U.S. issues rabies advisory for Bali visitors as control effort stumbles

From ANIMAL PEOPLE, January/February 2009:
JAKARTA, DENPASAR–The U.S. embassy to Indonesia on January
12, 2009 issued the outbreak notice that the Bali tourism industry
had feared would be coming since mid-November 2008, when reports
first circulated about four human rabies deaths resulting from dog
bites in two villages on the peninsula south of the Denpasar airport.
“Rabies has been confirmed in dogs from at least two villages
near popular tourist destinations on the southern tip of Bali,” the
outbreak notice advised. “At this stage rabies has been identified
in only one district, but the Centers for Disease Control &
Prevention advises travelers to take precautions on the entire
island,” the notice added.
The outbreak notice was distributed two days after Bali
governor Made Mangku Pastika announced, “We are closing the seaports
and airport to any dog trade.”

But the dog trade most likely to spread rabies throughout
Bali continued unabated. Dani Stokeld of the Bali Animal Welfare
Association forwarded to ANIMAL PEOPLE photographs documenting how
BAWA personnel followed a private dogcatcher as he captured as many
as 10 street dogs from the area where rabid dogs have been found: of
the first 50 dogs tested, nine were reportedly confirmed rabid. The
dogcatcher then hauled the dogs in gunny sacks to a dog meat
restaurant in Singaraja, on the far side of Bali, beyond the
central mountains.
“They followed this guy all the way to a woman’s house, who
said she makes dog satay and sells it at her restaurant, where local
police often eat,” BAWA founder Janice Girardi told ANIMAL PEOPLE.
“They know there is no law against this, and were quite open about
what they are doing. I mentioned it to the head of the Bali animal
husbandry service and he didn’t even show concern. I offered him the
license plate number” of the dogcatcher’s motorcycle, “and he just
was not interested.”
That was scarcely Girardi’s only frustration with Bali animal
husbandry chief Ida Bagus Ketut Alit. “He is following the
Indonesian protocol book for dealing with rabies,” Girardi explained.
The book, when Girardi obtained copies of it from the
national capital in Jakarta on January 5, turned out to be “Dutch
laws written in 1926,” when Indonesia was a Dutch colony.
“They will continue to cull all unvaccinated dogs, and will
only vaccinate owned dogs,” Girardi summarized. “They only have a
total of 20,000 vaccine doses,” to serve a dog population officially
estimated as about 550,000, but believed by ANIMAL PEOPLE to be
about half that, “and maybe they will get more, maybe not.”
The director of animal husbandry “doesn’t care if the animals
are not being euthanized humanely,” Girardi continued, describing
how officials were killing dogs with magnesium sulfate, a method
listed as “unacceptable” by the American Veterinary Medical
Association at least since 1993.
“He wants the streets cleaned up. He gets too many
complaints from tourists about the bad condition of street dogs, so
his answer is to kill them all. End of story,” Girardi said, after
trying to introduce Ida Bagus Ketut Alit to current rabies control
literature from the World Health Organization, World Society for the
Protection of Animals, the Alliance for Rabies Control, and U.S.
National Association of Public Health Veterinarians.
“I asked if I could buy vaccines for East Bali and our
clinic, and he said no, they are only for use by the government. I
asked about prevention for East Bali and he refused to listen,”
Girardi continued.
Girardi reported similar results from meeting with Bali
Directorate Center for Disease Control chief Wilfred Purpa. “He told
us that strays are illegal in Indonesia, but we can’t get a
definition of ‘stray,”” Girardi recounted. “Ninety percent of
Bali’s dogs live on the streets, owned or unowned. His plan is to
cull all the stray dogs. He is not concerned with incidental deaths
of non-target species, and does not feel there are any human health
concerns with distributing baited meat around the beaches and
populated areas.”
More than half of the human population of Bali is in the
southeastern quadrant of the island, just north of the Denpasar
airport, near the BAWA headquarters and also the head office of the
Bali Street Dog Foundation.
The rabies control strategy recommended by WHO, WSPA, the
Alliance for Rabies Control, and the National Association of Public
Health Veterinarians calls for vaccinating the entire dog and cat
population if possible, 70% at minimum, to create a vaccinated
barrier between infected animals and other animals and people.
Enlisting animal welfare societies to help vaccinate is part of the
protocol. But BAWA, trying for weeks to volunteer, reported mostly
getting the runaround.
Girardi eventually learned from Dewa Dharma, DVM, who
helped to legally incorporate BAWA, that “The government purchased
rabies vaccines produced in Java which only provide immunity for six
months. The government purchased 20,000 canine vaccines about a
month ago and is intending to purchase another 30,000. However,”
two months after the first four rabies deaths, “they have only used
2,000 of the 20,000.
“The government has now released some canine rabies vaccines
to our vets,” Girardi at last e-mailed on January 5. “However we
are only permitted to use these on dogs within the infected area.”

