Presented by Fred Unger at a training course for World Health Organization fellowship trainees from Sri Lanka on “Health approaches for rabies control and control of other zoonotic diseases”. Faculty of Veterinary Medicine, Chiang Mai University, Chiang Mai, Thailand, 20-24 May 2013.
2. Structure of presentation
1. Rabies in Indonesia and Bali – Background and chronology
2. EH/OH approach
3. Eco ILRI project
Optimizing Rabies Control Program in Bali: An Ecohealth Approach
3. History of rabies in Indonesia
• First reported in buffalo in 1884 (Esser)
• First case in dog was reported in 1889 (Penning)
and in human in 1894 (de Haan)
• Known to occur in West Java
• Since 1948 documented spread to other parts of
Indonesia
• By 2011, reported 23 of 33 provinces (Ditkeswan,
2011).
• Bali is the 24th province, since December 2008
Before, it was historically free.
6. Bali background
5,636.66 km2 or 0.29% of the total Indonesian
archipelago
3,741,952 people, 479 people per km2
Estimated dog population approx. 500,000++
Religion Hindu (87%)
8 Districts + Denpasar
Political structure: Governor of Bali
Economy from tourism and agriculture
7. Rabies Bali ‐ Chronology
21 Nov 2008 DIC Denpasar informed from local authorities
about a increase of dog bites in Badung District, Ungusan
village and the dead of 3 yr old boy
Boy had history of been bitten by dog on 19 Oct 2008
Dog appeared healthy but was killed by the family
2 more people died with history of dog bites (17 Sep & 14
Nov 2008) with encephalitis like symptoms
Investigation showed increased dog bites in the village but no
evidence of rabies in dogs
Villagers ordered to tied up their dogs after bitten somebody
8. Rabies Bali ‐ Chronology
The first confirmed human case
23 November 2008
• a 28-year-old male from Ungasan died with a
bite history from a stray dog (not found) on 16
September.
FAT Bbalitvet Laboratory in Bogor confirmed Rabies.
9. Rabies Bali ‐ Chronology
The first confirmed animal case
26 November 2008
• a dog bite case was reported from Banjar Pengenderan,
Kedonganan village, Central Kuta.
• A three-year-old child was bitten by a dog that had
shown abnormal behavior and had died a few hours after
the biting incident. The child received PEP and the dead
dog was diagnosed rabies
10. Rabies Bali ‐ Chronology
• Apart from the four human rabies cases (three based on
clinical symptoms with dog-bite histories and one
confirmed), health services shared history of a further
suspected human rabies case. The individual had been
bitten by an un-owned dog in July 2008.
• Suggest that the rabies virus could have been
introduced in the first half of 2008 and gone
undetected in the animal population until its diagnosis in
humans
11. Rabies Bali ‐ Chronology
Government response
• Mass vaccination in Badung District
• Dec 2008 until Feb 2009, 1st campaign
• 16,700 vaccinated dogs, estimated 35% of dog
population in this district
• Call for elimination of stray dogs (strychnine) critiqued
by international press and its appropriateness with
regard to animal welfare and effectiveness questioned.
15. Rabies Bali ‐ Chronology
• Rabies managed to spread north
• In 2009 and 2010 there was a significant increase in dog
bite cases.
• By October 2010 the Ministry of Health announced
56,259 bite cases in Bali with 168 human fatalities.
• Largest case of zoonotic disease outbreak ever reported
for Bali (e.g. AI only been 6 human fatalities)
16. Rabies Bali ‐ Chronology
• With the spread of rabies beyond Badung Prov Gov
ordered an island-wide stray dog elimination and mass
vaccination program.
• Target was to eliminate 20% and vaccinate 80% of the
dog population in Bali.
• Due to limited government resources only managed to
vaccinate 260,000 dogs and revaccinated 115,000 dogs
by October 2010
• Dog population estimates 2-3 times higher
• No accurate information on dog population
• Dog elimination heavily criticized by international media
18. Rabies Bali ‐ Challenges
• Limited government resources and coordination
• Lack of information crucial for a vaccination program:
• Dog population unknown or imprecise estimates,
varies from 400,000 to 800,000
• Population dynamics?
• Majority of dogs un-restrained, exact ratio between
retrained/unrestrained/not owned dog
• Underlying social cultural believes
19. Rabies Bali ‐ Challenges
• Rabies control cannot left with government alone
• Communities needs to be involved
• People of Bali is a unique community that has its own
unique relationship with the animals around it
• Alternative approaches are required – multi-sectoral,
across disciplines and institutions such as EH or OH
20. Eco Health & One Health versus classical
sector approach
21. Eco Health & One health
Ecosystem approaches to public health issues acknowledge the
complex, systemic nature of public health and environmental
issues, and the inadequacy of conventional methodologies for
dealing with them.
David Walter‐Toews, University of Guelph
One Health is the collaborative effort of multiple disciplines
working locally, nationally, and globally, to address critical
challenges and attain optimal health for people, domestic animals,
wildlife, and our environment
One Health Commission (http://www.onehealthcommission.org/ )
23. Introduction: Ecohealth Practice
• System thinking: System thinking suggests that the way to understand a
system is to examining the linkages and interactions between the
elements that make up the system.
