What resource environment this case is relevant to? How does it affect the disease impact on the population health? Why? Evaluate local public health structures and acti

SYSTEMS AND DISEASE

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C o p y r i g h t 2 0 1 6 . 5 m P u b l i s h i n g .

A l l r i g h t s r e s e r v e d . M a y n o t b e r e p r o d u c e d i n a n y f o r m w i t h o u t p e r m i s s i o n f r o m t h e p u b l i s h e r , e x c e p t f a i r u s e s p e r m i t t e d u n d e r U . S . o r a p p l i c a b l e c o p y r i g h t l a w .

EBSCO Publishing : eBook Collection (EBSCOhost) – printed on 3/22/2023 12:15 PM via UNIVERSITY OF MARYLAND GLOBAL CAMPUS AN: 1510846 ; Susan Cork, David Hall, Karen Liljebjelke.; One Health Case Studies : Addressing Complex Problems in a Changing World Account: s4264928.main.eds

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chapter 2 One Health approaches to rabies

control in Bali, Indonesia

David C. Hall, Anak Agung Gde Putra, Iwan Willyanto and Edi Basuno

2.1 Introduction

Rabies is one of the first reported diseases in written history. As early as 2200 bce, writings from Mesopotamia link dog bites with ill- ness in humans exhibiting rage-like symptoms (Adamson, 1977; Theodorides, 1974; Pritchard, 1955). In the eighth century bce, Homer wrote in The Iliad of ‘menin’ to describe the rage of Achilles and ‘lyssa’ in reference to Achilles’ rage, from which we derive the words meningitis1 and lys- savirus.2 By the sixth century bce, rabies was in China and thought to have expanded into Asia. More than four millennia after the first writings on canine rabies and despite development of a

vaccine by Pasteur and Roux in 1885, rabies is still a major disease burden for many parts of the world, causing not just death but also economic stress on health systems where post-exposure prophylaxis (PEP) treatment and vector control campaigns are mobilized. This chapter explores an epidemic of rabies in Bali, Indonesia, and examines elements of a One Health approach used in the epidemic and the impact of that approach.

The island of Bali is known for its beautiful beaches, Hindu culture and temples, and ter- raced rice fields amid integrated agricultural communities. Prior to late 2008, unlike most of Indonesia, there was no record of rabies in

Abstract

In 2008, Bali, Indonesia saw its first case of rabies. Initially the response was to cull unconfined dogs with limited vaccination, a response that did not control the epidemic. Following engage- ment with villagers, epidemiologists, ecologists and NGOs, and with assistance from the FAO and international researchers, a One Health approach was adopted focusing on understanding the complexity of dog ecology in Bali, community engagement and improved communication. The current approach follows a capture, vaccination, collar and release plan for unconfined dogs. Domesticated dogs are vaccinated and sterilization encouraged. At least half of all dogs on Bali are thought to have been vaccinated, and cases of human rabies have declined since 2010, although the epidemic continues.

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14 David C. Hall, Anak Agung Gde Putra, Iwan Willyanto and Edi Basuno

Bali. However, in November 2008 the death two months earlier of 46-year-old Putu Linda was diagnosed as being a result of rabies, probably brought to the island several months before that on a fishing boat from neighbouring Flores (Putra, 1998; Putra and Gunata, 2009).

The response to controlling the rabies epi- demic in Bali presents a compelling case study for supporting a One Health approach to health management. All six of the classic pillars of ecohealth are present, briefly identified here. Understanding the complexity of the epidemiol- ogy of the rabies epidemic has required learning about canine ecology on the island as well as the social and cultural importance of the dog in Bali society. Consideration of various alternative strategies to control the spread of the disease has taught that community participation is essential, particularly for sustainability of con- trol. Social inequity plays a role where members of lower-income communities are less likely to have attained higher levels of formal education allowing clearer understanding of the etiology of rabies and the importance of rapid post- exposure treatment to dog bites. Finally, learning from past efforts can inform local and national rabies policy, particularly with respect to how to engage with communities in order to foster sustainable approaches to control.

