‘‘SITUATION ANALYSIS OF RABIES IN NEPAL & RABIES RELATED PROGRAMME STRATEGIES IN NEPAL’’

A Term paper submitted to fulfill the partial requirement of BPH Third semester

[TPP 5.1 APPLIED EPIDEMIOLOGY-I]

SUBMITTED TO:

DEPARTMENT OF PUBLIC HEALTH,

LA GRANDEE INTERNATIONAL COLLEGE,

SIMALCHAUR-8, POKHARA

2012

SUBMITTED BY:

PURNIMA TIMILSINA

RAJESH KUMAR YADAV

KALPANA GURUNG

SAGUN PAUDEL

1. Acknowledgement

The students of Bachelor of Public Health 3rd semester of 2nd year like to express our humbly thanks to all those who have supported and helped us in accomplishing this term paper in the topic ‘‘SITUATION ANALYSIS OF RABIES IN NEPAL & RABIES RELATED PROGRAMME STRATEGIES IN NEPAL’’.

We would like to convey our heartfelt thanks to all those who were directly or indirectly concerned with this and to all our well wishers.

First of all we would like to thank our respected subject teacher Dr. PrasoonRana for giving us

opportunity to prepare this term paper. We are fully indebted to our coordinator Mr. DilipYadav

for expert guidance, regular supervision, untiring encouragement, inspiration and valuable

suggestion and full support during preparation of term paper.

This term paper is written in simple language, with every bit of necessary information related to

the topic so that studying independently also would not find any difficulties. We think that this

effort will help every individual to understand about the information of the related topic.

TABLE OF CONTENT

1. Acknowledgement ............................................................................................................................... 2

TABLE OF CONTENT ................................................................................................................................. 3

2. Introduction: ....................................................................................................................................... 4

Sign & symptoms; ................................................................................................................................ 4

3. Objectives:........................................................................................................................................... 5

specific objective: ................................................................................................................................ 5

General objectives: .............................................................................................................................. 5

4. Methodology ....................................................................................................................................... 6

5. Finding & Discussion: ........................................................................................................................... 7

South-East Asia Region ........................................................................................................................ 7

Burden of disease in Nepal: ................................................................................................................. 7

6.Epidemiological situation in Nepal ........................................................................................................ 8

7. Rabies control in the South East Asia Region ........................................................................................ 9

Strategies ............................................................................................................................................ 9

8. Rabies control activities and achievements in Nepal: ......................................................................... 10

9. Recommandations ............................................................................................................................ 10

10. Reference ........................................................................................................................................ 11

2. Introduction:

Rabies is a viral disease that causes acute encephalitis in endotherms. It is zoonotic , most commonly by a bite from an infected subject. For a human, rabies is almost invariably fatal if post exposure prophylaxis is not administered prior to the onset of severe symptoms. The rabies virus infects the central nervous system, ultimately causing disease in the brain and death.

The rabies virus travels to the brain by following the peripheral nerves. The incubation period of the disease is usually a few months in humans, depending on the distance the virus must travel to reach the central nervous system. Once the rabies virus reaches the central nervous system and symptoms begin to show, the infection is effectively untreatable and usually fatal within days.

Sign & symptoms;

The period between infection and the first flu-like symptoms is normally two to twelve weeks, but can be as long as two years. Soon after, the symptoms expand to slight or partial paralysis, cerebral dysfunction, anxiety, insomnia, confusion, agitation, abnormal behavior, paranoia, terror, hallucinations, progressing to delirium. The production of large quantities of saliva and tears coupled with an inability to speak or swallow are typical during the later stages of the disease; this can result in hydrophobia, in which the patient has difficulty swallowing because the throat and jaw become slowly paralyzed, shows panic when presented with liquids to drink, and cannot quench its thirst. Death almost invariably results two to ten days after first symptoms.

3. Objectives:

specific objective: To analyze the situation of rabies in Nepal and strategies applied for rabies related

programme.

