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4th National One Health Conference
Report of the Conference
Paro, Bhutan, 19-21 December 2018
Fund supported provided by WHO
Conference organized by Department of Livestock, Ministry of
Agriculture and Forests and Department of Public Health, Ministry of
Health
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Table of Contents 1 Introduction .................................................................................................................................................................. 1
2 Objectives of the One Health Conference ................................................................................................................... 3
3 Session 1: Opening session ........................................................................................................................................... 3
4 Session 2: Updates on One Health activities................................................................................................................ 5
4.1 Follow up of 3rd National One Health Workshop resolutions: Mr Rinzin Kinga Jamtsho, MoH ...................... 5
4.2 Update on One Health Activities from Public health sector: Dr Sonam Wangchuk, Royal Centre for Disease
Control, Ministry of Health ............................................................................................................................................. 8
4.3 Update on One Health Activities from Animal health sector: Dr Tenzin, National Centre for Animal Health,
Department of Livestock .................................................................................................................................................. 9
4.4 Update on One Health Activities from Wildlife sector: Dr Kinley Choden, Nature Conservation Division,
Department of Forests and Park Services ...................................................................................................................... 10
4.5 Update on One Health Activities from Food safety sector: Dr Kinley Penjore, BAFRA ................................... 11
4.6 Emerging and Re-emerging Infectious Diseases Scenario and Threat to BHUTAN: Dr Sonam Wangchuk,
Royal Centre for Disease Control, Ministry of Health ................................................................................................. 11
4.7 South Asia One Health Disease Surveillance Network: Dr Sithar Dorjee, Khesar Gyalpo University of
Medical Sciences of Bhutan, Thimphu, Bhutan ............................................................................................................ 12
5 Session 3: Performance Evaluation of human and animal health services ................................................................ 14
5.1 Joint External Evaluations for IHR Core Capacities: Mrs Jamyang Chodon, Ministry of Health .................... 14
5.2 Findings and recommendations of the OIE-PVS Evaluation: Dr Karma Rinzin, Department of Livestock .... 15
5.3 Findings and Recommendations of National IHR-PVS Bridging Workshop: Dr Sithar Dorjee, Khesar Gyalpo
University of Medical Sciences of Bhutan, Thimphu, Bhutan ..................................................................................... 16
6 Session 4: Projects ....................................................................................................................................................... 17
6.1 One health approach to determine antimicrobial resistance profile in Salmonella isolates collected from
human, animal and food samples: Dr RB Gurung, National Centre for Animal Health, Serbithang ....................... 17
6.2 An overview of Fleming Fund AMR project: Dr. Karma Rinzin, Department of Livestock ............................. 18
7 Session 5: AMR and Food safety ................................................................................................................................ 20
7.1 AMR surveillance in children under 5 years of age with diarrhoeal cases: Mr Tshering Dorji, Royal Centre for
Disease Control............................................................................................................................................................... 20
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7.2 Foodborne Disease Outbreak Investigation: A case study of One Health Approach: Dr Sithar Dorjee, Khesar
Gyalpo University of Medical Sciences of Bhutan ........................................................................................................ 20
7.3 Microbial load and prevalence of Salmonella in imported fresh beef at different points of meat handling: Mr
Kaling Dorji, Bhutan Agriculture and Food Regulatory Authority, Thimphu ............................................................ 21
7.4 Antibiotic resistance of Escherichia coli causing diarrhea; practices and factors influencing use of antibiotics
in swine farms in central region of Thailand: Dr Narayan Pokhrel, Dzongkhag Veterinary Hospital, Pemagatshel 22
8 Session 6: Zoonotic diseases ....................................................................................................................................... 23
8.1 Emergence of Brucellosis in Bhutan: animal Brucellosis and human case report: Dr RB Gurung, National
Centre for Animal Health, Serbithang .......................................................................................................................... 23
8.2 Status of Multi-drug resistant tuberculosis in the country (2014 – 2018): Mr Karchung Tshering, Royal
Center for Disease Control ............................................................................................................................................ 24
8.3 A Case-Control Study to Identify Risk Factors of Multi-Drug Resistance Tuberculosis (MDR-TB) among
New Pulmonary TB Patients in Bhutan, 2018: Dr Tandin Zangpo & group, Dechencholing BHU-I, Ministry of
Health, Thimphu ............................................................................................................................................................ 25
8.4 Acute Undifferentiated Febrile Illness surveillance: Preliminary finding of causing agents: Dr Sonam
Wangchuk, Royal Center for Disease Control .............................................................................................................. 25
8.5 Chronology of HPAI-H5N1 outbreak in Bhutan and genetic characterization of virus involved: Dr RB
Gurung, National Centre for Animal Health, Serbithang ............................................................................................ 26
9 Session 7: Diseases at human-animal-wildlife interface ............................................................................................. 27
9.1 Synantrophic rodents as reservoir of zoonotic pathogens in Bhutan: Dr Yoenten Phuentshok, National Centre
for Animal Health ........................................................................................................................................................... 27
9.2 Bat diversity in Bhutan – implications for emerging infectious disease control: Mr Sangay Tshering and
Tshering Gyelpo, College of Natural Resources, Royal University of Bhutan, Lobeysa ............................................. 28
9.3 Ecology of Lyle’s Flying Fox (Pteropus lylei) at the bat-human interface in Cambodia: Dr Kinley Choden,
Nature Conservation Division ....................................................................................................................................... 29
10 Session 8: Community Perceptions and Practices ...................................................................................................... 31
10.1 Determinants of Rabies PEP seeking and compliance behaviour – Hospital and commmuniy-based contact
tracing survey: Dr Kinley Penjor and group, Dewthang Military Hospital, Ministry of Health ................................ 31
10.2 One Health profile of local communities living within a protected area in Bhutan: Dr Kinley Choden,
NCAD 32
10.3 Knowledge, Attitude, and Practice survey rabies among cattle owners in two districts of Bhutan: Dr Sangay
Rinchen and group, Regional Livestock Development Centre, Tsimasham ................................................................ 33
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11 Session 9: Disease Prevention and control Strategies ................................................................................................ 34
11.1 Strategic framework for elimination of dog mediated rabies in Bhutan: Dr Tenzin, National Centre for
Animal Health, Department of Livestock, Serbithang .................................................................................................. 34
11.2 Strategy for prevention and control of zoonoses: Mr Rinzin Kinga Jamtsho, DoPH, MoH ........................ 36
11.3 Bhutan Wildlife Health Strategy: 2019 – 2028: Dr Kinley Choden, NCD ................................................... 37
11.4 Animal welfare with focus on dog population management in Bhutan: Dr Karma Rinzin, Department of
Livestock. ......................................................................................................................................................................... 39
12 Session 10: Group work and plenary presentation .................................................................................................... 41
13 Session 11: Closing session ......................................................................................................................................... 47
13.1 Conference Resolutions: Dr. Sangay Rinchen, Chief Rapporteur .................................................................. 48
14 Annex .......................................................................................................................................................................... 50
14.1 Annex 1: Conference Agenda ........................................................................................................................... 50
14.2 Annex 2: List of participants ............................................................................................................................ 54
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1 Introduction
Of the growing list of human pathogens, more than 60% originates from animals. Among emerging
infectious diseases, 75% are zoonotic in nature which mainly emerges at the animal-human-ecosystem
interface. The emerging and re-emerging zoonoses including human immunodeficiency virus, severe
acute respiratory syndrome (SARS), West Nile virus, Nipah virus, Ebola, dengue haemorrhagic fever,
and most notably, highly pathogenic avian influenza (HPAI) have caused substantial morbidity and
mortality to the human and animal populations, adverse effect on economies and livelihood systems of
many countries in the world, and presented immense challenges for public health and animal health
authorities. About 80% of the agents with potential bioterrorist use are zoonotic pathogens.
To mitigate the risk of emerging pathogens at animal-human-ecosystem interface, the One Health
Approach has been developed and recognized as a holistic and important approach by the international
organizations like World Health Organization (WHO), World Organisation for Animal Health (OIE)
and Food and Agriculture Organizations of the United Nations (FAO). The One Health concept was
formally endorsed during the 7th International Ministerial Conference on Animal and Human Pandemic
Influenza held in Hanoi, Vietnam in April 2010 (IMCAPI Hanoi 2010), resulting in the Hanoi
Declaration, which emphasized not only the need to continue the control of HPAI and H1N1 infection
in humans, but also the importance of extending the lessons learned from HPAI to other emerging
diseases. Following this meeting, the WHO‐FAO‐OIE prepared a tripartite concept note “Contributing
to One World, One Health - A Strategic Framework for Reducing Risks of Infectious Diseases at the
Animal-Human-Ecosystems Interface”. The importance of One Health approach is now increasingly
becoming recognized in many countries because it provides a strategy that increases the effectiveness and
efficiency of interventions for controlling diseases through multi-sector approach.
Bhutan is a landlocked country with an area of 38,394 square kilometers with a forest cover of 72 percent.
The population is largely rural, with 79 percent living in villages, and depends on subsistence agriculture
and livestock rearing for livelihood. This results in close interaction with domestic and wild animals.
Moreover, Bhutan has a fragile ecosystem and it is vulnerable to the impacts of global warming and
climate change, and also susceptible to natural disasters such as floods and earthquakes. As Bhutan is
located in the South Asia region, which is identified as one of the global hotspots for emerging and re-
emerging infectious diseases and having long porous international borders, the country faces serious
public health threats from emerging and re-emerging infectious diseases, including antimicrobial
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resistance (AMR) issues. As such, the zoonotic diseases remain a major concern to both animal and
human health in Bhutan. The increasing demand and establishment of intensive farming in livestock
and poultry and the increasing ease and frequency of animal or animal products movement further
increases the risk of such disease emergence and a significant challenge for prevention and control.
Although some amount of understanding and collaborative activities have been initiated in the past in
the areas such as prevention and control of HPAI and rabies, there is an imperative need for establishing
a firm institutional linkage with clear cut working relation mainly between the Ministry of Health and
the Ministry of Agriculture and Forests.
Considering the severe risks of emergence of emerging and re-emerging infectious diseases, and
recognizing the benefits of one health approach, the Ministry of Agriculture and Forests (MoAF) and
Ministry of Health (MoH) provided importance to formally institutionalize the One health program in
Bhutan. The two Ministry developed Bhutan One Health Strategy Plan (2017-2022) which was formally
approved by the Government in 2017. Following that the Memorandum of Understanding was signed
between MoAF, MoH and other collaborating partners (National Environment Commission (NEC),
Ministry of Home and Cultural Affairs and Universities) on 3rd November 2017 on the eve of World
One Health Day. The proposal for establishment of One Health Secretariat is currently being pursued
with the Royal Civil Service Commission. Both the Ministry accorded priority to set up One Health
Secretariat at Royal Centre for Disease Control in the proposed Fleming Fund Project on AMR. The two
Ministry also organized three round of National One Health Workshop/ Conference in the past to
mainly sensitize human and animal health personnel and other stakeholders at national, regional and
district levels on the concept of One Health in preventing and controlling the priority zoonoses through
multi-sectoral coordination and collaboration. In August 2016, Bhutan also hosted the Asia-Pacific
Zoonotic Influenza Workshop organized by WHO, OIE and FAO which was attended by the human
and animal health officials from 32 Member States.
The OIE fielded series of missions to carry out the evaluation of the performance of veterinary services
in Bhutan. The first PVS mission was field in June 2008 followed Gap Analysis Mission in November
2009 and a follow-up mission in March 2015. The OIE also fielded Laboratory Mission in January 2016.
Similarly, the WHO fielded International Health Regulations Joint External Evaluation mission in
November 2017. Bhutan is also one of the few countries who successfully carried out the National IHR-
PVS Bridging Workshop which was conducted in March 2018. The National Bridging Workshop came
up with number of recommendations to improve the prevention and control of infectious diseases at the
human-animal-environment interface.
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Although there is need to organize One Health Workshop on annual basis, MoAF and MoH is not able
to host the event due to unavailability of the fund. The need to have annual One health workshop was
recommended by the National IHR-PVS Bridging workshop as well. Therefore, 4th National One Health
Conference was proposed and financed by WHO from 19-21 December 2018.
2 Objectives of the One Health Conference
The main objectives of the conference were to:
1. To provide an update on situation of zoonotic diseases in the country and to share the updated
scientific information of recent emergence of zoonotic diseases that may have implications to
human-animal-wildlife health in the country
2. To strengthen collaboration among relevant sectors (Livestock, Health, BAFRA, Wildlife and
other stakeholders) in preventing and controlling of zoonoses;
3. To share experience(s) and expertise of any successful disease control interventions instituted by
the stakeholders and new technologies/tools/approaches being practiced in Bhutan and
elsewhere.
4. To present the research findings in the areas of one health.
5. To come up with action plan for implementation of one health activity in the 12th FYP and
integrated action plan for coordinated response to zoonotic diseases.
6. To align the recommendations of the National IHR-PVS National Bridging Workshop with the
12th FYP of the respective agencies.
3 Session 1: Opening session
Dr Karma Rinzin, Chief Veterinary Officer, Department of livestock, Ministry of Agriculture and Forests
extended his greetings and warm welcome and all the participants representing the Ministry of
Agriculture and Forests, Ministry of Health and other relevant OH partners for the conference. He
provided a brief background of the annual One Health conference which was first conducted in 2013, in
Phuentsholing, Bhutan. He also emphasized that ever since the OH concept has been adopted
tremendous achievements have been made in the field of One Health starting from the development of
the One Health Strategic document, signing of the MoU between Ministry of Health and Ministry of
Agriculture and Forests and other relevant stakeholders, and various OH research activities. He informed
the gathering that the process has led to institutionalization of OH secretariat which is currently being
pursued with the Royal Civil Service Commission (RCSC). He also stressed on enhancing collaboration
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among various stakeholder in effective early detection and response, and containment of zoonotic
diseases through enhanced sharing of resources and information.
Dr Pandup Tshering, Director General of the Department of Medical Services, Ministry of Health in his
opening remark expressed his pleasure and honour to address the conference. Given that Asia,
particularly Southeast and South Asia being the global hotspot for emerging and re-emerging, he stressed
on the importance of adopting the OH in mitigating the public health and economic impacts resulting
from these diseases. Giving a brief background on the twelve birdflu outbreaks that Bhutan has
experienced since 2010, he acknowledged the effort of the different stakeholders in successfully
containment the outbreaks without experiencing a single human case. Similarly, he also applauded the
effort of the relevant stakeholders in early detection and effective response to rabies outbreaks in dogs
that resulted in zero human cases in 2017 and 2018. Dr Pandup Tshering also spoke on the progresses
that had been made under the umbrella of One Health particularly pertaining to instituting the OH
secretariat. He acknowledged that getting different sectors working together for a common identified
goal is very difficult however, the OH collaboration between different stakeholders has risen above all
the odds and achieved greater heights in a very short span of time. Given these successes, he stressed the
floor to carry forward this effort, which is a proven and effective tool in mitigating the impact of the
diseases at the human-animal-ecosystem interface. He thanked all the stakeholders for the great work
and re-committed his support for the OH initiative in the country.