Monkeys

Meanwhile, reported Jakarta Post Denpasar correspondent Luh
De Suriyani, “The Denpasar-based Bali Badung Veterinary Main Office
has called on local administrations to closely monitor monkey
colonies in their respective areas to help contain the rabies
outbreak.”
The veterinary authorities expressed concern about monkeys
becoming infected at any of the 48 sites on Bali where troupes live,
four of which “are major tourist attractions.”
“In countries such as India and Pakistan, rabies among
monkeys has never been reported,” a veterinarian identified only as
Soegiarto said. “But that doesn’t mean we can be complacent about
it. The main thing is to monitor the monkey colonies and educate
people, particularly in tourist spots, about the danger of rabies.”
Responded U.S. Centers for Disease Control & Prevention
rabies program director Charles Rupprecht, “Why would one be
concerned about monkeys when dogs are not even being vaccinated?”
“There has been great delay in responding according to
international recommendations to this outbreak,” fumed globally
recognized rabies control expert Henry Wilde, of the Chulalongkorn
University faculty of medicine in Bangkok, Thailand. “Thus rabies
is surely by now present in other parts of Bali,” besides the
locations of the first known outbreaks. They will have to vaccinate
at least 75% of all dogs and cats on Bali or learn to live with
endemic canine rabies.
“This is a mess,” Wilde continued. “It is a repeat of what
I experienced at Flores,” where Indonesian officials killed more
than 500,000 dogs a decade ago, while more than 100 people died of
rabies, and the outbreak remains uncontained.
“You have total knuckleheads there in government,” Wilde
assessed. “Bali would be an ideal place to make a major effort to
vaccinate all dogs on the island, combining this with testing
immunological population control technology, which is now known but
needs to be tested in the real world. It could be combined with
testicular zinc injection for the males,” Wilde suggested. “We have
at least one veterinary scientist in Bangkok who could assist in such
a project, together with staff from WHO and the U.S. CDC. I must,
however, admit that I am sceptical that local officials are
interested. It never happened in Flores, and they still have canine
rabies.”

“Use Thai example”

Said the veterinary scientist Wilde mentioned, Chulalongkorn
University faculty of medicine colleague Thiravat Hemachudha, “Here
in Thailand, although we have reduced human rabies deaths down to
fewer than 10 from 300 a year, we still have to give post-exposure
prophylaxis to 500,000 persons per year, reflecting how bad it has
been as the result of not controlling dog population. We also have
spent several hundred millions per year for vaccinating dogs,
mostly owned. Please do not follow our bad example,” he pleaded.
“Use our example,” which looks very good compared to the Indonesian
record, “as a bad example, to develop a new action plan involving
the public, quick humane methods of sterilzation, and attractive
ways to convince public to bring the public dogs in for sterilization
and vaccination.”
If leadership is not coming from the government, wondered
Rupprecht, “Are there no prominent public figures in the country to
serve as a rallying point? Outside international pressure causes a
bunker mentality,” he warned. “We are all here to help, not to
force. This has to begin with an ‘of the people, by the people,
for the people’ philosophy. There is only one earth and one rabies
from a global perspective,” Rupprecht explained, “not a center to
the infectious disease universe. The solutions to dog rabies
elimination are clear. While human prevention is vital, this is not
HIV, flu, etcetra–this is a zoonosis in which homo is secondary.”
Meanwhile, updated Luh De Suryani of the Jakarta Post, a
four-year-old boy became the probable fifth human victim of the Bali
outbreak.
“The Badung health authority did not inform the press about
the boy’s death,” Luh De Suryani wrote. “The Jakarta Post learned
about it from a source who declined to be named because he was not
authorized to speak to journalists. The boy was a resident of Kutuh
village, South Kuta, which has been classified as a rabies-prone
area. Kutuh village chief I Wayan Litra confirmed that he was bitten
by a dog six months ago. The dog who bit him died a week later.
“Soon after the boy came down with a high fever but was
nursed back to health. Then last week he began convulsing
uncontrollably, so his parents took him to Sanglah Hospital, where
he died,” the chief said.
Noted Luh De Suryani, “Banners and billboards have been put
up in the area to warn people against transporting dogs, cats, or
primates into and out of Bali. Also, 503 dogs have been culled from
South Kuta.”
But the outbreak appeared to be farther than ever from
control.