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


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 …

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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  • 1. 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. 
  • 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.
  • 4. History of rabies in Indonesia
  • 5. Island of Bali 
  • 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.
  • 12. Studied Districts = observed villages
  • 13. Rabies Bali ‐ Chronology  • .
  • 14. Rabies Bali – First outbreak foci • .
  • 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:‐ 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 dogs.html Collars not cruelty in Bali: Saving street dogs from strychnine http://www.wspa‐‐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 ( ) 
  • 22. Introduction: Ecohealth Theory • Based on 6 principles: • • • • • • Systems thinking Knowledge to action Transdiciplinary Participation Equity  Sustainability • 4 interacting sub‐ systems influence  health Social Economic Political Ecological An approach to understand complex systems (socio‐economic, socio‐ ecological ect) 
  • 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
  • 28. Ecohealth Approach Review Dog ecology Study  (Behavior, Fecundity  and Demography of  Dog)  Social Culture Study Dissemination:  Pilot Village (A  community‐based  approach) +  Awareness in  Elementary School Knowledge to  Action (EP # 2) System  Thinking (ecohealth  principle (EP) #1) Trans‐diciplinary  Approach (EP# 3) Participation (EP # 4) Equity ((EP # 5) Sustainability(EP# 6)
  • 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
  • 30. Studied Districts = observed villages
  • 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
  • 34. 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
  • 35. Dog Behavior Study
  • 36. 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
  • 37. 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
  • 38. 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%
  • 39. Dog Demography Study
  • 40. Dog Demography Study Objectives: To better estimate the current dog population and demography Outcome: Estimates on dog population Dog to human ratio
  • 41. 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.
  • 42. 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
  • 43. 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
  • 44. Study on Social Cultural Relationship  between People and Dogs 
  • 45. 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
  • 46. 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.
  • 47. 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
  • 48. 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%).
  • 50. Objectives Awareness for Elementary Schools Providing information and knowledge on rabies and pet  ownership responsibility to elementary students 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
  • 51. Approaches and tools  Focus Group Discussion Presentation Interactive Discussion Medias (film, song, poster, leaflet) Training (class teaching, scenario‐simulation)  Monitoring – evaluation Community  Engagement
  • 52. Awareness for Elementary Schools Media: Presentation Brochure Poster Song (AYO CEGAH RABIES) arr by Drh. Ni Wajan Leestyawati-Bali Provincial Livestock offices
  • 53. 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)
  • 54. (1) School Community  Public  Awareness for  Students S C H O O L Connecting to  livestock & health  service office, village  leader 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 Source: CIVAS
  • 55. (2) Banjar Program Identification  of Village  Characteristics 1 FGD Presentation Movie (FGD +Banjar Head  Approach) •Father, Mother,  Youth •Head of banjar, gov  officer, teacher,  community Source: CIVAS *Mother –Father‐Youth Community * Topography, rural‐suburban * Community behavior Sosialization  / Information  Transfer  Proccess 2 Selection  for Rabies  Cadres 3 Training for  Rabies  Cadres *classes presentation, scenario‐ simulation, next plan * Rabies, pet‐ ownership responsibility,  cadres & communication technique,  dog registration program  •Banjar Status  (Dog Registration,  Update Rabies Cases,  Knowlegde Change,  Behavior Change) •Cadres Activities (Sosialization, dog  registration, case  repport follow‐up) 4 Monitoring ‐ Evaluation  &  Program  Adjusment 5
  • 56. Community based cadres for rabies control Source: CIVAS
  • 57. 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
  • 58. 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
  • 59. 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 !
  • 60. 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
  • 61. ILRI and where it works Head  quarter in  Nairobi ILRI  outposts ILRI outposts in SE  Asia: Jakarta, Hanoi,  Vientiane, Chiang