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© 2019 Indian Journal of Public Health | Published by Wolters Kluwer - Medknow S9
Abstract:
Original Article
IntRoductIon
Rabies is an acute progressive encephalitis caused by RNA
viruses in the Genus Lyssavirus. The major global reservoir is
the dog. Rabies has a case fatality ratio approaching 100%, the
highest of any conventional infectious disease.[1] An estimated
20,000 human rabies death and 17.4 million animal bites were
reported from India in 2004.[2]
Surveillance for human and animal rabies has been
inadequate throughout the world, which has contributed to
minimal awareness, public health prioritization, and resource
allocation for rabies prevention and control.[3-7] The WHO
states that information on the frequency of animal bite cases
associated with dog/animal bite injuries are needed for
more effective risk modeling assessments and inform about
strategies for rabies prevention and control.[6] Domestic dogs
are the principal reservoir and vector of rabies. There has
been no systematic evaluation of animal bites in the entire
country.
A lot of changes have taken place since the Indian Rabies
Survey of 2004, such as availability of modern rabies
postexposure prophylaxis (PEP), introduction of intradermal
rabies vaccination, withdrawal of nerve tissue vaccines, Animal
Birth Control Programme, and implementation of National
Rabies Control Programme. More and more people have
access to modern rabies PEP (rabies immunoglobulin [RIG]
and rabies vaccination).
Background: Rabies is a 100% fatal disease. There are inadequate data on animal exposures and rabies postexposure prophylaxis (PEP) from
community-based eld surveys in India. Objectives: The main objective of the study is to estimate the incidence of animal exposures (bite,
scratch, or lick) in the study population and to describe the rabies PEP among the cases. Methods: A descriptive survey was conducted in seven
states of India between July and November, 2017. In each state, multistage sampling methodology was followed for selection of district, taluka/
tehsil, block, and clusters within the block. The primary sampling unit was a household (HH). A case was a patient with animal exposure (bite,
scratch, or lick) in the last 1 year from the date of survey. The animal exposure was categorized based on the WHO guidelines (Category-I,
Category-II, and Category-III). The patients with the history of multiple animal exposures any time during the survey period was considered as
a single case. Results: A total of 1012 HHs were surveyed covering a population of 4294. 3016 (70.2%) participants were from rural settings
and 1278 (29.8%) were living in urban settings. 2181 (50.8%) participants were male and 2113 (49.2%) were female. The annual incidence
of animal exposure was 1.26% (condence interval [CI]: 0.93%–1.59%). The annual incidence in urban setting was 1.33% (0.70 - 1.96) and
rural settings were 1.23% (CI: 0.84 - 1.62). Majority (68.5%) of the cases were from rural settings, 61.2% of the cases were in the age group
of 15–60 years. Among the 43 cases who had received PEP, 21 had Category-II exposures, of whom 66.7% had completed vaccination with
either ve doses intramuscular or four doses intradermal route. Similarly, 22 had Category-III exposures and only 4 (18.2%) cases had received
rabies immunoglobulin and completed rabies vaccination. Six (11.1%) cases did not receive PEP. There was no report of human rabies case.
Conclusion: The incidence of animal exposure was 1.26%. Rabies PEP in the cases was not satisfactory.
Key words: Animal exposure, human rabies, India, postexposure prophylaxis
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DOI:
10.4103/ijph.IJPH_374_19
Address for correspondence: Dr. Pradeep BS,
Additional Professor, Department of Epidemiology, Centre for Public Health,
NIMHANS, Bengaluru, Karnataka, India.
E-mail: doctorpradeepbs@gmail.com
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How to cite this article: Ramesh Masthi NR, Pradeep BS, Bilagumba G.
A multicentric community survey on animal exposures among humans in
India. Indian J Public Health 2019;63:S9-14.
A Multicentric Community Survey on Animal Exposures among
Humans in India
Ramesh Masthi NR1, Pradeep BS2, Gangaboraiah Bilagumba3
1Professor and 3Former Professor, Department of Community Medicine, Kempegowda Institute of Medical Sciences,
2Additional Professor, Department of Epidemiology, Centre for Public Health, NIMHANS, Bengaluru, Karnataka, India
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Masthi, et al.: A multicentric community survey on animal exposures
Indian Journal of Public Health ¦ Volume 63 ¦ Issue Supplement 1 ¦ September 2019
S10
By evaluating the health-seeking practices of persons exposed
to dog/animal bites, we hope to discover possible weaknesses
in rabies PEP in local communities. The availability of medical
care personnel, facilities, and appropriate medicines for PEP
administration can also be known. This data will be used to
develop effective risk communication materials.
