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Rabies in Indonesia

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Rabies was first reported from Mesopotamia around 2300 BC and accurately described even then as "a fatal disease acquired by humans from the bite of a mad dog". With the possible exception of four cases (and more likely just one) of presumed rabies, clinical rabies in humans is invariably fatal without prior vaccination or prompt medical treatment.

Rabies is present throughout Indonesia, including on the resort island Bali. There were 36 confirmed cases of rabies in dogs in Bali, just in the first five months of 2014 alone. Each year, numerous people in Bali die from the disease. Avoid touching all animals during your stay, including monkeys. It may be difficult to get post-exposure vaccination in Indonesia, even in big cities.

The rabies virus is present in the saliva of infected animals. All warm-blooded animals are susceptible to rabies, and some may serve as natural reservoirs of the virus. Rabies is a viral disease contracted when bitten or scratched by an infected (rabid) animal, often a dog. Once it enters the body, the virus travels along nerves and causes paralysis. As it reaches important organs like the spinal cord and the brain, it causes coma and death. In countries with rabies, ALL animal bites, scratches and licks to broken skin must be treated seriously. Rabies vaccination is very effective in preventing the onset of rabies, even after a bite/scratch by a rabid animal.

Occurence

The disease is widespread but certain countries such as Australia, New Zealand, Japan, Hawaii, Taiwan and all other Pacific Islands, UK, Ireland, Spain, Portugal, Norway, Sweden, and some West Indian and Atlantic islands are completely free of rabies. Dog rabies is quite common in parts of Mexico, Colombia, Ecuador, El Salvador, Guatemala, India, Nepal, Peru, the Philippines, Sri Lanka, Thailand (high risk) and Vietnam; the disease also occurs in most African, and Asian countries. It is noteworthy that more than 50% of the human rabies cases in the United States are returning travelers and immigrants exposed to dogs outside of the United States.

The overall risk of exposure for travelers to Indonesia is low, but as with local populations personal risk is determined to a large extent by each individual's level of exposure to unvaccinated domestic animals. The risk for expatriate residents is of course cumulative, and children are at special risk since they may be less likely to avoid contact with animals, and they may notify anyone that they have been bitten if the bite is not serious enough (in their minds) to need adult or medical care.

Vaccination of pets and livestock is the most effective control measure in preventing disease and reducing the risk of human exposure.

Transmission

The most common mode of rabies transmission is by bites from rabid animals, defined as ANY penetration of the skin by teeth. Bites to the face and hands carry especially high risk. Less common modes of transmission include scratches from animals with contaminated claws, contamination of mucous membranes or scraped skin with infected saliva (as a result of licks, for example) or by wet infected body material.

Other types of contact such as touching rabid animals or being exposed to their blood, urine or feces do not constitute exposure and do not require post-exposure treatment with vaccines. However, because bat bites are small and may possibly go unnoticed, post-exposure prophylaxis may be wise after physical contact with bats unless bite or mucous membrane exposure can be reliably ruled out. In rare instances, transmission can occur by an airborne route, such as exposure to air in caves that are densely populated with rabid bats.

While the only verified cases of human-to-human transmission have occurred as a result of corneal implants from infected donors, bite or non-bite exposures inflicted by infected persons are said in some countries to have transmitted rabies to other humans. Skunks have been infected experimentally by being fed infected animals.

Incubation

The incubation period for rabies is 5 days to 1-3 years (with an average upper range of 2 months), with symptoms appearing within 30 to 50 days following exposure. In dogs, this incubation period is shorter and generally 14 to 60 days. A key factor in determining how quickly rabies will develop is how close the virus comes to nerve endings when the bite or other exposure occurs. Incubation also depends upon the severity of the associated soft tissue damage and the amount of virus introduced, but the distance of the bite from the brain is the most significant factor.

If the head of an animal or a person is severely bitten, symptoms may appear in as few as 14 days. Under rare circumstances, symptoms may not develop for a year or longer. The farther the bite is from nerve endings, the longer it takes to reach the nervous system and develop an infection. Therefore, post-exposure treatment with vaccines can still be effective in preventing rabies even with delays, especially if the bite was peripheral rather than central. It is also true that the bite of a rabies-infected animal does not invariably cause disease.