Dr. Tashi Samdup, Director General of the Department of Livestock, Ministry of Agriculture and Forests
in his remark informed the floor that Bhutan has come up a long way to operationalize OH concept in
the country. He mentioned that Bhutan is in the forefront in terms of carrying forward OH activities in
the region and this has been only possible due to the dedication and handwork of the relevant agencies.
Given that more than 60% of the human pathogens are of animal origin and more than 75% of the re-
emerging infectious diseases are reported in animals, he stressed on enhancing OH approach remains
critical in mitigating the public health and economic impact. Dr. Tashi Samdup also mentioned some of
the crucial milestones achieved since starting this program some of which are, development of OH
strategic plan, signing of the MoU between various stakeholders, joint researches and surveillance
program, which have led to formulate evidence-based disease prevention and control plan. He also
stressed the importance of swift containment of infectious diseases that minimize or reduce the risk to
public health and the livelihoods of farmers. Dr. Tashi also emphasized on information sharing as one
of the crucial component. On behalf of the MoAF, he committed full support to make OH a successful
and operational program to ensure a common goal of good health.
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Mr. Rinzin Jamtsho, Chief Program Officer, Department of Public Health, Ministry of Health thanked
the Director Generals, Directors and all the participants for showing interests and participating the
conference. He also thanked all the speakers for agreeing to present their findings and expertise in the
forum. He also thanked WHO for funding this conference. He expressed acknowledgements to the
organizer and the personnel working behind the scene in making this conference a successful one. He
wished fruitful deliberations and hoped for a productive outcome.
Dr. Tenzin, Head, Disease Prevention and Control Unit, National Centre for Animal Health, DoL
presented session wise agenda and the floor adopted the agenda. Rapporteurs for the conference were
introduced.
Given that the conference attendees come from different agencies, a brief introduction was given by each
participant before the start of the presentation session.
4 Session 2: Updates on One Health activities
4.1 Follow up of 3rd National One Health Workshop resolutions: Mr Rinzin Kinga Jamtsho,
MoH
Resolution #1: With OH, the collaboration between stakeholders have greatly strengthened, especially at
the central level; for e.g. the joint works on Brucellosis, Leptospira, CCHF conducted between NCAH
and RCDC. However, there is weak coordination and information sharing amongst the stakeholders at
the field level. Therefore, the house recommended developing a framework for information sharing and
strengthening coordination amongst the stakeholders at all levels.
Status of Implementation: No separate framework was developed for strengthening information sharing
system. However, all national disease prevention and control plans including HPAI, Anthrax, Rabies,
Scrub Typhus, Foot and mouth disease and PPR in animals have a section mentioning information
sharing mechanism for surveillance and outbreak investigation and containment process. Moreover,
NCAH has real-time disease outbreak information system (disease outbreak information shared to all
the relevant stakeholders immediately through e-mails to over 300 plus stakeholders). RCDC- has web based and SMS reporting system for all notifiable diseases and syndrome. Any outbreak, zoonotic or
foodborne notified by health centers in the system are shared to relevant stakeholders through emails.
BAFRA has launched BAFRA quarterly e-Newsletter which covers information on the achievements and
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Highlights of BAFRA relating to Bhutan’s Biosecurity, Biosafety and Food Safety in the Kingdom on
quarterly basis
Resolution #2: The response to the outbreak of HPAI by all the stakeholders was a good example of
collaboration and the floor felt that it should be replicated for other zoonotic diseases as well. Hence, the
floor recommended for joint outbreak investigation of zoonotic and food borne disease outbreaks.
Status of Implementation: As recommended, disease outbreak investigation and containment activities
for zoonotic and foodborne are being implemented jointly through OH approach at all levels. For
example, we have involved multi-sectoral stakeholders for rabies outbreaks in Trashigang, Panbang,
Chukha and Samtse foodborne disease outbreak in Thimphu
Resolution #3: Owing to the importance of food borne diseases and food safety in the country, the floor
felt that there should be clear delineation of the roles and responsibilities of BAFRA and RCDC with
regards to food borne disease outbreaks. However, the limited capacity at various levels of stakeholders
without specialized technicians and laboratory facilities at the moment are some of the contributing
factors to occupational health hazards and food safety. Hence, the floor suggested for the need to
strengthen and equip the relevant institutions to enable them conduct effective surveillance and
investigations during the outbreaks related to food-borne diseases.
Status of Implementation: There is no confusion in the roles & mandates for preventing food borne
outbreaks. BAFRA is responsible for taking lead in preventing foodborne outbreaks. However, in the
event of foodborne outbreaks, a collaborative mechanism between BAFRA, RCDC and other
stakeholders are in place for timely disease investigation (e.g. the food borne outbreak investigation at
Lama Bakery in June 2017, was conducted through One Health approach). Furthermore, RCDC and
BAFRA has also initiated to conduct joint foodborne illness surveillance in selected sites to understand
the foodborne illness pathogen in clinical specimens and high risk foods.
Resolution #4: In order to meet the objective of eliminating canine mediated rabies by 2030 and in view
of the absence of active rabies surveillance system currently, it was suggested that the rapid rabies test
and post mortem be performed on all suspected rabid animal deaths including wild animals. The rationale
behind this is to detect the absence or presence of the disease in all the parts of the country.
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Status of Implementation: Veterinary laboratories in the country have been performing postmortem
examination and laboratory tests on various animals’ species carcasses as part of surveillance to confirm
rabies in animals. Rabies surveillance system is also included in the National Rabies Prevention and
Control plan 2017.
Resolution #5: Owing to the outbreak of Giant African Land Snails (GALS) population in Gelpozhing,
Mongar the BAFRA had been actively involved in the control of GALS population. It has almost become
an annual event and there is a heavy financial implication involved in the control. As such, BAFRA is
facing difficulty without much assistance from other concerned agencies including general public. The
GALS are known to transmit diseases to humans causing public health concerns. In addition, it has also
serious implication to environment and animal health. Therefore, the floor felt that it is necessary to
sensitize the general public and involve all the relevant stakeholders including National Environment
Commission (NEC). The floor also suggested that a collaborative research in the control of GALS
population should be initiated; for instance, destroying the larvae and eggs with the adult snails.
Status of Implementation: In September 2016, a KAP study was conducted with the objective to study
the GALS status in Bhutan and evaluate the containment program at Gyelposhing and Mongar. A well-
structured questionnaire was designed, pretested and administered to the public in the study area. 83%
of the respondents were found to be aware of the risk posed by the GALS and means of spread of GALS.
91% of the respondents thought that the containment program must continue every year. However, 51%
of the respondents thought, the containment strategy was not adequate to address the problem. Since
the outbreak of GALS in 2010, there was increase in numbers of GALS intercepted at strategic point until 2015. The number of GALS declined from 2016 and no outbreak was reported in 2018. The reason
for drop in GALS could be credited to the intense awareness program given to the general public and
preventive measures taken by BAFRA.
Resolution #6: The wild life plays an important role in the zoonotic disease transmission and due to lack
of disease information in wild life population; it has become imperative to conduct disease screening of
zoonotic importance to establish baseline information. Therefore, the floor recommended to formally
institutionalize the disease surveillance and screening in wild animals between the NCAH and Wildlife
Conservation Division.
Status of Implementation: The Technical Core Working group was formed comprising of technical
experts from wildlife and animal health and KGUMSB. The team drafted Wildlife Health Strategy Plan
and incorporated all aspects of institutionalization and infectious disease surveillance at human-livestock-
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wildlife interface. Once the plan is approved by the MoAF, it will take care of all aspects of wildlife heath
surveillance, researches and collaboration among relevant partners. The draft plan will be presented on
the 3rd day of this conference.
Resolution #7: For sustainable prevention and control of zoonoses in the country, it is important to
institutionalize OH approach. It was deliberated at length whether there is need for a permanent OH
Secretariat in order to have more focus on the program. The floor suggested that the OH Tasks Force
should discuss on the pros and cons of the permanent and rotational OH secretariat and submit to the
cabinet accordingly.
Status of Implementation: As recommended, the need to establish permanent OHS at RCDC was justified
in the Strategic Plan document. This was endorsed by the 119th Lhengye Zhungtshog held on 22
November 2016. Currently, the establishment of One Health Secretariat is being pursued with the Royal
Civil Service Commission
Resolution #8: The presentation on the Bhutan One Health Strategic Plan (BOHSP) raised concerns over
the disparity in budgeting for different activities and hence suggested for the OH core group to revisit
the costing before submitting to the cabinet.
Status of Implementation: As recommended, the budget was revised accordingly and was put up to
cabinet for approval. The proposal was endorsed by 119th Lhengye Zhungtshog held on 22 November
2016 and the OH plan was launched for operationalization on 6 November 2017 with the signing of MOU between the key and collaborating stakeholders.
4.2 Update on One Health Activities from Public health sector: Dr Sonam Wangchuk, Royal
Centre for Disease Control, Ministry of Health
The One Health approach acknowledges that population health is dependent on interactions between
animal and human diseases. In a globalized world, humans and animals interact with greater frequency
and intimacy which offers the opportunity for the emergence and spread of disease agents (chemicals,
pathogens, etc.). This could adversely impact animal health, human health, or both which requires
multidisciplinary approach to address.
Bhutan has long history of practicing one health approach informally at technical level and formally
embraced one health approach and developed “Bhutan One Health Strategy Plan” to proactive address
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one health issues. The strategy was approved by the government in 2017 and MoU to implement one
health strategy was signed among concerned stakeholders in the same year.
Some key activities conducted by health sector:
1. Updated NIPPP for human health, developed strategy for elimination of rabies by 2023 and was
updated, and developed National guideline for prevention, treatment and control of scrub typhus.
2. Develop laboratory capacity at RCDC to detect Brucella, Crimean Congo Hemorrhagic fever
virus, Kyasanur Forest Disease Virus, Nipha virus (PCR), Hantavirus, Ebola virus and
importantly validated and certified BSL- 3 laboratory.
3. Assessment of rabies burden and PPE seeking behaviour among exposed human and screening
of blood samples from chronic failure cases for Hantavirus was conducted.
4.3 Update on One Health Activities from Animal health sector: Dr Tenzin, National Centre
for Animal Health, Department of Livestock
The Animal Health sector have implemented various OH activities during the past three years and
includes the following:
1) Disease Outbreaks Investigations, Containment and preparedness programme
• Investigation & Containment of Rabies outbreaks in Trashigang, Panbang, Orong, Samtse,
Phuentsholing, Gelephu, Lhamoizingkha and Samdrup Jongkhar
• Investigation & Containment of HPAI outbreaks (12 outbreaks between 2010 and 2018)
• Investigation & Containment of Anthrax outbreaks
• Coordinated World Rabies Day events and cross-border mass dog vaccination campaign
2) Evaluation and assessment of disease control program and capacity
• Evaluation of Rabies control program using SARE tool
• Conducted National Stakeholder workshop on Brucellosis Control (18-19 June 2018)
• Participated WHO-IHR JEE workshop (11-15 Dec 2017)
Organized IHR-PVS National Bridging Workshop (13–15 March 2018)
3) Development of disease control plan and guidelines including rabies, srub typhus, HAPI, anthrax, AI
communication strategy
4) Conducted OH Research
• AST profile of Salmonella in human, animal and food survey (WHO-AGISAR Project)
• Sero survey of Leptospirosis in human and animals (WHO supported)
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• Sero survey of Crimean Congo Haemorrhagic Fever (CCHF) virus in goats and cattle
• Rabies health seeking behavior and PEP compliance study (WHO supported)
• Rickettsia disease survey at human-animal interface
• Detection of zoonotic pathogens from rodents in Gedu, Bhutan
• Avian influenza survey
• Survey of Echinococcus in dogs
• Risk-based survey of brucellosis in dairy cattle
• Feral pigeon disease survey
• Ticks survey
4) Conducted training related to survey and diagnosis of zoonotic diseases
• Tick identification training to the laboratory officials in collaboration with RCDC, NCAH and
AFRIMS, Bangkok
• Training /simulation of National Influenza Pandemic Preparedness and Response Plan
• Training on brucellosis & rabies diagnosis
• Training on GIS and GPS
4.4 Update on One Health Activities from Wildlife sector: Dr Kinley Choden, Nature
Conservation Division, Department of Forests and Park Services
The wildlife sector implemented following activities as OH approaches:
Joint Disease outbreak investigation particularly with animal health sector
Joint development of protocol for feral/stray dog population management and wildlife disease
surveillance
o Surveillance conducted in the field and report submitted jointly by Gedu, Tashigang,
Tsirang, S/Jongkhar, Dagana, Mongar, Pemagatshel Divisions and RMNP, SWS,
JSWNP, BWS, JWS PAs
o Environmental and wildlife samples submitted to NCAH, Serbithang
Participated in the joint development of Strategy for elimination of dog mediated rabies in
Bhutan
Drafted Bhutan Wildlife Health Strategy (2019-2028) in collaboration with other relevant
agencies
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4.5 Update on One Health Activities from Food safety sector: Dr Kinley Penjore, BAFRA
The BAFRA implemented following activities as OH approaches:
Policy & Research Activities
National FMD Prevention & Control Plan
National Rabies Prevention & Control Plan
Developing Framework for stepwise approach for Brucellosis Control Program
OH approach in determining Antibiotic Susceptibility of Salmonella in human, animal & food
Food borne outbreak investigation
Training on Food borne disease outbreak investigation
Diseases Outbreaks Investigation and Containment
Rabies outbreaks investigation and containment
Foot and mouth disease outbreak investigation and containment
Avian influenza outbreak investigation and containment
Food Safety
Antimicrobial Residues in Imported pork
Eradication of Iodine Deficiency Disorder through test and provision of recommendations
Implementing mandatory food labelling for pre-packaged food
Participated in food/rice fortification process for prevention of diet/nutrient related deficiency
diseases in human
4.6 Emerging and Re-emerging Infectious Diseases Scenario and Threat to BHUTAN: Dr
Sonam Wangchuk, Royal Centre for Disease Control, Ministry of Health The incidence of emerging infectious diseases in humans has increased within the recent past or threatens
to increase in the near future. Over 30 new infectious agents have been detected worldwide in the last
three decades; 60 per cent of these are of zoonotic origin. Developing countries including Bhutan suffer
disproportionately from the burden of infectious diseases given the confluence of existing environmental,
socio-economic, and demographic factors. In the recent past, Bhutan has seen few outbreaks of re-
emerging diseases of zoonotic origin. It is likely that Bhutan will see more number of emerging and re-
emerging diseases of zoonotic origin because of its rich biodiversity and close interaction between human,
domestic animals and wild life. Prevention and control of emerging infectious diseases will increasingly
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require the application of sophisticated epidemiologic and molecular biologic technologies, changes in
human behavior, a national policy on early detection of and rapid response to emerging infections and
a plan of action. A comprehensive national strategy on infectious diseases cutting across all relevant
sectors with emphasis on strengthened surveillance, rapid response, partnership building and research is
needed to guide public policy.
