Rabies Situation in Bangladesh Dr. Moazzem Hossain Director Disease Control Directorate General of Health Services Ministry of Health & Family Welfare Chairman, Bangladesh Anti Rabies Alliance (BARA), Forum for Neglected Propical Diseases (FNTDs) & Institute of Allergy & Clinical Immunology of Bangladesh (IACIB)

Location of Bangladesh

Bangladesh

Dhaka, Capital of Bangladesh

National Flag of Bangladesh

Rabies ■Infects domestic and wild animals (dog, cattle, fox, jackal, cat, mongoose) ■ Almost 100% fatal & 100% preventable ■ Rabies is a zoonotic viral NTD ■ Transmitted through bite, saliva, scratches, licks on broken mucous membrane etc.

Presence of Rabies • ■ Approximately >55,000 human death annually world wide (but under reported) – ► Asia 31,000 (56%) – ►Africa 24,000 (44%)

• ■ Takes away live in every 10 minutes • ■ >50% victims are Children • ■ > 90% due to dog bites

Countries and territories reportedly free of Rabies (World survey of Rabies, WHO 1994)

AFRICA

ASIA

OCEANIA

AMERICA

EUROPE

Cape Verde

Bahrain

Cook Islands

Antigua and Barmuda

Albania

Congo

Cyprus

Fiji

Bahamas

E.Y.R. of Macedona

Libya

Hong Kong

French Polynesia

Barbados

Finland

Mauritius

Japan

Guam

Belize

Gibraltar

Reunion

Malaysia

New Caledonia

Falkland

Greece

Seychelles

Maldives

New Zealand

Jamaica

Iceland

Qatar

Papua New Guinea

Saintkitts and Nevis

Isle of Man

Singapore

Samoa

Trinidad and Tobago

Malta

Solomon Islands

Uruguay

Norway (except Svalbard and isl.)

Vanuatu

Portugal

Australia

Spain (except centa + Melilla) Sweden United Kingdom

Bangladesh situation ■ Death >2,000/year (Infectious Disease Hospital (IDH), Dhaka reported cases only) (India:20,000/yr; Africa:24,000/yr–WHO estimates)

■ >300,000 people receive Post-exposure treatment / year ■ >85% from rural areas ■ Large number of livestock die Grossly under reported.

Bangladesh situation (Contd) ■ Lack of awareness ■ Unavailability of appropriate Tissue Culture Vaccine (TCV) ■ Use of toxic Nerve Tissue Vaccine (NTV) ■ Treatment by traditional healers ■ Large number of unsafe dog population ■ No effort for controlling animal rabies

Age & sex distribution of Rabies cases attended at IDH, Dhaka in 2006

Principles of Rabies Post-Exposure Prophylaxis

[Source: Plotkin SA. Rabies. Clin Infect Dis 2000;30(1):4-12]

Effective control • •

Globally, greatest burden on human health from this disease is caused by uncontrolled rabies in dogs. Success depends on Integrated management approach(pub. educ, responsible animal ownership, manipulation of pop. carrying capacity of local habitat, vaccination) Sustained controlled measures on anim population (stray anim removal+mandatory vac) Political willingness Intersectoral cooperation Biomedical infrastructures Dedicated resources Economic stability

Strategic plan for rabies control in Bangladesh

Goal: To prevent death from rabies and to control animal rabies by 2020 through GO- NGO collaboration

Short term target (2010-2012) i) Baseline survey on animal bite, rabies cases and dog population ii) Registration , sterilization & vaccination of dogs iii) Introduction of Intra dermal (ID) TCV at national & divisional levels iv) Phase out NTV by 2011

Midterm target (2012-2016) i) Implementation of ID TCV at all levels ii) Dog population control (euthanization, vaccination, registration, ABC etc.) iii)Manufacture of TCV and immunoglobulin locally

Long term target (2016-2020) and onward

Sustainability of the program through coordinated approach of Ministry of Health, Local Government & Livestock & NGOs.

