Resurgence of Rabies Threatens Asia's Young and Poor

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Indonesia's health ministry officers carry dogs believed to be infected with the rabies virus in Jimbaran on November 27, 2008

The situation was ominous. Snarling dogs were attacking and biting residents of Indonesia's popular tourist destination, Bali, an island with a population of 3.5 million people in the central area of the country. Many of those animals — loved as pets by locals — carried rabies, a virus spread mostly through bites that kills nearly all people once they show symptoms of the disease. The problem seemed to spring out of nowhere, but when Bali recorded its first human death of rabies in November 2008, the government declared the island was "positive" for the virus. The ongoing epidemic has killed at least 78 people and prompted the U.S. and Australia to issue travel warnings to the island — though no foreigners are reported to have died. Adding to the panic, Bali experienced a severe shortage of a rabies vaccine for humans, a key injection administered right after bites that, with proper follow-up shots, can protect a person from the fatal disease.

Balinese health authorities took sweeping measures, arguing they didn't have much of a choice. While they vaccinated dogs that were brought to them from the streets, they also started a controversial culling campaign in which they killed, usually by shooting poison blow-darts, about 100,000 dogs around the island. Critics claimed the strategy was cruel and had failed to halt the spread of the virus. After lengthy negotiations with animal health organizations, Balinese officials reversed their policy. Last month, they announced they would resort to a new campaign in which they would inoculate 400,000 dogs — about 70% of the island's canine population — by the end of the year. "What makes countries vulnerable to rabies is having unvaccinated dogs," said Janice Girardi, founder of the Bali Animal Welfare Association (BAWA), a non-profit organization that is carrying out the inoculations with the government.

While the island is claiming it's on the path to victory, many other countries in Asia are experiencing a swift resurgence of the disease. Each year, about 55,000 people around the world die from rabies, more than 80% of them in Asia, according to the World Health Organization (WHO). In China, more than 2,400 people die of rabies each year, a sharp climb from less than 200 in 1996. Making the virus more tragic is that the victims tend be very young and very poor. Half of all human rabies deaths occur in children under the age of 15, says WHO, and more than 90% of human rabies victims in China are low-income farmers living in poor provinces, according to a study published in 2006 in the Chinese Journal of Epidemiology.

Dogs, bats, foxes and other warm-blooded mammals carry the virus in their saliva and spread it through bites, scratches or licks on open wounds. People who've been exposed can expect a hellish demise — unless they immediately clean their wounds and seek a post-exposure treatment. Typically between 10 days and a year after exposure, patients can experience headaches, irritation, a fever, insomnia and feel pain or twitching at the location of their bite wound. Two to 10 days after those first signs appear, patients hallucinate, convulse, become paranoid at the sight of water and experience seizures and paralysis before they die typically from respiratory failure. Rabies has the highest fatality rate of any infectious disease, according to Dr. Deborah Briggs, head of the Global Alliance for Rabies Control, a Kansas-based non-profit organization. She says, "Basically when you get it, you die."

Health officials point to a variety of reasons for the surge in rabies. In remote provinces in countries such as China, India and Bangladesh, many rabies infections go undocumented, making it difficult to swiftly pinpoint outbreaks and deliver the necessary post-exposure treatments. Meanwhile, over the past decade public health experts have been fighting urgent outbreaks such as swine flu, bird flu and SARS, overshadowing the gradual rise in the human rabies cases. The fact that poor people are most susceptible to rabies puts initiatives against the virus even further under the radar, says Dr. François-Xavier Meslin, the Geneva-based team leader for neglected zoonotic diseases at the WHO.

Others blame governments for not following through effectively. In the 1990s, some Asian governments blithely assumed they were close to eradicating rabies, leading them to prematurely cut down on much needed prevention and surveillance programs. In China, for example, the number of human rabies cases dropped from about 3,500 in 1990 to 159 six years later, thanks to the government's strict enforcement of domestic dog vaccination and the culling of stray ones. But after the government disbanded most of the country's rabies teams in the mid-1990s, the number of rabies cases predictably shot back up to over 2,000. It's a stark reminder of what can happen when a country doesn't stay on top of disease prevention, even if an epidemic appears to be withering.

The abundance of rabies vaccines for dogs and humans make these deaths completely preventable, Briggs says. Even after someone is bitten, health care workers can quickly inject around the wound a combination of a booster vaccine and rabies immunoglobulin, or antibody. After that, they typically follow up with four more injections every few days for the next month. For the world's poorest people, however, obtaining the vaccine can be prohibitively expensive, and Meslin argues that requires stronger government subsidies in countries such as China and Laos.

Few public health officials advocate the killing of animals unless absolutely necessary, and most Balinese are Hindu — a religion in which dogs are worshipped, because they're thought to be messengers from the god of death and guardians to the doors of Heaven. That's why officials in Bali have come to an agreement with Balinese animal welfare groups, relying on cheap and humane dog vaccines. With enough support and funding, Bali and other locations with a growing rabies problem can hope to repeat the success of Bohol, an island of 1.4 million people in the central Philippines that has witnessed the complete eradication of dog and human rabies. Prior to 2007, the island had one of the highest human rabies death rates in the country, but the government and health care organizations aggressively promoted education and surveillance and vaccinated over 70% of dogs according to WHO's guidelines. It shows that governments can curb Asia's growing rabies problem while saving its animals. Says Girardi of BAWA, "We now have a humane alternative for protecting our people and our animals."