Behavioral and structural barriers to human post-exposure prophylaxis and other preventive practices during a canine rabies epidemic

Abstract

A canine rabies epidemic started in early 2015 in Arequipa, Peru; the rabies virus continues to circulate in the dog population. Some city residents who suffer dog bites do not seek care or do not complete indicated post-exposure prophylaxis (PEP) regimens, increasing the risk of human rabies. The objectives of our study were to qualitatively assess knowledge about rabies, and preventive practices, such as PEP vaccination, following a dog bite. We conducted eight focus group discussions in peri-urban and urban communities with 70 total participants. We observed low awareness of rabies severity and fatality. Participants, especially those in peri-urban communities, recounted applying herbs or the hair of the dog that bit them to wounds rather than seeking appropriate care. Misconceptions about rabies vaccines and mistreatment at health centers also commonly prevents initiating or completing PEP vaccination. We identify important behavioral and structural barriers and knowledge gaps that limit evidence-based preventive strategies against rabies and may threaten the successful prevention of dog-mediated human rabies in this setting.

Spatial inequality hides the burden of dog bites and the risk of dog-mediated human rabies

“…Furthermore, newly-developed communities in peri-urban areas are often served by health posts rather than larger health centers. In a previous study of another peri-urban area of Arequipa, focus group participants expressed that disrespect from healthcare professionals at health posts and a shortage of materials like PEP vaccines discourages community members from seeking rabies-related healthcare there 44 .…”

“…Houses in peri-urban areas are also built with cheaper materials than urban dwellings. Characteristic stone or brick fences and corrugated metal roofs are not always effective at keeping pets inside or stray dogs out, especially if a female pet is in heat 40,44 . Geographic characteristics of peri-urban Arequipa are partially responsible for a higher dog density in peri-urban areas.…”

“…The high rate of dog bites in peri-urban areas is especially concerning for rabies risk because dogs are less likely to be vaccinated against rabies in peri-urban than urban areas 44,45 .…”

“…Distance to vaccination points and rugged topography of peri-urban regions are barriers for community members to vaccinate their dogs 44,45 . This finding suggests that a "one health" approach to rabies prevention in peri-urban Arequipa, which addresses rabies prevention in pets, wild animals and humans may lead to more effective interventions to decrease spatial inequality.…”

“…The time required to attend a medical appointment, especially if it is far away, can be a second barrier to receiving PEP and rabies-related medical care. This barrier can be especially salient for people living in peri-urban areas, many of whom work informal jobs 44,45 , where missing work may mean missing a day's wages or even putting their employment at risk 61 Findings should be understood within the context of some limitations. The percentage of people bitten by dogs represents only adults in peri-urban and urban areas of ASA.…”