All for 1- One health for all

All for 1- One health for all

Dharya Yadav

THIRD YEAR VCRI Namakkal , 637002 TANUVAS

Email-dharyay12199@gmail.com

One Health is a multi-sectoral, interdisciplinary, and collaborative approach to attain optimal health for animals, the environment, and humans (CDCP, 2020).  One Health can provide a framework for national authorities to understand and implement it for improved connectivity and collaboration among various stakeholders (Jarhult and El Zowalaty, 2020).

One Health offers an approach to yield added value from the collective strengthening of human, animal, and environmental health systems to enable their coordination and collaboration to address threats at the human-animal-environment interface for effective prevention, detection, response, and recovery.

One health includes  –

• Human health
• Animal health
• Agricultural and plant health
• Environment health

Implementation of One Health does not require merger of various sectors. Basic tenet of One Health is to strengthen core capacity in every sector that has a bearing upon prevention, detection, response and recovery to zoonotic infections and AMR, and assure a sustainable, strong, beneficial and productive mechanism of coordination and collaboration that results in synergistic action for public good.

One Health is an approach. On recognition of its importance, a process to initiate its implementation has to begin. Instead of commencing in a big way and across all diseases, it may be better to identify most practical few entry points, which can be considered in context with a rapid assessment for feasibility.

A few examples are:

• AMR
• pandemic or any other critical event
• endemic and epidemic zoonoses, and
• initiatives by professional bodies/associations

ONE HEALTH AND RABIES

Rabies is a highly fatal panzootic disease caused by Lyssavirus (Rhabdoviridae) which is a single stranded, negative sense, non-segmented  RNA that infects the nervous system and salivary glands . All species of domestic animals are susceptible to rabies. Rabies virus is highly neurotropic in the infected host causing acute fatal and progressive fatal encephalomyelitis. Virus transmission occurs mainly via animal bite and once the virus is deposited in the peripheral wounds, centripetal passage occurs towards the central nervous system. Rabies should be suspected in patients with concomitant history of animal bite and traditional clinical presentation, but lack of such clues makes ante-mortem diagnosis a major challenge (Rupprecht et al.,2002). Two clinical forms of Rabies are recognized  the dumb or paralytic type – primarily due to damage to the spinal cord and the furious form mainly due to damage to the brain. Rabies is a major public health threat causing an estimated 59,000 human deaths every year across the globe (Hampson et al., 2015), while approximately 20,000 people die annually in India. It is endemic throughout the country with the exception of Andaman, Nicobar and Lakshadweep Islands (Aneesh, 2017). A novel strategy for combating Rabies is the interdisciplinary “One Health approach”. The American Veterinary Association defines One Health as “the collaborative effort of multiple disciplines – working locally, nationally, and globally – to attain optimal health .

IN CONTEXT TO INDIA

Rabies is responsible for extensive morbidity and mortality in India. The disease is endemic throughout the country. With the exception of Andaman & Nicobar and Lakshadweep Islands, human cases of rabies are reported from all over the country. The cases occur throughout the year. About 96% of the mortality and morbidity is associated with dog bites. Cats, wolf, jackal, mongoose and monkeys are other important reservoirs of rabies in India. Bat rabies has not been conclusively reported from the country.

To address the issue of rabies in the country, National Rabies Control Programme was approved during 12th FYP by Standing Finance Committee meeting held on 03.10.2013 as Central Sector Scheme to be implemented under the Umbrella of National Health Mission.

Objectives

• Training of Health Care professionals on appropriate Animal bite management and Rabies Post Exposure Prophylaxis.
• Advocacy for states to adopt and implement Interdermal route of Post exposure prophylaxis for Animal bite Victims and Pre exposure prophylaxis for high risk categories.
• Strengthen Human Rabies Surveillance System.
• Strengthening of Regional Laboratories under NRCP for Rabies Diagnosis.
• Creating awareness in the community through Advocacy & Communication and Social Mobilization.

