Rabies in Uganda: rabies knowledge, attitude and practice and molecular characterization of circulating virus strains

Holistic application of the one health approach in the prevention and control of rabies: plausible steps towards achieving the 2030 vision in Africa

Rabies remains a significant public health challenge in Africa, primarily burdening impoverished rural communities, with children and young adults being the most vulnerable. Achieving complete elimination in the continent by 2030 requires a coordinated effort hinged on the One Health concept, external support from international organizations like the World Health Organization (WHO) and the national governments of endemic countries. Here, we reviewed the various socio-economic and ecological factors influencing the spatial distribution and molecular epidemiology of the disease. To mitigate the transmission of rabies on a global scale, and specifically in Africa, we proposed a multi-pronged approach including enhanced access to healthcare resources, cultural sensitization and massive health promotion with efforts geared towards promoting responsible dog and pet ownership and population management, effective monitoring, and mitigation of environmental changes.

Rabies in the Endemic Region of Algeria: Knowledge, Attitude and Practice (KAP) Survey among University Students

(1) Background: Rabies is a neglected zoonosis considered to be one of the most significant health threats in the world, responsible of thousands of deaths globally. Algeria is one of the main countries of concern, with more than 15 deaths and more than 100,000 bites by rabid-suspected animals being reported annually. This study was conducted to evaluate the level of knowledge, attitudes and practice (KAP) toward this disease among university students in the endemic region of Algeria. (2) Methods: a cross-sectional online survey was conducted between June 2023 and March 2024 using a self administered questionnaire. (3) Results: a total of 409 students completed the questionnaire. Overall, 91.2% of them were singles, 70.7% were females, and two-thirds (66%) were between their twenties and thirties in regard to age. The majority were studying for Bachelor's degrees, and the most represented fields of study were Humanities (31.5%) and Natural and Life Sciences (29.1%).The findings revealed a moderate level of knowledge (63% of correct responses), a positive attitude, and appropriate practices. However, the surveyed students have certain gaps in their information regarding disease transmission, its risk factors, and its clinical signs. In addition, some of them have also shown some negative attitudes, including approving of the systematic killing of a dog who bites someone regardless of its vaccine status (59.2%), and inappropriate practices, especially in regard to unawareness of the importance of early washing of bite wounds, which was reported among 64.5% of the surveyed students. The study also revealed the association of health sciences education with knowledge (AOR: 2.723, CI 95%: 1.317-5.634), attitude (AOR: 2.306, CI 95%: 1.113-4.779) and practice (AOR: 3.560, CI 95%: 1.632-7.769), and the effect of the high level of knowledge on the attitude of surveyed students (AOR: 1.607, CI 95%: 1.052-2.456). (4) Conclusion: These results provide the first report regarding rabies KAP among Algerian university students. Based on these results, the health deciders could adopt their preventive strategy by raising awareness of the less-informed categories, which would consequently affect their behaviors regarding this fatal disease.

Descriptive analyses of knowledge, attitudes, and practices regarding rabies transmission and prevention in rural communities near wildlife reserves in Uganda: a One Health cross-sectional study

BACKGROUND

Despite urban (domestic dog) rabies cycles being the main target for rabies elimination by 2030, sylvatic (wildlife) rabies cycles can act as rabies spillovers especially in settlements contiguous to wildlife reserves. Rural communities next to wildlife reserves are characterized by unique socio-demographic and cultural practices including bat consumption, hunting for bushmeat, and non-vaccination of hunting dogs against rabies among others. This study aimed to compare the knowledge, attitudes, and practices (KAPs) related to rabies transmission and prevention in the three districts of Uganda; (1) Nwoya, neighboring Murchison Falls National Park (MFNP) in the north, (2) Kamwenge neighboring Kibaale National Park (KNP), Queen Elizabeth National Park (QENP) and Katonga Game Reserve (KGR) in the west, and (3) Bukedea, neighboring Pian Upe Game Reserve (PUGR) in the east of Uganda.

METHODS

A community-based cross-sectional survey was conducted in settlements contiguous to these wildlife reserves. Using a semi-structured questionnaire, data were collected from 843 households owning dogs and livestock. Data were collected between the months of January and April 2023. Stratified univariate analyses by district were carried out using the Chi-square test for independence and Fisher's exact test to compare KAPs in the three study districts.

