A Prospective Study of the Epidemiological Profile of Dog Bite Cases and Determinants of Anti-Rabies Vaccination Compliance at a Rural Health Training Center from a Medical College in Gujarat

Abstract

Background:

India is endemic for rabies, the most dreaded complication of animal bites which accounts for 35-40% of the world’s rabies cases. The Anti-Rabies Vaccine (ARV) is the only proven way to prevent deaths due to rabies; however, its compliance is still a matter of concern. This study was conducted with objectives to (1) generate the epidemiological profile of dog bite cases and (2) assess the determinants of ARV compliance.

Methodology:

A prospective study was conducted at a Primary Health Centre (PHC), also the RHTC of a medical college in Ahmedabad, Gujarat. All consecutive incident cases of animal bite registered at RHTC between May-Dec 2023 were included and followed for 60 days (post-bite). All cases, whether ARV compliant or not were approached by home visits or telephonic meetings. Data were collected using a pre-designed semi-structured questionnaire.

Results:

There were 221 cases of dog bites. Most involved were stray dogs 175 (79.2%). Bites occurred more in public places (75.1%), during the evening and early night hours, accounting for 42.5% of cases with a peak during September-November (45.2%). As for the treatment-seeking pattern, 40.7% did not do anything at home. Maximum cases were from category II 58.4%, followed by 30.3% and 11.3% cases from categories I and III. ARV was indicated in 196 cases; 121 (61.7%) of them fully complied with ARV. Reasons for non/poor compliance were feeling cured, being out of the station, and a lack of specific reasons. Important compliance determinants were the occupation of the case and the status of the animal vaccination.

Conclusion:

Only 61.7% of cases had complete ARV compliance, highlighting compliance issues and the necessity of community-based awareness campaigns that emphasize wound care and ARV schedule completion.

INTRODUCTION

Human rabies with severe neurological symptoms invariably results in death.[1] Globally, every year, 59,000 deaths occur due to dog-mediated rabies and the majority (59.6%) occur in Asia.[2] However, this burden in the developing world is an underestimate because of poor surveillance, underreporting, frequent misdiagnosis, and absence of intersectoral coordination.[3] India with 17,000 deaths every year[3] alone accounts for 59.9% and 35% of the total deaths in Asia and the world, respectively.[4] Despite this, in India, the disease is not notifiable and a structured surveillance system is yet to be put in place.[5] Development of rabies can be prevented to a large extent through prompt and appropriate management of animal bites. However, delays in seeking treatment, improper wound care, and unnoticed wounds result treatment failure and subsequent death.[4]

The primary objectives of the study were to (1) generate the epidemiological profile of animal bite cases and (2) assess the compliance and determinants of ARV at a Rural Health Training Center (RHTC) of a medical college in Gujarat.

METHODOLOGY

A prospective study was conducted at PHC Rancharda in District Gandhinagar, which is also the RHTC of a teaching institute. RHTC has a provision of management of animal bites. It operates during the OPD hours on all working days. As per the inclusion criteria, all incident new cases who gave written consent or ascent after briefing and explaining the purpose of the study during the study period were recruited. Updated Thai Red Cross (TRC) regimen (2-2-2-0-2) was followed, comprising 2 intradermal doses (0.1 ml) on each visit scheduled on 0, 3, 7, and 28 days. These cases were followed up for 60 days since the bite or for 30 days after they completed the vaccinations on the 4^th visit. Sample Size and Sampling Technique: The compliance rate for the ARV varied between 52.3%[5] and 77%.[6] So, taking an average, it was 64.7% (p). At 95% confidence interval and relative precision as 10% of p, the estimated sample size was 210. All consecutive incident cases reporting for the first time during the study period were included in the study sample till the statistically derived sample size was achieved. Data were gathered on a designed semistructured questionnaire along with a checklist. The questionnaire was prepared and validated by subject experts during the validation workshop. All the investigators were trained for administering this questionnaire which was suitably modified after pilot testing. It collected basic demographic information, details of animal bites, and their management. It also had a few open-ended questions. Also, there were questions along with a “question-to-question” guide for those who did not report for subsequent doses (2^nd to 4^th); they were approached through home/telephonic visits. Ethical Issues: The study was conducted after approval from the Institutional Ethics Committee (ECR/404/nst/Gj/2013/RR-20). Statistical issues and analysis: (i) Exposure variable (epidemiological determinants) and (ii) outcome variable (compliance of ARV) were studied, and tests of significance were applied. Data was entered in MS Excel sheet, and parameters such as percentages, odds ratio, and Chi-square test at 95% confidence interval were calculated.

