Prioritized Zoonotic Diseases in Nepal.pptx

Globally more than 300 zoonotic diseases are identified among which about 60 have been identified in Nepal as emerging and re-emerging diseases.
The Ministry of Health and Population has newly listed 10 types of prioritized zoonotic diseases(2021)

1. P RIORITIZED ZOONOTIC D ISEASE IN NEPAL Presenter: Dr. Omija Shrestha

2. Introduction Z oonosis is any disease or infection that is naturally transmissible from vertebrate animals to humans (WHO) World Zoonoses day – July 6 Some zoonoses, such as rabies, are 100% preventable through vaccination and other methods Globally more than 300 zoonotic diseases are identified among which about 60 have been identified in Nepal as emerging and re-emerging diseases. The  Ministry of Health and Population  has newly listed 10 types of prioritized zoonotic diseases(2021)

3. Classification (Based on reservoir host) Anthropo-zoonoses infection transmitted to man from lower vertebrate animals Zooanthroponoses infection transmitted from man to lower vertebrate animals Amphixenoses infection transmitted in either direction

4. Classification (Based on Life cycle of infecting organism ) 1. Direct Zoonoses e g: rabies, brucellosis, trichinosis 2. Cyclo zoonoses eg : taeniasis; echinococcosis , pentastomida infection 3. Meta zoonoses eg : arbovirus infection; plaque ; schistosomiasis 4. Sapro zoonoses : eg : larva migrants ; mycoses

5. Factors impacting increase in zoonoses Rapid increase of the human population Ease of local and global travel; Increased human exposure to animals and animal products wildlife farming Hunting, handling, and transporting wildlife (including carcasses) with limited precautions Consumption of wild meat (such as bush meat) and Differences in agricultural practices

6. List of Prioritized Zoonotic Disease in Nepal 1. Influenza (Avian and Seasonal) 2. Rabies 3. Coronavirus (SARS- CoV and MERS- CoV , SARS- CoV2 ) 4. Leptospirosis 5. Brucellosis 6. Salmonellosis 7. Leishmaniasis 8. Zoonotic Tuberculosis 9. Cystode (Cysticercosis/Hydatidosis) 10. Toxoplasmosis

7. Avian influenza (Bird flu): Affects wild birds and poultry Caused by virus sub-types A(H5N1), A( H9N2 ). Rarely can infect pigs and humans and have pandemic potential First reported AI in birds – 1997, Hong Kong In 2006- spread rapidly through the Eastern Mediterranean Region with large non-human outbreaks reported in Afghanistan, Djibouti, Egypt, Iraq, Jordan, Palestinian territories, Pakistan and Sudan. 

8.  F irst reported human infections with  A( H7N9 )  viruses -2013 China.  F irst reported case of AI in birds in Nepal -on 16th Jan 2009 , Jhapa F irst human case of H5N1 in Nepal -on April 2019 ( resulting in the death , world’s first H5N1 human infection since 2017 )   The Federal government  has issued the Bird Flu Control Regulation, 2022 for prevention and control of the highly pathogenic avian influenza

9. News published on F eb 5,2023 Although rare, confirmed human cases for bird flu as reported by the WHO from 2003 to 2022 stands at 868 human cases and 457 deaths with case fatality rate standing at 53 percent. Nepal witnessed a massive bird flu outbreak in 2022 that saw outbreaks in 15 districts. Over 600,000 fowls were culled at the time. But authorities concerned have not yet provided compensation to the poultry farmers.

10. Transmission

11. Incubation period : 2-5 days Clinical features : mild, flu-like symptoms or eye inflammation to severe, acute respiratory disease and/or death. Rarely, gastrointestinal and neurological symptoms  Diagnosis : RT-PCR; RDTs Treatment : Antiviral drugs: Oseltamivir and Zanamivir can reduce duration of viral replication

12. Prevention and Control Personal protective measures -regular hand washing and proper drying Good respiratory hygiene -covering mouth and nose when coughing or sneezing Early self Isolation Avoid close contact with sick people Avoid touching eyes, nose and mouth Vaccine- in 2007, a vaccine was licensed for people 18 yrs. -64 yrs. (2 dose, 28 days apart)

13. Influenza(Seasonal): Around a billion cases of seasonal influenza occur annually, including 3–5 million cases of severe illness. C auses 290 000 to 650 000 respiratory deaths annually. 99% of deaths in children ( < 5 yrs ) occur in developing countries. F lu seasons are synchronized lasting from  Jan-Feb and July-Aug in Nepal. 4 types of influenza viruses: Types A, B, C and D. Influenza A and B viruses circulate and cause seasonal epidemics of disease. Only influenza type A viruses are known to have caused pandemics.

14. Epidemiology Research estimates that 99% of deaths is in children under 5 years seen in developing countries Greater risk population : pregnant women, children under 5 years of age, older people, chronic conditions , immunosuppressive conditions, Health and care workers Transmission : T hrough infectious droplets inhalation in crowded areas (schools and nursing homes) or By contaminated hands

15. Clinical feature : Mild -fever, cough, sore throat, body aches, runny nose, fatigue S evere - Pneumonia and sepsis Symptoms begin 1–4 days after infection and usually last around a week. Diagnosis Clinically D irect antigen detection virus isolation or RT-PCR

16. Treatment Recover spontaneously Rest Drink plenty of fluids High risk /severe symptoms : antiviral medications

17. Prevention Annual vaccination : pregnant women, children aged 6 mo to 5 yrs , >65 yrs , chronic condition , health workers Wash and dry your hands regularly Cover your mouth and nose when coughing or sneezing Dispose of tissues correctly Stay home when feeling unwell Avoid close contact with sick people Avoid touching your eyes, nose or mouth.