This chapter will briefly explain the history of the rabies epidemic in Bali, the approaches to control used thus far, and recommendations for furthering a One Health sustainable approach to managing control and local elimination of rabies in Bali and neighbouring islands in Indonesia.

2.2 Rabies in Bali – an outline of the epidemic

Until 2008, Bali was known as one of the very few Indonesian provinces that had never seen a case of rabies, in part due to the fact it is an island but also due to strict quarantine measures

for dogs brought onto the island. Although the latter control measure was generally respected by fishermen who travelled with their dogs as companions between the islands in the area, the index case of canine rabies was most likely in a dog brought to Bali by a fisherman probably from neighbouring Flores Island, where rabies was known to exist. This is supported by phy- logenetic analysis of the rabies strain in Bali (Mahardika et al., 2014), which is a descendent of the Kalimantan 00-18 strain, correspondingly an ancestor of the Flores and Sulawesi strains. By November 2008, two villagers had died of clinical signs consistent with rabies, and on 30 November, the governor of Bali declared rabies present on the island.

With full awareness of the importance of a rapid response to the introduction of this fatal zoonotic disease, in December 2008 the provin- cial government of Bali began a two-pronged approach to rabies control: (1) culling of uncon- fined dogs in the rabies confirmed regencies of Denpasar and Badung with the use of strychnine bait and blow-dart methods; and (2) vaccina- tion of dogs at selected locations with a locally produced vaccine that required a booster three months after first vaccination. From a survey of dog owners in Badung Peninsula (Putra et al., 2011), it was estimated that up to 40 per cent of all known dogs in Badung and Denpasar were vaccinated by March 2009; of those, slightly more than half received a booster vaccination by June 2009, suggesting effective protection of about one quarter of the owned dog population.

The low coverage of vaccination combined with other factors to suggest this approach would not be successful. For example, dog density is about one in eight in Denpasar, and most dogs are communally owned, fed and free- roaming (Morters et al., 2014), meaning human/ dog encounters resulting in bites from unvac- cinated dogs would not be uncommon. By September 2010, rabies was confirmed present in 221 or one-third of all villages in Bali. It was

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One Health approaches to rabies control in Bali, Indonesia 15

accepted that the rapid response had failed to control the rabies epidemic.

Involvement of NGOs and outside agencies

By 2010, a number of charitable organizations as well as outside government aid agencies had begun to participate in the efforts to reduce rabies in Bali. These included the Bali Animal Welfare Association (BAWA), the World Society for the Protection of Animals (WSPA, now called World Animal Protection), the Australian govern- ment (AusAID), the United States government

(USAID), the International Development Research Centre of Canada (IDRC) and the Food and Agriculture Organization of the United Nations (FAO). BAWA and AusAID led the charge in late 2010 to use vaccination (as well as sterilization) rather than culling as the sole tactic in the rabies containment and elimination strategy for Bali. This was through a Memorandum of Understanding developed in agreement with the governor of Bali and most regencies of Bali, indicating an early will- ingness of key stakeholders to discuss and agree on approaches for control, particularly when it included funding support for costly vaccines.

The strategy developed in late 2010 included several components that can be seen as incorpo-

Table 2.1 Timeline of rabies in Bali, Indonesia

Jan–May 2008 Rabies probably arrives via a dog from a neighbouring island (e.g., Flores Island); settles in Ungasan Village, Bukit Peninsula, Bali.

Jul 2008 Dog from Flores, normally placid, bites owner (Mr TA) and is claimed to have bitten a friend in August; this is thought to be the first human infection with rabies in Bali.

