June 29, 2014
In 2008, an unvaccinated rabid dog from Flores, a distant island suffering endemic canine rabies, was imported into Bali. Although Bali previously had been rabies-free, the outbreak went officially unrecognized for five months. Two years after the first case, however, rabies had spread throughout Bali, human rabies deaths were doubling every six months, and 44,000 people had received post-exposure vaccination after sustaining bites from suspected rabid dogs. What went wrong?
Bali lacked the resources for adequate disease surveillance and control. The response to the outbreak of this unfamiliar disease was to begin culling stray dogs. In a culture in which household pets and other animals roam freely, more than 200,000 dogs were put down by 2010. But the number of dog-bite cases surged despite the cull: in the first nine months of 2010 there were 38,000, up from 24,000 for the whole of previous year.
Culling is an approach that has been tried – and failed – many times. It has never been effective in either stopping the spread of rabies or reducing dog populations permanently. When rabies arrived in Flores, as much as 48% of the dogs were culled. But there is still rabies in Flores. In Bangkok, half a million dogs were killed between 1997 and 2000, yet but there was no reduction in human deaths and no lasting effect on dog population growth.
Finally, after having spent almost $3 million on post-exposure prophylaxis, Bali announced that it would focus on canine vaccination. In 2008, 4 cases were recorded. 2009 saw 48 cases. The largest number, 82 cases, was recorded in 2010. After the mass animal vaccination program, rabies cases in humans began to decrease. In 2011, 24 cases were recorded, and by 2012, only 8 cases had occurred. Once vowing to eradicate rabies from Bali by 2012, the government is now hoping for elimination in 2015. But rabid dogs are still found and people are still being bitten.
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Worldwide, rabies kills 55,000 people each year. Over 95% of these deaths occur in resource-poor nations in Africa and Asia. Almost all are the result of the bite of an infected dog; 40% of the victims are children. Each one of these deaths represents a preventable tragedy: rabies transmission among animals – especially domestic dogs and cats – is preventable, and the uniformly fatal human infection can be stopped with post-exposure immunoglobulin and vaccine. Making animal and human vaccines available to poor, rural populations in countries with inadequate financial and human resources is expensive, but it’s been estimated that the annual global cost associated with rabies is in excess of $ 120 billion.
Rabies is a case study in One Health—where animal vaccination is the best way to prevent a dreaded human disease. Rabies elimination will come through communication, collaboration, and cooperation among wildlife experts, veterinarians, researchers, human health care workers, and multiple government sectors. Rabies hits hardest in remote locations; the under-reporting of rabies prevents mobilization of resources from the international community for the elimination of human dog-mediated rabies. It will take cooperation to roll out enhanced surveillance, relevant diagnostic testing, and improved infrastructure to address this. It will take open communications channels to ensure that data is shared.
Although 15 million people worldwide receive post-exposure prophylaxis every year, many rabies victims die because they can’t access treatment. Communication and cooperation among governments, wildlife experts, veterinarians, researchers, and human health workers will be required to reduce both the cost and difficulty of receiving treatment.
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Clearly, rabies outbreaks such as the one in Bali can only be dealt with through a commitment to cross-sector collaboration at national, regional, and global levels. It will take commitment on the part of all of us to advocate for and implement the changes needed to eliminate rabies worldwide. I look forward to working with you.
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