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According to Ethiopian public health Institute rabies in Ethiopia is ... estimated between 150,000 and 200,000, of which 50% are stray dogs (EPHI, 2011).
 

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Table of Contents 1. INTRODUCTION.......................................................................................................................... 1 2. LITERATURE REVIEW.............................................................................................................. 4 2.1. Definition and Etiology ........................................................................................................... 4 2.2. Epidemiology ........................................................................................................................... 5 2.2.1. Distribution and host range...............................................................................................................5

2.3. Host Susceptibility ................................................................................................................... 6 2.4. Transmission ............................................................................................................................ 6 2.5. Life Cycle.................................................................................................................................. 7 2.6. Incubation Period .................................................................................................................... 7 2.7. Pathogenesis and Pathology ................................................................................................... 8 2.8. Clinical Sign ............................................................................................................................. 8 2.9. Diagnosis................................................................................................................................... 9 2.9.1. Laboratory diagnosis ......................................................................................................................10 2.9.1.1. Sampling and transportation of specimens ..............................................................................10 2.9.1.2. Viral antigen and antibody detection .......................................................................................11 2.9.1.3. Virus isolation..........................................................................................................................12

2.10. Control and Prevention....................................................................................................... 12 2.10.1. Prevention and Control in Human Beings ....................................................................................13 2.10.1.1. Exposure prevention ..............................................................................................................13 2.10.1.2. Public health education (Rabies awareness) ..........................................................................13 2.10.1.3. Pre-exposure prophylaxis vaccination ...................................................................................14 2.10.1.4. Post-exposure prophylaxis .....................................................................................................14 2.10.2. Prevention and control of rabies in canine ...................................................................................15 2.10.2.1. Canine vaccination ................................................................................................................15 2.10.2.2. Dog population management .................................................................................................15 2.10.3. Prevention and Control of Rabies in Wild Animals .....................................................................16

2.11. Economic and Public Health Significance......................................................................... 16 2.12. Status of Rabies in Ethiopia ............................................................................................... 17 3. MATERIAL AND METHODS.................................................................................................. 20 3.1. Study Area.............................................................................................................................. 20 ŝ 

3.2. Study Design and Study Population .................................................................................... 20 3.3. Sample Size Determination and Sampling Techniques ..................................................... 20 3.4. Inclusion and Exclusion Criteria ......................................................................................... 21 3.6. Data Management and Analysis .......................................................................................... 21 4. RESULTS ..................................................................................................................................... 23 5. DISCUSSION ............................................................................................................................... 34 6. CONCLUSION AND RECOMMENDATIONS ....................................................................... 40 7. REFERENCES ............................................................................................................................. 42 8. ANNEXES..................................................................................................................................... 51 

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1. INTRODUCTION Rabies disease is characterized by an acute encephalitis illness caused by rabies virus genus Lyssa virus in the family of Rhabdoviridae that affects virtually all mammals. Infected species invariably die from the disease once clinical signs are manifested (Jackson and Wunner, 2007). It is the most widely recognized example of salivary transmission of viruses. Inoculation of infected saliva through the bite of a rabid animal appears to be the predominant mode of rabies viral entry although contamination of broken skin and mucous membrane such as mouth, nasal cavity or eyes by fresh saliva or neurological tissues may result in infection (OIE, 2013). Rabies virus (RABV) is a highly neurotropic pathogen that typically leads to mortality of infected animals and humans. It is estimated that nearly 55,000 human RABV fatalities occur each year, though this number is likely much higher due to unreported exposures or failure of diagnosis. In the 21st century, rabies remains as one of the most feared and important threats to public health. As a neglected zoonotic disease, rabies is present throughout much of the world, with many deaths in human beings occurring in Africa and Asia in children younger than 15 years. Rabies is regarded as under-reported in many regions (Fooks, 2005). Dogs are the principal vector for human rabies, and are responsible for more than 99% of human cases. Hence, controlling rabies in dogs, and especially free-roaming VWUD\ GRJVLVWKH¿UVWSULRULW\IRUSUHYHQWLRQRIKXPDQrabies. The disease causes a severe and long-lasting societal and economic burden and the implications are especially apparent in poverty-stricken developing countries. Shortage of resources and a limited public health infrastructure in many rabies-endemic countries precludes data collection and analysis. Rabies has been successfully controlled in dog populations throughout the Americas, and rabies in both dog and terrestrial wildlife populations has been successfully eliminated from Western Europe. Thus, rabies can be controlled with suƥcient resources (Nottidge, 2005).

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The demographic characteristic of dogs biting humans and livestock have not been fully elucidated. Besides, the rabies status of dogs biting humans has not been known. It has been a common practice to provide post-exposure vaccines to humans bitten by dogs irrespective of their rabies status. In Ethiopia, rabies is an endemic disease with a high incidence rate (Jenberu et al., 2013). Unfortunately, individuals who are exposed to rabies virus often see traditional healers for the diagnosis and treatment of the disease. These widespread traditional practices of handling rabies cases are believed to interfere with timely seeking of post exposure prophylaxis (PEP). Rabies victims specially, from rural areas seek PEP treatment after exhausting the traditional medicinal intervention and usually after a loss of life from family members (Deressa et al., 2010). Community awareness about rabies is very crucial in rabies prevention and control. For efficiently increasing awareness, the knowledge gap among the community should be identified and targeted. Community awareness of all aspects of rabies is generally lacking or limited, such as first aid or management of animal bites, pre- and post-exposure prophylaxis, responsible pet dog ownership, dog population management. Regarding the immediate measures to be carried out after a bite exposure, there is inadequate knowledge of the crucial need to wash wounds with soap and running water and apply antiseptics and where vaccine is available. People may also contact local traditional healers for treatment, thus losing precious time and increasing the danger of infection and death (WHO, 2004). Community awareness creation is being under movement in some area of the country even though limited to towns and nearby research centers. In debark town elimination of stray dogs and prophylaxis vaccination was practiced in October 2015 but was limited to the three kebeles of the town. There is lack of accurate quantitative information on rabies both in humans and in animals and little is known about the awareness of the people about the disease to apply effective control measures in Ethiopia. Even if there were reports of death of humans and animals in the study area, no prior studies were undertaken about the prevalence and public awareness towards Ϯ 

rabies. Thus, the objective of this study was to assess the level of knowledge, attitudes and practices regarding rabies and associated risk factors among the communities of Debark District.

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2. LITERATURE REVIEW 2.1. Definition and Etiology The word rabies is derived from the Sanskrit word rabhas, ZKLFKPHDQV³WRUDJH´RU from the Latin word rabere, ZKLFKPHDQV³WRrave´ (Hankins and Rosekrans, 2004). Rabies virus (RABV) is the prototype virus of the genus Lyssavirus (from the Greek lyssa meaning 'rage') in the family Rhabdoviridae (from the Greek rhabdos meaning 'rod').The prototype RABV is a genotype 1 virus (formerly recognized as serotype 1). Lagos bat virus (LBV, genotype 2/serotype 2), Mokola virus (MOKV, genotype 3/serotype 3), Duvenhage virus (DUVV, genotype 4/serotype 4), European bat lyssa virus type 1 (EBL-1, genotype 5), European bat lyssa virus type 2 (EBL-2, genotype 6) and Australian bat lyssa virus (ABLV, genotype 7) are rabies-related lyssa viruses that reflect the genotypic diversity of the genus Lyssa virus (Kuzmin et al., 2005). It is a disease of mammals, but the sensitivity to the virus can vary between different mammal hosts (Quinn et al., 2002).

