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APPRAISAL ON IMPLEMENTATION OF INTRADERMALRABIES VACCINATION [IDRV] IN INDIA -

THE KERALA EXPERIENCE

Dr. François-Xavier MeslinTeam Leader, Neglected Zoonotic Diseases

Office of the Director, Department of Control of Neglected Tropical Diseases (NTD)World Health Organization

Geneva, Switzerland.

18-22 November, 2009

Appraisal by:

CONTENTS PAGE NO.

ACKNOWLEDGMENTS i

EXECUTIVE SUMMARY ii

1. INTRODUCTION 1

2. METHODOLOGY 3

3. RESULTS 4

3.1 Anti rabies Clinic, General Hospital, Thiruvananthapuram. 4

3.2 IDRV review meeting at Hotel S P Grand Days, Thiruvananthapuram. 6

3.3 Anti rabies Clinic, Medical college Hospital, Thiruvanathapuram. 9

3.4 Meeting with Principal Secretary, Department of Local Self Government, Kerala. 10

3.5 Visit to State Disease Control & Monitoring Cell (SDCMC). 11

3.6 Model Anti rabies Clinic, Govt. TD Medical College Hospital, Alappuzha. 12

3.7 Anti rabies Clinic, General Hospital, Alappuzha District. 14

3.8 Anti rabies Clinic, Taluk headquarter (Sub district) hospital, Thiruvalla. 16

3.9 Interactive session with Veterinarians. 18

4. OBSERVATIONS 21

5. RECOMMENDATIONS 22

6. ANNEXURES

I. List of participants of IDRV review meeting. 23

II. IDRV‐ Govt. Of Kerala order dated 18.11.2009. 27

III. List of participants of interactive meeting at Veterinary Council. 29

IV. Project proposal on canine rabies control in Thiruvanathapuram 31

District Kerala, India.

ACKNOWLEDGEMENTS

Dr. Francois‐Xavier Meslin, Team Leader, Neglected Zoonotic Diseases, Office of the

Director, Department of Control of Neglected Tropical Diseases (NTD), World Health

Organization, Geneva, Switzerland who led the team on appraisal of IDRV in Kerala.

Smt. P.K Sreemathi Teacher, Hon’ble Minister for Health and Social welfare, Kerala, who’s

administrative support has made IDRV a reality in Kerala.

Shri. Manoj Joshi IAS, Secretary, Health & Family Welfare, helped to make IDRV free of cost

to all regardless of APL/ BPL status.

Dr. Dinesh Arora IAS, Joint Secretary (Health), State Mission Director NRHM and Managing

Director (KMSCL), who has extended all support in terms of man power and logistics in the

implementation of IDRV all over kerala.

Dr. M.K Jeevan, Director of Health Services, who has paved the way for setting up the first

IDRV clinic at General hospital, Thiruvanathapuram.

Dr. M.K. Sudarshan, President, Rabies in Asia [RIA] Foundation; Principal & Professor of

Community Medicine, Kempegowda Institute of Medical Sciences (KIMS), Bangalore, whose

pursuit made Dr. F.X. Meslin’s visit to Kerala possible.

Dr. S. N. Madhusudana, Director, WHO collaborating centre on reference & research on

rabies & Additional Professor of Neurovirology, NIMHANS, Bangalore whose invaluable help in

providing results of sera samples of IDRV patients, gave tremendous confidence to all doctors

implementing IDRV in Kerala.

Dr. G. Sampath, President, Association for prevention & control of rabies in India (APCRI) &

Deputy Civil Surgeon, Institute of Preventive Medicine, Hyderabad who held the training of

trainers (TOT) at IPM, Hyderabad. His invaluable contribution is appreciated in conducting the

appraisal study of IDRV in Kerala.

Dr. Thomas Mathew, Nodal Officer, IDRV, Kerala; Secretary General, Association for

prevention & control of rabies in India (APCRI)& Professor of Community Medicine, MC,

Thiruvanatapuram, Kerala who coordinated all the activities during Dr. F.X. Meslin visit to

Kerala.

Dr. D.H. Ashwath Narayana, Executive Director, Rabies in Asia [RIA] Foundation who was

part of the study team conducting appraisal of IDRV in Kerala. He also provided invaluable

support in preparing this report.

The Rabies in Asia [RIA] Foundation sincerely acknowledges the help and support of

Novartis Vaccines, Mumbai, India.

Executive Summary

The Government of India approved intradermal (ID) administration of rabies vaccine in

February, 2006 as a cost effective alternative to intramuscular (IM) anti‐rabies vaccination.

Government of Kerala started implementation of intradermal rabies vaccination (IDRV) by

training of key staff of anti rabies clinic (ARC) of the state at Institute of Preventive Medicine

(IPM), Hyderabad during December 2008 ‐ January, 2009. The serosurveillance results received

from WHO Collaborating Center for Reference & Research on rabies, NIMHANS, Bangalore

boosted the confidence of Government of Kerala to formally launch IDRV from March 2009.

The Government of Kerala has set a vision of Rabies Free Kerala by 2015 involving all stake

holders in the rabies prevention activities.

Following a Invitation from Dr. M.K. Sudarshan, President, Rabies in Asia [RIA] Foundation &

Government of Kerala, Dr. F. X. Meslin, Team Leader, Neglected Zoonotic Diseases, Office of the

Director, Department of Control of Neglected Tropical Diseases (NTD), World Health

Organization, Geneva, Switzerland along with Dr. D.H. Ashwath Narayana, Executive Director,

Rabies in Asia [RIA] Foundation & Dr. G. Sampath, President, APCRI conducted the appraisal of

IDRV implementation in Kerala. The team visited anti rabies clinics of two district/General

hospitals (Thiruvanatapuram & Alappuzha), two ARC in medical college hospitals

(Thiruvananthapuram & Alappuzha‐ model ARC), one taluka (sub district) hospital. The team

perused the records & reports available at different ARC & at state disease control &

monitoring cell (SDCMC), observed IDRV & RIG administration at ARC, interviewed animal bite

victims & staff of ARC. The team had a discussion with officials of Department of Health &

Animal Husbandry & Local Self Government. The team also attended an IDRV review meeting in

the presence of Health Minister of the state & participated in an interactive session with

members of state veterinary council.

The study team observed that IDRV is being implemented in a phased manner through proper

Government orders & training of staff as per the guidelines of regulatory authorities. Presently,

IDRV is being implemented through 6 District hospitals, 5 Medical college hospitals, 3 Taluk

hospitals & one community health centre (Block level hospital). The study team highly

appreciates the strong political commitment with Honorable Health Minister leading the state

in implementing IDRV in Kerala. There are separate registers maintained for animal bite cases &

IDRV. Statistics on IDRV and health education materials are displayed at all ARC visited. ERIG or

HRIG (in Skin Sensitivity Testing positive cases) are given free to all poor patients in ARC visited

(viz. General Hospital, Thiruvananthapuram, Medical College Hospitals of Thiruvananthapuram

& Alappuzha). The study team observed increased proportions of cat and rodent exposures

reported to some ARC, which may be due to increased awareness on rabies & its prevention

among the populations served by these centers. It was noted from reports that most animal

bite victims are exposed to domestic animals (mostly dogs). Compliance to IDRV was found to

be very good from the fact that there only a small number of patients missed IDRV doses on

day 3 & 7.

The study team recommends that IDRV be expanded to cover more hospitals in the state after

necessary training of ARC staff. RIG should be administered to all WHO category III (severe)

exposures. Hands‐on training on Rabies Immunoglobulin (RIGs) administration must be given

to all ARC staff. In patients with positive SST, full dose of ERIG can be administered after pre‐

medication protocol to save on the cost of HRIG or as there is no scientific grounds for

performing a skin test prior to administration of ERIG because testing does not predict

reactions, to further reduce cost of RIG application an alternative is to omit SST altogether, use

ERIG in all category III and having medication ready for those very rare anaphylactic reaction (1

for 45000 PEP) (reference WHO WER, n° 49/59, 2007,82 425‐436). To avoid unnecessary

treatment of rodent bites, WHO Post exposure prophylaxis (PEP) guidelines stating that these

exposures seldom require PEP should be followed & steps to be taken to examine in the

laboratory whether rabies naturally occur in sylvatic rodents. Intense IEC activities to educate

public about avoidance of animal bites & rabies prevention should to be undertaken. Voluntary

pet dog licensing with emphasis on responsible pet ownership shall be undertaken.

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1. Introduction

Rabies in India has been a disease of low public health priority both in the medical and

veterinary sectors. This is very unfortunate as almost 20,000 people die of Rabies in India every

year. The owned dog population is estimated to be over 25 million in India and 1.3 million in

Kerala. The estimated animal bite incidence in India was evaluated through a multicentric

survey at 17.4 million annually. Annually about 6‐8 million PEP are administered in India today.

It has been estimated that India spends about 15 billion rupees (333 million US $ at 45 rupees

per 1 US $) for rabies vaccines alone. Kerala is spending about 250 million rupees or 5.5 million

US $ every year for active PEP immunization. This exerts a sizeable economic burden on the

government as well as on the bite victim.

