Rabies in Southeast Asia

Introduction.

Lack of coordination between various ministries  are expected to control rabies is the cause of failure of many programs intended to lower the number of incidents or create a sustainable system to eradicate rabies. Some countries do not even have an effective and consistent system of monitoring rabies incidents. The complex nature of rabies control activities requires cooperation of at least local governments, Health and Agriculture Ministries; each of them has other competing health and development priorities as well as generally limited financial and structural capabilities of developing countries in most affected by the disease. Hence, rabies control programs are largely neglected.

There is a growing recognition  the ministry dealing with animal health has a social responsibility for the control of rabies in animals. Ministry of agriculture  are normally focused on diseases of economically important animals which affect livestock productivity. Since dogs are not livestock, canine rabies control and dog population management are often neglected. Therefore, the balance of power in coordination between ministries is hard to maintain, which becomes a significant challenge, and undermines many efforts to address the issue productively or effectively.

Prevalence of rabies cases in local canine populations has direct impact on rates of transmission of rabies from animals to humans. Transmission of rabies from animals to humans is a cause of thousands of deaths worldwide, which makes control of rabies an important mission. Majority of the first world countries have eliminated rabies as a threat  has a significant impact on health of their populations with a few cases of transmission and sporadic deaths per year, while developing countries are still experiencing both widespread transmission and frequent death. In this study, I will focus on conditions and measures  affect rates of rabies transmission and human deaths from them in countries of Southeast Asia, particularly focusing on situations in Malaysia, India, and Indonesia.

Eight countries of Southeast Asia are endemic for rabies, while approximately 45% of rabies deaths occur in Asia. Countries  are endemic for rabies include: Bangladesh, India, Myanmar, Bhutan, Nepal, Sri Lanka, Thailand, Indonesia. Malaysia, Maldives, Timor-Leste, and some islands of India are considered free of rabies. Rabies is perceived as a rare disease resulting from the bite of a wild animal (a dog, a bat, or a fox), and does not receive the priority or attention it deserves as the most lethal virus known to human species. Alternatively, it is acknowledged  rabies impacted  Millennium Development Goals 2015, through increasing rates of child mortality, since children are the primary victims of dog attacks and, thus, are more likely to become rabies patients. Three member countries of the ASEAN Plus (China, Japan and Republic of Korea) set the goal of rabies elimination by year 2020 in 2009.

Dog bites are the primary source of human infection in all rabies-endemic countries and account for 96% of rabies cases in the Southeast Asia. Therefore, culling and sterilization to control canine population is one of the approaches governments take to curb outbreaks when sufficient medical care is unavailable. Another approach to control and prevent rabies is vaccinations, but organizing mass vaccinations is expensive and requires cooperation of various ministries and civil groups which is challenging with settings  largely have weak infrastructure. Globally it was shown  control of canine rabies can be achieved with sustained dog vaccination coverage of 70%, which may be challenging to achieve in countries with fragile and inadequate medical and veterinary care systems.

Strength and accessibility of health care and education, transparency and trust between different governmental and non-governmental organizations as well as their ability to cooperate, availability of human and financial resources, and extent of communication between organizations and general population affect prevalence of rabies worldwide. However, lower quality and accessibility of health care and education, fragility of connections between different department of governments, and general poverty of the majority of the population in countries of Southeast Asia have played a defining role in the expansion and spread of feral canine populations and rabies amongst them.

One case  has shown  such cooperation and concerted effort are possible is the Bohol Project in the Philippines. It is a successful community based project, which did not receive much international or national support. Which means  with enough political will and smart multilateral strategies rabies epidemic can be controlled or even eradicated locally.

Importance of Transparency.

