A man carries his dog to be immunised against rabies in Indonesia
A man carries his dog to be inoculated against rabies in Indonesia, where cases of the zoonotic disease have doubled since the Covid-19 pandemic. A diversion of resources to respond to the pandemic has resulted in a rise in rabies cases across Southeast Asian countries where the disease is endemic. Image: 

Rabies is spreading in Southeast Asia, fuelled by inequality and neglect

Rabies is not considered to be a disease of economic importance, because it does not hurt international trade and mainly affects marginalised communities. A new study explores how the ancient zoonotic disease has spread across Southeast Asia post-pandemic, and how it can be eliminated.

One of the world’s oldest diseases has been spreading across Southeast Asia, infecting poor communities in remote parts of the region where it has not previously been considered to be a problem.

Rabies, a zoonotic disease caricaturised by aggressive, salivating dogs that is virtually 100 per cent fatal once it enters the central nervous system, has spread because the resources needed to control the disease have been diverted to control Covid-19, according to experts in a new study on the prevalence of the virus in Southeast Asia and how to fight it.

Rabies is endemic in eight of the 10 countries in Southeast Asia, with 600 million people at risk. Around 26,000 people die from the disease a year in Southeast Asia, around half of global human rabies deaths, with economic, political and cultural issues presenting barriers to rabies control in the regional bloc.

Local authorities in the most susceptible parts of the archipelago have reported shortages of the vaccine to immunise dogs – which are responsible for 99 per cent of cases in humans through bites – while dog vaccination programmes have been rolled back due to Covid-related restrictions, budget constraints and a lack of local expertise to carry out inoculation programmes.

Catherine Besch, founder and director of Hoi An-based animal rescue and farm sanctuary veterinary care organisation Vietnam Animal Aid & Rescue, said Vietnam’s agriculture ministry has not allocated sufficient resources to rabies prevention after the pandemic. The authorities have focused on increasing livestock production rather than controlling zoonotic diseases, while vaccination efforts have been concentrated in cities rather than at-risk rural areas, she said. 

There is no obvious economic payback from tackling rabies. Unlike livestock, which is a business worth billions of dollars, with stray dogs – the main carrier of the disease – you do not gain monetarily from eliminating the disease. 

Dr Alicja Izydorczyk, director, Soi Dog Foundation

Human rabies cases in Indonesia have doubled since the pandemic, while spikes in human rabies deaths have been reported in parts of Vietnam previously not considered rabies hotspots, and in the Philippines, Thailand and even Malaysia, which was declared rabies-free as recently as 2013, only to lose that status after repeated outbreaks.

Children account for around half of rabies deaths. “Kids often don’t want to tell their parents that they were bitten by a cat or dog until it is too late,” said Dr Jerick De Villa of San Lazaro Hospital in Manila, who treats three cases of rabies per day.

The easing of Covid-19 travel bans has facilitated the spread of rabies. The virus has been carried across the border from Indonesia to Malaysia on Borneo by free-roaming dogs, between islands within the Philippines via dogs on fishing boats, and into Vietnam from neighbouring countries for the dog meat trade.

“Rabies is a transboundary problem,” said Gyanendra Gongal, a senior public health official at the World Health Organisation’s Southeast Asia office. Thailand is doing well [at reducing human rabies risk]. But unless Cambodia, Laos and Myanmar control rabies, Thailand will always have a problem.”

More cooperation is needed between countries to control the spread of the disease, through stricter border control measures for animals and tougher penalties for smuggling animals, he said.

Rabies symptoms: “If ever there was a case for euthanasia, this is it.”

The word “rabies” comes from the Latin word “rabere”, which means to rage or rave. The disease is thought to be the inspiration for zombie films, because once the disease spreads to the central nervous system, the victim will inevitably die. Stories of demonic possession in the Bible are also believed to have been inspired by rabies victims.