Kerala stopped production of NTV’s way back in 1993 and was the first State in the country to

start using modern CCV’s. For a State like Kerala, high cost of vaccine provided by IM route was

the major limiting factor in the fight against the disease. One dose of rabies vaccine would cost

about Rs. 300/‐ and a full course of 5 IM doses would cost about to Rs. 1500/‐, which is beyond

the reach of the common man. The use of ID route for tissue culture anti rabies vaccine was

approved by the Government of India in 2006 and is already being implemented partly in some

States like Uttar Pradesh, Orissa, Andhra Pradesh, Karnataka, West Bengal, Tamil Nadu and

Himachal Pradesh. National Guidelines put forward by NICD in 2007 was used as the base

document for implementing Intra Dermal Rabies Vaccine (IDRV) in Kerala.

The efforts towards rabies control in Kerala State took a new direction with the introduction of

the IDRV regimen in 2009. A workshop was held at Thiruvananthapuram on 20th & 21st

September 2008 to develop operational guidelines for implementing IDRV in Kerala. National

Guidelines put forward by N.I.C.D in 2007 was used as the base document to formulate

guidelines for implementing IDRV in Kerala. Following this, the Government passed an order for

implementation of IDRV in Kerala [GO(MS)No.557/2008/H&FWD dated 31st October2008].

Vaccines were procured through Kerala Medical Services Corporation Limited. Training of 30

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faculty members including doctors, nurses and health inspectors was held at the Institute of

Preventive medicine (IPM), Hyderabad from December 2008 to January 2009.

IDRV programme has been a great success in Kerala. NRHM, DHS, DME, KMSCL all have played

important roles in the success story. It has entered the second phase of implementation

wherein IDRV is being made available in the entire district and taluk (sub district) head quarter

hospitals of the State apart from the Medical colleges. The results of serosurveillance received

from NIMHANS, Bangalore was equally encouraging as the average antibody titer in immunized

patients in Kerala was 7.01 IU/ml (note: the WHO recommended minimum titer indicative of an

appropriate immune response to vaccination is 0.5 IU/ml).

The Government of Kerala has set a vision of Rabies Free Kerala by 2015 and the strategies

include control of animal rabies, free PEP for bite victims and most importantly increasing

community awareness. IDRV is a major step in that direction, which ensures free PEP to a larger

population. The success of the programme requires the integrated approach of the department

of health, animal husbandry and the local self government. Realizing the significance of

implementing IDRV in the State, the Government has decided to provide IDRV free of cost to all,

irrespective of their affordability (Above and below poverty lines status ‐APL or BPL‐). As of

today there are 21 centers providing this service in the State and the Government plans to scale

it to all hospitals in the State which caters to more than 5 bite victims per day.

In this background, Dr. M. K. Sudarshan, President, Rabies in Asia (RIA) Foundation requested

Dr. F. X. Meslin, Team Leader, Neglected Zoonotic Diseases, Office of the Director, Department

of Control of Neglected Tropical Diseases (NTD), World Health Organization, Geneva to visit

Kerala for an appraisal of the implementation of IDRV in the State. Following an invitation from

the Government of Kerala, Dr. F. X. Meslin along with Dr. D.H. Ashwath Narayana, Executive

Director of Rabies in Asia (RIA) Foundation & Dr. G. Sampath, President, Association for

Prevention and Control of Rabies in India (APCRI), visited Kerala from 18‐22 November, 2009.

The appraisal visit was coordinated by Dr. Thomas Mathew, Nodal Officer, IDRV, Kerala.

3

2. Methodology

The team comprising of Dr. F.X. Meslin, Dr. D. H. Ashwath Narayana & Dr. G Sampath visited

various hospitals implementing IDRV in Kerala. The day‐wise details of visit are as follows:

18‐11‐2009 (Wednesday):

a) Visit to Anti rabies Clinic, General Hospital, Thiruvananthapuram

b) IDRV review meeting at Hotel S P Grand Days, Thiruvananthapuram

19‐11‐2009 (Thursday)

a) Visit to Anti rabies Clinic, Medical college Hospital, Thiruvanathapuram

b) Meeting with Principal Secretary, Department of Local Self Government, Kerala

c) Visit to State Disease Control & Monitoring Cell (SDCMC).

20‐11‐2009 (Friday)

a) Visit to Model Anti rabies Clinic, Govt. TD Medical College Hospital, Alappuzha

b) Visit to Anti rabies Clinic, General Hospital, Alappuzha District

c) Visit to Anti rabies Clinic, Taluk headquarter (Sub district) hospital, Thiruvalla

21‐11‐2009 (Saturday): Meeting with Veterinarians

The study team perused the records & reports available at anti rabies clinics and State

Disease Control & Monitoring Cell. The team members observed the technique of

administration of IDRV & Rabies Immunoglobulins (RIGs) & cold chain maintenance. Interview

of animal bite victims & discussions with staff of ARC of General Hospitals & Medical College

hospitals was also carried out. The team had a meeting with officials of Department of Health,

Department of Animal Husbandry & Principal Secretary, Local self Government and discussed

various strategies to be employed for preventing rabies.

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3. Results

3.1 Anti rabies Clinic, General Hospital, Thiruvananthapuram

The study team visited the Anti rabies clinic (ARC) at General Hospital, Thiruvananthapuram

which manages animal bite cases in the capital city of Thiruvananthapuram. IDRV was started at

this ARC in March 2009. Anti rabies vaccine is administered by ID route to all cases as per

Updated TRC regimen. Category III animal bite cases are administered ERIG after skin sensitivity

test (SST). If patients are positive for SST, Human rabies immunoglobulin (HRIG) is administered

Instead of ERIG. All BPL animal bite victims receive IDRV & ERIG or HRIG (in case of positive

SST), free of cost. Details of exposures & PEP provided are recorded in separate registers and

the data is entered on the computer. A counsellor working at the ARC counsels the patients on

the need for completing the course of vaccination. All staff members working at the ARC are

trained in rabies prophylaxis & IDRV.

Photo 1: General Hospital, Thiruvanathapuram

Photo 2: The study team with Dr. Preetha, M.O of ARC

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Table 1: Details on animal bite cases reported at General Hospital, Thiruvanathapuram during 2009

Month Total no. of new cases

Cat. I bites Cat. II bites Cat. III bites

Adult Male

Adult Female Children

March 1003 10 716 277 427 340 226

April 840 34 600 206 374 295 171

May 747 25 536 186 322 253 182

June 854 34 620 200 361 314 179

July 582 32 341 209 270 205 107

August 877 37 539 301 393 314 170

September 690 11 452 227 320 231 139

October 875 19 555 301 383 314 178

TOTAL 6468 202

(3.1%) 4359

(67.4%) 1907

(29.5%) 2850(44%)

2266 (35%)

1352(21%)

Source: ARC, GH, Thiruvananthapuram

Table 2: Details on biting animal & type of animal


Biting animal Type of animal

Dog bite Cat bite Others Stray

animals Domestic animals

March 1003 770 164 69 248 755

April 840 640 128 72 133 707

May 747 603 96 48 150 597

June 854 596 149 109 182 672

July 582 419 111 52 124 458

August 877 653 141 83 238 639

September 690 522 122 46 174 516

October 875 673 154 48 243 632

TOTAL 6468 4876

(75.4%) 1065

(16.5%) 527

(8.1%) 1492

(23.1%) 4976

(76.9%) Source: ARC, GH, Thiruvananthapuram

Majority of animal bite victims were adults (79 %), had WHO category II exposures (67.4%).

Exposures to cat bite constitute 16.5 % of the total animal bite cases. 76.9 % of the patients

were bitten by domestic animals.

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3.2 IDRV review meeting at Hotel S P Grand Days, Thiruvananthapuram

The study team attended the IDRV review meeting in the evening attended by Honourable

Health Minister Smt. P.K. Sreemathy Teacher; NRHM Mission Director, Dr. Dinesh Arora, IAS;

Director of Health Services; State & district level stake holders (Annexure‐I). The Government

order on providing free anti rabies vaccine by intradermal route to all animal bite victims

irrespective of their socioeconomic status was released by Dr. Dinesh Arora in the presence of

the Honourable Minister for Health & family Welfare (Annexure‐II).

Photo 3: Dr. Thomas Mathew welcoming the guests (from left) Dr. G. Sampath, Dr. Dinesh Arora IAS, Hon’ble Health Minister Smt. P. K. Sreemathy Teacher, Dr. F. X. Meslin, Dr. D. H. Ashwath Narayana & Dr Karunakaran

Photo 4: Dr. D.H. Ashwath Narayana briefing on background of Dr. F.X. Meslin visit to Kerala

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Photo 5: Presentation on Implementation of IDRV in India

by Dr. G. Sampath

Photo 6: Dr. F. X. Meslin addressing the audience

Photo 7: Dr. Dinesh Arora, IAS delivering the keynote address

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Photo 8: Hon. Health Minister Smt. P. K. Sreemathy Teacher delivering the inaugural address.

