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Awareness of rabies prevention and control measures among public health workers in Northern Vietnam
p u b l i c h e a l t h x x x ( 2 0 1 5 ) 1 e6
Available online at www.sciencedirect.com
Public Health journal homepage: www.elsevier.com/puhe
Original Research
Awareness of rabies prevention and control measures among public health workers in Northern Vietnam* A.K.T. Nguyen a,*, H.T.T. Nguyen a, T.N. Pham a, T.V. Hoang a, B. Olowokure b a b
National Institute of Hygiene and Epidemiology, Hanoi, Viet Nam World Health Organization, Hanoi, Viet Nam
article info
abstract
Article history:
Objectives: To assess and compare rabies related knowledge and awareness of public health
Received 6 June 2014
workers at provincial and district levels in the seven provinces with the highest number of
Received in revised form
deaths from human rabies in northern Vietnam.
14 May 2015
Study design: A cross-sectional study.
Accepted 13 July 2015
Method: A survey was administered to a convenience sample of public health workers
Available online xxx
attending four workshops on rabies disease, control and prevention between 16 October and 21 November, 2012. Total knowledge scores (maximum 38 points) were categorized
Keywords:
into: ‘high’ (>30 points) ‘moderate’ (21e30) and ‘low’ (<21). The Chi-square test was used to
Public health workers
evaluate the statistical significance of the differences in responses between the
Knowledge
respondents.
Zoonosis
Results: Of the 105 public health workers attending the workshops: 57% were male; 76%
Rabies control
worked at the district level compared with 24% who worked at provincial level; and 45%
Veterinarians
had worked in rabies control for <1 year compared with 11% who had worked in rabies
Vietnam
control for >5 years. Overall knowledge was patchy and ranked as ‘moderate’. Important gaps in knowledge were identified particularly in relation to indications for rabies vaccine and rabies immunoglobulin, and routes of exposure to rabies virus. One in ten respondents did not know that rabies virus could be transmitted by the bite of an infected animal. When examining the overall mean knowledge scores, marginally significant differences were identified. The average scores for district level health workers (DLHW) and provincial level health workers (PLHW) were 28 ± 3 and 29 ± 3 points respectively (p ¼ 0.098), which fell within the study definition of ‘moderate’ knowledge. In contrast, when ‘high’ knowledge scores were compared, a significantly greater proportion of PLHW achieved >30 points compared to DLHW (44.0% vs 22.5%, p ¼ 0.044). Conclusions: Important gaps in knowledge and awareness of public health workers were identified particularly in relation to routes of exposure to rabies virus and indications for rabies vaccine and rabies immunoglobulin. Overall, comparison of knowledge scores revealed significant differences between district and provincial public health workers. The
*
The work was carried out in the National Institute of Hygiene and Epidemiology, Hanoi, Vietnam. * Corresponding author. National Institute of Hygiene and Epidemiology, 1 Yersin Street, Hai Ba Trung District, Hanoi, Viet Nam. Tel.: þ84 4 39724819; fax: þ84 4 39717526. E-mail address: [email protected] (A.K.T. Nguyen). http://dx.doi.org/10.1016/j.puhe.2015.07.019 0033-3506/© 2015 The Royal Society for Public Health. Published by Elsevier Ltd. All rights reserved. Please cite this article in press as: Nguyen A.K.T. et al., Awareness of rabies prevention and control measures among public health workers in Northern Vietnam, Public Health (2015), http://dx.doi.org/10.1016/j.puhe.2015.07.019
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p u b l i c h e a l t h x x x ( 2 0 1 5 ) 1 e6
results obtained suggest that in order for rabies control programmes to succeed public health workers at all levels need to have accurate and evidence-based knowledge. This may be facilitated by improving the quantity and quality of their training and education. © 2015 The Royal Society for Public Health. Published by Elsevier Ltd. All rights reserved.
Introduction Rabies is a potentially preventable zoonotic disease that has been eliminated from many countries, but remains a substantial health burden in Asia, mainly due to failure of rabies prevention and control programmes.1e3 In Vietnam rabies is enzootic and recent years have seen the number of reported deaths from rabies increase by 44%, from 68 deaths in 2009, to 98 deaths in 2012.4,5 An important factor in human rabies prevention and control programmes is that health workers involved in providing rabies control services at local level have an adequate awareness and understanding of rabies risks as well as the appropriate prevention and control measures.6,7 However, despite efforts made to raise awareness and promote rabies prevention programs, including the global observance of World Rabies Day, little is known of the rabies knowledge and awareness of preventive medicine workers (hereafter referred to as public health workers) in Vietnam. This study therefore aims to assess the knowledge and awareness of rabies prevention and control among Vietnamese public health workers attending workshops on rabies disease, control and prevention in northern Vietnam. It also compares knowledge and awareness among public health workers at provincial and district level. The latter being at the more peripheral health (‘frontline’) level and as such closer to the communities where rabies cases are initially identified, diagnosed and reported.
Methods Study design This cross-sectional study was carried out between 16 October 2012 and 21 November, 2012 to determine the knowledge and awareness of public health workers attending four workshops on rabies disease, control and prevention. Vietnam is divided into 63 provinces, each of which is subdivided into districts. Northern Vietnam comprises 28 provinces, and workshop participants were from the seven provinces with the highest number of deaths from human rabies in northern Vietnam from 2009 to June 2012. These were: Phu Tho, Yen Bai, Tuyen Quang, Ha Giang, Dien Bien, Son La and Nghe An.
Study participants Participants at the workshops were public health workers and animal health workers of the selected provinces. Altogether
189 persons attended the four workshops, of which 105 (56%) worked in the public health sector. Due to the impact of rabies on the human population in these areas this study focuses on the knowledge and awareness of public health workers, particularly those working at district and provincial level.
