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)

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), Ministry of National Health Services, Regulations and Coordination.
Additional information is available from source listed below.
Pakistan Health Research Council, Islamabad
Phone: 051-9207368, 9206092, 9217146 Fax: 051-9216774
Email: pmrc.rdc.ps@gmail.com, pmrc.rdcii@gmail.com

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

Background:
Rabies is one of the oldest known zoonotic disease to man. It is caused by the lyssa virus
present in the saliva of infected animals such as dogs and is generally transmitted through their
bite. Globally on an average, 55000 people die from rabies per year, and unfortunately more
than 98% of these deaths occur in the developing world in spite of the availability of effective
and economical control measures. Rabies disproportionately affects rural and socioeconomically disadvantaged communities. Experts around the globe have consensus that rabies
is under reported in most of the developing countries due to lack of true data. Number of
officially reported deaths usually underestimates the actual incidence of disease resulting in
lack of attention by national authorities. In 2013, World Health Organization (WHO) declared it
as one of the seventeen neglected tropical diseases of the globe.
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. Children in age
group (5-15 years) represent 40% human rabies death and dog-mediated rabies is a key
epidemiological pattern in SAARC countries, Meanwhile 1.5 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. However it is estimated that rabies takes the lives of 2000-5000
Pakistanis every year. In the past, globally all stress was given on the management of dog bite
and rabies with introduction of newer and cost-effective vaccines. Despite all this, the overall
treatment cost of dog bite cases is high and beyond the reach of many countries. However, now
there has been a shift in the rabies elimination and now there is more focus on dog vaccination
(both Pet and stray dogs). It is estimated that this cost is many folds less than the treatment of
dog bite cases.
In 2010, Federal government nominated focal persons for zoonosis and in same year Provincial
focal persons for Rabies were also nominated. In 2013, Country guidelines for Rabies
prevention and treatment were developed through WHO support in consultation with rabies
experts from the Provinces. Later Provincial Director Generals (Health) were asked to identify
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10 hospitals for dog bite management and upon identification, 2 providers from each hospital
were trained on the use of new rabies immunoglobulin (RIG) and the vaccines using intradermal
or intramuscular approach. The major mile-stone was achieved in 2015 where the country
switched over to cell culture vaccine production. Besides human health, rabies is also a concern
for animal health. Unfortunately, there is still no focal person nominated from animal health
department of all provinces.
Considering all these identified areas, a two days consultative meeting on Rabies prevention
and control in Pakistan was organized by Pakistan Health Research Council, Ministry of National
Health Services, Regulations & Coordination (NHSR&C) in collaboration with World Health
Organization from 11th -12th April 2016 at Islamabad. All key stakeholders were invited including
Provincial Focal Persons on rabies, experts from Animal Health Sciences and Live stock
departments, representatives of animal welfare societies, Municipalities (Capital Development
Authority) and WHO. Dr. Huma Qureshi, Executive Director, Pakistan Health Research Council
along with her team of researchers were facilitating this meeting.

Activities:
Day 1:
The activities of 1st day started with remarks from DG Health, Ministry of NHSRC. He
appreciated the efforts of PHRC in advancing steps towards rabies control from the country and
inviting all relevant stakeholders for the meeting. The Executive Director, 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.
This was followed by the presentations from Provincial focal persons and experts from public
and private hospitals who deal with dog bite cases. They presented rabies situation and its
management in their respective provinces.
Key Presentations:
1.

Dr. Zarfishan Tahir, Focal Person for rabies from Punjab highlighted the need to have a

national data on Rabies. She also suggested to keep the ball rolling, Provincial Focal person of
2

rabies from animal health should also be nominated who should work in collaboration with
their human health experts. She also stressed to adopt one health approach for successful
eradication of Rabies from the Country.
2.

Dr. Naeemul Haque Quraishi, 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. Nasim Salahuddin. 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.
3.

Dr. Jamal Akbar, Focal Person for rabies from Khyber Pukhtunkhwa (KPK) shared that

among 25 districts of KPK, there are 10 sites for rabies management. 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. He also shared the data of dog bite cases retrieved from
District Health information system (DHIS) in KPK from 2011-2016.
4.

