International Journal of Livestock Research ISSN 2277-1964 ONLINE
Vol 5(1) Jan’15
Knowledge, Attitude and Practice towards Human and Bovine Tuberculosis
among High School Students in Addis Ababa, Ethiopia
Abraham Haile Kidane1, Dessalegn Sifer1, Mesfin Aklilu1, Mahendra Pal2*
Ethiopian Public Health Institute, P. O. Box 1242, Addis Ababa, Ethiopia
2
Addis Ababa University College of Veterinary Medicine, Department of Microbiology, Immunology and
Public Health, P.O.Box: 34, Debre Zeit, Ethiopia
*Corresponding author: palmahendra2@gmail.com
Rec. Date:
Oct 27, 2014 02:07
Accept Date:
Dec 22, 2014 06:26
Published Online:
December 31, 2014
DOI
Abstract
Tuberculosis (TB) is among the top public health threats globally. Zoonotic tuberculosis due to
Mycobacterium bovis is common among developing countries. Due to the endemic immunosuppressive
disease, existence of huge livestock population paralleled with marginal awareness, risky practice and
lack of control strategy, bovine tuberculosis (BTB) has remained a public health concern among poor
countries. Health education targeting children can serve to shape their perception and also potentially
educating parents and breaking misperceptions about the disease. The objective of this study was to
assess the knowledge, attitude and practice of high school students towards BTB in comparison to human
TB in Addis Ababa, Ethiopia. A cross sectional study was conducted between November 2013 to
December 2013 at public secondary schools. A structured questionnaire was designed, pretested and selfadministered to ninth and tenth grade students in a local language. A total of 409 students (41.3% male
and 58.7%f female) were participated. Almost all (99.5%) had heard of human TB; however, only 57
(13.9%) knew BTB (X2= 613.9, P=0.0001). Information on human and animal TB was obtained mainly
from radio/TV (81.3%) and (75.4%), respectively. Knowledge on the infectious cause of human and
animal TB was known by 77.1% and 54.4%, respectively. However, misperception such as cold weather,
locally termed as “Berd” was implicated as cause to human TB. Inhalation was the commonly reported
route of transmission in human (93.7%) as well as in bovine (28%). Of all students, 89(21.7%) have
experienced TB themselves or among persons they knew; however, no association (p>0.05) was seen with
their knowledge on bovine 11/57(19.3%) and human TB 89/409 (21.7%).BTB is regarded as a public
health significant disease 38 (66.7%). Only 27(47.3%) and 9 (15.8%) considered raw milk, and yogurt as
vehicles to M. bovis infection, respectively. Overall, (66.2%) practiced use of pasteurized milk products.
The present study showed a much lower knowledge and awareness on bovine TB among students.Due to
concerted educational effort on human TB, the students awareness has evolved when, ironically, on BTB
is limited. Thus, the existing awareness intervention strategy should be operated along with animal TB
under a One Health umbrella.
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Key words: Attitude, High school students, Knowledge, Practice, Public health, Zoonotic tuberculosis
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International Journal of Livestock Research ISSN 2277-1964 ONLINE
Vol 5(1) Jan’15
Introduction
Tuberculosis (TB) is among the top public health threats globally (WHO, 2014). Pulmonary tuberculosis
occurs in 74 to 100 % of patients with HIV (Pal, 2005). It is a potential disease of mammalian species
including humans, and is caused by group of bacteria called Mycobacterium tuberculosis complex (Pal et
al., 2014b). It signifies different species including Mycobacterium tuberculosis and Mycobacterium bovis
(Thoen et al., 2009). M. tuberculosis (MTB) primarily causes TB in humans whereas M. bovis
predominantly affects cattle causing bovine tuberculosis (Pal et al., 2014b). Bovine tuberculosis (BTB) is
known to have a public health importance being transmitted from infected animals to humans through
close contact and ingestion of raw animal products (Cosivi et al., 1998; Ashford et al., 2001; Pal, 2007;
Pal et al., 2014b). Also, it represents financial burden due to loss of productivity to the livestock sector
that can be explained through reduction of milk production and carcass condemnation (Acha and Szyfres,
2001; Girmay et al., 2012).