Procedures At each workshop participants were given a four page structured questionnaire prior to the commencement of the workshop. All questions were close-ended and the questionnaire was divided into two sections. The first section requested demographic and occupational information, while the second section included items regarding knowledge and awareness with respect to rabies and rabies treatment, prevention and control. All workshop participants agreed to complete the questionnaire. The questions were prepared in accordance with a number of global and national guidelines used in Vietnam.1,8,9 From the returned questionnaires 38 items were used for knowledge scoring. A score of one was allocated to a correct response and zero to an incorrect or non-response. The questionnaire had previously been piloted and the comments and suggestions obtained used to modify the questionnaire. The questionnaire was originally developed in Vietnamese, then translated into English for review before being translated and then administered in Vietnamese.
Statistical analysis Data were summarised using descriptive statistics and the Chi-square test to evaluate the statistical significance of the differences in responses between the respondents. The total knowledge score obtainable (38 points) was categorized into three knowledge levels ‘high’ (>30 points) ‘moderate’ (21e30) and ‘low’ (<21). p values of <0.05 were considered statistically significant. Data were analyzed using SPSS version 16.0.
Results Characteristics of study participants are described in Table 1. Of the 105 public health workers attending the workshops: the mean age was 36 ± 10.0 years; 57% were male compared to 43% who were female (p ¼ 0.029); 45% (47/105) had worked in rabies control for <1 year compared with 11% (12/105) who had worked in rabies control for >5 years (p ¼ 0.0001) and; 76% (80/ 105) were district level health workers (DLHW) compared with 24% who were provincial level health workers (PLHW) (p ¼ 0.0001). Compared to PLHW a greater proportion of DLHW went to junior college (63% vs 28%, p ¼ 0.003). In contrast, a
Please cite this article in press as: Nguyen A.K.T. et al., Awareness of rabies prevention and control measures among public health workers in Northern Vietnam, Public Health (2015), http://dx.doi.org/10.1016/j.puhe.2015.07.019
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Table 1 e Characteristics of the study participants. Characteristics
District Provincial P value level public level public health workers health workers (n ¼ 80) (n ¼ 25) N (%) N (%)
Gender Female 39 (49%) 6 (24%) 0.0291 Male 41 (51%) 19 (76%) 0.0291 Age (years) 21e35 45 (56%) 12 (48%) 0.47 36e45 18 (23%) 6 (24%) 0.876 46þ 17 (21%) 7 (28%) 0.483 Education level High school 17 (21%) 3 (12%) 0.304 Junior college 50 (63%) 7 (28%) 0.003 University 13 (16%) 15 (60%) 0.0001 Duration of working in rabies prevention and control program (years) <1 35 (44%) 12 (48%) 0.709 1e5 38 (48%) 8 (32%) 0.173 >5 7 (9%) 5 (10%) 0.123
significantly greater proportion of PLHW went to university compared to DLHW (60% vs 16%, p ¼ 0.0001). Table 2 describes participants' rabies-related knowledge. Proportionately more PLHW indicated that rabies was an acute encephalomyelitis compared to DLHW (84% vs 61%, p ¼ 0.035). Dogs were named by all participants as a common source of rabies, and most participants (94%) correctly responded that cats were another source of rabies and that pigs (93%) were not. Less than two-thirds of participants named bats and ferret-badgers as other common sources of rabies. A greater proportion of DLHW correctly answered that buffaloes (91% vs 72%, p ¼ 0.013), monkeys (78% vs 68%, p ¼ 0.0337) and rats (76% vs 56%, p ¼ 0.05) were not common sources of rabies. The majority of participants reported that rabies would not be transmitted through intact skin. However, 10% of participants did not know that rabies could be transmitted to humans through the bite of an infected animal. Only 31% (33/105) of participants correctly answered that rabies could be transmitted by either aerosols or organ transplantation. When asked to identify transmission routes for rabies, most participants correctly identified that transmission occurred from domestic animals to humans (95%) and that transmission did not occur from humans to animals (99%). Only 58% of DLHW compared to 76% of PLHW correctly answered that transmission of rabies occurred between wild animals and domestic animals (p ¼ 0.096) while even fewer DLHW (46%) and PLHW (56%) knew that transmission could occur between wild animals. The majority of participants (98%) correctly answered that rabies is a preventable disease (Table 2). When asked about the immediate actions to be taken for an individual bitten by an animal potentially infected with rabies, most participants correctly answered that the wound should be washed immediately (96%), should not be bandaged (97%) and that antibiotics (91%) and traditional drugs should not be given (100%). However, there were differences between DLHW and PLHW with respect to other actions. Only 9% of DLHW and 28% of
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PLHW correctly indicated that the wound should be allowed to bleed freely (p ¼ 0.013). In contrast, compared to 88% of PLHW, 74% of DLHW knew not to cover wounds with traditional herbs/drugs. Among participants, 56% of DLHW correctly answered that human anti-rabies vaccine should not be the initial action when being bitten by a suspected rabid animal compared to 72% of PLHW (p ¼ 0.161). Questions about health care seeking behaviour following a bite from an animal potentially infected with rabies were correctly answered by most participants. However, in cases where individuals had been wounded while butchering a dog 45% of DLHW compared to 68% of PLHW (p ¼ 0.045) responded that vaccine should be given. When asked about actions that should be taken for those who had previously received a full course of either pre-exposure prophylaxis or post-exposure prophylaxis and were subsequently exposed to rabies, only 33% correctly indicated that the individual did not need to receive rabies immunoglobulin. Receipt of booster doses was correctly indicated by only 58% of DLHW compared to 84% of PLHW (p ¼ 0.016). PLHW were also more likely to indicate correctly the number of doses required (p ¼ 0.007). Questions on responsible dog ownership, namely vaccination of dogs (‘yes’) and walking dogs on the street without a muzzle (‘no’) were correctly answered by most participants (92% and 98% respectively). Differences between DLHW and PLHW with respect to dog registration (76% vs 92%, p ¼ 0.086) and keeping dogs at home rather than allowing dogs to roam freely (61% vs 96%, p ¼ 0.073) were marginally significant. When examining the overall mean knowledge scores, marginally significant differences were identified. The average scores for DLHW and PLHW were 28 ± 3 and 29 ± 3 points respectively (p ¼ 0.098), which fell within the study definition of ‘moderate’ knowledge. In contrast, when ‘high’ knowledge scores were compared, a significantly greater proportion of PLHW achieved >30 points compared to DLHW (44.0% vs 22.5%, p ¼ 0.044).