6 Sep 2008 Female child (Miss L) bitten in Ungasan village.

9 Sep 2008 Male adult (Mr MA, aged 32) bitten.

16 Sep 2008 Male adult (Mr KW, aged 28) bitten in Ungasan village.

17 Sep 2008 Miss L dies (thought to be first human death of rabies in Bali).

Sep 2008 Ms Putu Linda (aged 46) dies of rabies, diagnosed on post-mortem examination.

19 Oct 2008 Muhammad Oktav Rhamana Putra (male, aged 3) in Ungasan Village bitten by stray dog; PEP denied at Sanglah Hospital, Denpasar, Bali due to presumed absence of rabies on Bali.

14 Nov 2008 Mr MA dies.

21 Nov 2008 Muhammad Oktav dies after exhibiting clinical signs consistent with rabies.

23 Nov 2008 Mr KW dies.

24 Nov 2008 Regent of Badung requests rabies vaccines be sent to Bali.

26 Nov 2008 Human bitten in Kedonganan by a dog that later dies and is diagnosed positive for rabies using fluorescent antibody technique.

30 Nov 2008 Indonesian Department of Agriculture declares rabies present on Bali.

Dec 2008 Provincial government of Bali launches canine cull and vaccination campaigns.

16 Jan 2009 Mr TA dies (six months post-infection).

Apr 2013 130 people reported dead from rabies; PEP administered to more than 130,000 people following dog bites.

July 2015 Rabies deaths in humans has started to rise again; one in 2013 to 12 by July 2015.

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16 David C. Hall, Anak Agung Gde Putra, Iwan Willyanto and Edi Basuno

rating a One Health approach. These included a transdisciplinary approach to a vaccination strat- egy (dog ecology was recognized as important, as well as understanding the epidemiology of the disease and a communication plan) intend- ing to vaccinate 70 per cent of the dogs in Bali; a community education component, recognizing the importance of collaboration and community participation; and addressing equity by offer- ing free vaccination for those who could not afford to pay to vaccinate their dogs. As many as 239,000 of the more than 500,000 dogs in Bali were thought to have been vaccinated under this first stage of vaccination. A second stage was due to vaccinate 235,000 dogs, and a third round would cover 250,000 additional vaccinations. By the time of the second stage, responsibility for second implementation of the vaccination programme and subsequent phases had been assumed by the governments of Bali and Indonesia with strong technical coopera- tion assistance from FAO. Although a red collar programme existed, it was not possible to collar most free-roaming dogs (the majority of dogs in Bali) and thus it was not clear how many dogs were being revaccinated.

An additional element critical to surveillance for rabies was the integrated bite case man- agement (IBCM) system, generated through cooperation between animal and human health authorities and designed to improve both sur- veillance for rabies cases and medical response to human exposure. Bali is also home to a large number of chick hatcheries, and the ICBM sys- tem benefitted from Indonesia’s and Bali’s need for effective One Health surveillance experience with highly pathogenic avian influenza (HPAI), which resulted in several outbreaks in Bali as well as human illness and death. The experience with HPAI outbreaks led to development and col- laboration of a veterinary Participatory Disease Surveillance and Response (PDSR) programme and a human health District Surveillance Office (DSO) programme; it was around the experi-

ence and success of these HPAI surveillance and response programmes that the ICBM system was developed. An important part of the ICBM system has been a coordinated SMS messag- ing protocol used to communicate events and alert system members to possible rabies-linked events, accelerating response time and in order to ensure both animal and human health officials are aware of possible need for medical or other intervention.

Although the strategy was admirable in its efforts to bring together government, local and international agencies, and community mem- bers, the full logistics of the strategy were slow to roll out, delaying a second stage until May 2011. This difficulty in logistics (in hindsight, ‘operationalizing’ the One Health approach) may have been a costly opening in the vaccination coverage that began to roll out in 2010. From that point forward, the government of Bali with directive from the government of Indonesia and continuing input from FAO took charge of the rabies control campaign. Different stakeholders have varying views on reasons for this, but the summary conclusion seems to be concern on the part of the government that rabies cases were not decreasing rapidly enough under a vaccina- tion-only campaign, and it has since resorted to occasional sweeps of culling free-roaming dogs.