There is little to no transparency in the impact of rabies on populations in Southeast Asia, although it is considered to be one of the most important components of combating the issue by OIE, World Organization For Animal Health. Quantifiable data facilitates successful planning of actions and programs necessary to eliminate rabies and budgets needed to enact them. Since rabies today mainly affects developing countries with quite limited and widely insufficient human and monetary resources, knowing exactly how much resources would be necessary for each action is of integral importance and absence of such can be detrimental to success of measures taken, and every unsuccessful measure will discourage governments from supporting such measures in effort to avoid liquidation of their legitimacy, since every failure will raise questions and potentially enrage the population. It may eventually lead to demands to replace the government or leaders who are failing in their attempts to address the issue.

Another reason why transparency is conducive to combating rabies, as well as any other public health issue, is  it makes the process of attracting outside donors and assistance easier  which has shown to be integral in controlling epidemics in developing countries by numerous missions to control malaria in Africa and Asia, for instance The Lubombo initiative in South Africa. NGOs play the main role in controlling rabies in Southeast Asia today, as the issue is largely neglected or treated callously by governments of some major countries, such as India. NGOs such as Mission Rabies which is focused on India as the state with the worst statistics on rabies, raise awareness through educating local populations, organize mass dog vaccinations, and train educators and professionals to create a sustainable system of controlling rabies.  

Every aspect of work done by Mission Rabies depends on transparency. Education and training of local people needs to be supported by reliable statistics to show the importance of the issue problem and support legitimacy of claims of its importance. Without people trusting the information NGOs provide no progress can be achieved, since recommendations  come from an unreliable source tend to be ignored. Success of vaccination missions also depends on reliable statistics, however, it is a lot easier to quantify than success of educational efforts. It was said above  about 70% of animal population needs to be vaccinated to successfully control rabies, which means  sufficient amount of funding must be allotted to administer necessary number of vaccines. Through having sufficient funding NGOs can purchase needed amount of vaccines and hire needed number of professionals to perform the vaccinations. Without reliable statistics and data about the population of dogs, as well as other potential carriers of rabies, and the extent to which rabies is spread amongst it, vaccination efforts may be less productive or useless.

Role of Vaccines.

Rabies vaccines vary in their safety, possible risks of some vaccines used today include infection of potentially fatal encephalitis from myelin-containing nerve tissues used in their production, and appropriate time of administration, pre-exposure and post-exposure. Production of post- and pre- exposure rabies vaccines stimulates manufacturing facilities development, raises demand in education, and creates jobs in the region.

Most dangerous vaccines produced today are made through inactivation of infected chick embryos or suckling mouse brain. This technique is, however, a lot more accessible to developing countries than a safer alternatives because it requires higher qualifications and more advanced facilities to manufacture. The latter techniques include, but are not limited to, growing virus in hamster kidney cells or human diploid cells, namely, lungs. The accessibility of a more dangerous technology makes domestic production of vaccines possible, which has numerous benefits to the producing country, thus discouraging a switch to import of safer alternatives while adoption of the safer technique might be unaffordable.

India produces more modern and safer human vaccines: Human Diploid Cell Vaccine (HDCV), Purified Verocell Rabies Vaccine (PVRV), Purified Chick Embryo Cell Vaccine (PCECV) and Purified Duck Embryo Vaccine (PDEV). Countries  still produce Nervous Tissue Virus or NTV vaccines are Myanmar and Bangladesh, while Nepal, India, Indonesia, Sri Lanka, and Thailand have phased out its production because of WHO discouragement. This situation makes Bangladesh, Bhutan, Myanmar, Nepal, Indonesia, Thailand, and Sri Lanka dependent on Indian vaccines, since they are cheaper than vaccines produced outside of the region due to lower labor costs in India, which discourages domestic development of such productions.

Alternatively, animal rabies vaccines are produced in Indonesia and Nepal, as well as India. The need for animal rabies vaccines is considerably higher because 70% of large populations of stray dogs and wild foxes must be vaccinated prior to exposure to control rabies epidemics. However, requirements for safety and quality and demand for animal vaccines are lower than for human vaccines. Therefore, antiquated but cheaper methods of production with more dangerous techniques are used for animal vaccines, which leads to potential higher mortality rates in animals.

