Rabies and rabies prophylaxis in Egypt: a nation-wide cross-sectional study that calls for action

Rabies and rabies prophylaxis in Egypt: a nation-wide cross-sectional study that calls for action | Research Square window.SnipcartSettings = { analytics: { enabled: false } }; (function() { var accessVector = localStorage.getItem('access_vector') || ''; window.dataLayer = window.dataLayer || []; if (accessVector) { window.dataLayer.push({ user: { profile: { profileInfo: { snid: accessVector } } } }); } })(); (function(w,d,s,l,i){w[l]=w[l]||[];w[l].push({'gtm.start':new Date().getTime(),event:'gtm.js'});var f=d.getElementsByTagName(s)[0],j=d.createElement(s),dl=l!='dataLayer'?'&l='+l:'';j.async=true;j.src='https://www.googletagmanager.com/gtm.js?id='+i+dl;f.parentNode.insertBefore(j,f);})(window,document,'script','dataLayer','GTM-K279D39R'); Browse Preprints In Review Journals COVID-19 Preprints AJE Video Bytes Research Tools Research Promotion AJE Professional Editing AJE Rubriq About Preprint Platform In Review Editorial Policies Our Team Advisory Board Help Center Sign In Submit a Preprint Cite Share Download PDF Research Article Rabies and rabies prophylaxis in Egypt: a nation-wide cross-sectional study that calls for action Mohamed Basyouni Helal, Mohamed Ahmed Saeda, Ahmed Gamal Elshaar, and 12 more This is a preprint; it has not been peer reviewed by a journal. https://doi.org/ 10.21203/rs.3.rs-6968724/v1 This work is licensed under a CC BY 4.0 License Status: Under Review Version 1 posted 13 You are reading this latest preprint version Abstract Background: Rabies is a fatal but preventable viral disease that poses a global health threat, especially in developing countries. Despite the high incidence of animal bites reported annually in Egypt, limited data exist regarding the knowledge, attitudes, and practices (KAP) of the general population toward rabies and rabies prophylaxis. Methods: We conducted a nationwide cross-sectional study using a structured interview-based survey targeting individuals aged 18 years or older who attended outpatient clinics of nine university hospitals across Egypt. The survey assessed participants’ KAP regarding rabies prophylaxis and identified barriers to its uptake. Results: Among 1,777 participants responded to the survey, only (42.8%, n= 761) had good knowledge about rabies and rabies prophylaxis, while the majority (88.5%, n= 1,574) exhibited a positive attitude toward rabies prophylaxis. Knowledge was higher among those who had awareness campaign about rabies in their geographic areas (69.1% vs 40.5%, p < 0.001) and those who had been previously bitten or attacked by animals (56.1% vs 41.3%, p < 0.001). Of the participants (9.7%, n= 173) reported a history of animal bites; however, (18.5%, n= 32) of bite victims did not receive post-exposure prophylaxis, and (17%, n= 29) did not complete the vaccine schedule. Pre-exposure prophylaxis uptake was low, with only (4.3%, n= 23) of high-risk individuals receiving it. Key barriers to rabies prophylaxis included lack of knowledge about rabies (82.4%, n= 1,463) and the vaccine (81.7%, n= 1,451), as well as inadequate hospital facilities (43.1%, n= 765). Conclusions: Despite a generally positive attitude toward rabies prophylaxis, the knowledge and adherence to prophylactic measures, including preexposure and Post exposure prophylaxis remain relatively inadequate in Egypt. Public health interventions, such as educational campaigns and improved accessibility to vaccination services, are needed to address these gaps and mitigate the public health burden of rabies. Rabies Rabies vaccine Practices Knowledge Attitudes Rabies Egypt 1.0. Introduction Rabies remains one of the most serious and feared threats to public health in the 21st century. It’s caused by the rabies virus, which belongs to the Lyssavirus genus ( 1 ). This disease is transmitted to humans through the saliva of infected animals, with dogs being responsible for 99% of human cases ( 2 ). If left untreated, the virus can travel to the nervous system and cause viral encephalitis, which is incurable and fatal ( 1 , 3 ). Rabies has been associated with high fatality rates, resulting in 59,000 deaths worldwide every year with 36% of cases present in Africa ( 4 ). The majority of deaths occur in rural communities in developing countries in Africa and Asia ( 5 ), with a large economic burden costing 8.6 billion USD ( 4 ). Fortunately, Rabies is a 100% preventable disease with post-exposure prophylaxis for infected populations and pre- and prophylaxis for high-risk populations ( 6 ). In developing countries, there are associated problems with the use of post-exposure prophylaxis, according to a study in Senegal only 50% of patients followed the full schedule of post-exposure prophylaxis ( 7 ). In Egypt, the Ministry of Health and Population reported 200.000 animal bites each year ( 8 ), making the need for proper knowledge and practice regarding rabies prophylaxis crucial. However, data regarding knowledge and adherence to rabies prophylaxis is insufficient. While a survey assessing knowledge and practice toward rabies has been conducted, the data were limited to a single center and a very small population, which is not fully representative of the general population ( 9 ). In addition, data regarding attitude and practice are insufficient. Therefore, the present study aims to evaluate the level of knowledge and attitude towards rabies and rabies prophylaxis among the general population in Egypt. Furthermore, we aim to explore the Practice and potential barriers regarding the rabies vaccine to provide insights for improving rabies prevention and control strategies in Egypt. 2.0. Methods 2.1. Study design and setting We conducted a nationwide questionnaire based cross-sectional study in Egypt to assess the practice of rabies prophylaxis from the perspective of both the general and high-risk populations. Participants were recruited from outpatient clinics at nine university hospitals, geographically distributed across Egypt (Cairo region, Coastal region and Suez Canal, Delta region, and Upper Egypt). A complete list of the included study centers is provided in Fig. 1 . 2.2. Study population and sample The study included participants aged 18 years and older who attended outpatient clinics or waiting rooms at the selected study centers. Students in the medical field, healthcare workers, and individuals under the age of 18 were excluded. 2.3. Sampling and sample size calculation A convenient sampling method was used to recruit eligible study participants. The sample size was calculated using the online Raosoft sample size calculator ( 10 ), with the following parameters: a confidence interval of 95%, an expected frequency of 50%, and an acceptable margin of error of 2.5%. The anticipated sample size was 1428, which was later increased to 1,777 after data collection. 2.4. Questionnaire development and validation A structured questionnaire was developed specifically for this study to assess the current practices of rabies prophylaxis screening in Egypt from the perspectives of both the general population and high-risk groups. The primary objective was to evaluate the knowledge, perceptions, barriers, and practices related to rabies prophylaxis. Following a comprehensive review of the literature, the study team created an initial draft of the questionnaire. This draft was reviewed and discussed by two experts in the field to ensure its relevance and clarity. A pilot test was conducted with 20 participants to evaluate the clarity, accuracy, and relevance of each question, as well as the duration required for completion. Based on the feedback from the pilot study, the questionnaire was refined and finalized. Participants included in the pilot study were excluded from the final analysis. The finalized questionnaire included multiple sections: sociodemographic data, history and awareness of rabies, knowledge of rabies and its prophylaxis, perceptions toward rabies and its prophylaxis, barriers to rabies prophylaxis, and practices related to rabies prophylaxis. The sociodemographic section collected data on participants' gender, age, occupation, highest level of education, income, region, and residency. The history section examined participants’ prior awareness of rabies, personal experiences with animal attacks, and their connections to individuals who have been affected by rabies. The knowledge section contained 11 closed-ended questions: 7 focused on knowledge about rabies and 4 on knowledge of rabies prophylaxis. The perceptions section included 7 questions aimed at gauging participants' views on the risk and fatality of rabies, as well as their willingness to undergo both post-exposure and pre-exposure prophylaxis. The barriers section explored factors that could prevent individuals from seeking rabies prophylaxis, such as lack of knowledge, fear, financial burdens, or previous negative experiences with healthcare. Finally, the practices section focused on participants’ actual behaviors regarding rabies prophylaxis, distinguishing between those who had experienced animal bites and received post-exposure treatment and those who belonged to high-risk groups recommended for pre-exposure prophylaxis. The questionnaire was originally developed in English and then translated into Arabic by a language specialist to ensure it was understandable for the local population. A full version of the questionnaire can be found in Supplementary file 1 . 2.5. Data collection A team of well-trained data collectors was assigned to each university to manage the process of data collection. They reached the general population in their respective university outpatient clinics and waiting rooms. The data was collected in a structured interview format. 2.6. Ethical considerations The study was conducted according to the principles of the Declaration of Helsinki (1964, last revised in 2013) ( 11 ). This survey was voluntary, and all participants in this study were asked to give informed consent to participate in the study before starting data entry. Also, all participants received detailed explanations about the aim, objectives, and methodology of the study before completing the questionnaire. Participants’ anonymity and confidentiality were ensured throughout the study, including data collection and analysis. Ethical approval was obtained from the Ethical Committee for Scientific Research at the Faculty of Medicine, Alexandria University. 2.7. Statistical analysis The data were analyzed using IBM SPSS Version 28.0 for windows (Armonk, NY: IBM Corp.). Frequencies and percentages were used to describe the categorical variables for baseline demographic characteristics. The normality of the continuous variables was assessed using the Shapiro-Wilk test and Kolmogorov-Smirnov test. The median and interquartile range (IQR) were used to describe the non-parametric variables. Pearson’s Chi-square test, Fisher exact test, and Fisher-Freeman-Halton Exact test were used to explore the associations between the categorical variables. A p-value of < 0.05 was considered statistically significant. For the knowledge questions, answers were coded as 1 for correct and 0 for incorrect, yielding a score range of 0–11 per participant. If a question had multiple correct answers (e.g., animals that transmit rabies), the response is considered correct if the participant selects at least half or more of the correct options. A 60% cutoff was used to categorize knowledge as good ( 6 – 11 ) or poor (0–5). For the perception section, responses to closed-ended questions (e.g., recognizing rabies as a health risk or supporting prophylaxis) were coded as 1 for positive perceptions and 0 for negative perceptions. For scale questions ( 1 – 10 ), scores of 6 or higher were coded as 1, and below 6 as 0, resulting in a total perception score ranging from 0 to 7. A 60% cutoff was used to categorize perceptions as positive ( 4 – 7 ) or negative (0–3). Descriptive analysis included frequency and percentage of correct answers and positive perceptions, along with the median and IQR for both knowledge and perception scores. 3.0. Results 3.1. Demographic characteristics of the participants A total of 1,777 participants from nine Egyptian centers were included in the study, with a median age of 35 years (IQR = 23). (52%, n = 924) of them were females and (48%, n = 853) were males. About (75.7%, n = 1345) of our sample had secondary education or higher, and more than half were from rural areas (52.4%, n = 931). Almost (70%, n = 1244) of the participants work in occupations not considered vulnerable to rabies exposure and nearly half of the respondents (50.7%, n = 901) reported having sufficient income. A significant majority of participants (79.1%, n = 1405) had heard about rabies, with family and friends being the primary source of information (62.6%, n = 1113). Meanwhile, only (5%, n = 89) had previous discussions about rabies with a physician. Awareness or vaccination campaigns for rabies were reported by a small percentage only (7.8%, n = 139) of respondents. Almost half of the participants (50.8%, n = 903) knew someone who had been bitten or attacked by an animal, while only (7.7%, n = 136) knew a patient diagnosed with or who had died from rabies. Additionally, (9.7%, n = 173) of participants had personally been bitten or attacked by an animal (Table 1). 