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CONSULTATIVE MEETING

ON
PREVENTION AND CONTROL OF RABIES
IN PAKISTAN

PAKISTAN HEALTH RESEARCH COUNCIL

REPORT

ON
CONSULTATIVE MEETING
ON PREVENTION AND CONTROL OF
RABIES
IN PAKISTAN
(11th – 12th April 2016)

9217146 Fax: 051-9216774 Email: pmrc. Additional information is available from source listed below.rdc. Pakistan Health Research Council.com . Ministry of National Health Services. pmrc. Islamabad Phone: 051-9207368. 9206092. Regulations and Coordination.ps@gmail.com.CONSULTATIVE MEETING ON PREVENTION AND CONTROL OF RABIES IN PAKISTAN Pakistan Health Research Council 2016 This report summarizes the gaps and action plans identified in the "Consultative meeting on prevention and control of Rabies in Pakistan" organized by Pakistan Health Research Council (PHRC).rdcii@gmail.

....................................................................... 10 Short term plans (1-12 months): ........................................................Contents Background: .............................................................................. 9 Animal Health: ............................................................................................................................................. 12 ..................................................................................... 2 Day 1: .. 11 List of Facilitators: ................................................................................................................................................................................................................................. 5 Group work on Case study: ................................................................................................................................................................................................................................................................................ 5 Day 2: ........................................................................................................ 6 Action Plans: ................................................................................................................. 5 Group work on Development of Action Plan: ........................................................................................................................................................................................................................ 10 Medium to long term plans (1-4 years): ................................................................................................................................. 2 Group Work on Rabies Roadmap Matrix ...................... 10 List of Participants:.................................................................................................... 9 Human Health: ............................................................................................................................................................................ 2 Key Presentations: ......... 9 Short term Intervention (2 Years): ....................... 9 Long term Intervention (5 years): ................................................................................................................................................................................................................................................................................... 5 Group Work: ................................... 1 Activities:.....................................................................................................................

globally all stress was given on the management of dog bite and rabies with introduction of newer and cost-effective vaccines. Number of officially reported deaths usually underestimates the actual incidence of disease resulting in lack of attention by national authorities. Later Provincial Director Generals (Health) were asked to identify 1 . Rabies disproportionately affects rural and socioeconomically disadvantaged communities. In 2010.Background: Rabies is one of the oldest known zoonotic disease to man. Country guidelines for Rabies prevention and treatment were developed through WHO support in consultation with rabies experts from the Provinces. Children in age group (5-15 years) represent 40% human rabies death and dog-mediated rabies is a key epidemiological pattern in SAARC countries.5 billion people are at potential risk of rabies infection. In Pakistan human rabies is not a notifiable disease therefore there is scarce data on human rabies cases and death. In the past. It is caused by the lyssa virus present in the saliva of infected animals such as dogs and is generally transmitted through their bite. and unfortunately more than 98% of these deaths occur in the developing world in spite of the availability of effective and economical control measures. However. It is estimated that this cost is many folds less than the treatment of dog bite cases. Experts around the globe have consensus that rabies is under reported in most of the developing countries due to lack of true data. Despite all this. In 2013. Rabies is endemic in South Asian Association for Regional Cooperation (SAARC) countries and around 45% (21000-24000) of global burden of human rabies is in this region. In 2013. World Health Organization (WHO) declared it as one of the seventeen neglected tropical diseases of the globe. 55000 people die from rabies per year. the overall treatment cost of dog bite cases is high and beyond the reach of many countries. now there has been a shift in the rabies elimination and now there is more focus on dog vaccination (both Pet and stray dogs). Globally on an average. Federal government nominated focal persons for zoonosis and in same year Provincial focal persons for Rabies were also nominated. Meanwhile 1. However it is estimated that rabies takes the lives of 2000-5000 Pakistanis every year.