18. Out of 424 samples, 62 samples were positive (influenza type A - 33 and B- 29). R ate of influenza B virus infection was found higher 46.8% followed by influenza A subtype A/ H3 39%)and A/ H1N1 14% during the year 2018. 43 samples were from SARI case, of which 12 were influenza positive. In N epal peak activity was found in winter season (January–March), 2018.

19. Rabies Rabies(HYDROPHOBIA) is a vaccine-preventable viral zoonotic disease Estimated 59,000 human deaths occur every year across the world. Primarily a disease of warm-blooded animals like Dogs, Jackals, Wolfs, Mongoose, wild cats etc. Rabies-free countries: Australia, China, Cyprus, Iceland, Ireland, Japan, Malta, New Zealand, U.K., Finland, Norway, Sweden, The Liberian Peninsula, the islands of Western Pacific 19

20. In 4 years (2014–2017), 8 districts of Nepal ( Kanchanpur , Dailekh , Jajarkot , Chitwan, Dhading, Ramechhap , Siraha , and Morang) had more than 10 rabies outbreaks. Similarly, 4 districts ( Jhapa , Siraha , Sindhuli , and Surkhet ) had more than 10 rabies outbreaks in the year 2018. 2078/79: around 75,000 cases in pets and more than 100 human rabies cases occur each year with the highest risk in the Terai region.

21. Epidemiological Determinants Agent: Lyssavirus type 1, bullet-shaped, neurotropic RNA virus Host Factors: All warm blooded animals – susceptible Man – Dead end host Age group – 1- 24 years of age Higher risk : Laboratory staff working with rabies virus Veterinarians Dog Handler Hunters 21

22. Mode of transmission Source: Dogs in Asia and Africa Bats in USA and Canada Deep Bite or Scratch – infected animal Saliva of rabid animals in wounds Inhalation of virus through aerosol Infected organ transplantation Note: Ingestion of raw meat or other tissues from animals infected with rabies is not a source of human infection. 22

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24. Diagnosis Detection of Antigen using immunofluorescence of skin biopsy By virus isolation from saliva and other secretions Treatment -no specific treatment for rabies. PREVENTION a. Post-exposure prophylaxis. b. Pre-exposure prophylaxis. c. Post-exposure prophylaxis of persons who have been vaccinated previously.

25. Post exposure prophylaxis Local wound treatment Rabies Immunoglobulins (Passive Immunity) Rabies Vaccines Categories Type of contact with suspected or confirmed rabid animal Type of exposure Recommended post exposure prophylaxis I Touching or feeding of animals Licks on intact skin None None, if reliable case history is available II Nibbling of uncovered skin Minor scratches or abrasions without bleeding Minor Administer vaccine immediately . Stop treatment if animal remains healthy throughout an observation period of 10 days or is proved to be negative for rabies by a reliable laboratory using appropriate diagnostic techniques. III Single or multiple transdermal bites or scratches, licks on broken skin Contamination of mucous membrane with saliva ( i.e licks) Exposure to bats Severe Administer rabies immunoglobulin and vaccine immediately. Stop treatment if animal remains healthy throughout an observation period of 10 days or is proved to be negative for rabies by a reliable laboratory using appropriate diagnostic techniques.

26. Post- exposure prophylaxis: Intramuscular vaccine

27. Post- exposure prophylaxis- Intradermal administration The WHO approved regimen for intradermal route is the 1-week, 2- site IPC regimen (2-2-2-0-0) . The Government of Nepal has recommended the one-week IPC vaccine schedule to be used in the country.

28. For immunocompromised individuals Thorough washing of the wound should be emphasized Administration of a full course of rabies vaccine RIG in both Cat. II and III exposures, even if previously immunized

29. Post exposure treatment of persons who have been vaccinated previously Rabies Immunoglobulin: Administered only once, preferably at or as soon as possible after initiation of post-exposure vaccination

30. Rabies in Dogs CLINICAL: 2 forms - Furious rabies and Dumb rabies. Incubation period: 3-8 weeks, but it may be as short as 10 days or as long as a year or more Primary immunization at age of 3-4 months and booster doses should be given at regular intervals, every year or every 3 years , according to the type of vaccine used Fiscal year Number of cases of dog bites Number of cases of other animal bites No. of cases of animal bites (dog+ Other animal) Number of ARV vials consumed Reported Death 2077/78 54996 4418 59414 - 18 2078/79 75,562 9,921 85483 - 13

31. 31 Aligned with the WHO’s 2021-2030  Neglected Tropical Diseases roadmap Prioritizes integrated interventions and mainstreaming of NTD programme within national health systems

32. Activities and achievements in FY 2077/78 in Rabies control Program Awareness programs about Rabies for school students and general public. Celebration of World Rabies day on 28th September and co-ordination with province and local level health officials for its effective implementations. Epidemiological study on the active dog bites cases. Surveillance about Rabies on outbreak area. Orientation program about the benefit of Intradermal (ID) delivery of Anti Rabies Vaccine (ARV) for health workers. Orientation on application of immunoglobulin for provincial level health facilities. Procurement of cell culture ARV vaccine and immunoglobulin 32

33. In Vietnam, the incidence of rabies ranged from 1.7 to 117.2 per 100 000 population. The cumulative incidence in Sarawak was estimated at 1.7 per 100 000 population. In Indonesia, 104 human rabies cases were reported from 2008 to 2010, while in Thailand, a total of 46 rabies cases were reported in Thailand from 2010 to 2015. In the Philippines, the incidence of rabies ranged from 0.1 to 0.3 per 100 000 population

34. Coronavirus (SARS cov 2) Coronavirus disease (COVID-19) is an infectious disease caused by the SARS-CoV-2 virus. WHO first learned on 31 Dec 2019, as viral pneumonia in Wuhan, People’s Republic of China. Globally, new cases increased by 52% during the 28-day period of 20 Nov to 17 Dec 2023 as compared to the previous 28-day period, with over 850 000 new cases reported. The number of new deaths decreased by 8% as compared to the previous 28-day period, with over 3000 new fatalities reported.