Discussion This study has established for the first time the rabies knowledge and awareness of public health workers in northern Vietnam working in areas with the highest number of rabies deaths in recent years. The overall pattern of results obtained suggests that further education and training is required in several areas by both groups. When comparing rabies knowledge and awareness among public health workers from district and provincial levels, this study found that public health workers working at the district level, that is those working closer to the ‘frontline’ of rabies prevention and control, had overall poorer knowledge scores and provided more incorrect responses in a number of critical areas compared to their provincial level colleagues. While 100% of public health workers were aware that dogs were the most common transmitter of rabies, it is of some concern that overall 10% of respondents were not aware that exposure to rabies can occur from the bite of an animal infected with the rabies virus. Knowledge of cases arising from non-bite exposure in Vietnam, such as those occurring following the butchering of dogs for human consumption,
Please cite this article in press as: Nguyen A.K.T. et al., Awareness of rabies prevention and control measures among public health workers in Northern Vietnam, Public Health (2015), http://dx.doi.org/10.1016/j.puhe.2015.07.019
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Table 2 e Frequency of response of participants to knowledge questions regarding rabies prevention and control. Questions about knowledge and awareness of rabies
Correct answera
% Correct response District level public health workers (n ¼ 80) N (%)
P value
Provincial level public health workers (n ¼ 25) N (%)
1. Is rabies an acute encephalomyelitis? Rabies is an acute encephalomyelitis Y 49 (61%) 21 (84%) 0.035 2. Which of the following are common transmitters of the rabies virus? Dog Y 80 (100%) 25 (100%) Cat Y 77 (96%) 22 (88%) 0.121 Pig N 75 (94%) 23 (92%) 0.759 Buffalo N 73 (91%) 18 (72%) 0.013 Bat Y 52 (65%) 15 (60%) 0.65 Ferret Y 47 (59%) 18 (72%) 0.234 Monkey N 62 (78%) 17 (68%) 0.337 Rat N 61 (76%) 14 (56%) 0.05 3. What are the potential routes of exposure to the rabies virus? Bite of animal infected with rabies virus Y 70 (88%) 24 (96%) 0.226 Through normal skin N 76 (95%) 24 (96%) 0.838 Aerosol infected Y 24 (30%) 9 (36%) 0.573 Organ transplant from human infected with rabies Y 24 (30%) 9 (36%) 0.573 4. How is the rabies virus commonly transmitted? Wild animals to wild animals Y 37 (46%) 14 (56%) 0.395 Wild animal to domestic animals Y 46 (58%) 19 (76%) 0.096 Domestic animal to humans Y 76 (95%) 24 (96%) 0.838 Human to animals N 79 (99%) 25 (100%) 0.574 5. Is rabies a preventable disease? Rabies is a preventable disease Y 78 (98%) 25 (100%) 0.425 6. What initial action(s) should be taken after humans have been bitten by an animal potentially infected with rabies? Bandage the wound immediately N 78 (98%) 24 (96%) 0.694 Allow the wound to bleed freely Y 7 (9%) 7 (28%) 0.013 Immediately receive human anti rabies vaccine N 45 (56%) 18 (72%) 0.161 Wash the wound immediately with soap and water Y 77 (96%) 24 (96%) 0.955 Give antibiotics N 72 (90%) 24 (96%) 0.35 Cover wound with traditional drugs/herbs N 59 (74%) 22 (81%) 0.139 Give traditional drugs N 80 (100%) 25 (100%) 7. What should be done following the initial action(s)? No further treatment needed N 80 (100%) 25 (100%) Visit traditional healer N 80 (100%) 25 (100%) Go to a preventive medicine centre for consultation Y 79 (99%) 23 (92%) 0.077 regarding post-exposure prophylaxis 8. When should a person receive rabies vaccine immediately? Unable to observe the animal Y 67 (84%) 22 (88%) 0.606 Severe wounds (category III) Y 55 (69%) 20 (80%) 0.277 Wound received following butchering of dog Y 36 (45%) 17 (68%) 0.045 9. What would you tell a person who had previously received either pre-exposure prophylaxis or post-exposure prophylaxis and is then bitten by an animal potentially infected with rabies? Do they need to receive rabies immunoglobulin? N 24 (30%) 11 (44%) 0.195 Do they need to receive booster doses of vaccine Y 46 (58%) 21 (84%) 0.016 10. If they need to receive booster doses, how many doses are needed? How many are needed? (2) 12 (15%) 10 (40%) 0.007 11. Which of the following are appropriate behaviours for responsible dog owners? Register their dogs Y 61 (76%) 23 (92%) 0.086 Vaccinate their dogs against rabies Y 72 (90%) 25 (100%) 0.1 Keep their dogs at home Y 65 (61%) 24 (96%) 0.073 Walk dogs on the street without a muzzle N 79 (99%) 24 (96%) 0.38 a
Correct response is indicated as ‘yes’ (Y) or ‘no’ (N).
