Bali rabies situation not improving
A rabies epidemic continues in Bali, with little apparent control and inadequate access to vaccination. Another person died of rabies last week. He was bitten by a dog in July and taken to a local health centre, but rabies vaccine was not administered. It's not clear whether healthcare providers recommended post-exposure vaccination and the person declined or whether they did not offer vaccination.
Access to post-exposure treatment in such regions is a serous concern. Apparently, up to 50 people a day are denied potentially life-saving post-exposure treatment because of a lack of adequate vaccine supplies. Because of the limited availability, doctors are focusing on treatment of people bitten by dogs in areas that are heavily infected with rabies. That makes complete sense, but it's still not a good situation. It's not only those heavily infected areas that are a concern. More rabies vaccine needs to be secured so that everyone who has been potentially exposed can be properly treated. Local officials are blaming the current shortage on a holiday weekend, but it's unclear whether the situation is truly going to improve in the near future.
People traveling to any part of Bali need to be aware of the risks. You don't need to cancel your vacation, just use common sense. Don't approach any dogs or other mammalian pets or wildlife. If you are bitten, immediately go a physician. If rabies vaccination is not offered, ask for it. If it's not given, get on the next plane out of the country and get treated. You don't need to be vaccinated immediately after exposure, so don't panic, but you don't want to unnecessarily increase the risks if you have been bitten.
Rabies in Bali... Still
In April, I wrote about an ongoing rabies outbreak in the popular tourist destination of Bali. Because of widespread rabies in stray dogs and fatal human infections, there were calls for the government to take aggressive action and for tourists to be aware of the risk. Apparently, things haven't improved much since then.
At least 9 people have died of rabies in Bali in slightly over a year. That's completely unacceptable for a preventable disease.
The latest victim (whose father-in-law died of rabies in August) was from an area that has not been officially declared as being part of the epidemic, so it has not received much government support. She was bitten by a stray dog in August. In any rabies-endemic area (even in the absence of an outbreak), that's clearly an indication for post-exposure treatment. However, she did not receive post-exposure treatment until 15 days after the bite, by which point it was obviously ineffective.
- Rabies post-exposure treatment must be started as soon as possible. If you wait until signs of rabies are present, death is almost certain.
- Be informed and be your own advocate. The family in this case may very well have pushed for post-exposure treatment, but it's critical to look out for yourself. If you have potentially been exposed to rabies, make sure you get treated.
- If you are going to Bali, don't be paranoid about rabies. Be smart. Avoid any contact with dogs (especially strays) and other wildlife. If you are bitten, get medical care immediately. If the animal isn't identified and quarantined for 10 days to make sure it doesn't have signs of rabies, you need post-exposure treatment. If you can't get it in Bali, get out and get to somewhere where you can be properly treated.
- If you are traveling to Bali (or any other rabies-endemic area) with the intention of working with wild or stray animals (especially dogs), get vaccinated before you go.
- More aggressive rabies control and education (including physician education) efforts are needed in Bali. Clearly, this outbreak is not under control and the fact that the latest death occurred in a new region suggests that this problem could be spreading.
More information about rabies can be found on the Worms & Germs Resources page.
Fatal needle phobia: Rabies in Bali
ProMed mail reports two more rabies fatalities in an ongoing outbreak in Bali, Indonesia. The first person was bitten by a stray dog, which always must be considered a potential rabies exposure, especially in an area where an outbreak is underway. He received one rabies shot but did not undergo the whole post-exposure series because of a fear of needles, and he died.
The second person was bitten by both a stray and a pet dog, another clear indication for post-exposure treatment. She refused treatment because of a fear of needles, and also died of rabies.
These were two completely preventable deaths. The decision to forgo treatment almost certainly cost these people their lives - rabies is preventable with appropriate and timely post-exposure treatment. These cases also highlight the need for proper education of the public when it comes to rabies, both in terms of avoiding strays and the need for prompt attention when there's potential exposure to the disease. I have no idea how forcefully medical or public health personnel explained the need for proper treatment. For people that want to decline treatment, aggressive and comprehensive education is needed. Ultimately, people are allowed to make bad decisions, but we need to make sure they at least make informed bad decisions.
There are various other concerning issues with this outbreak, particularly the government's response to it. Multiple sources have apparently advised the government that aggressive vaccination and halting of dog movement between the peninsula and the mainland could contain this outbreak. So far, this has not been done. Amazingly, importing rabies vaccine into Bali was illegal until December 2008, and it is still illegal to vaccinate dogs outside of the outbreak area! The cost of vaccination has been used as an excuse not to do so. Certainly, financial issues are important in developing countries. However, the estimated cost is only about $0.50 US per dog. When one considers that this area is highly dependent on the tourist industry, they need to consider this as an investment to maintain their economy. Would you like to spend your vacation in an area with an ongoing rabies outbreak?
