Quantitative
Socio-demographic characteristics
Of the 800 rural and urban residents, 54.9 (439/800) and 45.1% (361/800) were males and females, respectively. The mean age of the respondents was 46.7 (95% CI: 45.6-47.9) with a range of 18 – 90 (median age 45) years. About 38.8 (310/800), 31.6 (253/800) and 29.6% (237/800) were from Gulomkada, Gant-afeshum and Adigrat districts, respectively. Regarding the professionals, 49.2% (30/61) were males while 50.8% (31/61) were females. More than sixty percent (61.7%, 37/62) were diploma graduates while 33.3 (20/62) and 5% (3/62) were respectively first and second degree holders (Table 1).
Knowledge of the disease, its causative agent and zoonotic nature
Community members: Sixty two percent (496/800) of the respondents said that they knew of the disease anthrax, locally (in Tigrigna) called Megerem. However, 38% (304/800) of them said that they did not know of the disease. The proportion who knew of anthrax was greater in female (63.4%, 229/361) than in male (60.8%, 267/439) respondents. The majority (77.6%, 621/800) of the respondents reported that they did not know the cause of the disease (Table 2). However, of the respondents (22.4%, 179/800) who believed to have known the cause of the disease: Only 9.3% (74/800) said that the disease was caused by a microbe/germ. About 8.9% (71/800) believed that the disease was God given, and 4.3% (34/800) mentioned other entities (heredity, witchcraft, lack of sanitation, hunger, insects, and thirst) as the causative agent of the disease. Of the respondents who claimed to know the disease, the majority (63.9%, 317/496) of them responded that they did not know the causative agent of the disease (Table 2). Regarding the zoonotic importance of the disease, 64.1% (513/800) did not know whether the disease was zoonotic or not. About 20.1% (161/800) of respondents claimed that anthrax was zoonotic while 15.8% (126/800) said that the disease was not zoonotic (Table 2). The level of knowledge of respondents regarding anthrax increased with age (Additional file: Fig A).
A logistic regression model was used to determine the effect of socio-demographic factors (age, sex, district, level of education, occupation and animal ownership) on the knowledge of anthrax and its zoonotic nature. Accordingly, age, sex, district, occupation, and animal ownership had a statistically significant association with knowledge of the disease anthrax. Respondents who were 58-65 years olds were found to be seven times more knowledgeable about the disease (OR: 6.7; 95% CI: 2.80-16.01; p<0.001) than those 18-25 years old. Male (OR: 0.6; 95% CI: 0.40-0.85; p<0.005), merchant (OR: 0.3; 95% CI: 0.12-0.80; p=0.016) respondents and participants from Gulomkada (OR: 0.3; 95% CI: 0.19-0.53; p<0.001) had a significantly lower level of knowledge about anthrax than females, civil servants, and participants from Adigrat, respectively. Respondents who owned animals (OR: 1.8; 95% CI: 1.10-2.83; p=0.02) had a better knowledge of anthrax than respondents who did not own animals. However, only districts had a statistically significant association with an awareness of the zoonotic nature of the disease. Respondents from Ganta-afeshum (OR: 0.4; 95% CI: 0.19-0.65; p<0.001) had a lower level of awareness regarding the zoonotic nature of the disease than respondents from Adigrat.
Professionals: About 56.6% of the respondents said that the causative agent of the disease was bacterial while 33.9% of them did not know. However, 9.7% claimed that the causative agent of anthrax was another organism (e.g., Leishmania and flies). The cutaneous form (67.2%) was the most well known form of the disease. More than ninety percent (90.1%) of the professional respondents knew that anthrax was zoonotic (Table 3). Socio-demographic factors such as age, sex, profession (animal and human experts), and level of education were analysed using a logistic regression model to determine whether there was a statistical association with the knowledge of the causative agent and zoonotic nature of anthrax or not. None of them was found to be statistically significant.
The respondents of the community members learned about anthrax in various ways: 55.8% (446/800) from family, friends and neighbours/colleagues, 2.8% (22/800) from health experts, 2.1% (17/800) from radio, and 2% (16/800) from veterinary experts (Additional file: Table A and Fig B).
