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A l’occasion de la Journ é e Mondiale contre la Rage, le 28 septembre, l’Institut Pasteur de Madagascar (IPM) et le Centre International de Recherche en Agronomie pour le D é veloppement (CIRAD) organisent un symposium intitul é « Rabies : sharing international experience to achieve “ Zero by 30” objective » les 8 et 9 octobre 2024 à l’h ô tel Radisson Blu Waterfront, Antananarivo. Cette rencontre est organis é e par le projet CORAMAD «Contr ô le de la rage dans la Commune Urbaine d’Antananarivo», co-coordonn é par l’IPM et le CIRAD et financ é par l’Ambassade de France à Madagascar. Le projet est men é en partenariat avec le Minist è re de la Sant é Publique (DVSSER, DLMT), le Minist è re de l’Agriculture et de l’Elevage (DSV) et la Commune Urbaine d’Antananarivo (CUA). Avec la participation des responsables du projet CORAMAD, des repr é sentants de toutes les institutions partenaires et du bailleur, de chercheurs, d’acteurs de la sant é publique et de la sant é animale, d’ é tudiants, de responsables nationaux et de scientifiques internationaux travaillant sur la surveillance et la lutte contre la rage, ce s é minaire vise à pr é senter les diff é rentes activit é s r é alis é es par le projet CORAMAD à Antananarivo. Durant deux jours, en r é unissant pr è s d’une trentaine de chercheurs internationaux provenant d’institutions scientifiques en Afrique, en Asie du Sud-Est et en Europe, le symposium est é galement l’occasion d’offrir un cadre d’ é change scientifique et de partage de savoir et d’exp é rience sur les moyens de lutte contre la rage, utilis é s dans le monde. 10/10/2025 20:48 Symposium « Rabies : sharing international experience to achieve “ Zero by 30” objective » - Institut Pasteur de Madagascar https://www.pasteur.mg/symposium-rabies-sharing-international-experience-to-achieve-zero-by-30-objective/ 3/6
Dans une approche «One Health», le projet CORAMAD a pour objectifs (i) de prot é ger la population humaine par le renforcement de la surveillance de la rage, (ii) d’am é liorer la couverture vaccinale de la population canine contre la rage et (iii) de fournir les connaissances sur la d é mographie canine de la CUA indispensables au contr ô le de la rage. « La rage tue encore mais on peut l’ é viter » Voir l’actualit é sur Facebook et Linkedin 10/10/2025 20:48 Symposium « Rabies : sharing international experience to achieve “ Zero by 30” objective » - Institut Pasteur de Madagascar https://www.pasteur.mg/symposium-rabies-sharing-international-experience-to-achieve-zero-by-30-objective/ 4/6
Mixed methods to evaluate knowledge, attitudes and practices (KAP) towards rabies in central and remote communities of Moramanga district, Madagascar ▪C. Leblanc, D. Kassié, [ ... ],H. Guis
INTRODUCTION
Rabies overview: •Rabies causes over 59,000 deaths yearly in Asia and Africa. •99% of human cases from infected dog bites. •100% preventable with vaccines, but fatal after symptoms appear. Global & Madagascar context: •Global financial burden: $124 billion/year. •Madagascar is rabies-endemic with limited awareness and access to treatment. •960 estimated annual deaths, PEP prevents 800 more. PEP access in Madagascar: •32 ARTCs provide free PEP nationwide. •Geographic barriers and poor infrastructure limit access, especially in rural areas. •Increased rabies deaths in areas far from ARTCs. Dog ownership and vaccination in Madagascar: •Vaccination rates: Only 21.6% of dogs in Antananarivo are declared vaccinated; 7.2% have valid certificates. •Rural coverage: Less than 5% of dogs vaccinated. •Mass campaigns: Sporadic, hindered by logistical issues. Study context (1)
