Rabies: knowledge, attitudes and practices in the Suhum municipality of Ghana

INTRODUCTION

The public health and economic burden of rabies are evident in developing countries where the disease is most prevalent, resulting in economic losses and the loss of over 60,000 human lives annually^[1]. Rabies cost Ghana more than 16 million dollars annually^[2].

Dogs are the source of rabies in 99% of human cases^[3], and the most prudent way to control the disease in humans is, therefore, to eliminate the disease from dog populations through vaccination^[4]. Rabies is recognised by WHO as a neglected tropical disease, and there is a global consensus led by WHO, OIE, FAO, and GARC to eliminate dog mediated rabies by 2030^[5]. The final strategic plan to eliminate rabies was adopted in 2015 in a collaborative effort dubbed “United Against Rabies”, which pledges international support while placing individual countries at the centre of action^[1]. In response to the need for such collaborations, non-governmental organisations have been working in close association with governments to roll out rabies control exercises in most endemic regions.

The Suhum Municipality, located in the Eastern Region of Ghana, is rabies endemic with human-rabies to dog-bite ratio of 3:1000^[6]. Hence the municipality has been a beneficiary of various rabies control partnerships, such as - the Rabies in West Africa (RIWA) - Suhum pilot rabies control project which commenced in 2017 with the aim of creating a network on rabies control in the Suhum Municipal District. The project, which lasted until 2019, involved various activities which exemplified combined stakeholder One Health efforts towards the prevention of human rabies by controlling the disease in dogs^[7]. Although rabies perceptions and dog-keeping practices of at-risk populations are products of socio-cultural influences^[8], not much work has been done in highlighting the knowledge, attitude and practices of Ghanaians on rabies. The objective of this study is to determine the knowledge, attitudes and practices of the people of Suhum Municipality regarding rabies and dog bites and explore the relationship between selected characteristics and knowledge, attitude, and practices regarding rabies and rabies control in the municipality. This is a baseline study that will serve as a foundation for further studies in Suhum Municipality and other parts of Ghana. The study will contribute information needed to develop rabies sensitisation content for rabies control at the local government and national level as the country is in the process of rolling out a national rabies control programme^[9].

METHOD

Study location

The Suhum Municipal Assembly is part of the Eastern Region of Ghana; it is located between latitude 00561°N and 6008°N and longitude 00331°W and 00161°W, with a landmass of about 359Km² and a population of about 90,358. The Municipality has 9 sub-municipalities under the operations of the Ghana Health Service, as depicted in Figure 1.

Figure 1. Map showing location of (A) Suhum as the white area in the rectangular box and (B) Sub-municipalities.

RESULTS

DISCUSSION

This study reports good knowledge of rabies which compares variably to 76.5% in the Upper East Region of Ghana^[12] and 49.5% in Debretabor, Ethiopia^[13]. This encouraging knowledge of the participants might be due to the level of education of participants, sensitisation activities by voluntary organisations such as RIWA-Ghana and other One Health partners^[14]. Although Awuni et al. (2019) reported that male dog owners are more likely to have good knowledge of rabies compared to females^[12], Palamar et al. (2013) reported the contrary^[15]. This might be due to cultural practices, where most males dominate and participate in outreach educational durbars and meetings. We did not assess the relationship between sex and education of participants. In developing countries, including Ghana, females are less disproportionally educated than males. Education disparities between males and females may be a contributing factor. Children are targets for rabies education because they have a higher risk of rabies infection. However, adults are more likely to attend education fora than juveniles. Education materials are more likely given to adults in household. Children and women will not read the material even if given. They will normally keep such materials for the landlord/family head, the man

The name Nkraman yareɛ (dog disease) given by respondence to mean rabies, reflects the position of rabies as the most talked-about dog disease in the countryand also^[16], in the zoonotic sense, the one which most locals can trace to dogs. Even though a misnomer as there are so many dog diseases - zoonotic or otherwise in Ghana, it is affirmed by the Twi Medical Glossary published through the Medical Education Partnership Initiative, Kwame Nkrumah University of Science and Technology (MEPI-KNUST). “Nkraman Abɔdam” literally means dogs madness - which better describes rabies - formed only a few responses.

Unlike in the Western Region of Ghana, where schools and mass media are the predominant sources of rabies information^[8], a majority of respondents in this study traced their rabies knowledge to family, neighbours, and friends, and a similar pattern was observed in Tanzania^[17]. This study found significant differences between the level of rabies knowledge and the source of rabies information. All of the respondents who learned about rabies from veterinary or medical officials had good knowledge of rabies. Medical and veterinary professionals through education and practice are more knowledgeable on the subject than the average citizen. They are, therefore, the most likely to provide authentic rabies information. Despite the perfect output from medical and veterinary sources, the number of respondents who made reference to either of them was very few. Regardless, it is an indication that a combined effort between human and animal health professional can orient society in a more positive direction in terms of rabies control, also reported by Sambo et al. (2014) in Tanzania^[17].