In Thailand, discontinuation of local production of NTVs and importation of increasing quantities of modern rabies vaccines have played a major role in the drastic reduction in the number of cases of human rabies.  There are several possible causes for such situation: modern rabies vaccines have less common and debilitating side effects, are more effective, and larger investment  they require due to higher costs often means  there is more attention paid to the infection they prevent. The last point seems the most interesting to me, as it means  it is not the vaccine  necessarily caused the reduction in human rabies, but rather the attention government paid to the issue. This inference is especially credible if one considers  government tends to invest into health issues  are noticed by their people to maintain legitimacy and approval ratings, since failures to address issues  are important to the population tend to induce uprisings and change of governments, or at least cause population to pressure government into taking necessary steps to address the issue. Therefore, implementation of more modern vaccines could only mark a transition to a period when reduction in number of human rabies would have happened under public opinion and attention pressure.

Administration of vaccines is also an important part of the process of vaccination, which may significantly affect its cost and efficiency. Currently, the most popular and supported approach is Intradermal rabies vaccination (IDRV), which was pioneered by the Queen Saovabha Memorial Institute of the Thai Red Cross Society during the 1980s and is agreed to be a more cost-effective vaccination schedule compared to its predecessors. WHO was providing technical support to introduce IDRV in rabies-endemic countries and to improve availability, accessibility, and affordability of the vaccines. Thailand, Sri Lanka and India have already introduced this vaccination schedule, while Bangladesh, Bhutan, Indonesia and Nepal are still in the process of doing so.  Intradermal rabies vaccination helps to reduce the financial burden on health ministries and NGOs supplying rabies vaccinations.

Limited financial resources, inadequate medical facilities, and lack of awareness of people are the main problems  prevent vaccines from being a universal measure to control rabies in developing countries. Although existing treatment of rabies, which includes a mixture of vaccinations and immunoglobulin injections,  has shown to be highly effective if applied immediately after the infection, the price of it may deter people from receiving medical assistance. For instance, the price of rabies post-exposure treatment in India was 1300 rupees or $27 in 2002, which is the equivalent of monthly income for some people there. It makes treatment unaccessible to most people, and makes them prefer to wait or refuse treatment, which may be deadly. It also means  people will be more likely to ignore minor bites, which may be the cause of transmission, relying on hope and luck and not medical testing and treatment for safety to avoid starvation  may be caused by paying the last money for the treatment.

Medical care in Southeast Asia is usually concentrated in urban areas, while rural agricultural communities are still prevalent there with 68% of rural population in India and 47% – in Indonesia. It creates several burdens to the delivery of vaccinations to human and canine populations alike. Firstly, it limits accessibility to the vaccines and treatments, as medical facilities may be absent altogether in some rural areas and are inadequate in most. It makes people less likely to seek any medical help, let alone expensive medical treatment  may not even be available in the medical centers located nearby. Secondly, raising awareness is significantly harder in rural than urban environment because communities are often small and isolated. Thirdly, rural communities have higher poverty prevalence which is a significant burden to obtaining treatment even when medical assistance is available, due to treatment’s price. Fourthly, access to education is limited in rural communities, which reduces people’s awareness of necessary measures to be taken after potential exposure to rabies. The combination of these factors leaves people in rural communities at higher risk of dying from rabies than people in urban areas, since urban communities are less affected by these issues.

Beforementioned challenges on the way to controlling rabies are hard to overcome, since they are deeply imbedded in developing countries and exacerbated by other factors, such as endemic diseases like malaria or economic and political corruption. Since improving national healthcare systems, reducing poverty, and improving accessibility of education are long term goals  require immense investment of resources, governments tend to seek more immediate and radical measures,  would instantly alleviate the strain by reducing the number of animals  serve as a reservoir for rabies.

Culling and Sterilization of Canine Populations as Rabies Control Measures.  

