Mission Rabies Ghana Bosomtwe District

9th to 20th February 2019

Background

Rabies is one of the world’s deadliest zoonotic diseases. Transmissible through saliva, it is a neurotropic lyssavirus which tracks up peripheral nerves to cause a fatal encephalitis. When clinical symptoms manifest, there is virtually no chance of survival and rabies results in the death of at least 40,000 - 100,000 people annually worldwide1, the majority of whom are children under the age of 161.

In Africa and Asia, 99% of all reported human rabies cases are contracted from the bite of a rabid dog2. To eliminate incidence of human deaths from canine transmitted rabies requires a comprehensive strategy that goes beyond the supply and administration of post exposure prophylaxis (PEP) in endemic areas. The source of endemic rabies must be targeted through effective canine vaccination campaigns, in order to establish herd immunity and eliminate the virus within the reservoir host.

Mission Rabies was set up in 2013 to assist with the global efforts to eliminate canine transmitted rabies. With support from several organisations including WSAVA Foundation, Rotary, Afscan, Dogs Trust Worldwide, MSD Animal Health, the Marchig Trust and Worldwide Veterinary Services – and working under the guidance of WHO, CDC, FAO and OIE - it is hoped we can contribute to achieving this shared target by 2030.

After initial success in India, Mission Rabies has expanded its work over the last 4 years to other parts of Asia and Africa. The charity now runs over 9 campaigns in 7 different countries and is continuing to expand. To date we have vaccinated over 1 million dogs and rabies educated over 3 million people in endemic global rabies hotspots.

Thanks to the huge support of WSAVA Foundation and the guidance of WHO, FAO and the Ghanaian Government, Mission Rabies has been able to conduct a proof of concept vaccination campaign in Ghana.

This pilot vaccination campaign project was run in Bosomtwe District, Ashanti Region, over a 2 week period, under the direction of Dr Moses Djimatey, District Director of Health.

This vaccination campaign was only possible due to the leadership of Dr Djimatey and the close cooperation and involvement of the regional Veterinary Services Department (VSD) in conjunction with the Ghanaian Health Services (GHS).

Also a significant thank you to Dr Bernadette Abela-Ridder, Dr Sally-Ann Ohene (WHO), Dr John Amuasi, Dr Garba Maina Ahmed and Dr Akunzule (FAO) for all their guidance and backing. Dr Effah, regional veterinary officer was also a huge support and the brilliant Ghanaian team in the district.

Bosomtwe district has not had an official human rabies death since 2017 and yet saw a significant increase in the number of dog bite cases being reported last year. This is most likely due to increased awareness about rabies generally in the region following a 300 dog vaccination campaign in the District in 2017 coordinated personally by Dr Djimatey, the GHS and VSD.

Aim

To deliver a proof of concept focused mass vaccination campaign showcasing a scalable, economic and effective implementation strategy achieving 70% coverage of all dogs in the Bosomtwe district in a 10day window.

Objectives • Establish a local dog population estimate • Engage a One Health approach to rabies elimination through cooperation between the

Ghanaian Health Services (GHS) and Veterinary Services Department (VSD) • Vaccinate at least 70% of dogs in Bosomtwe district utilising established Mission Rabies

protocols, epidemiological surveillance and a concurrent district education programme. • Report, present and hope to scale the project

Methods Dr Moses Djimatey was invited to Malawi to meet the Mission Rabies team, discuss potential for Ghana and evaluate the conduct of the charity regarding possible partnership to launch a project.

A subsequent recce visit to Ghana was conducted in November 2018 to establish links with key stakeholders, both governmental and international organisations. This visit was also intended to explore and decide upon the best working methods for the project through information and idea gathering from the GHS and VSD.

The project was then launched in February 2019.

Population estimate A final year veterinary student from KNUST University in Kumasi conducted a dog population survey as part of their final year project. Bosomtwe district was divided up into a number of roughly equal sized areas and categorised according to different geographic areas. A representative proportion of these were randomly selected to be surveyed. The survey method involved the student going to every house within the working areas and asking about dog ownership.

From this a dog population estimate was calculated using the most recent human census. A human to dog ratio was calculated and a dog population was estimated to be between 8,000 and 9,500. We estimated 7,000 doses of donated MSD Animal Health Nobivac rabies vaccine would be required to ensure buffer for the project.