Photo 9: Launching of APCRI website (From left) Dr. Anooplal, Abhilash, Dr.Ajith, Smt. P. K. Sreemathy Teacher, Dr. D. H. Ashwath Narayana and Dr. F. X. Meslin

Photo 10: Smt.P.K.Sreemathy Teacher presenting Aranmula mirror memento to Dr. F. X. Meslin

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3.3 Anti rabies Clinic, Medical college Hospital, Thiruvanathapuram

The study team visited the ARC run by the Department of Community Medicine, Medical

College, Thiruvananthapuram. IDRV was started at the ARC in March 2009. PEP procedures

and modalities are standardized and similar to those described for the General Hospital in

section 3.1.

Photo 11: Visit to IDRV Clinic, Medical College, Thiruvananthapuram

Table 3: Details of animal bite cases treated at MCH Hospital, Thiruvanatapuram, during 2009

Months July Aug. Sept Oct. Nov. Total Age < 14 years 14 16 14 18 11 73 (15.8 %)

>14 Years 76 75 72 84 81 388 (84.2%)Sex Male 39 47 41 54 46 227 (49.2%)

Female 51 44 45 48 46 234 (50.8 %) Animal

Dog 57 61 54 70 70 312 (66.7 %)Domestic 54 59 49 63 63 Stray 3 2 5 7 7

Cat 33 30 32 32 21 148 (32.1 %)Domestic 32 29 27 27 12 stray 1 1 5 5 9

Rodents 0 0 0 0 0 --NIL-- Others 0 0 0 0 1 01 (0.2 %)

Source: ARC, MCH, Thiruvananthapuram

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Table 4: Details on type of exposures

Months Total no. of new cases

Cat. I cases

Cat. II cases

Cat. III cases

No. of vials of vaccine used

July 90 16 53 21 96 August 91 22 53 16 117 September 86 14 68 4 107 October 102 12 80 10 138

Total 369 64 (17.3 %)

254 (68.8 %)

51 (13.8%)

458

Source: ARC, MCH, Thiruvananthapuram

Majority (84.2 %) of the bite victims were adults, 50.8 % were females, 32.1 % of the victims

were bitten by cat. 68.8 % of the bite victims had Category II exposures.

3.4 Meeting with Principal Secretary, Department of Local Self Government, Kerala

The study team met Sri. S. M. Vijayanand, IAS, Principal Secretary, Local Self Government

(Urban Development) and discussed the role of the Local Self Government in control of Dog

population management. Sri. S.M. Vijayanand, IAS briefed the team about the formation of a

State Level Co‐ordination Committee for rabies control & the coordination with different

departments in dog population management.

Photo 12: Dr. F. X. Meslin discussing with Sri. S. M. Vijayananth IAS (Principal Secretary, Local Self Government) accompanied by Dr. Sairu Philip, Dr. D. H. Ashwath Narayana and Dr. Thomas Mathew

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3.5 Visit to State Disease Control & Monitoring Cell (SDCMC)

State Disease Control & Monitoring Cell is the office of the State Nodal Officer for IDRV

implementation in the State and the focal point for IEC activities and advocacy regarding rabies

control in Kerala. The study team held discussion with Dr. Thomas Mathew, Nodal officer, IDRV

& other staff of SDCMC about problems encountered in implementation of IDRV. The team also

perused records & reports of various hospitals implementing IDRV.

Photo 13: (From left) Dr. Thomas Mathew, Dr. D.H. Ashwath Narayana, Dr. F. X. Meslin and Dr. G. Sampath

Photo 14: The study team with staff of SDCMC

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3.6 Model Anti rabies Clinic, Govt. TD Medical College Hospital, Alappuzha

Alappuzha is a district headquarters situated about 165 Km from Thiruvananthapuram the State

capital. The Anti Rabies Clinic functioning under the Department of Community Medicine, T. D.

Medical College was upgraded to a Model Anti Rabies Clinic with the introduction of IDRV on

March 16th 2009 under the leadership of Prof. Dr. Thomas Mathew. Dr. Sairu Philip, Associate

Professor, Sri. Mohammed Ashraff and Sri. Balanandan, Health Inspectors, had undergone

hands‐on IDRV Training at the Institute of Preventive Medicine, Hyderabad. The Medical Officer

in charge of IDRV clinic, Dr. Karthika was trained at GH, Thiruvananthapuram. The IDRV clinic

functions on all days and has imparted hands‐on training to doctors and nurses in 3 districts –

Alappuzha, Pathanamthitta and Ernakulam.

Dr. F. X. Meslin interacted with Dr. A. Sobha, Professor and Head of Community Medicine,

Medical Officers, Health Inspectors and the patients to learn about the functioning of the clinic.

He thoroughly examined the registers, technique of immunoglobulin administration and the

infrastructure. The details of exposures & management are recorded in separate registers.

Photo 15: Visit to Nodal ARC, Govt. T.D. Medical College, Alappuzha (From left) Dr. Thomas Mathew, Dr. F.X. Meslin, Dr. D.H. Ashwath Narayana, Dr.Sairu Philip, Dr. Shobha & Dr. Asheel.

Photo 16: Dr. F. X. Meslin observing RIG administration

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Table 5: Details on animal bite cases managed at TD Medical College Hospital, Alappuzha during 2009


Cat. I cases

Cat. II cases

Cat. III cases

No. of vials of vaccine used

No. of ERIG administered*

No. of HRIG administered*

April 196 0 139 57 280 71 31

May 181 0 138 43 293 65 28June 174 0 130 44 279 52 39July 168 0 132 36 256 69 38August 142 1 111 30 224 58 37September 140 0 101 39 215 47 34October 193 0 163 30 279 30 30Total 1194 1

(0.1%) 914

(76.9%) 279

(23.4 %) 1826 392 237

Source: ARC, TD, MC, Alappuzha *include referred cases for RIG administration. Table 6: Details on animal bite cases & biting animal

Months March April May June July Aug. Sept Oct. TotalAge (Yrs)

< 14 27 67 70 43 30 42 34 68 381 (29.5)> 14 70 129 111 131 138 100 106 125 910 (70.5 %)

Sex Male 46 105 101 94 79 76 87 11 699 (54.1 %)Female 51 91 80 80 89 66 53 82 592 (45.9%)

Animals

Dog • Domestic • Stray

Total

47 5 52

81 13 94

86 1 87

79 10 89

71 11 82

58 21 79

63 11 74

98 12 110

667 (51.7%) Cat

• Domestic • stray

Total

32 10 42

64 31 95

70 21 91

61 17 78

67 16 83

45 12 57

33 30 63

63 17 80

589 (45.6 %)

Rodents ‐ 3 2 1 1 3 1 1 12 (0.9%)Others 3 4 1 6 2 3 2 2 23 (1.8 %)

Source: ARC, TD,MC, Alappuzha

Table 7: Details on missed vaccine doses following IDRV at TDMC, Alappuzha

Months 2nd dose 3rd dose 4th dose April 13 15 41May 10 13 34June 16 9 26July 24 14 20August 17 7 22September 16 4 18October 22 12 23

Total 118 74 184 Source: ARC, TD,MC, Alappuzha

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Majority (70.5%) of bite victims were adults, 54.1 % were males, 76.9 % had WHO category II

exposures & 45.6 % of the bite victims had exposure to cat. 9.9 % & 6.2 % of the patients had

missed day 3 & day 7 dose of vaccine administered by ID route.

3.7 Anti rabies Clinic, General Hospital, Alappuzha District

The team visited the ARC at the District Hospital, Alappuzha and observed the facilities available

for IDRV at the casualty. The team interacted with Dr. Sangeetha, RMO of the Hospital. All the

doctors and nurses in the casualty service are trained in IDRV. The team examined the registers

& vaccine vials. The team appreciated the staff nurses who take note of the time of opening of

vial, enabling the staff to determine vaccines not used within 8 hours of opening and discard

the same. Animal bite victims with WHO category III exposures are referred to ARC, TD Medical

College, Alappuzha for ERIG administration.

Photo 17: Visit to General Hospital Alappuzha.

Photo 18: The team verifying IDRV register.

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Table 8: Details on animal bite cases managed at General Hospital, Alappuzha during 2009

Months JUNE JULY AUG SEPT OCT NOV Total AGE

(Yrs) < 14 9 36 40 33 55 30 203

(21.2%) >14 73 157 108 132 129 155 754

(78.8% ) SEX Male 44 101 71 80 102 96 494

(51.6 %) Female 38 92 77 85 82 89 463

(48.4%)

ANIM

ALS

DOG Total Domestic Stray

45 40 5

10193 8

8069 11

8977 12

95 84 11

98 79 19

508 (53.1%)

CATS Total Domestic Stray

33 27 6

7841 37

6343 20

7255 17

83 59 24

78 47 31

407 (42.5%)

Rodents 4 13 5 3 6 4 35 (3.7%)

Others ‐ 2 1 1 0 3 07(0.7 %)

Source: ARC, GH, Alappuzha

Table 9: Details on type of exposures reported at GH, Alapuzha during 2009.