Globally, 3.1% of human cases are attributed due to M.bovis (Cosivi et al., 1998). Case numbers are low
in developed countries because of efficient routine prevention steps like milk pasteurization and
implementation of eradication program. Developing countries mainly suffer due to the high cases of
HIV/AIDS, use of raw milk and poor living condition apart from lack of intervention system (Cosivi et
al., 1998; Thoen et al., 2009). In endemic areas, where milk pasteurization is limited, it is estimated that
about 10 to 15% human TB prevalence is due to M. bovis (Ashford et al., 2001). Ethiopia is one of the
high burdened countries in the world with human TB cases predominately due to MTB ( Pal et
al.,2014b;WHO, 2014). Nonetheless, it remains an epicenter for potential zoonotic diseases such as BTB
(Grace et al., 2012) putting the public health and livestock sector in jeopardy. With
ever growing
population of the country, there is high effort by the livestock sector to cope with the protein demand and
hence, high productive animals are reared under intensive farming system in urban and peri urban parts of
the country such as Addis Ababa (Ameni et al., 2007; Elias et al., 2008). This, however, creates a
favorable environment for diseases like bovine tuberculosis. M. bovis in cattle is pervasive throughout
different agro ecological zones of Ethiopia where the BTB prevalence in cattle ranged from 16.2% up to
65.8% in different farming systems (Shitaye et al., 2007). Recently, high prevalence of 50% in intensive
farms around the capital city has been reported (Firdessa et al., 2012). High BTB prevalence in humans
was also observed 14 (29.2%) and 6 (17.1%) at the eastern Shewa and southeastern part of Ethiopia,
respectively (Kiros, 1998; Kidane et al., 2002). Of an overall culture confirmed cases among children
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(34%) cases were due to M. bovis (CDC, 2014).
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International Journal of Livestock Research ISSN 2277-1964 ONLINE
Vol 5(1) Jan’15
Many developed countries have succeeded in controlling BTB by implementing the test slaughter strategy
paralleled with milk pasteurization. The culling of animals; however, presents financial challenge for
developing countries like Ethiopia. Hence, there is a need to stick to the second resort i.e. pasteurization
of milk; as this practice blocks the transmission path of M. bovis from animal to human with minimum
cost (Cosivi et al., 1998; Firdessa et al., 2012). So far, different studies have indicated a critical
knowledge gaps and the associated risky practice towards BTB in Ethiopia (Ameni et al., 2007; Tschopp
et al., 2009). In fact, educational efforts in Ethiopia were reserved to addressing human to human
transmitted TB even though the impact of TB from animal on human is not limited. While children are
part of the community at risk of acquiring BTB (Dankner and Davis, 2000), health education remains a
useful way in promoting awareness among themselves and even parents (Gopichandran et al., 2010). Yet
studies on awareness and educational efforts among youth are not available. This study was, therefore,
envisaged capturing the perception gaps among students towards animal TB and in comparison to human
TB in Addis Ababa; in order to provide information for guiding educational endeavors.
Methodology
Study area, population, design, sampling technique and sample size
The study was conducted in Addis Ababa, the capital of Ethiopia from November 2013 to December
2013. The study had cross sectional design of public elementary schools in Addis Ababa. List of the
schools was obtained from Addis Ababa education bureau, and five schools were selected by simple
random sampling of schools. Two classes from each school representing the grades of interest were
picked by convenience sampling of class, and all students in a class were handed to fill in questionnaire.
As suggested by school heads and teachers, convenience sampling was conducted in those classes that
were not engaged in teaching practice during the visit. A structured questionnaire was designed; pre tested
and self-administered to ninth and tenth grade students in a local language (Amharic). The questionnaire
consisted of basic questions to assess knowledge on transmission and cause of human and animal TB,
source of information for acquired knowledge, and habits in usage of animal product. Targeted groups
were believed to represent the elementary school and associated curricula. Only public schools were
involved while private schools were excluded, as there was stringent process and long appointments
besides problem of accessibility. the sample size was calculated considering 50% the expected awareness,
5% desired absolute precision and 95% level of confidence using single proportion population formula
Page
422. Data was entered into excel and transferred to be analyzed using SPSS software version 16. Chi
3
with an expected participation rate of 85% a targeted sample size of 384 was calculated and increased to
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International Journal of Livestock Research ISSN 2277-1964 ONLINE
Vol 5(1) Jan’15
square test was used to test for difference between gender and grades, and awareness, attitude and
practice. Statistical significance was set at p-value of 0.05.
