Rabies – One Health Model disease Outcome of Group work Regional Training in Animal and Human Health Epidemiology in South Asia

› Rabies kills at least 55,000 people every year in the world - One death every 10 minutes ~24,000 humans deaths every year in Africa ~31,000 human deaths every year in Asia ~20,000 humans deaths every year in India alone Global burden of rabies

Human Rabies in South Asia CountriesEstimated No. of human cases Human cases per 100,000 population % of dog bite in total animal bite cases Afghanistan N/A Bangladesh % Bhutan< % India >95% Nepal % Pakistan >90% Sri Lanka< %

Why elimination of human rabies in South Asia? The SAARC countries contribute 45% of global burden of human rabies More than 1.5 billion people are at potential risk of rabies infection in South Asia Each year, more than 4 million people receive anti-rabies vaccination There has not been any substantial decrease in the rabies incidence Rabies elimination is an ideal mission to move forward ‘One Health’ concept

Economic burden of rabies The estimated annual cost of rabies is US$ million (90% CI = US$ 540.1–626.3 m) Knobel et al., 2005: Re-evaluating the burden of rabies in Africa and Asia, Bulletin of World Health Organization, 83:

Cost-benefit dog vaccination and human PEP Projected costs of rabies control

Success story: Elimination of Urban Rabies from the principal cities of Latin America (1983) –to eliminate human rabies transmitted by dogs in major cities How? –Pan American Health Organization (PAHO) support –Mass dog vaccination (80% vaccination coverage) –Treatment of people exposed to rabid animals (PEP) –Epidemiological surveillance –1991: control program expanded to neglected areas and small villages –2005 as the target date for the control of rabies in the region – : rabies cases decrease by 93% in dogs, 91% in humans (to 35 cases).

CIP project- Rabies control in Bangladesh: Human behaviour following dog bites Regional Training in Animal and Human Health Epidemiology in South Asia

Objectives To assess incidence and epidemiology of dog bites. To determine behavioural responses of people following a dog bite: –wound care, seeking of health care, behaviours towards the biting dog. To determine risks associated with dog bites. To determine factors associated with failure to complete the full PEP vaccination schedule

Results Most of the dog bite victims were –male (70%), –< 20 years of age (51%), –Rural area (61%), –have no or primary education (70%) and –bitten by stray dogs (71%) Incidence of dog bite varies between study areas Knowledge about appropriate wound care among the dog bite victims was found to be inadequate Incomplete PEP course -7% (although given free of cost)

Recommendations Awareness education to reduce gap in knowledge about dog bite and wound care Include information on dog bite, dog behaviour and rabies in school curriculum to educate school children

CIP project- Enhancing Rabies Control in Bhutan Regional Training in Animal and Human Health Epidemiology in South Asia

Objectives To estimate the size of free-roaming dog population To assess the vaccination and sterilization coverage within the dog population management areas To capture and map the movement patterns and home ranges of free roaming dogs in a border town in south Bhutan To understand the epidemiology of dog bites and uptake of human rabies PEP in Bhutan

Findings Dog population in Bhutan is concentrated in urban areas–may be associated with availability of food resources Mapping movement patterns of stray dogs using GPS Collars demonstrated small home range size (0.69 to 53 ha)—median 3.6 ha –concentrated in the urban areas within Bhutan Minimal cross border movement of dogs –further study needed to examine the seasonal variability of movement pattern

Findings Increased trend of dog bites and post exposure prophylaxis uptake in children and in males (higher risk) No proper records are maintained –whether pet dog or stray dog bite Compliance of PEP – incomplete PEP course

Recommendations Need awareness education More than 70% vaccination coverage should be achieved to eliminate rabies Further estimations of dog population are needed to make proper planning of rabies control program

CIP Rabies Project –Sri Lanka Objectives To estimate the total owned and un-owned dog population in Sri Lanka To review the existing policies and practices for rabies control in Sri Lanka Recommendations To utilize the findings of dog population survey for planning rabies prevention & control activities Need to ensure the sustainability of Public health and Animal health sector collaborative Rabies control activities. National level dog population surveys should be conducted at regular intervals

Outcome of break-out Group discussions Regional Training in Animal and Human Health Epidemiology in South Asia

Challenges for rabies control: Animal health sector Lack of rabies awareness Lack of dog population data and inadequate rabies incidence/prevalence data Poor responsible dog ownership No legislation or inadequate implementation of legislation of dog population or rabies control Inadequate funding support Lack of cross border control programs Large stray dog population Low dog vaccination coverage due to high operation cost/shortage vaccine/poor awareness of vaccination Sporadic implementation of control program Limited diagnostics facilities and capacities Limited coordination between animal and human health sector Limited human resources

Challenges for rabies control : Human health sector Lack of awareness High cost and inadequate quantities of human rabies vaccine and rabies immunoglobulin (RIG) Inadequate awareness of appropriate early treatment/health seeking measures (ie wound treatment, PEP initiation) Poor compliance of post-exposure prophylaxis (PEP) Limited accessibility of PEP facilities Lack of education among children regarding dog bites and rabies Lack of coordination and sharing of resources between animal and human health Lack of a common rabies control guideline for a country Rabies not included as priority public health disease

Recommendations New technologies: Implement cost- effective vaccination program and develop better diagnostics Increase lab capacity Awareness and education Introduction in school curriculum Raise national awareness Regional Collaboration: Sustain regional vaccine bank Share data and information Identify regional diagnostic facilities Develop cross- border control projects Policies: Stronger political commitment One Health approach Improved surveillance Improved compliance Legislation

The Role of Wildlife Limited data on wildlife rabies Recommendation: We need to actively engage the wildlife sector to be involved in the One Health approach in surveillance and controlling rabies

Towards a cost effective Rabies Control Program Budget allocated for rabies control is inadequate thus the policy makers should be sensitized towards this issue Within countries a lead ministry should be identified and all action should be resources by different sectors (AH, PH, Wildlife) As a long term and most cost effective strategy the priorities should be: 1.Animal health: vaccination and sterilization of dogs 2.Public Health: awareness and PEP 3.Wildlife surveillance

Sharing of Resources in the SA region Diagnostic facilities Sharing of experience and expertise Regional human rabies vaccine bank? Establishing trans-border collaborations

Nervous tissue vaccines will be history in South Asia! Cost effective intradermal vaccination started in South Asia Sri Lanka (1995) Bhutan (1996) India (2005) Nepal (2006) Bangladesh (2010)  Pakistan (2014?)

RabiesBlueprint ( RabiesBlueprint : developed by global rabies experts to serve as a guide for countries that would like to prevent human rabies by eliminating animal rabies within their borders. Provides relevant international guidelines for rabies control and prevention, as well as practical information, advice and case studies