3.2. Knowledge The median knowledge score among respondents was 5 (IQR: 3) on a twelve-point scale (from zero to eleven). A total of 760 participants (42.8%) demonstrated good knowledge about rabies, with scores of 6 or higher. Only (25.9%, n = 461) of participants correctly identified rabies as a viral disease, while (13.1%, n = 232) could name the animals that transmit rabies. A significant majority, (88.4%, n = 1570) were aware of the mode of transmission of rabies. Only a minority of participants knew the signs of rabies in animals and humans (20.9%; n = 371 and 16.4%, n = 291 respectively). About (81.2%, n = 1443) believed that a person attacked by a rabid animal could recover with treatment. However, only (18.4%, n = 327) were aware that rabies is untreatable once clinical signs appear. Half of our sample (50.1%, n = 890) knew the appropriate first aid measures after an animal attack, (73.9%, n = 1314) knew that a rabies vaccine existed, and a majority (81.9%, n = 1455) knew when rabies post-exposure prophylaxis should be taken. About (47.8%, n = 849) of participants were knowledgeable about the appropriate candidates for pre-exposure prophylaxis (Table 2). Our study found that self-perceived good knowledge was higher among participants from urban areas compared to rural areas (50.7% vs. 35.6%, p < 0.001), in male participants compared to females (48.9% vs. 37.1%, p < 0.001), in people with occupations vulnerable to rabies (66.2% vs. 32.7%, p < 0.001), in participants with enough and higher income compared to low income (55.7%; and 77.8% vs. 27.4%, p < 0.001, respectively), in participants who reported awareness of vaccination campaigns for rabies ( 69.1% vs. 40.5%, p < 0.001), in people who had heard about rabies before (49.8% vs 16.1%, p < 0.001), individuals with history of animal attacks ( 56.1% vs. 41.3%, p < 0.001), those who Knew someone bitten or attacked by an animal ( 51.2% vs. 34.1%, p < 0.001), or diagnosed with or died from rabies (66.2% vs. 40.8%, p < 0.001). A significant association was found between regional distribution and good knowledge, particularly in Cairo (52.3% p < 0.001). Also, between educational level and good knowledge, notably among college graduates and those with postgraduate studies (50.3%, 63.9% p < 0.001, respectively), between Sources of knowledge about rabies and good knowledge as in School compared to radio/TV (76.5% vs 40.4%, p < 0.001, respectively) (Table 3). 3.3. Attitude The median attitude score among respondents was 7 (IQR: 1) on an eight-point scale (from zero to seven). The majority (88.5%, n = 1572) exhibited a positive attitude towards rabies and rabies prophylaxis, with scores of 4 or higher. Most of the participants thought that rabies is a risk to human health (91.2%, n = 1620) and is a fatal disease (82%, n = 1457) (Table 2). A significantly higher frequency of positive attitude was observed among rural residents compared to urban residents (89.9% vs. 86.9%, p = 0.046), and among younger participants aged 18–35 years (93.3% vs 87.6% and 66.1%, p < 0.001). Participants from the Delta regions and Cairo also demonstrated a higher frequency of positive attitudes (99.8% and 98.8%, p < 0.001, respectively). Educational level significantly influenced attitudes, with a higher percentage of participants with positive attitudes noticed among college graduates and those with postgraduate studies (94.6% and 100%, p < 0.001, respectively). Significant higher frequency of positive attitude was observed in participants with enough and higher income compared to those with low income (95.6%; and 100% vs. 80.4%, p < 0.001, respectively), in people with occupations vulnerable to rabies (99.2% vs. 83.8%, p < 0.001), in participants who knew someone bitten by an animal before (91.9% vs. 84.9%, p < 0.001) or diagnose /died from rabies before (99.3% vs. 87.6%, p < 0.001), in participants who had attacked/ bitten by an animal before (94.2% vs. 87.8%, p = 0.013), in participants who heard about rabies before (92.8% vs. 72%, p < 0.001), and in participants who reported awareness of vaccination campaigns for rabies (99.3% vs. 87.5%, p < 0.001). Also, we found that Participants with a higher frequency of good knowledge were more likely to have positive attitudes (99.5% vs. 80.2%, p < 0.001). Also, in participants whose source of knowledge was school compared to radio/television (99.3% vs. 77.3%, p < 0.001) while social media (p = 0.121) was not significantly associated with attitude, gender (p = 0.813) and discussions with physicians (p = 0.555) (Table 3). 3.4. Post-exposure prophylaxis The majority of participants in our study (90.3%, n = 1604) had no history of animal attacks. A subgroup analysis was conducted on participants who were exposed to the rabies virus (9.7%, n = 173) (18.5%, n = 32)) did not receive post-exposure prophylaxis, (6.4%, n = 9) initiated the first dose of the vaccine more than 24 hours after exposure, and (17%, n = 24) did not complete the full vaccine schedule (5 doses) (Table 4). We investigated the associations between variables and receiving post-exposure rabies vaccine among 173 individuals. Significant associations were found for age (p = 0.014), and region (p = 0.002), with the highest uptake in Upper Egypt (98%). Education level was also significant (p = 0.006). Awareness of rabies (p = 0.020), specific sources of rabies knowledge (social media, p = 0.035), discussion with a physician about rabies (p = 0.015), and knowledge of vaccination campaigns (p = 0.045) were positively associated with vaccine uptake. Knowledge level of rabies was significant (p = 0.005), with better knowledge linked to higher uptake. Gender (p = 0.828), residency (p = 0.166), occupation (p = 0.527), income (p = 0.605), and attitude towards rabies (p = 0.396) were not significantly associated with vaccine uptake (Table 5). 3.5. Pre-exposure prophylaxis Approximately one-third of the participants (29.9%, n = 533) were considered a vulnerable population for rabies. Of these, (59.8%, n = 319) were farmers or individuals living in rural areas, (22.5%, n = 120) lived in environments with stray dogs and cats, and (15.4%, n = 82) had pets at home. Only (4.3%, n = 23) participants received the rabies pre-exposure prophylaxis, and 18 of them completed the full vaccination schedule (3 doses) (Table 4). Also, we investigated the association between variables and pre-exposure rabies vaccine uptake among 533 vulnerable participants. Significant associations were found for region (p < 0.001), residency (p < 0.001), education level (p < 0.001), specific sources of rabies knowledge (social media, school with p < 0.001 and Family/Friend, p = 0.009), discussions with physicians about rabies (p < 0.001), awareness of vaccination campaigns (p < 0.001), and previous animal attacks (p 0.999) (Table 6). 3.6. Barriers Lack of knowledge about rabies vaccine and rabies disease were the most frequently reported barriers that prevent people from undergoing rabies prophylaxis (82.4% and 81.7%, respectively). Others included hospital facilities (43.1%), financial Burden (36.1%), fear of the process (28.7%), feeling uncomfortable about dealing with healthcare staff (13.8%), and previous bad experience (0.1%) ( Fig. 2 ). When asked to choose the only most important factor that would prevent people from undergoing rabies prophylaxis The majority (40.5%, n = 719) chose lack of knowledge about rabies as the most important barrier this was followed by lack of knowledge about vaccine (23.4%, n = 415), the hospital in your area doesn’t have the required facilities for rabies prophylaxis (14.0%, n = 249), financial Burden (11.7%, n = 208), fear of the process (8.0%. n = 142) and feeling uncomfortable about dealing with healthcare staff (1.6%, n = 29) 4.0. Discussion Rabies is a fatal zoonotic disease caused by the rabies virus. It is transmitted to humans through the bites or scratches of infected animals, especially dogs which are responsible for 99% of human rabies cases. Despite its 100% preventability through timely vaccination and post-exposure prophylaxis (PEP), rabies poses a significant public health challenge, particularly in regions with inadequate healthcare infrastructure and low awareness levels, mainly in Asia and Africa ( 2 ). Understanding the public’s knowledge about rabies is crucial for designing effective awareness campaigns, training healthcare workers, and improving preventive measures. Our study revealed that 42.8% of participants demonstrated good knowledge of rabies. Also, Positive attitudes towards rabies prevention were observed in 88.5% of participants, significantly influenced by higher education, occupations vulnerable to rabies, and awareness campaigns. Most of the participants in our study (90.3%) had no history of animal attacks. Among vulnerable populations, only 23 participants received pre-exposure prophylaxis with only 18 completing the full vaccination schedule (3 doses). Barriers to prophylaxis included mainly lack of knowledge (82.4%) and other factors like financial burden, and insufficient hospital facilities. Awareness and education were identified as critical for improving rabies prevention efforts. Under the guidance of WHO to eliminate deaths from dog-mediated rabies by 2030, ( 12 ) this is the first multicenter study carried out in Egypt to assess KAP toward rabies and barriers preventing people from having proper healthcare for rabies. The current study shows that 42.8% of the participants had sufficient knowledge regarding rabies, consistent with a survey conducted in Kenya. ( 13 ) Also, It is higher than the results found in other studies conducted in Tanzania ( 14 ) and Guatemala ( 15 ). On the other hand, it is lower than the reports of the studies in north India ( 16 ) and Ethiopia ( 17 ). These differences could be associated with the community's awareness level, educational status, and information access. Additionally, results show a good level of knowledge about the mode of transmission of rabies. However, they were unable to name animals that transmit rabies, this finding is consistent with reports in Guatemala ( 15 ) and Sri Lanka ( 18 ). Also the minority of participants knew the signs of rabies in animals and humans opposite to the results of other studies in Bangladesh and Tanzania ( 14 , 19 ) Furthermore, we found that the geographic region is a significant risk factor for rabies mortality. This could be because there are no vaccination or awareness programs in rural communities, and dogs are regularly observed walking freely on the streets. Dogs are not routinely vaccinated in these locations, which increases the danger of rabies transmission from animals to humans ( 20 ). Awareness was also linked to exposure to vaccination campaigns about the importance of pre-exposure and post-exposure prophylaxis, prior awareness of rabies, a history of animal attacks, and high educational levels, notably among college graduates and those pursuing postgraduate degrees. Sources of knowledge, such as school, family, and friends, played an important part in spreading information. All these factors indicate that the population in the study area is at a constant risk of disease because the participants lack sufficient knowledge regarding potential sources, prevention, and control of rabies. Comparing our survey to one similar conducted in Pondicherry, where approximately 77.5% of participants believed rabies to be a fatal disease ( 21 ), 82% of participants believed the same. Our perception of rabies fatality was also more favorable than that of a Puducherry study, which found that 74.8% of participants were aware that rabies is a deadly illness ( 22 ). The high perception of rabies fatalities indicates that the public will accept and have a good attitude toward the rabies vaccination program. It will also aid in improving the campaign's results and assisting it in reaching its objective. Therefore, raising awareness of the risk of fatalities from rabies before launching a vaccination campaign will be a smart first move in enhancing the program's cost-effectiveness and results. Similar to previous studies, the study participants exhibited a positive attitude toward rabies vaccine ( 23 , 24 ). In our study, 89.9% believed that after an animal bite, post-exposure prophylaxes should be received as soon as possible, and 88.9% believed that the PEP course should be finished. It's encouraging that so many respondents have a favorable opinion of PEP. It demonstrates that hospital PEP programs will be highly successful in achieving their main objective, which is to reduce the number of mortality cases. On the other hand, failing to use this leverage to implicate PEP programs will have deadly results. As a result, the general population needs to be made aware that they should get medical attention if their dog bites them. Vaccinating pets regularly and pursuing adequate post-exposure care, will greatly contribute to reaching the national and international goals of eliminating rabies by 2030 ( 25 ). The way that the dog population is managed in Egypt is by shooting or poisoning stray dogs. This reduces the number of dogs that are immune, which makes vaccination efforts ineffective and counterproductive. This is because the dogs who are easiest to vaccinate also happen to be the easiest to kill ( 26 ). Although it is recommended that animals be vaccinated to safeguard public health, there is no legal requirement for public compliance. Nonetheless, given the positive attitudes of survey participants regarding the deadly