4.7 South Asia One Health Disease Surveillance Network: Dr Sithar Dorjee, Khesar Gyalpo
University of Medical Sciences of Bhutan, Thimphu, Bhutan
The world is experiencing increasing events of emerging and re-emerging infectious diseases, and about
70% of emerging infectious diseases (EID) originated in animals. Furthermore, increasing incidence of
antimicrobial resistance (AMR) has been recognized as a serious public health and animal health threat.
The challenges of EIDs and AMR require a One Health approach that supports a holistic, multisectoral,
coordinated and collaborative network, not only at a country level but at a regional level. Several regional
disease surveillance networks have been established in Southeast Asia, East Africa, South East Europe,
Southern Africa, and Middle East, and recently in South Asia. The purpose of establishing South Asia
One Health Disease Surveillance Network are inter alia, to facilitate coordination and strengthening of
regional capacities for disease surveillance, rapid outbreak detection and response to controlling zoonoses
and pandemics at best at a country or regional levels, support development of effective disease
surveillance systems, create a common platform for timely sharing of disease information, coordinate
and organize training on disease surveillance, outbreak investigation and laboratory diagnoses, and
facilitate cross-sectoral and cross-border collaboration to address issues related to transboundary and
zoonotic diseases. This presentation will provide the overview of the network; its vision, purpose and
functions, progress thus far, opportunities and expected benefits of establishing this network through the
support of ECTAD-FAO and Ending Pandemics of US.
Discussion and deliberation of the session
The following issues and points were discussed and deliberated in this session:
Floor requested the organizer to include rabies outbreak containment activities undertaken in
Chukha & Samtse also in the implementation status of resolution 2 of 3rd One health conference.
On information sharing the house raised that current information sharing system amongst
various stakeholders is insufficient citing that few are web-based and others manual. The
chairman of the session advised organizers to take note of it and work on it to make uniform.
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Floor enquired about the surveillance procedure in place to tackle outbreaks of zoonotic diseases
like Japanese encephalitis in nearby Indian state to which presenter informed that they have
syndromic surveillance system in place.
Dr. Yonten shared with the house that recent study has shown that almost all the ticks that are
responsible for transmission of zoonotic diseases mentioned in the presentation are present in
Bhutan up to genus level and team is working on species identification to ascertain the prevalence
of the disease.
The floor submitted the suggestion on requirement of isolation chamber in JDWNRH and policy
review on requirement of screening procedure against yellow fever for health official.
The floor suggested exploring other alternatives rather than forming group on social media. Dr.
Sither shared with the floor that recent meeting at Bangkok resolved that FAO will fund to set
up webpage for the OH office for information sharing. Dr. Passang Tshering recommended
including OIE in this network. Identifying the need for a reliable platform to facilitate rapid and
real time sharing of information, expertise and resources among the relevant stakeholders under
the One Health umbrella, the floor resolved to develop a One Health webpage.
Need to appoint position holders in OH secretariat was also raised by the floor to which Director
General of DMS informed that Minister shall be apprised about it first and then sort out the
matter through inter-ministerial meeting
For the functioning of the impending OH secretariat, which is being currently pursued in the
RCSC, the floor discussed and suggested that the chairpersonship of the secretariat should be
rotated between the ministers: MoH and MoAF.
The floor commanded the numerous activities carried out jointly by different stakeholders which
have resulted in publication of several research articles and reports. The accessibility to these
reports were asked to which it was clarified that the plans are in pipeline to make them available
on the webpage. Meanwhile, RCDC representative informed the floor that the articles and
reports are available on their website.
The chairperson applauded the update, which was for the first time, on the One Health activities
undertaken by the wildlife sector. Furthermore, she also applauded the effort brought about by
BAFRA in initiating nutritional labelling of the food products which she said would have
tremendous impact on reducing the non-communicable diseases (NCD).
The chairperson commanded the strengthening collaboration since the first workshop that was
held in 2013. She stressed that to ensure the OH conference be conducted annually, there is need
to allocate budget by the agencies.
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5 Session 3: Performance Evaluation of human and animal health services
5.1 Joint External Evaluations for IHR Core Capacities: Mrs Jamyang Chodon, Ministry of
Health
The Joint External Evaluation (JEE) is a voluntary, collaborative process to assess country capacity under
the International Health Regulations (IHR) (2005) to prevent, detect, and rapidly respond to public
health threats whether occurring naturally or due to deliberate or accidental events. The JEE allows
countries to identify the most urgent needs within their health security system, to prioritize opportunities
for enhanced preparedness, response and action, and to engage with current and prospective donors and
partners to target resources effectively. During the Bhutan's JEE mission in December 2017, capacities
in 19 technical areas were evaluated through a peer-to-peer, collaborative process that brought National
subject matter experts together with members of the JEE team in a week of collaborative discussion and
field visits. This process led to consensus on scores and priority actions in 19 technical areas. The
assessors concluded that Bhutan’s commitment to building and/or maintaining capacities to detect,
assess, notify and respond to major public health events is genuine and strong.
Three overarching recommendations emerged during the JEE mission, intended to address challenges
affecting Bhutan’s capacities in a number of technical areas. These are:
1. Update IHR-related laws, regulations, guidelines and standard operating procedures to provide
clarity on roles, responsibilities and lines of communication. Bhutan’s national legislation and
policies have been revised in recent times to incorporate strengthening of IHR (2005) core
capacities, and the government is working to enhance the workforce. While existing good
practice should be noted, and collaboration across sectors generally functions well, it is also
apparent that the implementation of these core capacities could be better defined.
2. Implement joint mechanisms through which professionals from different sectors can adopt the
One Health approach. It was also noted that while Bhutan’s human and animal health sectors
demonstrate progress and good practice, communication and collaboration between the two
could be improved, with great consequent benefit for overall health security.
3. Establish a multisectoral comprehensive training and exercise programme to test, validate and
enhance preparedness and response operations. Finally, it was noticed that Bhutan’s existing
health security systems have not all been adequately validated and refined by a structured training
and exercise programme.
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In addition to these overarching recommendations, the JEE team developed 3-5 priority actions for each
technical area of the JEE.
5.2 Findings and recommendations of the OIE-PVS Evaluation: Dr Karma Rinzin,
Department of Livestock
The World Organisation for Animal Health (OIE) fielded series of missions to carry out the evaluation
of the performance of veterinary services in Bhutan. The first PVS mission was fielded in June 2008
followed by the Gap Analysis Mission in November 2009 and a follow-up mission in March 2015.
The OIE PVS follow-up mission took place seven years after the first evaluation and six years after the
PVS gap analysis designed for 2009-2014. Results show that notable improvement have been made in
physical and human resources, as well in some activities. The 20 DVHs, four RLDCs, many Geog
infrastructures, as well as NCAH and BAFRA central laboratories have been renovated and adequately
equipped. The most important progress has been the recruitment of veterinarians at the district levels.
BAFRA made significant progress in food safety, especially in meat shop hygiene. DRA has successfully
started to regulate veterinary medicines and vaccines including national production of vaccines following
the international standards.
However, these investments cannot produce their full impact as long as major policies and strategies are
defined. Staff are not given appropriate continuing education; specialised training in VPH has not been
undertaken. Moreover, veterinarians cannot have a clear understanding of their roles if they are not
defined properly between levels: strategic planning at the national level, operational planning at RLDC
level, field activities at DVHs and Geog levels. In particular, fieldwork is still considered to be the task
of veterinary para-professionals that veterinarians do not supervise effectively. In addition, the break in
the chain of command, without proper external coordination, hampers the capability of the VS to
implement national programs or to handle unexpected emergencies.
Most recommendations made in the follow-up mission report were previously made in the 2008 OIE
PVS evaluation and further detailed in the 2009 PVS gap analysis. Following the OIE follow-up mission
and based on the request of Bhutan, OIE fielded Laboratory missions in January 2016 and Legislation
mission in July 2018. The DoL and BAFRA is in the process of implementing the recommendations of
OIE follow-up missions and other missions (Laboratory and Legislation). Besides in the 12th five year
plan (FYP), DoL and BAFRA are focusing on the paradigm shift in the delivery of animal health and
food safety services.
The main strategies in the 12th FYP include:
1. Strengthen One Health and veterinary public health services
2. Enhance risk based disease prevention and control
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3. Strengthen laboratory diagnostic services
4. Promote professionalism and expertise in veterinary clinical services
5. Upscale cost recovery scheme for sustainable animal health services
6. Strengthen animal health research
7. Initiate herd health management services
5.3 Findings and Recommendations of National IHR-PVS Bridging Workshop: Dr Sithar
Dorjee, Khesar Gyalpo University of Medical Sciences of Bhutan, Thimphu, Bhutan
The National IHR-PVS Bridging Workshop was held from 13-15 March 2018 at Paro. It was organized
by WHO, OIE, MoH and MoAF. A total of 69 participants from MoH, MoAF, academic institutions
participated in the workshop. The objectives of the workshop were to jointly review JEE and PVS
evaluation findings and recommendations and identify options to improve coordination between sectors
to strengthen preparedness, spread and control of zoonotic diseases. The expected outcomes of the
workshop were to increase awareness and understanding on the IHR, IHRMEF, OIE PVS evaluation,
improve understanding on how the results of the PVS evaluation and IHRMEF can be used to strengthen
coordination and collaboration between the two sectors, develop joint roadmap for strategic planning
and capacity building for advancing One Health in the country. This presentation will highlight the key
findings and recommendations of the workshop such as level of collaboration between the sectors in 16
key IHR technical areas, key prioritization areas, development of harmonized and joint roadmap of key
priority activities identified during JEE and PVS evaluation exercises with that of the National One
Health Strategic Framework.
Discussion and deliberation of the session
The following issues and points were discussed and deliberated in this session:
Regarding the recommendations that were presented as the findings of the IHR-JEE, the floor
asked what are the action plans to implement the recommendations. The presenter clarified that
action plan has been developed and has been circulated to the relevant agencies. The
implementation status will be followed up. To ensure that the findings of the IHR-JEE were
followed up and implemented accordingly, one recommendation put forward by the presenter
was to convene annual executive meeting regarding IHR.
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The current trend of specialization among veterinarians in Bhutan has been in epidemiology and
veterinary public health. Having presented the findings of the OIE-PVS evaluation on the need
for an enhanced monitoring of para-veterinarians in the field, a concern was raised on how to
balance the inclination of the veterinarians in specializing in para-clinical courses and the
country’s need for clinical specialist given the void created by the current trend of specialization.
The CVO informed the floor that the Department of Livestock has been striving to make linkages
with the universities in Thailand to attract veterinarians to specialize in the mainstream
veterinary clinical subjects. He also acknowledged that the Bachelor of Veterinary Science and
Animal Husbandry (BVSc. & AH) degree conferred by the Indian Universities is not equated to
Veterinary Medicine degree conferred by other universities in the world and this has been one
of the stumbling block for veterinarians in Bhutan to avail opportunity to pursue higher studies
in clinical subjects, which otherwise is relatively easy for non-clinical courses.
6 Session 4: Projects
6.1 One health approach to determine antimicrobial resistance profile in Salmonella isolates
collected from human, animal and food samples: Dr RB Gurung, National Centre for
Animal Health, Serbithang
Penicillin was discovered in 1928 by Alexander Fleming heralding the era of modern medicine. Thereafter
several other antibiotics were discovered and used by human and veterinary health care systems. Over
the time, it was found that many of the antibiotics in use have become ineffective in controlling infection.
This was mainly due to resistance developed by microorganism against antibiotics that were normally
used for treatment. Scientific communities for antimicrobial resistance were concerned about the extent
that would significantly impact human and animal health. In 2017, World Health Organization-Advisory
Group for Integrated Surveillance of Antimicrobial Resistance (WHO-AGISAR) identified Bhutan
among several other countries to pilot a study on One Health Approach to determine Antibiotic
Susceptibility Test (AST) profile of Salmonella organism isolated from human, animal and food samples.
Subsequently, the human, animal and food sectors jointly conducted this study. In human sector, Royal
Centre for Disease Control (RCDC) and Jigme Dorji Wangchuck National Referral Hospital
(JDWNRH) collected stool samples from hospital patients and outbreak areas. In animal sector, National
Centre for Animal Health (NCAH) collected faecal samples from poultry. In food sector, National Food
Testing Laboratory (NFTL) collected samples from various food and meat samples. Laboratories from all
sectors used harmonized protocols for bacterial culture, identification and AST profiling. AST profiling
was performed based on CLSI guidelines. Panel of antibiotics used were ampicillin, ceftriaxone,
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ciprofloxacin, Sulfamethoxazole/trimethoprim, chloramphenicol and tetracycline. In total 49 isolates
were recovered from 1261 samples: RCDC- 3.02% (15/496); JDWNRH-2% (6/300); NCAH-3.43%
(12/350); and NFTL-13.91% (16/115). In animal sector majority of the isolates were resistant to
ampicillin and sulfamethaxozole/TMP. The isolates were also resistant to tetracycline, another antibiotic
extensively used in animal sector. In human sector, response to all six antibiotics was good. However,
there were two isolates resistant to Ciprofloxacin, a quinolone group, which is a WHO priority antibiotic
for Salmonella. Genetic characterization of these isolates may decipher the resistant determinant in them.
In contrast to animal sector, sulfamethaxozole/TMP in human sector is still serving intended purpose.
It is probably due to the decision that the human health sector made to stop its usage in the past and re-
introduced. In food sector, isolates were resistant to chloramphenicol in addition to ampicillin and
sulfamethaxozole/TMP. This indicated the concern to consider antibiotic usage in food producing
animals.
6.2 An overview of Fleming Fund AMR project: Dr. Karma Rinzin, Department of Livestock
Antibiotics are used widely in human and animal medicine over decades. The antibiotics have saved
millions of lives since they were first discovered. Antibiotics are used in animals for improving welfare
and for enhancing the production. Our generation has benefited enormously from these important
medicines. However, the indiscriminate use of antibiotics led to emergence of resistant bacteria in which
antibiotics no longer work. No new classes of antibiotic have been discovered since the 1980s in contrast
to emergence of new microorganisms (bacteria) each year. Resistant bacteria arising either in human,
animals or environment may spread from one to another making AMR a one health issue and a global
public goods.
The UK Government has established the Fleming Fund to respond to the global threat of drug-resistant
infections, also known as antimicrobial resistance (AMR). The Fleming Fund is critical to achieving the
resolution of the 68th World Health Assembly, 2015 (WHA A68/20); 84th World Animal Health
Assembly (WAHA 2016); and in realising the ‘Political Declaration of the High-Level Meeting of the
United Nation General Assembly (UNGA) on Antimicrobial Resistance, 2016’. The UK Department of
Health and Social Care has appointed Mott MacDonald as the Fleming Fund Management Agent for
the Fleming Fund Grants Programme. Mott MacDonald is a global company with expertise in multi-
sectoral international development and fund management.
The aim of the Fleming Fund Grants Programme is to improve the ability of recipient countries to
diagnose drug-resistant infections, with an emphasis on antibiotics, and improve data and surveillance,
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to inform policy and practice at national and international levels. The overall goal is to avert the human
and economic burden of AMR. The Fleming Fund Grants are provided to participating countries through
three funding channels viz. Country Grant, Fleming Fellowship Scheme and Regional Grants.
