Mission Rabies Tanzania

13th to 24th January 2018

Contents

Page

Background…………………………………………………………………………………………………………………………. 2 Partnership and staffing….…………………………………………………………………………………………………… 3 Location………………………………………………………………………………………………………………………………. 3 Program………………………………………………………………………………………………………………………………. 4 Data…………………………………………………………………………………………………………………………………….. 6 Experiences on the ground………………………………………………………………………………………………….. 8 Health and Safety………………………………………………………………………………………………………………… 11 International guests…………………………………………………………………………………………………………….. 12 Financials…………………………………………………………………………………………………………………………….. 13 Future work…………………………………………………………………………………………………………………………. 14 References…………………………………………………………………………………………………………………………..

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Background

Rabies is one of the deadliest viruses in the world, with an estimated 59,000 human deaths each year 1. Despite this it is 100% preventable through vaccination. As over 98% of human rabies cases are a result of exposure through dog bites2 vaccinating dogs against rabies will significantly reduce the number of human rabies deaths. Vaccinating at least 70% of the canine population creates herd immunity against rabies and effectively eliminates it from the canine population3; this has a knock on effect improving the welfare of both dogs and people.

Mission Rabies was set up in 2012 to help eliminate canine rabies from the world. With support from several organisations including the Dogs Trust, MSD, the Marchig Trust and Worldwide Veterinary Services it is hoped that this goal can be achieved by 2030. After the success and great results from working in India since 2013 Mission Rabies has expanded its work to other parts of Asia and Africa. Mission Rabies conducts yearlong vaccination campaigns in Goa, India; Ranchi, India; and Blantyre, Malawi. There are smaller campaigns in Zomba and Chiradzulu, Malawi and annual vaccination campaigns in Tanzania, Uganda and Sri Lanka. In January 2016 the first Mission Rabies – Mbwa wa Africa partnered vaccination drive was conducted in regions within Meru District, Tanzania. Initially 2 wards within Meru District were covered during a 2 week pilot vaccination campaign in Maji ya Chai and Usa River. This drive was repeated in 2017 and included an additional ward, Songoro. During the remainder of 2016 Mbwa wa Africa continued vaccinating following the Mission Rabies protocol within Meru District covering 3 additional wards, Nkoaranga, Nkoanekoli and Kin’gori. The 2017 campaign was opened up to International Guests (volunteers). This report details the 2017 vaccination campaign.

Mission Rabies employs four concepts in its work to reduce human rabies cases

1) Mass Canine Vaccination, targeting at least 70% of the dog population 2) Humane Canine Population Control 3) Community Rabies Education and Awareness 4) Canine Rabies Surveillance

Prior to and during the vaccination drive, Maureen from Mbwa wa Africa went into local schools to educate children about rabies and to encourage participation in the vaccination campaign. The education work is not detailed in this report. Mbwa wa Africa, in partnership with WVS, ran a spay- neuter campaign alongside the vaccination campaign as well as treating sick and injured dogs highlighted by the Mission Rabies vaccination teams. Since the first vaccination drive there was one suspected rabid dog in an unvaccinated ward in Meru District only and there are reports of human rabies vaccine sales drastically reducing in the locale. The Mission Rabies core staff responded to a suspected rabid dog at Nkoaranga hospital during the vaccination drive. This was on the edge of our Songoro vaccination zone, an area covered by Mbwa wa Africa in their July campaign. Unfortunately after 3 visits to the hospital, he dog was unable to be captured for quarantine and observation and was not reported to have been re-sighted by hospital staff.

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Partnerships and Staffing

Mission Rabies has partnered with Mbwa wa Africa to work in several wards in Meru District, Tanzania, where Mbwa wa Africa are based. Mbwa wa Africa was established by Jens Fissenebert and Sandra Kliegelhoefer in 2013, initially providing animal adoption, veterinary care and preventive care to animals in the region. In 2015 Mbwa wa Africa expanded into spay-neuter clinics, initially with the help of WVS, before partnering with Mission Rabies in mass vaccination campaigns.

