Rabies in Bali: A chronology and experience made with an EcoHealth approach for a better control of...

Rabies in Bali ‐a chronology and experience made with an EH approach for a better control of Rabies

Fred Unger ILRI

Training provided to WHO fellowship trainees from Sri Lanka on “Health approaches for rabies control and control of other zoonotic diseases”. Faculty of Veterinary Medicine, CMU, Chiang Mai, Thailand,

20 May 2013.

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

Structure of presentation

• 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.

History of rabies in Indonesia

History of rabies in Indonesia

Island of Bali

5,636.66 km2 or 0.29% of the total Indonesianarchipelago

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

Bali background

21 Nov 2008 DIC Denpasar informed from local authoritiesabout a increase of dog bites in Badung District, Ungusanvillage 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

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.


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 afterthe biting incident. The child received PEP and the dead dog was diagnosed rabies


• 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


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.


= observed villages

Studied Districts

• .


• .

Rabies Bali – First outbreak foci

• 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)


• 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


Rabid Dogs Kill 78 in Holiday Hotspot of BaliPublished August 02, 2010, Associated PressRead 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 VIRUShttp://www.baliadvertiser.biz/articles/greenspeak/2010/killing_dogs.html

Collars not cruelty in Bali: Saving street dogs from strychninehttp://www.wspa‐international.org/red‐collar/case‐studies/#.UZjMKsof2nY

Rabies Bali – Dog elimination ‐Mass media

• 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

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

Rabies Bali ‐ Challenges

Eco Health & One Health versus classical sector approach

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/ )

Introduction: Ecohealth Theory

• Based on 6 principles:

• Systems thinking• Knowledge to action• Transdiciplinary• Participation• Equity • Sustainability

• 4 interacting sub‐systems influence health

Social

PoliticalEconomic

Ecological

An approach to understand complex systems (socio‐economic, socio‐ecological ect)

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.

Case studies: added value of Eco healthOptimizing Rabies Control in Bali: An Ecohealth Approach.”

Case studies: added value of Eco healthOptimizing 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)

Case studies: EH Framework Optimizing Rabies Control in Bali

Control of Rabies in Bali

Socio‐science

‐Social cultural believes

Environments

Waste problemsMonkeys

Human health

- Capacity

Acceptance

Community

‐ Acceptance ‐ Feasibility

Political perspectives

‐Law and regulation

‐ Enforcement

Vet Science

‐Epidemiologist‐ Practionaires‐ Capacity

Tourism:

‐Major source of income

Private sector

‐ Vaccines

Media

‐Social acceptance

Case studies: added value of Eco healthOptimizing 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

Ecohealth Approach

Dissemination: Pilot Village (A community‐based approach) + Awareness in Elementary School

Dog ecology Study (Behavior, Fecundity and Demography of Dog) Social Culture Study

System Thinking(ecohealth

principle (EP) #1)

Knowledge to Action (EP # 2)

Trans‐diciplinary Approach (EP# 3)

Participation (EP # 4)

Equity ((EP # 5)

Sustainability(EP# 6)

Review

Location: ‐ Randomly selected villages, located in 3 districts ‐ District Karangasem, District Gianyar, District Denpasar

Time:‐ December 2010 – ongoing 2013Data :Survey, observation, interview, focus group discussion, etc

General Information on study area and time

= observed villages

Studied Districts

DOG ECOLOGY STUDIES

DOG FEGUNDITY STUDYDOG BEHAVIORDOG DEMOGRAPHIE

SOCIAL CULTURAL STUDYCOMMUNITY EMPOWERMENT(DISSEMINATION)

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

Dog Fecundity Study ‐ Objectives & 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

Dog Fecundity Study ‐Methodology

• 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%).

Dog Fecundity – selected first results

Source CIVAS

Dog Behavior Study

Dog Behavior Study

Objective: to understand the daily behavior of thefree‐ranged dog population

Outcome: Information on the average daily activity,home range, and contact frequency of free‐rangeddogs with other dogs, animals, and human

Dog Behavior Studies ‐Methods26 villages randomly chosen from 3 Districts Total 69 dogs Observation for 48 hours non‐stop/dog by 3Research group team (8 hours shift) The first dog seen when arriving at the center ofthe selected village 3 types of data

1. Data on activity of the dogs2. Data on dogs movements; and3. Data on feed source of the dogs

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 hourobservation period (mean <1km). ali dogs were active and had most contacts withother dogs in the early morning (1‐3 am) and during thenight from 10‐11pm

If dogs are confined during time of highest contact,then contact rate could be reduce by x%

Dog Demography Study

Dog Demography Study

Objectives:To better estimate the current dog populationand demographyOutcome:Estimates on dog populationDog to human ratio

Dog Demography survey ‐methodology•Village survey including all dogs within the villageborders•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 dogsResearch team will go through the whole village andphotograph all dogs within 25 meters, for 6 consecutivedays. New dogs and recaptured dogs (photographed againon a different day) will be identified and counted.

