rabies’control’ini.a.ve’in’tamil’nadu,’india:’a’ test’case ... ·...
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Rabies control ini.a.ve in Tamil Nadu, India: a test case for the ‘One Health’ approach
Syed Shahid Abbas & Manish Kakkar
Prince Mahidol Award Conference, Bangkok
1 Feb 2013
Need for Systems Thinking for Rabies Control
• Human resource capacity challenges – An average medical student/
graduate knows only 40-‐60% of what is needed
• Lack of evidence based planning – Only 263 rabies deaths reported;
‘Zero’ deaths in 18 states
• Research-‐Policy disconnect – Lack of health systems and policy
relevant research on rabies
CBHI, 2010
Study Background
• No consensus among naMonal policy makers on coordinaMon mechanisms for rabies control in India
• Tamil Nadu first state to implement populaMon level intervenMons to control rabies
• WHO commissioned PHFI to assess the intervenMons following reports of decreasing rabies incidence
Sources of Reported Data
Department Data reported Catchment area Directorate of Public Health & Preven.ve Medicine (DPH)
Dog bites by district by year Rabies cases/ deaths by district by year District census data
Rural TN (PHC and Block PHC)
Directorate of Medical Educa.on (DME)
Dog bites by district by year Rabies cases/ deaths by district by year
Urban TN
Directorate of Medical and Rural Health Services (DMS)
Dog bites by district by year Rabies cases/ deaths by district by year
Rural and urban TN (Taluka & District Hospitals)
Municipal Administra.on Department (MAD)
Stray dog populaMon by CorporaMon/ Municipality (4 year census) Number of ABC-‐AR procedure conducted by year by CorporaMon/ Municipality Municipality census data
Urban TN (CorporaMon/ Municipal limits)
Department of Animal Husbandry (DAH)
Dog populaMon census by stray/ pet (4 year census)
Rural and urban TN (by District)
Tamil Nadu Medical Services Corpora.on (TNMSC)
Vaccine consumpMon by district by year Rural and urban TN (by health facility at all levels)
Major Milestones in Rabies Control in TN
1999 • Licensing of dog rules
2004 • Ban on use of Neural Mssue vaccine
• IntroducMon of Tissue Culture Vaccine
2006 • Ban on stray dog killing Increased dog populaMon
• Strong public pressure
2007 • ABC-‐AR Pilot project launched
• IntroducMon of Intra dermal ARV for humans
2008 • Scale up of ABC-‐AR to all CorporaMons/ Municipal areas of Tamil Nadu
Animal IntervenMon
Human IntervenMons
Stray Dogs
Owned dogs AR
Dog bites ABC-‐AR
Dog populaMon
Dog rabies
Human rabies
IdenMfy dog bites
Diagnosis Treatment/ Referral
Begin t/t
Complete t/t
Local partnerships Staff training, Infrastructure
Legisla.on MIS surveillance, Burden of disease
MIS M&E
Waste Disposal
Community Awareness
Urban
Areas only
Rural + Urban
Awareness Vaccine & Igb availability
Staff training, Infrastructure
MIS surveillance, Burden of disease
MIS M&E
Interven.ons for rabies control
Human Interven.ons • Surveillance • AnM Rabies vaccinaMon • AnMbody provision • Community Awareness
Animal interven.ons • Animal Birth Control – AnM Rabies VaccinaMon
• Licensing of dogs • Community awareness • Livestock census
Environment interven.ons • Waste disposal system
Systems Interven.on • Procurement and Supply Chain Management System
Intersectoral coordina.on mechanism State level coordina.on
Planning & Implementa.on
Public Health Directorate
Municipal Admin
Town Panchayats
Informa.on sharing Public Health Surveillance
Municipal Dog Surveys & DAH Livestock Census
Health services: animal and human Health Dept.
Municipal AdministraMon, Animal Husbandry Dept.
Oversight Animal welfare bodies
Civil Society OrganizaMons
District level coordina.on
Implementa.on Public Health Directorate
Municipal AdministraMon
Town Panchayats
Informa.on genera.on Public Health Surveillance
Municipal Dog Surveys & DAH Livestock Census
Best pracMces
Awareness Public awareness and reso-‐
urce mobilizaMon
Communicate guidelines to breeders
Oversight Animal welfare bodies
Civil Society OrganizaMons
Health services: animal and human
Health Dept.
Municipal AdministraMon, Animal Husbandry Dept.
Reported number of dog bites (DPH) and vaccine consump.on (TNMSC)
-‐
200
400
600
800
1,000
1,200
1,400
1,600
-‐
50
100
150
200
250
300
350
2004 2005 2006 2007 No. of v
ials con
sumed
per 100,000
popu
la.on
Ann
ual dog bites incide
nce pe
r 100,000 rural pop
ula.
on in TN
Reported dog bite cases
Vaccine consumpMon at district level in Tamil Nadu
No. of dog bite cases being reported by different health directorates (Jan ‘08 – Aug ‘09)
-‐
5,000
10,000
15,000
20,000
25,000
30,000
35,000
40,000
45,000 Jan-‐08
Feb-‐08
Mar-‐08
Apr-‐08
May-‐08
Jun-‐08
Jul-‐0
8
Aug-‐08
Sep-‐08
Oct-‐08
Nov-‐08
Dec-‐08
Jan-‐09
Feb-‐09
Mar-‐09
Apr-‐09
May-‐09
Jun-‐09
Jul-‐0
9
Aug-‐09
Sep-‐09
Oct-‐09
Directorate of Public Health
Directorate of Rural and Medical Health Services
Directorate of Medical EducaMon
Lessons from Tamil Nadu Rabies Control ini.a.ve
Strengths • AR Vaccine availability • ABC-‐AR in Urban areas • Intersectoral coordinaMon mechanisms in place
• Responsive government • RegulaMons and policies in place • IdenMfied funding
Challenges • Limited CoordinaMon • Limited analysis of surveillance data • Rural areas missed in ABC-‐AR coverage • Limited involvement on Animal Husbandry • Need for a strategic approach
Expert consulta.on on rabies control in TN, August 2011
• Provided a plahorm for a dialogue between different sectors involved in rabies control
• Resulted in declaraMon of plans for developing a state-‐wide rabies control programme in Tamil Nadu
• Facilitated discussions around a naMonal zoonoses control strategy
• SARAH announces the rabies free stage of Sikkim