Rabes, Canine, Human - Indonesia (05) : (Bali)

RABIES, CANINE, HUMAN - INDONESIA (05): (BALI)
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A ProMED-mail post

ProMED-mail is a program of the
International Society for Infectious Diseases


Date: Wed 25 Mar 20009
Source: The Jakarta Post [edited]


The 8th victim of rabies, a 46-year-old man, died on Monday [23 Mar
2009] afternoon after being treated at the Sanglah General Hospital
in Denpasar since Sunday morning, a hospital official said Tuesday
[24 Mar 2009].

The victim was bitten in November [2008] and was a resident of
Pecatu, South Kuta district in Badung district, which had been
declared a rabies-infected area by the Bali provincial administration
late last year [2008]. "The suspect had shown acute clinical symptoms
and could not be saved," IGB Ken Wirasandhi, the secretary of the
hospital's rabies handling team, said. "We cannot confirm that [he]
positively died of rabies because the results of his blood tests are
not in yet."

The previous 7 suspected victims died after being bitten by rabid
dogs. The 1st victim was a 4-year-old child who died on 17 Sep 2008
[but see ProMED archive 20090106.0050 for a Jakarta Post article
giving his date of death as 30 Dec 2008, 6 months after being bitten.
- Mod.JW]. Other victims were [2 adults aged 32, an adult aged 45,
and 2 children aged 3 and another aged 5]. [So far, only the
45-year-old and one of the 32-year-old patients] have been confirmed
through blood tests to have suffered from rabies.

On Monday [23 Mar 2009], Ken said the 46-year-old patient showed
indications of the clinical symptoms of rabies like the past
suspected victims. "One thing is certain, the victim's diagnosis was
encephalitis," he said. The man's family has refused to divulge any
information. Head of the isolation ward, Ni Made Ratni, said Monday
that the man's wife had been hysterical since her husband was
declared a rabies suspect. "She kept on crying hysterically while her
husband was being treated," she said.

Badung Health Agency head AA Gede Agung Mayun confirmed the victim
suffered from the clinical symptoms of rabies. Ironically, the
46-year-old man had received 2 anti-rabies vaccinations (VARs) after
being bitten by a rabid dog. The 1st shot was given on 27 Nov 2008.
"Unfortunately, he did not continue with the 3rd and 4th vaccinations
after he felt much better," Mayun said. "A complete 4-shot
anti-rabies vaccination is mandatory, especially if a victim is
bitten on the arm or above." Mayun said the case was very surprising
because biting cases in South Kuta were actually decreasing, but he
did not give exact figures. Health authorities have yet to identify
which dog [bit] the deceased.

There have been proposals expressed, during various discussions on how
to handle rabies in Bali, that dog owners should be punished if their
dogs bite people. The aim is to involve the public in preventing the
spread of rabies. The health agency also said that only one of the
3-year-old children of the previous victims had shown rabies' unique
clinical symptoms, such as hydrophobia and hyper-salivation.

Meanwhile, the Badung Animal Husbandry, Fisheries and Maritime Agency
is finding it difficult to administer the booster vaccinations for
dogs, scheduled for April 2009.

[Byline: Luh De Suriyani]

Communicated by:
a correspondent who wishes to remain anonymous

[Little precise information has been reported in recent weeks
concerning the course of the outbreak of canine rabies and consequent
human fatalities in the Indonesian island of Bali. Particular
concerns have been expressed regarding the undeclared number of human
cases, the extent of the dog vaccination program and the availability
of vaccine and immunoglobulin for post-exposure treatment.

The above Jakarta Post report highlights the seriousness of the
current situation, with the declaration of 2 confirmed fatal cases of
human rabies and another 6 suspected fatal cases. Furthermore, the
program for control of canine rabies by vaccination seems to have
stalled. Intending visitors to the island of Bali should take note.

The location of the island of Bali can be found using the
HealthMap/ProMED-mail interactive map of Indonesia at:
.
A map of the island of Bali showing Denpasar region can be accessed at:
.
- Mod.CP]

Rabies, Canine, Human - Indonesia (03) : Bali, Request for information

RABIES, CANINE, HUMAN - INDONESIA (03): BALI, REQUEST FOR INFORMATION
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A ProMED-mail post

ProMED-mail is a program of the
International Society for Infectious Diseases


Date: Mon 9 Mar 2009
From: Henry Wilde

My personal information from Bali and local press reports indicate
that the rabies outbreak, which started last year [2008] in
previously rabies-free Bali is not being handled as recommended by
the World Health Organization (WHO), using general vaccination of all
dogs (at least 70 percent) on the island.