Besides human health. This was followed by the presentations from Provincial focal persons and experts from public and private hospitals who deal with dog bite cases. Focal Person for rabies from Punjab highlighted the need to have a national data on Rabies. Unfortunately. Activities: Day 1: The activities of 1st day started with remarks from DG Health. They presented rabies situation and its management in their respective provinces. Considering all these identified areas. Zarfishan Tahir. Provincial Focal person of 2 . All key stakeholders were invited including Provincial Focal Persons on rabies. She also suggested to keep the ball rolling. PHRC shared the current situation of Rabies in Pakistan and briefed the participants about the workshop objectives and activities to be followed in the next two days. Ministry of NHSRC. 2 providers from each hospital were trained on the use of new rabies immunoglobulin (RIG) and the vaccines using intradermal or intramuscular approach.10 hospitals for dog bite management and upon identification. representatives of animal welfare societies. Executive Director. experts from Animal Health Sciences and Live stock departments. He appreciated the efforts of PHRC in advancing steps towards rabies control from the country and inviting all relevant stakeholders for the meeting. Key Presentations: 1. The Executive Director. Ministry of National Health Services. Municipalities (Capital Development Authority) and WHO. The major mile-stone was achieved in 2015 where the country switched over to cell culture vaccine production. Dr. Huma Qureshi. Regulations & Coordination (NHSR&C) in collaboration with World Health Organization from 11th -12th April 2016 at Islamabad. a two days consultative meeting on Rabies prevention and control in Pakistan was organized by Pakistan Health Research Council. rabies is also a concern for animal health. there is still no focal person nominated from animal health department of all provinces. Pakistan Health Research Council along with her team of researchers were facilitating this meeting. Dr.

Dr. She emphasized to intensify the awareness both among general public and doctors. author of “Pakistan Rabies Control Guidelines for Animals”. She also suggested involving experts from animal health side for animal rabies control. Naseem Salahuddin. (UVAS) Lahore. Karachi informed that 4000 cases of dog bite cases were reported in 2015 and among them 31 died. He also shared the data of dog bite cases retrieved from District Health information system (DHIS) in KPK from 2011-2016. He also shared that Cell culture rabies vaccine is available in the Province which was provided by WHO and an NGOs but no RIG is available in public sector health facilities. Dr. Dr. Department of Infectious Diseases. 3. Indus hospital. Naeemul Haque Quraishi. She also stressed to adopt one health approach for successful eradication of Rabies from the Country. He said that the supply of human RIG and rabies vaccine from the health departments is very limited when comparing the spectrum of the problem in each Province. He stressed the need for ownership by Provincial Health Department and regular budget to achieve the objectives of the program. Rabies vaccine is available at all these sites and purchased by respective districts while RIG is not available at any of these sites and is self purchased by patient. Tahir Yaqub. Focal Person for rabies from Khyber Pukhtunkhwa (KPK) shared that among 25 districts of KPK. there are 10 sites for rabies management. 2. Dr. briefly 3 . attitudes and practices (KAP) of doctors and paramedics regarding rabies patient management. Focal Person for rabies from Sindh informed that the 10 dog bite management Centers were notified by the Sindh health department where trainings have been done by PHRC and Dr. Head. 4. Professor of Microbiology. 5. 6.rabies from animal health should also be nominated who should work in collaboration with their human health experts. Dr. dosage and route of cell vaccines and RIG administration is very poor. Abid Saeed. University of Veterinary and Animal Sciences. Nasim Salahuddin. to promote intradermal regimen in large hospitals. Focal Person for Rabies from Baluchistan informed the forum that there are 10 sites for Rabies management in the Province and shared the data of DHIS showing Jaffarabad district having highest dog bite cases in last 5 years. She shared that knowledge. Jamal Akbar.