Programme components

The Programme had two components – Human and Animal Components.

• Human Component for roll out in the all States and UTs through nodal agency National Centre for Disease Control (NCDC), Ministry of Health & Family Welfare, Government of India
• Animal Health Component for pilot testing in Haryana and Chennai through nodal agency Animal Welfare Board of India (AWBI) under the aegis of MoEF&CC, GOI.

Animal Health Component by AWBI has been ended with effect from 31.3.2017. The Human Health Component has been rolled out in 28 States and UTs.

The Strategies of the National Rabies Control Program are as follows:

• provision of rabies vaccine & rabies immunoglobulin through national free drug initiatives
• training on appropriate animal bite management, prevention and control of rabies, surveillance and intersectoral coordination
• strengthening surveillance of animal bites and rabies deaths reporting
• creating awareness about rabies prevention

National Action Plan For Dog Mediated Rabies Elimination

Ministry of Health & Family Welfare and Ministry of Fisheries Animal Husbandry & Dairying, Government of India jointly launched ‘National Action Plan For Dog Mediated Rabies Elimination (NAPRE) from India by 2030’. The stray dog population control and management of the stray dogs is the mandate of the local bodies. The Central Government has framed the Animal Birth Control (Dogs) Rules, 2023 which is to be implemented by the local authority to control the population of stray dogs. The main focus of the rules is on anti-rabies vaccination of stray dogs and neutering of stray dogs as means of population stabilization.

CONDITION

Rabies is an acute viral disease that causes fatal encephalomyelitis in virtually all warm-blooded animals including man. The virus is found in wild and some domestic animals and is transmitted to other animals and humans through their saliva (following bites, scratches, licks on broken skin and mucous membrane). In India, dogs are responsible for about 95% human rabies, followed by cats (2%). jackals, mongoose and others (1%). Therefore, the disease is mainly transmitted by the bite of a rabid dog.

Rabies has terrified man since antiquity. The fear is by no means unfounded since the disease is invariably highly fatal and perhaps the most painful and dreadful of all communicable diseases in which the sick person is tormented at the same time with thirst and fear of water (hydrophobia). Fortunately, the development of Rabies can be prevented to a large extent if animal bites are managed appropriately and in time. In this regard, the post-exposure treatment of animal bite cases is of prime importance.

National Rabies Control Programme (NRCP) is being implemented in the country since the 12 Five Year Plan with an objective to prevent deaths due to rabies in humans. National Centre for Disease Control is the nodal centre for implementation of the programme. The key strategies of the programme are:

• Strengthening surveillance of animal bites and human rabies
• Capacity building of health care professionals for appropriate management of Animal Bite victims
• Strengthening laboratory diagnosis of Rabies
• Increase awareness about Rabies in the community
• Strengthening Inter-Sectoral Collaboration with other sectors particularly veterinary and animal husbandry

National Centre for Disease Control (formerly National Institute of Communicable Diseases), Delhi, WHO Collaborating Centre for Rabies Epidemiology, organized an expert consultation in 2002 to formulate National Guidelines for Rabies Prophylaxis to bring out uniformity in post-exposure prophylaxis practices. These guidelines were revised in expert consultations in 2007, 2013 and 2015. Recently, the WHO position paper on rabies vaccines and WHO expert consultation on rabies, third report (WHO Technical Report Series, No. 1012) published in 2018, has provided new recommendations for rabies PEP. Consequently, an expert group meeting was called by NCDC, NRCP programme, Division for Zoonotic Diseases Programmes on 8th January 2019, to review the new recommendations of WHO. Based on the recommendation of the experts, the National Guidelines on Rabies Prophylaxis have been revised.