nature of rabies, Egypt's Ministry of Health might formulate a long-term plan to compel vaccination by law and attempt to persuade the populace of this requirement. Since doing so will enable us to develop herd immunity. According to the WHO, a community's dogs need to be immunized 70% of the time to develop herd immunity ( 27 ). Income was a significant predictor of attitude toward rabies, with people with not enough income having the least positive attitudes toward the rabies vaccine. This study bears similarities to previous research that found the minimum wage in a district affected the attitudes and practices related to rabies ( 24 ). A tenable explanation pertains to the respondents' socioeconomic position, whereby those with a higher socioeconomic status demonstrated a greater propensity to adhere to the initial management protocol and seek vaccinations in a medical facility. The people with the most positive attitudes toward rabies were those in the susceptible occupation. This could be explained by the fact that these people are constantly looking to learn more about rabies since they come into touch with rabies-infected patients more frequently than non-vulnerable groups. Despite our participants' good attitudes toward PEP, 9.7% of participants in our study were bitten by an animal, and 18.5% did not seek PEP. Our findings are in line with another study that found 20% of subjects did not seek PEP following an animal bite ( 28 ). This could be explained by the desire to seek out local healers due to cultural influences. Our health system is heavily burdened by this. Since most of these rabies cases do not benefit from local healers, they often develop complications that require hospitalization, further taxing our already overburdened health system following COVID-19 and reducing the number of beds available for other severe conditions. Therefore, making rabies vaccination more widely available in hospitals and health facilities will aid in lowering the number of fatalities and lessening the strain that rabies places on the healthcare system. Moreover, 95.7% of the vulnerable group did not receive the pre-exposure vaccination, and 61% of them did not believe that taking a prophylactic was necessary. This might be explained by restricted access to medical facilities. Which will influence their understanding and, consequently, their behavior regarding rabies, how it spreads, and the significance of taking precautions. Since the college group had the highest percentage of individuals taking pre-exposure prophylactics, inadequate literacy could be the cause of this. It's interesting to note that those between the ages of 36 and 60 were less motivated to seek PEP than those beyond 60. The elderly's good practices regarding PEP are consistent with other research that found a notably higher proportion of individuals in the older age group performing first aid using the suggested supplies (soap water) or alternative detergents, such as iodine constituents, or as determined by their availability ( 29 ). Nevertheless, those who were older were less knowledgeable and exhibited a less favorable attitude toward rabies. The explanation for this could be that individuals in their adult years are less concerned with maintaining their health and tend to exaggerate about it, whereas older people are more inclined to seek medical attention when they become unwell. Raising public knowledge has been identified as an essential strategy for controlling rabies ( 30 ). Individuals who have sufficient knowledge demonstrated a more positive outlook and increased adherence to PEP. This demonstrates the direct relationship between attitude and practice and knowledge, highlighting the necessity for improved knowledge to be disseminated throughout the community in order to foster the proper attitude and improved practices. This bears similarities to previous research conducted by Monje et al., which demonstrated that inadequate understanding of rabies has a detrimental impact on attitudes, which then affects practices related to rabies management ( 31 ). Primary care physicians should address the local community's knowledge, practices, and misunderstandings regarding serious and terrifying public health diseases like rabies in order to offer preventive and curative treatments. Our study identified several barriers to rabies prophylaxis, the predominant barrier to undergoing rabies prophylaxis was a lack of knowledge about the disease and the vaccine (82.4% and 81.7%, respectively). This finding is corroborated by a study highlighting that low awareness of rabies severity and misconceptions about vaccines are significant obstacles to effective rabies prevention ( 32 ). This emphasizes the crucial need for thorough educational campaigns to raise awareness about rabies transmission, prevention, and the significance of timely prophylaxis. Additionally, there is a barrier of inadequate healthcare facilities for rabies patients in local hospitals (43.1%). This finding is consistent with studies indicating that limited access to healthcare infrastructure hampers the timely administration of rabies prophylaxis ( 33 , 34 ). Furthermore, other barriers affect rabies prophylaxis such as financial Burden (36.1%), consistent with that reported by the WHO, ( 2 ) fear of the process (28.7%), feeling uncomfortable about dealing with healthcare staff (13.8%), and previous bad experiences (0.1%). Addressing these barriers involves a multimodal approach that includes increasing public education, strengthening healthcare infrastructure, supporting prophylactic costs, and developing favorable patient-healthcare provider relationships. Such attempts are critical for increasing the use of rabies prophylaxis and, ultimately, lowering the incidence of this fatal disease. Conclusion While most participants recognized rabies as a fatal and preventable disease, deficiencies in specific knowledge particularly regarding transmission, early signs, and appropriate prophylactic measures were evident. Moreover, adherence to pre and post exposure prophylaxis remains relatively low. Implementing organized national awareness programs may help to increase public knowledge and promote the adherence to prophylaxis guidelines. Abbreviations Abbreviation Full term CI Confidence Interval COVID-19 Coronavirus Disease 2019 IQR Interquartile Range KAP Knowledge, Attitudes, and Practices n Number of participants p p-value PEP Post-Exposure Prophylaxis PrEP Pre-Exposure Prophylaxis SPSS Statistical Package for the Social Sciences STROBE Strengthening the Reporting of Observational Studies in Epidemiology USD United States Dollar WHO World Health Organization Declarations Ethics approval and consent to participate Ethical approval was obtained in accordance with the Declaration of Helsinki from the Alexandria University Faculty of Medicine Research Ethics Committee with a serial number of (0306449) before starting data collection. Participation was voluntary and informed consent was obtained prior to starting data collection. Consent for publication Not applicable Availability of data and materials The datasets analyzed during the current study are available from the corresponding author on reasonable request. Competing interests All authors declare that they have no competing interests Funding This research did not receive any specific grant from funding agencies in the public, commercial, or not-for-profit sectors. Authors' contributions Conceptualization and methodology: Conceptualization and methodology: M.A.S., M.B.H., A.G.E., A.R.A. Investigation and data acquisition: M.E.Z., A.M.A., O.M.M., E.S.A., A.B., I.M.A., B.A.E., N.M.B.A., M.N., A.A. Formal analysis: M.B.H., A.R.A., A.M.M. Writing, review and editing: M.B.H., M.A.S., A.M.M., A.G.E., M.E.Z., A.R.A. Supervision and project administration: A.R.A. All authors read and approved of the final manuscript. Acknowledgements Not applicable Clinical trial number Not applicable References Fooks AR, Banyard AC, Horton DL, Johnson N, McElhinney LM, Jackson AC. Current status of rabies and prospects for elimination. Lancet. 2014;384(9951):1389-99. Organization WH. Rabies 2024 [Available from: https://www.who.int/news-room/fact-sheets/detail/rabies. Jackson AC. Rabies pathogenesis. J Neurovirol. 2002;8(4):267-9. Hampson K, Coudeville L, Lembo T, Sambo M, Kieffer A, Attlan M, et al. Estimating the global burden of endemic canine rabies. PLoS Negl Trop Dis. 2015;9(4):e0003709. Knobel DL, Cleaveland S, Coleman PG, Fèvre EM, Meltzer MI, Miranda ME, et al. Re-evaluating the burden of rabies in Africa and Asia. Bull World Health Organ. 2005;83(5):360-8. Rohde RE, Rupprecht CE. Update on lyssaviruses and rabies: will past progress play as prologue in the near term towards future elimination? Fac Rev. 2020;9:9. Diallo MK, Diallo AO, Dicko A, Richard V, Espié E. Human rabies post exposure prophylaxis at the Pasteur Institute of Dakar, Senegal: trends and risk factors. BMC Infect Dis. 2019;19(1):321. WHO. WHO, in collaboration with the Ministry of Health and Population of Egypt, celebrates World Rabies Day [Available from: https://www.emro.who.int/egy/egypt-news/world-rabies-day.html. Mekhail N, Shenouda MS, Mohamed AAA. Assessment of knowledge, attitudes, and practices toward rabies among visitors of a family health center. Egyptian Nursing Journal. 2022;19:287 - 305. Raosoft I. RaoSoft® Sample Size Calculator. 2004. World Medical Association Declaration of Helsinki: ethical principles for medical research involving human subjects. Jama. 2013;310(20):2191-4. Organization WH. Zero by 30: the global strategic plan to end human deaths from dog-mediated rabies by 2030. 2018. Mucheru GM, Kikuvi GM, Amwayi SA. Knowledge and practices towards rabies and determinants of dog rabies vaccination in households: a cross sectional study in an area with high dog bite incidents in Kakamega County, Kenya, 2013. Pan African Medical Journal. 2014;19(1). Sambo M, Lembo T, Cleaveland S, Ferguson HM, Sikana L, Simon C, et al. Knowledge, attitudes and practices (KAP) about rabies prevention and control: a community survey in Tanzania. PLoS neglected tropical diseases. 2014;8(12):e3310. Moran D, Juliao P, Alvarez D, Lindblade KA, Ellison JA, Gilbert AT, et al. Knowledge, attitudes and practices regarding rabies and exposure to bats in two rural communities in Guatemala. BMC research notes. 2015;8:1-7. Tiwari HK, Robertson ID, O’Dea M, Vanak AT. Knowledge, attitudes and practices (KAP) towards rabies and free roaming dogs (FRD) in Panchkula district of north India: A cross-sectional study of urban residents. PLoS neglected tropical diseases. 2019;13(4):e0007384. Bihon A, Meresa D, Tesfaw A. Rabies: knowledge, attitude and practices in and around South Gondar, North West Ethiopia. Diseases. 2020;8(1):5. Muthunuwan J, Ganhewa A, Perera H, Hishaam M, Bandara W, Gunasekera H. Preliminary survey on knowledge, attitudes and practices regarding rabies. Sri Lankan Journal of Infectious Diseases. 2017;7(1). Hossain M. Study on knowledge, attitude & practice about rabies & pet animals among school children in Bangladesh. J Microbiol Exp. 2017;4(1):1-15. Tiwari HK, O’Dea M, Robertson ID, Vanak AT. Knowledge, attitudes and practices (KAP) towards rabies and free-roaming dogs (FRD) in Shirsuphal village in western India: A community based cross-sectional study. PLoS neglected tropical diseases. 2019;13(1):e0007120. Joice YS, Singh Z, Datta SS. knowledge, attitude and practices regarding dog bite and its management among adults in rural Tamil Nadu. Medical Science. 2016;5(5). Krishnamoorthy Y, Vijayageetha M, Sarkar S. Awareness about rabies among general population and treatment seeking behaviour following dog-bite in rural Puducherry: A community based cross-sectional study. Int J Community Med Public Health. 2018;5:2557-63. Penjor K, Tenzin T, Jamtsho RK. Determinants of health seeking behavior of animal bite victims in rabies endemic South Bhutan: a community-based contact-tracing survey. BMC public health. 2019;19:1-11. Christopher PM, Cucunawangsih C, Adidharma AAGB, Putra IPDK, Putra DGS. Knowledge, attitudes and practices regarding rabies among community members: a cross-sectional study in Songan Village, Bali, Indonesia. International maritime health. 2021;72(1):26-35. Organization WH. WHO expert consultation on rabies: second report: World Health Organization; 2013. Organization WH. WHO expert consultation on rabies: third report: World Health Organization; 2018. Glasgow L, Worme A, Keku E, Forde M. Knowledge, attitudes, and practices regarding rabies in Grenada. PLoS neglected tropical diseases. 2019;13(1):e0007079. Lhendup K, Wangdi K. Knowledge, Attitude and Practices of rabies during an outbreak in Samtse Municipality, Bhutan: A cross-sectional study. Journal of family medicine and primary care. 2022;11(9):5361-8. Laishram J, Chaudhuri S, Devi HS, Konjengbam S. Knowledge and practice on rabies in an urban community of Manipur, India. J Evolution Med Dent Sci. 2016;5:2234-7. Balaram D, Taylor L, Doyle K, Davidson E, Nel L. World Rabies Day-a decade of raising awareness, Trop. Dis Travel Med Vaccines. 2016. Monje F, Erume J, Mwiine FN, Kazoora H, Okech SG. Knowledge, attitude and practices about rabies management among human and animal health professionals in Mbale District, Uganda. One Health Outlook. 