Date: Mon 25 Dec 2000
From: Merritt Clifton, Editor, ANIMAL PEOPLE <anmlpepl@whidbey.com>
Longtime subscribers to ProMED-mail will recall the posting of Arthur King,
founder of the World Health Organization's Southern and Eastern Africa
Rabies Group, in response to the East Flores dog pogrom which was praised
on 23 Dec by Henry Wilde.
Wrote King, "The policy of mass dog destruction is now questioned in many
quarters. It creates a vacuum which is quickly filled by susceptibles;
when properly costed, it is often more expensive than vaccination; and it
is usually totally unacceptable to the public, meeting with resistance
rather than the cooperation essential to successful campaigns."
The political context of the East Flores rabies outbreak and the official
response must also be considered. We assembled the following report from
the first-hand observations of a variety of foreign correspondents
stationed in Indonesia and other nearby nations, who were unanimously
skeptical (as were the ProMED experts) of the information released by the
East Flores authorities.
[I will not post the full statement but would like to shift the discussion
to the effectiveness of dog depopulation. Merritt Clifton's comments serve
to remind us of several worthwhile conclusions. First, vaccination is the
preferable method of dealing with a rabies epidemic in dogs that spills
over into the human population causing human mortalities. Arthur King's
comments, reproduced below, suggest the same conclusion. So do the
comments of Oscar Larghi concerning his experience in Latin America, also
reproduced below. Finally, I have provided a copy of Henry Wilde's 1998
comments, in which he suggests that a strategy of vaccination and reduction
of the stray dog population is optimal. Even my moderator's comments
emphasized that view.
However, it appears when disease control tactics were chosen, vaccination
was not an option because of local political and economic constraints. It
would be extremely valuable if vaccination resources could always be easily
obtainable, thus providing local disease control officials with expanded
possibilities. It would be wonderful if international donors could quickly
provide the needed vaccines at an affordable cost. However, constraints
are a real factor in particular decisions and it appears that the reduction
of dog populations, while being an unsophisticated, sub-optimal choice, was
the one chosen in this case. Prof. Wilde assures ProMED-mail that he will
look critically at the data and follow the epidemic to its end, so that we
can learn about the effectiveness of this particular tactic. Since we have
covered considerable ground, unless someone has new data, not just
opinions, this thread is cut. - Mod.PC]
[1]
Arthur King's comments of 10 May 1998
From: Arthur King <art.king@cableol.co.uk>
To answer your questions first, I'm not really familiar with rabies strains
in the Far East, but Smith, Yager and Orciari (1993) (Ondestepoort Journal
of Veterinary Research, 60. 4. 307-314) found that samples from Indonesia
were closely related to others from Thailand; Henry Wilde
<fmedhwl@chulkn.car.chula.ac.th> is very active in dog rabies in Thailand
and would no doubt be an excellent source for comment.
>From the messages, it seems most probable that this is straight canine
rabies; and wildlife species play little part, even if there is a wildlife
reservoir. The policy of mass dog-destruction is now questioned in many
quarters - it creates a vacuum which is quickly filled by susceptibles;
when properly costed (either bullet or poison, disposal of carcasses etc.)
it is often more expensive than vaccination; and probably most importantly,
it is usually totally unacceptable to the public and meets with resistance
rather than the essential co-operation during campaigns.
So much is missing from these articles. Is the (170 000) dog population
correct (human: dog ratio 23:1). Is canine vaccine available?
Is post-exposure treatment available or given? How are the dogs to be
destroyed?
Regarding the human survival time, Fishbein (1991) analysed the incubation
periods of 1555 cases which includes all U.S. cases with known incubation
periods between 1960 and 1987, and none died in less than 10 days, 29.8% in
10-30 days, 54.4% in 31-90 days, 14.6% in 91-365 days and 1.2% >365 days.
(Fishbein D. B. (1991). In: Natural History of Rabies, 2nd edition pp
519-549). This does not tie up at all well with Salean's quote: "rabies
victims normally die one week after being bitten."