Figure 1. Schematic representation of rhabdovirus virion Source: Bela-Ong et al. (2014). The rabies virion contains an internal ribonucleoprotein (RNP) core consisting of the single-strand, negative-sense genome RNA encapsidated with nucleocapsid protein (N), the virion-assodated RNA polymerase (L) and polymerase cofactor phosphoprotein (p) (figure 1). The RNP core in association with the matrix protein (M) is condensed into the typical bullet shape particle that is characteristic of rhabdoviruses. A lipid bilayer envelope (or membrane) in which the surface trimeric ϰ 

glycoprotein (G) spikes are anchored surrounds the RNP-M structure. The membrane 'tail' depicted in the drawing represents the trailing piece of envelope that is frequently observed in the electron microscope attached to the virus as it buds from the plasma membrane of the infected cell. Dinucleotide (N-P), two pentanucleotide (P-M and M-G) and one long 423- nucleotide sequence (G-L) which are unique to lyssa viruses (Frederick, 2007).

2.2. Epidemiology 2.2.1. Distribution and host range Classical RABV occurs worldwide, with the exception of Antarctica, Australia and some island nations. Lack of reporting and underreporting by some countries undermines knowledge of the true impact of the disease. In Africa, five lyssa virus species in addition to RABV have been documented; these include Lagos bat virus (LBV) and Mokola virus (MOKV), which circulate widely across the continent, Duvenhage virus (DUVV), isolated from bats in southern Africa, Shimoni bat virus (SHIBV) and Ikoma virus (IKOV) To date, only single isolates of the last two species have been recovered, so their range is unknowns (Susan and Nadin, 2015). Rabies virus is spread over geographical areas through mammal reservoirs. Different parts of the world have different mammal species as main reservoir for the disease, such as the red fox and raccoon dog in Europe and raccoons, skunks, foxes and bats in North America (Finnegan et al., 2002) and vampire bat in Central- and South America (Schneider et al., 2009). Globally, over 98% of all human rabies occurs following exposures to infected dogs (WHO, 2013). Domestic dogs are believed to contribute to a great extent as rabies virus reservoirs in African countries (Prager et al., 2012). Rabies is maintained in two epidemiological cycles, one urban and one sylvatic. In the urban rabies cycle, dogs are the main reservoir host. This cycle predominates in areas of Africa, Asia, and Central and South America where the proportion of unvaccinated and semi-owned or stray dogs is high. The sylvatic (or wildlife) cycle is ϱ 

the predominant cycle in Europe and North America. It is also present simultaneously with the urban cycle in some parts of the world. The epidemiology of this cycle is complex; factors affecting it include the virus strain, the behavior of the host species, ecology and environmental factors. In any ecosystem, often one and occasionally up to 3 wildlife species are responsible for perpetuating a particular strain of rabies. The disease pattern in wildlife can either be relatively stable, or occur as a slow moving epidemic (CFSPH, 2012). Rabies is a viral zoonosis associated with many species of Carnivora and Chiroptera, which are the primary hosts of the rabies virus; only Chiroptera species are the primary hosts of almost all other lyssa viruses (WHO, 2013). Although sporadic cases of rabies in wildlife have been documented across the African continent, convincing evidence for the circulation of rabies in populations of wild carnivores has been found only in southern Africa, where wild candies, such as jackals (Canisadustus and C. mesomelas) and bat-eared foxes (Otocyonmegalotis) are assumed to be primary hosts of rabies virus (Zulu et al., 2009). Additionally, members of the Herpestidae family (e.g. mongooses) appear to be responsible for transmission of a distinct variant of rabies virus in southern Africa (Van et al., 2010). Spillover rabies virus from dogs is threatening endangered wild African canids such as the Ethiopian wolf (C. simensis) and the African wild dog (Lycaonpictus) (Woodroffe et al., 2012).

2.3. Host Susceptibility All mammals are susceptible to infection; the degree of susceptibility may be influenced by some host factors like age, health, nutrition, etc (Heymann, 2008). The human immune response to natural rabies infection is insufficient to prevent disease (Bassinet al., 2009).

2.4. Transmission The virus is spread through infected saliva in bites, scratches and through licks from infected animals in open wounds or on mucosal membranes (WHO, 2013b, Depaniet ϲ 

al., 2012).The virus is then spread from the bite wound site via the peripheral nervous system and it generates clinical symptoms in step with destruction of the nervous tissue. This causes neurological signs, such as aggressiveness and an increased risk of biting people or other animals, and the risk of transmission of virus to occur simultaneously in an infected animal (Zachary, 2007). Some other tissues also get infected with virus, such as muscles and the salivary glands which is why saliva becomes infective to other individuals that come in contact with it (Quinn et al., 2002).

2.5. Life Cycle Fundamentally, viruses are infectious nucleic acids that have evolved efficient mechanisms for shuttling their genomes between the host cells that they depend upon for replication (David, 2014).The sequence of events in the RABV life cycle, i.e. replication in vitro and in vivo (in cell culture or animal) can be divided into three phases. The first or early phase includes virus attachment to receptors on susceptible host cells, entry via direct virus fusion externally with the plasma membrane and internally with endosomal membranes of the cell and uncoating of virus particles and liberation of the helical RNP in the cytoplasm. The second, or middle, phase includes transcription and replication of the viral genome and viral protein synthesis. The third, or late, phase includes virus assembly and egress from the infected cell. The early phase of the RABV life cycle, often regarded as the most difficult of the events in RABV infection to understand fully, has been studied in many different cell culture systems. These include neuronal and non-neuronal cell lines and primary, dissociated cell cultures derived from dissected pieces of nervous tissue (Frederick, 2007).

2.6. Incubation Period The incubation period is, on average, 30 to 90 day long but may last from a few days to several years (Mani and Murray, 2006). Length of incubation depends on wound severity, location in relation to nerve supply, and relative distance from the brain; the ϳ 

amount and variant of virus; the degree of protection provided by clothing and other factors (Heymann, 2008).

2.7. Pathogenesis and Pathology Neuro-invasiveness and neuro-tropism are the main features that define the pathogenesis of rabies. Although RABV pathogenicity is a multigenic trait involving several elements of the RABV genome, the RABV glycoprotein plays a major role in RABV pathogenesis by controlling the rate of virus uptake and trans-synaptic virus spread, and by regulating the rate of virus replication (Bernhard et al., 2008). The virus spreads by retrograde axonal transport from the peripheral nerves to the neuronal cell body, possibly by cytoplasmic dynein (Wang et al., 2005) after replication in the cell body of the primary neuron, infection proceeds via retrograde axonal transport and trans synaptic spread through several neurons. Trans synaptic spread is the ability of the virus to use synaptic junctions to propagate within the CNS (Dietzschold et al., 2005). When the central nervous system is reached, massive viral replication occurs with-in neurons, causing widespread neuronal inflammation and necrosis (McKay and Wallis, 2005). Microscopic examination of rabies-infected neurons often shows eosinophilic intracytoplasmic inclusions, known as Negri bodies, which contain masses of viral RNA, ribosome and virions (Durai and Venkatraman, 2006). From the central nervous system, the virus spreads centrifugally to the rest of the body, especially the salivary glands, via the peripheral nerves (Mani and Murray, 2006). It is at this stage that productive viral replication occurs with budding, particularly in the salivary glands, resulting in high viral concentrations in the saliva (McKay and Wallis, 2005).