may have influenced respondents. Nevertheless, in a rabies enzootic country such as Vietnam, we would have anticipated that all respondents would have answered this question correctly. Even more concerning was that the majority of the
respondents who answered this question incorrectly were working at district level. This is one question which should elicit a correct response from any person working in rabies prevention and control as it is a well-documented risk factor,
Please cite this article in press as: Nguyen A.K.T. et al., Awareness of rabies prevention and control measures among public health workers in Northern Vietnam, Public Health (2015), http://dx.doi.org/10.1016/j.puhe.2015.07.019
p u b l i c h e a l t h x x x ( 2 0 1 5 ) 1 e6
and is essential knowledge for any rabies prevention and control strategy. This lack of evidence-based knowledge means that persons bitten by animals potentially infected with the rabies virus may not be managed according to the appropriate guidelines.1,10e12 Studies have shown similar results regarding lack of PEP knowledge and awareness among health care workers and others and that this impacts on survival following a bite and whether or not those bitten by animals receive appropriate and timely prophylaxis.2,13e15 Approximately 5% of respondents did not recognize that wound washing immediately after being bitten by an animal is considered by WHO to be an important step in the initial post-exposure prophylaxis for rabies.1 Although it was encouraging to note that none of the respondents would have given traditional drugs, and that a small minority would have bandaged the wound, nearly one-quarter would have covered the wound with traditional drugs/herbs. This is despite evidence that only rabies vaccines can prevent the onset of clinical symptoms and prevent deaths from rabies. Reasons for reliance on this unproven method of treatment were not identified from this study. It may be that even though public health workers are aware that vaccine is required, embedded local beliefs, practices and culture persist and overlap with modern medicine. Other potential factors may be poor access to health services or inability to purchase rabies vaccine. Despite the availability of national legislation in Vietnam on responsible dog ownership which aims to support management of the dog population, district level workers scored poorly in this section of the questionnaire. This was particularly noticeable in relation to keeping dogs at home and dog registration.8 Globally it is recognized that promoting responsible dog ownership, including restricting the movement of dogs, dog registration and dog vaccination, contributes to reducing the risk of rabies in human populations.1,16e19 These results strongly indicate the need for a multisectoral approach.1,20 Public health workers have an important role to play in ensuring the dissemination and correct application of rabies disease prevention and control measures by individuals and communities. If the knowledge and awareness observed among district level workers in our study is indicative of that of the communities that they serve, then the communities may be unaware of the risks of rabies transmission, the need for prompt and appropriate post-exposure treatment, proper and adequate dog practices and responsible dog ownership. Efficient multisectoral collaboration is necessary for the rapid identification and effective management of rabies and successful interventions, as are public education and behavioural change. This study has identified important knowledge gaps and areas for strengthening rabies prevention and control strategies which can be the focus for future policy, research, training and educational interventions. Those who work in rabies prevention and control should receive early training and education followed by periodic refreshers. Ideally these should be joint activities together with veterinary health colleagues with similar rabies-related responsibilities, and take a 'One Health' approach. The Association of Southeast Asian Nations (ASEAN), of which Vietnam is a member, has set a target for rabies elimination in the Southeast Asian region by 2020.4 In order to attain this goal nationally and
5
contribute to regional achievement, public health workers at all levels especially those at the frontline need to have up to date accurate and evidence-based knowledge.
Limitations The findings of this study should be interpreted in the light of its limitations. One limitation is the cross-sectional nature of the study, which limits generalizability. Also, because the questionnaire involved translation from Vietnamese to English, and back to Vietnamese, errors may have arisen as a result of nuances of language. This may have been especially so for closed-ended questions and may have biased responses received. Although responses from participants may have been influenced by prior knowledge of the workshop and the potential for a pretest, the results would suggest that this knowledge may not have positively impacted on the overall knowledge scores obtained. It is also unlikely that the results of the convenience sample reported here are representative of all persons engaged in rabies-related prevention and control activities in Vietnam as participants were from several provinces with the highest numbers of rabies fatalities nationally. Another limitation is that the number of participants who were from the provincial level was small and may have led to undetected associations. However, the geographic diversity of participants may well be sufficiently adequate to reflect knowledge and awareness of rabies among public health workers in northern Vietnam. In addition, the close-ended questions may be misleading to and depending on how the question is asked.
Author statements Acknowledgements The authors thank all the study participants.
Ethical approval Not required. The ethical approval was not required because the research was not in the listed issues which need to be approved by ethical committee of the National Institute of Hygiene and Epidemiology and Ministry of Health, Vietnam, include clinical trial (vaccines, medicines, biological products …), medical, pharmaceutical and biological researches that request the invasion testing and animal testing or that influence to the personal and institutional/organizational dignity. The research followed the guideline of the National Institute of Hygiene and Epidemiology that all personal information related to the participants who took part in the research was in security and that all workshop participants were aware in advance of the fact that the data collected from their filled questionnaires would be used for making a report and all of them agreed to participate the research and complete the questionnaire.
Funding None.
Please cite this article in press as: Nguyen A.K.T. et al., Awareness of rabies prevention and control measures among public health workers in Northern Vietnam, Public Health (2015), http://dx.doi.org/10.1016/j.puhe.2015.07.019
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Competing interests None declared.
references
1. WHO. WHO expert consultation on rabies. Second report. World Health Organization Technical Report Series 982. Available at:, http://apps.who.int/iris/bitstream/10665/85346/1/ 9789240690943_eng.pdf; 2013 [accessed 09.02.14]. 2. Parviz S, Luby S, Wilde H. Postexposure treatment of rabies in Pakistan. Clin Infect Dis 1998;27:751e6. 3. Yin W, Dong J, Tu C, Edwards J, Guo F, Zhou H, et al. Challenges and needs for China to eliminate rabies. Inf Dis Poverty 2013;2:23. http://dx.doi.org/10.1186/2049-9957-2-23. 4. Nguyen TH. The Second International Conference of Rabies in ASIA (RIA) Foundation. Conference Proceedings. Hanoi, Viet Nam 9e11 September 2009. Available at: http://www. rabiesinasia.org/vietnam/riacon2009report.pdf. [accessed 09.02.14]. 5. Nguyen TTH, Hoang VT, Nguyen TH. Epidemiology of rabies in Vietnam, 2009 e 2012 [in Vietnamese]. J Prev Med 2013;7:29e37. 6. Koruk ST, Koruk I, Kutlu S. Where do we stand in the control of rabies? Knowledge and practices among physicians in a health district in Turkey. Wilderness Environ Med 2011;22:151e5. 7. Ross RS, Wolters B, Viazov SO, Roggendorf M. Awareness of rabies risks and knowledge about preventive measures among experienced German travel health advisors. J Travel Med 2006;13:261e7. 8. MOH. Decree 05/2007/NÐ e CP/on rabies control and prevention in animals issued on 9 January 2009. [In Vietnamese]. Available at: http://vanban.chinhphu.vn/portal/ page/portal/chinhphu/hethongvanban. [accessed 22.09.13]. 9. NIHE. Dispatch number 289/VSDTTU-DT on strengthening the quality of rabies control and prevention dated 20 March 2009. [In Vietnamese].
