What You Need To Know About The Rabies Epidemic In Bali
Seven top international rabies experts took part in a three-day workshop at Udyana University in late January, and agreed that the 14 month long rabies epidemic in Bali could have been quickly contained using World Health Organization (WHO) vaccination protocols. The inauguration of a new Head of Animal Husbandry and the news of yet more support from AusAid presents a welcome opportunity for a renewed approach to rabies control in Bali.
Since the November 2008 outbreak of rabies in Bali, at least 30 people have died of the disease. From a small outbreak in Ulu Watu which should have been easily contained had international protocols been observed, the virus is now present in 7 of Bali’s 9 regencies. All dog bites should be considered medical emergencies.
Rabies is a serious problem in the developing world, with 98% of all cases occurring in Asia and Africa. Rabies kills 55,000 people a year, about half of them being children under the age of 15. In my December 2008 story about rabies, I assumed that the situation would be quickly contained. Since then, rabies has been surging out of control across Bali. Media reportage has been inadequate and sometimes inaccurate. Here are some things you need to know.
DOG BITES
If you’re bitten by a rabid dog and do not immediately clean the bite wound properly and follow up quickly with a complete series of post-exposure rabies vaccinations, you are at high risk for contracting rabies. Rabies is a very unpleasant way to go, so please read carefully and share this information with your staff and other employees.
The rabies virus is carried in the saliva and when a person is bitten or licked over an open wound, spreads via the central nervous system to the brain. Bites to the head and extremities are particularly dangerous because of the many nerve endings and closer proximity to the brain. Bites to the face, head and neck result in 30-60% chance of contracting rabies, bites to the hand 15 – 40% and bites to the leg less than 10%. Symptoms may not appear for a year or more. Once symptoms do appear, death is inevitable.
Cleaning the wound immediately -- right then and there, not waiting until you get home or to a clinic -- is very important in preventing the virus from entering the body and reaching the central nervous system. Wash the wound for at least 10 full minutes with running water and detergent. (Detergent breaks down the wall of the virus.) If you’re doing this for someone else and have a cut on your hands, protect yourself from contamination with gloves or plastic bags over your hands. Then apply iodine or alcohol to the wound and get yourself to Sanglah Hospital pronto. The contact person for the Rabies Team at Sanglah hospital is Dr. Ken Wirasandhi at 081 2395 8111. Pray that they have VARS rabies vaccine (known at PEP internationally) and immunoglobulin (SAR) when you need it; often they don’t. These bites should not be stitched.
POST-EXPOSURE RABIES VACCINATION
Until a few weeks ago, this was not being done properly and heaven knows how many people were being sent home with inadequate treatment. Vaccination should ideally begin on the day of the bite. The day of the first vaccination called Day Zero. If the bite is a deep puncture wound or above the waist, Rabies Immunoglobulin should be injected into the wound as quickly as possible. Soon afterwards, also on Day Zero, the first two VARS injections are given and again on Days 7 and 21. If the dog is still alive 10 days after the bite, it is deemed rabies-free and the final vaccination is not necessary. There are different categories of bites/potential exposure, and SAR may not always be necessary.
Rabies immunoglobulin is an essential part of the treatment if the bite is above the waist as the bite location is closer to the brain. Because it takes the rabies vaccine about a week to start fighting the virus, it’s important to get the immunoglobulin at the wound site to start attacking the virus quickly. Unfortunately, many people were not given this shot because it costs a steep Rp 6,000,000 or more depending on body weight, or was simply unavailable. A lot of people were just given one VARS shot and sent home. This happened to my staff’s son who was unfortunate enough to be bitten during the Idul Fitri holiday when no rabies vaccine was available on Bali for several days. Putu was given a single dose on Day 5 –- useless. Thank heaven, the dog that bit him is still alive.
At time of writing on February 3 there was no rabies vaccine at any public hospital in Bali. The same day, the Jakarta Post reported that a course of rabies vaccine and emergency treatment at public hospitals will cost at least Rp 500,000 from now on. The government is planning to set up several animal bite centers in strategically located hospitals that will follow WHO post-exposure rabies prophylaxis guidelines. I will report on this when I have more information.
VACCINATION OF DOGS
World Heath Organization studies show that if 70% of dogs are vaccinated against rabies, the epidemic will quickly die out. If you haven’t already done so, have your dog vaccinated against rabies and make sure you get a collar or tag so it can be quickly recognized as a vaccinated pet. Try to keep your dog in your yard. Pet cats and monkeys should also be vaccinated, although 98% of rabies cases are transmitted by dogs.
