An evaluation of dog bite mitigation strategies aimed at reducing the health and economic burden of rabies in Nepal- an effectiveness trial involving in-school children and adolescents

Abstract

Background: Dog bites pose a significant public health concern, particularly in regions with high stray dog populations. In Nepal, the incidence of dog bites has remained high, affecting children and adolescents the most. Previous studies have suggested that interventions such as sterilization and education may help reduce bite rates, but their combined effectiveness had not been systematically assessed. Rationale: This study sought to evaluate the effectiveness of dog bite mitigation strategies through a Cluster-Randomized Control Trial (cRCT), focusing on school-based education and mass dog sterilization. Given the high burden of dog bites, particularly among children aged 11-17 years, understanding which interventions yield the greatest reduction in exposure is essential for shaping public health policy. Aim: The primary objective was to assess the impact of targeted interventions—sterilisation and education—on reducing dog bite incidents, with an emphasis on children and adolescents in Kathmandu. Design & Methods: The study was conducted across four municipality clusters, involving 2,427 children and 9,610 dogs. Baseline and post-intervention data were collected through canine population surveys and hospital records. Two interventions were applied: (1) sterilization of free-roaming dogs and (2) school-based education on dog behavior and bite prevention. The effectiveness of these interventions was measured by analyzing hospital-reported dog bite cases before and after the intervention. Findings: The study found a 7.82% overall reduction in dog bite cases over 12 months, with the most severe bite cases (requiring vaccination, wound care, immunoglobulin, and surgery) decreasing by over 60%. The strongest effect was seen among the target age group (11-17 years), where bite incidents significantly declined (p=0.017). Education proved to be the most effective standalone intervention, leading to behavioral changes that reduced exposure risk. Regression analysis highlighted key risk factors, including past exposure, fear of dogs, and lack of knowledge about canine behavior. Interestingly, sterilization alone had a moderate effect, but its impact was less immediate compared to education. Combined interventions did not demonstrate a significantly greater effect than individual interventions. Conclusion: This study provides strong evidence that school-based education is the most effective strategy for reducing dog bite exposure among children. While sterilization contributes to long-term risk reduction, it should be implemented alongside education rather than as a standalone intervention. These findings emphasize the need for multi-sectoral approaches to dog bite prevention, integrating behavioral education into public health initiatives to achieve sustainable impact.