An often-overlooked reason to eliminate rabies is the incalculable suffering that the disease manifests as well as almost certain death once symptoms appear. “Once you get it – that’s it. The only way to address rabies is through prevention,” said Dr Karl Henson, an infectious diseases consultant at The Medical City hospital in Manila.

In humans, the symptoms, which tend to progress in stages until an infected patient dies, are as bizarre as they are incapacitating: hydrophobia (fear of water), aerophobia (fear of fresh air), hyper-salivation, insomnia, anxiety, depression, delirium, seizures, hallucinations, aggression, paralysis, even priapism (permanent, painful erections in men). Beneath a video on the human cost of rabies on GARC’s YouTube channel, which features a barred room at a bite centre in the Philippines where rabid patients are kept until they die since patients can get aggressive, is posted the comment: “If ever there was a case for euthanasia, this is it.”

A disease that disproportionately affects the poor “not economically important”

A problem facing efforts to control rabies is that it is not considered to be a disease of “economic importance”, said Dr Terence Scott, director of programmes at the Global Alliance for Rabies Control (GARC), one of the few non-profits working to eliminate the disease.

Rabies has no impact on international trade, affects the poorest communities and kills a relatively low number of people, so tackling other diseases, such as lumpy skin disease in livestock in Indonesia or HIV/AIDS in people in the Philippines, has taken strategic priority.

Dr Alicja Izydorczyk, director of animal welfare for the Soi Dog Foundation, a Thailand-based non-profit, said: “There is no obvious economic payback from tackling rabies. Unlike livestock, which is a business worth billions of dollars, with stray dogs – the main carrier of the disease – you do not gain monetarily from eliminating the disease. You will only be spending money.”

But rabies does come with an economic cost. The disease is responsible for the loss of over 1.8 million disability adjusted life years a year and US$1.5 billion a year in treatment given to patients bitten by a rabid animal in Asia alone.

Mystic medicine and the awareness gap

Awareness of what rabies is, how it is transmitted and how people should respond to infections is dangerously low in the most susceptible areas to the disease, where there are large populations of free-roaming, unvaccinated dogs.

Folk medicinal practices, such as applying garlic, leaves or coins to bite wounds, or a traditional healer sucking and spitting out the blood from an infected wound, are still used to treat rabies in high-risk parts of Indonesia and the Philippines. Wahid Fakhri Husein, an infectious disease specialist who has written a paper on rabies control in Indonesia, told Eco-Business about the mystic belief among rural communities in parts of Sumatra and East Nusa Tenggara that eating the brain of a rabid dog that has just bitten a person provides protection against the disease – a custom that could have potentially fatal consequences.

Reaching vulnerable communities with rabies education campaigns is a challenge in geographically dispersed Southeast Asia. The most at-risk areas of the Philippines, such as Central Luzon, are typically far from bite treatment centres or hospitals, where vaccines are often unavailable. People who are aware of the dangers of rabies may choose not to seek medical attention if exposed, because they cannot afford to travel to a hospital – even if the vaccine is free, said Dr De Villa of San Lazaro Hospital.

Some families in remote areas are faced with the dilemma of choosing which of their family members gets vaccinated, because they cannot afford to vaccinate them all, said Chari Amparo, a public health research officer at GARC based in the Philippines. Rabies disproportionately affects vulnerable, disadvantaged areas that have poor access to vaccines,” she said.

Vaccinating free-roaming dogs is also a challenge. In Bali, which was rabies-free until 2008, free-roaming dogs were caught using nets, and then vaccinated, marked, and released. But subsequent re-vaccination efforts proved more difficult. “Dogs are smart animals. When the dog catchers came to vaccinate the dogs the following year, they just ran away,” recalled Fakhri.

Accurate reporting of rabies cases is also an issue. Experts suspect that the prevalence of the disease could be higher than official statistics suggest. In rural parts of Indonesia, some local governments are inclined to hide incidences of rabies for political reasons, said Fakhri.

Is the dog meat trade aiding rabies spread?