Results
Demographic characteristics of respondents
A total of 409 students completed the questionnaire, 96.9% of the target sample size with 3.1% nonresponse rate. The age of participants ranged from 13 to 21 years with a mean 16.4. Of which, (41.3%)
and (58.7%) were male and female, respectively. Participants represented tenth and ninth grades as
depicted in Table 1.
Table 1 Characteristics of study participants in elementary schools in Addis Ababa, Ethiopia
Characteristic
Gender
Male
Female
Grade
9th
10th
Age
≤16
Number
Percentage
169
240
41.3
58.7
182
212
44.3
51.8*
234
57.2
>16
175
*The percentage is less than 100% because of missing values
42.8
Knowledge on human and bovine tuberculosis
Human TB was recognized by 99.5% of students, while only 13.9% had heard of animal TB. There was
significant variation (p<0.05) between existing knowledge on MTB and BTB (X2= 613.9, P=0.0001).
Information on human and animal TB was obtained mainly from radio/TV (81.3%) and (75.4%),
respectively. TB patients, school, flyers were also reported as information source (Table 2). Knowledge
on the infectious cause of human and animal TB was known by 77.1% and 54.4%, respectively. However,
misperceptions such as cold weather, locally termed as “Berd” were implicated as cause to human TB.
Concerning the modes of human TB transmission, (98.3%) of respondents reported one or more ways.
Nonetheless, inhalation was the commonly reported route of transmission in human (93.7%) as well as in
bovine (28%) as depicted in Table 2.
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Category
Types of TB
Human TB
N =409
%
Animal TB
N=57
%
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Variable
4
Table 2 Knowledge towards TB and source of information for human and animal tuberculosis
among 9th and 10th grade students in public school in Addis Ababa, Ethiopia
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International Journal of Livestock Research ISSN 2277-1964 ONLINE
Heard of the disease
409
99.5
57
Vol 5(1) Jan’15
13.9
Radio/TV
334
81.7
46
75.4
TB patient
38
9.3
5
8.8
School
13
3.2
4
7.0
**Other sources
1
0.2
--------------multiple sources
23
5.6
2
3.5
385
94.1
16
28
Mode of transmission Inhalation
Contact
9
2.2
8
14
Ingestion of animal product --------------15
26.4
Both Inhalation and contact 10
2.4
--------------Didn’t know
1
0.2*
18
31.6
Microorganism
317
77.5
31
54.4
Cause of disease
Cold weather "Berd"
65
15.9
----------Both (cold weather and 4
1
----------microorganism)
did not know the cause
21
5.2*
26
45.6
**Other sources included flyers, friends *the percentage is less than 100% because of missing values
Source of information
Of all students, 320(78.2%) did not experienced TB themselves or among person they know while
89(21.7%) did; however, no association was seen (p>0.05) with their knowledge on bovine 11/57(19.3%)
and human TB 89/409(21.7%). As shown in Table 3, Knowledge towards human TB and BTB was better
in tenth (51.6%) and ninth grades (6.8%), respectively. Moreover, male had relatively better awareness on
BTB (7.3%) while female had (58.4%) towards human TB. The knowledge variation across gender and
grades; however, was not statistically significant (P>0.05).
