Rabies control initiative in Tamil Nadu, India: a test case for the ‘One Health’ approach

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Rabies control initiative in Tamil Nadu, India: a test case for the ‘One Health’ approach

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  Pleasecitethisarticleinpressas:AbbasSS,etal.RabiescontrolinitiativeinTamilNadu,India:atestcaseforthe‘OneHealth’approach. IntHealth (2011),doi:10.1016/j.inhe.2011.08.001 ARTICLE IN PRESS GModelINHE-118;No.ofPages9InternationalHealth xxx (2011) xxx–xxx ContentslistsavailableatSciVerseScienceDirect International   Health  journalhomepage:http://www.elsevier.com/locate/inhe Rabies   control   initiative   in   Tamil   Nadu,   India:   a   test   case   for   the‘One   Health’   approach Syed   Shahid   Abbas,   Vidya   Venkataramanan,   Garima   Pathak,   Manish   Kakkar ∗ ,on   behalf    of    the   Roadmap   to   Combat   Zoonoses   in   India   (RCZI)   Initiative PublicHealthFoundationofIndia,4,InstitutionalArea,VasantKunj,NewDelhi110070,India a   r   t   i   c   l   e   i   n   f   o  Articlehistory: Received19November2010Receivedinrevisedform3May   2011Accepted26August2011 Available online xxx Keywords: RabiesZoonosisIndiaOneHealthHealthpolicyCommunicabledisease a   b   s   t   r   a   c   t Although   India   accounts   for   nearly   50%   of    the   global   rabies   mortality,   there   isno   organ-ised   national   rabies   control   programme.   Rabies   control   isgenerally   confined   to   small   urbanpockets,   with   minimal   intersectoral   co-ordination.   Tamil   Nadu   isthe   first   state   inIndiatoimplement   astate-wide,   multisectoral   rabies   control   initiative.   The   CDC   Program   Eval-uation   Framework   guided   the   current   assessment   of    this   rabies   prevention   and   controlinitiativein   Tamil   Nadu.   Principle   stakeholders   were   engaged   through   a   series   of    interviewsinorder   to   document   policy   initiatives,   to   describe   the   programme   and   to   understand   theirvarious   roles.   Surveillance   data   ondog   bites   were   triangulated   with   vaccine   consumptionand   dog   population   data   to   identify   trends   at   the   district   level   in   the   state.   Findings   andrecommendations   were   shared   at   different   levels.   Rabies   control   activities   in   Tamil   Naduwereconducted   by   separate   departments   linked   bysimilar   objectives.   Inaddition   to   pub-lichealth   surveillance,   animal   census   and   implementation   of    dog   licensing   rules,   othertargetedinterventions   included   waste   management,   animal   birth   control   and   anti-rabiesvaccination,   awareness   campaigns,   and   widespread   availability   of    anti-rabies   vaccine   atall   public   health   facilities.   Inconclusion,   this   assessment   suggests   that   it   is   possible   toimplement   a   successful   ‘One   Health’   programme   in   an   environment   of    strong   political   will,evidence-based   policy   innovations,   clearly   defined   roles   and   responsibilities   of    agencies,co-ordination   mechanisms   at   alllevels,   and   a   culture   of    open   information   exchange. © 2011 Royal Society of Tropical Medicine and Hygiene. Published by Elsevier Ltd. All rights reserved. 