Observations

A total of 224 animal bite cases reported at the ARV clinic during the study period. Except for 3 bites caused by mice, the rest 221 (98.7%) were dog bites. These cases were categorized into Category I (28), Category II (129), and Category III (67). ARV is indicated only in categories II and III (196) as a policy. Therefore, while generating the profile of dog bite cases, the denominator was 221, and for assessing the vaccination compliance, the denominator was 196.

Epidemiological Determinants: Agent factor – Out of 221 cases, most of the dogs (175 or 79.2%) were stray/wild, and only 25 (11.3%) were vaccinated; either the rest were not vaccinated or their vaccination status was unknown. Observation of biting animals for 10 days for “behavior change” revealed that in 101 (45.7%) cases, either the dog was killed/died or its fate was unknown. In case of 49 (22.2%) cases, the same dog was involved multiple times including 5 instances when more than 10 individuals were bitten by the same animal. The most common site of the bite was lower limb 159 (71.9%), followed by the upper limb (51 or 23.1%), buttocks (6 or 2.7%), and head, neck, and face (4 or 1.8%). Out of 221 cases, 173 or 78.3% had unprovoked bites, 116 (52.5%) had breached skin/mucosa, and 77 (34.8%) had bleeding including 52 (23.5%) deep bites and 47 with multiple bites including 2 bites in 35 and ≥3 bites in 12 cases [Table 1].

Table 1.

Epidemiological profile of dog bite cases (n=221)

Agent Factors	Number (%)
Type of dog
Pet	46 (20.8)
Stray/Wild	175 (79.2)
Vaccination status of dog
Vaccinated	25 (11.3)
Not vaccinated/not known	196 (88.7)
Dog status (post-bite 10 days)
Healthy	120 (54.3)
Killed or died	11 (5.0)
Not known	90 (40.7)
Other persons bitten by the same animal
Yes	49 (22.2)
No	47 (21.3)
Don’t Know	125 (56.5)
If Yes, Number of other persons bitten by the same animal (n=49)
1-2	16 (32.7)
3-5	22 (44.9)
>6	11 (22.4)
Type of bite
Provoked	48 (21.7)
Unprovoked	173 (78.3)
Nature of bite
Intact skin	28 (12.7)
Broken skin	116 (52.5)
Bleed	77 (34.8)
Extent of bite
Superficial	169 (76.5)
Deep (clear breech of skin/mucosa)	52 (23.5)
Site of Bite*
Lower Limb	159 (71.9)
Upper Limb	51 (23.1)
Buttocks	6 (2.7)
Head, Neck, and Face	4 (1.8)
Lower Backside	3 (1.4)
Others**	4 (1.8)
No. of bites wounds
1	174 (78.7)
2	35 (15.8)
≥3	12 (5.4)

*Multiple responses, **Include abdomen (2) and trunk and axilla (1 each)

Host factors: There were 82 cases (37.1%) <19 years with very few (8 or 3.6%) <5 years. The mean age was 26.8 ± 15.1 (range 1.5–80) years. There were more males, 167 (75.6%), than females. There were 50 (22.6%) cases who had been previously bitten, and 40 (80%) of them were vaccinated [Table 2]. The study was done in rural areas; hence, most cases (79.6%) belonged to rural areas; the rest were from peri-urban areas of Ahmedabad city.

Table 2.

Host factor as epidemiological determinants for dog bite cases (n=221)