Americas eliminated dog rabies and 2020 is the target for South East Asia and Pacific region for rabies elimination. Animal Welfare Board and Dog Population Management Act may also be formulated. should be on board to coordinate activities and unify efforts.describe objectives of the guidelines. In addition to above. Senior Officer. Secondly. Lahore shared the gaps regarding rabies control. To eradicate rabies from Pakistan. Katinka de Balogh. Dr. She informed the participants regarding details of Stepwise Approach towards Rabies Elimination (SARE) tool and 6 stages (ranging from endemic to free from human rabies). Mahera Omar. She shared that local animal welfare groups end up dealing with injured puppies and dogs that are poisoned or shot and left to suffer. He informed the participants that no department owns dog as they are neither human health nor livestock and similarly not come under wildlife. She informed that in 2015. 8. Dr. Reduction in dog population will reduce rabies as one male dog can produce 12288 pups in 5 years. and awareness programs in schools and use of mass media will produce dramatic results in the Rabies control. She said that biggest challenge is availability and affordability of post exposure prophylaxis and to do massive dog vaccination. Co-founder and Director. Muhammad Zubair Shabbir. the government should make policy to control the disease in dogs through mass vaccination and dog sterilization. All stakeholders therefore. UVAS. She stressed to adopt one health approach for Rabies eradication. He recommended that massive dog vaccination along with chemical and surgical sterilization of stray dogs should be done to control dog population as this is the ultimate approach adopted worldwide. Assistant Professor. pet registration/vaccination. Once the country knows its present position then it is easy to move forward with careful planning. often by citizens themselves. Food and Agriculture Organization (FAO) of the United Nations delivered her presentation on Skype. this approach is less costly as compared to treatment cost and subsequent human mortality. Animal health and Production Regional Office for Asia and the Pacific. 9. She told that one of the objectives of this two days meeting was to define the stage where Pakistan is standing in rabies elimination. proper garbage disposal. 7. Pakistan Animal Welfare Society (PAWS) presented information about the inhumane stray dog killings by the civic administrations. Meanwhile there 4 .

For this activity. Sindh scored maximum score of 21 (23%) amongst accomplished activities. Finally. group representatives from each Province presented their data and score. participants were divided in three groups comprising of experts of different sectors i. None of the province could achieve 25% score (Table 1). PHRC. Muhammad Arif Nadeem Saqib. Group work on Case study: This exercise was intended so that participants may brain storm about how rabies cases are presently handled in Pakistan. Provincial representatives compiled activities that have been accomplished and that are pending in their Provinces. He briefed the participants about the scores of each Province. The aggregated score of SARE in all 07 components for each province was calculated. Day 2: Recall of day 1 was briefed by Dr. Senior Research Officer.e. Main objective was to identify the gaps and what can be done to plug these gaps. compiled the data of rabies cases from Provinces. Case study scenario was handed out to each participant. Group Work: Two groups were formed using the tool provided by Dr Katinka. Details are given as follows. while Baluchistan scored 11 (12%). all 20 participants were grouped into four provincial working groups to chalk out activities on Rabies Roadmap Matrix. Group Work on Rabies Roadmap Matrix At the end of first day. animal and human health. He also provided details about group work activities and how to move forward. Each participant was asked to note down their thoughts on what comes to their mind 5 . In this session by using SARE tool.is under reporting of dog bite cases in humans and livestock and knowledge of public and doctors in dog bite management and rabies is poor and needs to be improved through trainings. FAO. Each group comprised of members from human and animal health from same province.

five main actions each for the short term (1-12 months) and medium to long term (1-4 years) were determined for each sector along with identification of responsible person to take the action. 6 .regarding. Group work on Development of Action Plan: Participants were again divided in two groups. animal and human health. In this activity. Discussion was generated with the help of probing questions from the facilitators of PHRC. Main gaps were noted on flip chart and areas for which no clear procedures exist were also identified. The existing gaps identified by the participants are shown in table 2 and 3. how they would address the case and possible gaps along with the solution. Various stakeholders that should be engaged in a successful rabies control program were also identified. Representative from each group presented the findings.

