Geographic Variation in Access to Dog-Bite Care in Pakistan and Risk of Dog-Bite Exposure in Karachi: Prospective Surveillance Using a Low-Cost Mobile Phone System

Abstract

Dog-bites and rabies are under-reported in developing countries such as Pakistan and there is a poor understanding of the disease burden. We prospectively collected data utilizing mobile phones for dog-bite and rabies surveillance across nine emergency rooms (ER) in Pakistan, recording patient health-seeking behaviors, access to care and analyzed spatial distribution of cases from Karachi. A total of 6212 dog-bite cases were identified over two years starting in February 2009 with largest number reported from Karachi (59.7%), followed by Peshawar (13.1%) and Hyderabad (11.4%). Severity of dog-bites was assessed using the WHO classification. Forty percent of patients had Category I (least severe) bites, 28.1% had Category II bites and 31.9% had Category III (most severe bites). Patients visiting a large public hospital ER in Karachi were least likely to seek immediate healthcare at non-medical facilities (Odds Ratio = 0.20, 95% CI 0.17–0.23, p-value<0.01), and had shorter mean travel time to emergency rooms, adjusted for age and gender (32.78 min, 95% CI 31.82–33.78, p-value<0.01) than patients visiting hospitals in smaller cities. Spatial analysis of dog-bites in Karachi suggested clustering of cases (Moran's I = 0.02, p value<0.01), and increased risk of exposure in particular around Korangi and Malir that are adjacent to the city's largest abattoir in Landhi. The direct cost of operating the mHealth surveillance system was USD 7.15 per dog-bite case reported, or approximately USD 44,408 over two years. Our findings suggest significant differences in access to care and health-seeking behaviors in Pakistan following dog-bites. The distribution of cases in Karachi was suggestive of clustering of cases that could guide targeted disease-control efforts in the city. Mobile phone technologies for health (mHealth) allowed for the operation of a national-level disease reporting and surveillance system at a low cost. Resource constraints prevent adequate surveillance of neglected infectious diseases such as rabies in developing countries leading to a poor understanding of the disease burden and limited evidence with which to design effective control measures. We utilized a low cost mobile-phone based system to carry out the first prospective surveillance of dog-bites and rabies in Pakistan by screening all patients presenting to nine emergency rooms in eight cities over a two-year period. We found a large number of dog-bite cases (nearly a third of which were severe based on a World Health Organization classification) with substantial geographical variability in time to presentation as well as health-seeking behavior following dog-bites across the reporting sites. Spatial analyses of collected data from Karachi, Pakistan's largest city identified areas with increased risk of dog-bite exposure, which has implications for the design of necessary control measures such as dog vaccination. While mobile phone based technologies have the potential to address limitations in disease surveillance in developing countries, the cost-effectiveness of large scale implementations of such strategies need to be explored and further evaluated where appropriate.