The current rabies control strategy in Zambia is based on dog vaccination, dog population control and dog movement restrictions. In Nyimba district of Zambia, dog vaccination coverage is low but the incidence of dog bites is high which places the community at risk of rabies infection. The renewed global interest eliminating rabies in developing countries has spurred interest to identify determinants and barriers of dog vaccination in an effort to reduce the overall disease burden. A mixed methods cross sectional design was used in the study. This consisted of three parts: Evaluation of medical records regarding dog bite injuries, implementation and analysis of a household survey and in-depth review of key informant interviews. Data was collected into a Microsoft Excel database and subsequently transferred to STATA for descriptive, inferential and thematic analysis. Dog vaccination coverage overall was 8. 7% (57/655), with 3. 4% (22/655) in urban areas, 1. 8% (12/655) in peri-urban and 3. 5 (23/655) in the rural regions. Financially stable households were more likely to have their dogs vaccinated. Only 10. 3% (31/300) of the respondents had vaccinated their dogs and these had a reliable source of income as 6% (18/300) were peasant farmers, 2% (6/300) were dependants whose guardians were financially stable and 2. 3% (7/300) were in steady employment. Important barriers to dog vaccination included cost, limited awareness of vaccination program and access. Current rabies control strategies in Nyimba district, Zambia, appear quite limited. Improvements in the regional dog vaccination program may provide benefits. Enhancement of educational efforts targeting behavioural factors may also prove useful. Finally, the cost of dog vaccination can be reduced with scaled up production of a local vaccine.
Rabies has been a public health concern and has plagued both humans and animals since around 2000 BC [1]. The disease is endemic on all continents except Antarctica [2] and it is believed to cause approximately 59,000 human deaths annually [3]. Rabies is more prevalent in developing countries where management and control measures are poor; consequently, continents such as Asia and Africa have the highest incidence of rabies, accounting for over 95% of the global rabies cases [4]. Rabies can be transmitted between all warm-blooded species including man and studies have shown that several domestic and wild animals such as dogs, cats, cattle, wolves, foxes, jackals, bats and others can get infected with the rabies virus and transmit the disease to humans via bites or scratches. Human rabies is mostly due to dog-transmitted rabies virus (RABV) [5] which is an RNA virus of the Rhabdoviridae family genus Lyssavirus [6]. Following invasion of the central nervous system, rabies infection progresses rapidly [7] and death due to respiratory failure or cardiac arrest ensues [8]. While a very small number of patients with rabies have survived, the disease is untreatable and fatal once signs of encephalitis appear [9]. Fortunately, rabies post exposure prophylaxis (PEP) prevents rabies in humans exposed to the rabies virus [10]. Thus PEP is the cornerstone for rabies prevention in humans, and it is against this background that it is recommended for all persons that have been or suspected to have been exposed to the rabies virus. In developing countries, the domestic dog has been found to be responsible for the transmission of most of the human rabies cases [3] with over 90% of the rabies cases being transmitted via dog bites [11]. It is estimated that owned dogs account for the majority of the hundreds of millions of people that are bitten by dogs in the world each year [2]. Cases of rabies transmission between humans through transplant surgery have been reported but these are very rare [12]. The control of rabies since 1973 as recommended by the World Health Organisation (WHO) includes; mass dog vaccination campaigns and strict dog population control via restricted breeding, restricted movements and culling of unwanted dogs especially stray dogs [13]. Although these control measures have been in place for about 50 years, studies have shown that only a few developed countries are currently rabies free [14]. The vaccination of dogs against rabies is now regarded as the most effective rabies control strategy combined with secondary roles of population control, movement regulations and promotion of responsible dog ownership [11] and [15]. In developing countries were the prevalence of rabies is still significantly high; dog vaccination is a challenge. A number of successful dog vaccination campaigns have been carried out and research has demonstrated that rabies in these countries can be controlled [16]. Studies have further shown that the common assumption that dog vaccination in developing countries is hindered by operational constraints such as lack of dog population knowledge, low public rabies knowledge and inadequate implementation resources, may be erroneous [17]. Dog vaccination may not be a priority in some developing countries because of the limited resources available [18]. In Zambia, rabies is regarded as one of the endemic scheduled or notifiable diseases and the law under the Zambian Animal Health (Control and Prevention of Animal diseases) Order of 2014 stipulates that" animal owners vaccinate their animals against all scheduled or notifiable diseases" [19]. The WHO recommends that vaccinating at least 70% of the dog population against rabies over consecutive years may interrupt rabies transmission chains amongst dogs [20]. It has been found that vaccination coverage lower than 30% of the dog population is a waste of resources [11]. In Zambia, the actual dog population is not well known but it is widely assumed that only a small percentage of the Zambian dog population is vaccinated against rabies. In Nyimba district for instance, the dog population estimate is based on the 2006 Livestock Census. According to the Zambian National Livestock Epidemiologic Information Centre (NALEIC) and District Veterinary records, only 5. 