1.Introduction 1.1.Problemstatement  Rabies,aviralzoonoticdisease,isamongthemostneglectedinfectiousdiseasesinIndiaaswellasinotherlow-andmiddle-incomecountries.Annuallyitaccountsformorethan55000deathsglobally,approximately95%ofwhichoccurinAsiaandAfrica.Almostone-halfoftheglobalburden,or20000humanlives,arelostannually ∗ Correspondingauthor.Tel.:+911149566000;fax:+911149566063. E-mailaddress: manish.kakkar@phfi.org(M.   Kakkar). duetorabiesinIndia.Domesticdogsarethemainvector,causing94%ofhumancases.Two-thirdsofIndia’spopula-tionlivesinvillages.Theyaremorevulnerabletozoonoticinfectionanddisease,withnearly76%ofrabiescasesreportedfromthissegment. 1,2 Recentcommunitysurveysalsorevealedthatthemajorityofdog-bitevictimsdonotreceiveanyrabiesvaccine,demonstratinggrossnegligenceonthepartofboththebitevictimaswellasthehealthcaresystem. 2 1.2.Interventions AccordingtotheWHO,themostcost-effectivestrat-egyforpreventinghumanrabiesiseliminationofrabies 1876-3413/$–seefrontmatter © 2011 Royal Society of Tropical Medicine and Hygiene. Published by Elsevier Ltd. All rights reserved. doi:10.1016/j.inhe.2011.08.001  Pleasecitethisarticleinpressas:AbbasSS,etal.RabiescontrolinitiativeinTamilNadu,India:atestcaseforthe‘OneHealth’approach. IntHealth (2011),doi:10.1016/j.inhe.2011.08.001 ARTICLE IN PRESS GModelINHE-118;No.ofPages9 2  S.S.Abbasetal./InternationalHealth  xxx (2011) xxx–xxx indogsthroughanimalvaccinationandenvironmentalcontrol. 3 ManycountriesinSouthAmericaandAsiahavesuccessfullyusedthisstrategytoeliminatetransmissionof rabiesamonghumansandanimals. 4,5 Acombinedeffortbythepublichealthdeliverysystem,veterinarydepart-mentsandmunicipalitiescanleadtothecontrolofrabiesindogsandtherebyimpacttransmissionofthevirustothehumanpopulation.Whilsttheimportanceofsucheffec-tiveintersectoralcollaborationhasoftenbeenemphasisedasthekeytorabiescontrol, 3–5 suchmechanismscontinuetoeludemostofAfricaandAsia,includingIndiawhererabiespersistsasasignificantpublichealthchallenge. 1,2,6–8 Moreover,rabiesinterventionsprovideagoodillustrationfortheglobaldebateonthebestmechanismsofoper-ationalisingintersectoralcollaborationsunderthe‘OneHealth’framework.The‘OneHealth’conceptmaintainsthathumanandanimalhealthareirrevocablyentwinedandthatimprovementofbothrequiresclosecollabora-tionbetweenthemedicalandveterinaryprofessionswithsupportfromallieddisciplines. 9,10 1.3.Objectives Despitethehighdiseaseburdenofrabiesandtheavailabilityofeffectivepreventivestrategies,veryfewstatesinIndiahaveanorganisedrabiescontrolprogramme.Standalonepilotinterventionshavedemonstratedencour-agingresultsinseveralcitiessuchasJodhpur,Jaipur,Chennai,KalimpongandBangalore. 2,11–13 However,mostoftheseinitiativeshavebeenimplementedonasmallscalebynon-governmentorganisations(NGOs)ormunic-ipalitieswithlimitedcapacitiestoreachouttolargerpopulations.ThepresentstudywasconductedfollowingreportsthatTamilNaduhadmadeaco-ordinatedeffortinvolv-ingpublichealthandmunicipalagencies,puttinginplaceinterventionssuchasanimalbirthcontrolandanti-rabiesvaccination(ABC-AR)anduniversalvaccinesupplytoaddressthispublichealthchallenge.Thisstudysoughttooutlineandreviewtherabiespreventionandcontrolini-tiativesinTamilNadu,withspecialfocusonmechanismsputinplacetoachieveintersectoralco-ordination,aswellastodocumenttheeffectoftheseinnovationsonthestatusofdog-biteandrabiescasesinthestate. 2.Methods  2.1.Studydesign TheCDCProgrammeEvaluationFramework 14 wasusedtoguidethestudydesign,datacollectionanddis-seminationstagesasdescribedinTable1.Giventhelimitedprogrammedocumentationavailabletousandtheinvolvementofmultiplesectors,aniterativeprocesswasemployedtorefinethestudydesignalongsidethedatacollectionprocess.  