Dogs held in a pen awaiting slaughter in Hanoi, Vietnam

Dogs awaiting slaughter in Hanoi, a hotspot for Vietnam’s dog meat trade. The dog meat trade is a reservoir for rabies and is believed to have rebounded post-Covid as borders have re-opened. Image: 

The dog meat trade is a potential reservoir for rabies.

The trade is believed to have recovered since Covid-19 movement restrictions have lifted and made the transportation of dogs around the region easier, particularly into Vietnam, the second biggest consumer of dog and cat meat after ChinaAn estimated five million dogs are slaughtered in Vietnam alone for their meat, according to the Soi Dog Foundation. Dogs are also eaten in parts of the Philippines, where dog meat consumption is illegal, and Indonesia, where momentum has been growing in support of a national ban.

The trade poses a rabies risk because of the unregulated movement of dogs of unknown disease and vaccination status. Dog catchers and butchers are rarely vaccinated and the manner in which animals are caught, transported – typically in grim conditions – and slaughtered poses an ongoing problem for rabies transmission, said Rahul Sehgal, director, international advocacy, Soi Dog Foundation.

However, Besch of Vietnam Animal Aid & Rescue suggested that without the population control provided by the dog meat trade, Vietnam would have a far higher rabies rate. “Culling is inevitable if we ban the dog meat trade here because there are no widespread sterilisation projects or any veterinary training going on,” she said.

Mexico: a model for Southeast Asia to eliminate rabies

How to beat rabies

A broadly accepted strategy for rabies control consists of the following elements:

1. Strategic vaccination of dogs to a level that achieves herd immunity, at least 70 per cent of the dog population in a single mass vaccination exercise;

2. Education on rabies risk for the most vulnerable communities;

3. Ongoing surveillance to identify the most at-risk people and animals;

4. Improved access to the right medical care for bite victims.

Source: Centers for Disease Control and Prevention

A blueprint for Southeast Asia to follow to eliminate rabies is Mexico, which was declared dog-mediated rabies free by WHO in 2019.

The South American country, home to an estimated 26 million free-roaming dogs, has instituted free, mass vaccination campaigns for dogs, and has achieved 80 per cent vaccination coverage – the level WHO recommends to achieve herd immunity and prevent a rabies outbreak.

Mexico’s strategy was guided by One Health”, a concept that recognises the interplay between humans, animals and their shared environment. It runs regular public awareness campaigns, provides ongoing surveillance of at-risk dogs and people, and has made post-exposure prophylaxis treatment available in its hospitals. It has also introduced pet animal travel restrictions to prevent rabies from crossing its borders.

Key to Mexico’s success has been assigning rabies control to the health ministry rather than the agency responsible for animal matters – which tend to be poorly funded – and positioning dog vaccination as a public health issueDr Marco Antonio Natal Vigilato, zoonotic diseases and veterinary public health adviser at Pan American Health Organization, said that cooperation between countries in the Latin America region was also key. 

Experts warn against false solutions, however. Dog-culling, a strategy that has been deployed in Sarawak and Bali in recent years to reduce free-roaming dog numbers, is ineffective because it removes vaccinated dogs from the population, and results in an increase in rabies transmission as dog populations recover, according to Dr Natasha Lee, a veterinarian and founder of animal welfare consultancy Animal Happiness in Malaysia.

Eliminating rabies in Southeast Asia, and meeting the World Health Organisation’s target for zero human deaths from dog-mediated rabies by 2030, is not impossible, and a key motivation for doing so is the disease is that it is 100 per cent preventable, said Scott of GARC. “There is absolutely no need for anyone to die from it. We have the tools to eliminate rabies.”

For an in-depth analysis of the prevalance of rabies in Vietnam, the Philippines, Indonesia, Malaysia and Thailand, and how to eliminate the disease, read the Eco-Business white paper, Moving Towards A Rabies-Free Southeast Asia.

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