DECISION TO TREAT

In a rabies endemic country like India, where there is sustained dog-to-dog transmission, every animal bite is suspected as a potentially rabid animal bite, and treatment should be started immediately after exposure. Post-exposure prophylaxis needs to be considered in the following conditions:

• Bites by all warm-blooded animals.
• Exposure to wild animals: Exposures to all wild animals should be treated as Category Ill exposure.
• Rodent Bites: Exposure to domestic rodents, hare and rabbits do not ordinarily require PEP. However, rodent bites in forest areas necessitate institution of PEP.
• Exposure to bats: Bat rabies has not been conclusively proven in India and hence, at present, exposure to bats does not warrant PEP.
• Human-to-human transmission: The risk of human-to-human transmission is minimal and there are no well-documented cases, other than the few cases resulting from infected organ/tissue (cornea) transplant. However, people who have been exposed closely to the secretions of a patient with rabies may be offered PEP as a precautionary measure. Organ/ tissue (cornea) for transplantation should not be collected from suspected/confirmed rabies or Rabies-like encephalitis cases.

VACCINATION STATUS OF BITING ANIMAL:

An observation period of 10 days is necessary as no information is much animal about animals other than dogs and cats. Animals vaccinated against rabies do not suffer and transmit the disease. The history of animal vaccine failures may occur because of improper administration, inadequate doses, poor quality of the vaccine or poor health status of the animal. Rabies vaccination in an animal does not guarantee that the biting animal is not rabid. Therefore, in the absence of laboratory documentation of immunization (antibody titre), it cannot be presumed that a vaccinated dog is actually protected, given the variable efficacy of various anti-rabies vaccines in animals or health status of animals. Hence, irrespective of the vaccination status of the biting animal, the PEP should be given.

PROVOKED VERSUS UNPROVOKED BITE:

A bite by a provoked animal does not mean that the animal is not rabid. Therefore, a provoked dog bite should also be managed as exposure and PEP should be started immediately.

CONTRAINDICATIONS AND PRECAUTIONS:

As rabies is a nearly 100% fatal disease, there is no contraindication to PEP. Pregnancy, lactation, infancy, old age and concurrent illness are not the contraindications for Rabies PEP in the event of an exposure. Moreover, rabies vaccine does not have any adverse effect on pregnant woman, course of pregnancy, foetus or lactating mother. Hence, complete PEP should be given depending on the category of exposure. People taking Chloroquine for Malaria treatment or prophylaxis may have a reduced response to Intradermal (1D) Rabies vaccination. These patients should receive the rabies vaccine by Intramuscular (IM) route. As with all other immunizations, vaccinated persons should be kept under medical supervision for at least 15-20 minutes following vaccination. Previous reaction to any component of a vaccine is a contraindication to the use of the same vaccine for PEP or PrEP. The long and variable incubation period, which is typical of most t human r rabies cases, provides a window of opportunity to initiate PEP and protect the individual.This must be started at the earliest to ensure that the individual is immunized or protected before the rabies virus reaches the nervous system. However, people who present for treatment even months or years after a possible rabies exposure should be evaluated and treated as if the event had occurred recently. Risk assessment of potential rabies exposure can be complex and confusing. When in doubt PEP should be initiated and the attending physician should consulta specialist at Anti Rabies Clinics (ARC)

APPROACH TO POST-EXPOSURE PROPHYLAXIS (PEP)

PEP is a three-pronged approach as given below. All three carry equal importance and should be done simultaneously as per the category of exposure.

1Management of animal bite wound(s)

2 Passive immunization with Rabies Immunoglobulin (RIG)

3 Active immunization with Anti-Rabies Vaccines (RABIES VACCINE)

DURATION OFIMMUNITY

Modern Rabies Vaccines establish immunological memory that is assumed to persist for the life of the individual, even after titres of neutralizing antibodies decrease or are no longer measurable. Clinical data confirm that people vaccinated by modern Rabies Vaccine respond to booster immunization within 7 days, even if the initial course of PrEP or PEP was administered a decade back and regardless of the route of priming or booster immunization (IM or ID), and regardless of presence or absence of detectable titres of RABV-specific antibodies at the time of the booster.