RESULTS

The median age of study participants was 42 years (Q1, Q3 = 30, 52) with males comprising the majority (67%, n = 562). The key findings revealed that participants from the Nwoya district in the north (MFNP) had little knowledge about rabies epidemiology (8.5%, n = 25), only 64% (n = 187) of them knew its signs and symptoms such as a rabid dog presenting with aggressiveness and showed negative attitudes towards prevention measures (15.3%, n = 45). Participants in the Kamwenge district-west (KNP, QENP, and KGR) had little knowledge and negative attitude towards wildlife-human interaction pertaining to rabies transmission and prevention especially those with no or primary level of education (20.9%, n = 27) while participants from Bukedea in the east (PUGR) had remarkedly poor practices towards rabies transmission, prevention, and control (37.8%, n = 114).

CONCLUSIONS

Rabies from sylvatic cycles remains a neglected public health threat in rural communities surrounding national parks and game reserves in Uganda. Our study findings highlight key gaps in knowledge, attitudes, and practices related to rabies transmission and prevention among such communities. Communication and action between veterinary services, wildlife authority, public health teams, social science and community leaders through available community platforms is key in addressing rabies among the sympatric at-risk communities in Uganda.

Viruses of free-roaming and hunting dogs in Uganda show elevated prevalence, richness and abundance across a gradient of contact with wildlife

Domestic dogs (Canis lupus familiaris) live with humans, frequently contact other animals and may serve as intermediary hosts for the transmission of viruses. Free-roaming dogs, which account for over 70% of the world's domestic dog population, may pose a particularly high risk in this regard. We conducted an epidemiological study of dog viromes in three locations in Uganda, representing low, medium and high rates of contact with wildlife, ranging from dogs owned specifically for traditional hunting in a biodiversity and disease 'hotspot' to pets in an affluent suburb. We quantified rates of contact between dogs and wildlife through owner interviews and conducted canine veterinary health assessments. We then applied broad-spectrum viral metagenomics to blood plasma samples, from which we identified 46 viruses, 44 of which were previously undescribed, in three viral families, Sedoreoviridae, Parvoviridae and Anelloviridae. All 46 viruses (100 %) occurred in the high-contact population of dogs compared to 63 % and 39 % in the medium- and low-contact populations, respectively. Viral prevalence ranged from 2.1 % to 92.0 % among viruses and was highest, on average, in the high-contact population (22.3 %), followed by the medium-contact (12.3 %) and low-contact (4.8 %) populations. Viral richness (number of viruses per dog) ranged from 0 to 27 and was markedly higher, on average, in the high-contact population (10.2) than in the medium-contact (5.7) or low-contact (2.3) populations. Viral richness was strongly positively correlated with the number of times per year that a dog was fed wildlife and negatively correlated with the body condition score, body temperature and packed cell volume. Viral abundance (cumulative normalized metagenomic read density) varied 124-fold among dogs and was, on average, 4.1-fold higher and 2.4-fold higher in the high-contact population of dogs than in the low-contact or medium-contact populations, respectively. Viral abundance was also strongly positively correlated with the number of times per year that a dog was fed wildlife, negatively correlated with packed cell volume and positively correlated with white blood cell count. These trends were driven by nine viruses in the family Anelloviridae, genus Thetatorquevirus, and by one novel virus in the family Sedoreoviridae, genus Orbivirus. The genus Orbivirus contains zoonotic viruses and viruses that dogs can acquire through ingestion of infected meat. Overall, our findings show that viral prevalence, richness and abundance increased across a gradient of contact between dogs and wildlife and that the health status of the dog modified viral infection. Other ecological, geographic and social factors may also have contributed to these trends. Our finding of a novel orbivirus in dogs with high wildlife contact supports the idea that free-roaming dogs may serve as intermediary hosts for viruses of medical importance to humans and other animals.