2020;2:1-11. Castillo-Neyra R, Buttenheim AM, Brown J, Ferrara JF, Arevalo-Nieto C, Borrini-Mayorí K, et al. Behavioral and structural barriers to accessing human post-exposure prophylaxis and other preventive practices in Arequipa, Peru, during a canine rabies epidemic. PLoS neglected tropical diseases. 2020;14(7):e0008478. van de Burgwal LHM, Neevel AMG, Pittens C, Osterhaus A, Rupprecht CE, Claassen E. Barriers to innovation in human rabies prophylaxis and treatment: A causal analysis of insights from key opinion leaders and literature. Zoonoses Public Health. 2017;64(8):599-611. Ahmed T, Hussain S, Zia UU, Rinchen S, Yasir A, Ahmed S, et al. Knowledge, attitude and practice (KAP) survey of canine rabies in Khyber Pakhtunkhwa and Punjab Province of Pakistan. BMC Public Health. 2020;20(1):1293. Figures Figures 1 and 2 are not available with this version. Additional Declarations No competing interests reported. Supplementary Files SuplementaryFile1.docx Supplementary information Supplementary file 1: Knowledge, attitudes, and practice towards rabies and rabies prophylaxis: a nationwide survey. Cite Share Download PDF Status: Under Review Version 1 posted Editorial decision: Revision requested 08 Sep, 2025 Reviews received at journal 05 Sep, 2025 Reviewers agreed at journal 03 Sep, 2025 Reviews received at journal 01 Sep, 2025 Reviewers agreed at journal 01 Sep, 2025 Reviews received at journal 27 Jul, 2025 Reviewers agreed at journal 13 Jul, 2025 Reviewers agreed at journal 10 Jul, 2025 Reviewers invited by journal 10 Jul, 2025 Editor invited by journal 25 Jun, 2025 Editor assigned by journal 25 Jun, 2025 Submission checks completed at journal 25 Jun, 2025 First submitted to journal 24 Jun, 2025 You are reading this latest preprint version Research Square lets you share your work early, gain feedback from the community, and start making changes to your manuscript prior to peer review in a journal. As a division of Research Square Company, we’re committed to making research communication faster, fairer, and more useful. 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Also discoverable on Platform About Our Team In Review Editorial Policies Advisory Board Help Center Resources Author Services Accessibility API Access RSS feed Manage Cookie Preferences © Research Square 2026 | ISSN 2693-5015 (online) Privacy Policy Terms of Service Do Not Sell My Personal Information {"props":{"pageProps":{"initialData":{"identity":"rs-6968724","acceptedTermsAndConditions":true,"allowDirectSubmit":false,"archivedVersions":[],"articleType":"Research Article","associatedPublications":[],"authors":[{"id":484648873,"identity":"cbef2019-14b6-443a-a040-0fc0932f713e","order_by":0,"name":"Mohamed Basyouni Helal","email":"","orcid":"","institution":"Menoufia University","correspondingAuthor":false,"prefix":"","firstName":"Mohamed","middleName":"Basyouni","lastName":"Helal","suffix":""},{"id":484648874,"identity":"b567eb14-a981-44b9-a314-6db8e0f81800","order_by":1,"name":"Mohamed Ahmed Saeda","email":"","orcid":"","institution":"Menoufia University","correspondingAuthor":false,"prefix":"","firstName":"Mohamed","middleName":"Ahmed","lastName":"Saeda","suffix":""},{"id":484648875,"identity":"8b66066d-034d-479d-8b09-e28582180ce4","order_by":2,"name":"Ahmed Gamal Elshaar","email":"","orcid":"","institution":"Menoufia University","correspondingAuthor":false,"prefix":"","firstName":"Ahmed","middleName":"Gamal","lastName":"Elshaar","suffix":""},{"id":484648876,"identity":"df6b5b83-a4b1-4637-bf42-44db5fc08e5d","order_by":3,"name":"Mohamed Elsayed Zayed","email":"","orcid":"","institution":"Menoufia University","correspondingAuthor":false,"prefix":"","firstName":"Mohamed","middleName":"Elsayed","lastName":"Zayed","suffix":""},{"id":484648877,"identity":"01b08faa-060a-4eed-a18c-2ff9146f0867","order_by":4,"name":"Ali M. Abdelaziz","email":"","orcid":"","institution":"Alexandria University","correspondingAuthor":false,"prefix":"","firstName":"Ali","middleName":"M.","lastName":"Abdelaziz","suffix":""},{"id":484648878,"identity":"a26234c9-9eb6-4e75-b207-7fb9e0968e14","order_by":5,"name":"Omnia M. Mostafa","email":"","orcid":"","institution":"South Valley University","correspondingAuthor":false,"prefix":"","firstName":"Omnia","middleName":"M.","lastName":"Mostafa","suffix":""},{"id":484648879,"identity":"a566485d-8fb4-4ae7-a727-fd0748c9de3b","order_by":6,"name":"Enas Sherif Adwy","email":"","orcid":"","institution":"Benha University","correspondingAuthor":false,"prefix":"","firstName":"Enas","middleName":"Sherif","lastName":"Adwy","suffix":""},{"id":484648880,"identity":"e75555fc-6a52-48e7-bee4-29a52205006a","order_by":7,"name":"Ahmed Barakat","email":"","orcid":"","institution":"Assiut University","correspondingAuthor":false,"prefix":"","firstName":"Ahmed","middleName":"","lastName":"Barakat","suffix":""},{"id":484648881,"identity":"094c4272-700b-406e-9355-5344569d273e","order_by":8,"name":"Ibrahim Mohammed Abdelkader","email":"","orcid":"","institution":"Suez University","correspondingAuthor":false,"prefix":"","firstName":"Ibrahim","middleName":"Mohammed","lastName":"Abdelkader","suffix":""},{"id":484648882,"identity":"66e3591e-a4ea-4cf1-8d0a-dfa759ef92e1","order_by":9,"name":"Basma Amir Eldawody","email":"","orcid":"","institution":"Mansoura University","correspondingAuthor":false,"prefix":"","firstName":"Basma","middleName":"Amir","lastName":"Eldawody","suffix":""},{"id":484648883,"identity":"7c378514-27bf-4e7d-9a64-02c7e51642e6","order_by":10,"name":"Noor Maged Badrawy Ahmed","email":"","orcid":"","institution":"Ain Shams University","correspondingAuthor":false,"prefix":"","firstName":"Noor","middleName":"Maged Badrawy","lastName":"Ahmed","suffix":""},{"id":484648884,"identity":"182869dd-58bd-42eb-a539-97b867545db4","order_by":11,"name":"Mohanned Noah","email":"","orcid":"","institution":"Cairo University","correspondingAuthor":false,"prefix":"","firstName":"Mohanned","middleName":"","lastName":"Noah","suffix":""},{"id":484648885,"identity":"17da57e7-d34f-4e74-bea4-987986b13fe4","order_by":12,"name":"Ashraf Aboismail","email":"","orcid":"","institution":"Alexandria University","correspondingAuthor":false,"prefix":"","firstName":"Ashraf","middleName":"","lastName":"Aboismail","suffix":""},{"id":484648886,"identity":"5b45094a-1d0a-49df-bc0e-2cb5fa176b78","order_by":13,"name":"Abdelrahman Mohamed Mahmoud","email":"","orcid":"","institution":"Menoufia University","correspondingAuthor":false,"prefix":"","firstName":"Abdelrahman","middleName":"Mohamed","lastName":"Mahmoud","suffix":""},{"id":484648887,"identity":"1fe709ca-997b-49bf-af46-4bec731173a3","order_by":14,"name":"Abdallah R. Allam","email":"data:image/png;base64,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","orcid":"","institution":"Menoufia University","correspondingAuthor":true,"prefix":"","firstName":"Abdallah","middleName":"R.","lastName":"Allam","suffix":""}],"badges":[],"createdAt":"2025-06-24 20:23:11","currentVersionCode":1,"declarations":"","doi":"10.21203/rs.3.rs-6968724/v1","doiUrl":"https://doi.org/10.21203/rs.3.rs-6968724/v1","draftVersion":[],"editorialEvents":[],"editorialNote":"","failedWorkflow":false,"files":[{"id":86737349,"identity":"aa1938bd-dcef-48cf-8c6b-e37c10e7aa30","added_by":"auto","created_at":"2025-07-15 06:07:42","extension":"pdf","order_by":0,"title":"","display":"","copyAsset":false,"role":"manuscript-pdf","size":839041,"visible":true,"origin":"","legend":"","description":"","filename":"manuscript.pdf","url":"https://assets-eu.researchsquare.com/files/rs-6968724/v1/8fa09d6c-6b7f-4dbd-b2ac-bd5c7065750d.pdf"},{"id":86735818,"identity":"4ca99d8d-35a2-4325-91e6-1a177d6d7d58","added_by":"auto","created_at":"2025-07-15 05:35:41","extension":"docx","order_by":1,"title":"","display":"","copyAsset":false,"role":"supplement","size":30134,"visible":true,"origin":"","legend":"\u003cp\u003e\u003cem\u003e\u003cstrong\u003eSupplementary information\u003c/strong\u003e\u003c/em\u003e\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eSupplementary file 1: \u003c/strong\u003eKnowledge, attitudes, and practice towards rabies and rabies prophylaxis: a nationwide survey.\u003c/p\u003e","description":"","filename":"SuplementaryFile1.docx","url":"https://assets-eu.researchsquare.com/files/rs-6968724/v1/24ab9e6486a67647a40e0a67.docx"}],"financialInterests":"No competing interests reported.","formattedTitle":"Rabies and rabies prophylaxis in Egypt: a nation-wide cross-sectional study that calls for action","fulltext":[{"header":"1.0. Introduction","content":"\u003cp\u003eRabies remains one of the most serious and feared threats to public health in the 21st century. It\u0026rsquo;s caused by the rabies virus, which belongs to the Lyssavirus genus (\u003cspan citationid=\"CR1\" class=\"CitationRef\"\u003e1\u003c/span\u003e). This disease is transmitted to humans through the saliva of infected animals, with dogs being responsible for 99% of human cases (\u003cspan citationid=\"CR2\" class=\"CitationRef\"\u003e2\u003c/span\u003e). If left untreated, the virus can travel to the nervous system and cause viral encephalitis, which is incurable and fatal (\u003cspan citationid=\"CR1\" class=\"CitationRef\"\u003e1\u003c/span\u003e, \u003cspan citationid=\"CR3\" class=\"CitationRef\"\u003e3\u003c/span\u003e).\u003c/p\u003e\u003cp\u003eRabies has been associated with high fatality rates, resulting in 59,000 deaths worldwide every year with 36% of cases present in Africa (\u003cspan citationid=\"CR4\" class=\"CitationRef\"\u003e4\u003c/span\u003e). The majority of deaths occur in rural communities in developing countries in Africa and Asia (\u003cspan citationid=\"CR5\" class=\"CitationRef\"\u003e5\u003c/span\u003e), with a large economic burden costing 8.6\u0026nbsp;billion USD (\u003cspan citationid=\"CR4\" class=\"CitationRef\"\u003e4\u003c/span\u003e).\u003c/p\u003e\u003cp\u003eFortunately, Rabies is a 100% preventable disease with post-exposure prophylaxis for infected populations and pre- and prophylaxis for high-risk populations (\u003cspan citationid=\"CR6\" class=\"CitationRef\"\u003e6\u003c/span\u003e).\u003c/p\u003e\u003cp\u003eIn developing countries, there are associated problems with the use of post-exposure prophylaxis, according to a study in Senegal only 50% of patients followed the full schedule of post-exposure prophylaxis (\u003cspan citationid=\"CR7\" class=\"CitationRef\"\u003e7\u003c/span\u003e).\u003c/p\u003e\u003cp\u003eIn Egypt, the Ministry of Health and Population reported 200.000 animal bites each year (\u003cspan citationid=\"CR8\" class=\"CitationRef\"\u003e8\u003c/span\u003e), making the need for proper knowledge and practice regarding rabies prophylaxis crucial. However, data regarding knowledge and adherence to rabies prophylaxis is insufficient. While a survey assessing knowledge and practice toward rabies has been conducted, the data were limited to a single center and a very small population, which is not fully representative of the general population (\u003cspan citationid=\"CR9\" class=\"CitationRef\"\u003e9\u003c/span\u003e). In addition, data regarding attitude and practice are insufficient.\u003c/p\u003e\u003cp\u003eTherefore, the present study aims to evaluate the level of knowledge and attitude towards rabies and rabies prophylaxis among the general population in Egypt. Furthermore, we aim to explore the Practice and potential barriers regarding the rabies vaccine to provide insights for improving rabies prevention and control strategies in Egypt.\u003c/p\u003e"},{"header":"2.0. Methods","content":"\u003cdiv id=\"Sec3\" class=\"Section2\"\u003e\u003ch2\u003e2.1. Study design and setting\u003c/h2\u003e\u003cp\u003eWe conducted a nationwide questionnaire based cross-sectional study in Egypt to assess the practice of rabies prophylaxis from the perspective of both the general and high-risk populations. Participants were recruited from outpatient clinics at nine university hospitals, geographically distributed across Egypt (Cairo region, Coastal region and Suez Canal, Delta region, and Upper Egypt). A complete list of the included study centers is provided in Fig.\u0026nbsp;\u003cspan refid=\"Fig1\" class=\"InternalRef\"\u003e1\u003c/span\u003e.\u003c/p\u003e\u003cp\u003e\u003c/p\u003e\u003c/div\u003e\u003cdiv id=\"Sec4\" class=\"Section2\"\u003e\u003ch2\u003e2.2. Study population and sample\u003c/h2\u003e\u003cp\u003eThe study included participants aged 18 years and older who attended outpatient clinics or waiting rooms at the selected study centers. Students in the medical field, healthcare workers, and individuals under the age of 18 were excluded.\u003c/p\u003e\u003c/div\u003e\u003cdiv id=\"Sec5\" class=\"Section2\"\u003e\u003ch2\u003e2.3. Sampling and sample size calculation\u003c/h2\u003e\u003cp\u003eA convenient sampling method was used to recruit eligible study participants. The sample size was calculated using the online Raosoft sample size calculator (\u003cspan citationid=\"CR10\" class=\"CitationRef\"\u003e10\u003c/span\u003e), with the following parameters: a confidence interval of 95%, an expected frequency of 50%, and an acceptable margin of error of 2.5%. The anticipated sample size was 1428, which was later increased to 1,777 after data collection.\u003c/p\u003e\u003c/div\u003e\u003cdiv id=\"Sec6\" class=\"Section2\"\u003e\u003ch2\u003e2.4. Questionnaire development and validation\u003c/h2\u003e\u003cp\u003eA structured questionnaire was developed specifically for this study to assess the current practices of rabies prophylaxis screening in Egypt from the perspectives of both the general population and high-risk groups. The primary objective was to evaluate the knowledge, perceptions, barriers, and practices related to rabies prophylaxis.