MONTHS Total no.of new cases

Cat I. cases

Cat II. cases

Cat III. cases

no. of vials used

June (From 15/6)

82 0 67 15 63

July 194 0 152 42 191 Aug 148 0 128 20 189 Sept 165 0 143 22 183 Oct 183 0 156 27 183 Nov 185* 7 151 22 145 Total 957* 7

(0.7%) 797

(83.7 %) 148

(15.6 %) 954

* 5 cases with h/o of consumption of raw milk of rabid cow not categorized Source: ARC, GH, Alappuzha

Table 10: Details on missed vaccine doses following IDRV at GH, Alaphuza

MONTH 2nd dose 3rd dose 4th dose JUNE 13 3 27 JULY 31 10 37 AUG 16 10 34 SEPT 12 11 19 OCT 17 6 31 Total 89 40 148

Source: ARC, GH, Alappuzha

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Majority (78.8 %) of bite victims were adults & 51.6 % were males. 42.5 % had exposures to cat

& 3.7 % had exposures to rodents. 83.7 % of bite victims had Category II exposures. 9.4 % &

4.2 % of patients had missed day 3 & day 7 dose of vaccine.

3.8 Anti rabies Clinic, Taluk headquarter (Sub district) hospital, Thiruvalla

The study team visited the IDRV clinic at the Taluk Hospital, Tiruvalla, situated 24 kms from Alappuzha.

Dr. F. X. Meslin interacted with Dr. Sunil, Physician. He also observed how a patient with animal bite is

routed to the IDRV clinic from OP. Medical officers decide on the category of treatment and IDRV is

administered by trained nurses. After OP hours, the patient will get IDRV from the casualty. Patients

with category III exposures are referred to ARC, TD Medical College hospital, Alapuzha.

Photo 19: Thaluk Hospital Thiruvalla

Photo 20: Dr. F. X. Meslin interacting with Dr. Sunil, at THQ Hospital, Thiruvalla.

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Table 11: Details on animal bite cases managed at, Taluk headquarters hospital, Thiruvalla during 2009

Months July Aug Sept Oct Nov Total AGE

(Yrs) <14 14 16 14 18 11 73

(15.8%) >14 76 75 72 84 81 388

(84.2%) SEX Male 39 47 41 54 46 277

(49.2 %) Female 51 44 45 48 46 234

(50.8 %)

ANIM

ALS

DOG Domestic stray Total

543 57

592 61

495 54

637 70

63 7 70

312

(67.7%) CATS Domestic

stray Total

321 33

291 30

275 32

275 32

12 9 21

148

(32.1%) others ‐‐ ‐‐ ‐‐ ‐‐ 1 01

(0.2 %) Source: ARC, Taluk hospital, Thiruvalla

Table 12: Details on type of animal bite exposures reported at Taluk headquarters, Thiruvalla during 2009.

MONTHS Total no. of new cases

Cat I. cases

Cat II. cases

Cat III. cases

no. of vials used

July 90 16 53 21 96 Aug 91 22 53 16 117 Sept 86 14 68 4 107 Oct 102 12 80 10 138 Total 369 64

(17.4 %) 254

(68.8%) 51

(13.8%) 458

Source: ARC, Taluk hospital, Thiruvalla

Table 13: Details on missed vaccine doses following IDRV at Taluk headquarters, Thiruvalla during 2009

MONTH

2nd dose 3rd dose 4th dose

JULY 12 7 28 AUG 9 12 31 SEPT 5 5 35 OCT 5 14 34 Total 37 38 128

Source: ARC, Taluk hospital, Thiruvalla

18

Majority (84.2 %) of bite victims were adults, 50.8 % were females. 32.1 % of bite victims had

exposure to cats. 68.8 % of the bite victims had Category II exposures. 12.1 % & 12.4 % of the

patients had missed Day 3 & Day 7 vaccine doses respectively.

A total of 17,422 animal bite cases has been administered IDRV in the state of Kerala till 31st

October, 2009.

3.9 Interactive session with Veterinarians

An interactive session was arranged at the Kerala Veterinary Council, Thiruvananthapuram on Saturday

the 21st November 2009. Dr. Thomas Mathew, Nodal Officer, IDRV, Kerala introduced the guests and

welcomed everyone present. Dr. K. Udayavarman, President, KSVC introduced the topic and the

expectation from the deliberations. Dr. N. N. Sasi, Registrar, KSVC; Dr. Suma, Addl. Director;

Dr. Ramakumar, Former Secretary, VCI; Dr. APS Nair, State President, IV; Dr. D.H. Ashwath Narayana,

Executive Director, Rabies In Asia Foundation and Dr. Anuja , Asst. Professor, Dept. Of Community

Medicine, Medical College, Trivandrum & 20 veterinarians were present in the programme

(Annexure‐III)

Dr. Rani S.S., Asst, Director, Department of Animal Husbandry gave a detailed and explicit presentation

on the present scenario, plans, hurdles and progress in the control of Animal Rabies in the State.

Following her presentation, Dr. F.X. Meslin shared his wide experience, stressing the need for ecological

studies prior to an ABC/AR Program. He mentioned various methods (coded painting or colour‐coded

collars) for marking dogs at time of vaccination to indicate their place of vaccination and identify

through reobservation their place of origin. He also presented the statistics from many studies where

successful control of dog rabies reduced the number of people presenting themselves for PEP. Everyone

accepted the fact that without proper and intensive publicity the programme would not take off well.

Dr. Ramakumar presented a valid point on the need to create a new face for dog catchers and give them

an acceptable place in society. Dr. Swapna Susan, in charge of the Rabies lab at CDIO, Palode, detailed

the rabies incidence statistics and how the non availability of the FAT conjugate hampered the

programme at times.

The entire deliberations accepted the well known fact that field veterinarians are already doing

maximum work with minimum input. Hence the need for a support team and incentives for the

specialized work undertaken are imperative. Dr. A.P.S. Nair, Dr. N.N. Sasi and Dr. Suma spoke on the

19

topic and aired their views. Dr. D.H. Ashwath Narayana opined that unlike in other States, owned dogs

and responsible owners are more numerous in Kerala and hence vaccination could be administered

more easily. The concreteness of this program was realised, when Dr. Rama Kumar handed over the

project (Pilot programme for one District) prepared by Dr. Rani S.S. on behalf of the Animal Husbandry

Department and Indian Veterinary Association, Kerala, to Dr. F.X. Meslin for perusal and possible

financial help, as ABC programme for stray dog management requires additional resources like

manpower, equipments etc. to perform in a successful manner (Annexure IV).

Photo 21: Head quarters of Kerala State Veterinary Council.

Photo 22: Dr. N. N. Sasi welcoming the guests.

20

Photo 23: Dr. Rani presenting the present scenario of Animal Rabies Control in the state. Photo 24: Dr. F. X. Meslin sharing his experience

21

4. Observations

IDRV is being implemented in a phased manner through proper Government orders &

training of staff as per the guidelines of regulatory authorities. Presently, IDRV is being

implemented through 6 District hospitals, 5 Medical college hospitals, 3 Taluk hospitals &

one community health centre (Block level hospital). The study team highly appreciates the

strong political commitment with Honourable Health Minister leading the state in

implementing IDRV in Kerala.

Doctors and Nurses working at ARC of Government hospitals & Medical College hospitals

are adequately trained in IDRV.

Separate registers for animal bite cases & IDRV are maintained in all centres visited.

Special ink stamps indicating doses of vaccine and instructions/advice were available in the

local language at all the ARC visited

Daily reporting on number of cases treated at ARC is sent to State Disease Control &

Monitoring Cell (SDCMC) by all the ARC.

Statistics on IDRV and health education materials are displayed at all ARC visited.

ERIG or HRIG (in SST positive cases) are given free to all poor patients in ARC visited (viz.

General Hospital, Thiruvananthapuram, Medical College Hospitals of Thiruvananthapuram

& Alappuzha).

A significant proportion of visitors to ARC are exposed through cat and rodent contacts,

which may be due to increased awareness on rabies & its prevention among the

populations served by these centres.

A majority of animal bite victims are exposed through contact with domestic animals

particularly dogs.

There is better patient compliance with the ID route with more patients observed receiving

their PEP doses on day 3 & 7

22

5. Recommendations

The study team recommends that:

IDRV be expanded to cover more hospitals in the state after necessary training of ARC

staff.

RIG should be administered to all WHO category III (severe) exposures. Hands‐on training

on RIG administration must be given to all ARC staff.

In patients with positive SST full dose of ERIG can be administered after pre‐medication

protocol to save on the cost of HRIG OR as there is no scientific grounds for performing

a skin test prior to administration of ERIG because testing does not predict reactions, to

further reduce cost of RIG application an alternative is to omit SST altogether, use ERIG

in all category III and having medication ready for those very rare anaphylactic reaction

(1 for 45000 PEP) (reference WHO WER, n° 49/59, 2007,82 425‐436)

To avoid unnecessary treatment of rodent bites, WHO Post exposure prophylaxis (PEP)

guidelines stating that these exposures seldom require PEP should be followed & steps

to be taken to examine in the laboratory whether rabies naturally occur in selvatic

rodents.

Intense IEC activities to educate public about avoidance of animal bites & rabies

prevention should to be undertaken.

