Rabies is a highly fatal zoonotic
disease associated with 100% mortality rate; infected animals and humans die
within a week after the first neurological signs appear (Taylor, 2009; Depani et al., 2012). It is endemic in Uganda
like many African countries, mainly transmitted and maintained through bites of
infected animals to other animals and humans (Jemberu et al., 2013). Dogs are the
main source of rabies through their bites especially in the developing
countries of Africa, Asia and South America (Overall & Love, 2001;
Ozanne-Smith et al., 2001, Meslin
& Briggs, 2013).
Rabies is an important but underreported
and neglected disease of low income countries in Africa and Asia (Knobel et al., 2005, Hampson et al., 2015) associated with poverty
affecting vulnerable populations with most deaths occurring in children between
5-15years and the lowest socio-economic sectors who account for about 40% of
people exposed to dog bites in rabies endemic areas (Gongal and Wright, 2011,
(Meslin and Briggs, 2013).
Disparities in the affordability and
accessibility of post-exposure treatment and the risks of exposure to rabid
dogs result in skewed distribution of the disease burden across society; with
the major impact falling on the rural poor particularly children (Knobel et al., 2005). Highly educated people
know more about rabies (Palamar et al.,
2013) while uneducated people know less about rabies (Herbert et al., 2012). Even fewer people are
aware about the transmission and prevention of rabies (Fielding et al., 2012). Obstacles to
progress against canine rabies in Africa include; high population of stray
dogs, inability of owners to bring dogs for vaccination annually, lack of
canine rabies surveillance and diagnostic capabilities besides insufficient
resources for veterinary services delivery (Anderson and Shwiff, 2015).
Consequences of dog bites include direct
physical injury, psychological trauma and post-traumatic stress in addition to
the risk of contracting rabies (Gilchrist et
al., 2008) besides high financial costs for treatment, emergency
hospitalization and anti-rabies post-exposure prophylaxis (Overall & Love,
2001). The global burden of canine rabies is approximately $124 billions
annually (Anderson and Shwiff, 2015). In developing countries, availability of post-exposure
prophylaxis (PEP) is limited to a few referral hospitals and health centres
implying that dog bite victims must travel long distances associated with incidental
costs including transport, feeding and accommodation to access PEP. Globally
over 15 million people receive the rabies PEP treatment annually following dog
bite injuries (Cox, 2012).
When dogs bite and transmit rabies to
cattle, goats, sheep, working animals like camels and donkeys (Hampson et al., 2015, Anderson and Shwiff, 2015),
they undermine livelihoods of the households who depend on livestock. If these
animals die of rabies following dog bites, the livestock farmers suffer severe
economic losses. The number of animals and people dying of rabies annually in Uganda
are not known since there is neither systematic reporting nor effective
surveillance systems to capture all the victims of dog bites or who die of
rabies in all districts. Hence the study was done to estimate the estimate the
of dog bite victims who received PEP from Entebbe Grade A national rabies
referral hospital and economic costs involved.
The study was conducted at Entebbe Grade
A National Rabies Referral Hospital (Grade A) which is located in Katabi
sub-county, Busiiro county, Entebbe municipality, Wakiso district in central
Uganda. This is a government (public) hospital offering medical services ranging
from surgery, orthopedics, antenatal care, maternity, and immunization against
several diseases including rabies. It is approximately 37 kilometers
(23 miles) by road from Kampala, southwest of Mulago National Referral Hospital
located between coordinates 0°03’50.0″N and 32°28’18.0″E.
The study was retrospective using
secondary data from case records of people who reported animal bites at Entebbe
Grade A National Rabies Referral Hospital. Data were manually retrieved from
the rabies archives. The records indicated the patient’s names, home region i.e.
central, western, eastern and northern Uganda where he/she came from to access
PEP at the hospital. The patient’s age and sex; the species of the biting
animal (dog, cat or wildspecies e.g. fox), domestic or stray and the date of
the bite were captured in the records. Information about the cost and length of
treatment, whether there was an accompanying adult in case of children and the
region where they came from were factored in to estimate the financial costs
incurred by the victims.