Dog ecology and rabies knowledge, attitude and practice (KAP) in the Northern Communal Areas of Namibia

In 2021, a comprehensive dog demographic questionnaire combined with a KAP survey were conducted in the northern communal areas (NCAs) of Namibia with the aim of gaining a better understanding of dog populations, owner behaviour, and knowledge, attitudes and practices (KAP) relating to rabies. The survey of 3,726 households across the eight regions of the NCAs provided insights that will inform interventions in order to improve human rabies prevention and Namibia's dog rabies control strategy. The results showed a relatively low average human/dog ratio (HDR) of 5.4:1 indicating a surprisingly high dog population of at least 272,000 dogs in the NCAs, 93% of which appear to be owned but are free-roaming. Data analysis revealed opportunities but also highlighted needs for improvements in rabies surveillance and mass dog vaccinations. Although knowledge, attitude, and practice scores towards epidemiologic and clinical aspects, human rabies prevention, and dog rabies vaccination were deemed to be acceptable, the survey nevertheless revealed deficiencies in certain aspects in some of the population. Interestingly, data seemed to indicate relatively high dog bite incidences per 100,000 people, ranging between 262 and 1,369 and a certain number of unreported human rabies cases. Despite the very high number of dogs, only 50% of dog-owning households reported having vaccinated their dogs. In order to address these issues, the planning, announcement, and implementation of mass dog vaccination campaigns needs to be adapted to achieve adequate vaccination coverage. Another focus needs to be on rabies awareness and education if Namibia is to be significantly contributing to the global goal of "Zero by 30".

Comparison of Pan-Lyssavirus RT-PCRs and Development of an Improved Protocol for Surveillance of Non-RABV Lyssaviruses

Rabies is a zoonotic and fatal encephalitis caused by members of the Lyssavirus genus. Among them, the most relevant species is Lyssavirus rabies, which is estimated to cause 60,000 human and most mammal rabies deaths annually worldwide. Nevertheless, all lyssaviruses can invariably cause rabies, and therefore their impact on animal and public health should not be neglected. For accurate and reliable surveillance, diagnosis should rely on broad-spectrum tests able to detect all known lyssaviruses, including the most divergent ones. In the present study, we evaluated four different pan-lyssavirus protocols widely used at an international level, including two real-time RT-PCR assays (namely LN34 and JW12/N165-146), a hemi-nested RT-PCR and a one-step RT-PCR. Additionally, an improved version of the LN34 assay ((n) LN34) was developed to increase primer–template complementarity with respect to all lyssavirus species. All protocols were evaluated in silico, and their performance was compared in vitro employing 18 lyssavirus RNAs (encompassing 15 species). The (n) LN34 assay showed enhanced sensitivity in detecting most lyssavirus species, with limits of detection ranging from 10 to 100 RNA copies/µL depending on the strain, while retaining high sensitivity against Lyssavirus rabies. The development of this protocol represents a step forward towards improved surveillance of the entire Lyssavirus genus.

Awareness, Knowledge, and Perceptions Regarding Rabies Prevention Among Rural Communities in Masaka District, Central Uganda: A Qualitative Study

Rabies is a zoonotic disease that is mainly transmitted to humans through dog bites. It remains a major public health threat in many Asian and African countries, including Uganda. The main objective of this study was to investigate awareness, knowledge, and perceptions of communities toward human and dog health related to rabies prevention, as well as dog management practices within Masaka district, central Uganda. Data collection involved nine key informant interviews (KIIs) and six focus group discussions (FGDs). Methods used during focus group discussions included qualitative interviews (using open-ended questions), simple ranking, and proportional piling. Data from KIIs and FGDs were analyzed using content analysis in NVivo (version 12.0). This study reveals that community members in the rural settings uses herbal concoctions in replacement or as an alternative to dog vaccination. Furthermore, the study reveals that dogs play the vital roles in the households like as they offer protection to people and household properties, despite being ranked second least among the household animals. The commonest livelihood activity was a small-scale mixed farming. Most of the households kept dogs, but they are ranked at second lowest in terms of economic value among all domestic animals. Free roaming and tethering were the common dog-keeping systems, and home-based feed (food leftovers, bones) was provided mainly to the tethered dogs. Rabies, also locally known as “Eddalu Lyembwa” (that can be translated as “madness of the dogs”), was ranked as the disease of most important among dogs, besides other common diseases such as skin diseases, venereal diseases, worm infestations, and tick infestations. Inadequate vaccination services for both humans and dogs were reported, and dog bite victims traveled a long distance to seek for post-exposure prophylaxis after dog bites. It can be concluded that there is a clear request for periodic mass vaccination campaigns against rabies among dogs, and access to vaccines within reasonable distances by humans after a rabies exposure, but also pre-emptive vaccination for those at high risk, such as veterinarians, needs to be improved.