The disease is usually contracted from the bite of a rabid animal, but on rare occasions, contact of virus-laden saliva with broken skin may be sufficient to transmit infection. There have also been reported cases of human-to-human rabies transmission by corneal transplants, which demonstrates the importance of not using transplant tissue from anyone who died of a neurological illness of unknown cause.

When to suspect rabies in animals

Although it is not possible to determine that an animal is not infected with rabies by simple observation, signs which should lead you to suspect that it may be rabid are:
  • Nervousness
  • (Unusual) aggressiveness
  • Excessive drooling and foaming at the mouth
  • Other abnormal behaviour such as:
    • Wild animals losing their fear of human beings
    • Animals normally active at night being seen in the daytime.
If you suspect that an animal has rabies, do not attempt to catch the animal yourself! Notify the local health authorities

Other early signs of rabies in animals include fever, loss of appetite, and often altered phonation, such as a change in tone of a dog's bark. These signs are often slight, however, and may escape notice. After a few days, marked restlessness and agitation may develop along with trembling.

An affected dog may growl and bark constantly and will viciously attack any moving object, person, or animal it encounters. If not restrained, it may leave home and travel great distances, inflicting much damage as it goes. This excited state usually lasts three to seven days and is followed by convulsions and paralysis. In some instances, signs of excitement and irritability are slight or absent, and paralysis develops within a few days of disease onset. In cases of this type, an early sign is often paralysis of the lower jaw, accompanied by increased salivation. This may cause the animal to appear to be choking on a foreign object, constituting a dangerous trap for humans, who in attempting to be helpful may unwittingly expose themselves to infection.

Diagnosis of rabies in animals is similar, in most respects, to the procedure in humans, but the disease is easier to confirm at an early stage, since the animal can be killed for detailed brain studies. However, animals that die after long periods of illness may not have virus in the brain due to the so-called "auto-sterilisation" phenomenon. In that event, other tissue or spinal fluid may need to be tested for antibodies, a sophisticated procedure not usually available in many countries.

Once symptoms appear in humans, the only treatment is vigorous supportive measures to control the respiratory, circulatory, and central nervous system symptoms. Full recovery has occurred only in four reported cases.

Clinical diagnosis of rabies in humans is based on the patient's history of exposure and development of characteristic symptoms. To confirm the diagnosis (usually not possible until late in the disease), rabies virus must be demonstrated in saliva or brain tissue. The virus may be identified on the basis of animal inoculation tests or specific staining with fluorescent antibodies.

Preventative measures

abies vaccination is not a requirement for entry into any country. However, residents in and travellers to rabies-endemic countries should carefully weigh the risks of not being vaccinated. Dogs are the main reservoir of the disease in many developing countries, but all animal bites should be evaluated. Any animal bite or scratch should be thoroughly cleansed with soap and water to significantly reduce the risk of transmission.

Pre-exposure vaccination is recommended for persons living in or visiting (for more than 30 days) countries with endemic dog rabies. Pre-exposure vaccination greatly simplifies, but does not eliminate, the need for post-exposure treatment.It is especially important for children who may not tell their parents that they have been bitten/scratched. Exposed persons who were not previously vaccinated require more vaccine doses, plus injections of rabies immune globulin. Pre-exposure vaccination is given as a series of 3 injections (see below) and is used to protect travellers in circumstances where exposure may be inapparent, post-exposure therapy may be delayed, or locally available vaccines may pose a high risk of adverse reactions.

Pre-exposure vaccination is also recommended for travellers whose activities place them at frequent risk of exposure to rabies or potentially rabid animals in epizootic areas. Such people include hunters, forest rangers, taxidermists, laboratory workers, stock breeders, slaughterhouse workers, veterinarians or spelunkers (caving enthusiasts). Travellers who will remain at continuous or frequent threat of exposure due to high-risk activities or extended visits in high-risk areas should consult with their health providers every 2 years regarding the need to have their antibody levels checked and/or receive a booster dose of rabies vaccine.