General objectives: To study the Burden of disease and epidemiological situation. To study about the rabies prevention strategies in Nepal

To study the WHO strategies for rabies control for SEAR.

To study about Rabies control activities and achievements. Etc.

4. Methodology

Secondary data

5. Finding & Discussion:

South-East Asia Region Rabies, an invariably fatal viral disease, is transmitted to humans through animal bites, most commonly dogs. The disease is preventable through timely pre-and post-exposure vaccination. However, once the disease occurs, death is inevitable.

Countries Number of estimated/reported cases

Rate (Human cases per 100 000)

Bangladesh 180 (reported in 2008) Estimation: Approx. 2000

0.14

Bhutan Sporadic (Two cases in 2008)

0.28

DPR Korea Sporadic N/A India Approx. 20 000 3 Indonesia Approx. 100 0.045 Myanmar Approx. 1000 0.35 Nepal 32# (2007) 0.21 Sri Lanka 51^ (2008) 0.26 Thailand 8* (2008) 0.012 N/A: Not available #Personal communication, Epidemiology and Disease Control Division, Ministry of Health and Population, Kathmandu, Nepal ^Weekly Epidemiological Report, http://www.epid.gov.lk/wer.htm *http://thaigcd.ddc.moph.go.th

Burden of disease in Nepal: Rabies has been endemic in Nepal since ancient times. Most human cases of rabies in the Country are reported from urban areas where stray dogs outnumber pet dogs and dog rabies vaccination coverage is low. Canine rabies is the major epidemiological pattern and the dog is the primary source of rabies. Most human and animal rabies cases are reported on the basis of clinical observation and dog-bite history. In Nepal, 94% of the human cases occur after contact with rabid dogs. It is estimated that 200 people on average die annually due to rabies. National statistics show that about 30 000 people receive post-exposure prophylaxis (PEP), and the number of people seeking PEP is increasing every year. Most animal rabies cases are reported from rural and semi-urban areas and villages

adjoining wildlife parks and reserves. It is estimated that more than 1000 animals succumb to rabies each year. Cattle and buffaloes represented 84% of the total of 430 animal rabies cases reported to the Veterinary Epidemiology Centre during the period of 2006-2010 and it clearly shows the economic impact of rabies in livestock production in Nepal.

6.Epidemiological situation in Nepal

Rabies in Nepal is thought to circulate in two epidemiological cycles: an urban cycle involving maintenance of infection in dog populations and a sylvatic cycle involving mongooses, jackals, and wolves. There is a possibility of spill-over of rabies virus from dogs to wildlife and vice-versa. Rabies is unevenly distributed in Nepal. As can be seen from Fig. 1, Terai district is densely populated and there are wildlife parks and dense forest areas. Outbreaks of rabies are frequently reported in and around wildlife parks and domestic animals are mainly affected. Mountain districts rarely report rabies cases as human and animal population distribution is scattered and maintaining rabies transmission cycle is difficult due to geographical barrier and food scarcity.

Map showing high, moderate and low rabies risk districts, Nepal

7. Rabies control in the South East Asia Region

Rabies is a 100% fatal but at the same time, 100% preventable disease. It is a disease of poverty, affecting the very vulnerable populations and children. The necessary tools and methods for control and prevention of human and canine rabies are available and the proof of the feasibility of rabies elimination has been demonstrated in countries like Japan, Singapore and Malaysia. Rabies elimination programme focused mainly on mass vaccination of dogs are largely justified by the future savings of human rabies prevention programme.

A concerted effort between the human and animal health sectors and support from other stakeholders is needed to achieve the goals of rabies elimination. WHO will continue to provide technical inputs and support such effort.

Strategies WHO recommends the following five major activities to be initiated/strengthened in the Member Countries of the SEA Region :

1) Develop a comprehensive national rabies control programme: Consensus on national strategy and policy and multisectoral and coordinated approach for rabies control at different levels.