2.2.Preparatoryphase ThisstudyconsistedofaplanningphasethatinvolvedidentificationofprinciplestakeholdersinTamilNadu  Table1 Majorstepsoftheassessmentexercise Engagestakeholders • Identifystakeholdersandtheirroleintherabiescontrolinitiative •   Documentstakeholderconcerns Describetheprogramme •   Identifyprinciplepoliciesandmap   theirscope •   Drawalooseprogrammaticstructurefortherabiescontrolinitiative Focusevaluationdesign • Describeinformationneedsfortheassessment •   Preparedatacollectionprotocolfromidentifiedinformationsources Gathercredibleevidence •   Identifyindicatorstomeasureprogrammeperformance •   Collectdataintwophases  Justifyconclusions • Identifymicrotrends •   Triangulateinformationcollectedfromdifferentsources Ensureuseandsharelessonslearnt •   Preliminaryfindingssharedwithpublichealthofficialsforcomments •   Synthesisedfindingssharedwithstakeholdersatstateandnationallevel throughliteraturereviewandsnowballsampling.InitialinterviewswereconductedwithDepartmentofPublicHealthofficialstounderstandthemajorpolicyinitiativesandtoidentifyotheractorsinvolvedinrabiescontrolefforts.Aformativesitevisitwas   alsomadetoTamilNadutointerviewkeystakeholdersatthestatelevelandinonedistricttounderstandthedynamicsinvolvedinimplemen-tationoftheprogramme.Theinitialstate-levelassessmentsenabledustodoc-umentkeypolicies,co-ordinationandsurveillanceissuesfromtheperspectivesofdifferentstakeholdersand,accordingly,toidentifykeyissuestobestudied.Find-ingsfromtheinitialinteractionswereusedtodesignaprogrammelogicmodel,whichenabledustofocustheevaluationdesignforthedatacollectionphasebyclarify-ingstudyobjectives,identifyingstudysites,locatingstudyrespondents,andpreparinginterviewguidesforthenextphaseofdatacollection.  2.3.Analyticalphase Owingtothewidespreadnatureofinterventionsandtheabsenceofacentraldatabase,datawerecollectedfrommultiplesources(Table2)andtriangulationwasperformedtocompensateforthevariablequalityofinformationgath-eredfrommultiplesources.Studyparameterswerethendisaggregatedintourbanandruralandweregroupedintodifferenttercilessothatdistrictsintercile1hadlowestdiseaseburdenwhilstthoseintercile3hadthehighest.Thisallowedanalysisofstate-anddistrict-levelestimatesforfourparameters,namelydog-biteincidencerate,rabiesincidencerate,dogpopulationdensityandabsolutenum-berofanti-rabiesvaccinevialsconsumed.Officialwebsitesmaintainedbystate-levelagencieswereusedforsourcingcensusfiguresandboundarydemarcations.Datacollectionduringthesecondsitevisitwas   moreextensiveandcoveredsixdistrictshavingdifferentprofilesintermsofdog-biteincidence,dogpopulation,vac-cineconsumptionandhealthinfrastructure.Itinvolved  Pleasecitethisarticleinpressas:AbbasSS,etal.RabiescontrolinitiativeinTamilNadu,India:atestcaseforthe‘OneHealth’approach. IntHealth (2011),doi:10.1016/j.inhe.2011.08.001 ARTICLE IN PRESS GModelINHE-118;No.ofPages9 S.S.Abbasetal./InternationalHealth  xxx (2011) xxx–xxx  3  Table2 PrinciplestakeholdersandtheirroleinrabiescontrolinTamilNadu,IndiaStakeholderSetting/catchmentareaFunctionsDatareportedDirectorateofPublicHealth&PreventiveMedicine(DPH)RuralTamilNadu(PHCsandBlockPHCs)Provideanti-rabiesvaccinationthroughperipheralhealthfacilitiesImplementdiseasecontrolprogrammes,focusingonruralareasCollectdiseaseanddog-bitesurveillancedataCo-ordinatevaccinedeliveryDogbitesbydistrictbyyearRabiescases/deathsbydistrictbyyearDistrictcensusdataDirectorateofMedicalEducation(DME)UrbanTamilNaduProvideanti-rabiesvaccinationthroughmedicalcollegehospitalsSupervisemedicaltrainingCollectdiseaseanddog-bitesurveillancedataCo-ordinatevaccinedeliveryDogbitesbydistrictbyyearRabiescases/deathsbydistrictbyyearDirectorateofRuralHealth&MedicalServices(DHS)RuralandurbanTamilNadu(talukaanddistricthospitals)Provideanti-rabiesvaccinationthroughnetworkofhospitalsCollectdiseaseanddog-bitesurveillancedataCo-ordinatevaccinedeliveryDogbitesbydistrictbyyearRabiescases/deathsbydistrictbyyearMunicipalAdministrationDepartment(MAD)UrbanTamilNadu(corporation/municipallimits)ConductABC-ARprogrammesinurbanpopulationsWastemanagementinurbanareasProvideanti-rabiesvaccinationthroughmunicipalityhospitalsStraydogpopulationbycorporation/municipality(4-yearcensus)NumberofABC-ARproceduresconductedperyearbycorporation/municipalityMunicipalitycensusdataDepartmentofAnimalHusbandry(DAH)RuralandurbanTamilNadu(bydistrict)ProvideanimalhealthservicesthroughnetworkofanimalhealthcentresConductregularlivestockcensusProvidetechnicalassistancetorabiescontroleffortsimplementedbyMADDogpopulationcensusbystray/pet(4-yearcensus)TamilNaduMedicalServicesCorporation(TNMSC)RuralandurbanTamilNadu(byhealthfacilityatalllevels)ManageprocurementandsupplychainmanagementofalldrugsandvaccinesforhumanandanimalhealthsectorsVaccineconsumptionbydistrictbyyearCivil   societyorganisationsUrbanSustainedadvocacythatfacilitatespolicychangesPromoteawarenessaboutanimalrightsissuesProvideoversighttoABC-ARatdistrictandstatelevelsPolicyhistoryPHC:PrimaryHealthCentre;ABC-AR:animalbirthcontrolandanti-rabiesvaccination. interactionwithdistrict-levelstakeholdersinidentifieddistrictsandcollectionofdistrict-leveldatafrommultiplesources.Preliminaryfindingswerediscussedwithkeyrespon-dents;thefinalresults,findingsandconclusionsweresharedwithallofthestakeholdersatthestatelevelandforonwardtransmissiontodistricts. 3.Results  3.1.Programmedescription 3.1.1.Programhistory Until2004,rabiescontroleffortsinTamilNaduwerelimitedtotheeliminationofstraydogsinurbanareas.Courtinterventionsresultedinabanonkillingofdogs,leadingtoareportedincreaseinthenumberofstraydogsandacorrespondingincreaseindogbitesandrabiescasesinhumans.Strongpublicopinionandpressurefromcivilsocietyorganisationsensued.Baseduponthereportedsuc-cessesofABC-ARprogrammesintheChennaiMunicipalCorporationareaandinothercitiessuchasJodhpur,JaipurandBangalore, 11–13 theMunicipalAdministrationDepart-ment(MAD)re-launcheditsrabiescontrolefforts.Atthesametime,thedecisionwas   supportedbyevidenceaccu-mulatinginotherpartsoftheworldonsuccessfulrabiescontrolusingacombinationofinterventionswithABC-AR asthecentralstrategy.However,rabiescontroleffortsinTamilNaduarenotorganisedintoaprogrammaticstructure.Theactivitiescanbebestdescribedasasetofdirectserviceinterventionsemployedbydifferentagenciesandstakeholdersallof whichworktowardscontrolofrabiesinthestate.We   havethereforereferredtotheseastherabiescontrol‘initiative’orsetof‘efforts’inthispaper.  3.1.2.Stakeholders AgenciesinvolvedinprogrammeoperationsincludetheDirectorateofPublicHealth&PreventiveMedicine(DPH),DirectorateofMedicalEducation(DME),DirectorateofRuralHealth&MedicalServices(DHS),StateSurveil-lanceOfficeandTamilNaduMedicalServicesCorporation(TNMSC)undertheMinistryofHealthandFamilyWel-fare.Otherimportantstakeholdersinvolvedinprogramme  Pleasecitethisarticleinpressas:AbbasSS,etal.RabiescontrolinitiativeinTamilNadu,India:atestcaseforthe‘OneHealth’approach. IntHealth (2011),doi:10.1016/j.inhe.2011.08.001 ARTICLE IN PRESS GModelINHE-118;No.ofPages9 4  S.S.Abbasetal./InternationalHealth  xxx (2011) xxx–xxx operationsincludetheMAD,DepartmentofAnimalHusbandry(DAH)andthecivilsocietyorganisations.Animal-sideinterventions,includingcatchingofstrays,theirsurgery,immunisationandpost-operativerecov-ery,weremostlydeliveredbytheMAD   in50selectedurbanmunicipalities.TheTNMSCensuredregularsupplyofhumanaswellasanimalvaccine.Thethreedirec-toratesofthehealthdepartment(DPH,DME   andDHS)wereresponsibleforprovidingvaccinationservicesthroughtheirrespectiveinstitutions,whilsttheDPHwasprimar-ilyresponsibleforthesurveillanceofdog-bitecases.ThefunctionsofeachoftheseagencieswithrespecttorabiescontrolactivitiesaregiveninTable2.  