In this background, an estimation on the dog/animal bite
injuries in selected states of India was done with the objectives,
to estimate the incidence of animal exposure (Bite, scratch or
lick) in the study population along with coverage of rabies
PEP among them.
MateRIals and Methods
A descriptive epidemiological study was conducted across
seven representative states (Himachal Pradesh, Bihar, West
Bengal, Manipur, Kerala, Madhya Pradesh, and Gujarat)
in India between July and November, 2017. In each state,
multistage sampling methodology was followed for selection
of district, taluka/tehsil, block, and clusters within the block.
The primary sampling unit was a household (HH). The Census
of India, 2011 database was used as sampling frame for clusters
selection and clusters were dened as villages for rural areas
and wards for urban areas.[8]
Sample size calculation
The incidence of animal/dog bites was considered to be around
0.9%.[9] Precision taken was 0.4%.[6,9] Design effect considered
for the study was 2. The nal sample size was 4282 persons.
Assuming a nonresponse rate of about 15%, net sample size
calculated was 4924 persons. The number of individuals in
each state = 4924/7 states = 703 persons/state. The number of
HHs to be surveyed in each state (703/5) = 141 HH (average
of 5persons per HH) and number of HHs to be surveyed in
each cluster = 141 HH/6 cluster = 24 HH per cluster.
Random numbers were generated using the “Randbetween”
function of Microsoft Excel software for selecting one district
within the state, one taluka/tehsil, or block within the selected
district and within each block, a minimum of 6 clusters were
selected randomly. The number of rural and urban clusters
selected was based on the rural–urban demography of that
particular state (probability proportional to size sampling).
Selection of households for community survey
The WHO-EPI cluster evaluation survey methodology was
followed.[10] The teams surveyed every adjacent HH in a
counting series along mapped routes until 24 HHs per cluster
were covered. The head of HH was the preferred respondent,
but any adult responsible respondent living in the HH, female
or male, was also considered as an alternative. Inclusion criteria
consisted of: (i) respondent should have been a resident of
the HH for a minimum of 6 months in the last 1 year and
(ii) respondents who gave informed consent for participation.
Data collection
Data were collected by a community survey team from the
respective states. The faculty of the Department of Community
Medicine of a Medical College situated in the selected district
or the nearest Medical College in the neighboring district
within the state formed the community survey team. The
surveyors in selected states were trained for 1 day on the survey
methodology. Surveyors conducting eldwork used a handheld
Table 1: Sociodemographic characteristics of the cases (n=4294)
Characteristics Details Urban (n=1278),
n (%)
Rural (n=3016),
n (%)
Total (n=4294),
n (%)
Total number of cases 17 (1.33) 37 (1.23) 54 (1.26)
Age (years) ≤14 (children) 4/256 (1.56) 13/704 (1.84) 17/960 (1.77)
15-60 13/919 (1.41) 20/2066 (0.96) 33/2985 (1.10)
>60 -/103 4/246 (1.62) 4/349 (1.14)
Gender Male 9/645 (1.39) 28/1537 (1.82) 37/2182 (1.69)
Female 8/633 (1.26) 9/1479 (0.61) 17/2112 (0.80)
Religion Hindu 10/780 (1.28) 29/2266 (1.28) 39/3046 (1.28)
Christian 7/307 (2.28) 5/524 (0.95) 12/831 (1.44)
Muslim -/191 3/226 (1.33) 3/417 (0.72)
Education Illiterate 1/176 (0.57) 9/828 (1.09) 10/1004 (0.99)
Primary/middle/high school/preuniversity college 13/831 (1.56) 25/1891 (1.32) 38/2722 (1.39)
Degree/diploma/postgraduation 3/271 (1.11) 3/297 (1.01) 6/568 (1.06)
Occupation Cultivator/laborer (agricultural/nonagricultural) 4/62 (6.45) 10/674 (1.48) 14/736 (1.90)
Salaried employment/business 5/386 (1.29) 6/483 (1.24) 11/869 (1.27)
Housework 3/356 (0.84) 5/835 (0.59) 8/1191 (0.67)
Unemployed -/98 2/126 (1.59) 2/224 (0.89)
Student 5/376 (1.33) 14/898 (1.56) 19/1274 (1.49)
Marital Status Currently married 10/712 (1.40) 21/1666 (1.26) 31/2378 (1.30)
Never married 6/496 (1.21) 16/1211 (1.32) 22/1707 (1.29)
Divorced/separated/widowed 1/70 (1.43) -/139 1/209 (0.48)
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Masthi, et al.: A multicentric community survey on animal exposures
Indian Journal of Public Health ¦ Volume 63 ¦ Issue Supplement 1 ¦ September 2019 S11
personal digital assistance/device (PDA) that included a GPS
receiver or a smartphone (Android) and software application
specially developed by WHO India ofce, New Delhi, for
the survey.