Knowledge of symptoms, transmission, and control/prevention methods in animals
Community members: The number of community member respondents who knew one or more symptoms, transmission, or control/prevention methods of anthrax in animals was 26.3 (210/800), 21.3 (170/800) and 43.4% (347/800), respectively. Respondents who did not know symptoms, transmission, or control/prevention methods of anthrax were 73.8 (590/800), 78.8 (630/800) and 56.6% (453/800), respectively. The most well known symptom, transmission route, and control/prevention methods by the communities were sudden death in cattle (14.4%), ingestion grass contaminated by blood (13%) and isolation of anthrax infected animals (7.6%), respectively (Table 4).
Professionals: The number of professional respondents who reported one or more symptoms, transmission or control/prevention methods of animal anthrax was 74.2 (46/62), 79 (49/62) and 80.7% (50/62), respectively. Sudden death (53.2%) and contaminated soil (56.5%) were the most common symptoms and transmission routes, respectively, while they reported that vaccination (67.7%) of animals was the most effective control/prevention method (Table 4).
Knowledge of symptoms, transmission, and control/prevention methods in humans
Community members: The number of respondents who knew at least one anthrax symptom in humans was 36.8% (294/800) which was greater than in animals (26.3%, 210/800), and fever (22.4%) was the most recognized human symptom. Moreover, respondents who mentioned one or more transmission route and control/prevention method of human anthrax were 20.1 (161/800) and 45.6% (365/800), respectively. The respondents stated that consumption of infected animal products (raw meat & milk) was the most common transmission route (15.9%) while vaccination of animals (34.5%) was an effective mechanism of control/prevention (Table 5).
Professionals: The majority of professional respondents could name one or more anthrax symptoms (90.3%, 56/62), transmission routes (90.3%, 56/62), and prevention methods (91.9%, 57/62). The most recognized symptoms, transmission routes, and control/prevention methods were skin rash (cutaneous wound) (66.1%, 41/62), consumption of infected animal products (raw meat and milk) (83.9%, 52/62) and vaccination of animals (67.7%, 42/62), respectively (Table 5).
Attitude and practice towards anthrax
Fifty-two percent (416/800) and 32.4% (259/800) of the questionnaire participants believed that vaccination of animals could prevent anthrax in animals and humans, respectively. But although 4% (32/800) said that they had anthrax (Megerem) infected animals, about 28% (9/32) of them used traditional medication for their animals. Moreover, of the 10.5% (84/800) respondents who had an anthrax infected family member at some point, 71.4% (60/84) had visited local healers (Table 6).
Qualitative
Knowledge of anthrax/Megerem
Geographic variation on local names for anthrax: The researchers approached the participants by using the local name Megerem which is commonly known in Tigray. However, the researchers gave the participants an opportunity to give the local name of the disease in instances where they failed to recognize the name Megerem. In these instances, researchers described the clinical signs of the disease in animals and humans and asked respondents what they called this disease. Farmers usually named diseases based on their clinical signs and the lesions/pathology they identified in the animals.
“I do not know the disease Megerem, but I have heard about it. But I know Lalish and Gulbus in animals” (male participant, Sebeya). This participant called another person for help. The second participant gave a similar opinion with some clarifications.
“I do not know Megerem in animals. Perhaps we can learn from you. But in cattle, there are other diseases I know. One is “Lalish”, enlargement of the spleen. Moreover, there is another fatal disease called “Gulbus” showing cramp like symptoms and shivering. This disease may sometimes be confined around the head (neck swelling), in this case, an animal may not die soon” (the second male participant from Sebeya). This idea was supported by most of the participants in this FGD (Sebeya). The FGD participants from Ganta-afeshum district had a similar understanding about the disease. A 78 year-old male participant named the disease in animals Tafia (enlargement of the spleen) (Hagereselam tabia, Ganta-afeshum district). Similar suggestions had been given in Bizet tabia of the same district. Notably, a female participant told that Lalish was a severe disease of cattle (Bizet tabia, Ganta-afeshum district).
Anthrax/Megerem perceived only as human disease: The second participant from Sebeya said that Megerem appears in the neck/face of humans and could not be cured without treatment (modern medication). Another female participant from the same area shared her knowledge about human Megerem. “My daughter (one year old) was sick (swelling in the wrist). My daughter was waiting without medication for a few days. When the swelling had become bigger and bigger, I took my daughter to the health center. After medication, she was cured but she suffered.”
