Rabies in Bali: A chronology and experience made with an EcoHealth approach for a better control of rabies
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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.
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Rabies in Bali: A chronology and experience made with an EcoHealth approach for a better control of rabies
- 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
- 17. Rabies Bali – Dog elimination ‐ Mass media Rabid Dogs Kill 78 in Holiday Hotspot of Bali Published August 02, 2010, Associated Press Read more: http://www.foxnews.com/travel/2010/08/02/rabid‐ dogs‐kill‐holiday‐hotspot‐bali/#ixzz2Tk5mr8oC CBS/AP/ August 2, 2010, 10:07 AM Killing 200,000 Dogs Doesn't Halt Rabies in Bali MORE ABOUT RABIES ‐ WHY KILLING DOGS DOESN’T STOP THE VIRUS http://www.baliadvertiser.biz/articles/greenspeak/2010/killing_ dogs.html Collars not cruelty in Bali: Saving street dogs from strychnine http://www.wspa‐international.org/red‐collar/case‐ studies/#.UZjMKsof2nY
- 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
- 29. General Information on study area and time Location: ‐ Randomly selected villages, located in 3 districts ‐ District Karangasem, District Gianyar, District Denpasar Time: ‐ December 2010 – ongoing 2013 Data : Survey, observation, interview, focus group discussion, etc
- 32. Dog Fecundity Study ‐ Objectives & Methodology To get information on the fecundity of free‐ranged owned dogs and offspring characteristics and dynamics Sampling background: 100 Female Fertile Dogs Criteria • Fertile (not neuter) • Age > 1 year – 12 years (max) • Owned but free roaming dogs • Willingness the owner to participate in the study
- 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
- 35. Dog Fecundity – selected first results • 78% of dogs were of local Bali breed, 5% of exotic breed and 17% of mixed breed between local and exotic dogs • Of the 164 puppies, 30 died (18.3%), 84 were kept and were still alive at the time of the study (51.2%), 47 were given away (28.7%), 2 were sold (1,2%), 1 was lost (0.6%) and none were throw away. • Movement of puppies, given to others, could pose a risk for rabies spread across village, sub‐district or district borders especially if puppies are not routinely vaccinated) : approx. 30% were given away (28.7%) or were sold (1,2%). Source CIVAS
- 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%
- 41. Dog Demography Study Objectives: To better estimate the current dog population and demography Outcome: Estimates on dog population Dog to human ratio
- 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.
- 43. Dog Demographie and population survey The contained dog population will be counted as it is, while the estimated free‐ranging dog population will be calculated using the following formula by Beck (1973): K = estimator of total population Xi = daily captured total Xi,m = dogs previously photographed Xm = Xi ‐ Xi,m = dogs photographed for the first time or recaptured
- 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.
- 48. Social Culture Study – Methodology ‐ Overview Period of survey: 5 Months (February ‐ June 2011) Population of the Study 5 Vill. Rabies Cases 10 banjars 5 Vill. Non‐Rabies cases Data Collection QX and FGD • Governments officers • Religious/Cultural groups • General Public
- 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%).
- 53. Awareness for Elementary Schools Media: Presentation Brochure Poster Song (AYO CEGAH RABIES) arr by Drh. Ni Wajan Leestyawati-Bali Provincial Livestock offices
- 54. Community Empowerment in 2 Pilot Villages Targets Community in the Village + School Community Village 1 ( Positive case in Animal +Bite Case in human ) • Elementary School (4 ES) • Sub‐Villages (6 SV) Village 2 (Positive case in Animal +Positive Case in human ) • Elementary School (8 ES + 1 Junior high School ) • Sub‐Villages (10 SV)
- 57. Community based cadres for rabies control Source: CIVAS
- 58. Quotes of Community Opinion “I am glad to see my son can care of his dog more better, even telling her parents and people around him to take care the dogs responsibly. Socialization to children is important and already seen results, it needs to be continued” (I Wayan Subur – Banjar Bayad, Ds. Melinggih Kelod ; Evaluasi & Monitoring Meeting , Mar 12) “Socialization to school children has given benefits in our community. Please continue . Equipped with visual media or impressions of events, because such a community in banjar% u2013 they will care more about having seen film rabid“ (I Nengah Suparta– Banjar Dukuh, Ds. Sibetan ; Dialog Desa – Aug 12 Source: CIVAS
- 59. Next Plan • Result presentation to government (provincial livestock services) – advocation & legitimation • Paper & Film Publication • Phase II: To implement programs which are designed based on results of the first phase, such as: • Programs include: • Further public awareness • Community‐based dog registration • Community‐based rabies vaccination
- 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 !
- 62. Special thanks to the Team Members of Indonesian EcoZD Rabies Study for the provided information : • • • • • Anak Agung Gde Putra Iwan Willyanto Edi Basuno Soelih Estoepangestie Ari Rukmantara • • • • • M.D. Winda Widyastuti Sunandar Andri Jatikusumah Riana Aryani Arief Chaerul Basri More details will be presented by the CIVAS team at KVAC Khon Kaen , 6‐7th of June 2013 Thank you