Table 3 Knowledge and attitude towards human and bovine TB across genders and school grades
from public school students, in Addis Ababa
Variable
Characteristic
Grade
Gender
th
th
9 grade
10 grade
p- value
Male
Female
p- value
N (%)
N (%)
N (%)
N (%)
Heard of human TB
182(44.3)*
212(51.6)
P>0.05
169(41.1) 240(58.4) P>0.05
Heard of bovine TB
28(6.8)*
25(6.1)
P>0.05
30(7.3)
27(6.6)
P>0.05
Knew the Public health
importance of BTB
18(31.6)*
17(29.9)
P>0.05
22(38.6) 16(28.1) P>0.05
*The percentage is less than 100% because of missing values
implication of BTB was better known by ninth grades (31.6%) and male students (38.6%) as shown in
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Of those who knew BTB, (66.7%) regarded it as a public health significant disease.The zoonotic
5
Attitude and practice towards bovine tuberculosis
International Journal of Livestock Research ISSN 2277-1964 ONLINE
Vol 5(1) Jan’15
Table 3. However, no significance association was found. Informants believed susceptibility of cattle
33(62.3%) and other domestic animals such as dog 12(2.9%), cat 4 (1%) and other animals 4 (0.9%) to
BTB. Meanwhile, only 27(47.3%) and 9 (15.8%) considered raw milk and yogurt as vehicles to M. bovis
infection, respectively. As seen in Table 4, 66.2% used pasteurized milk products, while the rest
consumed raw, yogurt, or mixed milk products. Of the respondents who had awareness towards human
and bovine TB, (66%) and (56.1%) claimed to use pasteurized milk and milk products, respectively. Their
awareness was not statistically associated with milk consumption habit (p>0.05).
Table 4 Attitude and practice towards BTB
Variable (categories)
Did not consider BTB as zoonosis
Consider raw milk as source of BTB
Perceive yogurt as vehicles to BTB
Number
Percentage (%)
19
27
9
33.3
47.3
15.8
272
66.2
Milk consumption habit
Pasteurized*
Raw
50
12.2
Yogurt
56
13.6
Mixed milk products**
24
5.8
Did not like milk at all
9
2.2
* Include pasteurized milk and milk products including heat treated milk at household level ** Refer both
raw and pasteurized milk and milk products
Discussion
The present study revealed that overall students have heard of human TB (99.5%) while it was extremely
low in BTB case (13.9%). In agreement with this study, Gopichandran et al., (2010) and Renuka and
Muralidhar (2012); found a very impressive awareness on human TB among high school students in
India. Nonetheless, Romha and colleagues, (2014) indicated a lower (29.7%) awareness on TB
occurrence in animals among cattle owners in southern part of Ethiopia. Likewise, Munyeme and coworkers (2010) reported that 60.4% of respondents not to have heard of bovine tuberculosis from Zambia.
The awareness variation seen in this study between the two types of TB could be a reflection of
remarkable educational efforts towards the human TB through various mass Medias. In agreement with
this premise, this study indicated the usefulness of electronic media in health education. More than 80%
students reported to have acquired the awareness from TV and radio. Similarly, other investigators
neighbors, friends and family members as major source of information in India. Thus, different
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educational messages (Hoa et al., 2009). Nonetheless, Yadav and co-workers (2006) described that
6
showed that health education means such as television (64.6%) can play a pivotal role in disseminating
International Journal of Livestock Research ISSN 2277-1964 ONLINE
Vol 5(1) Jan’15
intervention means and efforts are suggested to consider the peculiar nature of each setting and target
group (Hoa et al., 2009). In contrary, there is lack of attention towards bovine tuberculosis as part of
educational endeavors. Although 45.6% did not know the actual cause of BTB, no false perception was
found. Moreover, misperception as cold weather “berd” was implicated as cause of human TB. Similarly,
Gebremariam et al. (2011) and Bati et al. (2013) had reported similar misperceptions among the general
community in Addis Ababa and in south western part of Ethiopia (Gambella region).
Significant portions (21.7%) of students have closely witnessed TB case in person they know; however,
there was no significant association with the existing knowledge. In agreement with this study, lack of
knowledge on the cause (17.5%) and airborne transmission (5.3%) of pulmonary TB transmission was
reported from Nepal among patients that have experienced TB themselves (Amgain et al., 2014).
Similarly, the cause and transmission was known by 43.9% and 54.9% of TB patients in Tanzania,
respectively (Wandwalo and Morkve, 2000).