35. As of 17 December 2023, over 772 million confirmed cases and nearly seven million deaths have been reported globally. The first case of COVID-19 was confirmed in Nepal on 23 rd  January 2020.  In Nepal till date, Total Cases: 10,03,450, Deaths: 12,031, Recovered: 9,91,322

36. Transmission

37. Clinical Features of COVID-19: F ever, cough, headache, fatigue,  breathing difficulties ,  loss of smell , and  loss of taste Severe COVID‐19 disease : Difficulty in breathing, especially at rest, or unable to speak in sentences Confusion Drowsiness or loss of consciousness Persistent pain or pressure in the chest Skin being cold or clammy, or turning pale or a bluish colour Loss of speech or movement.

38. High Risk Population Aged 60 years and over CO-morbid conditions Immunosuppression (including HIV), obesity, cancer Unvaccinated people are most at risk of severe illness. D iagnosis Molecular tests, such as polymerase chain reaction (PCR), Rapid antigen tests detect viral proteins Treatment Non-severe COVID-19: Nirmatrelvir -ritonavir; molnupiravir ; remdesivir Severe COVID-19: Corticosteroids; IL-6 receptor blockers (tocilizumab or sarilumab); baricitinib ; remdesivir.

39. HEALTH DESK

40. Major Activities of FY 2078/79: Continuation of response to COVID 19 pandemic Currently focusing about the COVID-19 pandemic, EDCD call center have 3 major functions: incoming call centre ; follow up call centre ; sms service In FY 2077/78- Government of Nepal has vaccinated 86% with the first dose and 87% with full dose/second dose for ≥12 year’s Nepal has reached the milestone of vaccinating 40% of the total population with full dose/second dose on 16 Jan 2022. From 03 April 2022: for ≥18 yrs who have completed primary series (full dose vaccination) with booster dose after 3 months of full dose vaccination. From 09 June 2022: booster dose started for 12-17 years after 3 months of full dose vaccination. From 23 June 2022(Pfizer): second phases for 5 to 11 yrs

41. Leptospirosis O ne of the most important zoonotic bacterial infections worldwide. A recent publication reports annual incidence rates of 1 million cases with an estimated mortality of around 60,000 patients per year worldwide. Depending on the series, mortality is between 5% and 20% of cases.  

42. Adolph Weil, first described leptospirosis in 1886 as a febrile illness  .Thus, the severe form was named ‘ Weil's disease ’. Descriptions reported much earlier in ancient texts  : ‘cane-cutter's disease’ or ‘swine-herd's disease’ in Europe, ‘rice field jaundice’ in ancient Chinese texts, and ‘ Akiyami (autumn fever)’ in Japan. The causative organism was first described in 1907 by Stimson, who demonstrated the presence of spirochaetes( question-mark shape organism )in the kidneys of a patient dying of the disease.

43. Epidemiology Leptospirosis is highly prevalent in the tropics, with 73% of cases occurring in this zone, in particular in South-East Asia, East Sub-Saharan Africa, the Caribbean and Oceania. Caused by spirochetes of the genus  Leptospira . Rodents and domestic mammals, such as cattle, pigs and dogs, serve as major reservoir hosts. The rat is by far the most important carrier responsible for human leptospirosis.  Farmers, those in contact with livestock, those exposed to rodents at their workplace, and people living in areas where sanitation is poor are at highest risk.

44. Incidence rates have generally been stable globally; however, numerous large outbreaks have occurred from time to time in certain countries, in some instances related to natural disasters associated with flooding . Mode of Transmission Direct Contact -through skin abrasions or mucous membranes by contact with urine or tissue of infected animal Indirect Contact – through ingestion of contaminated food and water or contact of broken skin with contaminated soil, water or vegetation with leptospirae

45. Effective control of leptospirosis is difficult because of two epidemiological features of the disease : Firstly, Leptospira are capable of developing a symbiotic relationship with many animal host, without causing disease to the host. Secondly, wild animals provide an important reservoir, continuously re-infecting domestic animals.

46. Fig : Epidemiology of leptospirosis

47. Major outbreaks : Jakarkata (2003), Mumbai (2005), Srilanka (2008) However,there are anecdotal reports of human and animal case in Bangladesh, Myanmar ,Nepal and Timor – leste .

48. On the date of 24 July 2017, the major national daily newspaper reported that there were 2 death cases from an unknown disease in the Morang district, Sundarharicha Municipality. A team of researcher and experts were mobilized in the affected area to investigate and identify the etiological and epidemiological causes   Out of 83 participants, 49% and 25% of the participants were positive to IgM and IgG antibodies of Leptospira species respectively. An outbreak exposure was consumption of unhealthy meat during social gathering .

49. C linical manifestations Mild, self-limiting acute febrile illness to a severe, life-threatening condition with multiple organ dysfunction. C onjunctival suffusion, jaundice, and acute kidney injury constitutes Weil's syndrome .  Pulmonary hemorrhage has recently been shown to be an important cause of mortality. Leptospirosis during pregnancy may lead to fetal death, abortion, stillbirth or congenital leptospirosis.