Education Community Health Officers (CHOs) are GHS employees that work closely with communities, providing health care information and interventions. The CHOs were trained in the Mission Rabies lessons and received copies of the associated lesson plans. Each CHO was given a WVS app log in to record education data.

The CHOs visited schools in their working areas and delivered lessons to children and communities. This was to be recorded in the app and synced so that the data could be accessed remotely. This will be compared with the traditional paper recording methods to see how many people used the app and whether it would have any further uses for the GHS in the field.

CHOs delivering lessons to children in Bosomtwe district. The photo on the right demonstrates how to stand to protect yourself if a dog looks like it might attack.

The CHOs did a great job of educating children about rabies. We found a child who knew how to protect themselves from a dog if one was approaching, though she hadn’t received the lesson herself. Her brother had taught her. This is a fabulous demonstration of the power and importance of education, and how the messages can be spread further than just the people the CHOs reached.

Sensitisation CHOs sensitised areas in advance of the vaccination teams arriving. This was done with varying efficiency and success depending on location.

Information centre announcements were the main modality that people found out about the vaccination campaign. They announced that Mission Rabies was present and that people should bring their dogs to a designated location for vaccination. In several locations the announcements could be heard in the mornings when teams arrived. However there were still a large number of people who didn’t hear about the campaign, this was most likely because they were at a distance from where the information centre was and so were unable to hear the announcement. This should be taken into consideration in subsequent projects.

The role of CHOs was important for sensitisation but it should be considered whether they should be part of the vaccination teams again next year. The CHOs might be more effective to sensitise areas that the information centres couldn’t reach.

Team structure Planning suggested 7 teams would be sufficient to cover the entire district in 10 working days. Each team comprised one veterinary services department employee, one driver, one MR staff member / 2 international volunteers. This was adapted slightly for 2 teams which needed additional VSD staff members. The project had 10 international volunteers who came from Italy, Australia, USA and the UK.

In addition to this we had one 2 person post vaccination surveillance team.

Working location

Bosomtwe District consists of 66 communities. Originally it was thought that one team could cover one district per day, however upon closer inspection some of the communities were very large and required multiple teams over multiple days to complete the areas, whilst other areas were very small and 2 (possibly more) communities could be covered in a single day by one team.

The map below shows the daily working zones. Each day had at least 7 working zones, one per team.

Day Colour Area 1 Black New Kokobiriko and Aputuogya 2 Light pink Abountem, Nkwanta, Dedesua, Aputuogya, Feyiase 3 Red Esereso, Adagya, Prabon 4 Brown Sawua, Awiom, Tetrefu, Homabenase 5 Magenta Feyiase, Prenuase, Akwaduo, Atobiase 6 Light pink Jachie, Pramso, Abrenkese, Toanfom 7 Blue Kuntanase, Yasse, Krom Adwafo, Akokofe, Amankwadei, Worakose, Onwi,

Kokodei 8 Orange Petrensa, Deduako, Apinkra, Nuaso, Adwumam, Adunku, Oyoko, Aduaben 9 Yellow Edwinase, Piase, Nyameani, Anyinatiase, Pippie, Abono, Asuoho Adwafo,

Aborodwum, Obo, Nkowi, Abasse, Nkwaintwanta 10 Purple Amekom, Adjamam, Beposo, Konkoma, Brodekwano, Mem, Asisiriwa,

Bonkokor

Some of the working areas were very large and dense. It was not possible for the teams to complete some of these areas in one day. This was anticipated and the plan was for teams to go back to areas that were not finished upon completion of other maps. Therefore teams were directed back to unfinished areas if they completed their intended map on a particular day. By the end of day 8 the

teams had caught up with the schedule. This was possible thanks to amazing volunteers, great team work and full cooperation between all teams.

Daily programme The first day started with an Opening ceremony that saw the District Chief Executive, The Regional Veterinary Director, a Representative for the Regional Director of Health Service, District Director of Health and the Chief of Deduako help support and open the vaccination campaign. Mission Rabies are very grateful to all the local government departments for showing their support for and during the project and it was a great honour to have such an opening ceremony.

Opening ceremony with important dignitaries in attendance.

