Date of Award
Master of Public Health (MPH)
Background: Haiti has been identified as one of only several countries in the Western Hemisphere in which canine rabies control efforts have succeeded in eliminating dog-mediated human rabies deaths. In 2016, a study was conducted to test several alternative vaccination methods that may compliment the current central point vaccination program. During this study, households within the Croix de Bouquet community completed a questionnaire regarding the dog ownership, roaming status, vaccination coverage of the dog and bite victims and their healthcare seeking behaviors within the household. The aim of this analysis was to determine the incidence of humans being bitten by dogs, and the victims’ healthcare seeking behaviors for medical care and post-exposure prophylaxis (PEP) regimen.With the goal of identifying barriers and developing programs to improve timely PEP delivery to persons with likely rabies exposures.
Methods: During the door-to-door (DD) vaccination campaign in August 2016, the surveyors completed a household questionnaire by interviewing respondents in the Croix de Bouquet community, West Department of Haiti. The questionnaires highlighted questions regarding bite events within the household. Information recorded on the event was the victim age, month of bite, animal ownership, bite location, case definition of a potential rabid case, whether the victim sought medical care after the bite event, and the choice to receive PEP and complete PEP. We were able to determine the incidence rate of humans bitten by dogs in this community. When applicable, 2-tailed Chi-square test or Fisher’s exact test were calculated to determine the relationship between variables. We also used Multiple Logistic Modeling to analyze the variance through likelihood ratio and Wald tests of fixed effects in generalized linear models to identify associations between dog ownership, dog vaccination, and human healthcare seeking behaviors.
Results:Among the total respondent population, there was 111 bite victims within the total household population reported (n = 6993). The annual bite incidence was 3.7% (95% CI 3.2% – 4.2%). A little over half of the victims (52.3%) sought healthcare for the bite wound. However, only 11.7% completed at least three doses of the rabies post-exposure prophylaxis series. Responsible dog owners for poor versus good was: (OR = 3.337) for adequate versus good was: (OR = 1.749) (p= .0032). Households with dogs that died of a rabies-like illness 1 death versus 0 deaths (OR = 2.43), 2 vs 0 deaths (OR = 5.441), and 3 vs 0 (OR = 16.662) (p
For healthcare seeking behaviors the following variables were modeled: risk surrounding the event, if the victim sought medical care, the number of people living in the household, rabies-like illness related deaths in the household within the past year, time from the hospital, victim’s age, if the household experienced more than 1 bite, and the economic status of the household. After backwards selection within the multivariate model for healthcare seeking behaviors, risk category was the only risk factor. The risk score comprised of the ownership of the animal that bit, anatomical location of the bite, and the case definition of a rabid dog, was a factor associated with PEP completion of the bite victim. Low risk versus high risk (OR = 8.750) and medium risk versus high risk (OR = 1.923).
Responsible dog ownership relates to lower incidence of canine bites within the Haiti community, Croix De Bouquet. A positive association between responsible dog ownership and completion of PEP series was noted, potentially indicating that awareness of dog-health issues improves dog owner’s understanding of the importance of rabies PEP. Respondents demonstrating a relatively high response rate to seeking healthcare, may be attributed the current HARSP program and Ministère de l'Agriculture, des Ressources Naturelles et du Développement Rural (MARNDR), in collaboration with the Ministère de la Santé Publique et de la Population (MSPP), Christian Veterinary Mission (CVM) and the United States Centers for Disease Control and Prevention (CDC) that was established in 2011.  Time required to reach a hospital was a barrier to seeking healthcare, health officials should consider establishing more community-bite centers to improve bite-victim healthcare seeking. Financial obligations were also implicated as a barrier to not seeking medical care as well as not completing the post-exposure prophylaxis dosage. Healthcare providers should consider providing the vaccination campaign on a routine bases to reach the population that are not able to pay for medical services.
Johnson, Gabrielle and Chowell, Gerardo, "Estimation of Dog-bite rates and evaluation of Healthcare Seeking Behaviors following dog bite, Haiti." Thesis, Georgia State University, 2018.