title: Geographic variation in access to dog-bite care in Pakistan and risk of dog-bite exposure in Karachi: prospective surveillance using a low-cost mobile phone system.
abstract: BACKGROUND
  Dog-bites and rabies are under-reported in developing countries such as Pakistan and there is a poor understanding of the disease burden. We prospectively collected data utilizing mobile phones for dog-bite and rabies surveillance across nine emergency rooms (ER) in Pakistan, recording patient health-seeking behaviors, access to care and analyzed spatial distribution of cases from Karachi.
  
  
  RESULTS
  A total of 6212 dog-bite cases were identified over two years starting in February 2009 with largest number reported from Karachi (59.7%), followed by Peshawar (13.1%) and Hyderabad (11.4%). Severity of dog-bites was assessed using the WHO classification. Forty percent of patients had Category I (least severe) bites, 28.1% had Category II bites and 31.9% had Category III (most severe bites). Patients visiting a large public hospital ER in Karachi were least likely to seek immediate healthcare at non-medical facilities (Odds Ratio = 0.20, 95% CI 0.17-0.23, p-value<0.01), and had shorter mean travel time to emergency rooms, adjusted for age and gender (32.78 min, 95% CI 31.82-33.78, p-value<0.01) than patients visiting hospitals in smaller cities. Spatial analysis of dog-bites in Karachi suggested clustering of cases (Moran's I = 0.02, p value<0.01), and increased risk of exposure in particular around Korangi and Malir that are adjacent to the city's largest abattoir in Landhi. The direct cost of operating the mHealth surveillance system was USD 7.15 per dog-bite case reported, or approximately USD 44,408 over two years.
  
  
  CONCLUSIONS
  Our findings suggest significant differences in access to care and health-seeking behaviors in Pakistan following dog-bites. The distribution of cases in Karachi was suggestive of clustering of cases that could guide targeted disease-control efforts in the city. Mobile phone technologies for health (mHealth) allowed for the operation of a national-level disease reporting and surveillance system at a low cost.
authors.affiliation: Interactive Research and Development, Karachi, Pakistan ; Department of International Health, Johns Hopkins Bloomberg School of Public Health, Baltimore, Maryland, United States of America.
authors.forename: Syed Mohammad Asad
authors.initials: SM
authors.lastname: Zaidi
authors.affiliation: Department of International Health, Johns Hopkins Bloomberg School of Public Health, Baltimore, Maryland, United States of America.
authors.forename: Alain B
authors.initials: AB
authors.lastname: Labrique
authors.affiliation: Interactive Research and Development, Karachi, Pakistan.
authors.forename: Saira
authors.initials: S
authors.lastname: Khowaja
authors.affiliation: Interactive Research and Development, Karachi, Pakistan.
authors.forename: Ismat
authors.initials: I
authors.lastname: Lotia-Farrukh
authors.affiliation: Interactive Research and Development, Karachi, Pakistan ; Center for International Health, University of Bergen, Bergen, Norway.
authors.forename: Julia
authors.initials: J
authors.lastname: Irani
authors.affiliation: Department of Infectious Diseases, Indus Hospital, Karachi, Pakistan.
authors.forename: Naseem
authors.initials: N
authors.lastname: Salahuddin
authors.affiliation: Interactive Research and Development, Karachi, Pakistan ; Department of International Health, Johns Hopkins Bloomberg School of Public Health, Baltimore, Maryland, United States of America.
authors.forename: Aamir Javed
authors.initials: AJ
authors.lastname: Khan
mesh_terms: D000293:Adolescent; D000328:Adult; D000818:Animals; D001733:Bites and Stings / Q000453:epidemiology* / Q000473:pathology / Q000628:therapy*; D040421:Cell Phone; D002648:Child; D004285:Dogs; D062665:Epidemiological Monitoring; D005260:Female; D006297:Health Services Accessibility / Q000191:economics / Q000706:statistics & numerical data; D006801:Humans; D008297:Male; D010154:Pakistan / Q000453:epidemiology; D010342:Patient Acceptance of Health Care / Q000706:statistics & numerical data; D011446:Prospective Studies; D012720:Severity of Illness Index; D019371:Topography, Medical; D055815:Young Adult