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Re: [aapn] (ID) Has rabies been eradicated in Bali?

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  • Lisa Warden
    With respect to the eradication of rabies in Bali, the Jakarta Post report from March 28, 2013
    Message 1 of 2 , Apr 2, 2013
      With respect to the eradication of rabies in Bali, the Jakarta Post report
      from March 28, 2013 (http://www.thejakartapost.com/bali-daily/2013-03-28/bali-will-soon-be-rabies-free-official.html)
      is misleading. Bali is unlikley ever to be rabies-free as long as dog
      culling continues as the standard response to suspected rabies cases.

      While the government is to be commended for continuing to stock human
      rabies vaccines and for their diligence in persevering with dog vaccination
      programs, it is necessary to point out the futility of then poisoning the
      very dogs that have just been vaccinated. Daily reports of dog poisoning in
      Bali continue to come in. In the case of a rabid dog north of Ubud only
      four weeks ago, for example, government workers went in and killed all the
      dogs in the area, including a dog that was a family pet confined to the
      family's yard, and that had been vaccinated twice previously. All dogs,
      vaccinated or not, were poisoned. The government had 100 kilos of
      strychnine in their budget. They continue to use the poison on a regular
      basis. Strychnine capsules can be purchased for the equivalent of US 50
      cents each (it takes two capsules to kill an adult Bali dog.) Poisoning of
      dogs by authorities and the public continues with monotonous regularity in
      Bali. The Jakarta Post report neglects to mention that in order for the
      mass vaccination drive to be successful, authorities in Bali must refrain
      from poisoning dogs that have already been vaccinated if they wish to
      maintain herd immunity. The only way to end a rabies epidemic is to
      vaccinate over 70% of the population, and then to refrain from killing the
      vaccinated dogs.

      For a somewhat more accurate picture on the situation in Bali, see *Response
      to a Rabies Epidemic, Bali, Indonesia, 2008-2011* in the April 2013 issue
      of *Emerging Infectious Diseases* (http://wwwnc.cdc.gov/eid/article/19/4/12-0380_article.htm), immediately

      Lisa Warden
      Director, DOGSTOP
      Jakarta, Indonesia

      *Response to a Rabies Epidemic, Bali, Indonesia, 2008-2011*

      Anak Agung Gde Putra[image: Comments to
      Katie Hampson, Janice Girardi, Elly Hiby, Darryn Knobel, Wayan Mardiana,
      Sunny Townsend, and Helen Scott-Orr
      Author affiliations: Disease Investigation Center, Denpasar, Bali,
      Indonesia (A.A.G. Putra); College of Medical, Veterinary and Life Sciences,
      University of Glasgow, Glasgow, United Kingdom (K. Hampson, S. Townsend); Bali
      Animal Welfare Association, Ubud, Bali (J. Girardi); World Society for the
      Protection of Animals, London, United Kingdom (E. Hiby); Faculty of
      Veterinary Science, University of Pretoria, Onderstepoort, South Africa (D.
      Knobel);Bali Province Livestock Services, Denpasar, Bali (I.W.
      of Veterinary Science, University of Sydney, Camden New South Wales,
      Australia (H. Scott-Orr)

      Emergency vaccinations and culling failed to contain an outbreak of rabies
      in Bali, Indonesia, during 2008–2009. Subsequent island-wide mass
      vaccination (reaching 70% coverage, >200,000 dogs) led to substantial
      declines in rabies incidence and spread. However, the incidence of dog
      bites remains high, and repeat campaigns are necessary to eliminate rabies
      in Bali.

      Rabies was first reported in Indonesia in 1884 and now occurs in 24 of the
      country’s 33 provinces
      –*3* <http://wwwnc.cdc.gov/eid/article/19/4/12-0380_article.htm#r3>). On
      Bali Island, the first cases of rabies in humans and dogs were confirmed in
      2008 on Bukit Peninsula
      Despite control efforts in 2008–2009, rabies spread across the island. In
      the following 3 years, >130 persons died from rabies (primarily persons who
      did not receive postexposure prophylaxis [PEP])
      and PEP was given to >130,000 persons with dog bites. This outbreak
      resulted in considerable fear and anxiety and cost >US $17 million. We
      report on the outbreak progression and the effect of initial and
      subsequently improved control measures.