There was at least one key static point location in most communities. These were locations used by the GHS for their projects and so ideal to be utilised by the vaccination teams for this project. Static point clinics ran in the morning for about 3hours and then teams progressed to door to door. This was to mop up and vaccinate any dogs which didn’t attend the static points.

We also trialled 2 smaller sub-teams with one sub team running the static point whilst the other sub-team would start door to door. This allowed more dogs to be vaccinated as those coming to the static point later in the day still had the opportunity to be vaccinated whilst those further away from the static point or those unable to handle their dogs were assisted by the door to door team. This methodology worked better and most teams started employing this method by the end of the project.

Vaccines and Surveys This pilot vaccination campaign saw us successfully vaccinate 4,370 dogs. Whilst this was actually a bit less than expected we exceeded the 70% vaccination coverage needed for rabies elimination.

The teams covered the areas well and the initial dog population estimate was slightly over inflated in calculation. It may be worth re-examining the population estimate and look at the areas that were surveyed now that we have greater knowledge of the working area.

Below are the daily totals of vaccinations at both static points, door to door and the overall total.

Date Static Point

Door to door

TOTAL

09/02/2019 140 218 358 10/02/2019 99 196 295 11/02/2019 230 257 487 12/02/2019 203 209 412 13/02/2019 114 306 420 16/02/2019 129 368 497 17/02/2019 120 385 505 18/02/2019 180 204 384 19/02/2019 207 360 567 20/02/2019 304 140 444 21/02/2019 1 1 TOTAL 1727 2643 4370

In addition to the vaccines administered by Mission Rabies a total of 108 dogs were recorded as having been vaccinated previously. This was predominantly through the agriculture department or with a private veterinarian. It is probable that teams didn’t record all previously vaccinated animals, therefore this number is likely to be higher than recorded.

4,370 dogs vaccinated

percentage of dogs vaccinated:

82.03%

This map shows every data entry. Yellow dots are static point entries. Blue dots are door to door entries. This demonstrates how thoroughly the areas covered and the reach of the teams.

Mission Rabies prides itself on working systematically in a scientific manner. Each day teams were allocated a region within Bosomtwe district to work in. They could see this area through the WVS data collection app we use to manage teams and to collect scientific and demographic data in the field.

Maps were visualised through this app and satellite images inspected to ensure every house was reached. The path tracking function represented where teams went each day. This helped teams direct where they work, ensured they did not miss houses and that they didn’t repeat the same areas.

Post vaccination surveys were carried out in areas where the map was completed, usually within 24 hours. Two post vaccination surveyors worked together walking on opposite sides of the road and visiting every house.

Since the post vaccination surveyors had to go in a vaccination vehicle and were dropped off at a map not too far from the vaccination teams, it meant that the areas chosen were not random. However, there was a good variation in the population density of the surveyed areas.

Pathtracker function on the WVS data collection app, helping teams work in the field

Post vaccination area Number of dogs in survey Percent vaccinated 1 3 82 87.88% 2 3 32 88.24% 2 7 7 100% 6 7 119 88.89% 7 1 and 7 2 74 68.18% 8 7 a 63 71.05% 8 7 b 59 84.38% 9 2 138 83.33%

Budget Thanks to the huge support of WSAVA Foundation and the vaccine donation from MSD Animal Health we have been able to run this project within budget. There was additionally significant buy in from local stakeholders as demonstrated through the provision of departmental vehicles free of charge. The Regional Veterinary Services supplied 2 of their vehicles, one came from the Bosomtwe Ministry of Food and Agriculture department, one from the Ashanti Regional Health Administration, one from Bekwai, a neighbouring district, District Health Administration, one from the District Assembly in Bosomtwe and one from the Business Advisory Centre. The vehicle related costs were reduced to fuel and repairs.

Total project budget: £10,500 GBP

Volunteer costs: £5,000 GBP

Volunteers covered all their own costs.

Administration, MR staff costs were also largely excluded from this budget and supported by Dogs Trust Worldwide and Other Income.

Total expenditure: £15,500. Final accounts are a work in progress.

Further support was provided by the VSD, who generously donated vaccination certificate slips that they issue for rabies vaccinations. Mission Rabies stamps were purchased and they were inked into the top right corner of the owners copy of the vaccination slip to demonstrate that this work was being done in partnership.