A pilot vaccination campaign was held in January 2016 to demonstrate the effectiveness of Mission Rabies’ working protocols and to how effective these would be in Tanzania. A total of 3,924 dogs were vaccinated over 11days of static point and mobile door-to-door vaccinations. This was estimated to be approximately 68% of the canine population in these regions.

In 2017, Maji ya Chai and Usa River regions were vaccinated for the second time with an additional ward added in Songoro. The total vaccination count was 4575 over 11 working days.

Mbwa wa Africa undertook most of the in country preparatory work for the 2018 vaccination campaign, under the guidance of the Mission Rabies team in the UK. Local Tanzanian volunteers were recruited to be part of the vaccination drive in addition to 2 Mission Rabies staff members, the Mbwa wa Africa coordinator and 10 international Mission Rabies volunteers.

Location

Vaccinations took place in 3 of the 17 wards of Meru District, which is close to the city of Arusha. Arusha is a tourist destination between Mt Kilimanjaro and several National Parks, including Serengeti and Ngorongoro crater. This area was selected as a result of a human rabies death in 2015 and several suspected canine rabies cases around the same time.

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Image 1. Tanzania 1a, Location of Meru Disrict in Tanzania. 1b, wards of Meru District.

The wards covered in this vaccination drive are: Maji ya Chai, Usa river and Songoro. Both Maji ya Chai and Usa River are areas which were covered for the third time this year, whereas it was our second year in Songoro. A 2012 census gives the human population at approximately 64,069 for the 3 wards covered in this vaccination campaign4.

Maji ya Chai consists of predominantly flat rural land at an elevation of 1400m above sea level with spaced out houses. Usa river is more densely populated with an urban core. Songoro is on the side of mount Meru and is very difficult terrain, more time was allowed for the coverage of Songoro region due to this.

Since the first vaccination campaign in this area of Meru District there have been no suspect rabies cases reported within these wards, though other cases have been suspected outside of this working area.

Program

The dog population estimate of Maji ya Chai, Usa river and Songoro wards was calculated to be 6,179 after the vaccination drive in 2017. To achieve 70% vaccination coverage of the canine population we would need to vaccinate approximately 4,300 dogs.

Mission Rabies’ Research and Programmes Intern, Amy, and Mission Rabies Project Coordinator, Paul were present for the duration of the vaccination campaign. All staff and volunteers were briefed before the start of the vaccination campaign. The briefing contained information about the history of Mission Rabies; the pathophysiology and epidemiology of rabies; exposure and post exposure protocols; how the vaccination campaign would run so that all team members were fully aware of their roles and responsibilities; and health and safety. All participants signed to say they had been present and understood the briefing. This was followed up with a practical brief introducing all volunteers to the WVS App. To help with the briefing, vaccination protocols, clinic protocols, English versions of the education material, an example complete vaccination certificate and App FAQ sheet was provided to the volunteers. These were made available for reference in each volunteer field kit.

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The programme ran from 11th to 24th January for 10 working days.

Image 2. Static point vaccination sites in Meru District. Different colours represent the different days for static point locations. Yellow areas were vaccination points for the first Saturday, Green the first Sunday, Red the second Saturday and blue the second Sunday.

The volunteers made up 8 teams of predominantly 3 but occasionally 2 people. On Saturdays and Sundays static point vaccination clinics were held at strategic points across the 3 wards (Image 2). They were chosen according to population size and density in the area as well as having suitable locations for hosting a static point vaccination site. Data from 2017 was analysed and this helped to identify areas where static point vaccination sites were successful. Monday to Wednesday the teams walked door to door in these wards recording dogs previously vaccinated and vaccinating and recording those that were vaccinated at that time. On day 1 of the static points, 2 teams did half day clinics followed by half days of door to door work. On the second Saturday, 1 team spent the whole day going door to door and 1 team had a half day static point followed by door to door. As there were only 6 static points on the final Sunday, 1 team did 2 half day static point in the morning and afternoon, leaving 3 teams to do door-to-door work.