      *The Study*

      When the 2008 Bali rabies outbreak began, the island had no policies for
      rabies PEP and no dog bite surveillance, rabies diagnostic facilities, or
      vaccines for dogs. In response to the outbreak, the Indonesian government
      provided Bali with postexposure rabies vaccine for humans (Verorab), for
      intramuscular administration according to World Health Organization
      guidelines, and vaccines for dogs
      The Australian government helped establish a direct fluorescent antibody
      (DFA) test at the Disease Investigation Center, Denpasar, Bali, and
      provided supplies for emergency dog vaccination. Surveillance was
      implemented by DFA testing of brain specimens from dogs that died or were
      killed after showing signs of rabies and from culled dogs. This
      surveillance, although imperfect, proved critical in tracking rabies spread
      (Figure <http://wwwnc.cdc.gov/eid/article/19/4/12-0380_article.htm#tnF1>).

      In Bali, the first 2 regencies (administrative divisions below provincial
      governments) affected by the rabies outbreak were Denpasar and Badung. In
      December 2008, the Balinese government began culling (using
      strychnine-laced baits or blow darts) unconfined dogs in areas of Denpasar
      and Badung with confirmed rabies cases and began vaccinating dogs at fixed
      posts. The locally manufactured vaccine required a booster after 3 months.
      It was estimated from a survey in Badung, where the human:dog ratio was
      8.3:1 (*5* <http://wwwnc.cdc.gov/eid/article/19/4/12-0380_article.htm#r5>),
      that 40% of dogs in Badung and Denpasar were vaccinated during December
      2008–March 2009 and that 25% received booster vaccinations by June 2009.
      Over 90% of the dogs in Bali are owned, but most are free-roaming and hard
      to catch for 1 parenteral vaccination, let alone booster vaccinations
      ,*7* <http://wwwnc.cdc.gov/eid/article/19/4/12-0380_article.htm#r7>). Thus,
      the emergency response failed to contain the outbreak, and by September
      2010, rabies had been confirmed in 221 (30.5%) villages throughout Bali (
      Table; <http://wwwnc.cdc.gov/eid/article/19/4/12-0380-t1.htm>

      In 2009, the Australian Government donated long-lasting vaccines for dogs,
      but operational funds for administration were unavailable. A local
      nongovernment organization, the Bali Animal Welfare Association (BAWA),
      developed a technique to improve vaccination coverage by training teams to
      catch dogs with nets. During December 2009–July 2010, 6-person BAWA teams
      using this technique piloted door-to-door vaccinations throughout Gianyar
      Regency, where BAWA is based. The teams vaccinated 48,000 dogs in Gianyar
      and 25,000 in nearby Bangli Regency. The World Society for the Protection
      of Animals donated supplies for this pilot, and BAWA covered operational
      costs. Surveys of collared (vaccinated) dogs on consecutive days after
      vaccinations indicated 70% coverage in almost all banjars (subvillages).
      Beginning in October 2010, BAWA teams and Balinese government staff worked
      together, with funding from the World Society for the Protection of
      Animals, to vaccinate dogs throughout most of Bali, subject to the official
      suspension of culling. By April 2011, a total of 249,429 dogs had been
      vaccinated, with coverage >70% in most banjars. During this campaign, dogs
      in Gianyar Regency were revaccinated because 18 months had passed since the
      pilot and coverage had declined because of population turnover and
      movement. A second island-wide campaign using these methods was completed
      in December 2011 by the Balinese government, coordinated by the Food and
      Agriculture Organization, and achieved similar coverage

      During 2010, rabies was confirmed in 417 dogs, 2 cats, and 3 cows. Of the
      417 dogs, 387 (93%) were probably unvaccinated; 30 had reportedly been
      vaccinated, but only 9 had a clear vaccination date; 5 were positive for
      rabies shortly after vaccination and were likely incubating the disease
      when vaccinated; and 4 cases were considered vaccination failures.