4% (138/2,556) and 5. 6% (157/2,804) of the estimated dog population were vaccinated against rabies in Nyimba district in 2013 and 2014 respectively. Despite the estimated low number of vaccinated dogs in the country, the number of notified dog bite cases has continued to rise. According to the Zambian report on rabies presented at the Southern and East African Rabies Group (SEARG) meeting of 2013; the number of notified dog bite cases in Zambia rose from 620 in 2010 to 732 in 2011. Veterinary records in Nyimba district also show that there has been a steady increase in the number of notified dog bite cases from 84 recorded in 2013 to 134 cases recorded in 2014. The rise in dog bite cases has led to an increase in the demand for PEP in the district as most of the victims bitten by unvaccinated dogs require prophylaxis. The WHO estimates that the global annual cost of PEP to be around $1. 6 billion [2]. This makes the use of PEP more expensive than simply vaccinating dogs against rabies. Although a number of mass dog vaccination campaigns have been carried out in the district, the coverage has been very poor and the majority of the dog population remains unvaccinated. Thus both the dog and human population are at risk of rabies infection. An analysis of suspected rabies cases recorded in Zambia between 1985 to 2004 found 1,088 rabies positive samples from various species, 747 of which were from dogs and 98 were from humans (Table 1) [21]. Another analysis of brain samples collected from suspected rabid dogs between January 2005 and December 2013 found 153 rabies positive cases [22]. Thus the dog mediated human rabies and dog rabies burden in the district and the country at large is still a challenge. The aim of the study was to identify the socio demographic determinants which influence dog vaccination and the local barriers to dog vaccination against rabies. The study tried to explore the perceptions and responses of the dog-owning households in relation to rabies control in Nyimba district. It was hoped that gaining an understanding of the various social norms prevailing in the communities in relation to rabies control would help in the tailoring of vaccination campaigns which would result in a wider coverage.
The study was conducted in Nyimba district which is one of the nine districts of Eastern Province in Zambia (please follow this link: https: //en. wikipedia. org/wiki/Eastern_Province, _Zambia#/media/File: Zambia_Eastern_Province_Districts. svg) [23]. The district lies on the southern part of the province and covers a total area of 10,509Km2 which is divided into valley and plateau areas. Nyimba district is situated approximately 340 Km from Lusaka the capital city of Zambia and 230 Km from Chipata the provincial centre of Eastern province. According to the 2010 national population and housing census, the district has a human population of 85,025 with 60% of the population living in the plateau and 40% in the valley. A number of ethnic groups found in the district including the Nsenga, Chewa, Ngoni and Tumbuka with the Nsenga being the indigenous group. Agriculture is the main source of livelihood in terms of crop and livestock farming for about 90% of the population while the rest depend on fishing, casual labour and the civil service. The research was conducted using a mixed methods (qualitative and quantitative) cross sectional design which was divided into three parts (Fig 1). The first part consisted of evaluating dog bite case records at the veterinary office and Nyimba district Hospital to determine the frequency of dog bites and the vaccination and ownership statuses of the dogs involved in the bites. The proportion of reported dog bite cases which received rabies post exposure prophylaxis (PEP) from 2010 to 2013 was 12. 3% (239/1,947). The postulated proportion of reported dog bite cases which received rabies PEP between 2013 and 2015 was hypothesized to be 5%. Calculations using statistical software at 0. 05 significance level and 80% power showed that the required sample size was 130 reported dog bite cases. There were 215 dog bite cases recorded from 2013 to 2015 and they were all included in the study. The second part was a survey of 300 households which responded to a household questionnaire which collected data on socio demographics, community knowledge with regards to rabies and data on dog population and vaccination coverage. The household survey sample was calculated using statistical software at 0. 05 significance and 80% power. According to literature from the Central Veterinary Research Institute (CVRI) in Zambia, the relative prevalence of rabies in the country was hypothesized to be 39. 7% and postulated to be 48%. The resulting sample size was 277 households which were rounded off to 300 households. The households were selected using a cluster randomized sampling method and the questionnaire was administered by the research assistants. The third part included in depth interviews with local rabies experts including the rabies control officers from the Council and Veterinary Department of Nyimba district and the Central Veterinary Research Institute in Lusaka. The in depth interviews were conducted by the researcher. For the in depth interviews with local rabies experts and the dog bite case record evaluation, verbal informed consent was obtained from the informers at both the hospital and the veterinary office. Written informed consent was obtained from respondents of the household questionnaire. Ethical clearance was obtained from Excellence in Research Ethics and Science (ERES) converge (Ref. No. 2015-June-018). All data collection was conducted in English except for the household questionnaire which was done in Nsenga in some cases and then translated into English. Questionnaire and dog bite case evaluation data were entered into Microsoft Office Excel 2007 and coded then transferred to STATA version 12 for analysis. Data from the in depth interviews with local rabies experts was entered into Microsoft Office Word 2007 and thematic analysis was done manually.