The vaccine is considered safe for use during pregnancy, but should only be given if the risk of transmission clearly outweighs any risk to the unborn baby. Many developing countries still utilize killed rabies vaccines prepared from baby mouse brains. Although effective, such unpurified vaccines may cause serious side effects as found in the original Pasteur formulation. Vaccinees may experience redness, swelling, and itching at the injection site, as well as headaches, nausea, abdominal pain and muscle aches. Also, 5-10% of people receiving the series will develop an "immune complex-like" syndrome 2-20 days later with itching, fever, fatigue, joint pain, arthritis, nausea, and vomiting. A few rare cases of neurological complications have been reported from this immunisation, but all were resolved without medical intervention.

For international travellers, three 0.1 ml intradermal OR three 1.0 ml intramuscular vaccinations are given over a 21-day period (usually given on days 0, 7, and 21 or 28) for pre-exposure vaccination.

Persons who will also be taking mefloquine or chloroquine for malaria prevention should complete their three-dose ID rabies vaccinations BEFORE these medications are begun as they may interfere with the antibody response to rabies vaccine. Otherwise, the intramuscular dose/route should be used as it provides a sufficient margin of safety for persons taking anti-malarial drugs.

Prevention of rabies after animal bites is based on physical removal of the virus by proper management of the bite wound and on specific immunological protection through post-exposure vaccination. It is essential that the wound is cleansed IMMEDIATELY and THOROUGHLY with soap and water to remove saliva from the area. The wound may then be squeezed to promote bleeding, since this will also help to clean it. The physician who treats the wound should again cleanse the contaminated area with a 20% solution of medicinal soft soap or similar cleaning solution, using a syringe to apply the solution to the full depth of the wound. The possibility of tetanus may necessitate more specific treatment such as excision of dead tissue if the wound is severe as well as prophylaxis. The wound should not be stitched, unless unavoidable for cosmetic or tissue support reasons, to allow free bleeding and drainage.

VACCINATION IS NOT A SUBSTITUTE FOR THOROUGH WOUND CLEANING.

If at all possible, the animal responsible for the bite should be captured alive and kept under surveillance. This may help the bitten individual avoid undergoing an unnecesary course of vaccination. If the animal remains healthy under confinement and veterinary observation for at least seven days, one may assume that it was not infected. However, if the animal becomes ill or dies, the bite victim should immediately begin treatment and the local health authorities notified immediately.

If bitten, scratched or licked (on broken skin) by an animal:

  1. Cleanse the wound with soap and water and a povidone-iodine solution if available.
  2. Seek medical help for thorough deep-wound cleansing.
  3. Injections of rabies immune globulin and vaccines as prescribed.
  4. Tetanus prophylaxis and antibacterial treatment when required.
  5. No sutures (stitches) for wound closure, unless unavoidable.
  6. Follow-up for completion of vaccine program and wound care.
  7. Notify local health authorities immediately to assess the need for rabies post-exposure vaccination, even
  8. if you have had pre-exposure vaccination. (THIS CAN BE LIFE SAVING).

Checklist for bites in children

It is not uncommon for a child to be bitten or scratched by a family pet - especially cats and dogs. Most of the time these injuries do not need the attention of a doctor. If the cut, scratch or puncture wound is minor, wash it thoroughly with soap and water. A loose, sterile bandage may be needed. Your child should see a doctor if:
  • The injury is severe enough to require stitches.
  • The cut or puncture wound is bleeding excessively.
  • There are signs of infection. Signs of infection include severe swelling, pain and drainage of pus.
  • Your child was bitten by an animal other than a vaccinated family pet.

Rabies always is a concern when an animal bite occurs, so your family pets should be vaccinated against rabies to protect both parties. Stray dogs or cats may not have been given a rabies vaccine, and wild animals also may be rabies carriers. However, most children are bitten or scratched by family or neighbourhood pets.


Additional info on Rabies from the US Center for Disease Control

We trust this information will assist you in making correct choices regarding your health and welfare. However, it is not intended to be a substitute for personalized advice from your medical adviser.

Our appreciation to International SOS, an AEA Company who has contributed this article in response to a growing health threat faced by expatriates in Indonesia.

If you have medical-related questions about living in Indonesia to ask of medical professionals, see Ask the Experts.

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