Communication 18 4 14 9 18 0 18 3 15 5 Prevention and control 25 6 19 7 25 7 18 5 20 6 Dog population related issues 3 1 2 0 3 0 13 0 3 7 Cross cutting Issues 15 0 15 4 15 0 15 01 14 92 14 78 21 71 12 80 11 81 % 15% Components Total a : Accomplished activities 23 % 13% 12% b : Pending activities Table 2: Identification of Gaps and suggested interventions regarding Human Health Actions Gaps Identified Intervention proposed Wound washing Lack of knowledge and practices among community and health care workers (HCWs) Health education (schools. knowledge and practices among HCWs Refreshers for health care workers Post Exposure Prophylaxis (PEP) Availability of vaccine/RIG Rationalize the usage of Vaccine/RIG.Table 1: Provincial SARE Score Punjab Sindh KPK Baluchistan Max score a B a b a b a b 1 Legislation 12 0 12 0 12 0 12 0 12 2 Data collection and analysis 9 0 9 1 9 2 7 2 7 3 Laboratory diagnosis 10 3 7 0 10 0 10 0 10 4 Information. community etc) Wound Categorization Lack of awareness in HCWs and general populations Refreshers for health care workers Past history of dog bite Medical History Lack of training. 7 . Education.

electronic. No system for dog registration. Hiring of trained HR and training of already present staff. in collaboration with education department through Print. Culling is not an option ethically. 8 . municipality). trained Human Resource. Communication to Public No Risk Communication to Public. No compulsory vaccination. Lack of integration among stakeholders involved in rabies prevention & Control. social media.Table 3: Identification of Gaps and suggested interventions regarding Animal Health Actions Capture the dog Isolate the cow and horse (same protocol PEP) Dog mass vaccination and sterilization in the area Legislation: Communication medical-veterinary officers Gaps Identified Identification of Dog/Identifying roles of stakeholders (vet. Public awareness campaign by livestock. Proper coordination among all stake holders needs to be established. Joint Animal/human case investigations. Vet Unit. No health education To Public. Provision of PEP facilitates at Lowest Civil Vet hospital level. Laboratory Lack of Lab. Allocation of funds/resource. No such system for action Disease is not notifiable. Establishment of reference. Response No surveillance system. Lack of trained/skilled Human Resource. Lack of Funding/Resources. Risk Communication by Livestock Health Education among Public by Health Dept. Lacking PEP facility vaccine etc). No intersectoral coordination. Ignorance among public. vaccination should be encouraged. Establishment of surveillance system. Establishment of system. Diagnostics. Stake holders Intervention proposed Identify the responsible stakeholder. Establishment of quarantine facility. Culling. Identify roles/responsibility of each partner and an integration mechanism among them from top to bottom. Legislation needs to be done. Dog vaccination campaigns.

awareness and risk communication material Federal and Provincial Focal Persons Dec 2016 5 Joint program activities/ meetings/targeted approach Federal and Provincial Focal Persons June 2017 Responsibility Timelines Long term Intervention (5 years): S. No Targets Responsibility Timelines 1 Development and submission of PC-I Provincial Focal Person Dec 2016 2 Making a case for politicians Federal and Provincial Focal Persons Dec 2016 3 Development of surveillance system and its integration Provincial Focal Person Dec 2017 4 Development of training.Action Plans: Following action plans were developed for human and animal health. No Targets 1 National /Provincial Strategic Document Federal and Provincial Focal Persons 2018 2 Legal frame work Federal and Provincial Focal Persons 2017-2018 3 Regular IEC programs Provincial Focal Persons 2017 4 Regular Surveillance System Provincial Focal Persons 2019-2020 5 Integration of disease in regular health services DG health and Provincial Focal Persons 2019 9 . Human Health: Short term Intervention (2 Years): S.

Federal/Provincial Authorities 12 months 3 12 months. Focal persons animal and human health 3 years 4 Setting up a surveillance system for animal rabies. Federal and Provincial Government. for stakeholders including veterinary. local Governments and community. Federal/Provincial Authorities with support of 6-12 months FAO/WHO 4 Dog population census to be started. 3 years 10 . 2-12 months Medium to long term plans (1-4 years): S. No Targets Responsibility Timelines 1 Develop preparedness plan Federal/Provincial Authorities with support from FAO/WHO. Veterinary sector together with local government. Veterinary sector. Livestock and Dairy Development (L& DD) in each province. Veterinary and local Government 3 years 2 Awareness and trainings. human. provincial and local Government. 3 years 5 Establishment of diagnostics facilities and vaccine Production for animal Rabies. 2 Establish Provincial task force for pilot study for mass vaccination and sterilization of dogs in each province Veterinary and local Government Department. 2 years 3 Legislation based on the policy document to be approved from provincial assemblies.Animal Health: Short term plans (1-12 months): S. 4 months 5 Prepare policy document to make animal rabies notifiable disease along with dog registration and its compulsory vaccination. No Targets Responsibility Timelines 1 Dog population management by mass dog vaccination and sterilization. Mass communication and awareness.