10. Malerczyk C, DeTora L, Gniel D. Imported human rabies cases in Europe, the United States, and Japan, 1990 to 2010. J Travel Med 2011;18:402e7. 11. Dodet B, Goswami A, Gunasekera A, Guzman FD, Jamali S, Montalban C, et al. Rabies awareness in eight Asian countries. Vaccine 2008;26:6344e8. 12. Wilde H. Failures of post-exposure rabies prophylaxis. Vaccine 2007;25:7605e9. 13. Moran GJ, Talan DA, Mower W, Newdow M, Ong S, Nakase JY, et al. Appropriateness of rabies postexposure prophylaxis treatment for animal exposures. Emergency ID Net Study Group. J Am Med Assoc 2000;284:1001e7. 14. Jeanpetit R, Bellanger AP, Piotte E, Haffner-Mauvais C, Marguet P. Knowledge, attitudes and practices of primary care physicians in the Franche-Comte region (France) regarding the risk of rabies. Zoonoses Public Health; 2013;. http://dx.doi.org/10.1111/zph.12082. 15. Blanton JD, Bowden NY, Eidson M, Wyatt JD, Halon CA. Rabies postexposure prophylaxis, New York, 1995e2000. Emerg Infect Dis 2005;11:1921e7. pez R, Mutinelli LE, Pons ER. 16. Suzuki K, Pereira JAC, Frı´as LA, Lo Rabies vaccination coverage and profiles of the owned-dog population in Santa Cruz de la Sierra, Bolivia. Zoonoses Public Health 2008;55:177e83. 17. Davlin SL, VonVille HM. Canine rabies vaccination and domestic dog population characteristics in the developing world: a systematic review. Vaccine 2012;30:3492e502. 18. Reece JF, Chawla SK. Control of rabies in Jaipur, India, by the sterilisation and vaccination of neighbourhood dogs. Vet Rec 2006;159:379e83. 19. Morters MK, Restif O, Hampson K, Cleaveland S, Wood JL, Conlan AJ. Evidence-based control of canine rabies: a critical review of population density reduction. J Anim Ecol 2013;82:6e14. 20. MOH and MARD. Joint Decree 16/2013/TTLT-BYT-BNN&PTNT on collaboration of relevant sectors for prevention and control of rabies issued by Ministry of Health and Ministry of Agriculture and Rural Development on 27 May, 2013. [In Vietnamese]. Available at: http://phapluat.tuoitre.com.vn/ Van-ban/Y-te/Thong-tu-lien-tich-16-2013-TTLT-BYTBNNPTNT-huong-.aspx. [accessed 09.02.14].
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Available online at www.sciencedirect.com
Public Health journal homepage: www.elsevier.com/puhe
Original Research
Awareness of rabies prevention and control measures among public health workers in Northern Vietnam* A.K.T. Nguyen a,*, H.T.T. Nguyen a, T.N. Pham a, T.V. Hoang a, B. Olowokure b a b
National Institute of Hygiene and Epidemiology, Hanoi, Viet Nam World Health Organization, Hanoi, Viet Nam
article info
abstract
Article history:
Objectives: To assess and compare rabies related knowledge and awareness of public health
Received 6 June 2014
workers at provincial and district levels in the seven provinces with the highest number of
Received in revised form
deaths from human rabies in northern Vietnam.
14 May 2015
Study design: A cross-sectional study.
Accepted 13 July 2015
Method: A survey was administered to a convenience sample of public health workers
Available online xxx
attending four workshops on rabies disease, control and prevention between 16 October and 21 November, 2012. Total knowledge scores (maximum 38 points) were categorized
Keywords:
into: ‘high’ (>30 points) ‘moderate’ (21e30) and ‘low’ (<21). The Chi-square test was used to
Public health workers
evaluate the statistical significance of the differences in responses between the
Knowledge
respondents.
Zoonosis
Results: Of the 105 public health workers attending the workshops: 57% were male; 76%
Rabies control
worked at the district level compared with 24% who worked at provincial level; and 45%
Veterinarians
had worked in rabies control for <1 year compared with 11% who had worked in rabies
Vietnam
control for >5 years. Overall knowledge was patchy and ranked as ‘moderate’. Important gaps in knowledge were identified particularly in relation to indications for rabies vaccine and rabies immunoglobulin, and routes of exposure to rabies virus. One in ten respondents did not know that rabies virus could be transmitted by the bite of an infected animal. When examining the overall mean knowledge scores, marginally significant differences were identified. The average scores for district level health workers (DLHW) and provincial level health workers (PLHW) were 28 ± 3 and 29 ± 3 points respectively (p ¼ 0.098), which fell within the study definition of ‘moderate’ knowledge. In contrast, when ‘high’ knowledge scores were compared, a significantly greater proportion of PLHW achieved >30 points compared to DLHW (44.0% vs 22.5%, p ¼ 0.044). Conclusions: Important gaps in knowledge and awareness of public health workers were identified particularly in relation to routes of exposure to rabies virus and indications for rabies vaccine and rabies immunoglobulin. Overall, comparison of knowledge scores revealed significant differences between district and provincial public health workers. The
*
The work was carried out in the National Institute of Hygiene and Epidemiology, Hanoi, Vietnam. * Corresponding author. National Institute of Hygiene and Epidemiology, 1 Yersin Street, Hai Ba Trung District, Hanoi, Viet Nam. Tel.: þ84 4 39724819; fax: þ84 4 39717526. E-mail address: [email protected] (A.K.T. Nguyen). http://dx.doi.org/10.1016/j.puhe.2015.07.019 0033-3506/© 2015 The Royal Society for Public Health. Published by Elsevier Ltd. All rights reserved. Please cite this article in press as: Nguyen A.K.T. et al., Awareness of rabies prevention and control measures among public health workers in Northern Vietnam, Public Health (2015), http://dx.doi.org/10.1016/j.puhe.2015.07.019
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p u b l i c h e a l t h x x x ( 2 0 1 5 ) 1 e6
results obtained suggest that in order for rabies control programmes to succeed public health workers at all levels need to have accurate and evidence-based knowledge. This may be facilitated by improving the quantity and quality of their training and education. © 2015 The Royal Society for Public Health. Published by Elsevier Ltd. All rights reserved.