Voluntary pet dog licensing with emphasis on responsible pet ownership shall be

undertaken.

23

ANNEXURE‐1

List of participants of review meeting on IDRV held at Hotel SP Grand days on 18.11.09 at Thiruvanathapuram

Sl.No. Name & Official Address Mail id Mobile Number

1 Smt. P. K. Sreemathi Teacher Hon’ble Minister for Health & Social Welfare

minister‐[email protected] 9447733400

2 Sri. Manoj Joshi, IAS Secretary H&FW

[email protected] 9995023269

3 Dr. Dinesh Arora IAS Joint Secretary & SMD, NRHM


4 Dr. G. Sampath, President, APCRI & Deputy Civil Surgeon, Institute of Preventive Medicine, Hyderabad


5

Dr. D. H. Ashwath Narayana, Executive Director, RIA Foundation & Associate professor of Community Medicine, KIMS, Bangalore

[email protected]

09341948189

MEDICAL EDUCATION

6 Dr.Thomas Mathew, Prof.of Community Medicine, MCH, TVM & Nodal Officer, IDRV, Kerala


7 Dr. Sairu Philip, Asso. Prof. of Community Medicine, TDMC, Alappuzha


8 Dr. Indu P.S Asso. Prof. of Community Medicine, MCH, Thiruvananthapuram


9

Dr. Karthika.M Senior Lecturer, Dept. of Community Medicine, T.D.Medical College, Alappuzha


10 Dr. Biju George, Sen. Lecturer, Dept of Community Medicine, Medical College, Calicut.


11 Dr.Nileena Koshy, Assoc. Professor of Community Medicine, Medical College, Thrissur


12 Dr. Ajith Chakravarthy.C.T, Community Medicine, Medical College, Trivandrum


13 Dr. Sobha, Professor of Community Medicine, TDMC, Alappuzha

[email protected]

9446793304

24

14 Dr.Anuja.U, Assistant Professor of Community Medicine, Medical College, Trivandrum

[email protected]

9447411642

15 Dr.Manjula V.D, Associate Professor of Community Medicine, Medical College, Kottayam


16 M.Sivankutty Nair Lecturer, State PEID Cell

9447101308

17 Dr.Khuraishabeevi, Asst Prof, State PEID Cell

9847528046

PRIVATE MEDICAL COLLEGE

18

Dr. Anooplal Assistant Professor of Community Medicine, SMIMS


19

Dr. Mubarack Sani T.P Professor & HOD of Community Medicine, Medical College, Pariyaram

9244042189

HEALTH SERVICE

20 Dr. M.K Jeevan Director of Health Services


21 Dr. P. K. Jameela Addl. Director of Health Services (FW) & SPM NRHM


22 Dr. Anilkumar K.S Additional DHS(PH), DHS Office


23 Dr. Gerald. G. Mathew CHC, Kothamangalam


24 Dr. Deepakumar.V THQ Hospital, Muvattupuzha


25 Dr. O. Vasudevan, DH, Kollam


26 Sri. Sureshkumar.S IDRV Councilor, GH, TVM

[email protected]

9349324245

27 Sri.K.M.Vinod Tech.Asst.Gr.I,DMO (H), EKM


28 Sri. R.Anil Kumar DEMO, DMOH Trivandrum


29 Sri. D. Sasi, DEMO, DMO(H) KKD

9946862275

30 Dr. G.Nandini DPM, Arogyakeralam,Thrissur


31 K.T.Mohanan T.A Grd.I, DMO (H) Kozhikode

9447711536

32 Dr. A.Shibulal DPM,NRHM,Malappuram


25

33 Dr. C.R.Mohandas DPM, NRHM, Kottayam


34 Dr. Peethambaran K.B Dy. DMO(H),Ernakulam

[email protected]

9447324541

35 Dr. M.Sivasuthan DPM,Kollam


36 Dr. K.Sakeena Dy. DMO(H),Malappuram


37 Dr. Preetha MO i/c IDRV Clinic, GH,Trivandrum

9447698530

38 Dr.Jacob Varghese Dy.DMO(Health), Alappuzha [email protected] 9447356127

39 Dr.T. Dilip Kumar Assistant Director(Entomology), Trivandrum


40 M. Umarul Farook State Entomologist (IDSP), DHS Office, Trivandrum


41 T.C.Balachandran Technical Asst.Gr.I, DMO(H), Kollam

9446075229

42 Dr.A.K.Radhakrishnan SHRC, Thycaud

9995220197

43 Sri.S.C Vijayakumar Technical Officer,HHD,Trivandrum

9946444230

44 Dr. Betty Jose DMO, Kozhikkode

9048010126

45 Dr.Preetha K.C DMO,Wyanad

94461043183

46 Dr.P.R.Karunakaran District Medical Officer, Palakkad


47 Dr.T.K. Kuttamani DPM,Palakkad


48 Sri. K.Vijayan TA, DMO(H),Wayanad

9447270668

49 M.Velayudhan TA, DMOH,Kannur

9895089130

ANIMAL HUSBANDARY

50 Dr.S.S.Rani Assistant Director, AHD


SDCMC

51 Dr.Anitha,SDCMC 9349260572 52 Dr.Muhammed Asheel 9895989327 53 Dr.Jagankumar,SDCMC 9895198976 54 Dr.Amrutha,SDCMC 9895696455 55 Sri.Venukumar,SDCMC 9995405517

26

56 Sri.R.Abhilash,SDCMC 9746200600 57 Sri.Unnikrishnan.R,SDCMC,TVM 9995353263

HLFPPT 58 Sri.Baby Prabhakaran, HLFPPT 9447750005 59 Smt.Sandhya,HLFPPT 9447750007 60 Sri.Feros, HLFPPT 9847448969 61 Sri.Febin, HLFPPT 9037414605 62 Ms. Arya, HLFPPT 9495910404 63 Sri.Kabeer,HLFPPT

27

ANNEXURE‐II

29

Annexure‐III

List of participants of interactive meeting at Veterinary Council, Kerala

1. Prof.(Dr) Ramakumar.V Retd. Secretary Vetinary Council of India

2. Dr. K.Udayavarman Additional Director Vetinary Council of Kerala

3. Dr. A.P.S.Nair President, IVA, Kerala Branch

4. Dr. Swapna Susan Abraham Vetinary Surgeon

5. Dr. V.I.Bhagyalakshmi Vetinary Surgeon

6. Dr. Giri.S.S Vetinary Surgeon

7. Dr. Aparna.S Vetinary Surgeon

8. Dr. Renjith.R Vetinary Surgeon

9. Dr. E.K.Easwaran Vetinary Surgeon

10. Dr. Rani.S.S AD, LMTC,Trivandrum

11. Dr. Anne Varghese.V.S VD, Pongamoodu

12. Dr. Jolly.C.G APO, RAIC,Trivandrum

13. Dr. S.Sreekala AD(P) RPF.K.Kanyaklumari

14. Dr. Rajee.P.V VS,ICDP,Trivandrum

15. Dr. R.Sana V.S ICDP,Trivandrum

16. Dr. N.Satheeshkumar D.D LMTC, Trivandrum

17. Dr. Sheela Saly.T.Geoarge SVS CH Chengannur

18. Dr. G.Vigajayankartha DD (AH), Kollam

19. Dr. C.Sreekumar V.S DAHO Office, Trivandrum

20. Dr. M.K.Prasad APO, RECC

21. Dr. Muhammed Sunil Vetinary Surgeon

22. Dr. Henny Joseph SVS,DVC,Kalpatta, Wayanad

30

23. Dr. R.Sreenivasan VPL, Pala

24. Dr. J.Hariharan Senior Vetinary Surgeon, Vetinary Hospital Chengalam

25. Dr. M.Abdul DDE

26. Dr. B.N.Baburaj AD, DAH

27. Dr. K.Viswanathan VS,VD, Anchutheghu

28. Dr. S.Jayachandran APO,

29. Dr. S.Giridhar Surgeon, Jersy Fam, Vithura

30. Dr. R.S.Bimal, Veterinary Surgeon, VD, Vilavoorkkal

31. Dr. Beena Ram.D.D DAH

32. Dr. J.Mohan Principal Trg Officer

33. Dr. S.Yohannan Dist. President, IVA, Trivandrum

34. Dr. R.R.Nair Advisor, ADCP

35. Dr. K.G.Suma Addl. DAH

36. Dr. Thomas Mathew, Nodal Officer, IDRV Kerala

37. Dr. Anuja Assist Professor of Community Medicine, Medical College, Trivandrum

38. Dr. V.A. Anilkumar Supt DLF

39. Dr. Muhammed Asheel, SDCMC

40. Dr. Ajith Chakravarthy.C.T Community Medicine, MCH, Trivandrum

41. Dr. Dilip Chandran.V.S IFEO Chettachal

42. Dr. F. X. Meslin WHO, Geneva, Switzerland

43. Dr. D. H. Ashwath Narayana RIA Foundation, Bangalore

31

Annexure IV

Project proposal on canine rabies control in Thiruvanathapuram District Kerala, India

EXECUTIVE SUMMARY

Though rabies is a deadly viral disease with no effective treatment, it is almost 100% preventable through timely Post Exposure Prophylaxis (PEP) and animal rabies control. This is a vaccine preventable disease both in animals and human. India still has the highest number of rabies deaths in the world, even though it is a fast developing nation with many firsts in science and technology. In Kerala the high literacy rate avert a good number of deaths through timely PEP. Suspected rabies exposures exert sizeable economic burden on local government as well as bite victims in endemic areas.