The researcher asked: What does the swelling look like? The same female participant responded: “the swelling starts out small. Then it increases in size with a depressed black eschar in the center.”
The researcher asked another question: Do you think that this disease can affect animals? “I do not know.” Where did your daughter acquire the disease? “I did not know its origin or where it came from. If I had known that I could have prevented and/or taken quick measures for my daughter during her suffering.”
Indeed, the second female participant from the same group partially supported the idea of the first female participant but she had a different view of the characteristics of the disease. This participant did not agree with the first female participant, especially with the nature of the lesion (depressed black eschar) in the center of the swelling. She said that the swelling had no depressed black eschar (Sebeya tabia, Gulomkada district). A female participant from Bizet tabia emphatically said that they should not be talking about Lalish in front of animals because animals could be panicked when they heard the word Lalish; indeed, she reflected the belief of the community. However, she failed to relate this to human Megerem (Bizet tabia, Ganta-afeshum district).
Anthrax perceived by the participants after they had been told its clinical signs: Most FGD participants from Fatsi and Anbesetefikada tabias (both from Gulomkada district) stated that they did not know the disease anthrax/Megerem, and that the disease has not occurred in their area. However, after the researchers had explained the nature/signs of the disease in animals and humans, a few individuals tried to share what they have heard/known about the disease.
“I have seen bleeding from natural orifices of dead animals. But I do not know the name of the disease” (male participant, Fatsi). Other participants said that they have seen bleeding through natural orifices and absence of rigor mortis of dead animals but they did not relate these signs to Megerem (Hagereselam and Bizet, Ganta-afeshum district).
Knowledge of the causative agent, transmission, and control/prevention methods for anthrax/Megerem
Most FGD participants did not know the causative agent, transmission, or control/prevention methods for anthrax/Megerem in animals and humans. Some of the participants associated Megerem in animals with the local belief Weqh’e (unidentified cause, but they stated that it caused sudden death), but the participants believed that it can be transmitted to humans through consumption of meat. Some of the participants also believed that the disease could occur in humans when there was stress (e.g. thirst, starvation), and consumption of meat (in humans), and alcohol (in humans and animals) might exacerbate the disease. According to these participants, the disease was commonly seen in animals with poor body condition and exacerbated when diseased animals had consumed water. Few participants mentioned that the disease was caused by microbes/germs. Regarding the control/prevention methods, FGD participants agreed that although the disease had been treated using traditional medicine, nowadays modern medication has become their best option in animals and humans. However, some of the participants still believed in traditional medicine, including heating the spleen using a hot iron or, if there was swelling around the bottom part of the neck. Moreover, bloodletting in animals were commonly used. None of the FGD participants recognized the GI and pulmonary forms of the disease in humans.
Attitude and practice
Some of the participants knew of the disease (in animals) by other names, including Lalish, Tafia (splenomegaly) and Gulbus (abdominal cramp and shivering). Some had perceived the disease only as a human disease while others recognized the animal disease after its clinical signs in animals and humans were described. Most of the participants did not know the transmission routes of the disease among animals, nor its zoonotic importance. However, during the discussion, they remembered precepts from the general health education given by the experts, e.g., not to eat the carcasses of dead animals. Some of the participants said that they were told not to eat animals that had died from anthrax/Megerem.
“I have heard that if animals died of Megerem, their meat should not be eaten and their blood should not be touched. But the community does not follow these recommendations” (male participant, Fatsi). In Sebeya, the researchers raised the issue of the outbreak that occurred in 2018 and asked the participants about the transmission routes and control/prevention measures that were taken: “We had been informed that a girl (tenth grade student) had died from eating dead animal meat. And experts told us that the animal died from a disease in which the carcass should not have been eaten…” (Participants from Sebeya).