2.8. Clinical Sign Clinical rabies is a continuum, not a series of easily defined stages. Prodromal period ± the first 1 to 3 days after the rabies virus reaches the brain. Typically, a prodrome lasts 2 to 10 day, and this duration correlates with viral invasion of the central ϴ 

nervous system. Prodromal symptoms are non-specific and include influenza-like symptoms and paresthesia, hyperesthesia, anesthesia, pain, and pruritus at the site of viral entry. Death usually follows within 10 days, due to paralysis (Hankins and Rosekrans, 2004, Plotkin, 2004). Excitative stage ± the next 2 to 3 days, which is the "furious rabies" stage - tame animals suddenly become vicious, attacking humans and other animals as they roam and wander. Some animals will chew and eat odd objects (rocks, sticks, etc.). Paralysis then begins, and loss of the ability to swallow will cause frothing at the mouth of the affected animal. Paralytic stage - follows the excitative stage, or is the main clinical presentation for some animals. The throat and chewing muscles will be paralyzed, and the animal is unable to swallow, causing excessive drool, the lower jaw is often dropped. This is a dangerous period for human contact with domestic animals such as cows and horses; "choke" (foreign body within the throat) can be a misdiagnosis of rabies, causing humans to be potentially exposed as they investigate the problem. Similar situations occur in dogs that appear to be choking (drooling and dropped jaw). This is also the period when wild animals may seem tame to humans and nocturnal animals are seen in the daylight. The paralysis progresses from the neck and jaw to all areas of the body, the animal falls into a coma, and dies within a few hours (WHO, 2010).

2.9. Diagnosis Clinical observation may only lead to a suspicion of rabies because signs of the disease are not characteristic and may vary greatly from one animal to another. A presumptive diagnosis of rabies, an acute, progressive encephalomyelitis, with the highest case fatality rate of any infectious disease, is simple in a person presenting with a compatible illness after documented exposure to a laboratory-confirmed rabid animal. Specific clinical signs of hydro- or aerophobia in humans provide a strong suspicion of rabies, if they are well documented. Classical signs of brain involvement include spasms in response to tactile, auditory, visual or olfactory stimuli (e.g. ϵ 

aerophobia and hydrophobia) alternating with periods of lucidity, agitation, confusion and signs of autonomic dysfunction (Rupprecht et al., 2004). Rabies should be included in the differential diagnosis of all patients who present with unexplained, acute, progressive viral encephalitis, even in areas where the disease is rare, as it can occur locally in wildlife, such as bats. In addition, it can be acquired during travel to enzootic areas and because imported cases of human and animal rabies continue to occur (Dacheux et al., 2010, Petersen and Rupprecht, 2011).

2.9.1. Laboratory diagnosis The only way to undertake a reliable diagnosis of rabies is to identify the virus or some of its specific components using laboratory tests. If possible, the animal that is suspected of having rabies should be captured. If it is not overtly rabid, it can be quarantined for 10 days and observed for signs of rabies. If the animal exhibits signs of rabies, it should be euthanized and its brain tissue should be submitted (Leung, 2007). In the brain, rabies virus antigen is particularly abundant in the thalamus, pons and medulla. It is recommended that a pool of brain tissues that includes the brain stem should be collected and tested (Binghan and van der Merwe., 2002).

2.9.1.1. Sampling and transportation of specimens In general, biosafety practices are adequate for routine laboratory activities such as handling animals, necropsy, collection preparation and processing samples. The basic facility design should be adequate, and precautions should include personal protective equipment (e.g. clothing, gloves, eye protection) and vaccination (Orciari and Rupprecht, 2011). Secretions, biological fluids (e.g. saliva, spinal fluid, tears) and tissues (skin biopsy samples and hair follicles at the nape of the neck) can be used to diagnose rabies during life. Three saliva samples taken at intervals of 3±6 h, skin and hair follicules are the most sensitive samples (Wacharapluesadee and Hemachudha., 2010). During post mortem sampling brain tissue is the preferred specimen for post-mortem ϭϬ 

diagnosis in both humans and other animals (Fooks, 2009). If a brain biopsy cannot be performed, such as in field studies, tissue samples can be collected via the transorbital or trans-foramen magnum route (Barrat et al., 2006). Specimens for rabies diagnosis should be shipped according to the national and international regulations to avoid exposure hazards. Diagnostic specimens should either be refrigerated or shipped (temperature: +4 °C or ±20 °C) in 50% glycerinsaline solution or dried smears of brain tissue on filter paper (temperature: +30 °C) also enables safe transportation of infected material (WHO, 2005).

2.9.1.2. Viral antigen and antibody detection The direct fluorescent antibody technique is a rapid, sensitive, specific method for diagnosing rabies in animals and humans and is the gold standard for rabies diagnosis (WHO, 2011). The test is based on microscopic examination of impressions or smears of brain tissue after incubation with anti-rabies polyclonal globulin or broadly cross-reactive monoclonal antibodies conjugated with fluorescein isothiocyanate. Impressions (or smears) of samples from the brain stem and cerebellum are recommended for high sensitivity of the test. The hippocampi (Ammonhorns) may be included but are not necessary for a definitive diagnosis (Orciari and Rupprecht, 2011). Immunoperoxidase methods can also be used as an alternative to FAT with the same sensitivity, but attention should be paid to the risk of nonspecific false-positive results. This risk is considerably reduced by the thorough training of the technicians. It must also be emphasised that this technique needs one incubation step more than the FAT (Lembo et al., 2006). Other methods for the detection of lyssa virus antigens, such as enzyme linked immunosorbent assays (ELISAs) have provided consistently reproducible results in several laboratories (Xu et al., 2008, Lembo, 2006). Neutralizing antibodies in the serum of unvaccinated patients or in cerebrospinal fluid can be measured with a virus neutralization test, including the rapid fluorescent focus ϭϭ 

inhibition test and the fluorescent antibody virus neutralization test. If virusneutralizing antibodies are present in serum, they tend to appear on average 7±8 days after clinical symptoms (Welch et al., 2009).Rapid detection of antibodies (immunoglobulins G and M) to other viral antigens, (e.g. nucleoprotein) may also be useful, as they may appear before neutralizing antibodies (Petersen and Rupprecht, 2011).

2.9.1.3. Virus isolation Virus might have to be isolated to confirm the results of antigen detection tests and for further amplification or characterization of an isolate. Viruses can be isolated in cell cultures, such as neuro blastoma cells, or by intracranial inoculation into mice. The viral RNA can be detected by different amplification techniques (molecular methods), such as the reverse transcription polymerase chain reaction (RT-PCR) and other (Meslin et al., 1996).