Following the series of missions fielded by the Mott McDonald to Bhutan from January to June 2018,
Bhutan submitted Request for Proposals (RFP) for the first Country Grant in July 2018 to address critical
gaps in surveillance of antibiotic-resistant bacteria in Bhutan. The proposal was approved by the UK
Department of Health and Social Care and project will kick start soon after signing of memorandum of
understanding between the donor and the Royal Government of Bhutan.
This first Fleming Fund Country Grant for Bhutan will focus on putting in place the foundations for
antimicrobial resistance (AMR) and antimicrobial use (AMU) surveillance in the human and animal
health sectors. It will facilitate a stronger One Health approach to surveillance bringing together multi-
sectoral stakeholders to share surveillance data and gain a better understanding of AMR and AMU.
Discussion and deliberation of the session
The following issues and points were discussed and deliberated in this session:
The floor commanded the hard work that NCAH and the collaborating agencies has invested in
coming up with a very informative research on antimicrobials. To the clarification sought by the
floor with regards to the rationale behind use of different break points for different antibiotics to
determine resistance, Dr. Gurung informed that the break points were adopted as from the
Clinical and Laboratory Standards Institute (CLSI) guidelines.
The floor was informed that the duration of the first phase of the Fleming project was two years
and that ensuring infrastructural development such as laboratory and procurement of equipment
within the timeline would fit in as one of the success indicators.
In the context of detecting resistance in a sample collected from the barn owl in Thimphu, the
floor enquired if the impending Fleming Fund Project plan to collect and test samples from the
wildlife, to which Dr. Gurung informed that the wildlife will also be covered in the coming up
project.
To the question raised by the floor on drawing correlation among between the resistance pattern
among the samples collected from diarrheal sample, animal sample and food sample, Dr. Gurung
clarified there would not be any correlations made as the sample were collected from different
locations.
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7 Session 5: AMR and Food safety
7.1 AMR surveillance in children under 5 years of age with diarrhoeal cases: Mr Tshering
Dorji, Royal Centre for Disease Control Diarrhoea is a major cause of morbidity among the children under 5 years of age in Bhutan. Although
it was reported as the second most reported disease for many years, study on causative agents and
antimicrobial resistance of bacterial pathogens was never attempted. A case control study was conducted
from 2011 to 2015 at the four major hospitals in the country. A total of 3100 children with diarrhea were
enrolled for this study over the period of 5 years. Through this study it was determined that the major
of cause of diarrhea among children under 5 years of age was due to viral enteric pathogens. However,
significant proportion of diarrhea was also caused by several bacterial pathogens. Campylobacter,
Salmonella, Shigella, Aeromonas and certain serotypes of E.coli were the bacterial agents, while Rotavirus
and Norovirus were the viral agents significantly causing diarrhea mong the children. However, no
pathogens were detected 29% of samples. This study also found that the bacterial pathogens are
becoming resistant to most of the commonly used antimicrobial drugs used in the country. Therefore,
Bhutan needs to closely monitor the antimicrobial resistance pattern in human, animal and food through
surveillance and multisectoral collaboration to mitigate, prevent and control antibiotic resistance in the
country. Further research needs to be conducted to understand other causes of diarrhea among the
children in Bhutan.
7.2 Foodborne Disease Outbreak Investigation: A case study of One Health Approach: Dr
Sithar Dorjee, Khesar Gyalpo University of Medical Sciences of Bhutan
Food safety is a growing public health concern worldwide and WHO estimated the global burden of
foodborne diseases caused by 31 food hazards to 600 million illnesses (95% UI 420–960) and leading to
420,000 deaths (95% UI 310,000–600,000) in 2010. Many cases of foodborne diseases also go unreported
in all countries. Food is one of the important medium for spread of pathogens including AMR organisms
of significant public health. Increasing number of foodborne disease outbreaks are being reported in
Bhutan, mainly in schools, mass gathering events, and from foods consumed in hotels, restaurants, and
bakeries. However, there is no adequate foodborne disease surveillance system established yet in Bhutan.
Food foodborne illnesses prevention and control are complex problems that require One Health
approach, particularly between food safety authority and public health sector. In this presentation, the
importance of One Health approach towards prevention, investigation and response management of
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foodborne disease outbreaks will be highlighted using an example of sever foodborne illness that occurred
in July 2017 in Thimphu.
The suspected food foodborne illness was reported to the Royal Centre for Disease Control (RCDC) by
medical doctor on 27 July 2017. The preliminary assessment of the event by the RCDC found out that
the potential source of outbreak was related to the consumption of cakes at two birthday party events.
Based on this hypothesis, a joint investigation by the RCDC and Bhutan Agriculture and Food
Regulatory Authority (BAFRA) was conducted to identify the source of outbreak. The joint investigation
later confirmed that the illness was caused by the consumption of birthday cakes bought from a bakery
in Thimphu. The causative organism of the outbreak was Salmonella spp. RCDC and BAFRA jointly
investigated and contained further outbreaks by implementing appropriate control measures at the food
source.
7.3 Microbial load and prevalence of Salmonella in imported fresh beef at different points of
meat handling: Mr Kaling Dorji, Bhutan Agriculture and Food Regulatory Authority,
Thimphu
Introduction: Meat is one of the major source of food-borne diseases for humans especially when they
are processed in unhygienic conditions. A large quantity of fresh beef are imported from the border
towns of India which may be contaminated by range of pathogens including Salmonella spp. The study
was conducted to assess the general microbial load and prevalence of Salmonella spp. in the imported
fresh beef at 3 different meat handling points in Bhutan.
Method: A total of 216 fresh beef samples of 50 grams were collected from 3 identified meat handling
points from July to September 2011. The Total Plate Count and isolation of Salmonella were done as per
the International Organization for Standardization (ISO 4833:2003 and ISO 6579:2002) methods
respectively. The microbial load was performed from 81 randomly selected samples and Salmonella
isolation in all the samples.
Result: The general microbial load (log cfu/g) was higher in samples obtained at retail point (7.36 ±
0.09SD) followed by destination point (6.99 ± 0.17SD) and import point (6.66 ± 0.23SD) with significant
differences among the groups (p=0.01). Overall, 9.7% (21/216) of the samples were positive for
Salmonella with the samples from the retail point showing the highest prevalence (16.7 %) followed by
destination point (8.3 %) and import point (4.2%). Prevalence of Salmonella was significantly different
between the retail point and the import point (P<.05)
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Conclusion: The current slaughter processes, transportation and meat storage facilities of the retail shops
favor growth and multiplication of the microbes. High microbial load and Salmonella contains are bound
to pose serious public health problems if timely preventive measures are not employed.
7.4 Antibiotic resistance of Escherichia coli causing diarrhea; practices and factors
influencing use of antibiotics in swine farms in central region of Thailand: Dr Narayan
Pokhrel, Dzongkhag Veterinary Hospital, Pemagatshel
Antibiotics are extensively used in swine production to control different kind of diseases in the farms,
extensive use of antibiotics in food producing animals enhance the risk of antibiotic resistance in the
commensal bacteria of these animals. It is essential to understand the background of the swine farms,
drug usage, practice and factors influencing use of antibiotics in swine farms. This study was conducted
to investigate practices and factors influencing use of antibiotics in swine farms using questionnaire
surveys among 90 pig farmers and laboratory investigation to determine antibiotic resistance for E. coli
isolated causing diarrhea in pigs in Central Thailand (Ratchaburi, Nakhonpathom and Suphanburi). 176
E. coli isolates were tested for resistance and ESBL-production against 18 antibiotics by VITEK 2 system
(Version 07.01, bioMerieux, USA). 88 out of 90 farms in the three provinces used eight classes of
antibiotics on their farms for therapeutic and prophylaxis purposes. Majority of the farms used colistin
(76%). 71 % of the farmers reported E. coli diarrhea on their farms, large quantity of antibiotic was used
to treat respiratory disease as compared to other disease in the last two years. 52% of the farmers relied
on experience to use antibiotics with no supervision of veterinary personnel and in 97% of the farms
non-veterinary people administer antibiotic in animals. 91% of the farmers had easy access to antibiotics.
Farmers with education equivalent to bachelor degree and above and farmers who had received awareness
on AMR showed better knowledge on antibiotic use and antibiotic resistant as compared to farmers with
less education and received no awareness on AMR. In laboratory study of antibiotic susceptibility testing
of E. coli showed that there was a high prevalence of multi-drug resistance and ESB- producing E. coli
isolates in the swine population. Multidrug resistance was seen for 99% of E. coli isolates. These findings
call for a want of prompt actions on antibiotic overuse, antibiotic misuse and strict regulation on the use
and access to antibiotics on piggery farms in Central Thailand.
Discussion and deliberation of the session
The following issues and points were discussed and deliberated in this session:
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To the query raised regarding the chances of selecting incorrect antibiotics for determining the
sensitivity of a pathogen, the floor were clarified that such errors occurring is unlikely as the
antibiotic selection for conducting sensitivity test are done based on the WHO guidelines.
The floor raised questions regarding the importance of the mean duration of diarrhoea and age
groups in studying the diarrhoeal pathogens. The presenter clarified that the mean duration of
diarrhoea is critical to be recorded as different pathogens have different disease course and
similarly there are age specificity for different pathogens for which recording different age groups
becomes important.
The presentation on the high rate of Salmonella detection in meat imported from India was
alarming and the floor was informed that the best way forward would be to adopt risk-mitigation
measures such as proper handling and cooking of meat besides the stringent regulatory measures
that BAFRA enforce in transportation and handling at the meat vendor level.
8 Session 6: Zoonotic diseases
8.1 Emergence of Brucellosis in Bhutan: animal Brucellosis and human case report: Dr RB
Gurung, National Centre for Animal Health, Serbithang
Brucellosis is a highly contagious disease of ungulates affecting multispecies. B abortus is predominantly
found in bovines. It is a disease of breeding stock, with non-specific or limited symptoms, variable or
often long incubation period. Congenital infection is a significant issue with abortion, still
birth/premature births and variable proportion of aborting females. The organism survives in
environment for a considerably long period of time. Source of infection is usually from milk, colostrum,
semen, vaginal secretions and abortion materials. Transmission usually occurs through direct contact,
introduction of infected animal and ingestion of contaminated materials. Globally, bovine Brucellosis is
reported from Asia, Africa, Middle East and Latin America. In 2015, in Bhutan the National Centre for
Animal Health conducted serosurveillance in government cattle farms to determine prevalence.
Subsequent investigations were conducted in farms with high seropositive rates. In 2017, the Centre
again conducted national level surveillance all 20 districts and all milk cooperatives. Relevant samples
(serum, milk, abortion materials) were collected and tested using various laboratory tests (RBT, ELISA,
CFT, Culture and PCR).
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Prevalence of Brucellosis in cattle farms was found to be 6.28% (30/478) with highest prevalence in
National Jersey Breeding Centre (NJBC) (24.6%; (28/114). Current update on the status of Brucellosis
at NJBC was: 36.92% (48/130) (RBT); 37.69% (48/130) (ELISA); 36.15% (47/130) (CFT) and 13.33%
(6/45) (Culture and PCR). National prevalence of bovine Brucellosis was found to be 2% (21/1099) with
infection in 10 districts with highest infection rate in Haa. The human laboratory also reported four cases
of human Brucellosis from symptomatic cases. Based on the findings of bovine Brucellosis, significant
policy changes were made in animal sector such as occupational health safety, approval for vaccination
in animals and food safety intervention.
8.2 Status of Multi-drug resistant tuberculosis in the country (2014 – 2018): Mr Karchung
Tshering, Royal Center for Disease Control
The National Tuberculosis Reference Laboratory (NTRL) under the Royal Center for Disease Control
(RCDC) has been conducting drug resistant surveillance for tuberculosis (TB) since 2010 to monitor the
proportion and trends in drug resistance among new and previously treated TB cases in the country for
evidence based intervention and policy discussion to prevent and control the emergence of drug
resistance. All cases of multi-drug resistant tuberculosis (MDR-TB) registered for treatment in three
MDR-TB treatment centers between January 2014 to November 2018 were included to update the status
of MDR-TB in the country. All the demographic and drug resistance information were collected from
the online Tuberculosis Information and Surveillance System (TbISS). A total of 280 patients with MDR-
TB were registered for treatment between January 2014 and November 2018. 97.86% (274/280) of the
cases were laboratory confirmed while 2.14% (6/280) were treated as suspected MDR-TB cases after
failure of Category II regimen. 67.86% (190/280) of MDR-TB were new cases and 32.14% (90/280) were
among previously treated cases. Almost 80% of the MDR-TB cases were among the productive age group
of 10 to 39 years and students constituting 27.86% (78/280) of the cases. MDR-TB cases were more
among females (166/114) and 19.64% (55/280) of the cases were house wife. 40.36% (113/280) of the
cases has been residing in Thimphu over the last five years followed by Phuntsholing (12.86%; 36/280)
and Samdrup Jongkhar (5.71%; 16/280). Emergence of multi-drug resistant tuberculosis in particular
increasing proportion among newly diagnosed case is a growing public health concern and a threat to
TB control in the country. Immediate and appropriate policy interventions and infection control
measures need to be put in place to reduce the spread of drug resistant strains into the general population.
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8.3 A Case-Control Study to Identify Risk Factors of Multi-Drug Resistance Tuberculosis
(MDR-TB) among New Pulmonary TB Patients in Bhutan, 2018: Dr Tandin Zangpo &
group, Dechencholing BHU-I, Ministry of Health, Thimphu
Introduction: Multi-Drug Resistant Tuberculosis (MDR-TB) is an emerging threat to TB control efforts
and public health care Bhutan. According to Drug Surveillance Report by the RCDC 2017, 13% MDR-
TB was reported among new pulmonary TB cases in Bhutan.
Aim: To determine the risk factors of MDR-TB development among the new pulmonary positive TB in
Bhutan, 2017.
Method: In this unmatched case-control study, we recruited 46 new MDR-TB cases and 138 PTB
(Pulmonary TB) controls (1:3 case-control ratio), sampled all across the country.
Results: The major significant risk factors identified in our study were delay in diagnosis (OR=24.893,
p=<0.001), poor ventilation (OR=3.564, p=0.023), history of contact with MDR-TB patients (OR=7.249,
p=<0.001), participants who lived alone (OR=10.770, p=0.016), health staff unfriendliness (OR=9.631,
p=0.004) and TB medicine unavailability (OR=16.533, p=0.024). We also found that increasing in age
was protective or on the contrary, the risk was higher among younger age group (OR=0.940, p=0.005).
Innovative contributions: Recommended the National TB Control Program to create MDR-TB awareness
and screening by focusing on economically productive age groups. Reinforce Infection prevention and
control (IPC) at all levels. Health workers should be sensitized on improved communication skills,
patient counselling and over all patient management. The health care centres should ensure continuity
of anti-TB drugs supply through proper planning and monitoring.