Dr. Abid Saeed, 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. 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.
5.

Dr. Naseem Salahuddin, Head, Department of Infectious Diseases, Indus hospital,

Karachi informed that 4000 cases of dog bite cases were reported in 2015 and among them 31
died. She shared that knowledge, attitudes and practices (KAP) of doctors and paramedics
regarding rabies patient management, dosage and route of cell vaccines and RIG administration
is very poor. She emphasized to intensify the awareness both among general public and
doctors, to promote intradermal regimen in large hospitals. She also suggested involving
experts from animal health side for animal rabies control.
6.

Dr. Tahir Yaqub, Professor of Microbiology, University of Veterinary and Animal

Sciences, (UVAS) Lahore, author of Pakistan Rabies Control Guidelines for Animals, briefly
3

describe objectives of the guidelines. 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. Reduction in dog population will reduce
rabies as one male dog can produce 12288 pups in 5 years. Secondly, this approach is less costly
as compared to treatment cost and subsequent human mortality.
7.

Mahera Omar, Co-founder and Director, Pakistan Animal Welfare Society (PAWS)

presented information about the inhumane stray dog killings by the civic administrations. She
shared that local animal welfare groups end up dealing with injured puppies and dogs that are
poisoned or shot and left to suffer, often by citizens themselves. To eradicate rabies from
Pakistan, the government should make policy to control the disease in dogs through mass
vaccination and dog sterilization. Animal Welfare Board and Dog Population Management Act
may also be formulated. All stakeholders therefore, should be on board to coordinate activities
and unify efforts. In addition to above, proper garbage disposal, pet registration/vaccination,
and awareness programs in schools and use of mass media will produce dramatic results in the
Rabies control.
8.

Dr. Katinka de Balogh, Senior Officer, Animal health and Production Regional Office for

Asia and the Pacific, Food and Agriculture Organization (FAO) of the United Nations delivered
her presentation on Skype. She stressed to adopt one health approach for Rabies eradication.
She informed that in 2015, Americas eliminated dog rabies and 2020 is the target for South East
Asia and Pacific region for rabies elimination. She said that biggest challenge is availability and
affordability of post exposure prophylaxis and to do massive dog vaccination. 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). She told that one of the objectives
of this two days meeting was to define the stage where Pakistan is standing in rabies
elimination. Once the country knows its present position then it is easy to move forward with
careful planning.
9.

Dr. Muhammad Zubair Shabbir, Assistant Professor, UVAS, Lahore shared the gaps

regarding rabies control. He informed the participants that no department owns dog as they
are neither human health nor livestock and similarly not come under wildlife. Meanwhile there
4

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.
Group Work on Rabies Roadmap Matrix
At the end of first day, all 20 participants were grouped into four provincial working groups to
chalk out activities on Rabies Roadmap Matrix. Each group comprised of members from human
and animal health from same province. In this session by using SARE tool, Provincial
representatives compiled activities that have been accomplished and that are pending in their
Provinces. Finally, group representatives from each Province presented their data and score.
The aggregated score of SARE in all 07 components for each province was calculated, Sindh
scored maximum score of 21 (23%) amongst accomplished activities, while Baluchistan scored
11 (12%). None of the province could achieve 25% score (Table 1).

Day 2:
Recall of day 1 was briefed by Dr. Muhammad Arif Nadeem Saqib, Senior Research Officer,
PHRC. He briefed the participants about the scores of each Province, compiled the data of
rabies cases from Provinces. He also provided details about group work activities and how to
move forward.
Group Work:
Two groups were formed using the tool provided by Dr Katinka, FAO. Details are given as
follows;
Group work on Case study:
This exercise was intended so that participants may brain storm about how rabies cases are
presently handled in Pakistan. Main objective was to identify the gaps and what can be done to
plug these gaps.
For this activity, participants were divided in three groups comprising of experts of different
sectors i.e. animal and human health. Case study scenario was handed out to each participant.
Each participant was asked to note down their thoughts on what comes to their mind
5

regarding, how they would address the case and possible gaps along with the solution.
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. Various stakeholders that should be engaged in a successful rabies control program
were also identified. Representative from each group presented the findings. The existing gaps
identified by the participants are shown in table 2 and 3.
Group work on Development of Action Plan:
Participants were again divided in two groups; animal and human health. In this activity, 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.