2) Promote prompt and proper care of dog bite wounds: Immediate and thorough cleansing and flushing of dog-bite wounds with simple soap water is the most effective first-aid treatment against rabies. There is a need to educate the public on this important first step in the prevention of rabies.

3) Increase access to tissue cell-culture vaccines (TCVs): TCVs are safe and effective, with very low failure rates. Multi-site intra-dermal administration of TCVs greatly reduces the cost of post-exposure treatment, without sacrificing safety and efficacy. WHO strongly recommends discontinuation of the old nerve-tissue vaccines (NTVs), which are still produced and used in two countries of the Region, viz. Bangladesh, and Myanmar. NTVs have a high rate of adverse reactions and failures, and lower efficacy.

4) Prevent dog rabies through dog vaccination and dog population management: This includes: organization of sustainable mass dog vaccinationprogrammes using highly potent

tissue-culture rabies vaccine; promotion of responsible dog ownership at the community level; promotion of oral rabies vaccine for stray dogs to improve vaccination coverage; dog population management through animal birth control (ABC) programme, and Control of trade and movement of dogs.

It has been seen that where >80% community dogs are properly vaccinated against rabies, the occurrence of human rabies cases ceases promptly.

5) Public health education and advocacy: This is an important component of any public health programme and Member States are encouraged to implement public education and awareness campaigns on rabies prevention and control.

8. Rabies control activities and achievements in Nepal:

Nepal has phased out production and use of Semple type vaccine for humans in 2006. Tissue culture vaccine for human use is purchased and supplied by the Ministry of Health and Population to government hospitals on regular basis. Tissue-culture dog rabies vaccine has been produced since 2005 and dog rabies vaccine is also imported by private sector. There is an ongoing study on possibility of local production of human rabies vaccine based on experience of animal tissue-culture rabies vaccine by Rabies vaccine Production Unit under Directorate of Animal Health. Dog rabies vaccination is not mandatory and pet dogs are vaccinated against rabies in urban areas. About 55 000 dogs are immunized against rabies. Dog vaccination campaigns are organized as a part of the World Rabies Day events by the government as well as non-governmental organizations. Many NGOs have been involved in animal birth control and dog rabies vaccination activities in major cities of Nepal in the last 10 years. In 2007 a workshop on "Consensus Building among National Alliance Partners to Eliminate Canine Rabies in Nepal and Development of Strategic Plan" was organized and supported by the World Health Organization (WHO). The Alliance Group for Rabies Control in Nepal has been formed, comprising the Department of Livestock Services, the Veterinary Public Health Division, Kathmandu Metropolitan City (KMC), Department of Public Health and Social Welfare, Kathmandu Animal Treatment (KAT) Centre and National Zoonoses and Food Hygiene Research Centre (NZFHRC). A National Workshop was organized in December 2010 to formulate a Rabies Control Strategy, which was attended by all partners involved in rabies control in Nepal. The Rabies Control Strategy will serve as a roadmap for control and subsequent elimination of human rabies.

9. Recommandations

The following all the actions that are needed: Establish national rabies control programmes, including appointment of National

Programme Officers, and develop five-year strategic plans of action. Improve rabies surveillance and data collection. Initiate measures to phase out nerve tissue vaccines and replace them with modern tissue

culture vaccines. Promote rational use of TCVs for PEP and encourage the introduction of cost-effective

intradermal (I/D) human rabies vaccination schedule in major rabies vaccination centres.

Strengthen inter-ministerial and intersectoral collaboration for rabies control in canine population through mass vaccination, dog population management and active community participation. Many NGOs and animal welfare groups are interested and involved in rabies control.

Develop appropriate measures to regulate movement of dogs from one place to another (rural to urban or island to island).

Community participation

10. Reference

www.searo.who.int

Rabies Country Profile: Nepal

www.nep.searo.who.int

k park.

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