8.4 Acute Undifferentiated Febrile Illness surveillance: Preliminary finding of causing agents:
Dr Sonam Wangchuk, Royal Center for Disease Control
Acute febrile illness is one of the most common reasons for seeking medical attention in Bhutan but
there is limited information on the frequency of specific infections. Rickettsia (Orientia tsutsugamushi
and Rickettsia typhi) was found as one of the common etiologies causing acute febrile illness and
outbreaks. Few leptospirosis cases were also diagnosed in human, however, no studies have been
conducted that attempt to determine the cause of acute undifferentiated febrile illness prospectively
through an entire year in admitted or OPD patients. The Royal Center for Disease Control has conducted
sentinel surveillance for past two years to determine etiologies among AUFI admitted patients. Among
common etiologies, orienta tsutsugamushi is found to be the most common causative agents of AUFI
followed by leptospira species and flavivirus (dengue virus chikungunya virus and Japanese encephalitis
26
virus). The proportion of those agents varies from place to place. The preliminary findings suggest more
study need to be conducted especially on rickettsial and related infection including anaplasmosis and cat
scratch disease that are vector and zoonotic origin.
8.5 Chronology of HPAI-H5N1 outbreak in Bhutan and genetic characterization of virus
involved: Dr RB Gurung, National Centre for Animal Health, Serbithang
Highly Pathogenic Avian Influenza (HPAI)-H5N1 virus is a notorious combination of HA and NA
subtypes that has impacted poultry and human since 1997. Until now, globally it has affected poultry
industries in 23 countries with at least one outbreak and 16 countries with human cases. Bhutan reported
first outbreak of HPAI-H5N1 in 2010. Ever since then Bhutan experienced 12 outbreaks in seven
different years until 2018. This study included the chronological orders of HPAI-H5N1 outbreaks from
2010-2018 encompassing spatial and temporal distribution. The study also included pathotyping and
genetic characterization of H5N1 virus involved in the outbreaks and determine its virulence and relation
to viruses reported in the region, respectively. Majority of the outbreaks were reported from border towns
or adjacent to border towns with India. The recent outbreak in 2018 was attributed to rescuing of birds
destined for slaughter. This is an indication to strengthen biosecurity at ground crossings points in border
towns. Given the small scale of poultry industry in Bhutan when compared to other developed nations,
the impact so far due to outbreaks has not been at disaster scale. All the outbreaks were rapidly contained.
Phylogenetically the virus HPAI-H5N1 involved in first outbreak in 2010 was assigned to clade 2.2.3
which is a close relative to A/Chicken/Bangladesh/CD-08(09)BL/-418/2009. Similarly, the virus from
2012, 2013 and 2015 outbreaks were assigned to clade 2.3.2.1a, a close relative of A/Water
fowl/Bangladesh/31935/2011/2.3.2.1a. The virus from 2016 and 2018 outbreaks were also assigned to
clade 2.3.2.1a, a close relative to A/Duck/Bangladesh/21909/2014. It was concluded that the HPAI-H5N1
viruses from Bhutan and Bangladesh outbreaks were common progenitor. Pathotyping of H5N1 virus
revealed presence of repeated basic amino acids at HA protein cleavage sites that attributed to high
pathogenicity.
Discussion and deliberation of the session
The following issues and points were discussed and deliberated in this session:
The floor raised question if the finding of sero-positivity to Leptospira spp. in human was
associated with Kidney failure to which Dr. Sonam Wangchuk clarified that they have collected
sample from patients with kidney issues, but they couldn’t find indication of leptospira however
27
he acknowledged that the sample size was very low. He expressed his plan of doing a more
organized study.
To the question asked regarding the detection of Mycobacterium bovis in the large number of
human TB reported, the presenter informed the detection of M. bovis was very low. Of the 400
samples that were positive to TB, only one case was of M. bovis.
To the concern raised by the floor regarding the lack of information sharing upon detection of
pathogens in the studies to the field hospital, Dr. Sonam Wangchuk informed the floor that
information has been shared through quarterly disease bulletin.
To an issue raised regarding the requirement of re-registration of TB patients outside Thimphu,
the floor was clarified that the database can be accessed from across the Bhutan and therefore,
once the patient is out of Thimphu, there is no need to re-register.
Regarding the brucellosis cases presented in the NJBC, the floor raised their concern regarding
the risk mitigation measures being applied to minimise the risk of spreading disease to other
parts of Bhutan since Samtse NJBC being a nucleus breeding farm. To this Dr. Gurung informed
the floor that the animals are screened before supplying and only the animals that test negative
are allowed to move out of the farm.
A discussion was ensued regarding the decision of vaccinating cattle against Brucella over test
and cull protocol. The floor enquired the rationale behind this decision to which Dr. Gurung
responded informing that the decision was made during the National Brucellosis Workshop
conducted at Paro between 18-19 June 2018. Some of the reasons that he provided were that
culling was against the sentiments of the cattle owners, there were no slaughter house in Bhutan,
and none of the cattle owners whose cattle tested positive to Brucella were willing to send their
cattle to the slaughter house. He also mentioned that brucellosis prevention and control plan will
be developed and implemented after understanding the real disease situation in the country.
9 Session 7: Diseases at human-animal-wildlife interface
9.1 Synantrophic rodents as reservoir of zoonotic pathogens in Bhutan: Dr Yoenten
Phuentshok, National Centre for Animal Health
The number of acute undifferentiated febrile illness cases (AUFI) has been on the rise recently in Bhutan
leading to mis-diagnosis and inadequate treatment. Bhutan, known for its rich biodiversity and strong
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conservation policies and has more than 200 species of mammals, including approximately 80 rodent
species. Rodents are the most speciose mammalian orders and are well known reservoirs and vectors of
many emerging and re-emerging infectious diseases globally. However, little is known about their role
inAUFI cases and zoonotic disease transmission in Bhutan. A cross-sectional study of zoonotic disease
pathogens in rodents was performed in Chukha district, Bhutan where a high incidence of AUFI cases
had been detected in people. Field collections of rodents were performed in 2016 and 2017. Rodents in
and around houses and agricultural fields were trapped using live wire mesh traps and samples. Samples
were tested by Polymerase Chain Reaction (PCR) for O. tsutsugamushi and other
bacterial and rickettsial pathogens causing Bartonellosis, Borreliosis,
human monocytic ehrlichiosis (HME), human granulocytic anaplasmosis (HGA), leptospirosis, and
rickettsiosis. A phylogenetic analysis was performed on all rodent species captured and pathogens
detected. Four out of the twelve rodents (33%) sampled in 2016 tested positive by PCR for a zoonotic
pathogen. Anaplasmaphagocytophilum, Bartonella grahamii, and B. queenslandensis were identified for
the first time in Bhutan. Leptospira interrogans was also detected for the first time from rodents in
Bhutan. Our study shows that sampling even few rodents in Bhutan can provide important information
about potential risks of rodent-borne zoonotic diseases. This is the first study conducted in Bhutan
dwelling into the role of rodents in transmission and maintenance of zoonotic pathogens and more
studies targeting a larger sample size, diverse species of rodents covering more localities, diverse
landscapes and varying seasons.
9.2 Bat diversity in Bhutan – implications for emerging infectious disease control: Mr Sangay
Tshering and Tshering Gyelpo, College of Natural Resources, Royal University of
Bhutan, Lobeysa
We investigated bat diversity and richness in broadleaf and conifer dominated forest of south-western
Bhutan. Fieldwork was carried out from July 2016 to April 2017 and from March to September 2018
using mist nets and scoop or hand nets. Main objective of the study was to document bat diversity and
richness of specific species. We captured 171 bats of 14 species belonging to five families. The two species
(Myotis siligorensis Horsfield, 1855 and Rhinolophus affinis Horsfield, 1823) accounted for almost
51.59% of the total capture. Species richness of bats differed depending on habitat types. Myotis
siligorensis were captured more often from broadleaf dominated forest whereas Rhinolophus macrotis
Blyth, 1844 and Rhinolophus affinis were more common around human habitation. The present study
contributed five new records for the country increasing bat diversity record to 70 species. Earlier Bhutan
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has 65 bat species documented which constitutes 33% of all mammal taxa of which nine species are
megachiroptera or fruit bats and 56 species are microchiroptera belonging to 5 families. The most
common group of bats in Bhutan is the evening bats (Vespertilionidae) with 34 species. Despite bats
being the most advantageous flying mammals on earth, it has been cursed as an evil spirit and vilified as
an ugly creature and dirty in many parts of the Himalayan region. In some other countries, bats are
known for spreading infectious disease. In Bhutan, little is known about bats as there is a lack of
appropriate baseline information on impacts of bats. To fill up this gap, detail study is required.
9.3 Ecology of Lyle’s Flying Fox (Pteropus lylei) at the bat-human interface in Cambodia:
Dr Kinley Choden, Nature Conservation Division
Introduction: Three Pteropus species are thought to occur in Cambodia. All three are listed in Appendix
II of CITES (convention on international trade in endangered species of wild fauna and flora, 2011) and
considered Vulnerable – IUCN Red List (“The IUCN Red List of Threatened Species,” 2008). Pteropus
species have been identified as the natural host for Nipah virus (NiV). NiV was initially isolated and
identified in 1999 during an outbreak of encephalitis and respiratory illness in Malaysia and Singapore.
Recurring outbreaks occur in Bangladesh. To improve understanding of NiV ecology and to elaborate
the frequency and magnitude of fruit bat movements, satellite telemetry is a valuable tool used to assess
abundance and long- range movements of P. vampyrus in Malaysia; to characterise the flying fox
colonies; to study the roosting behaviour and habitat selection of P. giganteus and to study the foraging
behaviour and landscape utilization of flying foxes. This can be used to develop appropriate host
management strategies that maximize the conservation of bat populations and minimize the risk of
disease outbreaks in domestic animals and humans.
The objective of this study is to describe the interface between Pteropus lylei and human and their
domestic animals in Koh Thom District, Kandal Province, Cambodia.
Materials and methods: Study site: Wat Pichey, Sakor, Koh Thom District, Kandal Province.
Study period: 18th April to17th May 2016. The collaring of the bats in two shifts: 9 bats from 18th to 21st
April and 5 bats from 3rd to 6th May 2016; Bat Collaring: Mist nets on two sites at the roost for bat
capture; Collar put on sedated bats after selection, fed and released
Data collection: two weeks after each collaring; Spatial data and site characterization: mapped on Google
Earth (version 7.1); Tree species visited by bats and ‘points of interest’ noted ~interview of villagers;
Habitat use: three major categories of GPS points: roost locations, foraging and commuting locations;
Foraging points: Residential area, plantation, agricultural lands (any cultivated land not included in
“plantations” and “residential areas”), uncultivated areas and rivers; Spatial Analysis: Used adehabitat
package in R software (Version 3.2.3) to calculate the MCP (Minimum Convex Polygon: smallest
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possible convex polygon around location data) and sp package in R software to calculate the maximum
linear distance travelled from the roost per night.
Results: Movement patterns and flight distance: Maximum distance travelled per night ranges widely
(6.88 to 105.14 km; average 28.3km); Site fidelity displayed by bats (returning to the same site from 3-
11 nights); All bats shared at least one and as many as eight foraging locations (average 3km from roost)
with another bat; QGIS to analyze the trajectories of each bat and to generate heatmaps based on kernel
density estimation. The density was calculated based on the number of points in a location, with larger
numbers of clustered points resulting in larger values.
Discussion: Our study bats mostly foraged in residential areas (53.7% of foraging locations), rather than
in plantations (25.6%): The greater diversity of fruit typically found in backyards compared to plantations
could possibly explain this; shows a particularly strong interface through residential backyards where
potential contact between bats and humans is expected to be higher due to continuous human presence;
some individuals also showed fidelity to foraging areas indicating repeat utilization once a food resource
was located. Studies say this is more energy efficient strategy rather than random foraging; Further
information on the use of fruit partially eaten by bats by local residents would help to characterize
transmission risks and inform preventative actions; Research on palm sap collection in the area is needed
to assess the risk associated with this potential transmission route; Movements to other roost sites are
relatively frequent. visits to four other roosts including one 105 km from the study site were observed.
These results are consistent with a regional circulation of different NiV strains in Southeast Asia
suggested in previous studies; Our study group had a male bias, with only one female tagged with the
GPS device. Other females caught were not included in the study as they were possibly pregnant or
lactating during this season. Therefore, it remains unclear if the sexes differ in their foraging behavior;
Also, similar study needs to to conducted at different times of the year to study their temporal behaviour
and movement patterns; We deployed GPS devices on a limited number of individuals, preventing us
from any generalization of the observed patterns at the population level. However, the results were
consistent between the different individuals, and provided useful information on the movement and
foraging ecology of P. lylei in Cambodia; Nine of the 14 GPS collars we deployed lasted for at least 10
nights (average 11.8 nights), and 80% of the data were valid; While our data represent a snapshot in
time, they nonetheless illustrate the potential for foraging behavior to potentially facilitate NiV
transmission to humans and domestic animals; To date, no transmission from P. lylei to human or
animals has been recorded despite the circulation of NiV in this species in Cambodia and Thailand;
Nevertheless, understanding the ecology of P. lylei may significantly improve our ability to target limited
resources for interventions, and educational campaigns that discuss the risks of NiV to people and their
domestic animals; Awareness and education for villagers regarding the ecological importance of flying
foxes; their role in disease transmission; and prevention measures seems to be a primary need.
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Discussion and deliberation of the session
The following issues and points were discussed and deliberated in this session:
With regards to the presenter’s comment on bats being believed as a reservoir for rabies, the
floor commented that the association of bat with rabies is not just a belief but a proven reality
and appropriate PPE set should be worn while handling bats.
Given that the presenter works with the bats and captures them for identification, the floor
expressed that such activity would be a great opportunity to screen for pathogens and would
provide an area of collaboration among the DoL, DoPH and DoFPS. The floor were informed
that a separate bat borne zoonosis research study is in plan in collaboration with scientist from
Japan.
Sample size for the rodent study was questioned to which presenter acknowledged that the study
had very small sample size nevertheless the team being able to isolate and record pathogens for
the first time from such a small number of rodent was very significant.
10 Session 8: Community Perceptions and Practices
10.1 Determinants of Rabies PEP seeking and compliance behaviour – Hospital and
commmuniy-based contact tracing survey: Dr Kinley Penjor and group, Dewthang
Military Hospital, Ministry of Health
Dog bites are the main source of rabies infection and death in humans, contributing up to 99% of all
cases. We conducted a contact-tracing study to evaluate the health seeking and treatment compliance
behaviors of people following potential exposure to rabies in rabies endemic south Bhutan.
The rabies post exposure prophylaxis (PEP) register was used to identify animal-exposed victims who
had visited five hospitals in south Bhutan between January and March 2017. They were traced and further
data were collected from them using a structured questionnaire. A snowballing technique was used to
identify victims who did not seek PEP.The survey was conducted between April and June 2017. Logistic
regression was performed to assess factors associated with PEP-seeking and compliance behavior by the
victims.