Table 1: Provincial SARE Score

Punjab

Sindh

KPK

Baluchistan

Max
score

1 Legislation

12

12

12

12

12

2 Data collection and analysis

Laboratory diagnosis

10

10

10

10

Information, Education,
Communication

18

14

18

18

15

5 Prevention and control

25

19

25

18

20

6 Dog population related issues

13

7 Cross cutting Issues

15

15

15

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, 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, 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 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,
municipality).
Ignorance among public, Vet
Unit. Lacking PEP facility
vaccine etc).
No such system for action

Disease is not notifiable.

No compulsory vaccination.
No system for dog registration.
No intersectoral coordination.
Lack of trained/skilled Human
Resource.

Communication to
Public

No Risk Communication to
Public. No health education To
Public.

Response

No surveillance system.
Culling.

Laboratory

Lack of Lab. Diagnostics.

Lack of Funding/Resources.
Lack of integration among
stakeholders involved in rabies
prevention & Control.

Stake holders

Intervention proposed
Identify the responsible
stakeholder. Establishment of
quarantine facility.
Public awareness campaign by
livestock. Provision of PEP
facilitates at Lowest Civil Vet
hospital level.
Establishment of system, trained
Human Resource.
Legislation needs to be done.

Proper coordination among all

stake holders needs to be
established. Hiring of trained HR
and training of already present
staff. Joint Animal/human case
investigations. Dog vaccination
campaigns.
Risk Communication by Livestock
Health Education among Public by
Health Dept. in collaboration with
education department through
Print, electronic, social media.
Establishment of surveillance
system. Culling is not an option
ethically, vaccination should be
encouraged.
Establishment of reference.
Allocation of funds/resource.
Identify roles/responsibility of each
partner and an integration
mechanism among them from top
to bottom.

Action Plans:
Following action plans were developed for human and animal health.

Human Health:
Short term Intervention (2 Years):
S. No

Targets

Responsibility

Timelines

Development and submission of

PC-I

Provincial Focal Person

Dec 2016

Making a case for politicians

Federal and Provincial Focal Persons

Dec 2016

Development of surveillance
system and its integration

Provincial Focal Person

Dec 2017

Development of training,
awareness and risk
communication material

Federal and Provincial Focal Persons

Dec 2016

Joint program activities/

meetings/targeted approach

Federal and Provincial Focal Persons

June 2017

Responsibility

Timelines

Long term Intervention (5 years):

S. No

Targets

National /Provincial Strategic

Document

Federal and Provincial Focal Persons 2018

Legal frame work

Federal and Provincial Focal Persons 2017-2018

Regular IEC programs

Provincial Focal Persons

2017

Regular Surveillance System

Provincial Focal Persons

2019-2020

Integration of disease in regular

health services

DG health and Provincial Focal

Persons

2019

Animal Health:
Short term plans (1-12 months):
S. No

Targets

Responsibility

Timelines

Develop preparedness plan

Federal/Provincial
Authorities with support
from FAO/WHO.

Establish Provincial task force for pilot

study for mass vaccination and
sterilization of dogs in each province

Veterinary and local

Government Department.

Mass communication and awareness.

Federal/Provincial
Authorities with support of 6-12 months
FAO/WHO

Dog population census to be started.

Livestock and Dairy

Development (L& DD) in
each province.

4 months

Prepare policy document to make animal

rabies notifiable disease along with dog
registration and its compulsory
vaccination.

Federal/Provincial
Authorities

12 months

12 months.

2-12 months

Medium to long term plans (1-4 years):

S. No

Targets

Responsibility

Timelines

Dog population management by mass

dog vaccination and sterilization.

Veterinary and local

Government

3 years

Awareness and trainings, for

stakeholders including veterinary,
human, local Governments and
community.

Veterinary sector,
provincial and local
Government.

2 years

Legislation based on the policy

document to be approved from
provincial assemblies.

Focal persons animal and

human health

3 years

Setting up a surveillance system for

animal rabies.