Iqbal Afridi Health Officer Directorate of Health Services Capital Development Authority. Islamabad 2. 15. Dr. Karachi. ASV/ARV Lab. Dr. Lahore 8. Infectious Disease Indus Hospital. Dr. Ms. Sindh Project Director. Dr. The Indus Hospital. Peshawar. Dr. Naseem Salahuddin Consultant. Islamabad. Hyderabad 17. Dr. Mahera Omar Co-Founder & CEO Pakistan Animal Welfare Society. University of Veterinary & Animal Sciences. Islamabad 4. Farnaz Malik Executive Director National Institute of Health. Nawabshah 9. Lahore 6. Dr. Mr. Korangi. Dr. Dr. 11 . Karachi 7. Karachi 11. 12.List of Participants: S. Muhammad Aftab Gohar Coordinator Rabies Program . National Institute of Health. Karachi 13. Prof. Asad Hafeez Director General (Health) Ministry of NHSR&C. Tahir Yaqub Professor of Microbiology Provincial Investigator of Rabies Project. 14. Huma Qureshi Executive Director Pakistan Health Research Council. Malik Ayaz Wazir Director Livestock & Dairy Development Department FATA. Naeemul Haque Quraishi Provincial Focal Person. Zarfishan Tahir Focal Person Rabies. Nadia Mukhtar Instructor Virtual University of Pakistan. Ms. Peshawar 10. Dr. Syed Jamal Akbar Assistant Director Director General Health Services. Muhammad Zubair Shabbir Assistant Professor University of Veterinary & Animal Sciences. # Name Designation Department 1. Lahore. Punjab Institute of Public Health. Islamabad 5. Seemin Jamali Head of Emergency Room Jinnah Postgraduate Medical Centre. Anwar Begum Chief BPD/Incharge Rabies Vaccine Production. Mrs. 16. Islamabad 3. Dr. M. Ali Akbar Soomro Director General Livestock & Fisheries Department.

Sumera Abid Research Officer Pakistan Health Research Council . Gilgit-Baltistan. # Name Designation Organization 1 Dr. Mr. Zain Bukhari Sanitary Inspector Sanitation Directorate. Sardar Khan Zimri Director Sanitation Sanitation Directorate Capital Development Authority. Dr. Livestock & Dairy Development. Zafar Qureshi SRO/APVO Veterinary Research Institute. Muhammad Arif Nadeem Saqib Senior Research Officer Pakistan Health Research Council . Nazarrat Hussain Veterinary Officer Directorate of Livestock Diary Development Department. Azad Jammu & Kashmir 25. Peshawar. Islamabad List of Facilitators: S. Dr. Islamabad 4 Mr. Dr. Abid Saeed Technical Support Officer Provincial Disease Surveillance & Response Unit. Dr. 20. Islamabad 5 Dr. Kabir Hussain Tahir Director General Livestock & Dairy Development Department. Lahore 24. 23. Dr. Lahore 22. Islamabad 3 Mrs. Muhammad Saleem Provincial Technical Officer Director General Health Services. Islamabad. Quetta. Ibrar Rafique Research Officer Pakistan Health Research Council . Ehtisham ul Haq Khan TAD Officer Directorate General Office. Provincial Health Directorate. Syed Asad Ali Shah Deputy Epidemiologist Director General (Extension). Islamabad 12 .18. 26. Peshawar. 21. CDA. Islamabad 2 Dr. Faiza Bashir Medical Officer Pakistan Health Research Council . 19. Muhammad Arif Munir Principal Research Officer Pakistan Health Research Council . Muzaffarabad. Mr.

Group photo of the workshop participants Chief Guests and Key Speakers 13 .

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Group Work and Discussions: 16 .