Rabies is endemic in southern Bhutan and children are the frequent victims of dog bites. We surveyed the knowledge, attitude, and practices on rabies among school children in three schools located in southern Bhutan. A total of 701 students (57.9% female, 42.1% male) with an age range of 12–21 years (mean: 15 years) participated in the survey, of which 98.2% had heard about rabies. Most of the students demonstrated a good level of knowledge (59.7%) and a favorable perception towards rabies (57.7%). Multivariable logistic analysis revealed the relation between knowledge and the awareness campaign (OR:1.5, 95% CI: 1.1–2.1). Similarly, higher grades of students (OR:1.9, 95%CI: 1.3–2.9) and employed mothers of the students (OR: 1.6, 95% CI: 1.0–2.7) were associated with more favorable perceptions. However, some knowledge gaps were identified in this study, such as students not being able to clearly mention the susceptible hosts of rabies, transmission routes, clinical signs, and prevention and control options. Therefore, regular awareness programs on rabies are necessary among school children in Bhutan.

Background: Rabies continues to pose significant public health challenges in many developing countries including Bhutan. A probable case of rabies was admitted to our hospital and its reporting led to the uncovering of an outbreak in domestic and wild animals. We discuss the challenges in the diagnosis and management of rabies in a resource-limited setting. Case presentation: A 35-year-old male presented with intermittent fever, bilateral lower limb weakness that was rapidly progressive, urinary incontinence with episodes of palpitations and sweating. He had sustained a Category III bite on the right lower thigh with four bite marks, inflicted by a stray dog. He had received post-exposure prophylaxis with intra-dermal anti-rabies vaccine. On initial examination, the patient was in distress but cooperative for the interview. He had pulse rate ranging from 60 to 100/min with episodes of diaphoresis and palpitations, but with normal capillary blood glucose. In the lower limb, the muscle power was zero with absent tendon reflexes in the lower limb and impaired abdominal reflex below T₁₀ level. He had hyperaesthesia below T₈, hydrophobia, aerophobia and photophobia. He had multiple spontaneous fasciculations in both the thighs and right deltoid and these later involved the intercostal muscles, neck and face muscles. He had altered sensorium and desaturation for which he required mechanical ventilation. Polymerase chain reaction for rabies virus was negative in cerebrospinal fluid and saliva. Rabies virus neutralizing antibody was negative in cerebrospinal fluid but had high titres in the serum. He received Human Rabies Immunoglobulin after admission. He was managed in the intensive care unit and died 23 days later. After this case was notified, a rapid response team was deployed in the field, and uncovered rabies outbreak in animals in the locality. Conclusions: This case called for a serious evaluation of the country’s efforts in achieving zero rabies deaths by 2030. The management of this case identified several critical areas of context-specific interventions in Bhutan. There is also an urgent need to improve diagnostic capabilities at the national reference laboratory and enhance the technical competencies of healthcare workers in the management of dog bite cases. Graphical

Rabies is one of the most important zoonotic diseases that mostly affect children. We conducted a rabies education among 129 secondary school children (intervention group = 94 students, control group = 35 students) in two schools in southeast Bhutan and evaluated the effectiveness of the lesson by comparing the knowledge, perception and safety behaviour score about rabies before and after education. We also assessed the knowledge retention capacity of the students at three months post intervention. Our findings indicated that short rabies lesson significantly (P<0.001) improved the mean knowledge score from 19.98(±2.72) to 26.96(±2.24) in the intervention group. Similarly, mean scores for perception and safety behaviour improved significantly (P<0.001) from 10.77 (±1.89) to 13.95 (±1.36) and 9.809 (±1.85) to 12.97 (±1.54), respectively. Although the scores have reduced significantly (P<0.001) at three months post intervention, most of the rabies information was largely retained by the students. In control group, significant increase in mean scores were also observed for perception from 10.17 (±2.38) to 11.2 (±2.44) and safety behaviour from 9.14(±1.44) to 10.74 (±1.95) after 3 months of education. The finding demonstrate that a short rabies lesson is effective in improving knowledge, perceptions and understanding of dog bites safety behaviour among the school children. However, there is a need for a frequent awareness program, at least quarterly or half yearly. Rabies education should focus on critical points such as dog bites being the main source of rabies and the importance washing a dog/animal bite wound with soap and water, and visiting the hospital for medical advice following animal bites.