3.1.3.Interventions 3.1.3.1.Rabiescontrolinurbanareas. TamilNaduhas147corporationareasadministeredbycitycorporationsandmunicipalities.AnABC-ARprogrammewasinitiallypilotedinfivecorporationsand50municipalitiesatthebeginningof2007withfundingfromtheAnimalWelfareBoardof India. 15 Thesehavesubsequentlybeenscaled-uptocoverallofthemunicipalitiesacrossthestate. 16 Underthepro-gramme,veterinariansandpara-veterinarianswerehiredonapart-timebasistosteriliseafixednumberofdogsperdayandtoprovidepost-operativecaretothemfor3–5days.Traineddogcatcherswereusedtocatchthedogsandlaterreleasetheminthesamearea. 15–17 Inter-ventionsonthehumansideconsistedofmakingrabiescellculturevaccineavailableatallgovernmenthealthfacilitatesandpromotingawarenessregardingrabiespre-vention.TheinterventionsaredescribedindetailinTable2.  3.1.3.2.Rabiescontrolinruralareas. InTamilNadu,health-careservicesaredeliveredthroughafragmentedbutextensivenetworkofgovernmenthospitals.Theprimaryhealthcarecentresinruralareas[HealthSub-centres,Pri-maryHealthCentres(PHC),BlockPHCs]areadministeredbytheDPH.DistricthospitalsarerunbytheDHS.AnimalhealthcareinruralareasisprovidedbytheDAHthroughVeterinarySub-centres,veterinaryclinicsanddistricthos-pitals.However,thefacilitiesarelimitedtopreventiveandcurativecareoflargeanimalsandruminants.Althoughregulationsondogownershipwereinplace,noABC-AR initiativeshavebeenimplementedinruralareas.TheDAHnetworkdoesnotprovidevaccinationtostrayorpetdogsexceptwhenrequestedbypetownersandpanchayats(inthecaseofstraydogs)uponpaymentofthecostofthevaccine.Therefore,themajorinterventionforrabiespre-ventionandcontrolinruralareasisprovidedthroughhumanpost-exposureprophylaxisbytheDPHandDHS.ThestrategyisoutlinedinTable2.  3.2.‘Programme’outcomes Itisdifficulttocommentupontheimpactofpro-gramme   strategiesonrabiesburdenamonganimalandhumanpopulationsinTamilNadubecauseoftheabsenceofappropriateinformation.However,itdoesallowustohighlightthedifferentpositive‘outcomes’thatfollowedimplementationofthebasketofstrategiesadoptedbydif-ferentagenciesinTamilNaduasfollows.  3.2.1.Increasedvaccineavailability ThestategovernmentofTamilNaduhaspioneeredatransparentandcentralisedprocurementandsupplychainmanagementsystemofallmedicalsupplies,includ-ingdrugsandvaccines,inthestatethroughtheTNMSC.Adedicatedsupplychainmanagementsystemhasensuredminimumstock-outsandresultedinwell-documentedconsumptionandexpendituredataonallmedicalcon-sumables.Thestategovernmentstoppedprocurementof neuraltissueanti-rabiesvaccineandintroducedcellcul-turevaccinein2004.Theavailabilityoffreevaccinesatallgovernmenthealthfacilitieswaswellpublicised.Anexaminationofprocurementdatashowedasharpincreaseinconsumptionofanti-rabiesvaccineper100000popu-lationfrom370in2004to1189in2005,andplateauingthereafter.  3.2.2.Increasedreportingofdogbites AsdepictedinFigures1and2,increasedvaccineavail-abilitywas   accompaniedbyincreasedreportingofdog-bitecasesacrossalldistricts.Thenumberofdog-bitecasesper100000ruralpopulationincreasedfrom202in2004to531in2009.Similarly,reporteddogbitesinterciles1,2and3districtsincreasedfrom124,156and315,respectively,to361,518and821.Intheabsenceofdisaggregateddata,therural–urbandistributionofdogbitecaseswasdeducedfromfiguresreportedfromDPHandDME,respectively.AsshowninFigure3,thenumberofdogbitesreportedper100000populationinurbanareaswas   aroundfivetimesthatreportedinruralareasin2008and2009. 