Evaluation and Enhancement of an Existing Rabies Control Program (original) (raw)

1. Background: Nepal is geo-ecologically divided into mountainous, hilly and terai (plain) region. It is administratively divided into 5 development regions, 14 zones, and 75 districts which constitute 58 municipalities, 3915 Village Development Committees (VDC), and nearly 36,000 wards. 22.73 M people reside in the country and 85% of them live in peri-urban and rural areas, however 15% live in urban areas (CBS, 2004). Livestock population is estimated to be 7.0 M cattle (milking cows: 0.87 M), 3.8 M buffalo (Milking: 0.99 M), 6.8 M goats, 0.83 M sheep, 0.93 M pigs, 28.9 M poultry (22.3 M broilers and 6.6 Layers) and 0.62 M Duck (Ministry of Agriculture and Cooperatives , Agri-Business Promotion and Statistics Division, 2002/2003). Rabies is a major animal disease of public health importance in Nepal. Outbreaks of rabies in animals and thereby exposure in human is reported from the several parts of the country. Due to lack of effective rabies control program, livestock and human are at constant risk of rabies. Canine rabies is the major epidemiological pattern as more than 95% of the human rabies (EDCD, 2003) and livestock rabies (CEU, 2003) cases are due to rabid dog bites. There is no effective birth control program in canine targeted especially to stray and community dogs. The dog population is estimated to be approximately 2 million in the country at the human: dog ratio of 12:1 in urban areas and 10:1 in rural or peri-urban areas (dog population survey, 2001). Rabies is maintained in two inter related cycles urban and sylvatic. Canine rabies is the most important epidemiological pattern of the disease. Densely populated terai belt, mid hills and the areas adjoining to the forest are as high-risk for rabies. Similarly veterinarians, animal health technicians, persons working at rabies laboratory and wild reserves etc. are at high risk. Stray and community dogs are mainly responsible for disease transmission to humans. However, 75% of the total dog population could be reached for vaccination in urban and peri-urban areas. At the present, the rabies surveillance in animal is done in an integrated manner by central epidemiology unit under animal health directorate. The method of information collection is passive and through the district livestock services offices on a monthly basis. There is no active form of rabies surveillance and the tracing back of the source. There is no laboratory based rabies surveillance in animals. Laboratory facilities for the diagnosis of rabies in human and animals are not available below central level. So far, the rabies virus sequencing from the brain sample taken in Kathmandu revealed Arctic fox genome virus (Jai JN & H. Bhouri, 1999). Rabies vaccine production laboratory (RVPL) under Department of Livestock Services (DLS) produces nervous tissue origin antirabies vaccine (NTO-ARV) for the pre-exposure prophylaxis of canine and felines. It also produces NTO-ARV for the post exposure treatment (PET) of animal and human. However, this laboratory is currently involved in the research and development of cell culture origin antirabies vaccine (CCO-ARV) for animal and human use. Currently, indigenous CCO-ARV for animal use is under trial. Rabies surveillance in human is done by Epidemiology and Disease Control Division (EDCD) under Department of Health Services (DHS). However, the collection of the information on the exposure and sources is passive and through district level hospitals on a monthly basis and immediate in case of an outbreak. This division is mainly responsible for the supply of NTO-ARV produced by RVPL to the affected areas. It is also actively involved in increasing public health education. Approximately 30,000 post exposure treatment cases of rabies in humans are estimated per annum. Annually, 25,000 people receive PET with NTO-ARV at free of charge. However, around 5000 people purchase the commercially available CCO-ARV per annum. Similarly, 100 hydrophobia (human rabies) cases are estimated per annum. World Health Organization (WHO) has been advising to cease the production and the usage of NTO-ARV and strongly recommends the use of CCO-ARV in human. However, the country couldn't immediately follow due to the high cost of commercially available CCO-ARV. But RVPL is putting efforts to produce CCO-ARV for human use. The country is looking for the transfer of technology at the level of quality control of the vaccine to be produced for human use. The primary objective of the National Health Policy is to extend the primary health care system to the rural population so that they benefit from modern medical facilities and trained health care providers. The National Health Policy mainly addresses preventive, promotive, curative and basic primary health care services. Based on above policy, EDCD has 3 main interventions under Essential Health Care Scheme (EHCS) namely a. Appropriate treatment of common diseases and injuries – addresses Rabies b. Vector borne disease control-addresses Malaria, Leishmaniasis, Japanese Encephalitis