In this document, the potential impact of bovine TB on human was not well known by students whereby
(33.3%) believed no transmission from animal to human even among those who knew it existed. In line
with this, Romha et al. (2014) and Bati et al. (2013) highlighted that only 22.9% and 16.6% of
respondents had believed the fact that TB can be acquired from animals, respectively. Apart from the
discrepancy due to the difference in the study population with varying cultural practice in the respective
study areas, it also implicates the wide knowledge gap among the general community regardless of age
group.
Mycobacterium bovis has been detected in milk and yogurt and hence, these products are regarded as
sources of infection (Franco et al., 2013; Mariam, 2014). However, in this study, significant proportion
(31.6%) used to consuming either raw or both pasteurized and raw milk products. Likewise, fewer than
half considered raw milk (47.3%) and yogurt (15.8%) as infection source. TB cases are reported in
different parts of the world due to habit of consuming raw milk (Cosivi et al., 1998; Kazwala et al.,1998;
Kahla et al., 2011; Njarui et al., 2011;pal et al.,2014). Different studies have reported the culture of raw
milk consumption in Ethiopia and potential transmission to humans (Ameni and Erkihun, 2007; Bati et
al., 2013; Romha et al., 2014). Dankner and Davis (2000) reported M. bovis as a significant (34%) cause
of TB among children raised in setting where raw milk is used. Herein, majority of students have
indicated inhalation (28%) and ingestion (26.4%) as means of transmission of BTB giving less priority to
milk and milk products (Cosivi et al., 1998). Nonetheless, inhalation is a great concern to individuals
7
having close contact with cattle (Acha and Szyfres, 2001) which is very unlikely in urban cities like Addis
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the later route of transmission. In fact, BTB is transmitted primarily through ingestion of contaminated
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International Journal of Livestock Research ISSN 2277-1964 ONLINE
Vol 5(1) Jan’15
Ababa and especially among youth. In our study, (93.7%) of all participants implicated inhalation as
means of human TB transmission. Student’s belief on BTB transmission through inhalation could be
attributed to their knowledge on human TB transmission having an indirect effect on bovine TB
awareness provided that students had low awareness in BTB transmission though ingestion. On the other
hand, students’ awareness on BTB may have influenced their practice towards pasteurized milk usage
(56.1%); however, there was no statistical significance. This could have been influenced be a small
sample size used in the study.
Taking into account the bad practice of milk usage and high prevalence in different farming systems
(Shitaye et al., 2007), the potential risk of acquiring milk borne pathogens such as M. bovis to human is
high (Ashford et al., 2001).Very recently, Firdessa and co-investigators (2012) reported high herd BTB
prevalence (50%) among farms supplying milk to the capital city. The existing farms will seemingly
continue to supply milk as well as M. bovis to the consumers as there are no control strategies in cattle
and hence, suggested BTB control measures fitting in local context are urgently needed (Firdessa et al.,
2012).
In this regard, one health oriented integrated researches are valuable to better understand the
epidemiology and risk factors and also to inform policy as zoonotic health problems are shared between
animals and humans. Such efforts involving both animal and public health sectors have been indicated as
an ideal way of combating zoonoses including BTB (Zinsstag et al., 2008; Pal et al., 2014a). Various
researches have been conducted work on human as well as bovine TB to build scientific knowledge in
Ethiopia; however, educational efforts were merely confined to human TB. Such integrated efforts
enabling prevention of many other zoonotic diseases such as brucellosis are very crucial (Plumb et al.,
2013). In this context, health education need to be guided by the nature of the disease and not subjected to
professional bias i.e. every health education on tuberculosis need to consider both human and animal TB
as one.
As a limitation, only children of specific group (public school) of limited study area chosen by nonprobability sampling were involved, therefore, our findings cannot be generalized to the whole area and
age group.
In conclusion, the present study indicated lower knowledge among students on bovine TB than human
on bovine TB is limited. Therefore, human TB awareness promotion strategy should be operated along
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with bovine TB under a One Health umbrella.
8
TB. Due to concerted educational effort on human TB, students awareness has evolved when, ironically,
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International Journal of Livestock Research ISSN 2277-1964 ONLINE
Vol 5(1) Jan’15
Acknowledgments
The authors would like to extend their deepest gratitude to school heads and participant students for their
kind support during survey.
Conflict of interest
The authors declare that they have no conflict of interest.
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