The study tool consisted of details on sociodemographic
characteristics of populations surveyed. A case was a subject
with animal exposure (bite, scratch, or lick) in the last 1 year
from the date of survey. The animal exposure was categorized
based on the WHO guidelines (Category-I, Category-II,
and Category-III). The patients with the history of multiple
animal exposures any time during the survey period was
considered as a single case. Rabies PEP consisted of wound
wash, administration of RIG, and rabies vaccination. Suspect,
probable, and conrmed rabid animal bites were classied as
per the WHO guidelines.[11] Bites from dogs, cat, cow, and
monkeys were considered as domestic animal bites; bites
from fox and jackal were considered as wild animal bites.
Information was collected from the respondents of the surveyed
population on any deaths due to rabies that they may have
come across as an additional information and was not part of
the main study. A case presenting with one or more than one
of the following symptoms: hydrophobia, aerophobia, and
photophobia during the study period of 1 year was dened as
human rabies case for the purpose of the survey.
Statistical analysis
Data were entered into the PDA at the place of data collection
using the digital platform developed for the study. The excel
sheet was imported from the digital platform and analyzed.
Appropriate descriptive statistics, such as frequencies and
proportions were generated.
Ethical aspects
Ethics committee reference number and date of approval was
KIMS/IEC/S15-2016. Informed signed consent (or thumb
impression from the illiterates with witness) was obtained from
all respondents. Condentiality of the data was maintained.
Results
A total of 1012 HHs were surveyed covering a population
of 4294. 3016 (70.2%) persons were from rural settings and
1278 (29.8%) were living in urban settings. The median age
with interquartile range was 30 (16,45) years. 2181 (50.8%)
persons were male and 2113 (49.2%) were female.
Animal exposure incidence
The annual incidence of animal exposure was 1.26%
(condence interval [CI]: 0.93%–1.59%), i.e., 54 cases out
of 4294 population surveyed. The annual incidence in urban
and rural settings were 1.33% (CI: 0.70 - 1.96), i.e., 17 cases
out of 1278 and 1.23% (CI: 0.84 - 1.62), i.e., 37 cases out of
3016, respectively [Table 1].
Sociodemographic characteristic of the cases
Among the 54 cases, majority (37 [68.5%]) of the cases were
from rural settings. 61.2% cases were in the age group of
15–60 years. The youngest case was 3 years old and oldest case
was 82 years old. The median age with interquartile range of the
cases was 35 (12, 48) years. 72.2% cases were Hindu by religion,
70.4% cases were school and preuniversity educated, 25.9%
cases were laborer (agricultural/nonagricultural) by occupation,
and 19 (35.2%) cases were students [Table 1]. The median income
with interquartile range was Rs. 78,000 (1217$) (Rs. 32,250–Rs.
240,000).The minimum and maximum income of the cases was
Rs. 5000 (78$) and Rs. 500,000 (7808$) per annum.
Cases exposure details
Out of the 54 cases, 59.3% exposures had occurred outside
home. Majority (44 [81.5%]) of the cases had single wound.
The median number of bite wounds with interquartile range
was 1 (1, 3). One case had a maximum of >10 bite wounds.
In 61.1% cases, site of bite was the leg and feet, followed by
the arms, forearms, and hand. Majority (57.4%) of the cases
had abrasion, 29 (53.7%) cases had Category-II bites and
25 (46.3%) cases had Category-III bites [Table 2].
Biting animal and vaccination
Dog (74.1%) was the main biting animal followed by cats
12 (22.3%), monkey (1.8%), and Ox (1.8%). Among dogs,
55.0% exposures were by pet dogs, 47.5% dogs were
unvaccinated, and 65.0% dogs were available for 10 days
observation. Five (45.4%) dogs in urban and 9 (31.0%) dogs
in rural areas were classied as suspected rabid animals.[12]
Thirty-one (57.4%) cases mentioned that the animal had not
bitten anyone else besides them, whereas 10 (25.0%) of the
cases had mentioned that in addition to them, others were also
bitten by the same animal and the remaining did not know.