50. Incubation period : wide variation, from 2-20 days, usually 7-12 days Clinical course has been classically divided into L eptospiraemic phase /septicaemic phase / acute phase last for 3 to 9 days, and presents as a non-specific acute febrile illness. Fever, chills, myalgia and headache are present. I mmune phase where IgM antibodies appear in the blood, and organisms are excreted in the urine. serious manifestations occur during this stage

51. Diagnosis Blood culture for leptospirosis: gold standard test( 1 st week of illness. ) Serological methods Microscopic agglutination test E nzyme-linked immunosorbent assay (ELISA) Management Mild and no comorbidities : Doxycycline 100 mg twice daily for 7 days.  Severe, or with comorbidities: IV penicillin is the drug of choice (1.5 MU IV, every 6 hours) Ceftriaxone (1 g IV, every 24 hours) can be equally effective.

52. Prevention A voidance of potential exposure to infection P harmacological prophylaxis to individuals at high risk: Doxycycline 200 mg weekly No human vaccine is currently available

53. Infection source control : Can be targeted to the local reservoir species of animals Reduction of certain animal reservoir populations, e.g. rats Separation of animal reservoirs from human habitations by means of fences and screens • Immunization of dogs and livestock • Removal of rubbish and keeping areas around human habitations clean

54. Brucellosis A lso known as “ undulant fever ”, “ Mediterranean fever ” or “ Malta  fever” B rucellosis is one of major bacterial zoonoses caused by various   Brucella  spp , which mainly infect cattle, swine, goats, sheep and dogs

55. According to the list of National notifiable Infectious diseases and conditions for 2020 (US annual report),there were 89 cases of Brucellosis . It is an important  human disease in many parts of the world especially in the Mediterranean countries of Europe, North and East Africa, the Middle East, south and central Asia and Central and South America and yet it is often unrecognized and frequently goes unreported. It is endemic disease in Asian countries, such as Sri Lanka, India, China ,Pakistan, Mongolia, Nepal .

56. Although brucellosis has been reported to be endemic in Nepal, neither the distribution nor the economic and public health impact of this disease is well characterized The presence of brucellosis in Nepal was first reported in 1977 by Pyakurel & Mishra  The first human case was reported in 1979 when the disease was diagnosed by the isolation of  B. melitensis  in a shepherd from Pokhara, who most likely acquired the disease from his sheep. Prevalence of brucellosis has been difficult to estimate as many cases remain undiagnosed .

57. Causative agent Four species affecting human : B.melitensis , B.abortus , B.suis, and B.canis B.melitensis is most virulent and invasive species(usually infects goat and sheep) Main reservoir of human infection are cattle, sheep, goat, swine , buffaloes and dogs . Infected animals excrete Brucella in urine, milk, placenta, uterine and vaginal discharge .

58. At risk population Mainly males: farmer, shepherds, butchers, abattoir workers, veterinarians and laboratory workers Overcrowding of herds, high rainfall, lack of exposure to sunlight, unhygienic practice in milk and meat production all favor spread of brucellosis .

59. Transmission 1) Contact infection By direct contact with infected tissues , blood , urine, vaginal discharge ,aborted fetuses, esp. placenta 2) Food borne infection - Indirectly by ingestion of raw milk, dairy products ,fresh raw vegetables, contaminated water 3)Air borne infection -Inhalation at cowshed environment

60. Clinical Features Swinging pyrexia (up to 40-41 deg C) Arthralgia /arthritis Low back pain Headache Splenomegaly and hepatomegaly Leucopenia Incubation period – usually 1 – 3 weeks , up to 6 month or more Diagnosis Culture of blood , bone marrow , exudates and biopsy specimen Serological test

61. Treatment Uncomplicated case: Tetracycline is TOC For complicated case D oxycycline 100 mg twice a day for 45 days, plus streptomycin 1 g daily for 15 days. Alternative therapy is doxycycline at 100 mg, twice a day for 45 days, plus rifampicin at 15mg/kg/day (600-900 mg) for 45 days F or pregnant women, neonates and children under 8, treatment is not yet determined

62. Prevention and Control In Animals Control and eradication of infection from animal reservoirs Test and slaughter Vaccine of B.abortus strain 19 for young animals Hygienic measure :clean sanitary environment for animals, sanitary disposal of urine and feces ,veterinary care In Humans Early diagnosis and treatment Pasteurization of milk Protective measures : exercise care in handling and disposal of animal discharges

63. Salmonellosis Salmonella is 1 of 4 key global causes of diarrheal diseases Diarrheal diseases are the most common illnesses resulting from unsafe food 550 million people falling ill each year, including 220 million children under the age of 5 years. Caused by the bacteria  Salmonella , Clinical Features: acute onset of fever, abdominal pain, diarrhea, nausea ,vomiting O nset of disease: 6–72 hours (usually 12–36 hours) after ingestion of  Salmonella , and illness lasts 2–7 days

64. Sources and transmission

65. Treatment severe cases: E lectrolyte replacement and rehydration Routine antimicrobial therapy is not recommended for mild or moderate cases in healthy individuals However, health risk groups such as infants, the elderly, and immunocompromised patients may need to receive antimicrobial therapy

66. Prevention and control Control measures at all stages of the food chain Avoid contaminated water and ice Avoid contact between infants / young children and pet animals. Wash hands, fruits/vegetables, utensils Avoid raw contaminated food/milk National and regional surveillance systems on foodborne diseases WHO response : WHO is working towards the strengthening of food safety systems in an increasingly globalized world. Setting international food safety standards, enhancing disease surveillance, educating consumers and training food handlers in safe food handling

67. F ood-borne outbreaks in the EU/EEA. In 2019, 89066 laboratory-confirmed cases of salmonellosis were reported, out of which 139 were fatal. In 2019, 89066 laboratory-confirmed cases of salmonellosis were reported, out of which 139 were fatal. The EU/EEA notification rate was 20.0 cases per 100 000 population. Young children (0−4 years) had the highest notification rate with 93.3 cases per 100 000 population, eight times higher than in adults (25–64 years).