2.10. Control and Prevention Through public awareness and education, inexpensive vaccination, sterilization, animal management and registration programs, canine rabies can be controlled and significantly decreased in rabies endemic regions (Cleaveland et al., 2006). Immune coverage to rabies virus of 70% (percent coverage or pc) among free ranging dog (stray, feral and neighborhood dogs) populations has been a traditional target promoted as sufficient to establish herd immunity and has been demonstrated to be sufficient in interrupting the transmission of rabies virus among dogs (WHO, 2004). Knowledge, attitude and practices (KAPs) analysis is an important way of generating information to identify knowledge gaps, behavioral patterns and cultural practices hindering rabies control and exacerbating disease burden. This information will act as base line data for planning, implementation and evaluation of public awareness and rabies control programs. KAPs studies have been used widely to increase community knowledge and change attitude and improve practices that aid in disease prevention and control (Sambo et al., 2014, Tiembré et al., 2014) ϭϮ 

2.10.1. Prevention and Control in Human Beings 2.10.1.1. Exposure prevention Due to the high mortality rate associated with Human rabies, adequate measures to ensure Prevention of transmission should be followed. Individuals should also be responsible pet owners, by maintaining current rabies vaccinations for all pets and preventing pets from coming into contact with wild animals by keeping them from roaming free. Health care workers involved in the direct care of patients who have had known or suspected exposure to the rabies virus should take precautions to ensure that they do not contract the virus from patients. Contact precautions, including barrier methods such as gloves, goggles, masks, and gowns, should be used WR DYRLG FRQWDFW ZLWK SDWLHQWV¶ ERGLO\ VXEVWDQFHV PXFRXV PHPEUDQHV RU RSHQ wounds, which could theoretically lead to exposure. Although no cases of patient-to± healthcare worker transmission have been reported to date, proper prevention of exposure is warranted (Andrea et al., 2009).

2.10.1.2. Public health education (Rabies awareness) The knowledge of rabies differs among groups of people depending on various factors. People with higher education tend to know more about rabies (Palamar et al., 2013). Illiterate persons tend to know less about rabies. Reports indicate that many people are somewhat familiar with the presence of the disease, but possess low awareness of the transmission and prevention of it (Jemberu et al., 2013), which might contribute to low vaccination coverage in rabies endemic areas. Rabies is most common in children and is more common in males than females (Dodet et al., 2008). Hence, public awareness and an increase of knowledge about rabies disease, first aid measures after dog bites, and increased knowledge about dog behavior and how to avoid getting bitten by dogs are suggested methods to prevent rabies in humans (Depani et al., 2012).

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2.10.1.3. Pre-exposure prophylaxis vaccination Pre-exposure can help to protect an individual against an unrecognized exposure to rabies virus that may occur due to one's vocation, hobby, or travel itinerary, or due to the endemicity of rabies in the region in which they live. Secondly, pre-exposure vaccination will simplify PEP in the event of subsequent exposure to rabies virus by reducing the required number of injections of vaccine from five to two doses and by eliminating the need to administer RIG. Scientists and technicians working in rabies research and diagnostic laboratories and rabies vaccine production facilities, veterinarians and veterinary assistants, spelunkers, wildlife officers and rehabilitators and animal handlers including animal control officers considered to be at increased risk (Frederick, 2007). Pre-exposure vaccination is administered as a three-dose series. In most instances, pre-exposure is administered intramuscularly as one full dose of vaccine on each of days 0, 3, 7, 14 and 28 (WHO, 2004).

2.10.1.4. Post-exposure prophylaxis After an exposure, thorough wound-cleaning and prompt administration of rabies immune globulin (RIG) together with a full course of rabies vaccination. Wounds should be cleansed with soap or a veridical antiseptic (e.g., povidone iodine) with copious irrigation and should not be sutured unless necessary. Post-exposure prophylaxis should be started as soon as possible, which includes a series of injections of rabies vaccine (Anthony et al., 2014). PEP for previously unvaccinated patients usually given on days 0, 3, 7, and 14 (Adrienne, 2013). Rabies immune globulin (RIG) is administered as a passive immune treatment in order to provide immediate access to neutralizing antibodies until the patient's immune system can begin to produce its own antibody. This usually occurs within 714 days after the initial dose of rabies vaccine has been administered (WHO, 2004). Some patients who require PEP have received either pre-exposure or PEP previously. If the vaccine that the patient received was a modern cell culture rabies vaccine, they ϭϰ 

should receive two boosters, one on day 0 and one on day 3. Previously vaccinated persons should not receive RIG because their immune system has already been primed and once they have received an additional booster dose of vaccine; their immune system will initiate an immediate anamnestic immune response (Frederik, 2007).

2.10.2. Prevention and control of rabies in canine 2.10.2.1. Canine vaccination The vaccines most commonly used in domestic animal species are inactivated (killed) injectable vaccines, which are safe and inexpensive. The safety, potency and purity of such vaccines should be assessed by validated methods before use. Inactivated vaccines are produced in cell culture with either primary cells or continuous cell lines infected with an adapted strain of rabies virus (Reece and Chawla, 2006). To achieve control and eventual elimination of rabies, programmes must ensure recurrent (usually annual) campaigns and achieve vaccination coverage of at least 70%. This coverage should be sufficient to maintain the required level of herd immunity in the vaccinated population in spite of dog population turnover (births, deaths, emigration and immigration) in the period between campaigns. Vaccination campaigns must be strategically planned, well managed and adequately resourced and IXQGHG 7KH µUDELHV EOXHSULQW¶ SUHSDUHG E\ WKH 3DUWQHUV IRU 5DELHV 3UHYHQWLRQ provides guidance on planning and implementing dog vaccination campaigns (WHO, 2013).

2.10.2.2. Dog population management Dog population management can be implemented in accordance with the national context and local circumstances. Euthanasia of dogs, used alone, is not an effective control measure. If used, it should be done humanely. Education and legislation for responsible ownership; Encouraging dog owners to be more responsible will reduce the number of dogs allowed to roam, improve the health and welfare of dogs, and minimize the risk that dogs pose to the community. Registration and identification of ϭϱ 

dogs (licensing), reproductive control (surgical sterilization, chemical sterilization and separation of female dogs during estrus), removal and handling (collect dogs that are not under direct supervision and verify their ownership), environmental control (exclude dogs from sources of food (e.g. rubbish dumps and abattoirs, and installing animal-proof rubbish containers)) and control of movement (export/import and within country) (OIE, 2015).

2.10.3. Prevention and Control of Rabies in Wild Animals Rabies has emerged as a threat to conservation after outbreaks in highly endangered populations of Ethiopian wolves (C. simensis) in the Bale Mountains National Park, in African wild dogs (Lycaonpictus) in eastern and southern Africa and in the Blanford fox (V. cana) in Israel (WHO, 2013). It is difficult to control rabies among wildlife reservoir species. Vaccination of free-ranging wildlife or point infection control is useful in some situations, but the success of such procedures depends on the circumstances surrounding each rabies outbreak (Slate et al., 2009). Rabies virus transmission within wild carnivore populations that are capable of sustaining an infection cycle is considered to be density-dependent. Reduction of animal populations with consideration of humane, economical and ecological aspects will prevent inefficient large-scale culling campaigns (WHO, 2013). Mass vaccination of the principal wildlife hosts is a more effective control method than culling. This method emerged independently in Europe and North America (WHO, 2005). An oral rabies vaccination strategy that works for one carnivore primary host species will not necessarily work for others. Adapted oral vaccine strategies have been used quite successfully not only for red foxes but also for other primary wildlife hosts, including coyotes, grey foxes and raccoon dogs, although they require optimization for raccoons (Slate et al., 2009). Different strategies are needed for other primary wildlife hosts.

