Outbreak Notice Rabies in Bali, Indonesia

In December 2008, the Indonesian Ministry of Agriculture reported a rabies outbreak in dogs on the island of Bali, Indonesia, to the World Organization for Animal Health. As of October 2009, the Indonesia Ministry of Health has reported 15 deaths caused by rabies on Bali. Most human and animal rabies cases have been confirmed near popular tourist destinations on the southern tip of Bali. However, because the situation is evolving, CDC advises travelers to take precaution on the entire island.

The following activities may put travelers to Bali at higher risk for rabies:

• Working closely with animals of unknown rabies exposure or vaccination history.
• Spending a lot of time in a rural area or doing outdoor activities such as bicycling, camping, or hiking. These activities increase the risk for coming in contact with animals.
• Touching or playing with animals.
• Adopting animals with the intention of bringing them home to the United States.

Information About Rabies

A threat to both human and animal health, rabies is a rapidly progressing, deadly disease. It is almost always spread by an animal bite but can also be spread when a rabid animal’s saliva gets directly into the eyes, nose, mouth, or broken skin. The primary sources of human infection worldwide are dogs and certain wildlife species, such as foxes, raccoons, mongooses, and bats.

Each year throughout the world, rabies kills approximately 50,000 people, mostly children. The risk of rabies from domestic animals is low for people in the United States. For people who travel to other parts of the world, the risk of rabies may be higher. Therefore, all travelers should know how to protect themselves from this disease.

Advice for Travelers

Follow these recommendations to protect you and your family from rabies:

Avoid animal bites.

• Avoid touching all animals, including wild animals and pets. Pets in other countries may not have been vaccinated against rabies.
• Resist the urge to rescue animals with the intent to bring them home to the United States. Dogs and cats may be infected with rabies but not show signs until several days or weeks after you first encounter them.
• Supervise children closely, especially around dogs, cats, and wildlife such as monkeys. This is important since children are more likely to be bitten by animals, may not report the bite, and may have more severe injuries from animal bites.
• If you are traveling with your pet, supervise your pet closely and do not allow it to play with local animals, especially strays.

Act quickly if an animal bites or scratches you.

• Wash the wound well with soap and water.
• See a doctor right away, even if you don’t feel sick or your wound is not serious. To prevent rabies, you may need to start a series of vaccinations immediately.
• To get vaccinated, be prepared to travel back to the United States or to another area. (Adequate vaccination for exposure to rabies is not available in all parts of the world.)
• After you return home, tell your doctor or state health department that you were bitten or scratched during travel.

Before your trip, find out if your health insurance covers health care overseas and medical evacuation. If it does not, consider buying supplemental health insurance for your trip.

Information for Health-Care Providers

GeoSentinel data indicate that the number of requests for rabies postexposure prophylaxis has increased among travelers returning from Bali since May 2008. GeoSentinel is a worldwide communication and data collection network for the surveillance of travel-related illness. It is operated in partnership between the International Society of Travel Medicine and CDC.

During pre-travel consultations, health-care providers should stress the importance of avoiding animal bites and recommend that travelers to Indonesia supplement their health insurance to cover emergency evacuation or health care abroad.

In December 2008 and January 2009, cases of rabies in dogs were reported in Badung and Denpasar districts in southern Bali [1, 2]. Dog rabies continues to be reported from Bali, with infected dogs most recently identified in the district of Tabanan [3]. As of 29 September 2009, more than 70,000 animals have been vaccinated across the three districts [3]. Nearly 20,000 dogs out of a population of more than 400,000 have been destroyed across nine districts of Bali [3].

In May 2009, the World Health Organization South East Asia Regional Office (SEARO) reported seven suspected cases and one laboratory confirmed case of rabies in humans [4].

The US Embassy in Indonesia reports that post-exposure rabies vaccine and immunoglobulin are in short supply [5].

Advice for travellers

The occurrence of rabies in Bali is a reminder of the importance of rabies prevention for travellers in many regions of the world. Rabies is transmitted following contact with the saliva from an infected wild or domestic animal (including bats in some countries) often via a bite, or a lick to an open wound. Human rabies is nearly always fatal.

The risk of exposure is increased by type of activity (e.g. running, cycling), occupation (e.g. veterinarians) and long duration of stay. Children are at increased risk, as they are more likely to have animal contact and may not report a bite, scratch or lick.

All travellers should avoid contact with any wild and domestic animals, including pets. Pre-exposure vaccination should be given to adults and children at increased risk of rabies (see above) or who are travelling to remote areas where medical care and post-exposure rabies vaccine and immunoglobulin are not readily available.

Following an animal bite, wounds must be thoroughly cleaned and an urgent medical assessment sought, even if the wound appears trivial. Prompt post-exposure treatment is required, even if pre-exposure vaccine has been received. Suitable vaccines and immunoglobulin are in short supply or unavailable in many areas of the world, including Bali. In some locations a flight back to the UK or to a medical centre in a nearby country may be necessary in order to obtain vaccine.

Travellers should ensure that they have comprehensive travel insurance and that it will cover them should they require medical evacuation.