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69. Leishmaniasis C aused by genus Leishmania protozoan parasites. Transmitted by the bite of infected female phlebotomine sandflies . They can result in various human diseases mainly: Visceral leishmaniasis aka Kala-azar (VL) cutaneous leishmaniasis (CL) Mucocutaneous leishmaniasis (MCL) Zoonotic cutaneous leishmaniasis (ZCL) Post-kala-azar dermal leishmaniasis ( PKDL ) Globally, over 90 species of sandfly are known to transmit leishmania parasites while around 70 animal species, including humans, have been found as natural reservoir hosts of leishmania parasites

70. Risk factors : There is an estimation of 7,00,000 to 1 million new cases every year, and affects most commonly to Poorest of the poor, Malnourished, Rural areas, Male twice as often as female, Workers who work at farm, forest etc., Migrant worker Environment changes : urbanization and human encroachment to forest area

71. Kala-azar in Nepal Visceral leishmaniasis is the main form of the disease in SEAR, which is also endemic for cutaneous leishmaniasis. 1 st case of kala-azar was in as early as 1960 Initially there were 12 district identified as endemic In 2016, 6 more district were added. by 2020 , endemic has reached 23 district including hilly region, year 2022 the disease was reported from Lumjung . Now, the cases has been reported from more than 70 district.

72. Kala-Azar elimination in Nepal 2005- Nepal had formulated a national plan eliminate Kala-Azar. ( stated annual incidence <1/10,000 at district level). 2010- recommended rapid diagnostic test kit and Miltefosine as the first line treatment for KA 2014- introduce Liposomal Amphotericin B and combination therapy in the national treatment protocol. 2019- single dose L- AmB , 10mg/kg as 1st line therapy and surveillance system was strengthen.

73. New kala-azar cases in Nepal : province Number of cases Koshi 9 Madhesh 12 Bagmati 18 Gandaki 7 Lumbini 54 Karnali 68 sudurpashchim 31 National NUMBER OF CASES FY 2077/2078 212 FY 2078/2079 322 FY 2079/2080 199 Source: Nepal Health Fact Sheets 2023, EDCD Year Under 5 2019 22 2020 42 2021 57

74. People don’t use sleeping nets here. Since it’s a hilly area. As many as 75 people were diagnosed with kala-azar in Okhaldunga over the past five years. gradual spread of the disease indicates that the climate in hilly areas is getting warmer and the mosquitoes and sandflies are moving to higher altitudes government provides rK39 kits at the primary health centres and other health facilities for free for kala-azar tests. underprivileged communities such as the Musahar community in 2021, the government started providing Rs7,000 per patient—Rs5,000 for treatment and Rs2,000 for transportation.

75. Clinical Features Incubation period: 2-6 months Most infected people do not develop any symptom. Should be suspected :an endemic area ;prolonged irregular fever; splenomegaly and weight loss as its main manifestations.

76. Laboratory diagnosis: Parasitological- Culture or Microscopic confirmation Rapid diagnostic test –rK39 Aldehyde test Serological : PCR Treatment : Liposomal amphotericin B is TOC M iltefosine  Pentavalent antimonial, such as sodium stibogluconate. Paromomycin Prevention and control No vaccines or drugs available P rotect from sand fly bites(protective clothing, insect repellent ) Early detection and effective treatment of infected person Spraying insecticides and using bed nets

77. A form of tuberculosis caused by Mycobacterium bovis , which belongs to the M. tuberculosis complex. Often affects sites other than the lungs (extrapulmonary) Mainly affects cattle, which are the most important animal reservoir, and can become established in wildlife. Result in economic losses and trade barriers with a major impact on the livelihoods of poor and marginalized communities. In 2016, there were an estimated 147 000 new cases of zoonotic TB in people globally, and 12 500 deaths due to the disease. The highest prevalence of bovine tuberculosis is in Africa and parts of Asia, but the disease is also found in countries in Europe and the Americas. Zoonotic tuberculosis (TB)

78. Over 50 animals have died of bovine TB in a year. It was in April 2022 that samples of various species like spotted deer, and black buck were tested positive for bovineTB . Sputum samples will be collected from the staff to detect the presence of TB.

79. Transmission -most common route of transmission of M. bovis to humans is through: contaminated food ( untreated dairy or meat products) airborne transmission also poses an occupational risk to people in contact with infected animals or animal products, including farmers, veterinarians, slaughterhouse workers and butchers.

80. Clinical signs Weakness Loss of appetite and weight Fluctuating fever Dyspnoea and intermittent hacking cough Signs of low-grade pneumonia Diarrhoea Enlarged, prominent lymph nodes.

81. KEY CHALLENGES Laboratory procedures most commonly used to diagnose TB do not differentiate M. tuberculosis from M. bovis . This leads to underdiagnosis of zoonotic TB. Zoonotic TB poses challenges for patient treatment and recovery. M. bovis is naturally resistant to pyrazinamide, Without drug susceptibility testing, patients may receive inadequate treatment. In humans, often initially extrapulmonary and may be misdiagnosed, and therefore initiation of treatment can be delayed.

82. WHO, World Organization for Animal Health (OIE), Food and Agriculture Organization of the UN (FAO) and the International Union Against Tuberculosis and Lung Disease (The Union) launched the first-ever roadmap for tackling zoonotic TB in October 2017. The roadmap is centered on a One Health approach . These fall under three core themes: Improve the scientific evidence base Reduce transmission at the animal-human interface Strengthen intersectoral and collaborative approaches

83. ZOONOTIC TB MUST BE PRIORITIZED IN THE GLOBAL HEALTH AGENDA The UN SDGs emphasize the importance of multidisciplinary approaches to improving health. In the context of the SDGs, WHO’s End TB strategy calls for diagnosis and treatment of every TB case. This must include people affected by zoonotic TB. Zoonotic TB in people cannot be fully addressed without controlling bovine TB in animals and improving food safety. Through a One Health approach, together we can save lives and secure live hoods.