2.11. Economic and Public Health Significance Rabies has the highest case fatality rate of any conventional infectious agent, at almost 100%. Neglected and poorly controlled in many parts of the world, rabies is ϭϲ 

responsible for an estimated 55,000 to 70,000 deaths globally each year. Rabies deaths are believed to be significantly underreported such that the actual global impact of this disease may be closer 100,000 human deaths annually worldwide. 95% of these human deaths are in Asia and Africa and approximately 97% of all rabies deaths are a result of domestic dog bites. At a global estimated annual cost of $4 billion USD, rabies is also a very expensive disease. This death toll confirms rabies as one of the most lethal zoonotic, or animal-transmitted diseases, causing more human deaths annually than SARS, H5N1 and Dengue fever (Adrienne, 2013). The economic burden of rabies in humans is mainly due to mortality, commonly expressed as Disability Adjusted Life Year (DALYs), and direct and indirect costs related to medical treatment. Globally, 55,000 people die every year as a result of rabies, representing a burden of over 1.7 million DALYs. Direct medical treatment costs include labor, overheads, and materials for treatment. Indirect medical costs include the number of working days lost for the patient and his or her careers as well as transport and accommodation costs when seeking treatment. Major economic costs also arise from diverting resources, which could be used elsewhere, to surveillance, vaccination and the culling of dog populations and other host groups with the objective of reducing the spread of the disease. Further economic costs accrue from the negative impact of rabies on dog welfare as well as the transmission of rabies to livestock and the resulting reduction in food productivity (IFAH, 2012).

2.12. Status of Rabies in Ethiopia Africa is, together with Asia, the continent that suffers from most human deaths related to rabies (WHO, 2013a). The people who are most subject to the risks of rabies are poor people and those living in rural areas, because there might be a limited access of vaccine and economical resources in those areas (Knobel et al., 2005). In addition, people in rural areas are less likely to seek modern treatment after a dog bite than people in urban areas, possibly because of a limited access to modern medical care in those areas or because people in rural areas are less aware of modern medicine and/or rabies (Jemberu et al., 2013). People in rural areas are also more likely to own ϭϳ 

dogs and are then to a greater extent put at risk of being bitten by a dog (Knobel et al. 2008). In Ethiopia, rabies is an important disease that has been recognized for many centuries. The first major outbreak of rabies in Ethiopia in dogs in many parts of Ethiopia (Tigrie, Begemder, Gojjam and Wollo) was recorded in 1884. The first case of an epidemic of rabies was reported in August 1903 and had a high prevalence in Addis Ababa. According to Ethiopian public health Institute rabies in Ethiopia is primarily a disease of domestic animals, particularly dogs; however, the involvement of other domestic animals like cats, cattle, sheep, goats and equines were reported. Moreover, the occurrence of rabies in wild animals was evidenced by laboratory confirmed rabies cases by direct fluorescent antibody test (FAT) in hyenas, jackals, foxes, mongoose, monkeys, rabbits, leopards, Servical cat and cheetah at Pasteur Institute of Ethiopia (EPHI, 2011). The number of dog to human ratio is approximately assumed 1:6 and 1:8 in urban and rural parts of Ethiopia, respectively. The total population of dogs in Addis Ababa is estimated between 150,000 and 200,000, of which 50% are stray dogs (EPHI, 2011). Although it is presumed that rabies is very much widespread throughout Ethiopia, the actual figure of the incidence of the disease is not well known throughout the country. In 1998 Ethiopia reported the highest number of human rabies deaths (Wunner and Briggs, 2010) in Africa and in 2012 it was assumed that approximately 10,000 persons/annum die of rabies which makes one of the highest rabies deaths in Africa (EVA, 2012) . According to Ethiopia public health institute, annual number of brain tissue samples examined between 1990 and 2010 ranges from 89 to 1,298 of which rabies positive samples ranged from 50.8% to 85.3%. Based on the above data, the highest number of rabies cases was reported in cold season (June to September) though animal rabies occurred throughout the year. This is most probably due to mass gathering and highest reproduction of dogs during the period which increases the contact between rabid and health dogs (EPHI, 2011). ϭϴ 

An increasing number of stray dogs in Ethiopia and the absence of legislation to determine and certify the status of vaccinated and non-vaccinated dogs create difficulty to control the disease. Moreover, lack of utilization of modern anti-rabies vaccines, low level of public awareness, lack of nationwide animal rabies surveillance and poor attention and resource allocation by government are major important problems that hinder the control of rabies in Ethiopia (Pritchard and Dagnatchew, 2010).

ϭϵ 

3. MATERIAL AND METHODS 3.1. Study Area The study was conducted from November 2015 to April 2016 to assess the level of knowledge, attitudes and practices towards rabiesin Debark district, North Gondar, Amhara regional state, Ethiopia. Debark district has a total of 30 kebeles which are located 830km far from Addis Ababa, the capital city of Ethiopia. The district has latitude of about 13.133oN and longitude of about37.900oE and an elevation ranging from 2712-3122 m.a.s.l. The area receives an annual rainfall of ranging from 9001400mm, which comes from long and short rainy seasons. The average minimum and maximum annual temperature ranges between 6.2 oc and 20.7oc, respectively with humidity of about 25%-83.5%.The total human population of the district is estimated about 169835, from which 85594 are male and 84242 are female population. Debark has a livestock population of cattle (380403), equine (27449), shoat (185922), poultry (159612) and dogs (15000) (CSA, 2009).

3.2. Study Design and Study Population A cross-sectional study design was employed to assess the knowledge, attitudes and practices (KAP) on rabies and associated risk factors among the community of Debark district. The study population was household heads or their spouses who had lived in randomly selected kebeles of Debark district (Mikara, Debir, Miligebsa, Kino, Kebele 01 and 02) as permanent residents for more than six months.

3.3. Sample Size Determination and Sampling Techniques The required sample size for this study was estimated by considering 50% of the population knowing about rabies since there is no awareness study on rabies in the study area before. Thus, the sample size was calculated according to Thursfield formula by using 95% confidence interval and 0.05 absolute precision as follow; (Thursfield, 2005) N=

ଵǤଽ଺మ ௉೐ೣ೛ ሺଵି௉೐ೣ೛ ሻ ௗమ

ϮϬ 

Where N = required sample size; Pexp = Expected proportion of population knowing about rabies are 50%;d2 = Desired absolute precision (0.05).As a result, 384 study population was selected by adding 10% non-response rate; thus, the total sample size was 422 subjects. A simple random sampling procedure was employed to select kebeles for this study. From the entire primary sampling unite i.e 30 kebeles (Lowest administrative structure), six were randomly selected using lottery method. Then, 70 households were selected and interviewed from each kebeles using systematic random sampling method, as WKHUHZDVQRVLJQLILFDQWGLIIHUHQFHLQQXPEHURIKRXVHKROG¶V:KHQHYHU the selected household was found locked, the next household (on the right side) was substituted automatically for interview. A pretested structured questionnaire consisting of closed ended questions was used for this study. The data were collected via face-to-face interview. The questionnaire was first developed in English and then translated in to Amharic language (native language) for appropriateness and easiness in approaching the study participants.

3.4. Inclusion and Exclusion Criteria Household who live more than 6 months as a permanent resident in the study area were included in this study and household who live less than six months and respondents in the household who cannot communicate and under 15 year were excluded from this study.