Host Factors	Number (%)
Age (Years)
Child (<19)	82 (37.1)
Adult (≥19)	139 (62.9)
Mean±SD (Range)	26.8±15.1 (1.5-80)
Sex
Male	167 (75.6)
Female	54 (24.4)
Previous animal bite (n=50)
Vaccination Received	40 (80.0)
Not received/don’t know or remember	10 (20.0)
Wound Management at Home (application of) (n=221)*
Only Water wash	61 (27.6)
Soap & Water	23 (10.4)
Dettol	11 (5.0)
Medicated ointment	10 (4.5)
Turmeric	6 (2.7)
Chilli	15 (6.8)
Chhikani (tobacco snuff)	37 (16.7)
Bandage/tied cloth	9 (4.1)
Others**	11 (5.0)
Not done anything	90 (40.7)
Time interval (hours) between bite and its reporting (n=221)
< 6 hrs	85 (38.5)
6-24 hrs	90 (40.7)
>24 hrs	46 (20.8)
Type of health facility as the first point of contact (N=221)
Government	182 (82.4)
Private/Trust	39 (17.6)
Reason for choosing private/trust facility (n=39)
Government Facility closed (After OPD hours, public holiday)	14 (35.9)
Close to residence	23 (59.0)
Others (referred by private physician)	2 (5.1)

*Multiple responses, **Applied drug, burnt cotton, tea, soil, salt, oil, matchstick, dressing at the private clinic

Treatment-seeking behavior: Among cases, 90 (40.7%) post-bite did not do anything for wound management at home, while 61 (27.6%) washed their wound just with water, and 44 (19.9%) used either soap, Dettol, or medicated ointment. In nine cases, bandages were applied or wounds were wrapped with cloth. Some cultural practices with no proven efficacy observed were the use of turmeric (2.7%), powdered form of Tobacco (snuff) (16.7%), and Chilli powder (6.8%). Total 85 (38.5%) reported to health facilities within 6 hours, followed by 90 (40.7%) within a day; the rest reported after 1 day. The majority victims (82.4%) first approached government facilities, mainly this RHTC; the rest went to private/trust-run hospitals (17.6%) [Table 2]. All Category III bite cases as per the guidelines were referred to the Civil Hospital (13 KMs) due to the nonavailability of Rabies Immunoglobulin (RIG) or for surgical wound management. They all were given Tetanus Toxoid and 1^st dose of ARV and were followed up.

Environmental factors: Temporal and spatial profile: During the study period (8 months), there were 221 bite cases (27.6 cases/month); cases varied from 19 in August to 36 in October. Winter season (September to December) accounted for 133 (60.2%) cases; the remaining months (May to August) from summer and rainy seasons accounted for rest of the cases (39.8%). Maximum bites (42.5%) took place during the evening and early night hours (6 PM to Midnight), followed by 29.4% and 25.8% between 6 AM and 12 noon and between 12 noon and 6 pm, respectively, with very few bites (2.3%) during midnight to 6 AM, respectively [Figure 1]. This difference was statistically significant. Maximum bites occurred in public places (75.1%), followed by homes (20.8%) and other places such as workplaces or neighborhoods (4.1%). Accessibility to existing animal bite management facilities at the study center was also considered an environmental factor. The majority, 139 (62.9%), cases were residing within the 5 km range, followed by 66 (29.9%) within 5–10 km, and 16 cases (7.2%) came from >10 km. The primary source of information for visiting health centers was relatives (27.6%), followed by neighbors (26.2%), friends (20.4%), and health staff (10.9%). For 62 cases (27.6%), wound management was done at the facility which included cleaning in all, application of ointment, and suturing (1 each). In other 3 cases, dressing was done; 197 (89.1%) received the Tetanus Toxoid vaccine at the first visit, while the rest did not due to the stockout of the vaccine [Table 3].

Figure 1.

Temporal distribution of bite cases (N = 221). Chi square = 74.8, df = 3, P = <.01 (Highly Significant)

Table 3.

Environmental determinants among dog bite cases (n=221)

Accessibility to the health facility	Number (%)
Distance of PHC from residence (Km)
<5	139 (62.9)
5-10	66 (29.9)
>10	16 (7.2)
Wound management at the Health Center
Yes	62 (28.1)
Management at Health Center* (n=62)
Wound Wash/cleaning	62 (100)
Suturing	1 (1.6)
Application of ointment	1 (1.6)
Dressing	3 (4.8)
Antibiotics	5 (2.2)
Vaccination Tetanus Toxoid	197 (89.1)
Source of information*
Relatives	61 (27.6)
Neighbor	58 (26.2)
Friends	45 (20.4)
Self	30 (13.6)
Health staff	24 (10.9)
Others**	3 (1.4)

* Multiple Responses, ** Include Teacher, Farm Supervisor, Employer (1 each)