Of the 630 who reported to hospitals, 70% (444) of people could be traced and additional 8% (39) who
did not seek PEP was identified through contact tracing. Therefore, a total of 483 people were
interviewed. Seventy one percent (344/483) of exposure were due to animal bites of which 80% (365/455)
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were considered to be provoked incidents. Common reasons for not seeking health care included
assumptions that risks of infection were minor if bitten by an owned or vaccinated dog. The victims who
are male (OR: 0.36; 95% CI: 0.16-0.77) and educated (OR: 0.41; 95% CI: 0.17-0.96) were less likely to
seek PEP, while those that experienced unprovoked bite (OR: 5.10; 95% CI: 1.20-21.77) were more likely
to seek PEP in the hospitals. Overall, 82% of the victims sought PEP from the hospitals within 24 hours
after exposure. Eighty three percent completed the PEP course prescribed by the physician. The
respondents living in urban areas (OR: 2.67; 95% CI: 1.34-5.30) were more likely to complete the
prescribed PEP course than rural dwellers.
In conclusion, there is high risk of rabies infection in southern Bhutan. It is critical to bridge knowledge
gaps and dispel existing myths which will help to improve PEP seeking and compliance behavior of
people exposed to rabies infection from animals. A risk-based advocacy program is necessary to prevent
dog-mediated human rabies deaths.
10.2 One Health profile of local communities living within a protected area in Bhutan: Dr
Kinley Choden, NCAD
A One health community-based study was conducted to assess the knowledge, attitudes and perceptions
regarding health issues of local people depending on their proximity to protected areas in Bhutan. Two
sub-districts were selected inside and outside Jigme Dorji National Park for comparison. Snowball
sampling method was applied for participant selection. Data was collected through use of both qualitative
and quantitative approaches involving individual interviews (n=61), 3 focus group discussions, personal
observations and active participation in villagers’ activities. Key areas of enquiry included the awareness
and perceptions of the role played by wildlife in the epidemiology of diseases in humans and their
livestock, the implications on coexistence between local communities and protected areas and on the
surveillance of disease outbreaks in human-livestock-wildlife interface areas.
The study found that more than 90% of the respondents reported owning at least one livestock. In terms
of veterinary health care services, animal owners found it was very easily accessible and the only concern
was the need for additional staff (20%). Livestock living inside the Park were reported to share the same
grazing area and water resources with wildlife more frequently than those living outside the Park. People
were generally aware of livestock animals and wildlife sharing some diseases (55.2%), while very few
were aware of possible disease transmission from animals to humans (11.7%). With regards to human
healthcare, people considered that the access was generally easy in both areas. Benefits derived from the
forest were reported to be higher for people living inside the Park. However, the damages from wildlife
to crops and livestock were also reported to be higher inside the Park. The willingness of people to
conserve wildlife species depended on their appreciation of aesthetics, of the level of damages that it
33
causes to their crops and livestock, and also on the religious belief that all animals are sentient beings
that shouldn’t be harmed. People living outside the Park were less aware of whom to inform for wildlife
rescue emergencies. People from outside the Park also believed that living inside the Park would be
oppressive, although they believed that they would be healthier living closer to nature.
The study highlights the need for awareness of zoonotic risks among communities living inside and at
the periphery of protected area, and the need for community engagement and participation in dealing
with health issues of human, livestock and wildlife.
10.3 Knowledge, Attitude, and Practice survey rabies among cattle owners in two districts of
Bhutan: Dr Sangay Rinchen and group, Regional Livestock Development Centre,
Tsimasham
Background
Rabies is eliminated from the northern and central parts of Bhutan, but it remains endemic in the
southern region that shares a porous border with India. Control programs are challenged by free cross-
border movement of dogs. Annually around 17 cases of rabies in dogs are reported. Frequent spill-over
infection from dogs to cattle and other livestock species poses serious threats to public health and
economic sustainability.
Materials and methods
As part of an approach to prevent rabies in cattle, we conducted a Knowledge, Attitude, and Practice and
risk perception survey among cattle owners in selected rabies endemic and non-endemic districts of
Bhutan. 563 cattle owners were interviewed using a structured questionnaire. The data were managed in
Epi Info version 7.0 and analysed using R. Descriptive statistics were used for analysing demographic
characteristics, and the association analysis was conducted using multivariable logistic regression.
Results
88% of participants had heard of rabies. Only 40% of the participants who had heard of rabies had
adequate knowledge about rabies. Multivariable logistic regression analysis showed that residing in
endemic areas and having seen a rabies case were significantly associated (α=0.05) with having adequate
knowledge. 70% of the participants who had heard of rabies had a favourable attitude towards rabies
prevention. Residing in non-endemic areas and having seen a rabies case were significantly associated
(α=0.05) with having a favourable attitude. 51% of the participants reported rabies as a curable disease.
92% of participants reported disposing of a bovine carcass that had died of illness. However, 8% reported
that they would either dress and sell the meat, dress for consumption, or sell the whole carcass. More
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than 70% of the participants reported engaging in farm activities that could potentially expose them to
rabies and other pathogens, although only 25% of the participants reported using personal protective
equipment while undertaking these activities.
Conclusion
Despite a high level of awareness, we observed that there is a lack of comprehensive knowledge about
rabies regarding hosts, transmission modes, the outcome of rabies infection, and health-seeking
behaviours. Our study highlights the need to enhance and strengthen rabies education programs to
address the knowledge gaps that have been identified.
Discussion and deliberation of the session
The following issues and points were discussed and deliberated in this session:
Regarding the study site selection for the KAP study, a question was raised on why the eastern
study area was considered rabies free when we have been experiencing outbreaks. The presenter
clarifed that the study was designed before the outbreaks occurred in the eastern Bhutan. Before
the rabies outbreak in 2016 in Trashigang, an eastern district of Bhutan, particularly Trashigang
was considered free of rabies.
11 Session 9: Disease Prevention and control Strategies
11.1 Strategic framework for elimination of dog mediated rabies in Bhutan: Dr Tenzin,
National Centre for Animal Health, Department of Livestock, Serbithang
Rabies cause approximately 59,000 human deaths annually globally, with the vast majority of deaths
occurring in Africa (36.4%) and Asia (59.6%). Domestic dog is responsible for more than 99% of human
rabies deaths in the world. Elimination of rabies in humans can be achieved by eliminating rabies in
dogs and other reservoirs. Rabies in dogs can be eliminated through sustained mass vaccination, control
of dog population and responsible pet ownership. Human rabies can be prevented through prompt
administration of post-exposure prophylaxis (PEP) following rabid animal bites. Efficient and effective
surveillance system is critical to detect cases in humans and animals. Adoption of an integrated One
Health approach is important in the management of rabies prevention and control strategies.
Rabies is a notifiable disease in Bhutan. Rabies commonly occurs in the southern belt of Bhutan along
the borders with India; however, isolated cases have been documented in the interior parts of the country,
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as a result of incursion from bordering areas. Therefore, it is important to control the disease at the
source and prevent endemic transmission in the country. As part of the global effort to eliminate rabies
by 2030, Bhutan has been actively implementing various strategies to control and eliminate dog-mediated
rabies in the country through One Health approach. Bhutan aims to achieve zero dog-mediated human
rabies death by 2023.
Although cross-border rabies transmission is a challenge, dog-mediated human rabies elimination is
feasible in the country. Bhutan has achieved drastic reduction of human rabies deaths over the decades
to zero cases during 2017 and 2018. Self-assessment of national rabies prevention and control program
was conducted on World Rabies Day i.e. 28 September 2017 through consultative workshop using
Stepwise Approach towards Rabies Elimination (SARE) tool. The assessment indicated that Bhutan is in
right track and is currently in Stage 3.5 with much of the activities being achieved. Therefore, this make
a good case for Bhutan to work towards elimination of dog mediated human rabies by 2023 as part of
12th Five Year Plan program. However, the maintenance of rabies free status would require continuous
implementation of various activities and enhance effective surveillance system to detect cases in both
human and animals for early response. For instance, dog vaccination, rabies awareness and risk
communication, making PEP accessible and building capacity for rabies diagnosis and surveillance are
crucial and are the common activities from the beginning and across all stages of the elimination
program. This “Strategic plan for elimination of dog-mediated human rabies in Bhutan” provides both
input and performance based indicator activities to be implemented to eliminate rabies deaths in humans
in Bhutan with following goal, objectives, strategies and organization set up to implement rabies
elimination program in the country:
Goal: To eliminate dog-mediated human rabies by 2023 and maintain freedom by 2030 in Bhutan
Objectives
1. To enhance rabies prevention and control in dogs;
2. To provide timely access to post exposure prophylaxis to all human following exposure to rabies;
3. To reduce dog population at a manageable level and promote responsible pet ownership;
4. To enhance community engagement on rabies prevention and control through community
awareness and education, and
5. To institute coordination and collaboration mechanism through One Health approach at all
levels
Guiding principles of the Strategic framework
1. Dog bites are the primary source of human rabies. Human rabies prevention is possible through
mass dog vaccination, promotion of responsible pet ownership and dog population control
programmes with a partnership approach (One Health approach).
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2. Dog bites are a medical urgency and thorough cleaning of a bite wound is an important step
which needs to be promoted at the community level through advocacy, awareness and education.
3. Post-exposure rabies prophylaxis should be made easily accessible, affordable and available for
those that require it.
4. Enhanced surveillance is the key for monitoring the progress of the control program
Strategies for Rabies elimination
The following are the key strategies that will be implemented to achieve rabies elimination plan in
Bhutan.
1. Organizational setup of rabies control
2. Prevention and control of rabies in dogs
3. Prevention of rabies in humans
4. Strengthen and enhance surveillance
5. Strengthen disease outbreak response
6. Conduct and promote operational research
7. Advocacy, communication and social mobilization
8. Enhance partnerships and coordination
9. Cross-border control
10. Resource mobilization
11.2 Strategy for prevention and control of zoonoses: Mr Rinzin Kinga Jamtsho, DoPH, MoH
We live in a region where animal and human populations live in ever-closer proximity, allowing cross
species transmission of pathogens including viruses that has pandemic potential. In particular, the Asia-
pacific region is known as the global hot spot for emerging infectious diseases and has witnessed several
outbreaks of high impact diseases such as avian influenza, Middle East respiratory syndrome Coronavirus
(MERS-COV), dengue, Zika virus including recent Nipah Virus Outbreak in Kerala, India from April
to May 2018.
In Bhutan, Scrub Typhus and Leptospirosis are one of the main causes of acute febrile illness with many
cases reported from southern and central districts of Bhutan. To date, 13 outbreaks of Avain influenza
(H5N1) have been recorded in poultry and an average of 17 Rabies outbreaks in animals annually with
the annual prevalence of 7,000 dog bites in human. Furthermore, prevalence of parasitic zoonotic diseases
such as echinococcosis, cysticercosis and trematodes is unknown although Neurocysticercosis (NCC) is
associated with 6% to 25% of epilepsy in a cohort from Bhutan. Furthermore, the presence of newer
37
threats such as environmental, chemical and radiological emergencies as well as uncommon patterns of
antimicrobial resistance (AMR) add to our regional vulnerability.
Particularly, Bhutan faces significant ant risk from zoonotic diseases due to: (i) increasing demand for
livestock products, (ii) growing number of intensive livestock and poultry farms, (iii) ease and increasing
movements of animal or animal products both within the country and through imports, and (iv)
increasing movement of humans. This has presented a significant challenge in terms of the technical
capacity, budgetary requirements and other resources for prevention and control of zoonoses. Therefore,
Prevention and control of zoonoses will increasingly require the application of sophisticated
epidemiologic and molecular biologic technologies, changes in human behavior, a national policy on
early detection of and rapid response to emerging infections and a plan of action. A comprehensive
programmatic strategy for prevention and control of zoonoses in addition to the Bhutan One Health
Strategic Plan 2017-21 needs to be developed.
11.3 Bhutan Wildlife Health Strategy: 2019 – 2028: Dr Kinley Choden, NCD
The main rationale behind developing Bhutan Wildlife Health Strategy are because of wildlife and
wildlife diseases impact on human health, livestock health on biodiversity and species conservation since
“wildlife disease monitoring, prevention and control are crucial factors for safeguarding biodiversity and
public and animal health worldwide –World Animal Health Organization (OIE)”. The draft document
contain the following:
Vision: A comprehensive and effective wildlife health program contributing towards conservation of
biodiversity, protection of health and life of humans and animals, and ensure sustainable livelihood.
Scope: This strategic documents is limited to management of wildlife health, research and diseases that
have potential to spread at human-domestic animals-wildlife interface
Objectives:
To institute and mainstream wildlife health program in the country;
To establish wildlife diseases surveillance program to detect emerging and novel infectious
diseases, including zoonoses
To strengthen human resources capacity for wildlife health programs
To establish and strengthen wildlife disease outbreak preparedness and response capacity
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To implement one health approach in prevention and control of infectious diseases at the human-
domestic animal-wildlife interface
To promote collaborative research on conservation medicine, wildlife health, ecology and
rehabilitation
To promote awareness and education on wildlife health and diseases
To strengthen institutional linkages at the national, regional and international levels
To mobilize resources to strengthen wildlife health programs
Startegic framework
Strategic goal 1: Establish and strengthen wildlife health facilities
Strategy 1.1: Develop Wildlife health policy and enabling instruments for functioning of Wildlife Health
facilities
Strategy 1.2: Institute wildlife health centersat strategic locations
Strategy 1.3: Strengthen HR capacity of wil
dlife health professionals
Strategic goal 2: Establish wildlife disease surveillance system
Strategy 2.1: Institute a wildlife disease information management system
Strategy 2.2: Generate profile of important wildlife diseases
Strategy 2.3: Establish early detection of wildlife diseases and pathogens
Strategy 2.4: Strengthen HR capacity for wildlife disease or pathogen surveillance
Strategic goal 3: Strengthen wildlife diseases preparedness, response and recovery system
Strategy 3.1: Prevention of new wild animal pathogens introduction and its associated events
Strategy 3.2: Establish effective wildlife disease preparedness and response system
Strategy 3.3: Strengthen human resource capacity to prevent and responds to wildlife disease outbreak
Strategy 3.4: Wildlife disease outbreak recovery plan and operations system
Strategic goal 4: Promote research and knowledge on wildlife health
Strategy 4.1: Establish and institutionalize wildlife health research
Strategy 4.2: Strengthen wildlife health research capacity
Strategy 4.3: Establish priority wildlife disease mapping
Strategy 4.4: Detection of wildlife disease in sentinel species
Strategy 4.5: Establish wildlife bio-repository and natural history museum
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Strategy 4.6: Establish disease reservoir capacity in wildlife species
Strategic Goal 5: Resource mobilization
Strategy 5.1: Secure financial resources
Strategy 5.2: Pursue internal support for human resource, technical facilities
Strategic Goal 6: Develop and strengthen liaison and collaborations with international and local partners
Strategy 6.1: Develop and strengthen collaboration amongst key national stakeholders
Strategy 6.2: Initiate and establish collaboration with international organizations
Strategic Goal 7: Strengthen advocacy and communication on wildlife health
Strategy 7.1: Efficient and effective management of communication at every level
Strategy 7.2: Increase awareness on wildlife health and diseases to the policy makers, Ministry of
Agriculture and Forests officials and other stakeholders
11.4 Animal welfare with focus on dog population management in Bhutan: Dr Karma Rinzin,
Department of Livestock.