VSD rabies vaccination slips, showing the Mission Rabies stamp and Nobivac rabies vaccination sticker

Dr Djimatey was able to acquire pre-exposure vaccines for all staff members for free and most of the post exposure vaccines from the Government Medical department. This was generously donated by this department and helped with cost saving.

This local support was fundamental to the success and viability of the project. It also serves to demonstrate local buy in and support for rabies elimination, making this project more sustainable and hopefully more appealing to external funders.

Health and Safety One volunteer was sick upon arrival in Ghana on Thursday 7th February. She attended the volunteer training but didn’t go into the field to work. By Sunday morning she felt a lot better but by the evening she felt tingling in her extremities. In previous experience this has sometimes been felt by volunteers when overly hot. The next morning the tingling had gone, but came back by the afternoon. Seeking medical attention had been offered previously. On this occasion the volunteer was taken to the teaching hospital in Kumasi for checkup. She had blood work done and this was all normal. She felt better the following morning, but unfortunately had to leave that day due to a family tragedy at home.

One VSD staff member was bitten and 6 international volunteers were bitten or scratched. Protocol was observed for each exposure. Any wound was washed with iodine and water for 15minutes and the individual received post exposure vaccinations. One international volunteer was bitten on the final day and received her 2nd PEP on day 3 upon her return home.

Several members of the public were bitten by their dogs. To follow the Ghanaian system the names and numbers of these people were recorded and the GHS team will follow up 10days later. Post exposure vaccinations will be issued if the dog has disappeared or died in that time.

The final dog vaccinated during the Mission Rabies Ghana 2019 vaccination campaign

Thanks and Future hopes The first Mission Rabies Ghana project was a success thanks in main to the outstanding direction of Dr Moses Djimatey and the support from WSAVA Foundation.

The guidance of WHO in strategizing the concept, advice from FAO and the leadership by Dr Jordana Burdon Bailey, MR Africa Projects Director, Dr Fred Lohr Director of Strategic Partnerships and Julie Comfort MR India Project Manager has been invaluable.

In short, the results are thanks to the great cooperation and support of all our international and local stakeholders in addition to our international volunteers. The generosity of local stakeholders demonstrates a local desire to eliminate rabies from Bosomtwe and this is something that we are deeply appreciative of and hold in high regard.

The local team and MR staff involved in this project have been inspiring. They worked incredibly hard, set up a project from scratch and delivered an excellent result. Crucially, this delivery motivates the entire charity to drive the project forward and ensure the proof of concept builds into something more.

Neighbouring districts and regions have heard about our work and are requesting to be a part of this next year. Momentum is building and the key is to seize it and galvanise practical action to keep rolling the project out.

Fundamentally, a proof of concept drive is never perfect. It showcases an effective and efficient methodology that is both viable and scalable. That said, we have learnt a lot from this pilot project

and these lessons shall be used to help shape future projects, constantly evolving and enhancing the campaigns.

One report that really struck home with this project was that on the second day of vaccinating, Mr Adusei and some of his team had to suddenly travel to a neighbouring district to collect samples from a person who had died from rabies. I also remember when Dr Djimatey was in Malawi last April, he was dealing with a drama on the phone, desperately trying to help a family source rabies PEP for their children – I believe one of whom had already died of rabies.

This is why projects like this matter. Rabies is a neglected disease that affects the poorest of the poor. Working together, we have the incredible opportunity to do something about it.

The ideal next step would be to cover the entire Ashanti region. This has 30 districts and based on its size and suspected dog population density would require about £370,000. It’s a huge jump from £12,500 – but one we could take if the funding could be found. Beyond that a national campaign would be within our grasp.

On behalf of the Mission Rabies team, thank you to the WSAVA Foundation for the opportunity to be a part of this initiative with you. In particular Professor Colin Burrows, Dr Gabriel Varga, Professor Michael Day who have tirelessly championed Mission Rabies in a myriad of ways.

Thanks again to Jo and Julie who ran this vaccination team on the ground, Fred who was so fundamental in the planning, Andy for all the app engagement and again to Jo – who wrote most of this report!

Best wishes,

Luke

Dr Luke Gamble BVSc DVM&S FRCVS

Chief Executive

Mission Rabies