The evaluation of the dog bite case records found that there were 215 reported dog bite cases recorded between January, 2013 and January, 2015. Thus out of these 46% (99/215) were female and 53. 95% (116/215) were male. Information on age was missing for 45% (98/215) of the cases but in 117 cases, the victims were aged between 1 and 68 years with a mean age of 16. 8 years (SD 14. 7). Approximately 62. 4% (73/117) of the dog bite victims were aged between 1–15 years, 23. 1% (27/117) were aged between 16–30 years and 14. 5% (17/117) were over 30 years of age. The household survey was conducted in order to determine a more accurate estimate of the dog population and vaccination coverage and also to determine community knowledge levels and responses to rabies and its control strategies. A total of 300 households consisting of 1,970 people completed the household questionnaire. The average number of people per household was 6. 57 and occupants ranged from 1 to 15 people in the households. Males made up 74% (223/300) of the respondents and 26% (77/300) were female. Two of the respondents were aged 14 years and they answered the questionnaire in homes where adults were not present at the time of the interview, the other 298 respondents were above 14 years of age (range 14–83 years, mean age = 38. 6 years). The spatial distribution of the 1,970 people covered by the survey was such that 78 (3. 9%) were from the urban areas, 106 (5. 4%) were from the peri-urban areas and 1,786 (90. 6%) were from the rural areas of the district. As a means of livelihood it was found that peasant farming was practiced by 262 (87. 3%) of the respondents while 15 (5%) were formerly employed and 23 (7. 7%) were dependents. The results showed that of the 300 respondents, 49 (16. 3%) did not have any formal education, 169 (56. 3%) had Primary education, 78 (26%) had Secondary education and only 4 (1. 3%) had Tertiary education.
The control of rabies in Nyimba district remains challenging. Our study showed that compliance with dog control and dog vaccination against rabies was low. Certainly, there were a number of significant social and economic barriers identified. We believe that interventions to reduce the impact of rabies need to include the local populations in order to maximise benefit. Dog vaccination rates could be improved with sustained efforts at improving dog behaviours, reducing reproduction rates, and increasing access to low cost vaccine. Educational efforts still have room for improvement as well. This study helped to elucidate some of the areas important for targeting efforts to reduce the morbidity of dog bites and the danger of rabies in this region.
Dog vaccination against rabies is the main method of rabies control in Zambia and it is mainly conducted by the Department of Veterinary Services under the Ministry of Fisheries and Livestock. This study explores the factors influencing dog vaccination against rabies and the local barriers to rabies control in Nyimba district of Zambia. The study was done in three parts; a review of dog bite cases (n = 215 cases), a household survey and questionnaire (n = 300 households) and in depth interviews with local rabies experts (n = 5). The study found that the community had adequate knowledge about rabies prevention in dogs and humans. The area of residence, the age and financial capacity of the dog owner determined whether or not the household dog was vaccinated or not. The survey of the 300 households revealed that only 8. 7% of the dogs were vaccinated against rabies and the dog bite case record review showed that the majority of the dog bite cases were caused by unvaccinated dogs most of which were owned. The study discusses the challenges in controlling rabies and possible reasons for non compliance to dog vaccination by the dog owners in Nyimba district.
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Insights and efforts to control rabies in Zambia: Evaluation of determinants and barriers to dog vaccination in Nyimba district