Follow-up for adverse events, determinants of ARV compliance, and reasons for poor compliance: Among 196 cases who received the first dose, 175 (89.3%) came for the second dose, 158 (80.6%) for the third dose, and 121 (61.7%) cases completed their schedule with full compliance. Among all cases, compliance was slightly better in category II than in category III bites, though the difference was statistically not significant (P=0.672) [Table 4]. While monitoring for adverse reactions following ARV, fever, pain, swelling redness at injection sites, and so on were observed in very few cases and they mostly occurred within 24 hours of vaccination. Signs/symptoms suggestive of rabies were not observed/reported in any case during the vaccination or the 60-day follow-up period. Epidemiological determinants, specifically sociodemographic ones like age, sex, education, socioeconomic class, poverty status, and distance from the health facility association, were found poorly associated (OR ± 95% CI included the value of 1); also, the differences were statistically not significant. However, compliance determinants showed significant associations with the occupation of the case (P = 0.02) and the vaccination status of the animal (P = 0.02) [Table 5]. Home visits were undertaken among cases to identify the reasons for noncompliance. Cases who either migrated or were nontraceable due to the wrong/incomplete address were telephonically contacted. Out of 75 cases who did not complete vaccination, 34 (45.3%) could not give any specific reason. The common reason mentioned was a perception “further doses not required” (22.7%), followed by “out of the station” (17.3%), “forgot to take” (14.7%), and “simply busy” (5.3%). Less common reasons seen in 1–2 cases were illness/death in family, advice from Tantrik, lost the case paper, misunderstood the schedule, family refused, pregnancy, and dog was pet healthy and vaccinated [Figure 2].

Table 4.

ARV compliance among cases of animal bites (n=196)

ARV doses	Cat II (n=129)	Cat III (n=67)	Total (196)
One	129	67	196 (100.0)
Two	115	60	175 (89.3)
Three	106	52	158 (80.6)
Partial Compliant	48 (37.2)	27 (40.3)	75 (38.3)
All four (Compliant)	81 (62.0)	40 (59.7)	121 (61.7)

Figures in parenthesis indicate percent values. Between compliant and partial compliant Chi-square=0.178, df=1, P=0.672 (NS)

Table 5.

Strength of association between epidemiological determinants and compliance of ARV

Determinants	ARV full compliance n=121	ARV partial compliance n=75	Odd’s Ratio and (95% CI)	χ2 Test, DF and P, Statistical interpretation
Gender (n=196)
Male	95	52	1.62 (0.84-3.11)	χ2=2.08, DF=1, P=0.15, NS
Female	26	23
Age (n=196)
Children (<19 years)	49	24	1.45 (0.79-2.65)	χ2=1.43, DF=1, P=0.23, NS
Adults ≥19 years	72	51
Education (n=174)
Illiterate	14	13	0.68 (0.30-1.56)	χ2=0.83, DF=1, P=0.36, NS
Literate	90	57
Occupation (n=138)
Unskilled/semiskilled	69	54	0.20 (0.04-0.88)	χ2=5.18, DF=1, P=0.02, SS
Skilled	13	2
Socioeconomic status (n=171)
Middle & Upper	99	55	2.5 (0.93-7.13)	χ2=2.57, DF=1, P=0.06, NS
Lower	7	10
Poverty status (n=154)
Above Poverty Line	58	26	1.88 (0.97-3.63)	χ2=3.54, DF=1, P=0.06, NS
Below Poverty Line	38	32
Comorbidity (n=196)
Yes	8	5	0.99 (0.31-3.15)	χ2=0.0002, DF=1, P=0.99, NS
No	113	70
Type of dog (n=196)
Pet	21	20	0.58 (0.29-1.16)	χ2=2.43, DF=1, P=0.12, NS
Wild/Stray	100	55
Vaccination status of dog (n=60)
Vaccinated	8	15	0.29 (0.10-0.86)	χ2=5.16, DF=1, P=0.02, S
Not vaccinated	24	13
Distance from facility (n=196)
≤10 Km	111	72	0.46 (0.12-1.74)	χ2=1.36, DF=1, P=0.24, NS
>10 km	10	3

NS=Not Significant, S=Significant, HS=Highly Significant

Figure 2.

Reason for missing ARV vaccine (After 1^st dose) (N = 75). * Multiple responses

DISCUSSION

This study generates an epidemiological profile of dog bite cases and finds out the epidemiological determinants of ARV compliance to identify the vulnerabilities for the dog bite cases and factors responsible for noncompliance/poor ARV compliance.