According to the key informants, the eating habits and lifestyle of the communities are high risk for contracting anthrax. “Indeed, no animals have died from anthrax. But when animals die for any reason (for example rabies), individuals will resist burying the carcass; they need to consume it” (Meida Agame health center director, Adigrat town district). Other key informants said that the communities often live with their livestock in the same house, and they slaughter animals for consumption at home (i.e., they never use an abattoir) (Bizet health center director, Ganta-afeshum district). Another challenge reported by officers is the negative attitude of the community towards animal vaccination against infectious diseases (including anthrax) (Gulomkada district animal health and Adigrat Veterinary clinic coordinators). Instead, they prefer visiting the local healers over modern treatment and vaccination (Gulomkada District Health coordinator).
Reasons for low KAP of the community towards anthrax
In general, the low KAP towards anthrax can be attributed to three primary drivers:
1) Animal and human health officers
Anthrax as a forgotten disease: Key informants already admitted that their respective communities had low KAP towards anthrax because the prevention of the disease was not a priority in the study area:
“Our community has a low awareness of anthrax because we do not deliver adequate health education specific to anthrax. Since the disease is not common, it is not in our top list. However, we inform the community about the general impact of zoonotic diseases like tuberculosis and rabies” (Fatsi health center director). Likewise, the director of Tekli Siwuat health center of Adigrat said, “we have no scheduled separate prevention program against anthrax. But we try to associate it with our rabies prevention program” (according to the director, rabies outbreaks are common in the town).
Similar suggestions had been given by other human health officers (Adi-aynom and Meida Agame health center officers from Ganta-afeshum and Adigrat town districts, respectively). They said that anthrax cases were not admitted to their health centers. Moreover, they stated that the disease had not occurred in their surroundings and that this was why health education given specifically for anthrax was poor. One of the key informants described anthrax as a “forgotten” disease. “A long time ago there were rare anthrax cases but nowadays it is being forgotten” (Meida Agame health center director, Adigrat town district).
Irregular health education: Some of the key informants said that health education was conducted in Sebeya and Bizet where anthrax outbreaks had occurred in their localities. The director of Sebeya health center said “there was an outbreak that killed a girl and left others infected in a village called Adibeteksian [found in Sebeya tabia]. The source of the case was a cow that died from anthrax. The girl was presented to our clinic with severe abdominal cramps and fever. The cause was ultimately diagnosed as anthrax (by Aider specialized hospital in Mekelle, the regional capital), but we failed to save the life of that innocent girl. Since that time, we have begun health education together with the veterinarians in the area. We started teaching the community during the funeral of the girl that it was because of the delay that she lost her life, and that they must immediately bring their children when they observe such signs and should avoid consuming animals that are sick and even the carcasses of apparently healthy animals which are not properly inspected.”
The animal science and health district coordinators of Gulomkada confirmed the above suggestions, and after the outbreak of anthrax occurred in Sebeya (in 2018), they created anthrax-oriented educational programs for Sebeya and its surroundings. However, during our interviews, we found that although health education was concentrated in areas where there were anthrax outbreaks, education was not continued once the outbreak had been controlled: “During the anthrax outbreak (to control the disease) we were cooperating with human health professionals in an integrated way. However, after the disease was under control we did not continue to work together for prevention purposes” (Animal science district coordinator in Gulomkada).
2) Government
Until recently, anthrax education and mitigation has not been a priority for the Ethiopian government. Funding specificied for anthrax prevention, education, and human vaccination has not been provided.
“To date, we have more than 15 vaccines in stock but there is no human anthrax vaccine, either independently or in combination with others, among the 15” (Fatsi health center director, Gulomkada district). Moreover, although anthrax can be prevented using ante- and postmortem inspections, the Bizet health center director in the Ganta-afeshum district reported that there was proper abattoir and slaughtering methods were not being utilized. The officer added that investors were not willing or able to invest in abattoirs. Other officers reported that there were inadequate veterinary clinics and drugs (Animal science district coordinator of Gulomkada) as well as man power (Adigrat veterinary clinic coordinator) to tackle the disease. “There are also remote areas that we cannot access it via vehicles even during anthrax epidemics. …Nowadays the community is reluctant to having people gather for health education; the community may need mass media communication that allows them to stay at home” (Gulomkada District Health coordinator).
3) Community
The negative attitude of the community towards anthrax contributed its own challenge to the prevention of anthrax. Focus Group Discussions and KIIs revealed that the community has continued to maintain local beliefs. Even though the communities have not been provided adequate education, they resist implementing what little they have been told, and restrict themselves to the traditional way of living.