In the absence of National Rabies Control programme, it is a requisite to have efficient regional programmes to control rabies. Success models like National control programme in Thailand and Serengeti (two districts) programme of Tanzania etc are replicable models in India and Kerala. Vaccination of domesticated dogs was a routine function of Animal Husbandry Department and destroying stray dogs and licensing of domestic dogs, the mandate of Local Self Government Institutions (LSGI). Consequent to 73rd constitutional amendments in the country (1996), decentralised planning was implemented and rabies control activity was transferred ‘in toto’ to LSGIs. This additional responsibility and central regulation viz. Animal Birth Control (dogs) rule 2001 prepared under the Prevention of Cruelty to Animal Act 1960 that made killing healthy stray dogs without provable reason a cognizable offence, slowed down Rabies control in Kerala.

In an attempt to improve the PEP coverage in man, Department of Health in Kerala tested and adopted Intra Dermal Rabies Vaccination regime and now extends free treatment to all bite victims. But the number of PEP management still keep increasing a there is no programme to control the stray dog population. For achieving the possibility to control Rabies in Kerala by 2015, the focus of rabies control needs a shift to animal sector.

Under the circumstances, the Government of Kerala now plans to test a complete rabies control programme involving all stakeholders. An expert committee was formulated to frame an effective control programme. It is a reality that the implementation of Animal Birth Control/Anti Rabis Vaccination (ABC/AR) of stray dogs needs lot of skilled manpower, infra structures and time. Financial constraints limit the implementation of a total control programme in a fruitful manner.

32

A pilot project is now being proposed for the state capital district, Thiruvananthapuram costing Rupees 100 lakhs ($2,00,000/‐). Availability of at least one institution from Health sector viz. a Primary Health Centre manned by a physician and a Veterinary Hospital manned by a Government veterinarian in all LSGIs is a point that increases the probability of success in Thiruvananthapuram. Kerala’s achievement of good health indicators like low IMR, MMR, high life expectancy and literacy rate were often projected internationally as goody health care at low cost . If financial assistance could be sourced for the pilot programme, it could be made a model project under the decentralized planning with the coordination of all stakeholders.

I. INTRODUCTION 1.1 Rabies or Hydrophobia

Rabies or Hydrophobia is a viral zoonosis distinguished as the disease with the highest case fatality rate known to human race. World Health Organization (WHO) counts rabies as an important public health problem and estimated around 55,000 human deaths every year globally.1‐3 Total deaths averted by the Post Exposure Prophylaxis (PEP) account for 2,80,000/year 4. More than 80 percent of people in developing countries are living at the risk of exposures1,5. Suspected rabies exposures exert sizeable economic burden on local government as well as bite victims in endemic areas for treatment cost, animal control expenses, livestock losses, surveillance cost (diagnosis), patient cost like travel cost and wage loss 6.

1.2 Rabies in India

As per the WHO sponsored national multicentric rabies survey in India (2003), the frequency of death is one in every 30 minutes and dog bite is one in every 2 seconds. The disease is endemic all over the country except Lakshadweep, Andaman & Nicobar Islands. Projected animal bite incidence in India is 17.4 million/year and current administration of PEP is about 18 lakhs PEP/year.7 India has the highest mortality, 20,000 per year contributing 62 percent of Asian deaths though country spends around 1500 crores towards vaccine cost for human treatment. Though rabies is a 100 percent fatal disease and highly endemic in India, it is not a notifiable disease and hence exists the problem of poor disease surveillance at all levels.8

1.3 Rabies control

Many Asian countries like Japan, Taiwan, Malaysia, Singapore could achieve rabies free/controlled status through comprehensive rabies control programme.9 With National rabies control programme, developing countries like Thailand and Sri Lanka could reduce the human deaths remarkably.10, 11Canine vaccination programme has made good results in Thailand.9,12 .In Tanzania, vaccinating domestic dogs has proved to be a very effective way of fighting rabies13. Because almost all human deaths in India happen from dog bites, effective canine rabies control programme can reduce human deaths and reduce over all cost of rabies prevention.

33

Integration of sectors like Health, Veterinary and Civic authorities was demonstrated in Central and South America, where medical authorities took lead role for animal control programme14.

II. CURRENT STATUS OF RABIES CONTROL PROGRAMME IN THE STATE The state had adopted the decentralised planning as early as in 1996. Rabies control was

a transferred function under the decentralised planning and stray dog control as the mandatory duty of LSGIs. Prophylactic vaccination programmes for dogs were implemented through Animal Husbandry Department (AHD) and Local Self Government Institutions (LSGI) during this period but the vaccination coverage was just around 20% (against the recommended 70‐80% for herd immunity). An expected 5% could go unreported as private veterinarians handle most of the pet practice.

Fig No.1 Prophylactic Anti Rabies Vaccination in dogs (in percentage) (Source‐ Annual Administration Reports, Animal Husbandry Department, Kerala)

There were no efforts to control stray dogs after the introduction of ABC (dogs) rules but in the absence of an effective animal control programme, animal bites increase annually with physical and psychological trauma to the bite victims.

III. RATIONALE FOR A NEW RABIES CONTROL PROJECT

Once symptoms (rabies encephalitis) develop, death is almost inevitable with no proven treatment. Social cost of dog bites and disease is very high with mental, physical and financial trauma to the bite victims. Despite Kerala being the most literate state in the country about 30‐40 deaths are reported annually. Currently there is no reporting system for recording the incidences of dog bite or PEP in Department of Health Services, making precise estimate. Annual expense on biologicals for treatment alone is around Rs. 25‐30 crores ($1‐2 Million). Of this one third (around 8‐10 crores) is spent by the Department of Health Services alone for providing the first dose free to all bite victims and rest of the doses as free only to Below

0

5

10

15

20

25

1996

-97

1997

-98

1998

-99

1999-

00

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-01

2001

-02

2002

-03

2003

-04

2004-

05

2005

-06

2006

-07

34

Poverty Line (BPL) patients that too subject to the availability of vaccine at government hospitals. Rabies control is always given only a low priority both in human and animal sectors. The two criteria considered in the health sector for disease control are morbidity and mortality and not the economic impact for treatment cost or other indirect losses. The influence of social status of the affected is another important criteria but here 70% of bite victims are rural poor and 30‐40% of the total are children below the age of 15 years. Unable to afford the transportation cost and wage loss for 3 days in the first week for minimum two persons, many are forced between a choice between debt and fate. Total man days lost would be more than 10 days in the month of bite incidence including rest.

Total disease control is possible only through animal control. There is a steep increase in the number of bites treated in animals, which is again an indication for increased risk to human.

Fig. No.2 Rabies in animals‐Post exposure treatments and deaths (Source‐ Annual Administration Reports, AHD, Kerala)

Dogs are the major animal vectors in the transmission of the disease in India and hence

effective canine rabies control programme can reduce human deaths and reduce over all cost of rabies prevention. As per the last livestock census, there are around 11 lakhs dogs and 7.35 lakhs cats in the state. Since the vaccination coverage of domesticated dogs in the state was below 15% under the decentralised planning, AHD also purchased rabies vaccine to improve vaccination coverage from 2006‐07 onwards but then LSGIs had almost withdrawn their vaccine purchase, as this is not a compulsory programme. At present vaccination status of dogs does not prevent PEP requirement in human, as immune status of dogs is not expected to a

0

2000

4000

6000

8000

10000

12000

Nu

mb

er

Year

Rabies in animals

Treated

Death

35

satisfactory level. Normally PEP in human is 20‐100 times costlier than vaccinating a dog in usual cases.

In the absence of a national rabies control programme, it is a requisite to have an

efficient regional programme to control this most dreaded disease. Though cost effective control measures exist, their application needs considerable efforts from all stakeholders, like Animal Husbandry, Health, Local Self Government Institution etc, which is possible better under decentralised planning. With strong policy decision and multi stakeholder participation, an effective rabies control programme is possible in Kerala under decentralised planning through the wide network of transferred institutions and proper budgetary support. IV. OBJECTIVES

1. Improve awareness about the dreaded disease and its control measures in animals and man.

2. Develop responsible dog ownership. 3. Break the transmission cycle of virus through 70‐80% vaccination of dogs and enforce

strict licensing. 4. Control stray dog rabies through ABC/AR programme. 5. Reduce public health expenditure for PEP gradually. 6. Reduce financial, physical and psychological trauma to the bite victims. 7. Licensing of slaughter houses and proper solid waste disposal. 8. Achieve rabies control by the year 2015 positively.+

V. COMPONENTS OF AN EFFICIENT RABIES CONTROL PROJECT

Essential components of a comprehensive project are

1) Awareness and publicity Though this is the most dreaded disease known to mankind, control of the disease lacks

priority among policy makers, bureaucrats etc. Though timely PEP is almost 100% effective, about 30‐40 people still die in this most literate state and that could be due to disparities in the awareness, availability, accessibility and affordability of PEP. Over 70% of the bite victims are from rural areas and their accessibility to both information and treatment should be enhanced. Children under 15 years constitute 30‐40% of the bite victims and there is possibility of under reporting or not reporting bite incidences and go unattended. Hence awareness among school children is highly essential. More than that they can be effectively utilised as an agent to percolate the message of rabies control to the society. This can be tried by incorporating in their school curriculum or awareness through the school health programme.