In India, the rabies outbreaks are invariably dog-mediated; the same was observed in the current study (98.7%), also in agreement with all other studies (91–96%)[7,8], occasionally being as low as 74%.[5] Sometimes due to the preponderance of dog bites, facility-based studies exclusively report only the dog bites.[9,10,11] India has more rabid dog bites and human rabies deaths than any other country due to the high proportion of stray dogs. In current study, the proportion of stray dog bites was almost 80% compared to >90% reported by others.[3,12] This epidemiology of dog-mediated rabies presents a typical picture, where very few dogs are vaccinated or tested for rabies.[13,14,15] It compares well with current study where only half of pet dogs were vaccinated. Nowadays, culture of having pet dogs is increasing not only in urbans but also in rural areas. At times, pet owners hold a wrong view that domestic animals are less exposed or risky than those roaming ones and do not need vaccination.[16] Therefore, primary care providers must educate bite cases to get the pets vaccinated (in addition to seeking timely aid and wound management).

A significant association (P < 0.001) has been reported between bite rates, air temperature, and humidity level resulting in two peaks, in June and August.[9] We observed a high proportion (45%) of cases between September and November 2023. Rainy season limits the interaction between dog and human and consequently reduces dog bite cases. We also found bites more during the evening and early night hours (6 PM to 12 midnight). A study from Pakistan[11] found common times of injury as late evening and early morning and attributed this to the poor visibility and ideal time for stray dogs on streets. Yet another study from Mumbai[10] reported most dog bites when the man–dog interaction was the highest. They found maximum bites between 4 PM and 12 midnight (49.6%) with a minimum between 12 midnight and 4:00 AM (4.8%) – a period with the least interaction between humans and dogs. They further found a significant association between age group and time of incidence wherein children had more bites during evening hours coinciding with their playtime and adults had more during the night when they were returning from their jobs.[10] Similar to the current study, bites were seen more in public places, followed by homes in most of the studies,[9] as these are the places of interaction.

The most common site of bite in current study was the lower limb (71.9%) due to the accessibility; however, in other studies from India[10,17] as well as from outside like Turkey[9] or Pakistan,[11] this proportion is around 50%. Most bite cases (58.3%) in the present study were in category II, followed by categories III and I. Other studies[5,17,18,19,20] also reported the same pattern. It may be because category I cases being mild are not brought to the health centers and category III owing to their serious nature (deep bleeding or multiple wounds) are directly taken to higher centers. The majority of the cases (75.6%) were males. A similar preponderance in the ratio of 3:1 has been reported by others,[5,10,21] with a simple explanation that males have more outdoor activity and mobility and hence have increased risk of exposure to bite.

No age is immune to the animal bite, and whosoever comes near to the animal is at risk. In the present study, it ranged between 1.5 and 80 years comparable with others.[5,18] The mean age of animal bite cases was 26.8 ± 15.1 years less than 29.3 years,[18] 32.9 years,[22] and 35.0 years[23] and 35.4 ± 11.4 years.[24] However, our findings are closer to 21.5 years[11] and 26.6 years.[9] Similarities and differences in this regard depend upon the inclusion criteria of the studies. The abovementioned risk factors were further compounded by the fact that 40.2% of cases did not do anything at home after the bite and 20.5% of cases reported after 24 hours. A study also from Gujarat has documented this delay in reporting by 68% of cases.[21] The WHO recommends immediate washing and flushing of wounds for at least 15 minutes with soap and water, or water alone and the application of antiseptics to destroy the outer coating of the rabies virus as essential after rabies virus exposure.[25,26] In the current study, only 27.6% of cases washed their wound just with water; it was even poorer (7.1%) in a study from rural parts from eastern India.[5] Further, in wound washing done at home, it cannot be relied on that the wound was washed for 15 minutes as in a study of 241 cases who washed their wounds, half of them did so by washing for <5 minutes.[27] This highlights a lack of awareness about the primary wound management among the masses. Treatment of dog bite victims in rabies-endemic countries like India needs to be initiated immediately since all animal bites are considered from suspected rabid animals.[26] Therefore, it is tragic if someone dies due to rabies when an effective vaccine is available free of cost in government facilities. However, some challenges in this regard are (1) the need to start vaccination from zero-day itself and (2) multiple visits for subsequent vaccinations. So, non-compliance for the rabies vaccine is a major issue.[6] It was observed in our study that 34.8% of cases had bleeding, 23.5% had deep bites, and 21.3% had multiple wounds (≥2), which emphasizes immediate appropriate bite management with full ARV compliance. Still, the compliance was only 61.7%. It was poor when compared with another study from Tamil Nadu (73.1%)[28] but higher than observed (47.9%) elsewhere.[3]