Rabies in the Tropics

Purpose of Review

Rabies is an ancient yet still neglected tropical disease (NTD). This review focuses upon highlights of recent research and peer-reviewed communications on the underestimated tropical burden of disease and its management due to the complicated dynamics of virulent viral species, diverse mammalian reservoirs, and tens of millions of exposed humans and animals - and how laboratory-based surveillance at each level informs upon pathogen spread and risks of transmission, for targeted prevention and control.

Recent Findings

While both human and rabies animal cases in enzootic areas over the past 5 years were reported to PAHO/WHO and OIE by member countries, still there is a huge gap between these "official" data and the need for enhanced surveillance efforts to meet global program goals.

Summary

A review of the complex aspects of rabies perpetuation in human, domestic animal, and wildlife communities, coupled with a high fatality rate despite the existence of efficacious biologics (but no therapeutics), warrants the need for a One Health approach toward detection via improved laboratory-based surveillance, with focal management at the viral source. More effective methods to prevent the spread of rabies from enzootic to free zones are needed.

Animal health is often ignored, but indispensable to the human right to health

Although preventable by vaccines, approximately 60′000 humans die due to canine transmitted rabies annually, mostly in Africa and Asia. The aim of this paper is to advocate for including animal health aspects into considerations of human health and human rights, and for equitable access to rabies vaccination for both animals and humans. An infringement of human - in particular of children’s - right to health will be illustrated with the case of rabies and poor dog management in Uganda.

Molecular Epidemiology of Rabies in Wild Canidae in Tunisia

Rabies is a viral zoonosis that is transmissible to humans via domestic and wild animals. There are two epidemiological cycles for rabies, the urban and the sylvatic cycles. In an attempt to study the epidemiological role of wild canidae in rabies transmission, the present study aimed to analyze the genetic characteristics of virus isolates and confirm prior suggestions that rabies is maintained through a dog reservoir in Tunisia. Virus strains isolated from wild canidae were subject to viral sequencing, and Bayesian phylogenetic analysis was performed using Beast2 software. Essentially, the virus strains isolated from wild canidae belonged to the Africa-1 clade, which clearly diverges from fox-related strains. Our study also demonstrated that genetic characteristics of the virus isolates were not as distinct as could be expected if a wild reservoir had already existed. On the contrary, the geographic landscape is responsible for the genetic diversity of the virus. The landscape itself could have also acted as a natural barrier to the spread of the virus.

Review of Detection and Quantification of Rabies Virus Antibodies

Rabies is an almost invariably fatal disease. According to the World Health Organization (WHO), rabies virus neutralizing antibody (RVNA) titers of ≥0.5 IU/mL are considered adequate for rabies protection. Therefore, detection and quantification of RABV antibodies are important. Many methods have been developed for detecting RABV antibodies. In the present study, we reviewed several methods of detecting RABV antibodies in human and animal samples and evaluated and compared their performance. Of 34 methods, 5 demonstrated unsatisfactory sensitivity or specificity. The others exhibited sensitivity and specificity of ≥75%. The correlation coefficient for five of eight methods was >0.8. The Bland-Altman mean bias of five of five methods was <±2.0. The kappa values of 25 of 28 methods were higher than 0.4, demonstrating at least moderate agreement. Analysis of the performance of these methods emphasized that any new technology should be considered carefully and objectively before being used as an appropriate and applicable alternative.

On the Use of Phylogeographic Inference to Infer the Dispersal History of Rabies Virus: A Review Study

Rabies is a neglected zoonotic disease which is caused by negative strand RNA-viruses belonging to the genus Lyssavirus. Within this genus, rabies viruses circulate in a diverse set of mammalian reservoir hosts, is present worldwide, and is almost always fatal in non-vaccinated humans. Approximately 59,000 people are still estimated to die from rabies each year, leading to a global initiative to work towards the goal of zero human deaths from dog-mediated rabies by 2030, requiring scientific efforts from different research fields. The past decade has seen a much increased use of phylogeographic and phylodynamic analyses to study the evolution and spread of rabies virus. We here review published studies in these research areas, making a distinction between the geographic resolution associated with the available sequence data. We pay special attention to environmental factors that these studies found to be relevant to the spread of rabies virus. Importantly, we highlight a knowledge gap in terms of applying these methods when all required data were available but not fully exploited. We conclude with an overview of recent methodological developments that have yet to be applied in phylogeographic and phylodynamic analyses of rabies virus.