\u003c/p\u003e\u003cp\u003eFollowing a comprehensive review of the literature, the study team created an initial draft of the questionnaire. This draft was reviewed and discussed by two experts in the field to ensure its relevance and clarity. A pilot test was conducted with 20 participants to evaluate the clarity, accuracy, and relevance of each question, as well as the duration required for completion. Based on the feedback from the pilot study, the questionnaire was refined and finalized. Participants included in the pilot study were excluded from the final analysis. The finalized questionnaire included multiple sections: sociodemographic data, history and awareness of rabies, knowledge of rabies and its prophylaxis, perceptions toward rabies and its prophylaxis, barriers to rabies prophylaxis, and practices related to rabies prophylaxis.\u003c/p\u003e\u003cp\u003eThe sociodemographic section collected data on participants' gender, age, occupation, highest level of education, income, region, and residency. The history section examined participants\u0026rsquo; prior awareness of rabies, personal experiences with animal attacks, and their connections to individuals who have been affected by rabies. The knowledge section contained 11 closed-ended questions: 7 focused on knowledge about rabies and 4 on knowledge of rabies prophylaxis. The perceptions section included 7 questions aimed at gauging participants' views on the risk and fatality of rabies, as well as their willingness to undergo both post-exposure and pre-exposure prophylaxis. The barriers section explored factors that could prevent individuals from seeking rabies prophylaxis, such as lack of knowledge, fear, financial burdens, or previous negative experiences with healthcare. Finally, the practices section focused on participants\u0026rsquo; actual behaviors regarding rabies prophylaxis, distinguishing between those who had experienced animal bites and received post-exposure treatment and those who belonged to high-risk groups recommended for pre-exposure prophylaxis.\u003c/p\u003e\u003cp\u003eThe questionnaire was originally developed in English and then translated into Arabic by a language specialist to ensure it was understandable for the local population. A full version of the questionnaire can be found in \u003cb\u003eSupplementary file 1\u003c/b\u003e.\u003c/p\u003e\u003c/div\u003e\u003cdiv id=\"Sec7\" class=\"Section2\"\u003e\u003ch2\u003e2.5. Data collection\u003c/h2\u003e\u003cp\u003eA team of well-trained data collectors was assigned to each university to manage the process of data collection. They reached the general population in their respective university outpatient clinics and waiting rooms. The data was collected in a structured interview format.\u003c/p\u003e\u003c/div\u003e\u003cdiv id=\"Sec8\" class=\"Section2\"\u003e\u003ch2\u003e2.6. Ethical considerations\u003c/h2\u003e\u003cp\u003eThe study was conducted according to the principles of the Declaration of Helsinki (1964, last revised in 2013) (\u003cspan citationid=\"CR11\" class=\"CitationRef\"\u003e11\u003c/span\u003e). This survey was voluntary, and all participants in this study were asked to give informed consent to participate in the study before starting data entry. Also, all participants received detailed explanations about the aim, objectives, and methodology of the study before completing the questionnaire. Participants\u0026rsquo; anonymity and confidentiality were ensured throughout the study, including data collection and analysis. Ethical approval was obtained from the Ethical Committee for Scientific Research at the Faculty of Medicine, Alexandria University.\u003c/p\u003e\u003c/div\u003e\u003cdiv id=\"Sec9\" class=\"Section2\"\u003e\u003ch2\u003e2.7. Statistical analysis\u003c/h2\u003e\u003cp\u003eThe data were analyzed using IBM SPSS Version 28.0 for windows (Armonk, NY: IBM Corp.). Frequencies and percentages were used to describe the categorical variables for baseline demographic characteristics. The normality of the continuous variables was assessed using the Shapiro-Wilk test and Kolmogorov-Smirnov test. The median and interquartile range (IQR) were used to describe the non-parametric variables. Pearson\u0026rsquo;s Chi-square test, Fisher exact test, and Fisher-Freeman-Halton Exact test were used to explore the associations between the categorical variables. A p-value of \u0026lt;\u0026thinsp;0.05 was considered statistically significant. For the knowledge questions, answers were coded as 1 for correct and 0 for incorrect, yielding a score range of 0\u0026ndash;11 per participant. If a question had multiple correct answers (e.g., animals that transmit rabies), the response is considered correct if the participant selects at least half or more of the correct options. A 60% cutoff was used to categorize knowledge as good (\u003cspan additionalcitationids=\"CR7 CR8 CR9 CR10\" citationid=\"CR6\" class=\"CitationRef\"\u003e6\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR11\" class=\"CitationRef\"\u003e11\u003c/span\u003e) or poor (0\u0026ndash;5). For the perception section, responses to closed-ended questions (e.g., recognizing rabies as a health risk or supporting prophylaxis) were coded as 1 for positive perceptions and 0 for negative perceptions. For scale questions (\u003cspan additionalcitationids=\"CR2 CR3 CR4 CR5 CR6 CR7 CR8 CR9\" citationid=\"CR1\" class=\"CitationRef\"\u003e1\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR10\" class=\"CitationRef\"\u003e10\u003c/span\u003e), scores of 6 or higher were coded as 1, and below 6 as 0, resulting in a total perception score ranging from 0 to 7. A 60% cutoff was used to categorize perceptions as positive (\u003cspan additionalcitationids=\"CR5 CR6\" citationid=\"CR4\" class=\"CitationRef\"\u003e4\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR7\" class=\"CitationRef\"\u003e7\u003c/span\u003e) or negative (0\u0026ndash;3). Descriptive analysis included frequency and percentage of correct answers and positive perceptions, along with the median and IQR for both knowledge and perception scores.\u003c/p\u003e\u003c/div\u003e"},{"header":"3.0. Results","content":"\u003cdiv id=\"Sec11\" class=\"Section2\"\u003e\u003ch2\u003e3.1. Demographic characteristics of the participants\u003c/h2\u003e\u003cp\u003eA total of 1,777 participants from nine Egyptian centers were included in the study, with a median age of 35 years (IQR\u0026thinsp;=\u0026thinsp;23). (52%, n\u0026thinsp;=\u0026thinsp;924) of them were females and (48%, n\u0026thinsp;=\u0026thinsp;853) were males. About (75.7%, n\u0026thinsp;=\u0026thinsp;1345) of our sample had secondary education or higher, and more than half were from rural areas (52.4%, n\u0026thinsp;=\u0026thinsp;931). Almost (70%, n\u0026thinsp;=\u0026thinsp;1244) of the participants work in occupations not considered vulnerable to rabies exposure and nearly half of the respondents (50.7%, n\u0026thinsp;=\u0026thinsp;901) reported having sufficient income. A significant majority of participants (79.1%, n\u0026thinsp;=\u0026thinsp;1405) had heard about rabies, with family and friends being the primary source of information (62.6%, n\u0026thinsp;=\u0026thinsp;1113). Meanwhile, only (5%, n\u0026thinsp;=\u0026thinsp;89) had previous discussions about rabies with a physician. Awareness or vaccination campaigns for rabies were reported by a small percentage only (7.8%, n\u0026thinsp;=\u0026thinsp;139) of respondents. Almost half of the participants (50.8%, n\u0026thinsp;=\u0026thinsp;903) knew someone who had been bitten or attacked by an animal, while only (7.7%, n\u0026thinsp;=\u0026thinsp;136) knew a patient diagnosed with or who had died from rabies. Additionally, (9.7%, n\u0026thinsp;=\u0026thinsp;173) of participants had personally been bitten or attacked by an animal \u003cb\u003e(Table\u0026nbsp;1).\u003c/b\u003e\u003c/p\u003e\u003c/div\u003e\u003cdiv id=\"Sec12\" class=\"Section2\"\u003e\u003ch2\u003e3.2. Knowledge\u003c/h2\u003e\u003cp\u003eThe median knowledge score among respondents was 5 (IQR: 3) on a twelve-point scale (from zero to eleven). A total of 760 participants (42.8%) demonstrated good knowledge about rabies, with scores of 6 or higher. Only (25.9%, n\u0026thinsp;=\u0026thinsp;461) of participants correctly identified rabies as a viral disease, while (13.1%, n\u0026thinsp;=\u0026thinsp;232) could name the animals that transmit rabies. A significant majority, (88.4%, n\u0026thinsp;=\u0026thinsp;1570) were aware of the mode of transmission of rabies. Only a minority of participants knew the signs of rabies in animals and humans (20.9%; n\u0026thinsp;=\u0026thinsp;371 and 16.4%, n\u0026thinsp;=\u0026thinsp;291 respectively). About (81.2%, n\u0026thinsp;=\u0026thinsp;1443) believed that a person attacked by a rabid animal could recover with treatment. However, only (18.4%, n\u0026thinsp;=\u0026thinsp;327) were aware that rabies is untreatable once clinical signs appear. Half of our sample (50.1%, n\u0026thinsp;=\u0026thinsp;890) knew the appropriate first aid measures after an animal attack, (73.9%, n\u0026thinsp;=\u0026thinsp;1314) knew that a rabies vaccine existed, and a majority (81.9%, n\u0026thinsp;=\u0026thinsp;1455) knew when rabies post-exposure prophylaxis should be taken. About (47.8%, n\u0026thinsp;=\u0026thinsp;849) of participants were knowledgeable about the appropriate candidates for pre-exposure prophylaxis \u003cb\u003e(Table\u0026nbsp;2).\u003c/b\u003e\u003c/p\u003e\u003cp\u003eOur study found that self-perceived good knowledge was higher among participants from urban areas compared to rural areas (50.7% vs. 35.6%, p\u0026thinsp;\u0026lt;\u0026thinsp;0.001), in male participants compared to females (48.9% vs. 37.1%, p\u0026thinsp;\u0026lt;\u0026thinsp;0.001), in people with occupations vulnerable to rabies (66.2% vs. 32.7%, p\u0026thinsp;\u0026lt;\u0026thinsp;0.001), in participants with enough and higher income compared to low income (55.7%; and 77.8% vs. 27.4%, p\u0026thinsp;\u0026lt;\u0026thinsp;0.001, respectively), in participants who reported awareness of vaccination campaigns for rabies\u003cb\u003e(\u003c/b\u003e 69.1% vs. 40.5%, p\u0026thinsp;\u0026lt;\u0026thinsp;0.001), in people who had heard about rabies before (49.8% vs 16.1%, p\u0026thinsp;\u0026lt;\u0026thinsp;0.001), individuals with history of animal attacks \u003cb\u003e(\u003c/b\u003e 56.1% vs. 41.3%, p\u0026thinsp;\u0026lt;\u0026thinsp;0.001), those who Knew someone bitten or attacked by an animal \u003cb\u003e(\u003c/b\u003e51.2% vs. 34.1%, p\u0026thinsp;\u0026lt;\u0026thinsp;0.001), or diagnosed with or died from rabies (66.2% vs. 40.8%, p\u0026thinsp;\u0026lt;\u0026thinsp;0.001). A significant association was found between regional distribution and good knowledge, particularly in Cairo (52.3% p\u0026thinsp;\u0026lt;\u0026thinsp;0.001). Also, between educational level and good knowledge, notably among college graduates and those with postgraduate studies (50.3%, 63.9% p\u0026thinsp;\u0026lt;\u0026thinsp;0.001, respectively), between Sources of knowledge about rabies and good knowledge as in School compared to radio/TV (76.5% vs 40.4%, p\u0026thinsp;\u0026lt;\u0026thinsp;0.001, respectively) \u003cb\u003e(Table\u0026nbsp;3).\u003c/b\u003e\u003c/p\u003e\u003c/div\u003e\u003cdiv id=\"Sec13\" class=\"Section2\"\u003e\u003ch2\u003e3.3. Attitude\u003c/h2\u003e\u003cp\u003eThe median attitude score among respondents was 7 (IQR: 1) on an eight-point scale (from zero to seven). The majority (88.5%, n\u0026thinsp;=\u0026thinsp;1572) exhibited a positive attitude towards rabies and rabies prophylaxis, with scores of 4 or higher. Most of the participants thought that rabies is a risk to human health (91.2%, n\u0026thinsp;=\u0026thinsp;1620) and is a fatal disease (82%, n\u0026thinsp;=\u0026thinsp;1457) \u003cb\u003e(Table\u0026nbsp;2).\u003c/b\u003e\u003c/p\u003e\u003cp\u003eA significantly higher frequency of positive attitude was observed among rural residents compared to urban residents (89.9% vs. 86.9%, p\u0026thinsp;=\u0026thinsp;0.046), and among younger participants aged 18\u0026ndash;35 years (93.3% vs 87.6% and 66.1%, p\u0026thinsp;\u0026lt;\u0026thinsp;0.001). Participants from the Delta regions and Cairo also demonstrated a higher frequency of positive attitudes (99.8% and 98.8%, p\u0026thinsp;\u0026lt;\u0026thinsp;0.001, respectively). Educational level significantly influenced attitudes, with a higher percentage of participants with positive attitudes noticed among college graduates and those with postgraduate studies (94.6% and 100%, p\u0026thinsp;\u0026lt;\u0026thinsp;0.001, respectively). Significant higher frequency of positive attitude was observed in participants with enough and higher income compared to those with low income (95.6%; and 100% vs. 80.4%, p\u0026thinsp;\u0026lt;\u0026thinsp;0.001, respectively), in people with occupations vulnerable to rabies (99.2% vs. 83.8%, p\u0026thinsp;\u0026lt;\u0026thinsp;0.001), in participants who knew someone bitten by an animal before (91.9% vs. 84.9%, p\u0026thinsp;\u0026lt;\u0026thinsp;0.001) or diagnose /died from rabies before (99.3% vs. 87.6%, p\u0026thinsp;\u0026lt;\u0026thinsp;0.001), in participants who had attacked/ bitten by an animal before (94.2% vs. 87.8%, p\u0026thinsp;=\u0026thinsp;0.013), in participants who heard about rabies before (92.8% vs. 72%, p\u0026thinsp;\u0026lt;\u0026thinsp;0.001), and in participants who reported awareness of vaccination campaigns for rabies (99.3% vs. 87.5%, p\u0026thinsp;\u0026lt;\u0026thinsp;0.001). Also, we found that Participants with a higher frequency of good knowledge were more likely to have positive attitudes (99.5% vs. 80.2%, p\u0026thinsp;\u0026lt;\u0026thinsp;0.001). Also, in participants whose source of knowledge was school compared to radio/television (99.3% vs. 77.3%, p\u0026thinsp;\u0026lt;\u0026thinsp;0.001) while social media (p\u0026thinsp;=\u0026thinsp;0.121) was not significantly associated with attitude, gender (p\u0026thinsp;=\u0026thinsp;0.813) and discussions with physicians (p\u0026thinsp;=\u0026thinsp;0.555) \u003cb\u003e(Table\u0026nbsp;3).