Not vaccinating beyond rabies hot zone leads to more human rabies deaths on Bali

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From ANIMAL PEOPLE, September 2009:

 

 

 

Not vaccinating beyond rabies hot zone leads to

more human rabies deaths on Bali

 

TABANAN, Bali--The rabies situation on

Bali " remains dire, " assessed International

Society for Infectious Diseases ProMed forum

moderator Craig Pringle on September 15, 2009.

" Little progress appears to have been

achieved in containing the outbreak, " agreed

fellow ProMed moderator Tam Garland on September

18.

The most recent human victim, Ni Ketut

Sari, 47, died on September 14. " She got bit

by her own dog, " who " was suddenly destroying

her kitchen " on July 20, reported the Bali Post.

" She was rushed to the health clinic in Kediri

and got a tetanus shot, " but was not given

post-exposure rabies vaccination--apparently

because her home in Tabanan was outside the

radius of officially acknowledged rabies cases.

" According to her husband Ketut Sunarta, "

the Bali Post said, " a few weeks after being

bitten she was scared of water and wind, but was

always thirsty and shivered. "

On September 12, the Bali Post

continued, she " experienced drastic sweating

around her head, chest pains, and had difficulty

to breath. She was then taken to Tabanan

Hospital, " and received " two types of

medications, " but " was told to rest at home. "

Only on September 13, 24 hours before Sari died,

was her condition recognized as rabies.

Because Bali is a hub of tourism,

including by yachters who carry dogs aboard,

rabies experts are increasingly concerned that

Bali may become the point from which canine

rabies jumps to Australia and other Southeast

Asian islands which are now free of rabies.

Boat traffic is believed to have brought

a rabid dog to Bali from Java at some point in

early to mid-2008.

Human rabies deaths in Tabanan in July,

August, and early September 2009 demonstrated

that the Bali outbreak has now spread from the

Bukit peninsula, at the far south of the island,

to possibly the whole of Bali. Beween the Bukit

peninsula and Tabanan is Denpasar, the Bali

capital city.

" Bali is divided into eight regencies and

one city, Denpasar. Three of these-- Badung,

Denpasar, and now Tabanan--must be considered

confirmed or probable rabies epidemic areas, "

warned Garland.

The " confirmed or probable " area now

covers the whole of the most densely populated

part of Bali.

The first known bite of a human by a

rabid dog came on September 6, 2008. That bite

and others leading to eight human fatalities

through March 2009 were all on the Bukit

peninsula. As the Bukit peninsula is almost

entirely cut off from the rest of Bali by the

Denpasar airport and access roads, a vigorous

vaccination program combined with halting all

transport of dogs from the peninsula could have

stopped the outbreak right there.

Instead, ineffective efforts were made

to massacre dogs in the afflicted areas before

any vaccination was done. The Bali government

enforced a policy in effect since 1926--since

Indonesia was under Dutch rule --against allowing

any dogs to be vaccinated outside of areas where

rabies was already officially recognized to

exist. Private dogcatchers continued to trap and

transport dogs from the Bukit peninsula and

nearby parts of Bali to dog meat restaurants on

the north coast.

The official response to the Tabanan deaths was little different.

" Officials have killed 320 stray dogs

and have ordered owned dogs to be chained inside

houses and to be vaccinated, " Bali animal

husbandry department chief Ida Bagus Alit told

the Bali Post on September 14, 2009. " At the

moment, " Alit said, " they have vaccinated 5,700

dogs from 10,000 available anti-rabies vaccines,

which are provided for Tabanan only. Nyoman

Sutedja, the head of the Bali health department,

has been in correspondence with the central

government to request more vaccines.

" In regards to closing the borders in

different regencies, " to curtail the possible

movement of infected dogs by meat traffickers,

Sutedja " strongly suggests to all head villagers

that that they should monitor animal transport

and have ports quarantine any incoming animals

from Java, " Alit summarized. " Local governments

with Animal Husbandry are accelerating mass

elimination of all stray dogs and stranded dogs, "

Alit said. " A stranded dog, " he defined, " is

an owned dog who is left wander around outside

with no food or care. There are many of these

dogs in Bali. "

The extermination campaign continued to

rely on distributing poisoned meat. The same

edition of the Bali Post that reported Alit's

remarks mentioned that a 44-year-old man " was

taken to hospital this week after eating a spicy

Balinese-style pork sausage that had been covered

in poison to kill dogs. The victim was found

unconscious at his home in Banjar Dukuh,

Penebei. "

Exactly what poison was used was unclear.

Bali officials have repeatedly claimed to be

using strychnine, after rejecting the use of

injectible substances that would require workers

to have direct contact with dogs, but three

ProMed experts including cofounder Jack Woodall

agreed that the victim probably would not have

survived ingesting strychnine.

