Verifying alleged outbreaks is critical to effective control & prevention
TABANAN Regency, Bali, Indonesia––Rabies-infected, or rabies-suspected?
That is the question that Program for Monitoring Emerging Diseases moderator Arnon Shimshony and Shamsudeen Fagbo, a leading Saudi-based One Health and animal rights advocate, took up in mid-May 2022, responding to recurring alleged rabies flare-ups in Bali, Indonesia.
The question “rabies-infected, or rabies-suspected?” appropriately applies to practically every situation in which a dog, or any other mammal, inexplicably bites one or several people and is not known to have been vaccinated against rabies.
Bali, however, happens to offer a particularly good example of why the question should be asked, and answered via laboratory testing, before anyone goes out killing dogs, or wildlife, in the mistaken belief that culling animals who may be vaccinated, and may be healthy, is a rabies control measure.
Often animals whom people believe at a glance to be rabid are actually suffering from other, unrelated conditions, which produce some lookalike symptoms: drinking saltwater, for example, or eating soap, or diseases including distemper and Japanese encephalitis, that are not transmitted through bites.
Killing vaccinated animals merely opens habitat to the unvaccinated. Killing healthy but unvaccinated animals, especially wildlife, encourages other animals to fill vacant habitat, some of whom may bring rabies with them.
Flare-up in Bali
On the island of Bali, Indonesia, a rabies outbreak that peaked and was nearly extinguished more than a decade ago smolders on, with 54 suspected rabid dogs killed by authorities in 2020, down from 126 in 2019.
Seven people in Dauh Peken Village, Tabanan Regency, were reportedly bitten by suspected rapid dogs during the first week of May 2022.
Recounted Bali Coconuts, “Tabanan animal control agency head Gde Eka Parta Ariana confirmed that out of the seven victims, only five have checked themselves to a local health care facility and received rabies shots.
“The official added that the agency had tracked three stray dogs in the area, though it has yet to be confirmed if they were the ones who bit the seven villagers. Nonetheless, the three dogs were put down, as they were suspected to have recently come in close contact with other rabies-infected dogs.”
The Tabanan regency administration plans to vaccinate 71,062 dogs against rabies in 2022, Bali Coconuts said.
“In Karangasem, which is located about 50 miles from Tabanan, 41 people have been bitten by rabies-infected dogs this year as of April 2022,” Bali Coconuts added.
Shimshony noticed a troubling imprecision in the Bali Coconuts report.
“The term ‘rabies-infected dogs’ is in need of clarification,” Shimshony pointed out to Program for Monitoring Emerging Diseases email list members.
“Has rabies been suspected clinically and confirmed by a lab test?” Shimshony asked.
“In case no confirmation becomes available, these animals should be termed as ‘clinically rabies-suspected dogs.’”
“From a One Health perspective”
Added Shamsudeen Fagbo a day later, “From a One Health perspective, the mislabeling of ‘rabies suspected dogs’ as ‘rabies infected dogs’ poses serious threats to animal welfare in Indonesia and beyond.
‘Mislabeling can result in the culling of animals that might have been previously vaccinated.
Culling can be counterproductive for rabies disease control itself: owners of truly infected animals or those exposed to infected animals may actively hide them from the surveillance system.
“For dogs labeled positive based on mere suspicion,” Fagbo continued, “questions arise: who decided they were positive, and on what basis?
“Did the health care workers managing dog bites elicit sufficient history to determine whether the animals could have been rabid, including asking if the attacks were provoked or unprovoked?
“In today’s global village,” Fagbo wrote, “unjustified death sentences ensuing from
mislabeling are a threat to animal welfare in Indonesia, which can translate to similar but real threats elsewhere.
“Dogs can be and have been needlessly hanged or clubbed to death in the past,” Fagbo reminded. “In other climes, the entire extermination of all stray animals, including
non-canines, has been suggested after human death due to attack from rabies-suspected (but unconfirmed) dogs.
Minks, pigs, hens, & hamsters
“When we juxtapose this with the animal welfare crisis associated with the COVID-19 pandemic, that has resulted in the collateral culling of not just minks, but pigs, hens, and hamsters, it becomes pertinent that we enhance the role and understanding of animal welfare in outbreaks and possible future pandemics.
“What can be done?” Fagbo concluded.
“For one, promote and fund more One Health-footed training/education at a global level. This will help address One Health competency deficiencies, one of which is appreciating and understanding the importance of animal welfare, amongst key players in the One Health work force.
“The newly signed One Health collaboration of the Quadripartite (FAO, OIE, UNEP, and WHO) international agencies is well placed to help achieve this,” Fagbo suggested.
“And the marvelous One Health done in Bali and other parts of Indonesia can serve as a model.”
A cab driver from the Indonesian island of Flores, his girlfriend, and their unvaccinated dog moved to the Ungasan peninsula in southern Bali in approximately May 2008.
Infected in Flores, the dog first displayed rabid symptoms in late June 2008. Three people were fatally bitten, including the cab driver, before the outbreak was detected, four months after the dog died.
As rabies occurred only on the Ungasan peninsula until early 2009, the outbreak could have been isolated and eradicated almost immediately through intensive vaccination.
Culling instead of vaccinating killed 150 people
Instead, despite the advice of ANIMALS 24-7 and the Bali Animal Welfare Association, shared with Bali authorities within hours after the first rabies case was disclosed, the Bali government for more than a year practiced only selective vaccination, culled as many as 150,000 dogs, and until mid-2009 actually prohibited vaccinating dogs outside of areas with active rabies cases.
More than 150 human rabies deaths followed.
For more than a year the Bali Animal Welfare Association demonstrated the value of vaccinating dogs, instead of culling, by keeping rabies out of the densely populated Gianyar regency, before getting official permission to try to vaccinate at least 70% of the dogs in all eight Bali regencies.
