Rabies outreak still underway in Bali
Bali's rabies outbreak continues to claim lives, largely because of inadequate access to proper healthcare. The death toll from this outbreak, which has been ongoing for about two years, is officially 58, although the true count may be higher.
The latest case was a 57-year-old temple priest who was infected after trying to break up a fight between strays dogs and his puppy. He was bitten by a stray dog in the process, but did not receive any post-exposure rabies vaccination because of a vaccine shortage. Rabies is basically 100% preventable when proper care is provided after an exposure, but inadequate access to proper treatment remains a problem, particularly in certain areas and in less developed countries. The priest started to develop signs of rabies about two months after the bite, which is a pretty typical time frame. Once signs of rabies are present, it's almost invariably fatal, and he unfortunately succumbed to the disease shortly after being hospitalized.
Despite ongoing efforts to control this outbreak, rabies remains a serious problem in Bali, and many stray dogs remain unvaccinated. Inadequate education of the public is a problem since not everyone who is bitten goes to a doctor, especially for minor bites. However, even if people go to a doctor, the shortage of rabies vaccine is a huge problem. This whole situation is clearly not under control.
Visitors to Bali need to be aware of this ongoing outbreak. If you are traveling to Bali:
- Avoid contact with stray dogs. You never know who's rabid.
- If you are bitten, promptly clean the wound and get to a physician.
- If you are bitten by a stray, make sure you get post-exposure treatment: a shot of anti-rabies-antibody and 4 (previously 5) rounds of vaccine over a few weeks. If you can't get the treatment started in Bali, get it as soon as possible. Rabies exposure is not an emergency, but you don't want to unnecessarily delay treatment. You don't need to be immediately evacuated from the country to a place you can be treated, but at the same time, you don't want to take your time, travel for a while, then get vaccinated a week or two later. You'd probably be fine, but rabies is not something with which to take chances. The incubation period is variable and the rapidity of onset depends in part on the severity and location of the bite. In particular, a severe bite to the head or neck region would be an indication for very prompt treatment. So, if you're bitten, don't panic, but try to get back home and get treated as soon as is reasonably possible.
Rabies vaccination of people planning on visiting Bali is not recommended, unless you are planning on having contact with dogs. If you are going to Bali to take part in stray dog vaccination, then rabies vaccination would absolutely be indicated. Otherwise, it's not really something that's needed. If you don't get bitten, you won't get exposed, and a little common sense goes a long way toward avoiding dog bites.
Bali rabies vaccination plan
A rabies epidemic has been underway in Bali for some time. There have been 25 deaths, with 2 occurring in the past 2 weeks. There are several reasons for this ongoing problem: large numbers of dogs (especially feral dogs) with limited vaccination, rabies circulating in the feral dog population, inadequate post-exposure treatment of people, and poor education of the public regarding the risks of rabies and how to properly address dog bites.
An encouraging sign is the institution of a mass rabies vaccination program for dogs. Unfortunately it won't start until February, which is disappointing because some people may get infected and die in the interim, but there are likely considerable logistical challenges to overcome, making some delay unavoidable.
The goal of this program is vaccination of 70% of all dogs in each affected regency. According to the recommendations of the World Health Organization (WHO), 70% is the proportion of the canine population that needs to be vaccinated in order to have a chance of eradicating of canine rabies from a given area. It's a challenging goal given the number of feral dogs and the limited resources available in Bali, but it's critical to vaccinate as many dogs as possible. It is estimated that there are approximately 500 000 dogs on the island. Approximately 137 000 dogs have already been vaccinated and another 39 000 have been culled (destroyed). Vaccination will not be performed in two regions because rabies cases have not been identified there. (Hopefully they have good enough surveillance to be very sure that rabies truly isn't in the dogs in those areas. It's a bit of a gamble otherwise.)
One thing that has not been specified is how they intend to handle vaccination of feral dogs. It's not clear whether the numbers mentioned here include feral dogs and whether efforts are being directed at pet dogs only or both pets and feral dogs. Poor compliance with booster vaccinations was cited as a concern, implying this was only focused on pets. Achieving 70% vaccination of the pet population is an important step, but if there is still uncontrolled circulation of rabies in the large pool of feral dogs, eradication will not be possible. Hopefully, trap-vaccinate-and-release programs or oral rabies bating will be used to address the feral dogs.
Image: Mt. Agung, southern Bali
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?
Rabies on vacation: Pack some common sense
A few years ago, a tour agent in a Caribbean country tried to convince me that taking my young children in an open-sided vehicle on a drive over the country's highways was perfectly safe. My response was that the laws of physics don't go on vacation when I do - meaning that a car accident with unrestrained children is a bad thing even on a nice sunny island. The same concept goes for infectious diseases: when on vacation, you should try to leave your worries behind, but not your common sense. Travel-acquired diseases are extremely common. Transient, annoying, but usually self-limiting problems like food poisoning affect thousands of people on vacation, but more serious diseases can also be encountered.
A recent rabies outbreak in dogs in Bali highlights some of these concerns. Rabies is common in stray/feral dogs in many countries, and there can be huge dog populations in some common tourist areas. It's human nature for many people to want to feed or pet these strays. However, people often forget about the potential for rabies exposure. An additional concern is that proper post-exposure treatment for rabies may not be readily accessible in many countries. Some countries are mounting aggressive vaccination programs of strays in response to the risk to local inhabitants and tourists, but people need to be aware that the risk exists and can be very significant. It has been reported that 23 people from Britain have died of rabies acquired abroad since 1946. That's not a huge number, but it's not good if you are one of those 23, and such tragedies are preventable.
Remember these simple points when you are on vacation:
- Stay away from strays (dogs or cats).
- Report dogs that are acting strangely to local authorities or someone else that might be able to help (such as a hotel concierge).
- If you are bitten, take it seriously. If you cannot identify the dog, confirm its rabies vaccination status and ensure that it is properly quarantined, you should probably be considered exposed to rabies. If that is the case, get post-exposure treatment as soon as possible.
- If you are going to have contact with stray dogs or wild mammals during your vacation, such as volunteering with animal care groups, get vaccinated against rabies before you go.
- Always remember to pack some common sense.