3.6. Data Management and Analysis After collecting, the data were cleaned and checked for its completeness. Those incomplete and inconsistent were corrected when possible and removed otherwise. After complete check-up the data were coded and entered to Microsoft Excel and transport to SPSS version 20.0 statistical packages for windows and analysis made. The frequency distribution of both dependent and independent variables were worked out by using descriptive statistics technique (Frequencies, mean, SD and percentage). Association between independent variables and KAP scores on rabies was calculated Ϯϭ 

XVLQJ3HDUVRQ¶V&KLVTXDUH$OOSYDOXHVOHVVWKDQZDVFRQVLGHred as statistical significance.

ϮϮ 

4. RESULTS Socio-Demographic Characteristics 422 heads of household were interviewed during the study period of this research. Of these, the data collected from six respondents were found to be incomplete and excluded from the analysis. Only data from 416 households were considered for the analysis. The majority of the respondents were male 240 (57.7 %) and the ages of the respondents were above 15 years old, of which 36.3% and 36.8% were between 1529 and 30-45 years old, respectively, with a response rate of 99.0%.The majority of the respondents 391(94.0%) were Orthodox followed by Muslim 25 (6%). Regarding family size 230 (55.3%) and 157(37.7%) of the participant were from family size of four to six and one to three persons, respectively. Concerning educational status, 182 (43.8%) of the participants were illiterate, 46 (11.1%) had profession with diploma and above and 113 (27.2%) were in high school and preparatory program. From the total respondents about 236(56.7%) were farmers and 43 (10.3%) were government employees (table 1).

Ϯϯ 

Table 1.Socio-demographic information of the study participants in Debark woreda Variables

Category

Frequency

Percent

Sex

Male

240

57.7%

Female

176

42.3%

15-29

151

36.3%

30-45

153

36.8%

>45

112

26.9 %

1-3

158

38.0%

4-6

230

55.3%

>6

28

6.7%

Educational

Illiterate

182

43.8%

status

Primary school

75

18.0%

Secondary

113

27.2%

46

11.1%

43

10.3%

Merchant

76

18.3%

Farmer

236

56.7%

Unemployed

7

1.7%

Other

54

13.0%

Orthodox

391

94.0%

Muslim

25

6.0%

Age (in years)

Household size

school Diploma and above Occupation

Government employee

Religion

Ϯϰ 

Community KAP about Rabies in Study Area Twenty-two questions were asked for each respondent regarding cause, sources and mode of transmissions, clinical singes and prevention practices and treatment measures of rabies. The questions were multiple choices. Respondents who answer the questions correctly had got one mark and those who select wrong answers had zero marks. The number of questions for which respondents give correct answer was counted and scored. Then, the scores were pooled together and the mean score was computed to determine the overall KAP of respondents. The respondents who score greater than or equal to the mean value (Mean=13.75, SD=3.15) grouped to good KAP and less than the mean value Poor KAP level. As table 2 indicates, out of 416 respondents, 251 (60.3%) and 210(40.7%) were found to have good and poor KAP towards to rabies.

Ϯϱ 

Table 2: Knowledge of participants related to cause and host range in Debark district Variables

Category

Frequency

Percent

Have you heard

Yes

416

100%

rabies before

No

0

0

Source of

Formal

143

34.4

information

Informal

146

35.1

Mixed

127

30.5

Can dog get rabies Yes

416

100

Cause of rabies

No

0

0

Psychological

1

.2

31

7.5

Virus

67

16.7

Starvation & thirst

264

63.5

,GRQ¶WNQRZ

52

12.5

Spp. Affected by

Dog

6

1.4

rabies

Human & dog

44

10.6

problem Associated with sprit

Human, dog, cattle, 135

32.5

equine & shoat Wild animals

-

-

All

231

55.5

Knowledge of Participants Related to Cause and Host Range All of the respondents (100%) were familiar with the disease rabies. and called it µYebed wusha EHVKDWD¶ DQG µlekift¶ locally, which mean madness. Out of 416 respondents 143(34.4%) were awarded about rabies disease through formal way such as radio and television. While 146 (35.1%) and127 (30.5%) of the respondents had

Ϯϲ 

the awareness through informal (such as traditional healers neighbors, friends and relatives) and both formal and informal ways, respectively. Sixty-seven (16.7%) of the respondents knows as virus is the cause of rabies. 404 (97.1%) were know that rabies transmitted from animal to human, 231(55.5%) know as all mammal can be affected by the disease and 363 (87.3%) were awarded that dog is the most common source of rabies (table 2).

Ϯϳ 

Table 3: Knowledge of participants related to mode of transmissions, sign and symptom and treatment in Debark woreda Variables

Category

Frequency

Percent

Transmit from

Yes

404

97.1

animal to human

No

12

2.9

Mode of

Biting

99

23.8

transmission

Scratching

10

2.4

Saliva contact with

5

1.2

All

302

72.6

Common source

Dog

363

87.3

of rabies

Dog & cat

3

.7

Dog &wild candies

50

12.0

17

4.1

68

16.3

Salivation

15

3.6

All

316

76.0

Immediately

7

1.7

-40 day

147

35.3

-90 day

208

50.0

,GRQ¶WNQRZ

54

13.0

Yes

412

99.0

No

2

.5

,GRQ¶WNQRZ

2

.5

Easily treatable

Yes

1

.2

after onset of

No

380

91.3

clinical signs

,GRQ¶WNQRZ

35

8.4

open wound

Sign and symptom Stops eating and drinking Biting and change in behavior

Incubation period

Is rabies fatal

Ϯϴ 

Knowledge of Participants Related to Mode of Transmission, Sign and Symptom and Treatment Biting, scratching and saliva contact with open wound were mentioned by 302(72.6%) of the respondents as a mode of transmission. Regarding to sign and symptom of the disease 316 (76.0%) stated that stop eating and drinking, change in behavior, hydrophobia; paralysis and salivation are common in rabid animals. 380 (91.3%) of the respondents were awarded as the disease could not easily treatable once clinical signs are manifested and 412 (99.0%) were awarded fatal nature of the disease (Table 3). Of all the respondents 144 (34.6%) had dog; among them 102 (70.8%) were vaccinated their dog and 11 (7.6%) were castrated their dog. Regarding to castration 254 (61.1%) have knowledge as castration decrease incidence of rabies.

Ϯϵ 

Table 4: Practices and attitudes to prevent rabies after suspected animal/dog bite in Debark woreda. Variables

Category

Frequency

Percent

144

34.6

No

272

65.4

Do you

Yes

102

70.8

vaccinated your

No

42

29.2

Was your dog

Yes

10

6.9

Castrated/spayed

No

134

93.1

Does castration

Yes

254

61.1

decrease

No

75

18.0

incidence

,GRQ¶WNQRZ

87

20.9

Family exposure

Yes

8

1.9

No

408

98.1

Immediate action

Tie the wound with

76

18.3

after bite

cloth 318

76.4

Apply herbal extract

16

3.8

,GRQ¶WNQRZ

6

1.4

Health center

175

42.1

Traditional healer

228

54.8

Holly water

9

2.1

279

67.1

Negative

137

32.9

Actions taken for

Let free

28

6.7

rabid animals

Tie

38

9.1

Killing

350

Do you have dogs Yes

dog

Wash with water and soap

After 1st aid

attitude to vaccine Positive

ϯϬ 

84.1

Measures to

Killing

235

56.5

control stray dogs

Animal birth control

10

2.4

Aware the owner

171

41.1

Is safe

Yes

270

64.9

consumption

No

100

24.0

,GRQ¶WNQRZ

46

11.1

rabid food animal

Practices and Attitudes to Prevent Rabies After Suspected Animal/Dog Bite in Debark District Concerning to immediate action taken after bite 318 (76.4%) of the participant were used wash with water and soap and 228 (54.8%) were used traditional healer after first aid and 175(42.1%) were used health center. The attitude on anti rabies vaccine was positive by 279 (67.1%) of the respondents. Killing of rabid animal was the first choice by 350 (84.1%) of the participants. Killing also the first option to control stray dog by 235 (56.5%) of the participants. 270 (64.9%) of the respondents revealed that meat of rabid domestic animals will not cause disease during consumption by human (table 4). Table 5: Factors Associated with Community KAP on Rabies in Debark woreda Variables