Postexposure prophylaxis of cases
Among 54 cases, 19 (35.2%) had washed the wounds with
water and soap and 8 (14.8%) had applied irritants [Table 3].
Forty-eight (88.9%) cases had sought PEP at the health
centre. Six ( 11.1%) cases had not taken PEP and the common
reasons attributed were 3(50.0%) were not aware/do not
know and 2(33.3%) gave reasons such as no need to go to
hospital. Among the cases who had sought PEP at the health
facility, 5 (10.4%) were not advised PEP by the health-care
provider and for calculation of PEP coverage, n = 43 was
considered.
Among the 43 (79.6%) cases, 21 had Category-II exposures,
of whom 14 (66.7%) had completed with either ve doses
intramuscular or four doses intradermal vaccination. Majority
(40 [93.0%]) had taken vaccine in the deltoid region [Table 3].
The median duration (interquartile range) in days between bite
and rabies vaccination was 2 (2, 3).
Similarly, 22 cases had Category-III exposures, only 4 (18.2%)
had received both RIG and completed the rabies vaccination.
Three (75.0%) had received equine RIG and one (25.0%) had
received human RIG.
Health‑care accessibility
About 53.5% cases had to travel 0–5 km to seek rabies PEP
and 12.9% had to travel >15 km. The median distance traveled
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Masthi, et al.: A multicentric community survey on animal exposures
Indian Journal of Public Health ¦ Volume 63 ¦ Issue Supplement 1 ¦ September 2019
S12
was 5 (2, 12) km, urban area was 1 (1, 2) km, and rural area
was 7 (3, 15) km. 45.4% cases, mode of transport was by
bike/car/jeep/auto-rickshaw, etc., 35.8% traveled by bus,
18.4% mentioned by walk, and least 0.3% said ambulance.
There was no mention of having come across a human rabies
case by the surveyed respondents during the study period of
1 year.
dIscussIon
A cross-sectional survey on the incidence of animal exposure
was conducted in seven states of India in 2017. The animal
exposures were categorized based on the WHO guidelines.
The annual incidence of animal exposure was 1.26%
(CI: 0.93%–1.59%). Majority of the cases were from rural
settings, 15–60 years of age, 14 (66.7%) cases had completed
Table 2: Details of exposure of the bite victims
Characteristics Details Urban (n=17), n (%) Rural (n=37), n (%) Total (n=54), n (%)
Place of bite Home 9 (52.9) 13 (35.1) 22 (40.7)
Outside home 8 (47.1) 24 (64.9) 32 (59.3)
Nature of bite Provoked bite 10 (58.8) 17 (45.9) 27 (50.0)
Unprovoked bite 7 (41.2) 20 (54.1) 27 (50.0)
Number of bite wounds One 11 (64.7) 33 (89.2) 44 (81.5)
Two 5 (29.4) 2 (5.4) 7 (13.0)
More than two 1 (5.9) 2 (5.4) 3 (5.5)
Site of bite* Leg/feet 9 (52.9) 24 (64.9) 33 (61.1)
Arm/forearm/hand 8 (47.1) 12 (32.4) 20 (37.0)
Head/face - 1 (2.7) 1 (1.8)
Buttock - 1 (2.7) 1 (1.8)
Type of wound* Abrasion 11 (64.7) 20 (54.0) 31 (57.4)
Puncture wound 4 (23.5) 12 (32.4) 16 (29.6)
Laceration 2 (11.8) 7 (18.9) 9 (16.7)
Category of bites Category-II 11 (64.7) 18 (48.6) 29 (53.7)
Category-III 6 (35.3) 19 (51.4) 25 (46.3)
*Multiple response possible
Table 3: Postexposure prophylaxis of the cases
Characteristic Details Urban (n=17), n (%) Rural (n=37), n (%) Total (n=54), n (%)
Wound care* Water and soap 9 (52.9) 10 (27) 19 (35.2)
Water 3 (17.6) 5 (13.5) 8 (14.8)
Nothing 1 (5.9) 7 (18.9) 8 (14.8)
Applied irritants/consulted traditional healer 1 (5.9) 7 (18.9) 8 (14.8)
Sought PEP at health
facility
Yes 15 (88.2) 33 (89.2) 48 (88.9)
No 2 (11.8) 4 (10.8) 6 (11.1)
Time gap for PEP
(n=48) (days)
<1 13/15 (86.6) 24/33 (72.8) 37 (77.1)
1-2 2/15 (13.4) 5/33 (15.1) 7 (14.6)
3+ - 4/33(12.1) 4 (8.3)
Rabies Vaccination (n=43) Yes 13 30 43
Site of vaccination Deltoid 13 (100.0) 27 (90.0) 40 (93.0)
Gluteal - 3 (10.0) 3 (7.0)
Number of doses 1 - 4 (13.3) 4 (9.3)
3 2 (15.4) 6 (20.0) 8 (18.6)
4 6 (46.1) 12 (40.0) 18 (41.9)
5 5 (38.5) 8 (26.7) 13 (30.2)
Health facility visited Government 9 (69.2) 26 (86.7) 35 (81.4)
Private 4 (30.8) 4 (13.3) 8 (18.6)
Category-III wounds (n=22) 6 16 22
Rabies immunoglobulin
(n=4)
Administered 1 (16.7) 3 (18.7) 4 (18.2)
ERIG 1 (100.0) 2 (66.7) 3 (75.0)
HRIG - 1 (33.3) 1 (25.0)