84. Sign and symptoms: Mostly asymptomatic Localized and disseminated infection Cervical lymphadenopathy Localized skin disease (butcher wart) Pulmonary disease (reactivated infection) Diagnosis test: Tuberculin test Treatment Pyrazinamide resistant Treat with isoniazid, rifampicin, ethambutol 9-12 months

85. Prevention and control Controlled by test and slaughter or test and segregation method Sanitation ad disinfection(5% phenol, iodine solution, glutaraldehyde, formaldehyde ) Rodent control in uninfected farm Vaccine: not available

86. Taeniasis A parasitic infection caused by the tapeworm species:  Taenia saginata (beef tapeworm),  Taenia solium (pork tapeworm), and Taenia asiatica (Asian tapeworm).

87. Epidemiology Is found worldwide , About 50 to 70 million people are affected worldwide Rural, developing countries with poor hygiene , places where pigs are allowed to roam freely and eat human faeces allows cycle to continue In 2010, WHO added T.solium -Cysticercosis to list of major neglected tropical disease In 2015, WHO identified it as leading cause of death from food borne disease.

88. Articles published between 1990 and 2017  Presence of  T. saginata  was described in 15 of 27 countries of the region, including Afghanistan, Cambodia, China, India, Indonesia, Japan, Lao PDR, Malaysia, Mongolia, Nepal, Pakistan, Philippines, South Korea, Thailand and Vietnam. Only country that reported an absence of  T. saginata  is Japan  

89. Habitat Adult worm live in small intestine of definitive host(man) Larval stage found in intermediate host tissue(cattle , pig) Eggs are diagnostic stage Mode of Transmission Through ingestion of undercooked meat Through ingestion of food, water, vegetables comminated with eggs Reinfection by retro peristalsis(rare) Incubation period: 8 to 14 weeks

90. Sign and Symptoms Most people: asymptomatic or mild symptoms. C an cause digestive problems: abdominal pain, loss of appetite, weight loss, and upset stomach. Most visible symptom: active passing of proglottids Rare: tapeworm segments become lodged in the appendix, or the bile and pancreatic ducts. Infection with  larval parasites in tissue, human  cysticercosis, has devastating effect -cause seizures(CNS) and muscle or eye damage

91. Diagnosis E xamination of stool sample History of passing tapeworm segments. Stool specimens (three different days )and examined Prevention and control Treatment of infected persons Meat inspection Health education

92. Treatment P raziquantel -single doses of (10 mg/kg) or N iclosamide children aged 2–6 years: 1 g adults and children over 6 years: 2 g Albendazole - 400 mg for 3 consecutive days In NCC ( specialized treatment): - long courses with high doses of praziquantel and/or albendazole, - supporting therapy with corticosteroids and/or anti-epileptic drugs, and possibly surgery.

93. A community-based survey was conducted among 289 households in south–eastern Nepal ,2012 showed the frequency of open defecation, backyard pig raising and pork consumption differed significantly (P < 0.005) among the different coexisting caste and ethnic groups. Tapeworm carriers were identified at a high prevalence among the Dum, one of the most disadvantaged communities of Nepal. A PCR-RFLP assay revealed that all collected tapeworm specimens were T. asiatica( T.solium appear to be more complex that thought so far.)

94. One hundred and ten pigs of slaughter age (approximately 8-16 months old) were purchased, slaughtered and the heart, liver, brain and half the body skeletal musculature were sliced using hand knives and the number and viability of T. solium cysts determined. Thirty two of the 110 animals were found to harbour T. solium cysticerci , of which 30 were found to have viable cysticerci (93% of the infected animals ).

95. HYDATIDOSIS

96. Echinococcosis/ Hydatidosis/Hydatid Disease Human echinococcosis is a parasitic disease caused by tapeworms of the genus Echinococcus. The two most important forms in humans are : C ystic echinococcosis ( hydatidosis ) and Alveolar echinococcosis. Echinococcus granulosus   causes cystic echinococcosis and is the form most frequently encountered. Another species,  E. multilocularis,  causes alveolar echinococcosis, and is becoming increasingly more common

97. More than 1 million people are affected with echinococcosis at any one time Cystic Echinococcus is highly epidemic in Southern Eastern Europe, Mediterranean countries, the Middle East, eastern Africa, Central Asia, Northwestern China, and in some regions of South America, with a human incidence as high as 50/100,000 persons/year Alveolar echinococcosis is confined to the northern hemisphere, in particular to regions of China, the Russian Federation and countries in continental Europe and North America.

98. Between 2000 and 2012, the highest annual burden was imposed by neurocysticercosis and congenital toxoplasmosis 14,268 DALYs and 9255 DALYs respectively), followed by cystic echinococcosis 251 DALYs .

99. Some species of Echinococcus circulate in domestic animals; others occur in wildlife (sylvatic) cycles or have both domestic and sylvatic cycles. Adult tapeworms are usually carried asymptomatically in their definitive hosts, which can include dogs, cats and wild carnivores. Dogs are particularly important in zoonotic transmission. Intermediate hosts: Many mammals and marsupials, including humans, livestock, pets and wildlife Intermediate hosts are usually asymptomatic in the initial stages, but the growing larvae, which often develop in the liver or lungs, may eventually cause illness and sometimes death.

100. Life cycle of E.granulosus Agent - hydatid or larval stage of the cestodes Definitive hosts - domestic dogs and some wild canids. Intermediate hosts - sheep, bovines, swine, goats, equines, camelids (Asian and American), cervids, and man.