Veterinary sector together

with local government.

3 years

Establishment of diagnostics facilities

and vaccine Production for animal
Rabies.

Federal and Provincial

Government.

3 years

10

List of Participants:
S. #

Name

Designation

Department

1.

Dr. Asad Hafeez

Director General
(Health)

Ministry of NHSR&C, Islamabad

2.

Dr. Huma Qureshi

Executive Director

Pakistan Health Research Council, Islamabad

3.

Dr. Farnaz Malik

Executive Director

National Institute of Health, Islamabad

4.

Mrs. Anwar Begum

Chief BPD/Incharge

Rabies Vaccine Production,

National Institute of Health, Islamabad

5.

Dr. Zarfishan Tahir

Focal Person Rabies,

Punjab

Institute of Public Health, Lahore

6.

Dr. Naseem Salahuddin

Consultant,
Infectious Disease

Indus Hospital, Korangi, Karachi

7.

Prof. Tahir Yaqub

Professor of
Microbiology

Provincial Investigator of Rabies Project,

University of Veterinary & Animal Sciences,
Lahore

8.

Dr. Naeemul Haque

Quraishi

Provincial Focal
Person, Sindh

Project Director, ASV/ARV Lab, Nawabshah

9.

Dr. Syed Jamal Akbar

Assistant Director

Director General Health Services,

Peshawar

10.

Dr. Seemin Jamali

Head of Emergency
Room

Jinnah Postgraduate Medical Centre, Karachi

11.

Ms. Mahera Omar

Co-Founder & CEO

Pakistan Animal Welfare Society, Karachi.

12.

Mr. Muhammad Aftab

Gohar

Coordinator

Rabies Program , The Indus Hospital,

Karachi

13.

Dr. Muhammad Zubair

Shabbir

Assistant Professor

University of Veterinary & Animal Sciences,

Lahore.

14.

Ms. Nadia Mukhtar

Instructor

Virtual University of Pakistan.

15.

Dr. M. Iqbal Afridi

Health Officer

Directorate of Health Services

Capital Development Authority, Islamabad.

16.

Dr. Ali Akbar Soomro

Director General

Livestock & Fisheries Department, Hyderabad

17.

Malik Ayaz Wazir

Director

Livestock & Dairy Development Department

FATA, Peshawar.

11

18.

Dr. Nazarrat Hussain

Veterinary Officer

Directorate of Livestock Diary Development

Department, Gilgit-Baltistan.

19.

Sardar Khan Zimri

Director Sanitation

Sanitation Directorate
Capital Development Authority, Islamabad.

20.

Dr. Muhammad Saleem

Provincial Technical
Officer

Director General Health Services,

Peshawar.

21.

Dr. Ehtisham ul Haq

Khan

TAD Officer

Directorate General Office, Lahore

22.

Dr. Abid Saeed

Technical Support
Officer

Provincial Disease Surveillance & Response

Unit, Provincial Health Directorate,
Quetta.

23.

Mr. Zafar Qureshi

SRO/APVO

Veterinary Research Institute, Lahore

24.

Dr. Kabir Hussain Tahir

Director General

Livestock & Dairy Development Department,

Muzaffarabad, Azad Jammu & Kashmir

25.

Syed Asad Ali Shah

Deputy
Epidemiologist

Director General (Extension), Livestock &

Dairy Development, Peshawar.

26.

Mr. Zain Bukhari

Sanitary Inspector

Sanitation Directorate, CDA, Islamabad

List of Facilitators:

S. #

Name

Designation

Organization

Dr. Muhammad Arif

Munir

Principal Research
Officer

Pakistan Health Research Council , Islamabad

Dr. Muhammad Arif

Nadeem Saqib

Senior Research
Officer

Pakistan Health Research Council , Islamabad

Mrs. Sumera Abid

Research Officer

Pakistan Health Research Council , Islamabad

Mr. Ibrar Rafique

Research Officer

Pakistan Health Research Council , Islamabad

Dr. Faiza Bashir

Medical Officer

Pakistan Health Research Council , Islamabad

12

Group photo of the workshop participants

Chief Guests and Key Speakers

13

14

15

Group Work and Discussions:

16