Introduction Rabies is a potentially preventable zoonotic disease that has been eliminated from many countries, but remains a substantial health burden in Asia, mainly due to failure of rabies prevention and control programmes.1e3 In Vietnam rabies is enzootic and recent years have seen the number of reported deaths from rabies increase by 44%, from 68 deaths in 2009, to 98 deaths in 2012.4,5 An important factor in human rabies prevention and control programmes is that health workers involved in providing rabies control services at local level have an adequate awareness and understanding of rabies risks as well as the appropriate prevention and control measures.6,7 However, despite efforts made to raise awareness and promote rabies prevention programs, including the global observance of World Rabies Day, little is known of the rabies knowledge and awareness of preventive medicine workers (hereafter referred to as public health workers) in Vietnam. This study therefore aims to assess the knowledge and awareness of rabies prevention and control among Vietnamese public health workers attending workshops on rabies disease, control and prevention in northern Vietnam. It also compares knowledge and awareness among public health workers at provincial and district level. The latter being at the more peripheral health (‘frontline’) level and as such closer to the communities where rabies cases are initially identified, diagnosed and reported.
Methods Study design This cross-sectional study was carried out between 16 October 2012 and 21 November, 2012 to determine the knowledge and awareness of public health workers attending four workshops on rabies disease, control and prevention. Vietnam is divided into 63 provinces, each of which is subdivided into districts. Northern Vietnam comprises 28 provinces, and workshop participants were from the seven provinces with the highest number of deaths from human rabies in northern Vietnam from 2009 to June 2012. These were: Phu Tho, Yen Bai, Tuyen Quang, Ha Giang, Dien Bien, Son La and Nghe An.
Study participants Participants at the workshops were public health workers and animal health workers of the selected provinces. Altogether
189 persons attended the four workshops, of which 105 (56%) worked in the public health sector. Due to the impact of rabies on the human population in these areas this study focuses on the knowledge and awareness of public health workers, particularly those working at district and provincial level.
Procedures At each workshop participants were given a four page structured questionnaire prior to the commencement of the workshop. All questions were close-ended and the questionnaire was divided into two sections. The first section requested demographic and occupational information, while the second section included items regarding knowledge and awareness with respect to rabies and rabies treatment, prevention and control. All workshop participants agreed to complete the questionnaire. The questions were prepared in accordance with a number of global and national guidelines used in Vietnam.1,8,9 From the returned questionnaires 38 items were used for knowledge scoring. A score of one was allocated to a correct response and zero to an incorrect or non-response. The questionnaire had previously been piloted and the comments and suggestions obtained used to modify the questionnaire. The questionnaire was originally developed in Vietnamese, then translated into English for review before being translated and then administered in Vietnamese.
Statistical analysis Data were summarised using descriptive statistics and the Chi-square test to evaluate the statistical significance of the differences in responses between the respondents. The total knowledge score obtainable (38 points) was categorized into three knowledge levels ‘high’ (>30 points) ‘moderate’ (21e30) and ‘low’ (<21). p values of <0.05 were considered statistically significant. Data were analyzed using SPSS version 16.0.
Results Characteristics of study participants are described in Table 1. Of the 105 public health workers attending the workshops: the mean age was 36 ± 10.0 years; 57% were male compared to 43% who were female (p ¼ 0.029); 45% (47/105) had worked in rabies control for <1 year compared with 11% (12/105) who had worked in rabies control for >5 years (p ¼ 0.0001) and; 76% (80/ 105) were district level health workers (DLHW) compared with 24% who were provincial level health workers (PLHW) (p ¼ 0.0001). Compared to PLHW a greater proportion of DLHW went to junior college (63% vs 28%, p ¼ 0.003). In contrast, a
Please cite this article in press as: Nguyen A.K.T. et al., Awareness of rabies prevention and control measures among public health workers in Northern Vietnam, Public Health (2015), http://dx.doi.org/10.1016/j.puhe.2015.07.019
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Table 1 e Characteristics of the study participants. Characteristics
District Provincial P value level public level public health workers health workers (n ¼ 80) (n ¼ 25) N (%) N (%)
Gender Female 39 (49%) 6 (24%) 0.0291 Male 41 (51%) 19 (76%) 0.0291 Age (years) 21e35 45 (56%) 12 (48%) 0.47 36e45 18 (23%) 6 (24%) 0.876 46þ 17 (21%) 7 (28%) 0.483 Education level High school 17 (21%) 3 (12%) 0.304 Junior college 50 (63%) 7 (28%) 0.003 University 13 (16%) 15 (60%) 0.0001 Duration of working in rabies prevention and control program (years) <1 35 (44%) 12 (48%) 0.709 1e5 38 (48%) 8 (32%) 0.173 >5 7 (9%) 5 (10%) 0.123
significantly greater proportion of PLHW went to university compared to DLHW (60% vs 16%, p ¼ 0.0001). Table 2 describes participants' rabies-related knowledge. Proportionately more PLHW indicated that rabies was an acute encephalomyelitis compared to DLHW (84% vs 61%, p ¼ 0.035). Dogs were named by all participants as a common source of rabies, and most participants (94%) correctly responded that cats were another source of rabies and that pigs (93%) were not. Less than two-thirds of participants named bats and ferret-badgers as other common sources of rabies. A greater proportion of DLHW correctly answered that buffaloes (91% vs 72%, p ¼ 0.013), monkeys (78% vs 68%, p ¼ 0.0337) and rats (76% vs 56%, p ¼ 0.05) were not common sources of rabies. The majority of participants reported that rabies would not be transmitted through intact skin. However, 10% of participants did not know that rabies could be transmitted to humans through the bite of an infected animal. Only 31% (33/105) of participants correctly answered that rabies could be transmitted by either aerosols or organ transplantation. When asked to identify transmission routes for rabies, most participants correctly identified that transmission occurred from domestic animals to humans (95%) and that transmission did not occur from humans to animals (99%). Only 58% of DLHW compared to 76% of PLHW correctly answered that transmission of rabies occurred between wild animals and domestic animals (p ¼ 0.096) while even fewer DLHW (46%) and PLHW (56%) knew that transmission could occur between wild animals. The majority of participants (98%) correctly answered that rabies is a preventable disease (Table 2). When asked about the immediate actions to be taken for an individual bitten by an animal potentially infected with rabies, most participants correctly answered that the wound should be washed immediately (96%), should not be bandaged (97%) and that antibiotics (91%) and traditional drugs should not be given (100%). However, there were differences between DLHW and PLHW with respect to other actions. Only 9% of DLHW and 28% of