The costs incurred by dog bite victims
to access PEP included direct and indirect costs and were estimated according
to the approach adopted from (Knobel et
al., 2005). The direct costs included the medical costs for the complete
PEP treatment and indirect costs such as incidental costs such as transport
costs for the victim and parents or attendants, food, airtime or communication
costs and accommodation costs for people
from rural areas. The human PEP administered to dog bite victims in
Uganda is a five dose regimen treatment given at 0, 3,7,28 and 90 days
intervals. The data was entered into MS Excel and analyzed using descriptive
statistics including percentages and frequencies.
The researchers obtained an introductory
letter from the Dean School of Veterinary Medicine, Animal Resources and
Biosecurity, College of Veterinary Medicine, Animal Resources and Biosecurity Makerere
University which they used to approach the department of Veterinary Public
Health in the Ministry of Health (MOH).
The researchers obtained an introductory
letter from the Assistant Commissioner Veterinary Public Health in the MOH to
the District Health Officer (DHO) Wakiso district who then gave an
authorization letter to conduct the study in Entebbe Grade A Hospital. We took
the authorization letter from DHO to the Medical Superintendent of the Hospital
and were granted access to the rabies victims’ records for the two years 2014 and
The number of animal bites was
relatively constant throughout the two years under study, with a slight peak
from March to May in 2014 and April to June in 2015 (Figure 1 and Figure 2).
Animal bites were reported among all age groups, although the age bracket below
eighteen years was most affected (Table 1). Prevalence of animal (dog) bites in
Uganda by region is as shown in Figure 3.
The prevalence of dog bites reported at
Entebbe Grade A Hospital in the two years 2014 and 2015 was highest for central
Uganda (Figure 3). Probably this could be explained by the location of the
hospital within central Uganda therefore making it more accessible to victims
from this region as opposed to those from Northern, Eastern and Western Uganda.
More males were bitten by animals including dogs than females. This may be
attributed to the fact that many times when females are attacked they cry out
for help and males run to their rescue thus coming in confrontation with the
vicious animals (Table 2).
Dog bites have economic implications.
They are costly to treat and involve substantial monetary expenses to access
PEP as shown in Table 3. A person from Arua district (one of the farthest
districts) spends an estimated 980,000 Ugandan shillings (288.234 USD) to receive
a full dose of the five regimens PEP at Entebbe Grade A Hospital.
A dog bite victim from Kampala in
central Uganda spends approximately 310,000 Ugandan shillings (91.177 USD) get
the same PEP treatment at Entebbe Grade A. So the person spends between 91.177
USD to 288.234 USD to receive the PEP at Entebbe Grade A referral hospital
depending on one’s place of residence. The exchange rate of: 1USD = 3400 Ugandan
Shillings was used.
The prevalence of dog bites (90.5%) was
very high, a picture similar to Knobel et
al., (2005) despite under-reporting of dog bites in Uganda given that the
country lacks an active surveillance system for dog bites and rabies, many dog bite victims from the rural areas do
not report to health centers and are excluded. It is possible to prevent a
person from becoming ill with rabies after a dog bite by neutralizing the virus
with antibodies vaccination and or use of immunoglobulin (post-exposure
prophylaxis) before the virus invades the nervous tissue (Nilsson, 2014).
Majority of dog bite victims were males
below 18 years which is in agreement with (Meslin and Briggs, 2013) that most
of the people who suffer from dog bites and rabies are children. This can be
attributed to the fact that mainly boys participate in outdoor activities such
as herding and hunting. Young boys also stay out of home longer and later than
girls of the same age. Hence education
of the public about dog behavior particularly children is very important in
preventing dog bites (Lakestani et al.,
The cost of complete PEP treatment for
dog bite victims at Entebbe Grade A hospital ranged from USD 91.177 to USD
288.234. The variance is attributed to the incidental costs such as transport,
food and accommodation which depend on the region and district of origin where
the victims come from to access PEP at Grade A.
Mass dog vaccination must be intensified
throughout the country since it is the cheapest and most effective means for preventing
exposure of people to rabies. Public awareness and education should be stepped
up to highlight the risk of contracting rabies from dog bites as well as
encourage responsible dog ownership and communities to ensure that dog bite
victims are taken to health facilities for PEP.