KAP studies & knowledge gaps: •Rabies knowledge: Limited understanding, especially of rabies being incurable after symptoms. •Transmission knowledge: 75.4% know rabies spreads via bites, but only 19.1% understand it's fatal after symptoms. •PEP awareness: Many victims don't seek PEP due to minor wounds, unavailability, or lack of awareness. Awareness campaigns: •Limited reach: No national rabies awareness campaigns in the past decade, mostly led by NGOs. •World Rabies Day: Initiatives restricted to a few towns. Study objectives Evaluate KAP toward rabies: •Knowledge & Practices: Assess rabies knowledge and practices in households near and far from ARTC. •Attitudes: Explore community attitudes toward dogs, bite management, and care-seeking after dog bites. Study context (2)
METHODS
Location overview: •Moramanga district: Middle-eastern Madagascar, part of Alaotra-Mangoro region. •Population: 350,724 (2018), 115 km from Antananarivo. Rabies situation: •Endemic: Rabies present in both animals and humans. •ARTC: Located in Moramanga city. Study area: •Urban: Moramanga city. •Rural: Ambohibary and Ampasimpotsy communes. KAP study focus: •Households near (<5 km) and far (>15 km) from ARTC. Study area
Knowledge and practices : quantitative approach(1) Study design and sampling Study design: •Type: Prospective cross-sectional study (Oct 30 –Dec 22, 2018). •Location: Moramanga city, Ambohibary, and Ampasimpotsy. Sample population: •318 households: 159 in Moramanga city, 159 in remote areas (>15 km). Randomization method: •GPS data from the MHURAM project of IPM, used for household registration. Eligibility criteria: •Households from Moramanga district; no plans to move in 3 months. Data collection Tool: •Standardized, pre-tested questionnaire covering socio-economics, dog ownership, rabies knowledge/practices, and ARTC awareness.
Factors influencing rabies knowledge Knowledge score: •Median score: 16.25 (range: 0-22), average: 15.8. •Central area had higher scores (16.41) than remote areas (15.21, p < 0.002). Variables influencing knowledge: •Higher scores linked to: •Higher socio-economic status (p = 0.001). •Living in central area (p < 0.01). •Prior rabies awareness (p = 0.07). •Awareness of ARTC (p = 0.10). •Dog ownership in past 5 years (p = 0.19). Statistical findings: •Logistic regression: Higher socio-economic status and central living significant for higher scores. •Spatial clustering of knowledge scores detected (p = 0.004). But no significant clustering within central or remote areas
Bites incidence & prevention practices Bite incidence: •7.5% of households reported a bite in the past 5 years (2013-2018). •Crude incidence: 0.53 per 100 person-years in central areas (p = 0.03), 0.22 in remote areas. •61% of bites were unprovoked; 65% of victims sought care, 52% received PEP. Bite victim characteristics: •Average age: 22 years; 13% were children under 5. •97% of victims were healthy post-bite; 1 death (3%). Practice score: •Median score: 12, average: 11.8. •Lower in remote areas (11.2) vs. central areas (12.3, p < 0.001). Wound care practices: •45.5% would wash a wound (higher in central areas, p = 0.011). •87.7% would seek medical care (30% doctor, 60% medical center). •Higher intention to seek PEP and medical care in central areas.