Animals have always been an important part of Bhutanese culture and have helped contribute to the
socioeconomic development of the country, whether it be through the production of food and fibre, draft
power, transportation or as part of the country’s cultural identity. More recently in the larger urban
areas, companion animal ownership of dogs and cats is becoming an increasingly common trend.
Good animal welfare requires not only the combination of good nutrition, good health, suitable living
environment, good handling practices and a humane slaughter or death, but also the ability of the animal
to express natural behaviours. Animal welfare thinking these days is now moving beyond the traditional
‘Five Freedoms’ which focused on the absence or minimization of negative states (e.g. hunger, fear,
disease, pain), towards recognition of the importance in also providing opportunity for the animal to
experience positive experiences such as comfort, pleasure, stimulation and satisfaction.
The DoL and BAFRA developed Bhutan Animal Welfare Standards and Guidelines for different types of
animals such as dairy, piggery, poultry, working and companion animals by covering all aspects of animal
welfare. This standard and guideline should be considered in conjunction with Chapter IX and other
relevant Chapters and sections of the Livestock Rules and Regulations of Bhutan 2017, relevant guidelines
and specific disease prevention and control plans.
40
Considering the number of problems associated with increasing free-roaming dogs in Bhutan, several
control measures have been attempted since 1970s to control rabies and reduce dog population in Bhutan.
This include shooting and poisoning in 1970’s and early 1980’s; translocation in 1990’s; and impounding
in mid 2000’s. The past control measures were not successful due to number of animal welfare issues
and poor acceptance of the Bhutanese people. In 2009, the Department of Livestock, Royal Government
of Bhutan and Humane Society International (HSI), USA embarked on a long term project titled the
“National Dog Population Management and Rabies Control Programme in Bhutan” (NDPM & RCP).
Through this project the capture-neuter-vaccinate-release (CNVR) programme has been carried out with
dogs being captured, neutered, vaccinated and released back to their place of origin. From 2014 onwards
community animal birth control was initiated with the aim to involve the local communities and relevant
stakeholders. As of December 2018 about 95,000 dogs were sterilized and vaccinated covering all the
districts.
The DoL in consultation with other stakeholders developed National Dog Population Management
Guidelines. This guidelines aims to formally institute and mainstream dog population management
(DPM) in the country; encourage community engagement; create conducive policy and legislation
framework for DPM; reinforcing CNVR program; and continuous monitoring and evaluation of the
DPM program. Through implementation of these strategies we aim to improve the welfare of dogs;
reduce the dog population to acceptable and manageable level; and achieve zero dog mediated human
death due to rabies by 2023.
Discussion and deliberation of the session
The following issues and points were discussed and deliberated in this session:
The floor raised issues regarding the challenges faced in implementing the National Influenza
Preparedness Plan (NIPPP) during the events of bird flu outbreaks. Further, as the current
version of NIPPP was last revised in 2014, a need was felt to revise the document by incorporating
short-comings and experiences learnt so far. In this regard the floor resolved that a technical
working to be formed and incorporate the changes as amendment in the existing the NIPPP
document.
Integrated Bite Case Management (IBCM) was discussed as an important option that Bhutan
should adopt to achieve the goal of eliminating dog-mediated human rabies. In this regard, the
41
floor decided to form a technical group to frame pragmatic IBCM modalities for implementing
IBCM in the country.
12 Session 10: Group work and plenary presentation
Dr Pasang Tshering facilitated the group work session. During the world café session, the participants
were broken down into four groups. Each group were assigned to work on few of the selected topics
presented below in the table
At the end of the group exercises, a plenary presentation was done to present the outcome of the
discussion.
Station A Station B Station C Station D
Facilitator-Dr Sithar
Dorjee
Dr Sonam Wangchuk Dr Tenzin Mr Rinzin K
Jamtsho
Institutionalization
of one health at
every levels
Strategy for
sustainable
funding for one
health activities
Identification and
prioritization of one health
activities for implementation
Inventory of expertise related
to
zoonosis/OH/Epidemiology/
lab capacity
Identification
of priority one
health research
for
implementation
Sustainable
education on
one health in
the institutions
Strengthening
of
collaboration
and
networking
First round-30
minutes
1. Appoint a rapporteur for each Group who populates the outputs on
a flip chart. He/she stays at the first station and finalizes the final
outputs
2. After the station rotation is complete the groups will return to the
first station and refine the outputs.
Rotation between
stations after every
15 minutes each
Refinement of
outputs – 15-30
minutes
14:00- 15:00 Plenary session of World Café: 15 minutes for each station group.
42
Group findings
Group A: Institutionalizing of OH at Every Level & Sustainable funding
District OH Committee
• Dasho Dzongda, Chair
• DVO
• DLO
• CMO/MS
• CFO
• OIC, BAFRA
• Thromdey Representative
• Disaster Focal Person
• SP/OC, RBP
• Member secretary: DHO/DLO
Additional Members proposed by other groups:
• Immigration, Armed Forces, Point of entry OIC
• DYT Chairperson
• Open invitation for academia
• Technical staff of regional offices (Livestock and Hospital)
Thromdey OH Committee
• Dasho Thrompon, Chair
• MS/CMO
• TVO
43
• CFO
• TEO
• OIC, BAFRA
• Disaster Focal Person
• SP/OC, RBP
• Member secretary: TVO/DHO
Additional Members proposed by other groups:
• Suggest to include Thromdey Health Officer as and when appointed
• Establishment of Dungkhag and Gewog OH Committee need to assessed after 5-10 years
• TOR for the committees needs to be developed
Sustainable Funding for OH
• Permanent OH Secretariat (upon approval): RGoB will fund the Maintenance and Operational
Cost
• Initial Set up by Fleming Fund
• OH Secretariat will mobilize funds for Conferences (possible donors are WHO, OIE, FAO,
NGOs etc.)
• Funding for District/Thromdey Level Meetings: Dzongkhag annual budget (Member secretary
will ensure incorporation of the budget)/OH Secretariat will mobilize
• Collaborative Research: Fund mobilization by OH Secretariat/Sectors while research might be
carried out by Technical agencies initially….
• OH Contingency Funding/Emergency Funding……????
Proposal: Disaster management and specific sector
• OH Advocacy and Awareness: Take Advantage of sectoral specific meetings, sharing and pooling
of funds
Group B: Priority OH activities
National Level
• Develop plan for resource mobilization
• Capacity building for field staffs on surveillance and outbreak management
44
• Advocacy on guidelines, SOP and strategies related to zoonoses
• Develop Information sharing mechanism at national level and district level
• Annual OH conference
• Institution of OH secretariat (
• Quality assurance system for surveillance and laboratory system
• Monitoring and Evaluation
Regional/District level
• Develop capacity to conduct disease outbreak and response for priority zoonoses
• Advocacy on priority zoonoses
• Disease surveillance on priority zoonoses
• Develop plan for resource mobilization at district level
• Information sharing mechanism at District and Geog level
• Establishment of OH core-group at district, Thromdey and Geog level
Inventory of expertise: Laboratory and Epidemiology in the country
Health Animal Health Food safety Wildlife
Laboratory capacities (Diagnostics)
Brucellosis,
Salmonella,
Leptospirosis, scrub
typhus, murine
Brucellosis, rabies,
salmonellosis, HPAI,
leptospirosis,
shigellosis, anthrax,
Salmonellosis,
Enterobacteriacae,
Biosafety
(GMO/LMO),
Basic diet and scat
analysis, DNA
extraction(UWICE),
parasitology (Taba),
45
typhus,
campylobacter,
shigellosis, KFD,
CCHF, MersCoV,
Ebola, Nipah, AI,
E.coli,parasitology,
AMR, BSL-3.
parasitology, AMR,
BSL-2+
mycotoxin, pesticides
and antibiotics, heavy
metals
Epidemiology capacity
Epidemiologists,
Laboratory tech,
virologist,
Microbiologist,
Immunologists,
Medical Doctor (OH),
QA Specialist
Epidemiologist,
Microbiologist,
Laboratory tech,
Pathologist,
Parasitologists,
Veterinary OH.
Food tech, Laboratory
tech, Microbiologist,
Biotechnologist,
Chemists, Veterinary
OH.
Epidemiologist,
Veterinary OH, dart
specialists,
veterinarians, wildlife
biologist
Group C: Identification of priority OH research for implementation
• Economic analysis to demonstrate cost effectiveness of OH approach (using rabies as priority
disease)
• AMR (surveillance on human and animal)
• Neglected tropical disease (taenesis and echninococcus, kala azar)
• Bat borne zoonoses
– Prevalence study
• Snake species (poisonous and non-poisonous) and geographic distribution
• Brucellosis at human/ animal interface
• Rodent borne zoonoses
• Tick borne diseases (impact on human health)
• Risk factor on HPAI outbreaks in poultry
• Bovine TB (Zoonotic TB)
• Leptospirosis (Risk factors and disease profile)
46
• Vector borne disease (dengue) – risk factors
• Animal/human value chain studies (value chain analysis-joint assessment)
• Community KAP and Risk mapping of scrub typhus
• Anthrax – risk mapping
• Impact of landfill waste on health – Human, animal and environment
• Study on plant diseases impacting human and animal health
• Surveillance of pesticides and chemical residue in food and meat, fruits and vegetables and dairy
products
• Survey of Infectious diseases that threaten conservation of fauna (rabies, canine distemper)
• Impact of climate change on human and animal health
• Impact assessment of rice fortification
Sustainable education on OH in the institution
• Proposal on OH concept to be included in the school education
• Develop curriculum/module on OH
• Capacity development to educators
• FETP-V
• Invitation of guest lecture and speaker form different departments
• Continuing Education on OH
• Introduce online OH course (MOOC)
• Institutional linkages with regional and international OH bodies
• Develop social media platform for educating OH
• Include OH in conference and scientific session by institution
• Introduce OH Masters/ PhD program
• Research on OH topic to be given to the students
• Education and awareness on OH on Monk bodies
Station D: Strengthening OH collaboration and networking
At Central Level
47
• Conduct Regular Meetings (at least once a year)
• Create Social media groups (wechat, facebook, skype, teleconference etc.,)
• Establish efficient real-time OH disease information sharing system hosted under OHS (OHS
website)
• Conduct/ organize national OH conference (annually/ biannually)
• Resource sharing mechanism (financial, HR, technical)
• Allocate certain fund/ budget for implementation of OH activities by all stakeholders
• Conduct collaborative researches (MoH, Livestock, BAFRA, Wildlife, environment, CNR etc)
• Seek high level/ government support
• Provide update/ briefing to executive officials of all relevant stakeholders
• Provide platform for OH socialization
• Establish efficient linkage and coordination between central and district levels
District level
• Introduce and advocate OH concept
• Establish OH core group
• Carry out joint disease outbreak investigation at district as well as LG levels
• Create social media groups
• Conduct annual OH meeting in coordination with regional offices
• Conduct joint CME and CVE annually
• Resource sharing mechanism (financial, HR, technical)
• Involve LG and thromde officials for all OH activities
• Conduct joint advocacy and awareness in communities and institutions/ schools etc.
• Conduct collaborative researches
• Awareness on OH in MSTF and CBSS
13 Session 11: Closing session
48
13.1 Conference Resolutions: Dr. Sangay Rinchen, Chief Rapporteur The following resolutions were presented and adopted during the conference:
Resolution #1: Identifying the need for a reliable platform to facilitate efficient and real time sharing of
information, expertise and resources among the relevant stakeholders under the One Health umbrella,
the floor resolved to develop a One Health webpage.
Action: DoL and DoPH
Resolution #2: To ensure that there is a uniform and sustained implementation of One Health activities
at national and district level, the floor resolved to establish One Health committees at the district and
national levels. The conference also recommended that the technical working group will be constituted
at the National level immediately and should draft the following terms of references and prioritise the
research activities:
TOR for national, district and Thromde level committees.
SOP for information sharing at every level
List of priority research activities to be undertaken immediately during 12th FYP and
designating the lead agencies
Mapping of experts in all relevant sectors and institutions
Action: DoL and DoPH
Resolution #3: The floor raised issues regarding the challenges faced in implementing the animal health
National Influenza Preparedness Plan (NIPPP) during the events of bird flu outbreaks. Further, as the
current version of NIPPP was last revised in 2014, a need was felt to revise the document by incorporating
short-comings and experiences learnt so far. In this regard the floor resolved that a technical working
group comprising from the relevant agencies should be formed to incorporate the changes as amendment
in the existing NIPPP document.
Action: DoL and BAFRA
Resolution #4: Integrated Bite Case Management (IBCM) was discussed as an important option that
Bhutan should adopt to achieve the goal of eliminating dog-mediated human rabies. In this regard, the
floor decided to form a technical working group to frame pragmatic IBCM modalities for implementation
in the country.
Action: DoPH and DoL
Resolution #5: The institutionalization and establishment of OH secretariat is currently being pursued
in the RCSC. In the event of the proposal not getting through RCSC, the floor recommended the OH
technical working group to come up with an alternative model to continue the ongoing OH program.
Action: DoPH and DoL
49
Resolution #6: Having recognized the importance of carrying out OH activities, the floor deliberated on
the importance of designating the Chair of IMCOH in line with National One Health Strategy Plan. In
this regard, the floor recommended that IMCOH meeting be convened to designate the Chair and lead
agency for the next One year.
Action: DoPH and DoL
Resolution #7: The floor recommended that to facilitate and formalize collaborative food safety
investigation procedure, the DoPH and BAFRA discuss and sign agreement on the existing draft Food
Safety Investigation Protocol.
Action: BAFRA, RCDC and DoPH
Resolution #8: In order to sustain One Health capacity building through continued education, it was
recommended that Khesar Gyalpo University of Medical Sciences of Bhutan start One Health Field
Epidemiology Training Program as soon as possible.
Action: KGUMSB
Closing remarks Dr. Tashi Samdup, Director General, DoL, MoAF, expressed his happiness and commanded the diversity
of the audience, presentations, and a well thought conference agenda. The Director General remarked
that conference of this sort was unique and first of its kind. He expressed his appreciations to the
conference organizer – Department of Livestock and Department of Public Health and other officials
working behind the scene for a wonderful organization of the conference. He also expressed his
appreciations to the presenters and the rapporteurs. He also thanked the WHO for providing fund
support to organize this conference.