101. Signs and symptoms Cystic echinococcosis / hydatid disease Incubation period: last month to years leads to the development of one or more hydatid cysts located most often in the liver(75%) and lungs(5-15%), and less frequently in the bones, kidneys, spleen, muscles and CNS (10-20%) Abdominal pain, nausea and vomiting (when hydatids occur in the liver). chronic cough, chest pain and shortness of breath( If the lung is affected), Non-specific signs include anorexia, weight loss and weakness.

102. Alveolar echinococcosis : asymptomatic incubation period of 5–15 years and the slow development of a primary tumor-like lesion weight loss, abdominal pain, general malaise and signs of hepatic failure. Larval metastases to the liver (for example, the spleen) or distant locations (such as the lungs, or the brain) If left untreated, alveolar echinococcosis is progressive and fatal.

103. Diagnosis Clinical : History of residence, close association with dog and presence of slowly growing cystic tumor Xray, USG , MRI, CAT scan Serological: indirect immunofluorescent test, ELISA Treatment percutaneous treatment of the hydatid cysts with the PAIR (Puncture, Aspiration, Injection, Re-aspiration) technique; Surgical removal of cyst anti-infective drug treatment “watch and wait”.

104. Prevention and Control Periodic deworming of dogs with praziquantel (at least 4 times per year) I mproved hygiene in the slaughtering of livestock P ublic education campaigns Vaccination of sheep with an  E. granulosus  recombinant antigen ( EG95 ) offers encouraging prospects ( registered in China and Argentina. )

105. Toxoplasmosis Toxoplasmosis is caused by the  protozoan  parasite  Toxoplasma gondii . P arasite can persist for long periods of time in the bodies of humans (and other animals), possibly even for a lifetime. In various places throughout the world, it has been shown that more than 60%  of some populations have been infected with  Toxoplasma.

106. Infection is often highest in hot, humid climates and lower altitudes, because the oocysts survive better in these types of environments. I n the context of vertical transmission from mother to child during pregnancy, it is estimated an average of 190,100 incident cases of congenital toxoplasmosis yearly, with 1.5 neonatal cases occurring per 1,000 live births globally. In the United States it is estimated that 11% of the population 6 years and older have been infected with  Toxoplasma but very few have symptoms because the immune system usually keeps the parasite from causing illness

107. The search identified 152 published studies that examined a total of 648,010 subjects. From these, 166,255 were seropositive for T. gondii infection indicating an average global seroprevalence rate of 25.7% (95% CI: 25.6 – 25.8%). The overall range of seroprevalence was determined to be 0.5 – 87.7%. African countries had the highest average seroprevalence rate of 61.4%, followed by Oceania with 38.5%, South America with 31.2%, Europe with 29.6%, USA/Canada with 17.5%, and Asia with 16.4%

108. Nearly half of Nepalese are Toxoplasma seropositive h owever, neither the prevalence of congenital toxoplasmosis (CT) nor the confirmed case to CT is reported from Nepal yet. In this case report, first case of CT in a 53 days old full term male baby (weight: 2,600 grams) delivered by caesarean section is reported. The baby had hepatosplenomegaly and optic nerve coloboma with large scar in the right eye. The TORCH panel test showed significantly high Toxoplasma IgM antibody level (5.77 OD Ratio) compared with IgM antibody level against other agents. The baby was diagnosed as a case of CT and treatment was started accordingly. The baby, however, did not improve with the treatment and died after six days. 

109. This study collected 150 confirmed domestic and nine patients with imported toxoplasmosis. There was an increasing trend in the incidence of toxoplasmosis, 0.09–0.89 cases per 10,00,000 people, peaking in 2017. The average annual toxoplasmosis incidence was 4.4, 13, and 18 during 2007–2011, 2012–2016, and 2017–2020, respectively

110. Risk factors and Mode of transmission Foodborne Eating undercooked, contaminated meat(especially pork, lamb, and venison) or shellfish (like oysters, clams, and mussels)) H andling them and not washing hands thoroughly ( Toxoplasma  cannot be absorbed through intact skin) Drinking contaminated water Unpasteurized goat milk(tachyzoite)

111. Animal to human (Zoonotic )- Cats play an important role : Cleaning a cat’s litter box having cat feces; Touching or ingesting anything that contain  Toxoplasma; or Accidentally ingesting contaminated soil . Mother-to-child (congenital) Rare instances ( Receiving an infected organ transplant or infected blood via transfusion) High risk population: infants born to mothers Persons with severely weakened immune systems

112. Signs and symptoms  Asymptomatic (mostly) Cervical lymphadenopathy and/or a flu-like illness Severe toxoplasmosis: - causing damage to the brain, eyes, or other organs O cular toxoplasmosis: - c an include reduced vision, blurred vision, pain (often with bright light), redness of the eye, and sometimes tearing.  Congenital toxoplasmosis - Most infants  have no symptoms at birth, but they may develop symptoms later in life (serious eye or brain damage at birth)

113. Diagnosis Direct microscopy - detection of tachyzoite in blood and tissue cyst in tissue biopsy Staining method -Giemsa , -PAS, -silver stain -Immunoperoxidase stain Molecular diagnosis Animal inoculation Tissue culture Imaging method

114. Treatment Healthy people (nonpregnant): recover spontaneously, if not - can treated with a combination of drugs-pyrimethamine and sulfadiazine, plus folinic acid. Pregnant women, newborns, and infants: S piramycin (if diagnosed before 18 weeks gestation)  Pyrimethamine, sulfadiazine and leucovorin(after 18 weeks gestation) Persons with ocular toxoplasmosis Depends on the size, location, and characteristics of eye lesion (acute active, versus chronic not progressing). Persons with compromised immune systems Pyrimethamine and sulfadiazine, plus folinic acid(until improve) For AIDS patients, may continue medication for the rest of their lives

