Four human victims
DENPASAR, Bali, Indonesia––Someone brought a rabid dog to Bali. Yachting, fishing, or trading goods, the culprit apparently came by boat, docking near Ungasan village, where about 170 families live on a peninsula forming the southernmost part of Bali.
The rabid dog arrived at about the same time that more than 200 animal advocates from nearly 30 nations met at Sanur Beach, just to the north, for the Asia for Animals 2008 conference. The last visiting delegates had just left when the first human victims were bitten in mid-September 2008.
The bite victims did not seek immediate post-exposure vaccination. Between November 14 and November 23, 2008, four victims died at hospitals in Denpasar and Badung: a 32-year-old, a 28-year-old, an 8-year-old, and another child whose age was not disclosed.
Outbreak could have been contained
Containing the outbreak should have been easy. Fences, runways, and access roads surrounding the Ngurah Rai Airport inhibit dog movement between Ungasan and the heavily populated southeastern part of Bali, including Denpasar, the capital city.
The Yudisthira Swarga Foundation, Bali Street Dog Foundation, and Bali Animal Welfare Association have among them sterilized nearly 40,000 dogs in southeastern Bali during the past 10 years. If the Bali government had allowed the animal welfare societies to vaccinate the dogs against rabies at the same time they were sterilized, in accordance with international protocol, a barrier of already vaccinated dogs would have combined with the isolation of Ungasan to prevent any likelihood of the outbreak spreading.
A vaccination drive targeting all dogs on the Ungasan/Ululatu peninsula, combined with euthanizing any dogs showing signs of exposure, might then have extinguished the outbreak within a matter of days.
Instead, the 40,000 sterilized dogs were not vaccinated against rabies because Balinese officials mistakenly believed the vaccine might itself introduce the disease.
“Unfortunately, the Balinese government has been short-sighted in not permitting the distribution of the rabies vaccine across Bali, and by turning a blind eye to the illegal importation of animals into Bali,” acknowledged BAWA acting operations manager Dani Stokeld in a post to the Asian Animal Protection Network. “Only one hospital in Bali maintained a minimal stock of the human post-exposure rabies vaccine, and the government has not allowed any rabies vaccine for pets to be imported to Bali”.
“Bali has been free of rabies for decades; we haven’t had any need for a vaccine in the island,” BAWA spokesperson Tinneke Indrajaya told the Jakarta Post. “So the Bali animal advocates did not push hard against the ban on importing rabies vaccine.”
Little panic before there was major panic
“There was little initial panic when rabies appeared,” indicated Jakarta Post reporter Andra Wisnu. “The Badung Health Agency obtained enough human post-exposure vaccine to treat another 76 Ungasan residents who had been bitten by dogs in the preceding two months. Yudisthira Swarga Foundation volunteers euthanized 11 dogs found in the vicinity of the biting incidents by lethal injection, and sent their heads to be tested for rabies at a laboratory in West Java. Other agencies killed another six dogs, whose heads were also sent for testing.”
Only one dog turned out to have been rabid. But Bali governor Made Mangku Pastika on November 29, 2008 ordered the Balinese people to conduct a mass culling of stray dogs, reported Ni Komang Erviani of the Jakarta Post.
“Residents can just go ahead by taking the initiative to kill stray dogs. If the mass dog culling relied only on government officials, it would take too long,” Pastika told a public forum.
“Pastika also demanded the strict supervision of the entrance of other animals into Bali, like monkeys and cats, which transmit diseases to human beings,” Ni Komang Erviani added.
Flores bad example
Word of Pastika’s edicts appeared on the International Society for Infectious Diseases’ ProMED-mail online bulletin board five days later.
“This method of disease control does not work,” objected Alliance for Rabies Control executive director Deborah K. Briggs. “For example, officials on Flores Island,” like Bali a part of Indonesia, “tried to eliminate a canine rabies outbreak eight years ago by killing over 500,000 dogs, yet rabies is still present on that island. Similarly, when canine rabies spread to the region of Sulawesi in Indonesia approximately five years later, mass culling of dogs was again attempted without successfully eliminating rabies.