Good

Poor

x2

Pvalue

Sex

Age(in

Male

155(64.6%) 85(35.4%)

Female

96(54.5%)

80(45.5%)

15-29

82(54.3%)

69(45.7%)

30-45

94(61.4%)

59(38.6%)

>45

75(67.0%)

37(33.0%)

year)

ϯϭ 

4.275

0.039

4.429

0.109

House hold 1-3

94(59.9%)

63(40.1%)

1.719

0.633

size 4-6

139(60.4%) 91(39.6%

>6

18(64.3%

10(35.7%)

89(48.9%)

93(51.1%)

Primary school

42(46.0%)

33(44.0%)

Secondary school

78(69.0%)

35(31.0%)

Educational Illiterate

32.534 0.000

status

Diploma and above 42(91.3%)

Occupation Government

4(8.7%)

39(90.7%)

4(9.3%)

42.023 0.000

Merchant

60(78.9%)

16(21.1%)

Farmer

114(48.3%) 122(51.7%)

Unemployed

4(57.1%)

3(42.9%)

Other

34(63.0%)

20(37.0%)

Orthodox

235(60.1%) 156(39.9%) 0.149

Muslim

16(64.0%)

employee

Religion

0.699

9(36.0%)

Factors Associated With Community KAP on Rabies in Debark Woreda Association between independent variables and KAP scores on rabies was calculated XVLQJ 3HDUVRQ¶V &KL VTXDUH 7DEOH 5). There was significantly association between KAP scores and sex (p < 0.05). The good KAP scores were recorded higher in males 155 (64.6%) than females 96 (54.5%). Educational status had strong significant associated with KAP scores (p =0.00). All respondents with diploma and above education levels had good KAP of rabies. As table 5 indicated, there was no ϯϮ 

significant association (p>0.05) between KAP score and age and religion of the respondents. Occupation had statistically significant association with knowledge levels (p=0.001); in which government employee has good KAP level (90.7%) than unemployed (57.1%) respondents.

ϯϯ 

5. DISCUSSION The findings of this study indicated that, almost all respondents (100%) were aware of rabies and dog are the common source of rabies. In line with current report, another studies conducted by Digafe et al. (2015) and Singh and Choudhary (2005) in Gondar Zuria District and rural community of Gujarat, India indicated that 99.3% and98.6 % of people have heard about rabies before, respectively. Jemberu et al. (2013) also reported high level of awareness (98 %) about rabies in Gondar Zone, Ethiopia. However, the current investigation is higher than other reports from Addis Ababa, Ethiopia and India that reported 83% and 68.7 %, respectively (Ali et al., 2013, Ichhupujani et al., 2006). The reason could be due to real difference in incidence of rabies in the study areas and living status of the community as stated by Digafe et al. (2015) as rural community has better communication and information about what is happening in their residential area, including animal disease situations, which may contribute to their high level of awareness. The case of KAP level of the community about 60.3% of the respondents had good level of knowledge, attitude and practices about rabies was obtained during the research period. A relatively similar result was reported (64.1%) among the community of Bahir Dar town (Tadesse et al., 2014).This association may be due to the awareness level due to different factor such as source of information and repeated out break which increase awareness. In contrast to this finding higher KAP level was reported from Sri Lanka (Gino et al., 2009). This difference probably explained by sample size deference and lack of health education programs about rabies in Ethiopia. The source of information for the majority of the participants(34.4%) were formal and (35.1%) was through mixed(both formal and informal) which was higher compared to the result reported from Bahir Dar town (10.7%) by Tadesse et al.(2014) and from Addis Ababa (21.5%) by Ali et al.(2013). This difference may be due the presence of community based radio station in the study area and radio is the major source of information in the rural area of Ethiopia. ϯϰ 

Of those respondents, 63.5% had misunderstanding on the cause of rabies; they believed that the disease in dog is caused by starvation and thirst. This result is higher when compared with the result obtained from study conducted in and around Dessie town, Ethiopia which was 49.6% (Gebeyaw and Teshome, 2016) and in Bahir Dar town, 39.9% Tadesse et al. (2014). In addition, current study was higher than the findings of Jemberu et al. (2013) which was 86%, from Gondar and Dabat, Ethiopia. This could be due to sample size difference, study area and community awareness difference. Beside this, the higher misunderstanding result could be given from probable explanation in relation to the notion of asymptomatic rabies carrier dogs in which stressors like starvation and thirst might induce development of clinical rabies in these carrier dogs. However, the notion of asymptomatic rabies carrier dogs by itself is a contentious issue (Zhang et al., 2008, Wilde et al., 2009). Human rabies caused by the classical rabies virus continues to be almost 100% fatal, with no specific treatment available anywhere in the world (WHOb, 2013). In the present study, KAP analysis revealed that 99.0% of respondents recognize rabies as danger and a fatal disease. The fatality of the disease was supported with the study conducted in Bahir Dar town (94.5%) by Tadesse et al.(2014)and New York, USA(94.1%) by Eidson et al., (2004) of the study participants know rabies as a killer disease and 73.5% of the respondents identified that dogs are major sources for the spread of rabies in human population. But, this result was disagreed with the study reported (30.97%) from Addis Ababa (Ali, et al., 2013). This could be due to the high rate of incidence and frequent death of the affected host in the study area. In the study area, 55.5% respondents knew that the disease could affect all mammals of domestic and wild animals. In contrast to this study, Tadesse et al. (2014) reported a lower result (21.4%) from Bahir Dar. This difference may be due to the availability of different host range in the rural district of our study site. Higher result (71.9%) was also reported in the city of New York, USA (Eidson et al., 2004) which could be due to the educational status and/or awareness of the community. ϯϱ 

Regarding to public health importance, about 97.1% of the respondents were claimed as the disease transmit from animal to human and the mode of transmission was through biting only by 23.8% and biting, scratching and saliva with open wound by 72.6% of the respondents. This finding was supported by report from Addis Ababa, 75.5% of respondents knew that rabies to be transmitted through animal bite Ali et al. (2013). A higher result was reported from North Gondar, Ethiopia by Jemberu et al.(2013); 84% of the participant stated any type of contact (irrespective of the skin condition) with saliva of affected individual could transmit the disease. A few respondents were mention as rabid equine and donkey can transmits the disease but ruminant could not transmit the disease to human through biting or through their milk and meat during consumption. Inoculation of infected saliva through the bite of a rabid animal appears to be the predominant mode of rabies transmission (Radostits et al., 2007). Contact of infected saliva with broken skin or mucous membrane can transmit the disease (WHO, 2014). About 76.0% of the respondents were aware of common clinical signs of rabies in animals. This finding was in line with Tadesse et al. (2014) and Asabe et al.(2012) reported from Bahirdar, Ethiopia (76.8%) and Nigeria, respectively. In the present study, dog vaccination was practiced by 24.5% of the respondents. In line with this report, Dog vaccination practice was generally very low and very nonexistent in rural district of Dabat and was good in Gondar town (Jemberu et al., 2013). In contrast to result, higher result (36%) was reported in and around Dessie city by Gebeyaw and Teshome (2016). This low level of report for vaccination in study area was claimed by the UHVSRQGHQWV¶GXH to lack of access and low awareness towards rabies vaccines. Raising awareness about dog vaccination and improving access and affordability of the vaccine should be considered in control of the disease, as dogs are the main reservoir of the disease. 2.6% the participant had been castrated their dog and most of them used to castrate through traditional method by removing the testicle but at the movement they tend to use in vet clinic. Most of the respondents (61.1%) had awareness as castration ϯϲ 