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PLHW correctly indicated that the wound should be allowed to bleed freely (p ¼ 0.013). In contrast, compared to 88% of PLHW, 74% of DLHW knew not to cover wounds with traditional herbs/drugs. Among participants, 56% of DLHW correctly answered that human anti-rabies vaccine should not be the initial action when being bitten by a suspected rabid animal compared to 72% of PLHW (p ¼ 0.161). Questions about health care seeking behaviour following a bite from an animal potentially infected with rabies were correctly answered by most participants. However, in cases where individuals had been wounded while butchering a dog 45% of DLHW compared to 68% of PLHW (p ¼ 0.045) responded that vaccine should be given. When asked about actions that should be taken for those who had previously received a full course of either pre-exposure prophylaxis or post-exposure prophylaxis and were subsequently exposed to rabies, only 33% correctly indicated that the individual did not need to receive rabies immunoglobulin. Receipt of booster doses was correctly indicated by only 58% of DLHW compared to 84% of PLHW (p ¼ 0.016). PLHW were also more likely to indicate correctly the number of doses required (p ¼ 0.007). Questions on responsible dog ownership, namely vaccination of dogs (‘yes’) and walking dogs on the street without a muzzle (‘no’) were correctly answered by most participants (92% and 98% respectively). Differences between DLHW and PLHW with respect to dog registration (76% vs 92%, p ¼ 0.086) and keeping dogs at home rather than allowing dogs to roam freely (61% vs 96%, p ¼ 0.073) were marginally significant. When examining the overall mean knowledge scores, marginally significant differences were identified. The average scores for DLHW and PLHW were 28 ± 3 and 29 ± 3 points respectively (p ¼ 0.098), which fell within the study definition of ‘moderate’ knowledge. In contrast, when ‘high’ knowledge scores were compared, a significantly greater proportion of PLHW achieved >30 points compared to DLHW (44.0% vs 22.5%, p ¼ 0.044).
Discussion This study has established for the first time the rabies knowledge and awareness of public health workers in northern Vietnam working in areas with the highest number of rabies deaths in recent years. The overall pattern of results obtained suggests that further education and training is required in several areas by both groups. When comparing rabies knowledge and awareness among public health workers from district and provincial levels, this study found that public health workers working at the district level, that is those working closer to the ‘frontline’ of rabies prevention and control, had overall poorer knowledge scores and provided more incorrect responses in a number of critical areas compared to their provincial level colleagues. While 100% of public health workers were aware that dogs were the most common transmitter of rabies, it is of some concern that overall 10% of respondents were not aware that exposure to rabies can occur from the bite of an animal infected with the rabies virus. Knowledge of cases arising from non-bite exposure in Vietnam, such as those occurring following the butchering of dogs for human consumption,
Please cite this article in press as: Nguyen A.K.T. et al., Awareness of rabies prevention and control measures among public health workers in Northern Vietnam, Public Health (2015), http://dx.doi.org/10.1016/j.puhe.2015.07.019
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Table 2 e Frequency of response of participants to knowledge questions regarding rabies prevention and control. Questions about knowledge and awareness of rabies
Correct answera
% Correct response District level public health workers (n ¼ 80) N (%)
P value
Provincial level public health workers (n ¼ 25) N (%)
1. Is rabies an acute encephalomyelitis? Rabies is an acute encephalomyelitis Y 49 (61%) 21 (84%) 0.035 2. Which of the following are common transmitters of the rabies virus? Dog Y 80 (100%) 25 (100%) Cat Y 77 (96%) 22 (88%) 0.121 Pig N 75 (94%) 23 (92%) 0.759 Buffalo N 73 (91%) 18 (72%) 0.013 Bat Y 52 (65%) 15 (60%) 0.65 Ferret Y 47 (59%) 18 (72%) 0.234 Monkey N 62 (78%) 17 (68%) 0.337 Rat N 61 (76%) 14 (56%) 0.05 3. What are the potential routes of exposure to the rabies virus? Bite of animal infected with rabies virus Y 70 (88%) 24 (96%) 0.226 Through normal skin N 76 (95%) 24 (96%) 0.838 Aerosol infected Y 24 (30%) 9 (36%) 0.573 Organ transplant from human infected with rabies Y 24 (30%) 9 (36%) 0.573 4. How is the rabies virus commonly transmitted? Wild animals to wild animals Y 37 (46%) 14 (56%) 0.395 Wild animal to domestic animals Y 46 (58%) 19 (76%) 0.096 Domestic animal to humans Y 76 (95%) 24 (96%) 0.838 Human to animals N 79 (99%) 25 (100%) 0.574 5. Is rabies a preventable disease? Rabies is a preventable disease Y 78 (98%) 25 (100%) 0.425 6. What initial action(s) should be taken after humans have been bitten by an animal potentially infected with rabies? Bandage the wound immediately N 78 (98%) 24 (96%) 0.694 Allow the wound to bleed freely Y 7 (9%) 7 (28%) 0.013 Immediately receive human anti rabies vaccine N 45 (56%) 18 (72%) 0.161 Wash the wound immediately with soap and water Y 77 (96%) 24 (96%) 0.955 Give antibiotics N 72 (90%) 24 (96%) 0.35 Cover wound with traditional drugs/herbs N 59 (74%) 22 (81%) 0.139 Give traditional drugs N 80 (100%) 25 (100%) 7. What should be done following the initial action(s)? No further treatment needed N 80 (100%) 25 (100%) Visit traditional healer N 80 (100%) 25 (100%) Go to a preventive medicine centre for consultation Y 79 (99%) 23 (92%) 0.077 regarding post-exposure prophylaxis 8. When should a person receive rabies vaccine immediately? Unable to observe the animal Y 67 (84%) 22 (88%) 0.606 Severe wounds (category III) Y 55 (69%) 20 (80%) 0.277 Wound received following butchering of dog Y 36 (45%) 17 (68%) 0.045 9. What would you tell a person who had previously received either pre-exposure prophylaxis or post-exposure prophylaxis and is then bitten by an animal potentially infected with rabies? Do they need to receive rabies immunoglobulin? N 24 (30%) 11 (44%) 0.195 Do they need to receive booster doses of vaccine Y 46 (58%) 21 (84%) 0.016 10. If they need to receive booster doses, how many doses are needed? How many are needed? (2) 12 (15%) 10 (40%) 0.007 11. Which of the following are appropriate behaviours for responsible dog owners? Register their dogs Y 61 (76%) 23 (92%) 0.086 Vaccinate their dogs against rabies Y 72 (90%) 25 (100%) 0.1 Keep their dogs at home Y 65 (61%) 24 (96%) 0.073 Walk dogs on the street without a muzzle N 79 (99%) 24 (96%) 0.38 a
Correct response is indicated as ‘yes’ (Y) or ‘no’ (N).
