Response to a Rabies Epidemic, Bali, Indonesia, 2008–2011

Anak Agung Gde Putra

, Katie Hampson, Janice Girardi, Elly Hiby, Darryn Knobel, Wayan Mardiana, Sunny Townsend, and Helen Scott-Orr

Author affiliations: Disease Investigation Center, Denpasar, Bali, Indonesia (A.A.G. Putra); College of Medical, Veterinary and Life Sciences, University of Glasgow, Glasgow, United Kingdom (K. Hampson, S. Townsend); Bali Animal Welfare Association, Ubud, Bali (J. Girardi); World Society for the Protection of Animals, London, United Kingdom (E. Hiby); Faculty of Veterinary Science, University of Pretoria, Onderstepoort, South Africa (D. Knobel); Bali Province Livestock Services, Denpasar, Bali (I.W. Mardiana); Faculty of Veterinary Science, University of Sydney, Camden New South Wales, Australia (H. Scott-Orr)

Abstract

Emergency vaccinations and culling failed to contain an outbreak of rabies in Bali, Indonesia, during 2008–2009. Subsequent island-wide mass vaccination (reaching 70% coverage, >200,000 dogs) led to substantial declines in rabies incidence and spread. However, the incidence of dog bites remains high, and repeat campaigns are necessary to eliminate rabies in Bali.

Figure

Thumbnail of Timing of confirmed rabies cases in villages across Bali since the first case was confirmed on the island in November 2008. Darker shading indicates earlier detection according to the months since the first case was detected in the index village (marked), lighter shading indicates later detection, and white shading indicates no detected cases by December 2011.

Figure. . . Timing of confirmed rabies cases in villages across Bali since the first case was confirmed on the island in November 2008. Darker shading indicates earlier detection according to the...

Rabies was first reported in Indonesia in 1884 and now occurs in 24 of the country’s 33 provinces (1–3). On Bali Island, the first cases of rabies in humans and dogs were confirmed in 2008 on Bukit Peninsula (Figure). Despite control efforts in 2008–2009, rabies spread across the island. In the following 3 years, >130 persons died from rabies (primarily persons who did not receive postexposure prophylaxis [PEP]) (4), and PEP was given to >130,000 persons with dog bites. This outbreak resulted in considerable fear and anxiety and cost >US $17 million. We report on the outbreak progression and the effect of initial and subsequently improved control measures.

The Study

When the 2008 Bali rabies outbreak began, the island had no policies for rabies PEP and no dog bite surveillance, rabies diagnostic facilities, or vaccines for dogs. In response to the outbreak, the Indonesian government provided Bali with postexposure rabies vaccine for humans (Verorab), for intramuscular administration according to World Health Organization guidelines, and vaccines for dogs (10). The Australian government helped establish a direct fluorescent antibody (DFA) test at the Disease Investigation Center, Denpasar, Bali, and provided supplies for emergency dog vaccination. Surveillance was implemented by DFA testing of brain specimens from dogs that died or were killed after showing signs of rabies and from culled dogs. This surveillance, although imperfect, proved critical in tracking rabies spread (Figure).