For the door to door days’ teams were allocated specific regions of the wards to cover on the Mission Rabies App. 40 wards were covered door to door by the teams over 10 working days. These regions were mostly bordered by roads to make navigation easier and were of a size thought to be sufficient for a day’s work. Some locations took longer than a day to complete and so the teams returned to those regions to complete the area before moving onto their next area. Towards the end of the project, teams worked together to compete wards

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Image 3: Showing wards covered by teams over the 2 weeks

Alongside the vaccination programme Mbwa wa Africa, in partnership with WVS, held a spay neuter campaign. Owners were asked if they would like their dog to be sterilised by the vaccination teams and their telephone numbers collected where applicable. This data was used to contact owners for the sterilisation campaign. As well as sterilising dogs this team also provided medical care for any sick or injured dogs encountered by the vaccination team. The Mission Rabies App was used to tag locations of all dogs requiring immediate care so that a response person could collect the dog whilst the vaccination team could continue with their work. Where a dog needed treatment, but it wasn’t urgent, this was highlighted in the app and the response team could respond at a later time. As an example, this method was adopted for dogs identified with TVT.

Data

A total of 4,789 dogs were vaccinated over the vaccination campaign, of which 3,374 (359 dog increase from 2017) were at static points and 1,415 (145 dog decrease from 2017) were vaccinated on the door to door days. Using the data collected a revised population estimate for the 3 wards was calculated. This gave a population estimate of 6690, meaning that overall we vaccinated 71.6% of the dog population during this vaccination drive. Image 4 illustrates all the data points from the door to door vaccinations. This demarcates where every dog found during the door to door days was located showing the thorough coverage of these areas.

Looking at each ward individually provides more specific information. In Maji ya Chai 2,739 dogs were vaccinated. This equates to 71% of the canine population, with an estimated population size of 3,801. In 2017 we vaccinated 2,665 dogs and 78% of the estimated population.

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Overall Coverage Static Already Already Vaccinated Point Date Vaccinated by New Vaccination Not Vaccinated Grand Total at Static Point Vaccinati other on Static Point 3374 3374 13/01/2018 871 871 14/01/2018 937 937 20/01/2018 691 691 21/01/2018 870 870 22/01/2018 5 5 Door to Door 1587 57 1415 198 0 3257 13/01/2018 11 32 43 14/01/2018 1 1 15/01/2018 188 195 35 418 16/01/2018 257 6 163 20 446 17/01/2018 179 6 245 32 462 20/01/2018 37 8 66 10 121 21/01/2018 128 11 83 21 243 22/01/2018 199 16 252 42 509 23/01/2018 324 7 202 21 554 24/01/2018 264 3 176 17 460 Total 1587 57 1415 198 3374 6631 Total new vaccinations 4789

Table 1. Static point and door-to-door vaccinations. New vaccination = vaccine given at the time; Not vaccinated = no vaccine given now; Already vaccinated by other = vaccine not given now but has been vaccinated in the past year

In Usa river 65% of the estimated population of 1,016 dogs were vaccinated. In 2017, 1,057 dogs were vaccinated giving 65% of the estimated population. The population was estimated to be 1,632 in 2017 and 1,557 in 2017, a reduction of 75 dogs. This reduction in the population could be due to the focused efforts of animal birth control by Mbwa wa Africa within Usa River over the past year. For the past 3 years the percentage vaccinated just fell short of the recommended 70% vaccination coverage for rabies elimination, though this doesn’t seem to have affected the campaign efficacy as there have been no reported rabies cases in this region over the past 2 years. It is unknown why it is so difficult to reach 70% vaccination coverage in this particular ward. One possibility is that people in neighbouring wards come to the static point vaccination sites in Usa river. These dogs will never be re-seen on the door to door days as they are not within the ward boundary. This affects our results by artificially elevating the population estimate and therefore reduces the percentage vaccination coverage.