115. Prevention and control Reduce Risk from Food Cook food to safe temperature Safe food handling Handwashing Reduce Risk from the Environment Avoid drinking untreated water. Wear gloves on any contact If pregnant or immuno-compromised: prenatal and antenatal screening to detect T.gondii Proper handling Screening of organ donor and blood donor

116. Reported cases of the Prioritized Zoonotic Diseases on EWARS for the period from 2019 - 2021 Disease / Period 2019 2020 2021 Total COVID-19 2 18870 17633 36505 Influenza Like Illness 135 3636 2899 6670 Kala azar 91 220 269 580 Leptospirosis 17 10 17 44

117. Impact of zoonoses Zoonoses have myriad impacts on human and animal health Animal deaths caused by zoonotic diseases can impose massive economic losses A ffected individuals may develop mental health issues. Human health and nutrition are also affected  due to the reduced supply Ireland suffered a severe economic loss due to Salmonella contamination in its pork products It is noteworthy that the global economy was severely impacted by the SARS outbreak, which impacted multiple sectors including the tourism When outbreaks of BSE occurred in the UK, most European countries banned importing British beef.

118. Brucellosis in cattle resulted economic losses in Kenya ,Argentina and Nigeria Recent COVID-19 outbreak has significantly impacted the global economy and impacted all sectors (health, education, financial, travel and hospitality and sports) Millions of people will face extreme poverty due to the stalled growth resulting from this pandemic losses on the livestock sector of any country From 1995 to 2008, the global economic impact of zoonotic outbreaks had exceeded 120 billion USD In 2007, the UK faced drastic food-borne pathogen problem by Campylobacter spp., Salmonella (non-typhoidal), E. coli ( VTEC ) According to the World Bank , Australia has lost 16% of the value of its livestock sector due to outbreaks that impacted beef and sheep

119. Zoonoses control and eradication Zoonoses surveillance, diagnosis, isolation and quarantine, Restriction on animal transportation, Treatment and vaccination programs, Inspection of meat and milk, and Biosecurity

120. Activities and achievements in 2078/79 in Prioritization of Zoonotic Disease 1. Laboratory and Surveillance Capacity assessment and building to identify prioritization of zoonotic diseases. 2. Orientation of medical officers, nurses and other health workers regarding identification of prioritized zoonotic disease in federal and provincial level. 3. Regular meeting on National Technical Working Group on Zoonotic disease

121. Zoonoses and One Health For the prevention and control of infectious diseases such as zoonotic diseases, international organizations and researchers described the relationship among human, animals, and environments and adopted a concept known as “ One Health Concept” or “One Health Approach ”. This concept was adopted to properly deal with global health challenges The one health concept encourages collaborations among wildlife biologists, veterinarians, physicians, agriculturists, ecologists, microbiologists, epidemiologists, and biomedical engineers to ensure favorable health for animals, humans, and our environment.

122. WHO, OIE, FAO, US Centers for Disease Control and Prevention (CDC), US Department of Agriculture (USDA), United Nations System Influenza Coordination (UNSIC), and European Commission recognize the prevention and control strategies involving the one health approach Approaches that rely on the principles of one health policies need to be adopted

123. Challenges for control Identification of disease in animals and human Cooperation between veterinarians and medical doctors Globalization "New" zoonoses Prioritization Lack of knowledge Resistance to change S everal challenges at the level of implementation

124. Conclusions The majority of the human infectious diseases have animal origins. These pathogens do not only cause diseases in animals, but they also pose a serious threat for human health. Because of the strong interrelatedness among animals, humans, and environment; research focusing on the one health approach need to be prioritized to identify critical intervention steps in the transmission of pathogens.

125. References Park’s Textbook of Social and Preventative Medicine, 24 th Edition Costa F, Hagan JE, Calcagno J, et al.. Global morbidity and mortality of leptospirosis: A systematic review.  PLoS Negl Trop Dis   2015;9:e0003898 . Rajapakse S. Leptospirosis: clinical aspects. Clin Med ( Lond ). 2022 Jan;22 (1):14-17. doi : 10.7861/ clinmed.2021 -0784. PMID : 35078790; PMCID : PMC8813018 .   Pyakural S, Mishra U. Sero -epidemiological evidence of animal brucellosis in Nepal.  Bull Vet Sci Anim Husb Nepal.  1977;6 [ Google Scholar ] [ Ref list ] https:// www.cdc.gov / healthypets / CDC Centre for disease control and Prevention

126. National Library of Medicine https:// www.ncbi.nlm.nih.gov / pmc /articles/ PMC6715885 /#:~:text= Of%20the%2039%20zoonotic%20diseases,by%20the%20ZCP%20%5B24%5D . Zoonotic Diseases: Etiology, Impact, and Control https:// www.ncbi.nlm.nih.gov / pmc /articles/ PMC7563794 /pdf/microorganisms-08- 01405.pdf https:// www.cdc.gov / onehealth /what-we-do/zoonotic-disease-prioritization/ index.html (Brunetti et al.  2010 ; Casulli et al.  2022 ,  2023 ) Wiley online library https:// onlinelibrary.wiley.com / doi /10.1111/ j.1365-3156.2012.03017.x World Health Organization. Zoonoses: key facts [Internet]. 2020. [cited 2021 Oct 31]. Available from:  https:// www.who.int /news-room/fact-sheets/detail/zoonoses WHO(2018),Fact sheet, Echinooccosis,8 th February 2018 Acha PN , Szyfres B (Pan American Health Organization [PAHO]). Zoonoses and communicable diseases common to man and animals. Volume 3. Parasitoses . 3rd ed. Washington DC: PAHO; 2003. Scientific and Technical Publication No. 580. Hydatidosis; p. 184-99.