Delays in subsequent doses were attributed to various factors, such as being out of the station, facility closure, and other reasons more or less similar to those reported, which include the long distance of travel to the anti-rabies clinic, interference with school timings, negligence, forgotten dates, and interference with work timings.[11] Compliance determinants in our study showed significant associations with occupation and animal vaccination status. A study from Mumbai[10] also showed a significant association with occupations. For other variables like age, sex, education, and distance from the health facility, associations were poor and results were also statistically not significant. Rabies disproportionately affects poor rural communities, and most of the expenditure for post-exposure prophylaxis is borne by those who can least afford it. Poor people in the current study adjudged by social classification and BPL status reported more dog bite cases and poor ARV compliance. Here, odds ratios were more for those who were poor; however, the differences when tested statistically had P < .06. More dog bites from low socioeconomic areas reported may be due to the fact these communities have small houses, larger families, and lack of recreation facilities, especially for children; as a result, they play on streets and are prone to get exposure to stray dogs.[11] In our study too, odd’s ratios were more for those who were poor as judged by social classification or the below poverty line (BPL) status; however, the differences were statistically not significant. Most victims of animal bite cases (96.7%) visited government facilities in an institution-based study from New Delhi;[27] in the present study too, the preferred choice was this facility (82.4%); however, the rest went first to private/trust hospitals due to the inaccessibility (beyond OPD hours or public holiday).

Despite being broadly aware of rabies and the urgency of dog bite management, many cases in our study were using home-available remedies like chhikni (a tobacco product), turmeric, and chili powder over the wound (with no proven value) or were consulting the quacks or visiting the temple of goddess (HADKAI MATA). The most commonly used household remedy observed in another study[27] was chili paste in 35.6% of cases along with vaccination. It is indeed unfortunate in this era of technological advancements where knowledge is freely available over the Internet and other sources, people from different sections of the society are still resorting to different domiciliary practices with no proven benefit.

Given the importance of prompt reporting/categorization and wound management, including ARV administration, some system at PHCs is needed to treat them 24 × 7.

It is also to be noted that the elimination of canine rabies is essential for the control of human rabies and is epidemiologically and practically feasible through mass vaccination of domestic dogs. Domestic dog vaccination provides a cost-effective approach to the prevention and elimination of human rabies deaths.[29]

CONCLUSION

Except for 3, all cases were of dog bite and were largely unprovoked and by stray dogs. Up to 40% of them post-bite did not do any wound management at home. The study highlighted the need of ARV in 88.6% of cases including 30.3% also in need of immunoglobulin. Challenges in compliance (only 61.7% fully compliant) were observed. Among various epidemiological determinants, except for occupation of the case and the vaccination status of the animal, all showed poor association with ARV compliance.

Limitations of the study: This is an institution-based study, and findings are based on cases, who reported at the facility. Findings may not be valid for the residents of the catchment area of RHTC who either go to the alternate facilities or do not report to any facility.

Recommendations

1. Community-based awareness activities are required to protect from animal bites and saving their lives by seeking timely and proper healthcare services.

2. Local authorities should do mass dog vaccination (stray/pet) as well as sterilization to control the dog population.

3. Many patients misplace their case paper and are unaware of the need for further vaccination. Many cases are missed due to incorrect contact details or noncompliance with follow-up advice. These challenges emphasize the need for improved awareness and accessibility of ARV. A mechanism for prompt reporting/categorization and management of wounds including administration of ARV and follow-up of animal bite cases is needed to ensure the availability of immunoglobulins (crucial for management of category III wounds) at PHCs. It is imperative to provide emergency services (24x7) for animal bite management, even at PHC level.

Conflicts of interest

There are no conflicts of interest.

Funding Statement

State Health System Resource Centre (SHSRC), Gujarat.