The spread of rabies on Bali both refuted

the most optimistic claims and underscored the

fears expressed in two papers presented at the

May 2009 Australian Veterinary Conference by

Helen Scott-Orr, director of an Australian

Centre for International Agricul-tural Research

aid project in Bali. Scott-Orr has advised the

Bali rabies control program, and arranged for it

to receive $100,000 in Australian aid funding,

she told Sarina Locke of the Australian

Broadcasting Corporation.

" About 42,000 dogs [were] vaccinated and

2,000 strays eliminated in the target area near

confirmed outbreaks by May 2009, " Scott-Orr and

Indonesian colleagues reported. " An intensive

program of rabies post-exposure prophylaxis of

people bitten by dogs was instituted, " which

" has so far prevented further human deaths, "

Scott-Orr stated before the most recent deaths

occurred, " but may be masking further spread of

the virus in dogs. Massive effort only achieved

an approximate 40% vaccination coverage of the

estimated total dog population in the target

area. This is well below the minimum 70% needed

to break the rabies virus transmission cycle. "

Counting dogs

Scott-Orr and colleagues guesstimated

that the present Bali dog population is about

700,000, more than twice the ANIMAL PEOPLE

estimate projected from local counts in various

parts of the island, done in September 2008.

Scott-Orr et al noted that the Bali dog

population was estimated at 220,000 by the World

Health Organization in 1984, but was said to be

875,000 by a local source; was said to be

125,000 by another local source in 1992, but was

projected to be 540,000 ten years later by the

Yudisthira Foundation; and was estimated at

425,000 by the Badung Livestock Service in early

2009.

Similar discrepancies have plagued the

rabies control program in Flores, the focus of

the other Scott-Orr paper presented to the

Australian Veterinary Conference.

" Rabies entered Flores in 1997 and

gradually spread east to the adjacent island of

Lembata and west throughout Flores island. It is

now endemic, with approximately 1,000

post-exposure prophylactic treatments and some

human deaths each year, " reported Scott-Orr and

colleagues. " A strategy of mass dog vaccination

with effective oral and injectible vaccines is

being developedŠThis mass vaccination would aim

to achieve at least 80% coverage of the dog

population across Flores and Lembata within a

period of one month. It would be repeatedly

annually for one or more years depending on

disease and population modeling, as well as the

results of intensive surveillance of subsequent

rabies incidence in humans and dogs, and of

vaccination coverage and immune response in the

dog population. "

Dogs " are eaten as a major source of

animal protein and are required for particular

ceremonies in different parts of the island, "

Scott-Orr et al wrote. " This leads to a lot of

dog trading between districts and the import of

dogs from other islandsŠDogs are also highly

valued as guards, " around houses and villages,

and " also to guard crops on steep mountainsides

from wild pigs and monkeys. As well, they are

used for hunting wild deer and pigs, and are

considered essential companions for fishers

undertaking long trips in small boats. "

Due largely to cultural resistance,

Scott-Orr et al concluded, " Rabies will not be

eradicated from Flores and Lembata in the

foreseeable future using the current tools of

injectible killed vaccines and dog elimination. "

Australian veterinarian Stephen Cutter in

an influential 2003 paper entitled Rabies & Dog

Ecology in Flores estimated that the Flores dog

population was about 600,000, or two dogs for

every human resident, when rabies arrived. This

would have been more than twice the ratio of dogs

to humans found in the U.S. and Costa Rica,

which have the highest documented ratios of dogs

to humans of any nations, and would have been

more than four times the highest ratio ever found

in Asia.

The Cutter number was derived from

interviewing residents about the numbers of dogs

kept by their households, rather than by

actually counting dogs.

Government officials during the first

four years of the rabies outbreak reported

killing 295,569 dogs. The Flores dog population

by 2002 was officially down to 127,482, rose to

169,035 in 2003, soared to 250,372 in 2005, and

was 203,478 in 2007. Throughout this time the

dogs to humans ratio has remained close to 1/12.

Taking into account the effects of the

four-year dog purge, the carrying capacity

implied by the post-2002 data, and the

reproduction rate of dogs, ANIMAL PEOPLE

projects that the actual Flores dog population in

1997 was probably 125,000 to 150,000, was not

more than 200,000, and was probably down to

about 57,000 in 2000, when the dog purge was at

peak intensity.

Using the Cutter estimate of the dog

population when rabies arrived has allowed

Indonesian officials to claim that killing dogs

had an effect in reducing rabies which could be

accurately attributed only to subsequent

vaccination efforts. The success of the

vaccination campaign, in contrast to the earlier

emphasis on killing dogs, was detailed in The

Rabies Epidemic on Flores Island, Indonesia,

2001-2003, by Caecelia Windiyaningsih, Henry

Wilde, Francois Meslin, et al.

--Merritt Clifton

 

--

Merritt Clifton

Editor, ANIMAL PEOPLE

P.O. Box 960

Clinton, WA 98236

 

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