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Image 4. Data points for door-to-door vaccination campaign

As Songoro ward was not fully covered in 2017, we felt it was important to send the teams here slightly earlier than planned to ensure full coverage. This was achieved and alongside some brilliant static point work we managed 82 % coverage across the whole Songoro ward.

Overall 70.5% of vaccinations were given at static points. This shows a good turn out to the static point clinics and highlights that the people of Meru District understand the importance of vaccination. Last year 66% of vaccinations were given at static points. This increased presence at static points is probably due to a combination of factors including greater pre-project announcement and involvement of local village leaders and increased acceptance and awareness of our project.

Each static point location was assigned a 4 digit code which was written on the top of the vaccination card. When going door to door, teams were asked to record the static point code of all vaccination cards they were shown. The analysis of this will be in a following report.

Experiences on the ground

Overall the project ran smoothly throughout and was well organised by the partner organisation. The team members worked well and it is only with their dedication that we were able to succeed in this project. The programme was a success and the international volunteers enjoyed their time with Mission Rabies. All members of the team were responsible and worked as a team.

The materials provided to the volunteers during the briefing greatly benefited their comprehension of the project. A couple of the new volunteers, slightly nervous about the project, took the materials

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back to their rooms the night before to familiarise themselves with the protocols. This minimised the questions asked during the mass drive and was a common point of reference for all teams. It could be beneficial to produce protocols for each project.

As was the case in 2017, there was some resistance to vaccination in the areas bordering the national parks – owing to a non-descript history of death following vaccination by the government – details as reported by residents to teams, were variable and unclear. Whilst we do not believe that the vaccinations were linked to the canine deaths, there was a belief within some of the community members. Knowing that this has been the case from previous years, this topic was covered in the Tanzanian and international volunteer briefings and volunteers were advised to deal with these situations maintaining politeness and diplomacy. The teams that worked in these areas, for the most part, were able to convince people that the vaccine was not the cause of the dog deaths and that the vaccine is very safe. The Tanzanian team members showed great patience and people skills in this situation.

In 2017, local volunteers, drivers and project leaders continued vaccination over the 2 day break. So, in the planning of the 2018 project, the project leaders tried to find a way of ensuring everyone got to use the rest days, not just the international volunteers. The 2017 static point data was analysed and 7 static points where 50 or less dogs were presented over a whole day were made into half day static points. This maximised efficiency of the teams’ time and allowed them to start on the door to door work earlier, ensuring more regions were covered over the entirety of the trip. In total 40 wards were covered in 10 days. These half days were effective and would be used by the team leaders in the future.

Mobile static points were used for the first time in USA River. This was due to there being a few highly spaced out areas where static points had had a low turnout in 2017. Teams in mobile static point areas would assess their map at the start of the day and identify 6 or so regions where they would set up static points. Each team would arrive and extensively announce their static point using loud speakers, they would then remain in that area for roughly 1 hour or until no more dogs were being brought to them. This was reported by the teams involved to be an efficient use of time and this was reflected in the number of dogs vaccinated, e.g. Manyata Kati ward showed a 53 dog increase at mobile static point compared to the 2017 static point.

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Image 5: Example of mobile static point work. Team Tarangire covered this highly spread out ward using 3 static points.

Support from Songoro region was phenomenal this year with the static points being a huge success. Hand-made posters were seen in many locations across the wards and local commitment to vaccination was shown in the increased number of dogs being presented at static point.

Dogs of all ages were brought for vaccination, at both the static point and door to door vaccinations. Whilst there is often concern amongst people over vaccinating young animals this didn’t seem to be a feature in Meru district meaning that we were able to vaccinate a greater proportion of the canine population and protecting all ages of dogs.

This year the work of Mission Rabies was supplemented by an Mbwa wa Africa/WVS sterilisation and treatment clinic, funded by a grant sourced by Mbwa wa Africa with 4 veterinary volunteers facilitated by WVS. This collaboration allowed sick, ill or injured dogs found by the Mission rabies teams to get the treatment required, this is especially important when international volunteers are working on projects as some do struggle when we are unable to help animal that we see. Due to circumstances out of any of our control, coordination of this WVS/ Mbwa wa Africa project was left to the Mission Rabies project coordinator. This put quite a strain on the logistical side of the Mission Rabies project. Despite this these situations were managed well and all teams were provided for and were able to complete their work. In the future, it may be better to either provide an additional logistical team member or a car for the existing team, which would be necessary due to the remote location of the accommodation.