With regards to the mode of transmission of rabies, exposures such as scratches and licks to broken skins which were rarely identified demonstrate limited knowledge of rabies’ mode of transmission. This implies that those forms of exposure other than bites are less likely to be taken seriously and may invariably lead to rabies in human victims. This suggests the need for education about rabies in the municipality.

Health seeking behaviour in Tanzania showed that a few dog bite victims would apply the right first aid before going to the hospital whereas 95% would go to the hospital without taking any action^[17]. In this study, respondents indicated that they would use traditional remedies before reporting for medical attention. This is worrying and points to the need for more public education on the importance of taking first aid and seeking immediate health care after a dog bite. Traditional medicine remains enshrined in the African way of life^[18]. In Ethiopia, as high as 81% of dog bite victims trust traditional remedies more than the approved postexposure prophylaxis (PEP) after the bite and many would not cross a river because it is associated with the onset and severity of rabies^[19]. The most talked about myth in this study was applying kola nut, human urine, hair of the offending dog, and salt to bite wounds to prevent rabies. This practice along with several variations have been observed worldwide^[20]. Interestingly, some respondents harbored the belief that blacksmiths possess the power to neutralize the causative agent of the disease, which, to those respondents, was a toxin. From the scientific viewpoint, not only are such practices ridiculous but they present health hazards too. Capturing a suspected rabid animal to pluck its hair, for instance, puts more people at risk of being bitten and contracting rabies. Despite being ineffective, most of these practices are substitutes for proper PEP, and dog bite victims who go through them risk coming down with rabies if the offending dog was rabid. Killing of suspected rabid dog and reporting to animal health officials were the most dominant practices as reported in Tanzania and Ethiopia^[17,19]. The vaccination figures in this study compare better to those reported in Kenya^[21], Ethiopia^[22], and elsewhere in Ghana^[8,13]. The high proportion of vaccinated dogs in this study can be traced to the free vaccination campaigns led by RIWA Ghana, considering that the majority of the vaccinations reported by this study happened at a RIWA Ghana campaign site, and only 1.5% of previous vaccinations happened outside the period of the campaign.

Sustained dog immunity is key to interrupting rabies transmission and for rabies elimination. Despite the encouraging vaccination turnout in first vaccinations, only 40% of previously vaccinated dogs had been revaccinated. There were significant differences in revaccination levels among sub-municipalities, with Nankese - the most rural of the three - recording the least (13.3%). Reasons given by dog owners for not vaccinating or revaccinating their pets varied. Difficulty in restraint and transportation of dogs to vaccination sites are predominant excuses given by dog owners for non-participation in dog vaccination exercises^[23]. Vaccination cost is also an obstacle to dog vaccination across Ghana, and Africa as a whole^[19,13,8]. Responsible dog ownership is important if we are to eliminate rabies by the year 2030. However, much research is required on the use of static vaccination points and other reasons cited here to overcome barriers to rabies control^[24].

More than half of the known victims of dog bites in this study were below 15 years, and this agrees with the global trend that rabies cases occur among children under 15 years^[3]. Children are less likely to identify warning signs from dogs and can easily fall victim to dog attacks. However, it is enlightening to report that participation of children in vaccination was found to be encouraging. In most households, children were the ones who took the dogs for vaccination. Children are most at risk of rabies and involving them in rabies control efforts will help protect them against the disease and make them more responsible pet owners with rabies eradication at heart.

This study establishes a significant relationship between rabies awareness and dog vaccination which unanimously agrees with findings in Ghana, Tanzania, and elsewhere^[12,17,25]. Whereas these studies found the influence of rabies knowledge on dog vaccination significant and stressed the need for public awareness creation, this study reports contrary on awareness. This would not have been the case if as many people who were aware of rabies were as knowledgeable in the subject. Also, the number of dogs in a household was found to significantly hamper dog vaccination efforts, as too many dogs may be difficult to capture and transport to vaccination sites - a predominant excuse for non-vaccination of dogs by respondents.

In conclusion, this study reveals some of the gaps in rabies practices in the Suhum Municipality. The study found that most of the respondents are aware and have good knowledge about rabies. However, their practices in disease prevention and control were poor.

The findings suggest the need to bridge the rabies awareness and knowledge gaps, transform that awareness into good knowledge, and good knowledge into good practices. Continued and strengthened education through One-Health collaboration of stakeholders and the cooperation of local community will be required for effective rabies control.

Studying in an unplanned developing community was a challenge, especially in providing a sampling frame. The convenient sampling in some of the communities in this study might affect the outcome of this study. The free rabies campaign in the communities prior to this study may have also influenced the findings of vaccinations from this study.