\u003c/b\u003e\u003c/p\u003e\u003c/div\u003e\u003cdiv id=\"Sec14\" class=\"Section2\"\u003e\u003ch2\u003e3.4. Post-exposure prophylaxis\u003c/h2\u003e\u003cp\u003eThe majority of participants in our study (90.3%, n\u0026thinsp;=\u0026thinsp;1604) had no history of animal attacks. A subgroup analysis was conducted on participants who were exposed to the rabies virus (9.7%, n\u0026thinsp;=\u0026thinsp;173) (18.5%, n\u0026thinsp;=\u0026thinsp;32)) did not receive post-exposure prophylaxis, (6.4%, n\u0026thinsp;=\u0026thinsp;9) initiated the first dose of the vaccine more than 24 hours after exposure, and (17%, n\u0026thinsp;=\u0026thinsp;24) did not complete the full vaccine schedule (5 doses) \u003cb\u003e(Table\u0026nbsp;4).\u003c/b\u003e We investigated the associations between variables and receiving post-exposure rabies vaccine among 173 individuals. Significant associations were found for age (p\u0026thinsp;=\u0026thinsp;0.014), and region (p\u0026thinsp;=\u0026thinsp;0.002), with the highest uptake in Upper Egypt (98%). Education level was also significant (p\u0026thinsp;=\u0026thinsp;0.006). Awareness of rabies (p\u0026thinsp;=\u0026thinsp;0.020), specific sources of rabies knowledge (social media, p\u0026thinsp;=\u0026thinsp;0.035), discussion with a physician about rabies (p\u0026thinsp;=\u0026thinsp;0.015), and knowledge of vaccination campaigns (p\u0026thinsp;=\u0026thinsp;0.045) were positively associated with vaccine uptake. Knowledge level of rabies was significant (p\u0026thinsp;=\u0026thinsp;0.005), with better knowledge linked to higher uptake. Gender (p\u0026thinsp;=\u0026thinsp;0.828), residency (p\u0026thinsp;=\u0026thinsp;0.166), occupation (p\u0026thinsp;=\u0026thinsp;0.527), income (p\u0026thinsp;=\u0026thinsp;0.605), and attitude towards rabies (p\u0026thinsp;=\u0026thinsp;0.396) were not significantly associated with vaccine uptake \u003cb\u003e(Table\u0026nbsp;5).\u003c/b\u003e\u003c/p\u003e\u003c/div\u003e\u003cdiv id=\"Sec15\" class=\"Section2\"\u003e\u003ch2\u003e3.5. Pre-exposure prophylaxis\u003c/h2\u003e\u003cp\u003eApproximately one-third of the participants (29.9%, n\u0026thinsp;=\u0026thinsp;533) were considered a vulnerable population for rabies. Of these, (59.8%, n\u0026thinsp;=\u0026thinsp;319) were farmers or individuals living in rural areas, (22.5%, n\u0026thinsp;=\u0026thinsp;120) lived in environments with stray dogs and cats, and (15.4%, n\u0026thinsp;=\u0026thinsp;82) had pets at home. Only (4.3%, n\u0026thinsp;=\u0026thinsp;23) participants received the rabies pre-exposure prophylaxis, and 18 of them completed the full vaccination schedule (3 doses) \u003cb\u003e(Table\u0026nbsp;4).\u003c/b\u003e Also, we investigated the association between variables and pre-exposure rabies vaccine uptake among 533 vulnerable participants. Significant associations were found for region (p\u0026thinsp;\u0026lt;\u0026thinsp;0.001), residency (p\u0026thinsp;\u0026lt;\u0026thinsp;0.001), education level (p\u0026thinsp;\u0026lt;\u0026thinsp;0.001), specific sources of rabies knowledge (social media, school with p\u0026thinsp;\u0026lt;\u0026thinsp;0.001 and Family/Friend, p\u0026thinsp;=\u0026thinsp;0.009), discussions with physicians about rabies (p\u0026thinsp;\u0026lt;\u0026thinsp;0.001), awareness of vaccination campaigns (p\u0026thinsp;\u0026lt;\u0026thinsp;0.001), and previous animal attacks (p\u0026thinsp;\u0026lt;\u0026thinsp;0.001). No significant associations were found for age (p\u0026thinsp;=\u0026thinsp;0.134), gender (p\u0026thinsp;=\u0026thinsp;0.538), income (p\u0026thinsp;=\u0026thinsp;0.155), overall rabies awareness (p\u0026thinsp;=\u0026thinsp;0.280), or attitude towards rabies (p\u0026thinsp;\u0026gt;\u0026thinsp;0.999) \u003cb\u003e(Table\u0026nbsp;6).\u003c/b\u003e\u003c/p\u003e\u003c/div\u003e\u003cdiv id=\"Sec16\" class=\"Section2\"\u003e\u003ch2\u003e3.6. Barriers\u003c/h2\u003e\u003cp\u003eLack of knowledge about rabies vaccine and rabies disease were the most frequently reported barriers that prevent people from undergoing rabies prophylaxis (82.4% and 81.7%, respectively). Others included hospital facilities (43.1%), financial Burden (36.1%), fear of the process (28.7%), feeling uncomfortable about dealing with healthcare staff (13.8%), and previous bad experience (0.1%) \u003cb\u003e(\u003c/b\u003eFig.\u0026nbsp;\u003cspan refid=\"Fig2\" class=\"InternalRef\"\u003e2\u003c/span\u003e\u003cb\u003e).\u003c/b\u003e When asked to choose the only most important factor that would prevent people from undergoing rabies prophylaxis The majority (40.5%, n\u0026thinsp;=\u0026thinsp;719) chose lack of knowledge about rabies as the most important barrier this was followed by lack of knowledge about vaccine (23.4%, n\u0026thinsp;=\u0026thinsp;415), the hospital in your area doesn\u0026rsquo;t have the required facilities for rabies prophylaxis (14.0%, n\u0026thinsp;=\u0026thinsp;249), financial Burden (11.7%, n\u0026thinsp;=\u0026thinsp;208), fear of the process (8.0%. n\u0026thinsp;=\u0026thinsp;142) and feeling uncomfortable about dealing with healthcare staff (1.6%, n\u0026thinsp;=\u0026thinsp;29)\u003c/p\u003e\u003cp\u003e\u003c/p\u003e\u003c/div\u003e"},{"header":"4.0. Discussion","content":"\u003cp\u003eRabies is a fatal zoonotic disease caused by the rabies virus. It is transmitted to humans through the bites or scratches of infected animals, especially dogs which are responsible for 99% of human rabies cases. Despite its 100% preventability through timely vaccination and post-exposure prophylaxis (PEP), rabies poses a significant public health challenge, particularly in regions with inadequate healthcare infrastructure and low awareness levels, mainly in Asia and Africa (\u003cspan citationid=\"CR2\" class=\"CitationRef\"\u003e2\u003c/span\u003e). Understanding the public’s knowledge about rabies is crucial for designing effective awareness campaigns, training healthcare workers, and improving preventive measures.\u003c/p\u003e\u003cp\u003eOur study revealed that 42.8% of participants demonstrated good knowledge of rabies. Also, Positive attitudes towards rabies prevention were observed in 88.5% of participants, significantly influenced by higher education, occupations vulnerable to rabies, and awareness campaigns. Most of the participants in our study (90.3%) had no history of animal attacks. Among vulnerable populations, only 23 participants received pre-exposure prophylaxis with only 18 completing the full vaccination schedule (3 doses). Barriers to prophylaxis included mainly lack of knowledge (82.4%) and other factors like financial burden, and insufficient hospital facilities. Awareness and education were identified as critical for improving rabies prevention efforts.\u003c/p\u003e\u003cp\u003eUnder the guidance of WHO to eliminate deaths from dog-mediated rabies by 2030, (\u003cspan citationid=\"CR12\" class=\"CitationRef\"\u003e12\u003c/span\u003e) this is the first multicenter study carried out in Egypt to assess KAP toward rabies and barriers preventing people from having proper healthcare for rabies.\u003c/p\u003e\u003cp\u003eThe current study shows that 42.8% of the participants had sufficient knowledge regarding rabies, consistent with a survey conducted in Kenya. (\u003cspan citationid=\"CR13\" class=\"CitationRef\"\u003e13\u003c/span\u003e) Also, It is higher than the results found in other studies conducted in Tanzania (\u003cspan citationid=\"CR14\" class=\"CitationRef\"\u003e14\u003c/span\u003e) and Guatemala (\u003cspan citationid=\"CR15\" class=\"CitationRef\"\u003e15\u003c/span\u003e). On the other hand, it is lower than the reports of the studies in north India (\u003cspan citationid=\"CR16\" class=\"CitationRef\"\u003e16\u003c/span\u003e) and Ethiopia (\u003cspan citationid=\"CR17\" class=\"CitationRef\"\u003e17\u003c/span\u003e). These differences could be associated with the community's awareness level, educational status, and information access.\u003c/p\u003e\u003cp\u003eAdditionally, results show a good level of knowledge about the mode of transmission of rabies. However, they were unable to name animals that transmit rabies, this finding is consistent with reports in Guatemala (\u003cspan citationid=\"CR15\" class=\"CitationRef\"\u003e15\u003c/span\u003e) and Sri Lanka (\u003cspan citationid=\"CR18\" class=\"CitationRef\"\u003e18\u003c/span\u003e). Also the minority of participants knew the signs of rabies in animals and humans opposite to the results of other studies in Bangladesh and Tanzania (\u003cspan citationid=\"CR14\" class=\"CitationRef\"\u003e14\u003c/span\u003e, \u003cspan citationid=\"CR19\" class=\"CitationRef\"\u003e19\u003c/span\u003e)\u003c/p\u003e\u003cp\u003eFurthermore, we found that the geographic region is a significant risk factor for rabies mortality. This could be because there are no vaccination or awareness programs in rural communities, and dogs are regularly observed walking freely on the streets. Dogs are not routinely vaccinated in these locations, which increases the danger of rabies transmission from animals to humans (\u003cspan citationid=\"CR20\" class=\"CitationRef\"\u003e20\u003c/span\u003e).\u003c/p\u003e\u003cp\u003eAwareness was also linked to exposure to vaccination campaigns about the importance of pre-exposure and post-exposure prophylaxis, prior awareness of rabies, a history of animal attacks, and high educational levels, notably among college graduates and those pursuing postgraduate degrees. Sources of knowledge, such as school, family, and friends, played an important part in spreading information.\u003c/p\u003e\u003cp\u003eAll these factors indicate that the population in the study area is at a constant risk of disease because the participants lack sufficient knowledge regarding potential sources, prevention, and control of rabies.\u003c/p\u003e\u003cp\u003eComparing our survey to one similar conducted in Pondicherry, where approximately 77.5% of participants believed rabies to be a fatal disease (\u003cspan citationid=\"CR21\" class=\"CitationRef\"\u003e21\u003c/span\u003e), 82% of participants believed the same. Our perception of rabies fatality was also more favorable than that of a Puducherry study, which found that 74.8% of participants were aware that rabies is a deadly illness (\u003cspan citationid=\"CR22\" class=\"CitationRef\"\u003e22\u003c/span\u003e). The high perception of rabies fatalities indicates that the public will accept and have a good attitude toward the rabies vaccination program. It will also aid in improving the campaign's results and assisting it in reaching its objective. Therefore, raising awareness of the risk of fatalities from rabies before launching a vaccination campaign will be a smart first move in enhancing the program's cost-effectiveness and results.\u003c/p\u003e\u003cp\u003eSimilar to previous studies, the study participants exhibited a positive attitude toward rabies vaccine (\u003cspan citationid=\"CR23\" class=\"CitationRef\"\u003e23\u003c/span\u003e, \u003cspan citationid=\"CR24\" class=\"CitationRef\"\u003e24\u003c/span\u003e). In our study, 89.9% believed that after an animal bite, post-exposure prophylaxes should be received as soon as possible, and 88.9% believed that the PEP course should be finished. It's encouraging that so many respondents have a favorable opinion of PEP. It demonstrates that hospital PEP programs will be highly successful in achieving their main objective, which is to reduce the number of mortality cases. On the other hand, failing to use this leverage to implicate PEP programs will have deadly results. As a result, the general population needs to be made aware that they should get medical attention if their dog bites them. Vaccinating pets regularly and pursuing adequate post-exposure care, will greatly contribute to reaching the national and international goals of eliminating rabies by 2030 (\u003cspan citationid=\"CR25\" class=\"CitationRef\"\u003e25\u003c/span\u003e).\u003c/p\u003e\u003cp\u003eThe way that the dog population is managed in Egypt is by shooting or poisoning stray dogs. This reduces the number of dogs that are immune, which makes vaccination efforts ineffective and counterproductive. This is because the dogs who are easiest to vaccinate also happen to be the easiest to kill (\u003cspan citationid=\"CR26\" class=\"CitationRef\"\u003e26\u003c/span\u003e). Although it is recommended that animals be vaccinated to safeguard public health, there is no legal requirement for public compliance. Nonetheless, given the positive attitudes of survey participants regarding the deadly nature of rabies, Egypt's Ministry of Health might formulate a long-term plan to compel vaccination by law and attempt to persuade the populace of this requirement. Since doing so will enable us to develop herd immunity. According to the WHO, a community's dogs need to be immunized 70% of the time to develop herd immunity (\u003cspan citationid=\"CR27\" class=\"CitationRef\"\u003e27\u003c/span\u003e).