In addition, published data indicate that periodic booster doses of vaccine are not required after primary rabies vaccination, except as an additional precaution in people with documented immune-deficiency should be evaluated individually. Patients with immune-compromised conditions (HIV/AIDS, patients on chemotherapy, long term steroid therapy, cancer etc.) may have a significantly lower or no detectable neutralizing antibody response to Rabies Vaccine In most of the settings, it is not possible to determine the severity of immune suppression when patients consult for PE. Therefore, in all Immune compromised individuals, in whom the presence of immunological memory is no longer assured, the following protocol should be followed:-

• Proper wound management followed by local infiltration of RIG in both Category Il and Ill exposures.
• After this, a complete course of Rabies Vaccine by IM route in both the category II and III exposures should be undertaken.
• Preferably, if the facilities are available, anti-rabies antibody titre estimation should be done 14 days after the completion of the course of vaccination to assess the need for additional doses of vaccine

Prevention

Paved floors, walls and permanent standings were disinfected by burning litter straw over the surface and by using blow lamp on the walls followed by washing thrice with 5 % solution of carbolic acid and 10% chlorinated lime coating. Soil surface of day standings occupied by infected animals were scrapped off and burnt using litter straw. Mangers, drains and day standings were sprinkled with chlorinated lime, blow lamped and exposed to sunlight for a fortnight. Water troughs and sidewalls were painted with chlorinated lime. All bedding or excrements in contact with suspected animals were destroyed by incineration. All the disinfection procedures were repeated on fortnightly basis. The vehicle used for transportation of carcasses was thoroughly disinfected using sodium hydroxide solution, blow lamp and exposing to sunlight. Animal handlers and veterinary staff were educated on risk of transmission of disease and precautions to be adopted.

Movement restriction and liaison

Restriction on movement of animals and animal attendants were imposed till the completion of prophylaxis. Stables have been kept under active surveillance for a period of one year. Additional fencing was also constructed to surround the animal stables to prevent any entry of carnivores to animal premises. Veterinary bodies of States and District are communicated about the incidence of Rabies for strict monitoring and adoption of measures to check transmission of the zoonotic disease in civil population and close liaison with veterinary and livestock development office has been maintained.

Discussion

One health approach employed can be a guiding source for control of any public health emergencies occurring in any developing or underdeveloped country in future. Due to repeated re-emergence of this viral disease and consequent threat to human and animal lives and economic losses involved, on the recommendation of veterinary authorities prophylactic anti-rabies vaccination has been added in the schedule of annual vaccinations/inoculations of army equines. The controlof zoonotic diseases such as Rabies requires inter-disciplinary and inter-sectoral collaboration. This fact is recognised globally by the concept of ‘one-Health agenda’ currently encouraged by the Food and Agriculture Organization (FAO), World Health Organization (WHO) and World Organization for Animal Health (OIE) (Adomako et al.,2018). Rabies represents an economic burden globally for all countries due to huge expense of human post-exposure treatment, diagnosis, surveillance and immunization of domestic animals and wildlife, requires more attention towards control of the disease and research on its various aspects (Toloueiand Mostofi, 2017). As in other warm-blooded animals, equine. Rabies is a severe and rapidly progressive neurological disease (Wilkins and Del Piero, 2007). Although Rabies in horses is low (around 5% of the total cases reported) and relatively uncommon, it’s potential for human exposure makes it lethal (Fernanda, 1914). WHO recommends that immunizing70% of dogs will be sufficient to prevent or control outbreaks of dog Rabies (Coleman and Dye,1996). One need not be clairvoyant to state that ‘one health approach’ is only the effective approach to prevent or control zoonotic diseases such as Rabies.

Conclusion

The dreaded Rabies outbreak is controlled through multipronged approach which involves coordinating the efforts of veterinarians, medical practitioners, laboratory, local population and administrators to tackle a public health problem. And thus is an approach towards ONE HEALTH APPROCH towards the spread of the disease which should be understood and motivated by all as the extreme priority .

 All For 1 : One Health for All