Bali is still not instituting a dog rabies vaccination program and
only does "ring-vaccination" around identified cases. There have been
several human deaths. Tourists must be aware that any dog or cat or
monkey bite in Bali is a potential rabies exposure and that it needs
to be treated under WHO post exposure guidelines.

Long stay tourists or expats in Bali with rural and extensive street
exposure should consider pre-exposure rabies vaccination. I am also
not sure whether human or WHO standard equine rabies immunoglobulins
are readily available in Bali. This would be an other indication for
pre-exposure vaccination of long-term visitors. It seems now that due
to the long delay by local authorities to act appropriately, this may
be a repeat situation as happened in Flores and later Ambon, Indonesia.

Henry Wilde, MD, FACP
Professor of Medicine
Division of Research Affairs
Faculty of Medicine
Chulalongkorn University
Rama IV Road,
Bangkok,
Thailand 10330

[Little precise information has been reported in recent weeks
concerning the course of the outbreak of canine rabies, and
consequent human fatalities, in the Indonesian island of Bali. In
particular, there is concern about the extent of the dog vaccination
program and the availability of vaccine and immunoglobulin for
post-exposure treatment of humans unlucky enough to be attacked by a
rabid animal. Professor Wilde's call for disclosure of information is
timely and endorsed by ProMED-mail.

The location of the island of Bali can be found using the
HealthMap/ProMED-mail interactive map of Indonesia at:
. - Mod.CP]

Rabies, Canine, Human - Indoensia (02) ; Bali, Alert

RABIES, CANINE, HUMAN - INDONESIA (02): BALI, ALERT
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A ProMED-mail post

ProMED-mail is a program of the
International Society for Infectious Diseases


Date: Fri 30 Jan 2009
Source: The Telegraph online [edited]


Bali tourists warned about rabies
---------------------------------
The authorities in Bali are battling a rabies outbreak that has
spread across the island and is threatening its tourism industry. The
1st cases were reported in Denpasar and Badung districts last
November [2008], but this month it spread to Kuta, one of the main
tourist resorts.

Since the beginning of January [2009], the number of infected people
has increased from a "handful" a week to at least 10 a day, hospital
staff have said. A total of 6 deaths have been reported. More than 24
000 pet dogs have been vaccinated, while more than 1000 strays have
been culled.

"It could be that in the past few months there were a number of cases
that weren't reported," said Ken Wirasandhi, the director of services
at Sanglah, Bali's largest hospital. "We've received calls from
tourists asking about the rabies situation, but we haven't received
reports of any tourists being bitten by dogs," said Gede Nurjaya, the
head of the Bali Tourism Authority.

Tour operators report that the outbreak has not yet led to
cancellations, but admit it is vital that the spread of the disease
is contained quickly. A spokesman for the tour operator Kuoni, which
reported this week that Indonesia had moved up from 20th in 2007 to
16th in its annual list of popular long-haul destinations, said it
was making passengers aware of the risks, but that no one had cancelled.

Since the onset of the financial downturn, Bali has struggled to
attract visitors. The number of tourists has failed to reach the
levels experienced before the bombings in October 2002, which killed
202 people. A further setback has been the banning of Indonesia's
main carrier, Garuda, from European territory, because of safety concerns.

The Foreign Office has joined the United States and Australia in
issuing a warning to travellers about rabies in Bali. Rabies has been
reported on the Indonesian islands of Java and Flores [see ProMED
refs. below. - Mod.JW], but this is the 1st time it has been recorded
on Bali.

The World Health Organisation estimates that more than 40 000 people
die from rabies every year. Most deaths take place in developing
countries, particularly in South-East Asia. Since 1946, there have
been 23 deaths among Britons infected with rabies abroad. A woman,
from Belfast, was the last Briton killed by the virus. She died
earlier this month [January 2009] in a hospital.

Byline: Charles Starmer-Smith]

Communicated by:
ProMED-mail


[The Indonesian authorities' efforts to contain the outbreak of
canine rabies to a restricted region of the island of Bali do not
appear to be succeeding, since the identification of a handful of
suspected human cases in late 2008/early January 2009 to the current
10 infected [bitten?] people a day, and a total of 6 fatalities, is a
measure of the lack of success in controlling the spread of canine
rabies on the island. Previous experience on other neighboring island
indicates that canine rabies cannot be controlled in the absence of a
comprehensive and systematic vaccination programme.

A map of the island of Bali showing the location of the endangered
tourist area of Kuta at the base of the southernmost peninsula, is
available at:
.

