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?