[Arthur is a founder-member of SEARG [South East Asia Rabies Group] [Sic-
Southern and Eastern African Rabies Group - Mod. PC] now associated with
WHO. For many years he was the rabies virologist at the UK/MAFF Central
Veterinary Laboratory. - Mod.MHJ]
******
[2]
Henry Wilde's Comments of 11 May 1998
From: Henry Wilde <fmedhwl@chulkn.car.chula.ac.th>
Arthur gave you the current view regarding mass dog killing with which we
here agree. Our patients with encephalitic rabies rarely survive more than
one week unless in the ICU, on a respirator etc. Patients (humans) with GBS
type rabies may live as long as one month with good nursing care. I would
suspect that your survival reports count from the date of the bite. We have
had one documented child with multiple facial bites develop encephalitic
rabies 4-5 days later. Usual is as stated by Fishbein and most of ours
develop disease within one month. In Thailand human deaths have come down
from about 400 per year two decades ago to less than 70 last year. This was
done mostly by provision of good PET [post-exposure treatment] with tissue
culture vaccines and RIG and not by dog control. Only way to control dogs
is by mass vaccination. They [in the current financial problems in
Indonesia] will probably need help from abroad.
If [the Indonesians] can send us some frozen dog and/or human brain tissue,
we can do monoclonal strain analysis. Other places that do this are Henri
Tsiang at Pasteur-Paris and US-CDC Dr. Rupprecht in Atlanta. I suspect
[they] have the standard Asian dog strain, which has several sub-variants.
In case ProMED-mail missed it, [we did] Dr. Omala Wimalaratne from the Sri
Lanka Med Research Institute, Colombo reported a rabies FAT positive
elephant a few months ago. We did strain identification here and found it
to be the Asian dog strain. Our local elephant experts suggested that the
animal must have been bitten on its trunk as the skin elsewhere would be
too thick for inflicting a transdermal wound.
[Thanks to Arthur & Henry for their informed comments. In the original
posting some 51 people were reported as hospitalised and three others had
died. With 5 more deaths, that leaves some 46. It would be of value to
know their outcomes, whether they received PET, and how successful it has
been. - Mod.MHJ]
*****
[3]
Oscar Pedro Larghi's comments of 17 May 1998
From: Oscar Pedro Larghi <oplarghi@pinos.com>
The control of rabies in developing countries can be very successful if
based on:
1. Appropriate planning
2. Health education of human populations
3. 70% vaccine coverage of dog populations
4. Epidemiological surveillance
These parameters, with little emphasis in dog population reduction (less
than 10% of the estimated population), were applied in the metropolitan
area of Buenos Aires, Argentina (10.5 million inhabitants), Lima-Callao,
Peru (6.5 million) and Sao Paulo, Brazil (14 million). Dog rabies cases
were reduced to zero, from close to 5000 cases per year in Buenos Aires,
1000 in Lima and 1200 in Sao Paulo.
******
[4]
Henry Wilde's comments of 12 May 1998
From: Henry Wilde <fmedhwl@chulkn.car.chula.ac.th>
Addendum to previous comments from Bangkok:
We had a discussion about [the] predicament with the rabies outbreak in
Indonesia. As we stated previously, mass killing of dogs will only allow
others from the countryside to come in and replace the culled ones. This
has been tried in other places, Yemen, for one, years ago. Malaysia
(Peninsular) has managed to control rabies quite well. The culture and
geography there is similar to Indonesia. It is a Moslem and not Buddhist
country, and some culling of stray dogs, which is not acceptable in
Thailand, is thus possible. They did both ... mass vaccination and
continuous check on vaccine status of dogs and the reduction of the stray
and community dog population as well. Read TY Soon, Rabies in Malaysia, SE
Asian J Trop Med and Publ Health 1988; 19: 535-36. We would suggest the
authorities in Indonesia seek help from the Malaysian ones.
--
ProMED-mail
<promed@promedmail.org>
[Numbers like those presented in item [3] above are hard to argue with. If
you combine
the strategy suggested there with the previous comments of Henry Wilde and
Arthur King, total elimination of dogs appears to be unnecessary for
successful control. T
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