Wifi at the accommodation was poor to non-existent at times, meaning the data analysis at the end of each day was challenging and took up a lot more time than it would do normally. In the future, it could be useful to purchase a dongle or other alternative source of data for the project team.

The data from 2017 was analyses prior to the project and paper copies of each individual map was created with the name of the ward, date and location of any nearby static points, how the area would be best covered (i.e. on foot, by car or a combination), estimated dog population (based on 2017 figures) and a satellite image. These were given to each vaccination team when they were assigned an area. Volunteers reported that they though these paper slips were very useful in both

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navigation and planning of routes, giving an idea of number of dogs that they need to find and in areas with little roads, allowing them to identify houses without using the phone map which was frequently delayed.

Syringes in Tanzania are able non-reusable and individual needles are not available for purchase. As a result it was decided that needles and syringes should be brought from Malawi. Unfortunately, import permits were not obtained for these materials and as a result they were held in customs for the entire project. We were able to recover this stock when leaving Tanzania and return half back to Malawi and half back to the UK. Fortunately, Mbwa wa Africa was able to provide a limited amount of needles and syringes to the project and we had another 2000 syringes donated. This enabled us to complete the vaccination but incurred a substantial amount of waste. For future projects, import licences will be obtained for all materials entering Tanzania.

8 phones were required for the running of the project. As Mission Rabies Tanzania only runs for 2 weeks of the year, it was decided that we should being the phones from Zomba, Malawi. Furthermore, the older phones were starting to not cope well with the updated app and so it was decided that new phones were required for the Zomba project, so 5 new phones were purchased by the Zomba project manager. However, these were also held by customs in the belief that they were being brought into the country to be sold, despite being without original packaging. This issue was not able to be resolved until a monetary deposit was placed for each phone to be refunded once outward travel commenced. We were unable to get an answer on how to avoid this in the future.

Frequent issues were reported with the power packs and wires brought from Zomba, Malawi. 4 power packs and 3 wires were deemed unusable within the first week leading to the need for team leaders and occasional volunteers to use their personal ones and during the 2 day break 3 additional power banks were purchased. There was also an issue with being able to charge all of the power banks sufficiently due to frequent power cuts and very low voltage output of the hotel sockets. One volunteer had a very robust solar powered power pack which would recharge on the outside of her backpack during the day. This may increase the reliability of power bank charging and is a renewable energy. Hence, I would suggest that this could be an avenue to look into in the future when purchasing replacement power banks.

Health and Safety

Mission Rabies prides itself on running safe and efficient vaccination campaigns. An important aspect of this is ensuring health and safety of staff, volunteers and members of the public. All participants were briefed prior to the start of the project about rabies, exposures, rabies prevention and the working methods used. All injuries, incidents and accidents were to be recorded in the Mission Rabies App.

4 Mission Rabies volunteers (1 Tanzanian and 3 international) and one Mission Rabies staff member required post exposure vaccination during the course of the drive. Any person who was potentially exposed, via a category 2 or 3 exposure, were instructed to wash the affected area for 15minutes using soap or iodine and water. All members of the public were advised to seek medical attention and that they would require post exposure prophylaxis, especially if their dog became sick or died within the following 10days.

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Vehicles were an additional health and safety concern. Each team had its own vehicle and drivers were instructed to remain within 10 minutes of the volunteers at all times. The most remote locations were covered by the teams containing a Mission Rabies staff member.

All team phones had the ambulance phone number stored in the contacts.

A more detailed health and safety report can be found in the shared drive.

