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.

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

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.

History of rabies in Indonesia

Island of Bali

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

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

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.

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

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

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.

Studied Districts
= observed villages

Rabies Bali ‐ Chronology
• .

Rabies Bali – First outbreak foci
• .

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)

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

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

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

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

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
Economic
Political
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 health
Optimizing Rabies Control in Bali: An Ecohealth Approach.”

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)

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

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

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)

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

Studied Districts
= observed villages

DOG ECOLOGY STUDIES
DOG FEGUNDITY STUDY
DOG BEHAVIOR
DOG DEMOGRAPHIE
SOCIAL CULTURAL STUDY
COMMUNITY EMPOWERMENT
(DISSEMINATION)

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

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

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

Dog Behavior Study

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

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

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%

Dog Demography Study

Dog Demography Study
Objectives:
To better estimate the current dog population
and demography
Outcome:
Estimates on dog population
Dog to human ratio

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.

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

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 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

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.

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

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%).

COMMUNITY EMPOWERMENT IN 2
PILOT VILLAGES AND AWARENESS FOR
ELEMENTARY SCHOOLS

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

Approaches and tools
Focus Group Discussion
Presentation
Interactive Discussion
Medias (film, song, poster, leaflet)
Training (class teaching, scenario‐simulation)
Monitoring – evaluation
Community
Engagement

Awareness for Elementary Schools
Media:
Presentation
Brochure
Poster
Song (AYO CEGAH
RABIES) arr by Drh. Ni
Wajan Leestyawati-Bali
Provincial Livestock
offices

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)

(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

(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

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
More details will be presented by the CIVAS team at
KVAC Khon Kaen , 6‐7th of June 2013
Thank you

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