Site of administration
(n=4)
Into the wound 1 (100.0) 1 (33.3) 2 (50.0)
Deltoid - 2 (66.7) 2 (50.0)
*Multiple response possible and nonresponders, ERIG: Equine rabies immunoglobulin, HRIG: Human rabies immunoglobulin
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Masthi, et al.: A multicentric community survey on animal exposures
Indian Journal of Public Health ¦ Volume 63 ¦ Issue Supplement 1 ¦ September 2019 S13
PEP in Category-II exposures and 4 (18.2%) had received RIG
and completed the rabies vaccination schedule in Category-III
exposures.
Survey coverage
In the present study, 7 states (28 rural and 14 urban communities)
were covered compared to the Indian rabies survey 2004, where
18 states (21 urban and 63 rural communities) were covered.[12]
Hence, the comparison between the two studies is not ideal,
and the results cannot be generalized to the entire country.
Incidence of animal exposure
The annual incidence of animal exposure was lower in the
present study compared to 1.74% (CI: 1.63%–1.85%) observed
in the Indian Rabies Survey.[2] Studies from other urban and
rural settings had observed the incidence of animal exposure
varied from 1.6% to 2.6%.[12,13]
Profile of cases
The mean age of the cases in Bhutan was 21.2 years and Babol,
Iran, was 33.68 ± 17.23 similar to the present study.[14,15] The
incidence of animal exposure was nearly twice in children than
adults in 2004 study, 47.5% in multicentric study of 2008, 65%
in Haiti, and 45% in a region endemic to rabies in difference
to the observation of the present ndings.[15-18] From studies
across different settings, it was observed that majority of cases
were male (68%–82%) similar to the ndings of the present
study.[13-15,17] Females had the highest rate of cat bites.[5] In the
multicentric study of 2008, 63% had Category-III exposure,
when compared to the present study, where Category-II
exposures were more in number.[16]
Body part involved
In the studies done in Bhutan and Babol, 73% had exposure
on the legs and 18% on the hand/arms, 46.9% on the shoulder
and upper organs, and 41% lower extremities similar to the
observation of the present study.[14,15]
Biting animal
In the Indian Rabies Survey, the biting animals were mainly
dogs (91%), stray (63%) compared to the 22% exposures due
to cats in the present study.[12] Low- and middle-income country
data reveal that dogs account for 76%–94% of animal bite
injuries. Worldwide, cat bites account for 2%–50% of injuries
and monkey bites account for 2%–21% of animal bite injuries.[5]
A small proportion of transmission was via wildlife.[19]
Surveillance status of animals
On the basis of descriptive case histories, 48.1% of animals
were noncases and 51.9% were suspect rabies in the current
study compared to 60% suspect rabies in regions endemic to
rabies.[19] In Bhutan, majority (59%) of the victims mentioned
that the rabies status was unknown, 32% mentioned normal
and 9% suspect rabies.[15]
Wound wash
In the Indian Rabies Survey and multicentric study of 2008
about 39% and 58% had washed wounds with soap and water
in concordance to ndings observed in the present study.[12,16]
Antirabies vaccination and rabies immunoglobulin
administration
88.2% had received three doses of rabies vaccine and 2.8%
had received ve doses of rabies vaccine in Babol similar to
the present study.[15] The interesting observation was that the
coverage of ARV in rural area was better compared to urban
areas. The cases usage of RIG was 18.4% compared to 2.1%
usage in 2004.[12] However, the RIG usage continues to be
poor and needs to be strengthened along with introduction and
scaling up of human rabies monoclonal antibodies. In a region
endemic to rabies, it was observed that the cost of PEP varied
depending on the health facility and the date of presentation.[17]
Majority preferred government hospitals (59%) for rabies PEP
than private hospitals (36%) similar to the present study.[11]
conclusIon
The incidence of animal exposure was 1.26% in the surveyed
population. Postexposure rabies vaccination and RIG coverage
were not satisfactory.