Since dog bites are the primary source of human infection in all rabies-endemic countries and account for 96% of rabies cases in the Southeast Asia Region, governments often see elimination or reduction of stray dogs as a cheap solution to a number of issues with health and security they create, including rabies transmission and dog attacks. It must be acknowledged  today stray dogs in developing countries are not merely pets  lost their owner, in contrast to developed countries, but semi-feral animals attracted to human settlements by garbage  provides them with sustenance.

Dogs are also an important part of human culture. People rely on them for companionship as pets, assistance as service dogs, and protection of property as guards. Dogs’ role is especially important in developing countries where people cannot afford implementing technology to replace dogs as drug or explosives detectors or property guards. However, continuous widespread use of dogs and little accountability for abandoning them led to overwhelming stray dogs populations in Southeast Asia.  Therefore, abundance of stray or feral dogs, with the threats of attacks and diseases transmission they pose on people around them, are a systemic problem in developing communities,  cannot be solved only by elimination of significant number of individuals.

Dog culling efforts in India and Malaysia made headlines in Western media this year. Inhumane approach to controlling canine populations was highlighted by media both inside and outside of these countries, and made people start campaigns to stop such measures. For instance, #BoycottKerala Movement in India,  opposes menace of dogs and raises awareness about it or a petition to Malaysian prime minister from the population Demand Malaysian Government Stop Killing Stray Dogs, which received 31 999 signatures out of 180 000 goal.  Which indicates  there are people with active civil position present there, and an issue like this may spark a larger involvement in the politics, which leads to the development of civil institutions. They, in turn, have important role for development of a country.

Removing stray and feral dogs from villages and cities is a necessity, but dogs have been companions of humans for our entire history, and they play more significant role in developing countries. Dogs in developing countries are relied to perform guarding or herding duties more often than in developed countries. Thus, people are more likely to see them as members of their communities or even families, however feral, or families. Although in developed countries most people who have an animal  is considered part of their family invest into their pet’s health by providing an animal with vaccinations and necessary treatment, such treatment is not normally an option for pets in developing countries. Since people often lack access to health care services themselves, they are much less likely to provide it for their animals.

It does not, however, diminish sympathy people have for animals targeted by local governments for sometimes cruelly performed elimination, culling, or simply killing. Efforts to stop violent killing of dogs led to creation of shelters and NGOs  protect rights of animals inside the region, such as The Asia Canine Protection Alliance and Boycott Kerala Movement, but also attracted NGOs such as OIE (World Organization For Animal Health) and Rabies Alliance from abroad. Involvement of these international organizations is  important, as they are often the main drivers of rabies control measures.

Role of All-Around Approach.

Children between ages 5-12 account for 40% of victims of rabies because they do not recognize the danger of minor wounds from dog bites and leave the infection unattended until it is too late. Children are also more likely than adults to engage with stray dogs during play. Since dogs are abundant and, as it was already said, control of their population is a challenging and taxing task, there are few things  can shield children or adults from dog attacks and consequential potential infection.

Avian flu has had similar challenges, as it is a disease  is carried and transmitted by birds  are not cattle and are endemic to most areas. The recent avian flu outbreak highlighted the lack of coordination, and stimulated implementation of better communication and coordination mechanisms between agricultural and health ministries, which will benefit country in the future, since a precedent of successful cooperation was created. It will expedite response to future challenges and potentially lower their severity due to rapid responce.

To this point, only challenges of the task were discussed. Now I would like to introduce examples of successful rabies control projects in Southeast Asia, specifically, Bohol province of Philippines, and consequently, in Bali, Indonesia. The Bohol Rabies Prevention and Elimination Project (BRPEP) has taken place before the Balinese project, and served as a model for Bali. It was possible because these communities share some important characteristics: they are located on separate islands, involvement of large numbers of local people was achieved, and most dogs had had owners before the project started.