The location of the island of Bali can be found using the
HealthMap/ProMED-mail interactive map of Indonesia at:
. - Mod.CP]

Rabies, Canine, Human -Indonesia: (Bali), Suspected

RABIES, CANINE, HUMAN - INDONESIA: (BALI), SUSPECTED
***********************************************
A ProMED-mail post

ProMED-mail is a program of the
International Society for Infectious Diseases


Date: Tue 6 Jan 2008
Source: The Jakarta Post online [edited]


A 4-year-old boy, who was suspected of contracting rabies after a dog
bit him 6 months ago, died in Sanglah Hospital last Tuesday [30 Dec
2008?]. The Badung health authority did not inform the press about
the boy's death. The Jakarta Post learned about it from a source who
declined to be named because he was not authorized to speak to
journalists. The Post managed to get official confirmation of the
death on Monday [5 Jan 2009].

The boy was a resident of Kutuh village, South Kuta, which has been
classified as a rabies-prone area. It is not yet clear whether the
boy had in fact died of rabies, as hospital officials could not
provide laboratory results yet, but observations indicated the boy
had shown symptoms similar to rabies-infected patients prior to his
death, including fear of water, uncontrollable convulsions and
excessive drooling.

"Public testimonies and the physician in the South Kuta public health
center said the boy was exhibiting symptoms of rabies infection, but
he died before the laboratory results had come back," said I Ketut
Suiadnyana, head of Disease Observation and Prevention at the Badung
Health Agency. "We are currently working to gather the boy's medical
history." Kutuh village Chief I Wayan Litra confirmed the boy had
been bitten by a dog 6 months ago, and the dog that had bitten 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," Litra said.

Head of South Kuta's public health center, Sastrawan, said he planned
to interview the boy's parents to verify whether the boy had been
bitten a 2nd time and to gather other relevant medical information.

Four people are believed to have died from rabies in the past few
months. The alleged victims all died after being bitten by dogs. Of
the 4, only one showed clinical symptoms specific to rabies-infected
patients. The discovery of a rabid canine on 26 Nov 2008 [see
ProMED-mail references below] and the number of deaths have prompted
Bali Governor Made Mangku Pastika to declare south Kuta a rabies-prone area.

The province conducted a mass culling and vaccination program in the
area, which was recently expanded to include south Denpasar, the area
adjacent to south Kuta. The program is called Lirikan Indah,
literally meaning a beautiful glance. It stands for kenali
(identify), hindari (avoid), laporkan (report), vaksin (vaccinate)
and rumahkan (leash). Banners and billboards have been put up in the
area to warn people against transporting dogs, cats, or primates into
and out of Bali until the rabies situation is under control.

Also, 503 wild dogs have been culled from south Kuta since the
outbreak. I Gusti Ngurah Mahardika, a veterinarian and rabies
management team member, said rabies was 100 percent preventable if an
infected person was immediately vaccinated and the bite wound
immediately cleaned with soap. "The most important thing is to not
let dogs roam wild outside the house. One infected dog can transmit
the disease to 10 other dogs within a week," he said.

[Byline: Luh De Suryani]

Communicated by:
Thomas Schmidt
CEO mediScon worldwide
International Institute for Travel and Health
Kaulbachstr. 25
30625 Hannover - Germany


[Commendable efforts are being made to alert the population of the
southern part of the island of Bali to the dangers of rabies
infection in the canine population and to achieve control and
eradication by a combination of culling and vaccination. Strangely,
the medical authorities seem reluctant to employ post-exposure
vaccination to protect the human population. As of yet, none of the
suspected cases of human rabies have been confirmed by laboratory
diagnosis. The outcome of these investigations is awaited.

A map of the island of Bali showing the location of Kuta at the base
of the southernmost peninsula, the site of the rabies outbreak, is available at
.
The location of the island of Bali can be found using the
HealthMap/ProMED-mail interactive map of Indonesia at:
.
- Mod.CP]

Indonesia & attempts to control Rabies

... ny good friend, Dr Deborah Briggs, the executive director of the Alliance for Rabies Control in Edinburgh, Scotland, along with Dr Henry Wilde of the Chulalongkorn Univerity in Bangkok, Thailand commented recently in a posting to Pro-Med Mail of the failed attempts to control rabies outbreaks by the mass culling of dogs in enzootic areas of Rabies outbreaks.

... experience has shown over the years of attempts to cull large dog populations, e.g. 500,000 at a time are to no avail. Rabies continues to be a problem especially on those islands where extermination programs have taken place. Not only is the culling of large dog populations gruesome and barbaric, it will not reduce the incidence of Rabies.

... what does work is the vaccination of at least 70 % of the prevailing dog population along with the continual monitoring of disease outbreaks.

... the above is an abstract of an original article: Pro-Med posting 20081204.3821
"Rabies, canine, human - Indonesia (03):(Bali)"

... submitted in the interests of better animal health & Rabies control by Walter M Woolf, V.M.D. .. Principal Owner, and Managing Director ... Air Animal Pet Movers, Tampa, Florida