Limitation of the study
The sample size of 4924 was calculated based on the
assumption of ve persons per HH with 1008 HHs to be
surveyed. However, a total of 1012 HHs were surveyed and
only 4294 persons were available (4.24 persons per HHs).
Resurvey was done in 50 HHs. (Gujarat [n = 2], Madhya
Pradesh [n = 34], Himachal Pradesh [n = 6], and Kerala
[n = 8]), as there was technical error in uploading data on to
PDA. The study involved only selected states in India and
generalization of the results for the country was not attempted.
Recall Bias – There may be a possibility of recall bias in
remembering the bite/exposure, time taken between bite and
wound wash, wound wash and vaccination. The information
bias in the categorization of animal exposure and rabies PEP
was minimized by prior training of surveyors, in data collection
and asking leading questions to verify the type of exposures.
Acknowledgment
The authors would like to thank Dr. Bernadette Abela-Ridder,
Team Leader, Neglected Tropical Diseases, World Health
Organization (WHO), Geneva, Switzerland; Dr. Lea G
Knopf, Neglected Tropical Diseases, WHO, Geneva,
Switzerland; Dr. Ritu Singh Chauhan, National Professional
Ofcer–IHR, WHO Country Ofce for India, New Delhi; and
Mr. Avijit Chaudhury, WHO Country Ofce.
The authors gratefully acknowledge the help and support of
Dr. Anmol Gupta, Professor and HOD of Community Medicine,
Indira Gandhi Medical College, Shimla, Himachal Pradesh;
Dr. Chittaranjan Roy, Professor and HOD of Community
Medicine, Darbhanga Medical College, Darbhanga, Bihar;
Dr. Longjam Usharani Devi, Professor and HOD of
Community Medicine, Jawaharlal Nehru Institute of Medical
Sciences, Imphal, Manipur; Dr. Dipankar Mukherjee, Assistant
Professor, KPC Medical College, Kolkata, West Bengal;
Dr. M Geetadevi, Associate Professor, Government Medical
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Masthi, et al.: A multicentric community survey on animal exposures
Indian Journal of Public Health ¦ Volume 63 ¦ Issue Supplement 1 ¦ September 2019
S14
College, Kottayam, Kerala; Dr. Arun Kokane, Professor and
HOD of Community Medicine, AIIMS, Bhopal, Madhya
Pradesh; and Dr. Abhay Kavishvar, Associate Professor,
Government Medical College, Surat, Gujarat, for conducting
the community survey in the respective states. We would
like to thank with gratitude the staff, postgraduates/interns of
community medicine departments from all the surveyed states
for their cooperation in the study.
The authors also thank Dr.M K Sudarshan,Former Dean and
Principal; Dr.D H Ashwath Narayana,Professor and Head;Dr.T
V Sanjay and Dr. Ravish H S, Professor; Dr. Anwith H S,
Assistant Professor; and Dr. Manasa AR and Dr. Afraz Jahan,
Postgraduates, Department of Community Medicine, KIMS,
Bengaluru, for data management and assistance in the project.
Financial support and sponsorship
The study was nancially supported by the WHO India Country
Ofce, New Delhi.
Conflicts of interest
There are no conicts of interest.
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Fellowship Award to Life Members
Nominations are invited from Life Members of Indian Public Health Association for the Award of
Fellowship.
The prescribed Fellowship application form is available at the IPHA website www.iphaonline.org
The nominations should reach the IPHA HQ Office, at 110, C.R. Avenue, Kolkata – 700073 by 30th
September 2019.
Nominations should be accompanied by relevant supporting documents (details available at
website – www.iphaonline.org
Sd/- Dr Sanghamitra Ghosh
Secretary General, IPHA
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