• Knowledge to action: Knowledge to action refers to the idea that
knowledge generated by research is then used to improve health and
well‐being through an improved environment.
• Transdisciplinarity inclusive vision of health problems by scientists from
multiple disciplines, community and policy actors
• Participation aims to achieve consensus and cooperation within
community and scientific and decision‐making groups;
• Equity involves analyzing the respective roles of men and women, and
various social groups;
• Sustainability: ecohealth research should aim to make ethical, and
lasting changes which are environmentally sound & socially acceptable.
24. Case studies: added value of Eco health
Optimizing Rabies Control in Bali: An Ecohealth Approach.”
25. Case studies: added value of Eco health
Optimizing Rabies Control in Bali: An Ecohealth Approach.”
The problem:
• Rabies is an emerging zoonoses since its introduction
• Conventional control measures show limited success
Objective:
To help the government of Bali in controlling rabies in dogs
through better understanding of the dog population, dog
demography in Bali and its relationship with the local community.
Conventional vet approach:
Vaccination & population control (sterilisation)
26. Case studies: EH Framework
Optimizing Rabies Control in Bali
Socio‐science
Media
Private sector
Political perspectives
‐Social cultural
believes
‐Social
acceptance
‐ Vaccines
‐Law and regulation
Tourism:
‐ Major source of
income
Community
‐ Acceptance
‐ Feasibility
‐ Enforcement
Vet Science
Control of Rabies
in Bali
Environments
Waste problems
Monkeys
‐Epidemiologist
‐ Practionaires
‐ Capacity
Human health
- Capacity
Acceptance
27. Case studies: added value of Eco health
Optimizing Rabies Control in Bali: An Ecohealth Approach
Eco Health perspective:
Apart from a “classical” control implemented by
Government and agencies (FAO) a set of studies was
designed to reflect dog population, communities
believes, behaviors and empowerment
33. Dog Fecundity Study ‐ Methodology
• Information collected:
• Birth frequency and time
•
•
•
litter size
male to female ratio of litter
puppy mortality, puppy movement
•
pregnancy and birth, heat activity,
• Data were collected 3 times, at month 1, 6, and 12 of the study,
by interviewing its owner using a structured questionnaire
37. Dog Behavior Study
Objective: to understand the daily behavior of the
free‐ranged dog population
Outcome: Information on the average daily activity,
home range, and contact frequency of free‐ranged
dogs with other dogs, animals, and human
38. Dog Behavior Studies ‐ Methods
26 villages randomly chosen from 3 Districts
Total 69 dogs
Observation for 48 hours non‐stop/dog by 3
Research group team (8 hours shift)
The first dog seen when arriving at the center of
the selected village
3 types of data
1. Data on activity of the dogs
2. Data on dogs movements; and
3. Data on feed source of the dogs
39. Dog Behavior Studies – Selected results
Average home range for juvenile dogs of 0.23 km2
and 0.49 km2 for adult dogs
Dogs travelled up to 2.7 km in the 48 hour
observation period (mean <1km).
ali dogs were active and had most contacts with
other dogs in the early morning (1‐3 am) and during the
night from 10‐11pm
If dogs are confined during time of highest contact,
then contact rate could be reduce by x%
42. Dog Demography survey ‐ methodology
•Village survey including all dogs within the village
borders
•Each village surveyed for 6 days.
•Door to door survey: to count contained pet dogs
•Photographic capture and recapture (free ranged dogs)
For counting of free‐ranged dogs
Research team will go through the whole village and
photograph all dogs within 25 meters, for 6 consecutive
days. New dogs and recaptured dogs (photographed again
on a different day) will be identified and counted.
46. Study on Social Cultural Relationship
between People and Dogs
Objective: To understand the social cultural
relationship
community
between
dogs
and
the
Balinese
Study conducted on a banjar level.
Banjar ‐ smallest social structure in Bali which is
based on tradition; it is different from the
government’s
village
structure
and
one
government village can contain several banjars
47. Study on Social Cultural Relationship
between People and Dogs ‐ Methodology
10 randomly selected banjars, which will consist of 5
banjars with a history of rabies in human and 5 banjars
with no history or rabies
Focus group discussions:
qualitative data to understand respondent feelings, concerns,
and perspectives regarding dog ownership and management.
Household survey questionnaires
quantitative data, to demonstrate the magnitude of the socio‐
cultural impacts on how dogs are seen and managed in Bali.
49. Study on Social Cultural Relationship
between People and Dogs – Results
Most of the Balinese prefer male dogs because they will not
produce offspring
let animals roam during the day and restrain them at home at
night
provide food
The attitude towards dog ownership and rabies control in
general were positive and very similar in banjars:
with experienced human rabies cases (97.3%)
and those that had remained free (96.7%).
60. Conclusions – Perspectives ‐ Challenges
• Information on dog ecology information could be used in
general for Indonesia, but should be adjusted to the local
context
• Described social cultural characteristics are specified for
each local area (e.g. Bali VS. Kalimantan or Flores)
• Used community engagement for a better rabies control
was able to have a wide outreach
• Only conventional approach to control rabies has failed
to be successful in Bali
• Demonstrated integrated approach can help to make
needed conventional approaches more effective
• Sustainability !