decrease the incidence of the disease. Castration (sterilization) is another option for canine population management of male dogs, which has been used in Mexico, Brazil and other countries (Oliveira et al., 2012, Soto et al., 2009). However, sterilization efforts should not focus only on males, as females are also critical target for effective population management (Jackman and Rowan, 2010). More often, however, rabies control programs have attempted to cull dog populations, even though this approach has been shown to be ineffective (Dalla et al., 2010, Morters et al., 2013). Such lethal management strategies require the elimination of 50±80% of dogs a year, which is neither financially possible nor ethically acceptable (Rupprecht et al., 2002). Among the immediate action,taken after bite wash with water and soap was reported by most of the respondents (76.4%) in this study. This result is higher compared to the study conducted in Gondar zuria district (30.7%) (Digafe et al., 2015) and in a Rural Community of Gujarat, India (31.1%) (Singh and Choudhary, 2005). The variation may be due to the study area and awareness level of the community. Washing of rabies-infected wounds with soap and water can increase survival by 50 % (Radostits et al., 2007). This treatment is cheap, readily available and feasible for all to apply. From all the participant 279 (67.1%) have positive attitude for anti-rabies vaccine. This result is higher compared to a study conducted in Bahirdar (42.8%) (Tadesse et al., 2014). This difference could be due to skill and awareness of the community for vaccination. However, a low level (42.1%) of preference for health center (for PEP) was observed in this study. Most respondents choose other options like traditional healer (54.8). Similarly, studies conducted in Gondar zuria district, Ethiopia, reported 62.2% of the study participants had strong beliefs in traditional medicine (Digafe et al., 2015). A higher (84 %) reliance of respondents on traditional treatment was reported from Dabat and Gondar (Jemberu et al., 2013). In contrast to these report, almost all respondents agreed to consult health professional in case of animal bite was reported in Addis Ababa (Ali et al., 2013). The preference for traditional practices might be arise from many factors including easy access to traditional medicine, lack of awareness, long duration of treatment. Reliance on ϯϳ 

traditional medicines with unproven efficacy is very risky and nothing can be done to VDYH RQH¶V OLIH DIWHU WKH ILUVW V\PSWRPV RI WKH GLVHDVH RFFXU $IWHU VXVSHFWHG RU proven exposure to rabies virus, immediate use of efficient anti-rabies vaccine with proper

wound

management

and

simultaneous

administration

of

rabies

immunoglobulin is almost invariably effective in preventing rabies (WHO, 2005). Most of the respondents (64.9%) in our study claimed that meat of rabid food animal is safe for consumption. This result were consistent with that of reported in Gondar zuria district by Digafe et al. (2015) which revealed consumption of cooked or boiled meat from rabid animals was considered as safe by 67.0 % of the respondents and about 19 % replied even raw meat is safe for human consumption. According to (WHO, 2014), consumption or preparation of meat from rabid animals is a risk. The consumption of raw meat from an infected animal requires PEP. Cooked meat does not transmit rabies; however, it is not advisable to consume meat from an infected animal (WHOb, 2013). Even though the extent of transmission varies, all possible modes of transmission including bite, contact with saliva, and consumption of animal products from diseased animal should be avoided. During analysis of KAP with independent variables, the good scores were higher in males (64.6%) than females (54.5%). The same proportion of statistically difference on KAP score of male (53.4%) and female (10.75%) was reported in Bahirdar town by Tadesse et al.(2014) and comparable result was reported from Addis Ababa in male (77.09% moderate and 10.55% good) and female (73.62% moderate and 5.08% good) (Ali et al., 2013). The statistically significant difference (P45

2. Household size..... a 1-3 b 4-6 c >6 3. (GXFDWLRQDOVWDWXV« a. Illiterate b. Primary school c. secondary school d. diploma and above 4. Occupation.... a. Government employee b. Private employee c. mercchant d. farmer e. unemployed f. other 5. Religion a. Orthodox b. Muslim ϱϭ 

Mikara

Debr

c. Protestant d. Catholic e. other 6. Have you heard about rabies before? a. Yes b. No c. I GRQ¶WNQRZ 7. Source of information? a. formal b. informal c. mixed 8. Can dogs get rabies? a. Yes b. No c. ,GRQ¶WNQRZ 9. What is the cause of rabies? a. Psychological problem b. Associated with sprit c. Virus d. Starvation & thirst I,GRQ¶WNQRZ 10.Species affected by rabies? a. Human b. Dog c. Human & dog ϱϮ 

d. Human, dog, cattle, equine & shoat e. Wild animals g. All

11.Can rabies transmit from animal to human? a. Yes b. no F,GRQ¶W 12.What is the mode of transmission from animal to animal/human? a. Inhalation b. Biting c. Scratching d. Saliva contact with open wound e. All 13.What are the common sources of rabies? a. Dog b. Dog and cat c. Dog and wild canines d. dog and equine e. Others 14.Sign and symptom of the disease? a. Stops eating and drinking b. Biting and change in behavior ϱϯ 

c. Paralysis d. Salivation e. Hydrophobia f. All of these

15.Incubation period of the disease? a. Immediately b. 40 day c. 90 day d. ,GRQ¶WNQRZ 16.Is the disease easily treatable after clinical sign observed? a. Yes b. No F,GRQ¶WNQRZ 17.Is the disease fatal? a. Yes b. No c. I GRQ¶WNQRZ 18.Do you have dog? a. yes

b. no

19.Have you ever vaccinated your dog? a .yes

b. no

20.Did you spay/castrate your dog before? ϱϰ 

a. yes b. no 21.Does castration reduce the incidence of rabies? a\HVEQRF,GRQ¶WNQRZ 22.Family exposure to animal before? a. yes

b. no

23.What are the immediate action taken after bite of rabid animal at home? a. Tie the wound with cloth b. Wash with water and soap c. apply herbal extract d. ,GRQ¶WNQRZ 24.What would be done after the above first aid? a. Health center (for vaccination) b. Traditional healer c. Holly water 25.What is your attitude for anti-rabies vaccine? a. Positive

b. Negative

26.At which stage does, anti-rabies vaccine is effective after a suspected animal bite? a. Immediately b. Later c. At any time d. I GRQ¶WNQRZ 27.Actions taken for rabid animals a. Let free b. Tie ϱϱ 

c. Killing 28.Measures to control stray dogs a. Killing b. Animal birth control c. Aware the owner d. Tinning 29.Methods of disposal of food animal? a. Burning / burring b. Used for consumption/food F,GRQ¶WNQRZ 30.Is it safe for consumption? a. Yes

b. No

c. ,GRQ¶W know

ϱϲ