Dr Karma Lhazeen, Director, Department of Public Health thanked Director General, DoL for attending
and guiding the entire sessions of the conference. She expressed her regrets for not being able to attend
the presentations, despite her willingness, due to some unavoidable circumstances. She thanked the
WHO for providing fund support to organize this conference. She made a remark that the collaboration
and mechanism to combat zoonotic diseases have grown stronger with every passing workshop. Further,
from this workshop resolutions she expressed her hopes that the collaborations among the different
stakeholders will be strengthened. In line with the control of zoonotic diseases, the Director expressed
her thoughts of Department of Livestock being operationally stronger and mature. Nevertheless, she
informed the floor that the Ministry of Health is developing at rapid rate. Talking about rabies, she raised
her concern about the increasing dog bite cases. With the Integrated Bite Case Management (IBCM) to
50
be implemented in the country, she expressed her hopes in reducing the use of Post-exposure
prophylaxis. Furthermore, she asserted that there should be a sustained collaboration among various
stakeholders. Lastly, she acknowledged the organizers, facilitators, presenters, rapporteurs, and officials
working behind the scene in successful organization of the conference. She committed her support in
combating the emerging and re-emerging diseases. She informed the floor that she had briefed the Health
Minister about the One Health strategy plan. She closed her remark with the quote, “All is well that
ends well”
14 Annex
14.1 Annex 1: Conference Agenda
4th National One Health Conference
“Enhancing national health security through one health approach” Venue: Namsay Choeling Resort, Paro
Date: 19 to 21 December 2018
Conference Programme
Time Program Responsibility
Day 1: Session 1: Opening Ceremony
8:45-9:15 Registration of participants NCAH
9:15 - 10:15 Welcome address
Address by MoH
Address by MoAF
Vote of thanks
Dr. Karma Rinzin, CVO, AHD
Dr. Pandup Tshering, DG, DMS
Dr. Tashi Samdup, DG, DoL
Mr. Rinxin Jamtsho, CPO, CDD
10.15 – 10.45 Photo session and Refreshment
Day 1: Session 2: Update on One heallth activities
Chairman: Dr. Tashi Samdup, DG, DoL
10:45-10:50 Adoption of agenda Dr. Tenzin, NCAH
10:50 -11:10 Follow up of 3rd National One Health Conference Rinzin Kinga Jamtsho, PO, DoPH,
MoH
11:10-12:00 Update on One health activities
51
- Human Health
- Animal Health
- Wildlife Health
- Food safety
Dr. Soanm Wangchuk, RCDC
Dr. Tenzin, NCAH
Dr. Kinley Choden, NCD
Ms Kinley Penjore, BAFRA
12:00-12:40 Update on the emerging and re-emerging infectious
diseases
Dr. Sonam Wangchuk, RCDC
12:40-13:00 South Asia One Health Disease Surveillance Network Dr. Sithar Dorjee, KGUMSB
13:00-14:00 Lunch Break
Day 1: Session 3: Performance evaluation of human and animal health services
Chairman: Dr. Karma Lhazeen, Director, DoPH
14.00 – 14.20 Findings and recommendations of the WHO IHR Joint
External Evaluation
Jamyang Choden, DMS
14.20 – 14.40 Findings and recommendations of the OIE-PVS
Evaluation
Dr. Karma Rinzin, AHD, DoL
14.40 – 15.00 Findings and recommendations of National IHR-PVS
Bridging Workshop
Dr. Sithar Dorji, KGUMSB
15:00-15:30 Tea Break
Day 1: Session 4: Projects
Chairman: Dr. Pandup Tshering, DG, DMS
15.30 – 16.00 One Health Approach to determine AST profile of
Salmonella in human, animal and food: Study
supported by WHO-AGISAR Project
Dr. R.B. Gurung, NCAH
16.00 – 16.30 An overview of Fleming Fund AMR project Dr Karma Rinzin, DoL
16:30-17:00 General discussion and recommendations
Day 2: Session 5: AMR and Food safety
Moderator: Dr. Sonam Wagchuk, RCDC
9:00 - 9:20 AMR surveillance on bacterial pathogens isolated from
diarrhoeal cases among children under 5 years
Tshering Dorji, RCDC
9:20 - 9:40 Foodborne disease outbreak investigatio: A case study of
One Health approach
Dr. Sithar Dorji, KGUMSB
9.40 – 10.00 Microbial load and prevalence of Salmonella in imported
fresh beef at different point of meat handling in Bhutan
Kaling Dorji, BAFRA
52
10:00-10:20 Antibiotics resistance of E. Coli causing diarrhoea in pigs
in Thailand
Dr. Narayan Pokreal, DVH,
Pemagatshel
10:00-10.40 Panel discussion
10:40 - 11:00 Tea Break
Day 2: Session 6: Zoonotic Diseases
Moderator: Dr. Karma Rinzin, DoL
11.00 – 11.20 Emergence of Brucellosis in Bhutan: Animal Brucellosis
and Human Case Report
Dr. RB Gurung, NCAH
11.20 – 11.40 Status of Multi Drug Resistant Tuberculosis (MDR-TB)
in the country
Karchung Tshering, RCDC
11.40-12.00 Risk Factors of MDR-TB among newly diagnosed
Pulmonary TB in Bhutan – A Case Control Study
Dr. Tandin Zangpo, DoPH
12.00 – 12.20 Acute undifferentiated febrile illness surveillance:
Preliminary findings of causative agents
Dr. Sonam Wangchuk, RCDC
12.20 – 12.40 Chronology of HPAI H5N1 outbreak in Bhutan and its
genetic characterization
Dr. RB Gurung, NCAH
12.40 – 13.00 Panel dicussion
13.00 – 14.00 Lunch Break
Day 2: Session 7: Diseases at human-animal-wildlife interface
Moderator: Dr. Sithar Dorjee, KGUMSB
14.00 – 14.20 Synantrophic rodents as reservoir of zoonotic pathogens
in Bhutan
Dr. Yoenten Phuentshok, NCAH
14.20 – 14.40 Bat diversity in Bhutan – implications for emerging
infectious disease control
Mr Sangay Tshering, CNR
14.40 – 15.00 Ecology of Lyle’s Flying Fox (Pteropus lylei) at the bat-
human interface in Cambodia
Dr. Kinley Choden, NCD
15.00 – 15.20 Panel discussion
15:20-15:40 Tea Break
Day 2: Session 8: Community Perceptions and Practices
Moderator: Dr. R.B. Gurung, NCAH
15.40-16:00 Rabies PEP seeking and compliance behaviour –
Hospital and commmuniy-based contact tracing survey
Dr. Kinley Penjor, MoH
16.00 – 16.20 One health profile of local communities within and
outside a protected area in Bhutan
Dr. Kinley Choden, NCD
53
16.20 – 16.40 Community-based KAP survey on rabies among cattle
owners in Bhutan
Dr. Sangay Rinchen, RLDC
Tsimasham
16.40 – 17.00 Panel discussion
Day 3: Session 9: Disease Prevention and Control Strategies
Moderator: DG / Director
9:00 - 9:20 Disease prevention and control strategy in animals
with focus on Stepwise approach to elimination of
dog-mediated rabies in human
Dr. Tenzin, NCAH
9:20 - 9:40 Public health disease prevention and control
strategy
Mr Rinzin K Jamtsho, DoPH
9.40 – 10.00 Bhutan Wildlife Health Strategy : 2019 - 2028 Dr. Kinley Choden, NCD
10:00-10:20 Animal welfare with focus on dog population
management in Bhutan
Dr. Karma Rinzin, DoL
10:00-10.40 Panel discussion
10:40 - 11:00 Tea Break
Day 3: Session 10: World Café
Moderator: Dr. Pasang Tshering, OIE Consultant and One Health Core Group
11.00 – 13.00 Morning session : World Café
- Institutionalization of one health at every
levels
- Strategy for sustainable funding for one health
activities
- Sustainable education on one health in the
institutions
- Identification and prioritization of one health
activities for implementation
- Identification of priority one health research
for implementation
- Strengthening of collaboration and
networking
Inventory of expertise related to
zoonosis/OH/Epidemiology/ lab capacity
ALL
3.00 – 14.00 Lunch Break
54
Day 2: Session 7: Plenary session
Moderator: One Health Core Group
14.00 – 15.30 Plenary session - World CAFÉ outcome ALL
15:30-16:00 Tea Break
Day 2: Session 8: Workshop Closing
Moderator: One Health Core Group
16:00-17:00 - Adoption of Workshop Resolutions
- Closing remarks by MOAF
- Closing remarks by MOH
Rapporteurs:
- Dr Sangay Rinchen, RLDC, Tsimasham
- Dr Kezang Dorji, S/Jongkhar Hospital
- Dr Sonam Pelden, DVH, Zhemgang
- Dr Kuenzang Gyeltshen, BAFRA, Phuentsholing
14.2 Annex 2: List of participants
Dr.Tashi Samdup
Director General
DoL, MoAF, Thimphu
e-mail: [email protected]
Dr.Pandup Tshering
Drector General
DMS,MoH
Thimphu
e-mail: [email protected]
Dr.Karma Lhazeen
Director
DoPH,MoH
Thimphu
e-mail: [email protected]
Dr.Sithar Dorjee
Director
KGUMSB
Thimphu
e-mail: [email protected]
Dr.Sonam wangchuk
Chief Lab.Officer
RCDC,MoH
Serbithang
e-mail: [email protected]
Dr.Kinley Penjor
CMO
Dewathang Hospital
55
e-mail: [email protected]
Dr.Kezang Dorji
CMO
Samdrupjongkhar Hospital
e-mail: [email protected]
Ms.Jamyang Choden
Program Officer
EMSD,DMS,MoH
Thimphu
e-mail: [email protected]
Mr.Passang Tshering
Sr.Dzongkhag Health Officer
Dungkhag Administration
Phuentsholing,Chhukha
e-mail: [email protected]
Mr.Rinzin Kinga Jamtsho
Program Officer
ZDP,DoPH,MoH
Thimphu
e-mail: [email protected]
Ms.Sonam Choden
Livestock Extension Supervisor
Shershong LEC,Gelephu
Sarpang Dzongkhag
e-mail: [email protected]
Mr.Kinley
Sr.Dzongkhag Health Officer
Dzongkhag Administration
Tsirang
e-mail: [email protected]
Mr.Dorji Wangchuk
Dzongkhag Livestock Officer
Dzongkhag Administration
Tsirang
e-mail: [email protected]
Dr.Sangay Rinchen
Sr.VO
RLDC,DoL
Tsimasham,Chhukha
e-mail: [email protected]
Dr.R.B.Gurung
Program Director
NCAH,DoL
Serbithang,Thimphu
e-mail: [email protected]
Mr.Drodhel Zangpo
Asst.Environment Officer
EACD,NEC
Thimphu
e-mail: [email protected]
Dr.Chendu Dorji
Sr.Veterinary Officer
RLDC,DoL,MoAF
Tsimasham,Chhukha
e-mail: [email protected]
Dr.Sandip Tamang
GDMO
Chhukha BHU I
56
e-mail: [email protected]
Dr.Tshering Dema
GDMO
Lhamoyzingkha BHU I
e-mail: [email protected]
Mr.Tshewang Norbu
SPO,MoHCA
Thimphu
e-mail: [email protected]
Mr.Tshering Dorji
DCLO,MoH
Thimphu
e-mail: [email protected]
Dr.Kinley Choden
Sr.Veterinary Officer
Wildlife(NCD),DoFPS
Thimphu
e-mail: [email protected]
Dr.Heruka Mahat
DCVO
NCAH,DoL
Serbithang,Thimphu
e-mail: [email protected]
Dr.Yoenten Phuntshok
Sr.Veterinary Officer
DPCU,NCAH,DoL
Serbithang,Thimphu
e-mail: [email protected]
Dr.Karma Wangdi
Sr.Veterinary Officer
LHD,DoL,MoAF
Thimphu
Mr.Karchung Tshering
Sr.Laboratory Officer
MoH,Thimphu
e-mail: [email protected]
Dr.Pema Tshewang
DCVO,NAH,DoL
Mothithang,Thimphu
Dr.Yoriko Nishizawa
Neonazologist
KGUMSB,THimphu
e-mail: [email protected]
Dr.Sithar Dorjee
Director
KGUMSB,Thimphu
e-mail: [email protected]
Dr.Jigme Tenzin
Dy.CFO
WMD,DoFPS
Thimphu
e-mail: [email protected]
Mr.Rinzin Jamtsho
57
CPO,MoH
Thimphu
e-mail: [email protected]
Ms.Yoezer Dema
Sr.RQI,BAFRA
Gelephu,Sarpang
e-mail: [email protected]
Dr.Kuenzang Gyeltshen
Sr.RQO,BAFRA
Phentsholing,Chhukha
e-mail: [email protected]
Dr.Pema Wangchuk
Sr.Veterinary Officer
Zhemgang Dzongkhag
Dr.Tenzin Wangchuk
Sr.Veterinary Officer
Paro Dzongkhag
e-mail: [email protected]
Dr.Sonam Pelden
Sr.Veterinary Officer
DVH,Zhemgang
e-mail: e-mail: [email protected]
Dr.Karma Phuntsho
Sr.Veterinary Officer
SVL,DoL,Nganglam
e-mail: [email protected]
Dr.Kinley Penjor
Sr.RQO,BAFRA
Thimphu
e-mail: [email protected]
Mr.Kaling Dorji
Sr.RQO,BAFRA
Thimphu
e-mail: [email protected]
Mr.Naina Sing Tamang
Sr.DLO,
Trashigang Dzongkhag
Mr.Purna Bdr Mahat
LES,Sampheling geog
Chhhukha Dzongkhag
e-mail: [email protected]
Ms.Sangay Zam
Lecturer,FNPH
Thimphu
e-mail: [email protected]
Dr.Narayan Pokhrel
Sr.Veterinary Officer
Pemagyatshel Dzongkhag
e-mail: [email protected]
Dr. Karma Dorji
GDMO,Pemagyatshel
e-mail: [email protected]
58
Mr.Wangchuk
Sr.Lecturer
FNPH,Thimphu
e-mail: [email protected]
Mr.Lethro Tshering
Sr.Lab Officer
NFTL,BAFRA,Yusipang
e-mail: [email protected]
Dr.Ngajay Jamtsho
GDMO,Rangjung BHU-I
Trashigang Dzongkhag
e-mail: [email protected]
Mr.Sonam Gyeltshen
Sr.RQI,BAFRA
Samdrupjongkhar
e-mail: [email protected]
Dr.Tandin Zangpo
MO,Dechencholing BHU-I
Thimphu
e-mail: [email protected]
Dr.Tenzin
PLHO, NCAH,DoL
Serbithang,Thimphu
e-mail: [email protected]
Dr.Karma Rinzin
CVO,DoL,MoAF
Thimphu
e-mail: [email protected]
Dr.Sonam Wangchuk
GDMO,Yebileptsha Hospital
Mr.Sangay Tshering
Lecturer
CNR,Lobeysa
Mr.Jambay Dorji
Sr.DLO
Bumthang Dzongkhag
e-mail: [email protected]
Dr.Dorji Tshering
Sr.Mo,Bajo Hospital
Wangdiphodang dzongkhag
Dr.Chempay
GDMO,MRRH
Moggar Hospital
e-mail: [email protected]
Dr.Jigme Tenzin
GDMO.
Lhuntse Dzongkhag
e-mail: [email protected]
Mr.DN Champagai
ADLO
Haa Dzongkhag
e-mail: [email protected]
Mr.Tshewang Dakpa
Accountant
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NCAH,Serbithang
e-mail: [email protected]
Ms.Tshewang Dema
Lab.Tech
NCAH,Serbithang
Mr.Kinzang Namgay
LHS,NCAH
Serbithang,Thimphu
e-mail: [email protected]