In hindsight, there was considerable prog- ress towards a 70 per cent coverage in several regencies by 2012 – including Denpasar, Badung, Gianyar and Bangli – which saw more than 235,000 dogs vaccinated in each of the two vaccination campaigns (Putra et al., 2013). However, it is impossible to say how many dogs were repeat vaccinates, how many escaped vac- cination altogether and how many were simply inaccessible, leaving the claim of 70 per cent total coverage on the island unclear. Further challenges in the 2010 and 2011 campaigns were cold chain management, varying access to and supply of vaccine, funding liquidity and data reporting and management.

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One Health approaches to rabies control in Bali, Indonesia 17

At time of writing, rabies remains in the dog population in Bali. By July 2015 there were 12 more human deaths from canine rabies and there continue to be human/dog confrontations with dog bites numbering around 150 a year (see Figure 2.1). As a result, the official target for freedom from rabies in Bali has been pushed out to 2016. The government of Bali continues to recognize vaccination and sterilization as valid options for rabies control but also actively and vigorously pursues culling of free-roaming dogs (Erviani, 2014), noting that in their opinion, control results from vaccination alone have been slow and not completely satisfactory.

2.3 Dogs in Bali

The dog plays an important cultural role in Balinese society, adding further complex- ity to the mix of dog ecology and stakeholder interaction that continues to be a part of the investigation of rabies epidemiology in Bali. The fact that most Balinese dogs are free-roaming further confounds the issue. Both the cultural

role and free-roaming as an issue for disease control are described here.

The dog has long been a part of community life in Bali, functioning as a guard dog for house and garden, a companion in hunting and fishing, and a pet (Putra et al., 2011). Most Balinese are Hindu; in Hindu culture, the dog is referred to as the guardian of Heaven and Hell. Caring for dogs is thus considered a conduit to Heaven, as well as a way to avert calamity (Lodrick, 2009). As well, certain colours of dogs are used in cultural ceremonies by the Balinese, who also believe dogs may cure certain diseases and prevent mis- fortune. Clearly, killing off all the dogs would not be a culturally respectful nor reasonable approach to rabies control.

Dog ecology

Dog ecology has been studied and reported as part of understanding, designing and interpret- ing the sero-epidemiology of rabies in Bali by Putra and colleagues in several Balinese publi- cations (Putra and Gunata, 2009; Putra et al.,

Figure 2.1 Confirmed human rabies deaths in Bali, 2008–2015 (2015 data are up to June 2015)

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18 David C. Hall, Anak Agung Gde Putra, Iwan Willyanto and Edi Basuno

2009, 2011). It was also noted as an important part of a transdisciplinary, ecohealth-based approach to policy formulation to address rabies in Bali (Willyanto et al., 2012). These studies have identified several important findings with respect to free-roaming indigenous (kampung) dog ecology including:

• There are close to half a million free-roaming dogs in Bali and about 10,000 ‘high bred’ dogs (i.e., not free-roaming and kept as house pets).

• The free-roaming dog-to-human ratio is about 1:8.

• The largest age group of free-roaming dogs captured, vaccinated and released are less than one year of age.

• The majority of free-roaming dogs observed are three years of age or younger.

• Dog density is highest around urban areas at 256/km2, with density in peri-urban at 184/ km2 and rural village areas at 129/km2.

• Puppies are least likely to be born during the wet season (December to May).

• Free-roaming dogs tend to congregate near sites associated with people and food includ- ing temples, garbage drops, markets and beaches.

• Among kampung dog-keepers (e.g., fishermen, guard dog needs), there is a preference for an intact male dog.

