Bacillus anthracis-related knowledge, attitudes, and practices in Koraput, India: A mixed methods study

Study design and setting

A cross-sectional mixed-methods approach was adopted, integrating quantitative household surveys with in-depth qualitative interviews with key stakeholders from the department of health, veterinary, forest and panchayati raj to explore programmatic challenges and community perceptions. This study was conducted over three months (July–September 2024) in seven anthrax-endemic blocks of Koraput district, Odisha namely Dasamanthpur, Laxmipur, Koraput, Semiliguda, Boipariguda, Lamtaput and Nandpur ( Fig. 1). Among these seven blocks, Boipariguda reported the highest number of cases (116), followed by Dasamanthpur and Semiliguda (70 each). Laxmipur (61), Nandpur (51), Lamtaput (47), and Koraput block (30) contributed significantly to the overall burden, reflecting a widespread yet varied distribution of anthrax across the district.⁸

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Fig. 1.

Study settings map (Source: QGIS v3.10, GIS mapping software used to generate map).

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Sampling method

A multi-stage cluster sampling design was used to obtain a geographically representative sample of residents from anthrax-endemic areas of Koraput. From 14 blocks, seven endemic blocks were selected; from each selected block 2 Gram Panchayats (GP) were selected and from each GP 2 villages were randomly chosen (total 28 villages). Within each village we used systematic random sampling to recruit an equal number of respondents ( Fig. 2).

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Fig. 2.

Sampling methods for selection of respondents.

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The target sample size (n=700; 25 respondents per village based on the sample size calculation) was determined to ensure adequate precision for estimation of key proportions of Knowledge, Attitude and Practices (KAP). Assuming a worst-case proportion of 0.5, 95% confidence and a 5% margin of error, the simple-random-sample requirement was ∼384. Accounting for clustering (design effect=1.5) increased this to ∼576; allowing for 20% non-response yielded ∼691. For operational feasibility and to ensure uniform allocation across clusters, we aimed to enrol 700 participants; however, a total of 696 participants were ultimately enrolled across the selected blocks for the quantitative assessment of anthrax-related knowledge, attitudes, and practices. For qualitative inputs we conducted 21 In-depth Interviews (IDIs) with block level officials from the health, veterinary, and panchayati raj departments. Alongside this, we conducted seven focus group discussions (FGDs) with tribal community members, one each from selected blocks for study ( Table I). All recorded IDIs and FGDs were transcribed in Odia and translated into English, followed by thematic analysis of the translated data.

Data analysis

The frequency distribution and percentages of the variables were calculated. The multivariate logistic regression determined whether selected variables influenced the knowledge of anthrax at a significance level of 0.05 using Stata v 17.0 (StataCorp LLC, College Station, TX, USA). The qualitative transcripts were systematically coded manually in excel, and recurring patterns were identified to generate key themes. These themes were then reviewed, organised, and interpreted to provide deeper insights into participants’ perspectives using thematic analysis.

Quantitative findings

Qualitative findings

The interviews with officials gave insights into how departments plan, coordinate, and respond to anthrax, the community discussions reported the community level experiences, cultural practices, and the challenges they face in dealing with the disease. By bringing these two sources together, the study was able to capture both the institutional viewpoints and community realities. The narratives were examined carefully through thematic analysis, and from this process, five broad themes emerged which reflect the knowledge, attitudes, and practices related to anthrax prevention and control.

Inter-departmental coordination

Stakeholders across departments strongly agreed that anthrax is a multi-sectoral issue that ‘cannot be managed by one department alone.’ However, most respondents felt that existing coordination platforms were reactive and temporary, becoming functional mainly during outbreaks.

‘When disease comes, we all sit together, but once the crisis ends, no one calls us again. During non-outbreak periods, departments tend to work in isolation, focusing on their routine mandates rather than collaborative prevention measures’.

(male, 36 yr, PRI member)

Joint awareness drives were described as fragmented, with little sustained follow-up. The need for a formal One Health coordination mechanism emerged as a consistent recommendation.

Livestock vaccination

Veterinary officers unanimously regarded vaccination as the ‘main preventive measure’ against anthrax. Yet several challenges hindered effective coverage: irregular vaccine supply, shortage of manpower, and community reluctance.

‘By the time livestock inspector reach in village for vaccination, the animals have already gone for grazing. Due to the scattered nature of villages and lack of prior intimation, it becomes difficult to ensure that all animals are present during vaccination drives’.

(male, 35 yr, Livestock Inspector)

FGDs with tribal participants revealed that migratory and free-grazing livestock often missed vaccination, leaving gaps in protection. A tribal elder stated,

‘No one comes for the vaccination of our livestock to the forest where they go for grazing whole day and no information is being provided us in this regard’.

(female, 38 yr, Community Member)

Respondents emphasised the need for annual, well-planned vaccination campaigns with adequate resources and community engagement.

Surveillance network

Delays in reporting were highlighted by both veterinary and health department stakeholders. Villagers sometimes concealed livestock deaths out of fear of restrictions, while human cases often came to notice only after symptoms became severe.

‘In most cases, people delay visiting health centres until the illness becomes severe or unmanageable at home. Many villagers initially rely on home remedies or traditional healers, often being unaware of anthrax symptoms’.

(male, 32 yr, Medical Officer)

Panchayati Raj representatives acknowledged that frontline workers and volunteers are central to surveillance but noted their limited training.

‘We know fever and wounds, but no one told us these could be symptoms of anthrax.’

(female, 28 yr, Community member)

The findings indicate a strong demand for a community-based surveillance system to ensure timely detection and response. Also highlighted the need for awareness building to educate the communities with regards to the disease, its sign symptoms and transmission cycle.

Laboratory facilities

Weak diagnostic capacity was a recurrent concern. Veterinary staff explained that samples were sent to State level laboratories but results often arrived late.

‘By the time the laboratory confirmation report comes, the carcass is already disposed. Sample collection and transport from remote villages are often delayed due to limited cold chain and logistics support, leading to late confirmation and missed preventive actions.’

(male, 28 yr, laboratory technician)

Health officials echoed similar concerns, pointing to the lack of biosafety facilities and rapid diagnostic kits at local levels. Strengthening district laboratories with rapid testing and biosafety measures was seen as a critical step for timely case confirmation and outbreak response.

Prevention and control strategies

Stakeholders described multiple preventive approaches. Veterinary staff emphasised safe carcass disposal but acknowledged cultural resistance.

‘People do not want to burn or bury their animals; they see it as a big loss. Instead, they tend to remove the skin and sell it, along with the meat, in the market’.

(female, 32 yr, assistant veterinary surgeon)

Health workers focused on community education for safe meat handling and early treatment. Panchayati Raj leaders highlighted their role in mobilisation but requested stronger guidelines and institutional support.

‘When a cow dies, people share its meat instead of discarding it, as livestock are seen as both wealth and food. For many poor households, such occasions provide a rare chance to eat meat’.

(male, 42 yr, community member).

Overall, there was consensus that effective prevention requires sustained vaccination, culturally sensitive awareness programmes, early detection, and inter-sectoral collaboration.

The findings highlight that stakeholders across health, veterinary, and governance sectors recognise anthrax as a complex zoonotic challenge. Despite awareness of preventive strategies, persistent gaps remain in coordination, vaccination coverage, surveillance, laboratory facilities, and culturally appropriate prevention measures. A One Health approach integrating departments and empowering community participation emerged as the central recommendation for long-term anthrax control.