Both the Dinas Perternakan (DP) and the Bali Animal Welfare Association (BAWA) are vaccinating owned dogs banjar by banjar. BAWA also vaccinates street dogs. Dogs vaccinated by BAWA wear an orange collar and may be marked with paint; DP-vaccinated dogs may wear a red collar or not be marked at all. Vaccinated dogs frequently lose their collars, so it’s not always possible to tell. Private vets will also vaccinate your dog and give you a metal tag to attach to its collar.
Until recently, the DP was using a very temperature-sensitive Indonesian vaccine. The 170,000 dogs that have been vaccinated to date will no longer have immunity, as the vaccine was low quality nerve tissue vaccine that lasts only 3 months. Most vaccines must be kept constantly at a stable cold temperature until used. With the many power cuts in Bali over the last few months, the efficiency of this vaccine is almost certainly compromised and it was not a powerful vaccine to start with. The vaccine of choice is called Rabisin. It is manufactured in France, is much more temperature-stable and provides protection for up to three years.
Forty thousand doses of Rabisin have been donated to BAWA by the World Society for the Protection of Animals (WSPA) for use in Gianyar Regency. Four BAWA teams, each including a vet, three catchers and a recorder, aim to vaccinate 70% of the dogs in each banjar. They have vaccinated over 6,000 dogs in the past five weeks to the time of writing. Staff is being increased to reach a target of vaccinating 48,000 dogs in the next four months. Dogs are often difficult and time-consuming to catch, but one BAWA team can vaccinate 84 dogs a day. Vaccination costs just over two dollars per dog including salaries, transport, vaccine and equipment.
Rabid dogs can carry the virus for six months (rarely up to a year) without being contagious. When the virus reaches the brain it becomes present in the animal’s saliva and the first symptoms begin to appear. The animal will die of the disease a maximum of ten days after the first symptoms. About 40% of affected dogs will display symptoms of ‘dumb rabies’ by becoming very quiet and seeking dark, quiet places. The other 60% will show signs of ‘furious rabies’ -– frothing at the mouth and aggressively attacking anything that moves (unprovoked bites). If you notice your dog’s personality has changed, this could be a sign of rabies. A usually friendly dog may become aggressive and vice versa. Dogs may appear unsteady on their feet or stare blankly into space.
RABIES MANAGEMENT
The Bali Animal Welfare Association and Udayana University invited a group of seven international rabies experts to Bali recently for a three-day workshop on rabies. The workshop featured Dr. Henry Wilde, who develops the protocols for the World Health Organization (WHO); Dr Francois Meslin, Director of Zoonosis, Neglected Diseases, WHO Geneva; Dr. Darryn Knoble, who has a doctorate in rabies management; a team of rabies experts from Chulalongkorn University in Bangkok and the Thai Red Cross Institute. (For full details of the delegates and their findings please email bawabali@aol.com) The workshop was attended by the health minister from Jakarta, representatives from the FAO and the pharmaceutical companies, the head of the Rabies Team from Sanglah Hospital, Dr. Putu Sumantra, the new Head of Animal Husbandry, and several doctors, scientists and veterinarians. The workshop –- literally a Master Class on rabies -- was organized by BAWA and the delegates’ air tickets and accommodation were sponsored by the Southeast Asian office of the Act Now Children’s Fund.
Dr. Francois Meslin of the WHO said, “Dog culling has never had a significant impact on rabies reduction or dog population density anywhere in the world. Only vaccination of at least 70% of the dogs will eradicate rabies.”
The workshop also featured Dr. Henry Wilde, a world-renowned vaccine and rabies expert, who stated, “There is only one answer to this and that is island-wide sustainable dog vaccination using a potent imported canine tissue culture vaccine. Funds that are now being used or planned to be used for non-productive exercises such as how best to kill dogs, with what dose of strychnine and the use of radio-collars for movement studies of Bali dogs is a waste of time, man-power and scarce funds. These funds should be immediately allocated to post-exposure treatment of bitten humans. Free post-exposure treatment must be your first priority and must be started immediately. Every day that you wait will result in additional unnecessary human deaths.”
To report a possibly rabid dog, call BAWA at 081 138 9004.
LAST ISSUE’S GREENSPEAK – Apologies to the Eco-Laundry in Nyuh Kuning, I forgot to include its contact details tel 9119696 or 085 2385 55317
Dragons in the Bath, a collection of Ibu Kat’s stories, is available in Bali from Dijon in Kuta, Ganesha Books at Biku in Seminyak and Ganesaha Books and selected shops in Ubud. It can be ordered nationally and internationally through www.dragonsinthebath.com <http://www.dragonsinthebath.com>