36

A survey conducted among the veterinarians of AHD to understand the reasons for not taking effective programme in their LSGI, revealed lack of adequate community participation, lack of proper funding and lack of political will as the major reasons. This shows lack of awareness among political leadership and policy makers about the importance of this menace. Lack of awareness about responsible pet ownership, vaccination, licensing and leashing of dogs, control of stray dogs, first aid and PEP in human etc should also to be addressed. Widespread awareness programmes and publicity about the dreadfulness of the disease and control measures should be given, as did in Pulse Polio Immunisation programme.

2) Disease Surveillance

Surveillance is a critical tool for monitoring the disease. WHO recommends surveillance of animal exposures, and rabies cases in man and animals and to exchange the information between both departments. Reporting system needs to be established in both the sectors with exchange of information. Laboratory based surveillance in animals should be enhanced. Testing of suspected samples from animals has to be encouraged to establish the prevalence of disease, for which more laboratories need to be established and testing fee to be subsidized.

3) Vaccination and licensing of domesticated dogs

Vaccination is proved to be the single most effective method to break the transmission cycle of rabies in dogs with 70‐80% vaccination coverage with in 3‐4 weeks time. Rabies control is a public good with little direct benefit to an individual dog owner unless herd immunity could be achieved through vaccination of at least 70% of dogs15. Because almost all human deaths occur in India from dog bites, effective canine rabies control programme can reduce human deaths and reduce over all cost of rabies prevention. Though we have canine vaccination programme, total coverage is well below 25%, which neither prevents rabies in dogs nor the requirement of post exposure treatment in man. Strategies to ensure at least 70‐80% coverage is to be adopted. Licensing of dogs is an existing legal statute but never been tried to enforce compulsorily. Importance of responsible dog ownership can be percolated only through awareness and compulsory licensing. Identification of vaccinated dog and leashing them in confinement also are important to prevent contact with infected animals. Sterilization of those dogs should be encouraged, which are not reared for breeding purpose through friendly persuasion.

4) Stray dog control

37

Though we were adopting killing of stray dogs for the last 50 years, only transient only transient or no reduction of their menace is on record. The rate of destruction was proved ineffective with the increased survival rates of dogs3. In India, following the inception of the Animal Birth Control (Dog) rules 2001 under the Prevention of Cruelty to Animals Act 1960, stray dogs are to be neutered, vaccinated and rehomed at the same place. Difficulty in getting dog catchers, absence of infrastructures to perform Animal Birth Control (ABC) surgery, lack of skilled technicians, contradictory court orders, and interference from some Animal Welfare Organisations (AWO) had changed the priority of LSGIs and gradually withdrawn from this mandatory function. But Hon. Courts of India have directed all states to follow ABC (dogs) rules 2001. More over the cruel untrained killing methods had invited lots of protests, which had tarnished the image of the state to an extent.

Abundance of edible food waste particularly in urban areas together with absence of control of dog population had resulted in a definite increase in their population. Incidence of bites in animals and human is on an increase. Hence ABC/AR is the only available option to control stray dog population along with food and habitat control. But it requires lot of skilled human resource and financial commitment. 5) Slaughter house licensing and solid waste disposal

Rather than thinking of killing stray dogs, it is important to remove the conducive atmosphere for the propagation of stray dogs and their ganging. Prompt collection and disposal of solid waste could be crucial in controlling their food source and habitat access. Status of slaughterhouses and waste disposal facility is another contributing factor to the stray dog population. Licensing of slaughterhouses must be strictly enforced.

VI. PILOTING THE PROGRMME

Current development

All stakeholders of rabies control‐Animal Husbandry, Health, Local Self Governments, etc had participated observed the World Rabies Day jointly on September 2009 at Thiruvananthapuram and had a consensus to have a co‐ordinated efforts to control to achieve rabies control in Kerala by 2015.Consequently an expert committee was constituted by the Government to prepare a rabies control programme with guidelines for piloting (Annexure2). It would be ideal to pilot the programme in selected LSGIs or in a district to study the feasibility of the strategies envisaged in this project before going for a state wide programme. Why Thiruvananthapuram?

Considering the importance of capital city of the most literate state, it would be ideal to pilot the programme in Thiruvananthapuram district. Being the political and administrative nerve centre of state, it is easier to monitor the programme closely and appraise the higher

38

officials frequently. Availability of veterinary institutions and personnel to work with the project also are more when compared to other districts. This is expected to add the probability of success. Factual Notes about Thiruvananthapuram district

Consequent to the 73rd amendment of the Constitution and the new Panchayat Raj‐Nagarapalika Act, the Kerala Panchayat Raj Act came into being on 23rd April, 1995 .The elected representatives took over charge on the Gandhi Jayanthi day of 1995 and decentralised planning instituted by 2006, first time in India. In this three tier administrative set up, there is one district panchayat, 12 block panchayats and 78 Grama panchayats in the district. One Corporation and 4 Municipalities also exist in the district.

Map of Thiruvananthapuram

39

Geographic borders of project area.

East Thirunalveli district of Tamil Nadu state South Kanyakumari district of Tamil Nadu West The Arabian Sea North Kollam district, Kerala

Human population Area 2,192sqkm Population 32,34,356 Density 1476/sqkm No. of households 759,382 (2001 census)

Dog population (2007 census)

Domesticated dogs 1,42,696 Stray dogs 23,213 Total 1,65,909 Cats 1,10,388

Man‐dog ratio 19

Veterinary Hospitals and sub centres

40

Veterinary Hospitals manned by Veterinary Surgeons 97 Sub centres manned by Para veterinary staff 145 Veterinary Doctors 104 Para veterinary staff 245

PROGRAMME ENVISAGED FOR PILOTING

Action plan proposed earlier will be tested in the district with suitable modifications wherever required. Since 95% of animal bites and almost all rabies deaths in the state is from dog bites, it is ideal to start with a canine rabies control programme at the first phase. Vaccination of domesticated dogs, sterilization of dogs/cats, which are not reared for breeding purpose, also will be encouraged. ABC/AR will be taken in a separate phase

1. Awareness and publicity 2. Disease surveillance system 3. Vaccination of domesticated dogs 4. ABC/AR for stray dog management

VII. ACTION PLAN FOR THE COMPREHENSIVE RABIES CONTROL PROGRAMME

1. Declaration of a rabies control policy for the state

a) Frame policy guidelines with clear roles and responsibilities of all stakeholders and declaration of policy through executive orders (LSGD/AHD/Health).

b) Formation of a State Level Co‐ordination Committee for rabies control. This committee shall do the overall monitoring of the programme. Chief Secretary as the chairman, Principal Secretary of LSGD as the Member Secretary. Govt Secretaries of Health, Animal Husbandry, Finance, Planning and directors of Health, AHD, Urban Affairs, Panchayat, Public Relations, Suchithwa Mission, Executive Director of Kudumbasree, Education etc should be members.(LSGD).

c) Decision to implement a suitable programme through piloting and to be followed later by a robust programme for at least 3‐5 years.

d) Formation of co‐ordination committees at local level from Health, AHD, LSGI, AWO etc (LSGIs).

e) Decisions to enforce the provisions of Kerala Panchayat Raj Act, Municipality Act etc for the strict enforcement of licensing of dogs, stray dog control, slaughter houses, solid waste disposal etc. which is mandatory for the accomplishment of rabies control in the state (LSGD/LSGIs)

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2. Awareness and publicity

a) Training of trainers (ToT) about the disease control, programme, ABC surgery etc (LGSD/KSVC/KILA).

b) Awareness to policy makers, bureaucrats, public, all school children, Residents Associations, AWOs, Anganwadi/ASHA workers/Kudumbasree workers (KILA/AHD/Health).

c) Incorporating into school curriculum/school health programme (Health/NRHM/Education).

d) Making of an exhaustive and informative video film depicting the importance of responsible dog ownership, first aid, treatment, dog vaccination & licensing, stray dog control and its telecasting through electronic media.(Health/NRHM/AHD/Public Relations).

e) Printing and distribution of publicity materials (AHD/Health/LSGIs). f) Conduct of awareness week at LSGI level –rabies rally and cultural programme‐

incorporating schools, political leaders, bureaucrats, residents associations, Anganwadi, Kudumbasree members etc(LSGIs/all stakeholders)

3. Disease Surveillance a) Collection of baseline information on bite incidences and rabies deaths in animal and man (AHD/Health). b) Reporting system on bite incidences & deaths in animals & man –with software support

(AHD/Health). c) Regular risk communication between stakeholders (AHD/Health). d) Establishment of rabies diagnostic laboratory and testing at free of cost/ subsidized

cost–one per district (District Panchayat/AHD). 4. Vaccination of domesticated dogs and licensing

a) Selection & training of village volunteers (Kudumbasree/Anganwadi/ASHA workers).