\u003c/p\u003e\u003cp\u003eIncome was a significant predictor of attitude toward rabies, with people with not enough income having the least positive attitudes toward the rabies vaccine. This study bears similarities to previous research that found the minimum wage in a district affected the attitudes and practices related to rabies (\u003cspan citationid=\"CR24\" class=\"CitationRef\"\u003e24\u003c/span\u003e). A tenable explanation pertains to the respondents' socioeconomic position, whereby those with a higher socioeconomic status demonstrated a greater propensity to adhere to the initial management protocol and seek vaccinations in a medical facility. The people with the most positive attitudes toward rabies were those in the susceptible occupation. This could be explained by the fact that these people are constantly looking to learn more about rabies since they come into touch with rabies-infected patients more frequently than non-vulnerable groups.\u003c/p\u003e\u003cp\u003eDespite our participants' good attitudes toward PEP, 9.7% of participants in our study were bitten by an animal, and 18.5% did not seek PEP. Our findings are in line with another study that found 20% of subjects did not seek PEP following an animal bite (\u003cspan citationid=\"CR28\" class=\"CitationRef\"\u003e28\u003c/span\u003e). This could be explained by the desire to seek out local healers due to cultural influences. Our health system is heavily burdened by this. Since most of these rabies cases do not benefit from local healers, they often develop complications that require hospitalization, further taxing our already overburdened health system following COVID-19 and reducing the number of beds available for other severe conditions. Therefore, making rabies vaccination more widely available in hospitals and health facilities will aid in lowering the number of fatalities and lessening the strain that rabies places on the healthcare system.\u003c/p\u003e\u003cp\u003eMoreover, 95.7% of the vulnerable group did not receive the pre-exposure vaccination, and 61% of them did not believe that taking a prophylactic was necessary. This might be explained by restricted access to medical facilities. Which will influence their understanding and, consequently, their behavior regarding rabies, how it spreads, and the significance of taking precautions. Since the college group had the highest percentage of individuals taking pre-exposure prophylactics, inadequate literacy could be the cause of this.\u003c/p\u003e\u003cp\u003eIt's interesting to note that those between the ages of 36 and 60 were less motivated to seek PEP than those beyond 60. The elderly's good practices regarding PEP are consistent with other research that found a notably higher proportion of individuals in the older age group performing first aid using the suggested supplies (soap water) or alternative detergents, such as iodine constituents, or as determined by their availability (\u003cspan citationid=\"CR29\" class=\"CitationRef\"\u003e29\u003c/span\u003e). Nevertheless, those who were older were less knowledgeable and exhibited a less favorable attitude toward rabies. The explanation for this could be that individuals in their adult years are less concerned with maintaining their health and tend to exaggerate about it, whereas older people are more inclined to seek medical attention when they become unwell.\u003c/p\u003e\u003cp\u003eRaising public knowledge has been identified as an essential strategy for controlling rabies (\u003cspan citationid=\"CR30\" class=\"CitationRef\"\u003e30\u003c/span\u003e). Individuals who have sufficient knowledge demonstrated a more positive outlook and increased adherence to PEP. This demonstrates the direct relationship between attitude and practice and knowledge, highlighting the necessity for improved knowledge to be disseminated throughout the community in order to foster the proper attitude and improved practices. This bears similarities to previous research conducted by Monje et al., which demonstrated that inadequate understanding of rabies has a detrimental impact on attitudes, which then affects practices related to rabies management (\u003cspan citationid=\"CR31\" class=\"CitationRef\"\u003e31\u003c/span\u003e). Primary care physicians should address the local community's knowledge, practices, and misunderstandings regarding serious and terrifying public health diseases like rabies in order to offer preventive and curative treatments.\u003c/p\u003e\u003cp\u003eOur study identified several barriers to rabies prophylaxis, the predominant barrier to undergoing rabies prophylaxis was a lack of knowledge about the disease and the vaccine (82.4% and 81.7%, respectively). This finding is corroborated by a study highlighting that low awareness of rabies severity and misconceptions about vaccines are significant obstacles to effective rabies prevention (\u003cspan citationid=\"CR32\" class=\"CitationRef\"\u003e32\u003c/span\u003e). This emphasizes the crucial need for thorough educational campaigns to raise awareness about rabies transmission, prevention, and the significance of timely prophylaxis.\u003c/p\u003e\u003cp\u003eAdditionally, there is a barrier of inadequate healthcare facilities for rabies patients in local hospitals (43.1%). This finding is consistent with studies indicating that limited access to healthcare infrastructure hampers the timely administration of rabies prophylaxis (\u003cspan citationid=\"CR33\" class=\"CitationRef\"\u003e33\u003c/span\u003e, \u003cspan citationid=\"CR34\" class=\"CitationRef\"\u003e34\u003c/span\u003e).\u003c/p\u003e\u003cp\u003eFurthermore, other barriers affect rabies prophylaxis such as financial Burden (36.1%), consistent with that reported by the WHO, (\u003cspan citationid=\"CR2\" class=\"CitationRef\"\u003e2\u003c/span\u003e) fear of the process (28.7%), feeling uncomfortable about dealing with healthcare staff (13.8%), and previous bad experiences (0.1%).\u003c/p\u003e\u003cp\u003eAddressing these barriers involves a multimodal approach that includes increasing public education, strengthening healthcare infrastructure, supporting prophylactic costs, and developing favorable patient-healthcare provider relationships. Such attempts are critical for increasing the use of rabies prophylaxis and, ultimately, lowering the incidence of this fatal disease.\u003c/p\u003e"},{"header":"Conclusion","content":"\u003cp\u003eWhile most participants recognized rabies as a fatal and preventable disease, deficiencies in specific knowledge particularly regarding transmission, early signs, and appropriate prophylactic measures were evident. Moreover, adherence to pre and post exposure prophylaxis remains relatively low. Implementing organized national awareness programs may help to increase public knowledge and promote the adherence to prophylaxis guidelines.\u003c/p\u003e"},{"header":"Abbreviations","content":"\u003ctable border=\"0\" cellspacing=\"0\" cellpadding=\"0\"\u003e\n \u003ctbody\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 101px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eAbbreviation\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 456px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eFull term\u0026nbsp;\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 101px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eCI\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 456px;\"\u003e\n \u003cp\u003eConfidence Interval\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 101px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eCOVID-19\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 456px;\"\u003e\n \u003cp\u003eCoronavirus Disease 2019\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 101px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eIQR\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 456px;\"\u003e\n \u003cp\u003eInterquartile Range\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 101px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eKAP\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 456px;\"\u003e\n \u003cp\u003eKnowledge, Attitudes, and Practices\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 101px;\"\u003e\n \u003cp\u003e\u003cstrong\u003en\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 456px;\"\u003e\n \u003cp\u003eNumber of participants\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 101px;\"\u003e\n \u003cp\u003e\u003cstrong\u003ep\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 456px;\"\u003e\n \u003cp\u003ep-value\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 101px;\"\u003e\n \u003cp\u003e\u003cstrong\u003ePEP\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 456px;\"\u003e\n \u003cp\u003ePost-Exposure Prophylaxis\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 101px;\"\u003e\n \u003cp\u003e\u003cstrong\u003ePrEP\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 456px;\"\u003e\n \u003cp\u003ePre-Exposure Prophylaxis\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 101px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eSPSS\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 456px;\"\u003e\n \u003cp\u003eStatistical Package for the Social Sciences\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 101px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eSTROBE\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 456px;\"\u003e\n \u003cp\u003eStrengthening the Reporting of Observational Studies in Epidemiology\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 101px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eUSD\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 456px;\"\u003e\n \u003cp\u003eUnited States Dollar\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 101px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eWHO\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 456px;\"\u003e\n \u003cp\u003eWorld Health Organization\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003c/tbody\u003e\n\u003c/table\u003e"},{"header":"Declarations","content":"\u003cp\u003e\u003cstrong\u003e\u003cem\u003eEthics approval and consent to participate\u003c/em\u003e\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eEthical approval was obtained in accordance with the Declaration of Helsinki from the Alexandria University Faculty of Medicine Research Ethics Committee with a serial number of (0306449) before starting data collection. Participation was voluntary and informed consent was obtained prior to starting data collection.\u0026nbsp;\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003e\u003cem\u003eConsent for publication\u003c/em\u003e\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eNot applicable\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003e\u003cem\u003eAvailability of data and materials\u003c/em\u003e\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThe datasets analyzed during the current study are available from the corresponding author on reasonable request.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003e\u003cem\u003eCompeting interests\u003c/em\u003e\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eAll authors declare that they have no competing interests\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003e\u003cem\u003eFunding\u003c/em\u003e\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThis research did not receive any specific grant from funding agencies in the public, commercial, or not-for-profit sectors.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003e\u003cem\u003eAuthors' contributions\u003c/em\u003e\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eConceptualization and methodology: Conceptualization and methodology: M.A.S., M.B.H., A.G.E., A.R.A. Investigation and data acquisition: M.E.Z., A.M.A., O.M.M., E.S.A., A.B., I.M.A., B.A.E., N.M.B.A., M.N., A.A. Formal analysis: M.B.H., A.R.A., A.M.M. Writing, review and editing: M.B.H., M.A.S., A.M.M., A.G.E., M.E.Z., A.R.A. Supervision and project administration: A.R.A. All authors read and approved of the final manuscript.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003e\u003cem\u003eAcknowledgements\u003c/em\u003e\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eNot applicable\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003e\u003cem\u003eClinical trial number\u0026nbsp;\u003c/em\u003e\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eNot applicable\u003c/p\u003e"},{"header":"References","content":"\u003col\u003e\n\u003cli\u003eFooks AR, Banyard AC, Horton DL, Johnson N, McElhinney LM, Jackson AC. Current status of rabies and prospects for elimination. Lancet. 2014;384(9951):1389-99.\u003c/li\u003e\n\u003cli\u003eOrganization WH. Rabies 2024 [Available from: https://www.who.int/news-room/fact-sheets/detail/rabies.\u003c/li\u003e\n\u003cli\u003eJackson AC. Rabies pathogenesis. J Neurovirol. 2002;8(4):267-9.\u003c/li\u003e\n\u003cli\u003eHampson K, Coudeville L, Lembo T, Sambo M, Kieffer A, Attlan M, et al. Estimating the global burden of endemic canine rabies. PLoS Negl Trop Dis. 2015;9(4):e0003709.\u003c/li\u003e\n\u003cli\u003eKnobel DL, Cleaveland S, Coleman PG, F\u0026egrave;vre EM, Meltzer MI, Miranda ME, et al. Re-evaluating the burden of rabies in Africa and Asia. Bull World Health Organ. 