Unconventional practices after bites Unconventional practices: •13.5% of respondents mentioned at least one unconventional method for treating bites, such as applying oil •73.1% believed in human rabies vaccination, and 91.3% in dog vaccination to prevent rabies Dog management after bites: •48.8% of respondents would kill a dog that bit a person (significantly fewer in central areas, p < 0.01) •19.2% would consult a veterinarian (higher in central areas, p < 0.001) •40% of respondents in central areas would consult a doctor (vs. 15% in remote areas, p < 0.001) Factors affecting practice scores: •Higher practice scores were associated with: •Living in the central area (p < 0.001) •Higher socio-economic status (p = 0.06) •Prior awareness of rabies (p = 0.02) •Awareness of the ARTC (p = 0.002) •Respondents with higher knowledge scores had significantly higher practice scores (p = 0.002) Statistical findings: •Practice score model had acceptable discrimination capacity (AUC ROC = 0.73) •Significant spatial clustering for practice scores was observed across the entire study zone, but no clustering within central or remote areas
RESULTS Qualitative approach on attitudes
Five categories of dogs: •Unowned free-roaming dogs: in both rural and central areas; seen as a threat or nuisance, including feral dogs. •Free-roaming guard dogs: Owned dogs, mostly in rural areas; perceived as a threat despite familiarity with humans. •Restrained guard dogs: Confined to owner's property, with minimal contact with humans. •Free-roaming hunting dogs: Found only in remote rural areas, used for hunting. •Pet dogs: Exclusive to urban areas, considered family members, well cared for, but a small minority. •Unowned & guard dogs: Common in rural areas, seen as threats. •Pet dogs: Found mainly in urban areas, well cared for but rare. Dog ownership Trends: •Most owned dogs serve as guard dogs. •Pet dogs are rare and mostly urban. Dog vaccination practices: •Few dogs vaccinated despite recognition of its importance. •Barriers: Perceived harmlessness, financial constraints, cultural beliefs. •Vaccination seen as a luxury in rural areas. Social pressure & Rabies: •Dog owners face social pressure to cover health costs after bites. •Rabies vaccination valued to prevent financial and social disruption. Human-dog interactions
Practices concerning bite management Bite incidents & dog types: •28 bite cases: 19 by free-roaming dogs, 7 by guard dogs, 2 by pet dogs. •No bites by feral dogs, despite perceived threat. Rabies cases in biting dogs: •Rabies confirmed in 7 dogs: 3 bitten by others' dogs, 4 by their own. •Rabid dogs showed aggressive behavior, biting multiple people. Bite victim care pathway: •Victims sought care at local centers or ARTC in Moramanga. •5 rabid dogs bit multiple people the same day. •Rabies confirmed post-mortem in dogs. Wound treatment practices: •Most washed bites with soap; superficial bites often untreated or treated with oil/zebu fat. •Free-roaming dog bites led to health center visits.
Dog Owners’ role and factors influencing care seeking Dog owners’ role: •Bite victims often sought the dog owner for vaccination confirmation and treatment cost assistance. •Few dogs were killed after a bite; only 5 respondents mentioned doing so, usually their own dog. Rabies surveillance: •Monitoring biting dogs for rabies was rare; only 2 of 28 cases involved tying the dog for observation. Factors influencing medical care seeking: •Community advice: Encouraged care, especially when rabies was known locally. •Cost coverage: Care was sought if the dog owner agreed to cover costs. •Rabies perception: Signs of rabies (drooling, "mad eyes") prompted faster medical action.
DISCUSSION & CONCLUSION
Discussion Study objective: •Assess KAP toward rabies in Moramanga district. •Quantitative: Focus on distance to ARTC and its impact on knowledge and practices. •Qualitative: Explore attitudes toward dogs, bites, vaccination, and care-seeking behavior. KAP methodology: •Quantitative: Descriptive but lacks behavioral context. •Qualitative: In-depth insights, limited by small samples. •Combination: Clarifies results and context. •Satisfactory knowledge of rabies transmission, limited understanding of first aid and medical care.
Conclusion Geographic impact: •Lower KAP scores in rural areas farther from ARTC, highlighting the need for focused awareness. Awareness of ARTC: •Awareness of ARTC linked to better practices. Socio-economic factors: •Lower socio-economic households had less rabies knowledge, needing targeted outreach. Key data for rabies control: •Collected data on dog ownership, dog-to-human ratios, vaccination rates, and bite incidence to guide future campaigns. •Care-seeking influenced by wound severity, dog ownership, vaccination status, and owner's willingness to cover costs. Challenges in rural areas: •Poor rabies knowledge, low vaccination rates, and inadequate practices in remote areas. •Campaigns should prioritize remote rural populations.