      When the first island-wide vaccination campaign began in 2010, a total of
      140 (19.4%) villages still reported rabies (>1 case in the previous 6
      months), and 81 (11.2%) villages that previously reported cases were
      considered rabies-free (no cases detected for >6 months). In addition,
      during this island-wide campaign (October–April 2011), rabies was detected
      in 48 previously rabies-free villages. By December 2011, only 30 (4.1%)
      villages were not considered rabies-free
      Before island-wide vaccination, rabies was detected in 10 new villages per
      month; during the first and second island-wide vaccinations, rabies was
      detected in 6.8 and 1.6 villages per month, respectively. The monthly
      number of confirmed cases before mass vaccination was also much higher
      (44.7 cases) than during the first (10.8 cases) and second (6.0 cases) mass
      vaccination campaigns, and concomitantly, the island-wide attack rate
      (confirmed rabid dogs per estimated unvaccinated population) declined from
      0.027% to 0.01% (Table<http://wwwnc.cdc.gov/eid/article/19/4/12-0380-t1.htm>).
      Reported dog bites declined slowly, from 6,256 bites per month before
      island-wide vaccination to 4,589 and 4,197 bites per month during the first
      and second vaccination campaigns, respectively. However, human deaths from
      rabies declined from 94 (4.3/month) before island-wide vaccination to 34
      (4.8/month) during the first campaign (24/34 persons were bitten during the
      prevaccination period) to 9 (1.1/month) deaths during the second campaign.

      Rabies was detected in Bali in 2008; it was probably brought by fishermen
      from the island of Sulawesi (Indonesia), as happened on the island of
      Flores (Indonesia)
      and subsequently spread throughout the island. Early containment attempts
      by limited fixed-point dog vaccination and culling were unsuccessful. This
      was likely due to insufficient funding, largely inaccessible free-roaming
      dog populations with high turnover, limited availability of long-lasting
      dog vaccines (and means to identify vaccinated dogs), and inconsistent cold

      These issues were gradually addressed, and island-wide vaccinations in 2010
      and 2011 approached the recommended target of 70% coverage
      ,*9* <http://wwwnc.cdc.gov/eid/article/19/4/12-0380_article.htm#r9>);
      postvaccination surveys of collared dogs enabled better coverage estimates.
      Considerable coordination was required among Bali’s provincial and regency
      governments, which was facilitated through training and data management
      systems. Nonetheless, reporting remained challenging due, in part, to
      limited infrastructure.

      Vaccination campaigns reduced rabies incidence and spread, resulting in
      decreased attack rates at the regency level and island-wide. In contrast,
      culling was ineffective in suppressing rabies and can be counterproductive (
      *10* <http://wwwnc.cdc.gov/eid/article/19/4/12-0380_article.htm#r10>).
      Although panic led to demand for culling in some locations, many
      communities objected because of religious beliefs and, especially, when
      owned (often vaccinated) dogs were culled. New puppies were brought to
      replace culled dogs, and some dogs were moved to avoid culls, possibly
      resulting in the transportation of infected dogs. Incidence declines due to
      vaccinations reduced the public health threat and panic that triggered
      culling; ≈108,000 dogs were culled before island-wide vaccination, compared
      with 40,000 during the 2 vaccination campaigns. However, long-term
      acceptable dog population control is still sought on Bali.

      DFA testing proved an effective surveillance method; dog bites were a less
      sensitive measure. The incidence of reported bites is higher on Bali than
      in Indonesian provinces where rabies is endemic; this may reflect
      heightened awareness about rabies or be related to the high densities of
      humans and dogs. Rabid dogs generally bite without provocation and die <10
      days after clinical signs develop
      thus, a short observation period
      may allow more judicious PEP administration but is often impractical with
      unrestrained dogs.

      Mass dog vaccinations substantially reduced rabies incidence on Bali and
      must be continued if elimination is to be achieved. Further research is
      needed to assess how many more campaigns are needed. Improved surveillance
      and control of inter-island dog movement are necessary to prevent further
      rabies spread within Indonesia.

      On Fri, Mar 29, 2013 at 1:17 PM, Lisa Warden <lisa.warden@...> wrote:

      > **
      > Surprisingly (or perhaps not), there is no mention in the article below
      > about the efforts of BAWA (the Bali Animal Welfare Association), without
      > whose persistence and efforts the progress made against rabies in Bali thus
      > far would have been impossible. Before BAWA intervened, the standard MO was
      > mass culls.
      > Regards,
      > Lisa Warden
      > AAPN Moderator
      > Published Date: 2013-03-28 19:50:48
      > Subject: PRO/AH/EDR> Rabies - Indonesia (03): (BA) canine, human,
      > eradication target
      > Archive Number: 20130328.1608694
      > ******************************************************************
      > A ProMED-mail post
      > http://www.promedmail.org
      > ProMED-mail is a program of the
      > International Society for Infectious Diseases
      > http://www.isid.org
      > Date: Thu 28 Mar 2013
      > Source: The Jakarta Post
      > [edited]
      > http://www.thejakartapost.com/bali-daily/2013-03-28/bali-will-soon-be-rabies-free-official.html
      > Observing that almost a year has passed since the last rabies case was
      > reported, the provincial administration expressed its confidence that
      > the island would soon be completely free of rabies.
      > The latest rabies case occurred last April [2012]. To be acknowledged
      > with the status "rabies free," Bali has to have 2 consecutive years
      > without a single occurrence of rabies in either animals or humans.
      > "It could be possible that Bali will be free of rabies, because the
      > last rabies case found in a human was last April [2012]," head of the
      > Bali Health Agency I Ketut Suarjaya said on Tuesday [26 Mar 2013].
      > Sanglah Hospital stated that only about 2 percent of dog bite cases
      > were positive for rabies virus infection.
      > Rabies cases in humans in Bali have been decreasing in recent years.
      > While in 2008, 4 cases were recorded, and 2009 saw 48 cases, and the
      > largest number, 82 cases, was recorded in 2010, after the mass dog
      > vaccination program was implemented in Bali, a reduction in cases
      > started to be seen. In 2011, 24 cases were recorded, and by 2012 only
      > 8 cases occurred.
      > Meanwhile, Sanglah Hospital's Secretary of the Rabies Mitigation Team,
      > Dr. Ken Wiransadhi, acknowledged that rabies vaccination distribution
      > had become more selective these days. The rabies vaccine is
      > prioritized for multiple and deep wounds caused by stray dogs.
      > Free-of-charge rabies inoculations are provided at state-owned
      > hospitals only for dog bite wounds in vital organs, including the
      > head, face, fingers and genitalia. The vaccine can also be purchased
      > at medical clinics.
      > Last week, the Bali Health Agency stocked up with 5000 vials of
      > anti-rabies vaccine that is estimated to be sufficient for around 1250
      > people for the next few months. Some 750 vials have been distributed
      > to rabies centres in Regencies. The head of the Bali Husbandry Agency,
      > Putu Sumantra, also announced that stage 4 of the mass dog vaccination
      > for all the 300 000 dogs in Bali would start in mid-April 2013 and run
      > until June this year [2013].
      > According to agency records, the latest mass rabies vaccination
      > program included 80 percent of the dog population on the island,
      > around 250 000 dogs, while 500 more had been sterilised. The Bali
      > administration is confident that the island will be able to achieve
      > its target of being free from rabies by 2015. However, residents are
      > expected to bring their dogs to have this free vaccination. Over the
      > past couple of years, Bali has attempted to control the spread of
      > rabies through a mass dog vaccination program and sterilization.
      > Since the island's rabies outbreak started in 2008, there has not been
      > much improvement in the way that Balinese communities care for their
      > pet dogs, say experts. "There's only been a small change in attitude
      > in the way they care for their dogs. The dogs are still let loose to
      > look for food on the streets," chairman of the Bali chapter of the
      > Indonesian Association of Veterinarians, I Gusti Ngurah Mahardika,
      > said recently. Mahardika said it was urgent for Balinese communities
      > to care for their dogs by feeding them at home and vaccinating them
      > regularly. "Dogs do bite. Thus, preventing them from contracting
      > rabies is most important," said the virologist, citing that the main
      > methods of prevention are proper care and regular vaccinations for the
      > dogs as well as public awareness of the need to have a rabies shot
      > after being bitten by a dog.
      > Meanwhile, Arie Rukmantara, spokesman for the national commission on
      > zoonoses, said that the main challenge to free the island from rabies
      > was maintaining people's commitment and participation. "If an outbreak
      > occurs for several years, it is crucial to maintain the commitment of
      > local people to participate in the eradication efforts. He said the
      > 2015 target was reasonable, considering that the administration had
      > implemented efforts to accomplish this since the 1st case of rabies
      > was found in Jimbaran in 2008.
      > [Byline: Luh De Suriyani]
      > [Non-text portions of this message have been removed]

      [Non-text portions of this message have been removed]
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