2005;83(5):360-8.\u003c/li\u003e\n\u003cli\u003eRohde RE, Rupprecht CE. Update on lyssaviruses and rabies: will past progress play as prologue in the near term towards future elimination? Fac Rev. 2020;9:9.\u003c/li\u003e\n\u003cli\u003eDiallo MK, Diallo AO, Dicko A, Richard V, Espi\u0026eacute; E. Human rabies post exposure prophylaxis at the Pasteur Institute of Dakar, Senegal: trends and risk factors. BMC Infect Dis. 2019;19(1):321.\u003c/li\u003e\n\u003cli\u003eWHO. WHO, in collaboration with the Ministry of Health and Population of Egypt, celebrates World Rabies Day [Available from: https://www.emro.who.int/egy/egypt-news/world-rabies-day.html.\u003c/li\u003e\n\u003cli\u003eMekhail N, Shenouda MS, Mohamed AAA. Assessment of knowledge, attitudes, and practices toward rabies among visitors of a family health center. Egyptian Nursing Journal. 2022;19:287 - 305.\u003c/li\u003e\n\u003cli\u003eRaosoft I. RaoSoft\u0026reg; Sample Size Calculator. 2004.\u003c/li\u003e\n\u003cli\u003eWorld Medical Association Declaration of Helsinki: ethical principles for medical research involving human subjects. Jama. 2013;310(20):2191-4.\u003c/li\u003e\n\u003cli\u003eOrganization WH. Zero by 30: the global strategic plan to end human deaths from dog-mediated rabies by 2030. 2018.\u003c/li\u003e\n\u003cli\u003eMucheru GM, Kikuvi GM, Amwayi SA. Knowledge and practices towards rabies and determinants of dog rabies vaccination in households: a cross sectional study in an area with high dog bite incidents in Kakamega County, Kenya, 2013. Pan African Medical Journal. 2014;19(1).\u003c/li\u003e\n\u003cli\u003eSambo M, Lembo T, Cleaveland S, Ferguson HM, Sikana L, Simon C, et al. Knowledge, attitudes and practices (KAP) about rabies prevention and control: a community survey in Tanzania. PLoS neglected tropical diseases. 2014;8(12):e3310.\u003c/li\u003e\n\u003cli\u003eMoran D, Juliao P, Alvarez D, Lindblade KA, Ellison JA, Gilbert AT, et al. Knowledge, attitudes and practices regarding rabies and exposure to bats in two rural communities in Guatemala. BMC research notes. 2015;8:1-7.\u003c/li\u003e\n\u003cli\u003eTiwari HK, Robertson ID, O\u0026rsquo;Dea M, Vanak AT. Knowledge, attitudes and practices (KAP) towards rabies and free roaming dogs (FRD) in Panchkula district of north India: A cross-sectional study of urban residents. PLoS neglected tropical diseases. 2019;13(4):e0007384.\u003c/li\u003e\n\u003cli\u003eBihon A, Meresa D, Tesfaw A. Rabies: knowledge, attitude and practices in and around South Gondar, North West Ethiopia. Diseases. 2020;8(1):5.\u003c/li\u003e\n\u003cli\u003eMuthunuwan J, Ganhewa A, Perera H, Hishaam M, Bandara W, Gunasekera H. Preliminary survey on knowledge, attitudes and practices regarding rabies. Sri Lankan Journal of Infectious Diseases. 2017;7(1).\u003c/li\u003e\n\u003cli\u003eHossain M. Study on knowledge, attitude \u0026amp; practice about rabies \u0026amp; pet animals among school children in Bangladesh. J Microbiol Exp. 2017;4(1):1-15.\u003c/li\u003e\n\u003cli\u003eTiwari HK, O\u0026rsquo;Dea M, Robertson ID, Vanak AT. Knowledge, attitudes and practices (KAP) towards rabies and free-roaming dogs (FRD) in Shirsuphal village in western India: A community based cross-sectional study. PLoS neglected tropical diseases. 2019;13(1):e0007120.\u003c/li\u003e\n\u003cli\u003eJoice YS, Singh Z, Datta SS. knowledge, attitude and practices regarding dog bite and its management among adults in rural Tamil Nadu. Medical Science. 2016;5(5).\u003c/li\u003e\n\u003cli\u003eKrishnamoorthy Y, Vijayageetha M, Sarkar S. Awareness about rabies among general population and treatment seeking behaviour following dog-bite in rural Puducherry: A community based cross-sectional study. Int J Community Med Public Health. 2018;5:2557-63.\u003c/li\u003e\n\u003cli\u003ePenjor K, Tenzin T, Jamtsho RK. Determinants of health seeking behavior of animal bite victims in rabies endemic South Bhutan: a community-based contact-tracing survey. BMC public health. 2019;19:1-11.\u003c/li\u003e\n\u003cli\u003eChristopher PM, Cucunawangsih C, Adidharma AAGB, Putra IPDK, Putra DGS. Knowledge, attitudes and practices regarding rabies among community members: a cross-sectional study in Songan Village, Bali, Indonesia. International maritime health. 2021;72(1):26-35.\u003c/li\u003e\n\u003cli\u003eOrganization WH. WHO expert consultation on rabies: second report: World Health Organization; 2013.\u003c/li\u003e\n\u003cli\u003eOrganization WH. WHO expert consultation on rabies: third report: World Health Organization; 2018.\u003c/li\u003e\n\u003cli\u003eGlasgow L, Worme A, Keku E, Forde M. Knowledge, attitudes, and practices regarding rabies in Grenada. PLoS neglected tropical diseases. 2019;13(1):e0007079.\u003c/li\u003e\n\u003cli\u003eLhendup K, Wangdi K. Knowledge, Attitude and Practices of rabies during an outbreak in Samtse Municipality, Bhutan: A cross-sectional study. Journal of family medicine and primary care. 2022;11(9):5361-8.\u003c/li\u003e\n\u003cli\u003eLaishram J, Chaudhuri S, Devi HS, Konjengbam S. Knowledge and practice on rabies in an urban community of Manipur, India. J Evolution Med Dent Sci. 2016;5:2234-7.\u003c/li\u003e\n\u003cli\u003eBalaram D, Taylor L, Doyle K, Davidson E, Nel L. World Rabies Day-a decade of raising awareness, Trop. Dis Travel Med Vaccines. 2016.\u003c/li\u003e\n\u003cli\u003eMonje F, Erume J, Mwiine FN, Kazoora H, Okech SG. Knowledge, attitude and practices about rabies management among human and animal health professionals in Mbale District, Uganda. One Health Outlook. 2020;2:1-11.\u003c/li\u003e\n\u003cli\u003eCastillo-Neyra R, Buttenheim AM, Brown J, Ferrara JF, Arevalo-Nieto C, Borrini-Mayor\u0026iacute; K, et al. Behavioral and structural barriers to accessing human post-exposure prophylaxis and other preventive practices in Arequipa, Peru, during a canine rabies epidemic. PLoS neglected tropical diseases. 2020;14(7):e0008478.\u003c/li\u003e\n\u003cli\u003evan de Burgwal LHM, Neevel AMG, Pittens C, Osterhaus A, Rupprecht CE, Claassen E. Barriers to innovation in human rabies prophylaxis and treatment: A causal analysis of insights from key opinion leaders and literature. Zoonoses Public Health. 2017;64(8):599-611.\u003c/li\u003e\n\u003cli\u003eAhmed T, Hussain S, Zia UU, Rinchen S, Yasir A, Ahmed S, et al. Knowledge, attitude and practice (KAP) survey of canine rabies in Khyber Pakhtunkhwa and Punjab Province of Pakistan. BMC Public Health. 2020;20(1):1293.\u003c/li\u003e\n\u003c/ol\u003e"},{"header":"Figures","content":"\u003cp\u003eFigures 1 and 2 are not available with this version.\u003c/p\u003e"}],"fulltextSource":"","fullText":"","funders":[],"hasAdminPriorityOnWorkflow":false,"hasManuscriptDocX":true,"hasOptedInToPreprint":true,"hasPassedJournalQc":"","hasAnyPriority":false,"hideJournal":false,"highlight":"","institution":"","isAcceptedByJournal":false,"isAuthorSuppliedPdf":false,"isDeskRejected":"","isHiddenFromSearch":false,"isInQc":false,"isInWorkflow":false,"isPdf":false,"isPdfUpToDate":true,"isWithdrawnOrRetracted":false,"journal":{"display":true,"email":"[email protected]","identity":"bmc-public-health","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":false,"externalIdentity":"pubh","sideBox":"Learn more about [BMC Public Health](http://bmcpublichealth.biomedcentral.com/)","snPcode":"","submissionUrl":"https://www.editorialmanager.com/pubh/default.aspx","title":"BMC Public Health","twitterHandle":"@BMC_series","acdcEnabled":true,"dfaEnabled":false,"editorialSystem":"em","reportingPortfolio":"BMC Series","inReviewEnabled":true,"inReviewRevisionsEnabled":true},"keywords":"Rabies, Rabies vaccine, Practices, Knowledge, Attitudes, Rabies, Egypt","lastPublishedDoi":"10.21203/rs.3.rs-6968724/v1","lastPublishedDoiUrl":"https://doi.org/10.21203/rs.3.rs-6968724/v1","license":{"name":"CC BY 4.0","url":"https://creativecommons.org/licenses/by/4.0/"},"manuscriptAbstract":"\u003cp\u003e\u003cstrong\u003eBackground: \u003c/strong\u003eRabies is a fatal but preventable viral disease that poses a global health threat, especially in developing countries. Despite the high incidence of animal bites reported annually in Egypt, limited data exist regarding the knowledge, attitudes, and practices (KAP) of the general population toward rabies and rabies prophylaxis.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eMethods: \u003c/strong\u003eWe conducted a nationwide cross-sectional study using a structured interview-based survey targeting individuals aged 18 years or older who attended outpatient clinics of nine university hospitals across Egypt. The survey assessed participants’ KAP regarding rabies prophylaxis and identified barriers to its uptake.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eResults: \u003c/strong\u003eAmong 1,777 participants responded to the survey, only (42.8%, n= 761) had good knowledge about rabies and rabies prophylaxis, while the majority (88.5%, n= 1,574) exhibited a positive attitude toward rabies prophylaxis. Knowledge was higher among those who had awareness campaign about rabies in their geographic areas (69.1% vs 40.5%,\u003cem\u003e p \u003c/em\u003e\u0026lt; 0.001) and those who had been previously bitten or attacked by animals (56.1% vs 41.3%,\u003cem\u003e p\u003c/em\u003e \u0026lt; 0.001). Of the participants (9.7%, n= 173) reported a history of animal bites; however, (18.5%, n= 32) of bite victims did not receive post-exposure prophylaxis, and (17%, n= 29) did not complete the vaccine schedule. Pre-exposure prophylaxis uptake was low, with only (4.3%, n= 23) of high-risk individuals receiving it. Key barriers to rabies prophylaxis included lack of knowledge about rabies (82.4%, n= 1,463) and the vaccine (81.7%, n= 1,451), as well as inadequate hospital facilities (43.1%, n= 765).\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eConclusions: \u003c/strong\u003eDespite a generally positive attitude toward rabies prophylaxis, the knowledge and adherence to prophylactic measures, including preexposure and Post exposure prophylaxis remain relatively inadequate in Egypt. Public health interventions, such as educational campaigns and improved accessibility to vaccination services, are needed to address these gaps and mitigate the public health burden of rabies.\u003c/p\u003e","manuscriptTitle":"Rabies and rabies prophylaxis in Egypt: a nation-wide cross-sectional study that calls for action","msid":"","msnumber":"","nonDraftVersions":[{"code":1,"date":"2025-07-15 05:35:37","doi":"10.21203/rs.3.rs-6968724/v1","editorialEvents":[{"type":"communityComments","content":0},{"type":"decision","content":"Revision requested","date":"2025-09-08T08:25:24+00:00","index":"","fulltext":""},{"type":"editorInvitedReview","content":"","date":"2025-09-05T16:18:55+00:00","index":"hide","fulltext":""},{"type":"reviewerAgreed","content":"22981588084161145485257509399494251893","date":"2025-09-03T18:58:58+00:00","index":"hide","fulltext":""},{"type":"editorInvitedReview","content":"","date":"2025-09-02T01:27:45+00:00","index":"hide","fulltext":""},{"type":"reviewerAgreed","content":"113453875474052313698091767579880864644","date":"2025-09-02T00:12:48+00:00","index":"hide","fulltext":""},{"type":"editorInvitedReview","content":"","date":"2025-07-28T02:28:25+00:00","index":"hide","fulltext":""},{"type":"reviewerAgreed","content":"114584514270609874907756021673499713174","date":"2025-07-13T06:20:45+00:00","index":"hide","fulltext":""},{"type":"reviewerAgreed","content":"24735662057625018723969441993403614201","date":"2025-07-11T00:18:35+00:00","index":"hide","fulltext":""},{"type":"reviewersInvited","content":"","date":"2025-07-10T22:56:58+00:00","index":"","fulltext":""},{"type":"editorInvited","content":"","date":"2025-06-25T10:43:03+00:00","index":"","fulltext":""},{"type":"editorAssigned","content":"","date":"2025-06-25T05:54:38+00:00","index":"","fulltext":""},{"type":"checksComplete","content":"","date":"2025-06-25T05:53:55+00:00","index":"","fulltext":""},{"type":"submitted","content":"BMC Public Health","date":"2025-06-24T20:11:01+00:00","index":"","fulltext":""}],"status":"published","journal":{"display":true,"email":"[email protected]","identity":"bmc-public-health","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":false,"externalIdentity":"pubh","sideBox":"Learn more about [BMC Public Health](http://bmcpublichealth.biomedcentral.com/)","snPcode":"","submissionUrl":"https://www.editorialmanager.com/pubh/default.aspx","title":"BMC Public Health","twitterHandle":"@BMC_series","acdcEnabled":true,"dfaEnabled":false,"editorialSystem":"em","reportingPortfolio":"BMC Series","inReviewEnabled":true,"inReviewRevisionsEnabled":true}}],"origin":"","ownerIdentity":"5139f991-5ef1-4411-a5cd-6fcde5b4c6f7","owner":[],"postedDate":"July 15th, 2025","published":true,"recentEditorialEvents":[],"rejectedJournal":[],"revision":"","amendment":"","status":"under-review","subjectAreas":[],"tags":[],"updatedAt":"2025-10-17T17:38:07+00:00","versionOfRecord":[],"versionCreatedAt":"2025-07-15 05:35:37","video":"","vorDoi":"","vorDoiUrl":"","workflowStages":[]},"version":"v1","identity":"rs-6968724","journalConfig":"researchsquare"},"__N_SSP":true},"page":"/article/[identity]/[[...version]]","query":{"redirect":"/article/rs-6968724","identity":"rs-6968724","version":["v1"]},"buildId":"8U1c8b4HqxoKbykW_rLl7","isFallback":false,"isExperimentalCompile":false,"dynamicIds":[84888],"gssp":true,"scriptLoader":[]}