In a rabies control and elimination campaign, knowledge of dog ecology can be highly valuable to increasing efficacy. From the work conducted in Bali, we know a well-planned strategy would target truly free-roaming dogs (such as catch, vaccinate, tag and release tactics) as well as con- tained dogs, although the former are far more difficult to handle and vaccinate. A strategy should also consider that free-roaming dogs tend to stay close to human habitation, very young dogs will require a second booster in a matter of months, and vaccination programmes would be

best to target two seasons: first, the pre-breed- ing season in the first two months of the year and, second, in October and November with the appearance of new-born puppies.

From the above data and estimates from Putra et al. (2011, 2013), it seems the coverage rate of free-roaming dogs in the first two waves of vac- cination was closer to 10 per cent, which was far from the minimum of 70 per cent required to stop maintenance of the disease in the dog population. As well as the challenges noted above, understanding of dog ecology in Bali as well as the role of communities and coopera- tive coordination with government was crucial to mounting a successful catch-and-release vaccination campaign.

2.4 Community/participatory approach

The response to the Bali rabies epidemic has demonstrated the need for a participatory approach to solving a complex problem, involv- ing numerous stakeholders including several levels of government, health professionals including veterinarians and physicians, epide- miologists and ecologists, communications and logistics experts and, of course, members of the local community. The village community plays a particularly important role in Bali in part because of the free-roaming nature of the dogs, making it difficult for outsiders to identify locally cared- for dogs that are fed and considered part of the community.

Communication is a vital element of a suc- cessful participatory approach to rabies control as much for human post-exposure treatment as prevention and control of rabies in dogs. Of 104 cases of human rabies investigated from 2008 to 2010 (Susilawathi et al., 2012), 92 per cent had history of a dog bite but fewer than 6 per cent had their wounds treated and received PEP vaccine (none received PEP immunoglobulins).

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One Health approaches to rabies control in Bali, Indonesia 19

The authors concluded this was primarily due to lack of awareness of rabies risk, understanding of rabies in dogs or the need for urgent post-bite care, and limited awareness or availability of PEP treatment. Because Bali had been free of rabies up to 2008, there was a general lack of awareness or concern for either rabies following a dog bite or for control of rabies in communities. Thus communication and educational programmes would be essential to raising public awareness and assisting in identifying rabies cases in dogs, helping human bite victims seek urgent medical care, and implementing a surveillance and rapid response mechanism.

Effective collaboration with community part- ners can take several years to foster and maintain, but in a transdisciplinary participatory approach, community members are as vital a stakeholder as governments and scientists. Components of effective collaborations with communities in Bali vary depending on the regency and community, but there are several commonalities:

• Communities are a part of the government- led PDSR/DSO and ICBM programmes.

• Multilevel age-appropriate training and edu- cation programmes in recognizing the threat of rabies and management of free-roaming dogs in the community.

• Heightened awareness of how to respond to dog bites.

• Improved participation in mass rabies vac- cination of dogs including post-vaccination marking with a long-lasting collar to prevent culling of vaccinated dogs.

• Training and signposted identification of community members who act as village rabies awareness wardens; children are taught to seek help from these respected commu- nity members in the event of dog threats or attacks.

• Community environmental management to reduce the risk of rabies including garbage management.

• Improved animal welfare of free-roaming dogs including veterinary care and awareness of sterilization as a healthy option to prolong the life and welfare of all dogs.

It is worth noting the importance of a com- munity-based One Health approach in rabies control has been appreciated in other countries in Asia, notably Bhutan. The dog-neutering pro- gramme in Bhutan ensures that feral dogs are also vaccinated against rabies during concurrent public awareness campaigns and vaccination of pet dogs. The neuter and vaccination pro- gramme is well described in Tenzin et al. (2012a, 2012b), and engages veterinary professionals, para-professionals and community members. The awareness programme engages profession- als from human and animal health and includes the development of new inter-sectoral govern- ment guidelines for the prevention of rabies in humans. The ongoing collaborations (at all lev- els of government service) and the joint disease investigations conducted by field staff from the Department of Public Health and Department of Livestock in Bhutan demonstrate a genuine commitment to the One Health approach.