Background: The perception of illness and health-seeking behaviours, including rabies differ from one culture to another. Depending on the cultural setting of the society in which people live, the definition of the causal factors of illness may range from natural biological causes to supernational causes which greatly influence subsequent health-seeking behaviour. To ensure best health practices and plan effective health interventions for the control of dog-mediated-human rabies, we explored how school children and adult communities perceive and respond to illnesses, including rabies in southern Bhutan.Methods: We collected quantitative data related to the causes of illness and health-seeking practices of school children using a questionnaire survey (QS). Qualitative data were collected through focus group discussions (FGDs) and in-depth interviews (IDIs) with older members of communities (≥ 18 years) that work closely with school children. Descriptive analysis was performed for the quantitative data and thematic analysis was performed for the qualitative data.Results: The participants during the FDGsand IDIshave linked the illnesses to past actions, spirits, energy channels, planetary movement, sorcery, black magic, food, physical or environmental factors, individual habits and social factors. The survey of the school children reported microorganisms (75%), past actions (16.8%), spirits (9.6%) and black magic (9.1%) as causal factors for illnesses. Health seeking behaviours reported by the participants included visiting hospitals, performing spiritual or religious rituals and local treatments. Similarly, school children also mentioned that illnesses can be treated by visiting hospitals (98%), performing rituals (59.1%), and seeking traditional treatments practices (18.8%). Both school children and adult members of the communities that we interviewed were well aware on the causes of rabies and need for allopathic treatments rather than seeking spiritual or local treatments.Conclusion: There is a need for the consideration of the socio-cultural context in the planning and implementation of health-related policies, including the rabies prevention programs in Bhutan, by involving traditional healers and religious entities with “One Health” public health sectors.

BackgroundThe perception of illness and health seeking behaviors differs from one culture to another including rabies. Depending on the cultural setting of the society in which people live, definition for causal factors of illness may ranges from modern biological causes to supernational causes which greatly influence subsequent health seeking behavior. To ensure best health practices and planning effective health intervention strategies including rabies, we explored how school children and adult health and education professionals perceive the causes of illness and their associated health seeking behaviors in southern Bhutan.MethodsWe collected quantitative data related to causes of illness and health seeking practices of the school children using questionnaire survey. Qualitative data were collected through focus group discussions and key informant interviews from the education and health communities that closely associated with school children. Descriptive analysis was performed for the qualitative data collected from school children and thematic analysis were performed for the qualitative data collected from community members that closely interact with students.ResultsSchool children associated the causes of illness with microorganisms (n=526, 75%), badkarmicactions n=118, 16.8%), spirits (n=67, 9.6%) and black magic practices (n=64, 9.1%). They further indicated that these illnesses can be treated through medical intervention by visiting hospitals (n=687, 98%), performing rituals (n=414, 59.1%), and seeking traditional treatments practices (n=131, 18.8%). Similarly, the education and health professional surveyed in the study associated illnesses with bio-physical causes (e.g. microorganisms), supernatural or religious related causes (e.g. spirits, deities) and social causes (e.g. taboos, family problems). In addition to the allopathic medicines, most of the participants indicated the importance of performing religious healing practices to cure the illness. However, most respondents were well aware of the need for allopathic treatments for rabies, such as washing of the bite wound with soap and water and anti-rabies vaccine injection.ConclusionThere is need for the consideration of socio-cultural context in the planning and implementation of health-related policies, including rabies prevention program in Bhutan, associating traditional healers and religious entities with “One Health” public health sectors.