Success of The Bohol Rabies Prevention and Elimination Project is attributed to inclusion of rabies awareness and responsible pet-ownership into elementary school curriculums in local school, along with standard vaccinations of animals and potentially exposed people. Awareness among children was given one of the main roles in decreasing prevalence of rabies by Dr. Adrian Vos, a global rabies expert who visited BRPEP in 2011, who said, “Involving school children was very important. I believe  educating the children about rabies and responsible dog ownership can reduce the rabies cases by 50 percent.” However, it is not surprising, since children account for disproportionate number of human rabies deaths.

The structure of the projects differs from efforts taken elsewhere in southeast Asia. Most of the time, only one or two strategies are implemented at the same time, and almost never the effort is sustained for long periods of time. This leads to only temporary results, such as in vaccinating and culling efforts taken in India and Malaysia discussed before. All around efforts  included education, vaccination, culling, and responsible pet ownership and were sustained for a long time have shown to make the success in decreasing or eliminating rabies prevalence lasting and sustainable, as nearly complete elimination of rabies was maintained in Bohol since 2010 and number of cases of rabies transmission and deaths in Bali has almost reached the pre-2008 or pre-breakout levels.

The fact  both projects has taken place on islands was determining for their success, as animal populations were prevented from migration by the borders of the island, thus limiting a possibility of re-introduction of the virus to both human and animal populations of the island where the project was taking place. It circumscribed the population  needed monitoring and treatment, therefore, allowing the vaccinations, diagnosis, sterilizations, and culling to be more target specific. In case of culling and sterilization, isolation of treated population is necessary for success, since replacement of culled and sterilized populations undermines effects of the efforts. Isolation allowed for simplification of the process of moderating the progress, collecting data on animal populations, and prevalence of rabies in these populations, thus, expediting and lowering the cost of these aspects of the projects. Such luxury is not available for communities located on mainland, in countries like India, which makes rabies transmission easier and rabies control harder.

Isolation also allowed the projects to have a focus, since both projects functioned on local level, with some assistance received from national and regional resources. This meant the leaders of the projects were primarily from local societies, which implies  they received more trust and support, and, therefore – legitimacy, from local people. Not only potential pre-existing relationship can augment building trust inside the projects, but also deep familiarity with available resources and existing challenges of the area is more expected from denizens of the area, and not government officials coming from another city or province.

Alternatevely, isolation of the community might have had negative impact on the available human and financial resources. Neither Bohol nor Bali have sophisticated education systems, finding administrators inside the local communities might have been challenging,  which, in turn, might have stymied the progress of implementation of rabies control measures. Since large projects like these require extensive administrative work to communicate with governments and control the progress along with work on the ground,  is necessary to implement any measure to control rabies. Although administrative work only requires a fraction of the number of people necessary to work on the ground educating, vaccinating, and collecting data, administrators are important.

 

Conclusion.

Cooperation and multi-faceted approach have shown to make larger and longer lasting impact than short term vaccination or culling efforts on the prevalence of rabies in southeast Asia. Although this was to be expected, there may be other factors helped people of Bohol and Bali curb prevalence of rabies more successfully than other communities around them. Specifically, their relative isolation from other islands and areas made transmission of the virus back to the treated animal population from neighbouring non-treated areas and migration of the non-treated populations  would have significantly reduced success of culling and sterilization efforts by replacing eliminated parts of animals populations.

Overall, through this research I found  larger institutions, such as national government, tend to choose less expensive, faster, and less sustainable solutions to immediately react to an increase in rabies deaths or transmission to appease the people. However, these efforts only bring temporary relief, as they are being performed on a regular basis without bringing a sustainable and lasting solution, but it requires government to pay for each round of culling, sterilization, or vaccination without addressing the root of the problem: stray dogs. Conversely, implementation of a well-rounded and continuous approach allowed Bohol and Bali to get rabies epidemic under control and keep it this way for several years. Introducing accountability for dog’s well-being and imposing a registration fee allowed government to control dogs population before it expands to uncontrollable numbers and provide a permanent program with outside funding, so there is no cuts necessary to other sectors of governmental services, such as education and medicine,  are  important in the vulnerable communities of developing countries.  

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