2.5 Impact on tourism

More than 40 per cent of tourism income in Indonesia comes from Bali (Bali Daily, 25 January 2013), generating more than US$5.4 billion in 2012, up from US$4 billion in 2011. The eco- nomic impact on tourism in Bali attributable to fear of rabies has not been calculated. However, despite travel warnings for Bali because of rabies that have been issued by the governments of Australia, UK and the US, arrivals to Bali have increased significantly every year since the first case was reported (Figure 2.2) and show no sign of decreasing. The absence of evidence of a slowdown in tourism is made more surpris- ing given that Indonesia is the second highest

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20 David C. Hall, Anak Agung Gde Putra, Iwan Willyanto and Edi Basuno

reported country after Thailand for travellers who were bitten by animals and received rabies PEP (Gautret et al., 2015). Despite these data being made available to travellers online and via health personnel, there seems to be a general lack of awareness among travellers of the risks, as well as a lack of pre-travel advice issued by health professionals. Furthermore, most trav- ellers neither seek nor receive pre-exposure rabies vaccination (Gautret et al., 2015), and of those who are bitten, less than a third seem to seek any medical care at all (Piyaphanee et al., 2012). Our conclusion is that rabies has had no appreciable impact on tourism in Bali, but that travellers and health professionals may not be well aware of either the epidemic or pre-travel prevention options.

Policy development

Prior to the rabies epidemic in Bali, no policies existed for dog control, dog-bite surveillance or canine rabies vaccination. Today there are mul- tiple informal policies in place to address these

matters, including the guidelines for engage- ment and support of the PDSR, DSO and ICBM programmes described above. A formal rabies control and elimination policy recognized by provincial and federal governments and formu- lated with the cooperation of all stakeholders, whether it be a set of standard operating pro- cedures or a provincial decree, has not been developed in Bali. Current vaccination policy is guided by two main elements: first, techni- cal cooperation agreements that are developed between the governments of Bali and Indonesia and partners including FAO, international donors and NGOs; and, second, community-led initiatives that operate as part of wider pro- grammes.

Well-developed One Health policies are needed for broad zoonotic control and elimi- nation programmes to guide science-based decision-making and allocation of resources in a coordinated manner with understanding of lon- ger-term needs such as the role of surveillance, while being cognisant of shorter-term demands including controlling free-roaming biting dogs and having urgent access to PEP treatment. But

Figure 2.2 Arrivals of foreign tourists to Bali, Indonesia from 2008 to 2014. Calculations by Hall using data

from Bali provincial government.

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One Health approaches to rabies control in Bali, Indonesia 21

just as is the case for HPAI in Southeast Asia (Cork et al., 2015), policy to support rabies con- trol in Bali faces a challenge: how to formulate strict and enforceable standards while minimiz- ing disruption of property rights. The benefits of a One Health approach to this policy formu- lation problem include the opportunities for dialogue and agreement among stakeholders by taking a participatory approach, recognition of the complexity of a health problem allowing changing standards and methods, and adopting a transdisciplinary approach that reduces mar- ginalization of important stakeholders while bringing together critical expertise.

Among the policy challenges Bali faces in rabies control and elimination are two important barriers that have yet to be overcome: a reliance on foreign aid for programme inputs including vaccines, and clear distinction between commu- nity, provincial and central government policy intent and results. Of Indonesia’s total revenue from tourism, at least 40 per cent is generated by Bali (Bali provincial government, 2015), amounting to several billion US dollars per annum. This is clearly worth protecting, but so too does it seem extraordinary that a fraction of these funds are not used to completely cover the costs of maintaining vaccine and PEP supplies. The second barrier is harder to overcome, in part due to the devolution of Indonesian gover- nance structure and responsibility, but here One Health offers part of a means to solution through participatory approaches to problem-solving, and recognition of the importance of addressing social inequities in z

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