International Guests

For a second year we opened up Mission Rabies Tanzania to volunteers. A total of 10 volunteers participated, of which 7 were from Italy, 2 from the United States of America and one Canadian volunteer. The Italian international volunteers from the states had heard about Mission Rabies through 3 returning volunteers, one of the American volunteers was returning and had brought along the Canadian volunteer. The 10 places were filled within a month.

Of the 8 teams in the field 4 had two international volunteers, two teams had one international volunteer and the final two teams had one Mission Rabies staff member present. All volunteers appeared to enjoy the project. The volunteers adapted quickly to their environment and worked well together and with their vaccination teams. The teams were mixed up after 1 week, giving 2 different international volunteers the chance to lead the teams, this was well received by almost all volunteers. One volunteer expressed displeasure at the mixing up of the teams and the issue was discussed with Amy – the volunteer’s team was reshuffled to include one of their old local team members with which they worked well.

Business VISA fee waivers were obtained for all volunteers on the project, ensuring that only the fee for the tourist VISA was needed to be paid. The letter for this waiver was provided to the volunteers and was tried and accepted at immigration by the project leader (following a phone call to Jens and a long time explaining the situation at immigration in KIA airport). No problems were reported by the volunteers themselves.

Volunteer accommodation was in Ndoro Lodge on the outskirts of Usa River. $34 dollars per person per day was paid for full board plus 2 sodas. The lodge was situated just off of the main road, so access to the project sites was easy. The staff were accommodating, the food of a decent quality and the rooms comfortable and clean. The lodge was able to provide a secure store room for our project kits. This would be a very suitable location for volunteer accommodation for future projects.

All volunteers have been asked to fill out a post-project survey that covers all aspects of the volunteer experience, including accommodation, by Mission Rabies. The data shall be analysed once participants have completed the survey and details can be obtained at a later date, if desired.

During the two day’s free time the international volunteers were given the opportunity to go on a safari. None of the volunteers opted for the safari package proposed by Tanzanian Experience – a company with links to Mbwa wa Africa – and most found packages themselves, with 2 volunteers choosing to remain in the accommodation. Half of the group departed the night before the 2 days off commenced, the rest the next morning, all returned by the 2nd evening for the next week briefing. For next year a cheaper, smaller safari company would be preferred, Amy has the contact

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details of one of the Safari companies from the international volunteers and will look into packages available before the next trip. None of the Mission Rabies team members accompanied the volunteers on these trips as they were independently arranged, this allowed the analysis of data and planning for the following week.

Overall it is believed the volunteers enjoyed the experience and that the project is suitable for volunteers.

Financials

The budget for this program was £10,000 including expenses for the production of Mission Rabies T- shirts and wristbands, expenses of the Mission Rabies representatives and rabies vaccines. Rabies vaccines were donated to Mission Rabies thanks to MSD. Thanks to the Marchig Trust and Dogs Trust Worldwide for their support with this.

Cost type Budget Expenditure Tanzanian in country costs 7736.73 £10,000 UK costs 2728.28 IG costs £6,000 4591.89 15056.90 Total £16,000 Table 5. Costs incurred by Mission Rabies for the Mission Rabies Tanzania project in GBP *

Future work

The project ran well and is a suitable project for volunteers. Therefore it is possible to run the same project next year in a similar manner.

Mbwa wa Africa continue to be actively involved with the Tanzanian National Rabies Control strategy and attended a workshop during the second week of the vaccination drive. This is a positive development for Tanzania and as the strategy develops and is implemented we will see how/if this affects our project in any way.

Currently no post-vaccination transect surveys are carried out in Tanzania. These have been used in a number of other projects, particularly in Africa, to help strengthen our population and vaccination coverage estimates. These involve a surveyor walking through the wards either randomly or following a designated path and asking households to fill out a questionnaire regarding the number and ago of dogs they have and which of these dogs have been vaccinated. This may be something to consider in the future.

References

1. Hampson, et al (2015) PLOS 9 (4) 1-20 2. Canine Rabies Blueprint 3. WHO, http://www.who.int/rabies/about/en/ 4. https://www.citypopulation.de/php/tanzania-northern-admin.php?adm1id=0202

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