Dog Demographie and population surveyThe 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 populationXi = daily captured totalXi,m = dogs previously photographedXm = Xi ‐ Xi,m = dogs photographed for the first time or recaptured

Dog Demography Study – selected results

Dog : Human Dog Sex Ratio( M : F )

Denpasar 1 : 24 1 : 1(Urban)

Gianyar 1 : 35 3 : 1(Sub‐urban)

Karangasem 1 : 14 3 : 1(Rural)

Source: CIVAS

Study on Social Cultural Relationship between People and Dogs

Study on Social Cultural Relationship between People and Dogs

Objective: To understand the social culturalrelationship between dogs and the Balinesecommunity

Study conducted on a banjar level.Banjar ‐ smallest social structure in Bali which isbased on tradition; it is different from thegovernment’s village structure and onegovernment village can contain several banjars

Study on Social Cultural Relationship between People and Dogs ‐Methodology

10 randomly selected banjars, which will consist of 5banjars with a history of rabies in human and 5 banjarswith no history or rabies

Focus group discussions:qualitative data to understand respondent feelings, concerns,and perspectives regarding dog ownership and management.

Household survey questionnairesquantitative data, to demonstrate the magnitude of the socio‐cultural impacts on how dogs are seen and managed in Bali.

5 Months (February ‐ June 2011)Period of survey:

Population of the Study

10 banjars

5 Vill. Rabies Cases

5 Vill. Non‐Rabies cases

• Governments officers• Religious/Cultural

groups• General Public

Social Culture Study – Methodology ‐ Overview

Data Collection QX and FGD

Study on Social Cultural Relationship between People and Dogs – Results

Most of the Balinese prefer male dogs because they will notproduce offspring let animals roam during the day and restrain them at home atnight provide food

The attitude towards dog ownership and rabies control ingeneral were positive and very similar in banjars:with experienced human rabies cases (97.3%) and those that had remained free (96.7%).

COMMUNITY EMPOWERMENT IN 2 PILOT VILLAGES AND AWARENESS FOR ELEMENTARY SCHOOLS

Awareness for Elementary SchoolsProviding information and knowledge on rabies and pet ownership responsibility to elementary students

Objectives

Community Empowerment Empowered the community to participate actively on rabies control program independently• by increasing their understand and knowledge on rabies• identification and training of cadres

Approaches and tools

Community Engagement

Focus Group DiscussionPresentation

Interactive DiscussionMedias (film, song, poster, leaflet)

Training (class teaching, scenario‐simulation) Monitoring – evaluation

Media:Presentation

Brochure

Poster

Song (AYO CEGAH RABIES) arr by Drh. Ni Wajan Leestyawati-Bali Provincial Livestock offices

Awareness for Elementary Schools

Community Empowerment in 2 Pilot Villages

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)

Targets Community in the Village + School Community

SCHOOL

(1) School Community

Public Awareness for

Students

Short Seminar for Teacher

•Elementary + Junior High School•2 step program ‐ Pre‐post test evalu•Classes presentation, movie, singing,

scenario, interactive discussion

≥ 40% targeted students increase their knowledge

Connecting to livestock & health

service office, village leader

Source: CIVAS

(2) Banjar Program

Identification of Village

CharacteristicsSosialization / Information

Transfer Proccess

Selection for Rabies Cadres

Training for Rabies Cadres

Monitoring ‐Evaluation & Program Adjusment

•Banjar Status (Dog Registration,

Update Rabies Cases, Knowlegde Change, Behavior Change)•Cadres Activities(Sosialization, dog registration, case repport follow‐up)

FGDPresentation

Movie

(FGD +Banjar Head Approach)

•Father, Mother, Youth•Head of banjar, gov officer, teacher, community

*Mother –Father‐YouthCommunity

* Topography, rural‐suburban* Community behavior

*classes presentation, scenario‐simulation, next plan* Rabies, pet‐ ownership responsibility, cadres & communication technique, dog registration program

1

2

3

4

5

Source: CIVAS

Community based cadres for rabies control

Source: CIVAS

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

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

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 !

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

Thank you

More details will be presented by the CIVAS team atKVAC Khon Kaen , 6‐7th of June 2013

ILRI and where it works

Head quarter in Nairobi

ILRI outposts in SE Asia:Jakarta, Hanoi, Vientiane, Chiang

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