Their work and incentives to be fixed. Duties like awareness to public, publicity, dog

survey, supply of dewormer, motivation of people to bring dogs for vaccination,

licensing and leashing. They my have to do 3‐4 visits. (LSGI/AHD/Health/LSG).

b) Pre exposure vaccination of all staff/volunteers‐handling dogs (LSGI/Health).

c) Procurement of vaccine‐Vaccine to be procured to vaccinate all domesticated dogs and

stray dogs planned to be sterilized for a year. A rate contract fixed with a reputed firm

so that all LSGIs can procure required vaccine at rate fixed (AHD).

d) Procurement of vaccination equipments and cold chain equipments. AHD may purchase

42

and supply / procure locally (LSGI/AHD)

e) Conduct of vaccination camps after wide publicity. Organize camps in convenient spots

to cover maximum number of dogs with in 2‐3 weeks in an LSGI. Drop outs may be

located and motivated to bring to hospital for vaccination and if not, do at their door

step –complete the vaccination with in one month (minimum of 80% should be

covered). All vaccinated dogs should be licensed along with the vaccination process. The

Panchayat official and ward member should attend camp.

(AHD/LSGI/Volunteers/AWOs/Residents Associations)

f) Identification of vaccinated dogs through collar and badge. Amount to be collected or

subsidized towards vaccine cost, licensing and identification materials have to be fixed

by the LSGI.(LSGI(AHD).

g) Post bite management /euthanasia of infected animals (AHD/LSGI).

h) Promote sterilization of all domesticated dogs kept not for breeding purpose

(AHD/LSGI/Residents Associations).

i) Sero surveillance‐ random testing of sera samples to confirm immune status of

vaccinated dogs (AHD).

5. Stray dog management

a) Stray dog survey by trained volunteers (AHD/Kudumbasree/ASHA).

b) Selection and training of dogcatchers. Under Block Panchayat (3nos)/Corporations

(2Nos). Awareness about the disease, first aid and treatment should be given. They

must be immunized periodically. Uniform, Insurance coverage etc also may be given to

these persons considering their occupational risks. All Grama panchayat in the

jurisdiction of Block Panchayat can source the service on payment.(BP/LSGI).

c) Dog catching van with driver‐This service also may be arranged at Block

Panchayat/Corporation (BP/LSGI).

d) Setting up of ABC centres with surgery facilities‐at one Veterinary hospital having space

and other facilities in a Block Panchayat. Grama panchayat shall inform this squad well

in advance and to arrange the dog catching and to associate with pre and post‐operative

43

care and rehoming. Incentives to veterinary /para veterinary staff may be considered to

motivate them to do this difficult task in a faster mode.

e) Incurably ill and infected dogs may be euthanized and disposed. LSGI must find suitable

place for disposal of carcass and all waste. Volunteers for doing the postoperative care

of dogs should be arranged by the LSGI. Identification of the sterilized dogs can be done

by ear notching/colored fibre collar (AHD/LSGI/BP/AWO).

f) Adoption of sterilized dogs after postoperative care must be encouraged by the AWOs

by starting shelter homes and left over may be rehomed in the same place.

6. Control of conducive environment for stray dogs

a) Strict licensing of slaughter houses with scientific waste disposal (LSGI/PCB).

b) Construction of new /scientific modernization of existing one (LSGI).

c) Proper collection and disposal of solid waste (LSGI/PCB/Residents Associations).

7. Evaluation of the programme

a) Internal Assessment‐by assessing the targets fixed for the specific period and also from

incidences of animal bites treated and rabies cases in man and animals at different

levels‐LSGI,district and state (LSGI/AHD/Health/AWO).

b) External assessment by a competent agency (LSGD).

VIII. FINANCIAL BREAK UP FOR THE PILOT PROGRAMME

Sl no Activities Expenditure (Rs)

Total Expenditure (Rs in lakhs)

1 Awareness & Publicity

1.1 Training of staff 15,00,000

1.2 Preparation of video films and telecasting through audio‐visual media

50,00,000

1.3 Printing of leaflets/brochures/posters 10,00,000 75.00

2 Vaccination of domestic dogs

2.1 Dog survey and distribution of leaflets, notice, dewormer, drop out identification etc by trained volunteers (4 visits‐first visit to all houses and subsequent visits to houses having dogs)

50,00,000

2.2 Procurement of vaccine, syringes, needle, cool pails, collar, metal token, health card, dog catching device etc

235,00,000

2.3 Vaccination day‐camp organization, mike announcement, hiring of 20,00,000

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vehicles etc

2.4 Setting sero monitoring facility and random testing 25,00,000 330.00

3 Stray dog management

3.1 Van with kennels (one per block) 12 nos 25,00,000

3.2 Ambulance to release the dogs back‐6 nos 20,00,000

3.3 Dog catching devices 4,00,000

3.4 Building with 25 kennels each(12) 145,00,000

3.5 Operation theatres with medicines, instruments, equipments (12) 300,00,000

3.6 Honorarium to veterinarians, para vets, attendants for ABC surgery(12,000/yr)

25,00,000

3.7 Vaccination & identification (12,000 dogs/yr) 6,00,000

3.8 Post operative care –food, wages(12000/yr) 15,00,000 540.00

4 Disease surveillance

4.1 Rabies diagnostic laboratory 20,00,000

4.2 Reporting system with software and hardware support, telecommunication etc

10,00,000 30.00

5 Evaluation of the programme

5.1 Internal and external evaluation and documentation of the programme

25,00,000 25.00

Grand Total (Rupees One thousand lakhs only) 1000.00

IX. CONCLUSION

Rabies being the most fearful disease known to man kind without any effective treatment, its control needs priority irrespective of the number of deaths. Considering the social cost of rabies and the huge public health expenditure spent annually for PEP, rabies control must be enforced both in animal and human. Health sector has adopted Intra Dermal Rabies Vaccination, the most economical PEP regime to extend free treatment to all bite victims. But without animal control, there is no way to achieve rabies control in the state. Stray dog menace; vaccination and licensing of domestic dogs etc have to be addressed through strict enforcement of legal statutes and efficient control programmes. Rabies control in Kerala is an achievable target if we could invest for all the essential components and work with co‐ordinated efforts by all stakeholders, which is more ideally possible under the decentralised planning through transferred institutions.

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RABIES IN ANIMALS‐NUMBER TREATED, DEATH AND PROTECTED

District 2004‐05 2005‐06 2006‐07

Sl.No

Treated

Death

PAR

Treated

Death

PAR

Treated

Death

PAR

1 Thiruvananthapuram 1261 21 12891 1991 27 8829 2856 91 18385

2 Kollam 854 13 12719 1125 29 13528 1456 25 27489

3 Pathanamthitta 230 15 7379 223 9 5248 296 94 15820

4 Alappuzha 11 62 13844 228 113 11882 446 59 22761

5 Kottayam 91 6 7505 442 28 8032 186 7 18447

6 Idukki 32 0 650 14 0 806 10 0 6150

7 Ernakulam 161 16 18335 143 14 18256 699 21 30820

8 Thrissur 665 72 16340 469 53 15049 565 35 21597

9 Palakkad 1600 82 3147 871 58 2702 1238 67 6442

10 Malappuram 320 71 1902 422 75 1514 651 61 4279

11 Kozhikkode 242 28 5849 545 13 3184 640 45 6765

12 Wayanadu 198 6 4302 93 10 4934 190 4 6404

13 Kannur 187 25 3327 103 1 3271 558 181 5055

14 Kasargod 498 44 4727 493 43 3678 520 27 6248

Total 6350 461 112917 7162 473 100913 10311 717 196662

(Source‐Annual Administration Reports, AHD, Kerala) NB‐PAR‐Prophylactic Anti Rabies Vaccination.

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ABBREVIATIONS USED

ABC/AR ‐‐ Animal Birth Control/Anti Rabies vaccination AHD ‐‐ Animal Husbandry Department ASHA ‐‐ Accredited Social Health Activists AWO ‐‐ Animal Welfare Organization BP ‐‐ Block Panchayat BPL ‐‐ Below Poverty Line DP ‐‐ District Panchayat IDRV ‐‐ Intra Dermal Rabies Vaccination IEC ‐‐ Information Extension and Communication IMR ‐‐ Infant Mortality Rate KILA ‐‐ Kerala Institute of Local Administration KMSCL ‐‐ Kerala Medical Services Corporations Limited KSVC ‐‐ Kerala State Veterinary Council LSGD ‐‐ Local Self Government Department LSGI ‐‐ Local Self Government Institutions NGO ‐‐ Non ‐Governmental Organization NRHM ‐‐ National Rural Health Mission MMR ‐‐ Maternal Mortality Rate PCB ‐‐ Pollution Control Board PEP ‐‐ Post Exposure Prophylaxis SHG ‐‐ Self Help Group WHO ‐‐ World Health Organization

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