Rabies post-exposure healthcare-seeking behaviors and perceptions: Results from a knowledge, attitudes, and practices survey, Uganda, 2013

Background

Rabies is a viral disease of animals and people causing fatal encephalomyelitis if left untreated. Although effective pre- and post-exposure vaccines exist, they are not widely available in many endemic countries within Africa. Since many individuals in these countries remain at risk of infection, post-exposure healthcare-seeking behaviors are crucial in preventing infection and warrant examination.

Methodology

A rabies knowledge, attitudes, and practices survey was conducted at 24 geographically diverse sites in Uganda during 2013 to capture information on knowledge concerning the disease, response to potential exposure events, and vaccination practices. Characteristics of the surveyed population and of the canine-bite victim sub-population were described. Post-exposure healthcare-seeking behaviors of canine-bite victims were examined and compared to the related healthcare-seeking attitudes of non-bite victim respondents. Wealth scores were calculated for each household, rabies knowledge was scored for each non-bitten survey respondent, and rabies exposure risk was scored for each bite victim. Logistic regression was used to determine the independent associations between different variables and healthcare-seeking behaviors among canine-bite victims as well as attitudes of non-bitten study respondents.

Results

A total of 798 households were interviewed, capturing 100 canine-bite victims and a bite incidence of 2.3 per 100 person-years. Over half of bite victims actively sought medical treatment (56%), though very few received rabies post-exposure prophylaxis (3%). Bite victims who did not know or report the closest location where PEP could be received were less likely to seek medical care (p = 0.05). Respondents who did not report having been bitten by a dog with higher knowledge scores were more likely to respond that they would both seek medical care (p = 0.00) and receive PEP (p = 0.06) after a potential rabies exposure event.

Conclusions

There was varying discordance between what respondents who did not report having been bitten by a dog said they would do if bitten by a dog when compared to the behaviors exhibited by canine-bite victims captured in the KAP survey. Bite victims seldom elected to wash their wound or receive PEP. Having lower rabies knowledge was a barrier to theoretically seeking care and receiving PEP among not bitten respondents, indicating a need for effective and robust educational programs in the country.

Knowledge, attitudes and practices towards rabies: A survey of the general population residing in the Harare Metropolitan Province of Zimbabwe

BACKGROUND

Rabies remains endemic to the Harare Metropolitan Province of Zimbabwe, with a lack of public participations potentially contributing to the limited success in eliminating the disease. We hypothesized that rabies intervention campaigns were less successful than they could be as a result of poor understanding of the disease at the community level, and thus aimed to identify the knowledge, attitudes, and practices towards rabies in the province.

METHODS

A cross-sectional survey, using a semi-structured questionnaire, was implemented between January 2017 and June 2018 across the province and data were collected from 798 respondents. Frequency distributions and logistic regressions were undertaken to determine the factors associated with the adequacy of the prevailing rabies knowledge, pet ownership characteristics and the existing preventative practices.

RESULTS

The results of our study suggested that the majority of the respondents (92%) had heard of rabies. However, the level of rabies knowledge could be classified as "adequate" in only 36% of respondents. The multivariate logistic regression analysis indicated that pet ownership and type of occupation were statistically associated with a better understanding and knowledge of the disease. Off all the respondents, 49% owned at least one dog or cat and suburb density and occupation were statistically associated with owning a pet. Amongst the pet owners, 57% consulted an animal health practitioner at least once a year and 75% were aware of a rabies vaccine for their pets. The multivariate logistic regression analysis indicated that age, education and gender were statistically associated with pet owners taking their pet(s) to an animal clinic.

CONCLUSION

This study showed that the majority of the respondents lacked comprehensive knowledge about rabies, with the knowledge pertaining to health seeking behaviour and the importance of rabies vaccination being the most lacking. Additional public education relying on key messages, aimed at the different target audiences, is required in the province.