“The first round of mass vaccinations was funded by the World Society for the Protection of Animals, the Australian government, and the International Fund for Animal Welfare,” said an April 5, 2011 World Society for Animal Protection news release, adding that the program was also supported by the World Health Organization and the United Nations Food & Agriculture Organization.
BAWA vaccinated 210,000 dogs in six months
Vaccinating 210,000 dogs in the six months ending on March 31, 2011, the Bali Animal Welfare Association achieved a 48% reduction in human rabies deaths and a 45% decrease in dog rabies cases.
This was the fastest containment of a rabies outbreak in the history of Indonesia, achieved even as a 13-year-old outbreak continued in Flores, where officials had fought rabies mainly by culling dogs.
During the six-month vaccination sweep, the Bali Animal Welfare Association established by counting dogs from house to house in every village that the Bali dog population is “just over 300,000 dogs, about 1 dog to 12.5 people,” BAWA founder Janice Girardi said–exactly the estimate produced by ANIMALS 24-7 in late 2008 when the rabies outbreak was first recognized.
Bali government estimates were half again to twice as high. Because Bali government officials hugely over-estimated the dog population, they also hugely over-estimated the cost and time that would be required to eradicate the rabies outbreak through vaccination.
Concluded Shimshony, “Repeat vaccination campaigns combined with public education are prescribed.”
Jigs Gaton says
So sad to hear about the outbreak in Bali… when it happens here in Nepal, it’s always traumatic, and lots of dogs die, vaccinated or not. But for some reason, the government here would rather cull than vaccinate or develop a national rabies system, or require tagging or marking of all vaccinated dogs. I know Jan Salter when she was alive did a lot to help, and Lucia DeVries when she was here, but I don’t see anyone pushing for a rabies plan. And u know it’s lurking, out there just waiting to strike 🙁
Merritt Clifton says
A rabies outbreak is underway in Nepal at this very moment, described to the membership of the Program for Monitoring Emerging Diseases on May 18, 2022 by Dr. Sher Bahadur Pun, M.D., PhD., of the Clinical Research Unit at the Sukraraj Tropical & Infectious Disease Hospital in Kathmandu.
Wrote Dr. Pun:
“On 12 May 2022, a 27 year old unmarried woman was admitted to Sukraraj Tropical & Infectious Disease Hospital (STIDH) with a history of painful arm, aerophobia, and hydrophobia. She had been bitten on her right palm by her pet puppy a month ago, in April 2022. According to her brother, the puppy was adopted as a stray a couple of months before, and had been living with their family. The puppy died five days after the bite, but after falling into a water tank. Thus, a veterinary doctor did not suspect any infection, particularly rabies, as a cause of death, and even suggested against rabies vaccination. The woman consistently refused to get vaccinated, despite her brother’s suggestion. She died of rabies complications two days after admission, on 14 May 2022.
“In this case, it seems that the patient believed or was influenced by her veterinarian’s suggestion, although a laboratory test was not performed on brain tissue from the deceased dog to rule out rabies virus. Thus, careful counseling and suggestion (from a veterinarian) is essential in order to avoid death from this vaccine-preventable disease, especially where burden of rabies is high (or in rabies-endemic areas/districts).
“Nepal has committed to end dog-mediated rabies by the year 2030,” Dr. Pun continued. “Despite this commitment, the number
of human deaths from rabies has not decreased, but instead has increased gradually over the years. In the past six months, nearly a dozen patients have died of rabies at the Sukraraj Tropical & Infectious Disease Hospital, which shows that between 2015 and 2022, rabies cases rose by nearly 100%. Reasons for vaccine hesitancy need to be identified and addressed simultaneously to achieve the 2030 dog-mediated rabies elimination goal in Nepal.”
Dr. Pun has led the rabies prevention effort in Nepal for many years. I had the opportunity to discuss it at length with him in his office at the Sukraraj Tropical & Infectious Disease Hospital in January 2014, and have occasionally corresponded with him about it by email since then. The underlying problem, as Dr. Pun’s description of this latest death makes clear, is that rabies is much feared in Nepal, as in most of the world where rabies still occurs, but is very poorly understood by much of the public. When rabies deaths occur, or are believed to have occurred, public and political demand for culling dogs ensues, at huge cost to whatever vaccination work has already been done. Intensive vaccination campaigns are obviously needed, but must be preceded and accompanied by equally intensive public education–and it is essential to realize that governmental funding and support for the needed amount of vaccination will come only when nonprofit organizations have sufficiently educated the public about rabies to transition the traditional demand for culling into a demand for vaccination instead.
Shamsudeen Fagbo says
You’re right about education. And this applies elsewhere and not only in Indonesia or Nepal. And education programs should target professionals involved in rabies control including veterinarians, doctors and animal control officers. The challenges to achieving the paradigm shift or change sought needs to be methodically addressed.
Jamaka Petzak says
If nations, states, and communities prioritized SPAY & NEUTER and practiced it universally except for small pools of individuals for companion animals, this would probably not be a problem in these species. But as in the U.S., I guess that’s too easy. Ensuring that every animal leaving a shelter, rescue, humane society, ACC or sanctuary is spayed or neutered and vetted would benefit everyone. According to friends in Finland, there is no overpopulation there and those who wish to adopt cats pay for this privilege. Other nations in Europe, I am told, also have their overpopulation under control. The less there is of anything desirable, the more it is prized and ostensibly, the better it is cared for. No nation in 2022 should have any excuse for unwanted populations of dogs, especially, roaming the streets. My opinion — I know others will disagree. But for the safety of communities and the wellbeing of the animals involved, this is the answer.