 0.01 3.30 1.23—8.80 .01

OR, odds ratios; CI, confidence interval; P, probability.

378 M. Herbert et al.

Table 4 Attitude of the respondents to control of stray dog population.

Variable Frequencyn = 185 Percentage (100%)

Are stray dogs a problem?Yes 123 66.5No 62 33.5Stray dogs are a problem because:They bark and create nuisance 69 37.3Attack and bite people 54 29.2Not a problem 62 33.5Can vaccination prevent rabies in pet dogs?Yes 105 56.8No 52 28.1Don’t know 28 15.1What will you do if the biting animal develops symptoms of rabies?Capture and send to laboratory 22 11.9Kill the animal 78 42.2Chase away the animal 65 35.1Others 20 10.8Which is the best method to control the stray dog population?Immunization of dogs 47 25.4Animal birth control 32 17.3Killing them 66 35.7Others — specify 12 6.5Don’t know 28 15.1Who do you think is responsible for the control of the stray dog population?Government only 107 57.8People in the community/NGOs only 50 27.0Government + people in the community/NGO 12 6.5Don’t know 16 8.6

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13.5% mentioned that they would apply turmericand oils or tie a cloth around the wound site as firstaid measures. Awareness about the rabies vaccinewas reported by 42.7% of the participants. All of theindividuals who had knowledge of rabies respondedthat they would consult a doctor if they were bittenby an animal. The majority (64.9%) of the peoplein urban slums preferred to seek treatment fromgovernment health facilities for animal bites. How-ever, only 11.9% knew that it is necessary to capturethe animal and send it to a laboratory for furthertesting.

Of the respondents, 56.8% were aware that thevaccination of pet dogs can help to prevent animalrabies (Table 4). The role of the community in con-trolling the stray dog population was acknowledgedby only 24.9% of the participants; the majority(57.8%) felt it was the responsibility of the govern-ment to do so.

Discussion

This study has identified certain high-risk groupsthat should be targeted in future efforts to

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romote rabies awareness. Males were found toave less awareness about rabies than females. Thiss a point of concern, as males are more likely toe the victims of animal bites than females. Hence,ncreasing rabies awareness among men is crucialo preventing cases of human rabies. The studyound that rabies awareness among individuals withs little as a primary education was greater thathan of illiterate individuals. This is an indicatorhat informational, educational and communicationIEC) activities must be complemented by effortso improve the overall socio-economic conditions.lder age groups were found to be less aware of

abies than younger age groups, possibly becausef the increasing literacy rate among the youngerenerations.

The participants in this study reported that theirajor source of information about rabies was theass media, suggesting that this channel of commu-

ication is the most effective method of conveyinghe appropriate information to the community.

The results of our study show that 74.1% of thetudy participants were aware of rabies. A multi-enter study by Sudarshan et al. conducted in Indiaeported that 68.7% of the participants were aware

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f rabies [14]. The figure in our study may be higherecause a greater number of subjects in our studyopulation had more education (43.2% had a highchool education or higher).

Our study found that most of the respondentsnew that dogs were mainly responsible for trans-itting rabies, but half of them were unaware that,

n addition to bites, licks and scratches can alsoransmit rabies. Without knowing this information,ndividuals may trivialize some forms of exposurend subsequently fail to seek post-exposure prophy-axis.

The recommended first aid for rabies is immedi-te flushing and washing of the wound with soap andater for a minimum of 15 minutes [9]. This processelps to remove the rabies virus from the wound.ur study found that only half of the participantsere aware of this important first aid measure. Thisbservation correlates with the practices observedy Sudarshan et al. in their multi-center study con-ucted in India [12]. Our study also reported thathe practice of applying powders and other topicalreatments to the wound still exists, although onlymong a minority of the participants. Previous stud-es have also confirmed that these practices persistn India and other countries [16,18,20].

A study by Singh and Choudhary in Anand, India,eported that 30.2% of study participants were cer-ain that rabies can be cured with treatment. Inontrast, our study found that 54.1% understoodhat rabies is fatal and has no cure [21]. However, asreviously noted, the higher education level couldccount for this difference.

Many of the respondents (42.2%) felt that killingabid animals is the best method for controllingabies within the stray dog population. This is aawed attitude that needs to be altered. There iso evidence that the removal of dogs alone has everad a significant impact on dog population densitiesr on the spread of rabies. The population turnoverf dogs may be so high that reproduction rates couldasily compensate for even the highest recordedemoval rates (approximately 15% of the dog popu-ation) [9]. However, there may be indirect benefitsrom selectively eliminating unvaccinated dogs thatre not in compliance with control regulations andhat congregate around markets, abattoirs and foodusinesses [22].

In Bangalore, animal birth control programs areun under the aegis of the civic body, the Bruhatangaluru Mahanagara Palike. In 2001, its activitiesere transferred to registered animal welfare orga-

izations in the city. A performance audit of theBC program in 2007 reported that the impact ofhe ABC program could not be measured becausehere was no estimate of the stray dog population

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efore or during its implementation [23]. The publicelieves that stray dog control is largely the respon-ibility of the government. As a result, people areot mindful of the role they can play in stray dogontrol (e.g., avoiding the indiscriminate dumpingf food waste in public spaces, vaccinating their petogs).

This study revealed that most people (57.8%)laced the responsibility for controlling the dogopulation on the government. This result contrastsith a study conducted in Sri Lanka by Matibag etl., in which most participants felt accountable forhe increase in the stray dog population and didot believe it was right to pass the responsibilityolely to the authorities [24]. This is precisely thettitude that must be promoted because no publicealth program can be successful without ensuringommunity participation. Creating awareness in theommunity about the role they can play in healthrograms can make the difference between a suc-essful program and a program that fails. Changinghe current public perceptions of rabies preven-ion and control should be a fundamental aspectf ongoing rabies control efforts. Key activitieso educate the public should include increas-ng rabies awareness through media activities,undraising and education programs. Public aware-ess activities should prioritize the individualsost at risk of exposure, including the underprivi-

eged segments of society, school children and thelderly.

Unfortunately, the community practices foresponding to animal bites could not be simulta-eously assessed during the study. This informationould have helped to correlate knowledge and atti-udes with actual practices in the community.

onclusions

eople who live in slum communities have gaps inheir knowledge and attitudes regarding rabies pre-ention and stray dog control. Our results indicatehat males, older individuals and illiterate indi-iduals should be the target groups for awarenesseneration activities.

Advocacy programs are needed to generate pub-ic awareness and political commitment for rabiesontrol. Policymakers should be informed about theurden of rabies and educated about the needs for

systematic and sustained control program, for

ufficient resource allocation and resource mobi-ization, and for multi-sector coordination. Finally,edia, religious leaders, local community leaders

nd other influential groups should be mobilized to

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create awareness and promote community involve-ment in rabies control activities.

Conflict of interest

We, Mrudu Herbert, Riyaz Basha S, Selvi Thangaraj,declare that we have no conflict of interest todeclare. We declare that we have not received anyexternal financial support or any other form of assis-tance in the conception, design or execution of thestudy.

Acknowledgements

We thank Dr. T.S. Ranganath for his cooperationand support in executing the study. We gratefullyacknowledge all of the individuals who consentedto participate in our study and spent their valuabletime with us.

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