Effective implementation requires

1. Rabies control program should be an integral part of Ministry of Health, Livestock and Local govt. system 2. Partnership with NGOs 3. Sustained political commitment 4. Adequate human and financial resources

Role of MOH&FW ■ Development of national guidelines ■ Identify disease burden and use of ID TCV ■ Capacity building ■ Development of national surveillance system ■ Phase out of NTV ■ Production of TCV ■ Public awareness (Implementation through GO- NGO)

Role of LGRD ■ Ensuring post exposure management of animal bite cases. ■ Pre-exposure vaccination of at risk population (dog & animal handlers) ■ Management of dog population by● Registration of pet dog in cooperation with Dept of Livestock Services ● Vaccination of pet and stray dogs ● Eliminating suspected rabid dog ● Animal birth control (ABC) ■ Updating laws and regulations for rabies control in coordination with health and LSD

Role of Dept. of Livestock Services ■ Base line survey & strengthen animal population

control ■ Immunization of pet & stray dog ■ Availability of animal rabies vaccine ■ Establishment of surveillance system for animal ■ Awareness creation

Implementation plan ■ Formation of National Steering Committee (NSC) ■ Technical Working Group (TWG)

National Steering committee • • • • • • • • • • • • • • • • • •

Minister, MOH & FW – Chairman Minister, M/O Fisheries and Livestock – Vice Chairman State Minister, M/O LGRD -Vice Chairman Mayor, Dhaka , CTG, Rajshahi, Khulna, Barisal, Sylhet City Corporation - Member Secretary, M/O, LGRD -Member Secretary, MOH& FW -Member Secretary, M/O, Livestock-Member Inspector General of Police - Member Director General of Health Services -Member Director General of Livestock Service -Member Dean, Faculty of Veterinary science, BAU, Mymensingh. -Member Joint Secretary, (WHO & PH),M/O Health &FW - Member Joint Secretary (Dev) M/O, LGRD - Member President Municipal Association of Bangladesh, Mayor (Tongi), - Member General Secretary, Municipal Association of Bangladesh (MAB) - Member Chairman, Bangladesh UPZ Chairman Association - Member Chairman, Bangladesh UP Chairman Association - Member Director, Disease Control, DGHS – Member Secretary

Technical Working Group (TWG) • • • • • • • • • • • • • • • •

Director, Disease control, DGHS - Convener Deputy secretary (Pourashava), LGRD - Member CSO Zoonosis, IEDCR – Member Director IPH – Member Director,( Admn & Animal Health) Live Stock Services – Member Director, LRI – Member Chief Health Officer, Dhaka City Corporation – Member Veterinary Officer , Dhaka City Corporation – Member PSO, CDIL, Livestock Services – Member Sr. Consultant, IDH, Dhaka – Member Deputy Director, CDC, DGHS – Member Chairman, RIAF, Bangladesh, & Member, AREB – Member Veterinary Officer, Tongi, Pourashava - Member Representative from MAB - Member Representative from CAB - Member Coordinator , Bangladesh Anti Rabies Alliance (BARA) – Member

Activities done by DGHS (from May 2010) ■ Development of National Guidelines ■ Procurement of TCV for ID use ■ Country wide studies on Rabies ■ Training of doctors and nurses on rabies control and ID vaccination ■ Renovation of Infectious Disease Hospital (IDH), Dhaka for ID vaccination training

Activities done by DGHS cont’d

■ Pilot study at Raipura Upazila under Narsingdi district; Isolated 6 unions surrounded by Meghna river with ABC jointly by BARA & DGHS. ■ Planning meeting with 7 divisional Health Directors & other stakeholders for introduction of ID TCV vaccination at Divisional level. ■ Training on Animal Birth Control (ABC) by Nonsurgical Sterilant- first time in the country

ID Vaccination Schedules

WHO recommended IDRV schedules are followed as follows: 0.1ml per site (two sites on deltoid skin ) on days 0, 3, 7, and 28

Rabies Vaccine ■ NTV used June 2009-July 2010 2,882,935 ampoules (41184 pts)

=

■ Daily NTV production by IPH , Dhaka (Insufficient per need) ►10 ml size 150-200 ampoules ► 5 ml size 1200-2000 ampoules

• TCV privately sold/year 1,000,000 vials for rich ( NOT produced locally) Source: IPH Mohakhali & Private pharmaceuticals

Future plans ■ Training of health staffs to be expanded upto all district levels ■ Conduction of pilot study to islands for both human & animal Rabies control & ABC through BARA and expansion in the whole country. ■ Phase out of NTV by TCV by 2011 ■ Availability of TCV & RIG in the country ■ Health Education Program at School levels (Teachers & students) on Rabies ■ Include Rabies as a separate program from next Health sector plan (2011-2016) ■ Strengthening rabies control activity through GO- NGO ( PPP)

Constraints ■ Lack of trained manpower ■ Frequent transfer of trained manpower ■ Fund problem ■ Monopoly of TCV & RIG suppliers ■ Lack of awareness

Let us make rabies-free Bangladesh by… “working together to make rabies history” Thank you all