“Mass vaccination works”
“On the other hand, mass vaccination of dogs against rabies does work,” Briggs emphasized.
“There are many countrywide examples proving that when the World Health Organization recommendation of vaccinating 70% of the dog population against rabies is applied, the spread of rabies throughout the dog population is stopped. Excellent examples of successful programs exist in Latin America, where the Pan American Health Organization spearheaded mass canine vaccination programs throughout the continent, resulting in a dramatic reduction in the prevalence of both canine rabies and human rabies.
“Similar success has been reported in Africa,” Briggs continued, “for example in Tanzania, where mass canine rabies vaccination cleared rabies from the community dog population surrounding the Serengeti region, protecting endangered wildlife within the park.
“The tools to prevent the existence and spread of rabies in dogs already exist and have been proven to work,” Briggs finished. “They only need to be utilized.”
Henry Wilde testifies
Supporting testimony came from Henry Wilde, M.D., of the Chulalongkorn University Faculty of Medicine in Bangkok, Thailand, who visited Flores on behalf of WHO.
“Fishermen had imported three dogs, and with them, rabies,” Wilde recalled. “Within one year, over 100 humans died on this island of about one million human population. A local decision was made to cull as many dogs as possible,” contrary to Wilde’s advice to vaccinate the dogs instead.
Wilde noted that the custom of dog-eating persists among the Christian population of Flores. Dog-eaters often believe that dogs who have been vaccinated against rabies cannot be eaten safely.
After his Flores visit, Wilde remembered, “I met with a health official in Bali who expressed great anxiety that some similar event might happen there. His fear was justified,” Wilde concluded. “Culling alone does not work!”
At a November 30 strategy meeting chaired by Bali director general of disease control and environmental health Tjandra Yoga Aditama, “officials from animal husbandry agencies, the Bali Health Agency, police, tourism offices, community health centers, the state-run Sanglah Hospital, and other related institutions, agreed to cull stray dogs and vaccinate domesticated dogs in areas 10 kilometers from Ungasan and Kedonganan villages,” reported Luh De Suriyani and Hyginus Hardoyo of the Jakarta Post Denpasar bureau.
Kedonganan is at the neck of the Ungasan/Ululatu peninsula.
“At least 20,000 doses of rabies vaccine for dogs have been sent from Jakarta,” Luh De Suriyani and Hyginus Hardoyo added. “Dog owners are encouraged to fence their dogs so they are not infected by sick animals.”
Luh De Suriyani quoted Yudisthira Swarga Foundation veterinarian Rina Dwiasih’s recommendation against poisoning dogs.
“The government has commenced a rabies vaccine program for dogs, but only for dogs in the infected area,” affirmed Stokeld. “Sadly, there are reports of the culling of healthy Bali street dogs, and poisoning has commenced on the beaches in the tourist area of Kuta,” the first village north of the airport.
“BAWA is trying to form a coalition with other animal welfare organizations and the Bali Vet Association to lobby the government to act responsibly and to take a more pragmatic approach,” Stokeld said. “We would like to see the government support a Bali-wide vaccination and de-sexing program for dogs and cats; public education about responsible pet ownership and zoonoses; and pass the animal welfare laws that have been sitting in the Indonesian legislature for years.”
BAWA steps up efforts
“We have been assisting the farm department to administer rabies vaccines in the Bukit area,” BAWA founder Janice Girardi said, but as of December 5, 2008 she had been unable to get a meeting with Pastika.
“At the moment we are trying to get enough human vaccines for all of our staff,” Girardi added. “Of course we need to increase the amount of sterilization we do, especially north of the infected areas, to keep the dogs from straying. As if animal welfare wasn’t hard enough in Bali, without laws, with rabies life just got even harder.
There are many pet stores in that area,” Girardi noted, “so we will try to inspect the pet shops and warn all the owners. I’d love to get the pet shops closed down. Often we see many dogs together in a small cage, out in the hot sun with no water. We can give the animals water, and try to educate the employees, but without animal welfare laws nothing will really change.”