may have influenced respondents. Nevertheless, in a rabies enzootic country such as Vietnam, we would have anticipated that all respondents would have answered this question correctly. Even more concerning was that the majority of the
respondents who answered this question incorrectly were working at district level. This is one question which should elicit a correct response from any person working in rabies prevention and control as it is a well-documented risk factor,
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and is essential knowledge for any rabies prevention and control strategy. This lack of evidence-based knowledge means that persons bitten by animals potentially infected with the rabies virus may not be managed according to the appropriate guidelines.1,10e12 Studies have shown similar results regarding lack of PEP knowledge and awareness among health care workers and others and that this impacts on survival following a bite and whether or not those bitten by animals receive appropriate and timely prophylaxis.2,13e15 Approximately 5% of respondents did not recognize that wound washing immediately after being bitten by an animal is considered by WHO to be an important step in the initial post-exposure prophylaxis for rabies.1 Although it was encouraging to note that none of the respondents would have given traditional drugs, and that a small minority would have bandaged the wound, nearly one-quarter would have covered the wound with traditional drugs/herbs. This is despite evidence that only rabies vaccines can prevent the onset of clinical symptoms and prevent deaths from rabies. Reasons for reliance on this unproven method of treatment were not identified from this study. It may be that even though public health workers are aware that vaccine is required, embedded local beliefs, practices and culture persist and overlap with modern medicine. Other potential factors may be poor access to health services or inability to purchase rabies vaccine. Despite the availability of national legislation in Vietnam on responsible dog ownership which aims to support management of the dog population, district level workers scored poorly in this section of the questionnaire. This was particularly noticeable in relation to keeping dogs at home and dog registration.8 Globally it is recognized that promoting responsible dog ownership, including restricting the movement of dogs, dog registration and dog vaccination, contributes to reducing the risk of rabies in human populations.1,16e19 These results strongly indicate the need for a multisectoral approach.1,20 Public health workers have an important role to play in ensuring the dissemination and correct application of rabies disease prevention and control measures by individuals and communities. If the knowledge and awareness observed among district level workers in our study is indicative of that of the communities that they serve, then the communities may be unaware of the risks of rabies transmission, the need for prompt and appropriate post-exposure treatment, proper and adequate dog practices and responsible dog ownership. Efficient multisectoral collaboration is necessary for the rapid identification and effective management of rabies and successful interventions, as are public education and behavioural change. This study has identified important knowledge gaps and areas for strengthening rabies prevention and control strategies which can be the focus for future policy, research, training and educational interventions. Those who work in rabies prevention and control should receive early training and education followed by periodic refreshers. Ideally these should be joint activities together with veterinary health colleagues with similar rabies-related responsibilities, and take a 'One Health' approach. The Association of Southeast Asian Nations (ASEAN), of which Vietnam is a member, has set a target for rabies elimination in the Southeast Asian region by 2020.4 In order to attain this goal nationally and
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contribute to regional achievement, public health workers at all levels especially those at the frontline need to have up to date accurate and evidence-based knowledge.
Limitations The findings of this study should be interpreted in the light of its limitations. One limitation is the cross-sectional nature of the study, which limits generalizability. Also, because the questionnaire involved translation from Vietnamese to English, and back to Vietnamese, errors may have arisen as a result of nuances of language. This may have been especially so for closed-ended questions and may have biased responses received. Although responses from participants may have been influenced by prior knowledge of the workshop and the potential for a pretest, the results would suggest that this knowledge may not have positively impacted on the overall knowledge scores obtained. It is also unlikely that the results of the convenience sample reported here are representative of all persons engaged in rabies-related prevention and control activities in Vietnam as participants were from several provinces with the highest numbers of rabies fatalities nationally. Another limitation is that the number of participants who were from the provincial level was small and may have led to undetected associations. However, the geographic diversity of participants may well be sufficiently adequate to reflect knowledge and awareness of rabies among public health workers in northern Vietnam. In addition, the close-ended questions may be misleading to and depending on how the question is asked.
Author statements Acknowledgements The authors thank all the study participants.
Ethical approval Not required. The ethical approval was not required because the research was not in the listed issues which need to be approved by ethical committee of the National Institute of Hygiene and Epidemiology and Ministry of Health, Vietnam, include clinical trial (vaccines, medicines, biological products …), medical, pharmaceutical and biological researches that request the invasion testing and animal testing or that influence to the personal and institutional/organizational dignity. The research followed the guideline of the National Institute of Hygiene and Epidemiology that all personal information related to the participants who took part in the research was in security and that all workshop participants were aware in advance of the fact that the data collected from their filled questionnaires would be used for making a report and all of them agreed to participate the research and complete the questionnaire.
Funding None.
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Competing interests None declared.
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Please cite this article in press as: Nguyen A.K.T. et al., Awareness of rabies prevention and control measures among public health workers in Northern Vietnam, Public Health (2015), http://dx.doi.org/10.1016/j.puhe.2015.07.019