050100150200250300350020040060080010001200140016002004   2005   2006   2007 N o. of   d  o g b i   t   e s  p er 1  0  0  0  0  0     N  o .  o   f  v  a  c  c   i  n  e  v   i  a   l  s  p  e  r   1   0   0   0   0   0 Year  Vaccine vials per 100 000Dog bites per 100 000 Figure1. Vaccineconsumptionandreporteddogbitesper100000populationinTamilNadu,India,2004–2007[TamilNaduMedicalSer-vicesCorporation(TNMSC)andDirectorateofPublicHealth&PreventiveMedicine(DPH)].  Pleasecitethisarticleinpressas:AbbasSS,etal.RabiescontrolinitiativeinTamilNadu,India:atestcaseforthe‘OneHealth’approach. IntHealth (2011),doi:10.1016/j.inhe.2011.08.001 ARTICLE IN PRESS GModelINHE-118;No.ofPages9 S.S.Abbasetal./InternationalHealth  xxx (2011) xxx–xxx  5 01002003004005006007008009002004   2005   2006   2007   2008   2009    Average (2004–09)    N  o .  o   f   d  o  g   b   i   t  e  s  p  e  r   1   0   0   0   0   0 Year  Tercile 3 districts   Tercile 2 districts   Tercile 1 districts   Rural Tamil Nadu Figure2. Reporteddogbitesper100000populationacrossdistrictsinruralTamilNadu,India,2004–2009[DirectorateofPublicHealth&PreventiveMedicine(DPH)]. 0500100015002000250030002008   2009    N  o .  o   f   d  o  g   b   i   t  e  c  a  s  e  s  p  e  r   1   0   0   0   0   0 Year  Rural Urban Figure3. Variationinreporteddog-bitecasesinruralandurbanareasof TamilNadu,India,2008–2009[DirectorateofPublicHealth&PreventiveMedicine(DPH)andDirectorateofMedicalEducation(DME)].  3.2.3.Formationofco-ordinationmechanisms Althoughinterventionsrelatedtorabieshadbeentak-ingplacesincebefore2004,thegovernmentofTamilNaduannouncedthelaunchofanABC-ARprogrammein2007,whichwassubsequentlyscaled-uptocoverallmunicipal-itiesin2008. 15,16 Thepilotprogrammeentailedformationofdistrict-level‘monitoringcommittees’thatwouldover-seeimplementationoftheprogramme.Thecommitteecomprisedrepresentativesfromthemunicipaldepartment(aschairperson),publichealthdepartment,animalwelfaredepartment,aveterinarydoctor,arepresentativeofthedistrictsocietyforpreventionofcrueltytowardsanimals(SPCA)andatleasttworepresentativesoflocalanimalwel-fareorganisations.Themonitoringcommitteesweresup-posedtoprovideoverallguidancetothepilotprogrammeaswellassupervisethemanagementofsickanimals.Basedupontheexperiencesofthedistrictcommittees,asimilarbodywas   createdatthestatelevelin2008,calledtheState-LevelCoordinationCommittee(SLCC).TheSLCCconsistedofrepresentativesfromdepartmentsresponsibleforurbanadministration,ruraladministration,localgov-erningbodies,publichealthandhealthservices,agricultureandlivestockhealth,aswellasanimalwelfarerepresen-tatives.Thefunctionsforthecommitteewereoutlinedasoversightofdatacompilationandanalysis,provisionof animalandhumanservices,andimplementationofinter-ventionstrategies. 18 4.Discussion TherabiescontrolinitiativeinTamilNaduisthefirstcomprehensiverabiescontroleffortinIndiawithuniversalcoverageandwhoseinterventionstargetanimalaswellashumanpopulations. 4.1.Policyinnovations Theinitiativehasbeenabletodrawuponseveralpolicychangesthathavetakenplaceoverthelastdecade.ThesehavebeendescribedinTable3andincludethefollowing. 4.1.1.Co-ordinationmechanisms RabiescontrolinitiativesinTamilNaduowetheirstrengthinlargeparttotheintersectoralco-ordinationmechanismsinstitutedatthestate-anddistrict-level
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