Happy New Years everyone! The horrible year of 2016 is over, and we are welcoming 2017 with open arms. Or at least, I am trying…
January 10th, 2017. It was my second day in my new temporary home in Bona, Bali, Indonesia which I found through Airbnb. My partner and I chose Bona because it was quiet enough to finish writing and publish my research paper. Bona is also a 30-minute car or motorbike ride from Ubud, so it’s close enough that we could have some adventures.
As my partner and I were walking to the local convenience store to pick up some groceries, I saw a dog that looked like she had recently had puppies on the road ahead of me. Let’s refer to her as Mama Bitch (to be clear, bitch is the colloquial term for a female dog). It wandered off to other side of the road after seeing my partner and I walking towards it. We also saw one of it’s puppies dash away from us as we walked up the road. Both my partner and I stopped to see if we could still see the puppy, and all of a sudden, I felt something painful on the back of my left leg. Turns out, Mama Bitch didn’t like us being near her or her puppy and decided to give me a sassy warning. Luckily, she only broke the skin a little and drew a tiny bit of blood. For those of you that don’t know, Indonesia, has a major problem with rabies.
***I’m giving you warning if you’re squeamish, the photo below is of my minor bite. It may be graphic to some. ***
My minor bite wound after treatment at the hospital.
Ironically, my first blog post, “The (Un)controversial Hero: Vaccines” outlined importance of being vaccinated to have some form of immunity against virulent diseases and illnesses. I even used rabies as an example to highlight what happens if you are not pre-vaccinated. Fortunately, I was wise enough to get the three preventive vaccination shots prior to my travels which gave me some assurance as I followed these international health guidelines in case of an animal bite, lick or scratch (rabies is transmitted through Saliva):
“If you are bitten, scratched or licked on an open wound by an animal.
- Wash the wound vigorously with copious amounts of soap and warm water for at least five minutes (though 15 minutes is best). (Use povidone-iodine or 3% hydrogen peroxide if available). Thoroughly flush the wound with water.
Doing this will greatly reduce the risk of infection.
- Seek medical care immediately even if you have received rabies vaccine! Immediate and adequate medical care is critical for preventing rabies.
- If no pre-exposure vaccination was given, you will need Rabies Immune Globulin (RIG) serum administered as well as 4 doses of rabies vaccine at 0, 3, 7, and 14 days.
- If you have received pre-exposure vaccination, you will need two doses of vaccine over a 3-day period. However, no RIG serum is necessary.
- Now if you are in a developing country, then the vaccine may be available, however, sometimes the RIG serum is not. If that is the case, then I hope you have travel insurance because medical evacuation may be necessary.
- Avoid suturing the wound until RIG is administered.
- Rabies prevention is only successful if started before symptoms appear. Symptoms appear approximately 3-4 months after the bite and by that point, it is very likely that you will die .
I completed step 1 as above and then rushed off to the closest hospital, Rumah Sakit Ari Canting in Gianyar which is 20 minutes away. I was also very fortunate to get there with my Balinese neighbor’s daughter to translate. I was admitted very quickly and saw two doctors in what seemed to be to the Emergency Clinic.
After presenting my Vaccine booklet and explaining what I did after the bite, the doctors assured me that I would not need any PEP shots because I had been recently immunized in October. One of the doctors’ laughingly joked that I was so prepared and cleaned the wound so quickly that it seemed like I wanted to get bitten. They had a nurse clean up my wound with some hydrogen peroxide and iodine and then prescribed some antibiotics to fight off infections. At the time, I was very impressed by how quick and efficient everything was. I was in and out of the hospital within 45 minutes.
However, when I got home, something felt awry. I called the nurse hotline in British Columbia, my travel medical clinic doctor and World Nomads, my travel insurance company to tell them I had to make another claim. When I recounted the story to each of them, they were all shocked that I did not receive the PEP shot immediately after being bitten. They all said that I required one PEP shot on day 0 (day I was bitten) and day 3, as Indonesia is a high-risk zone. All three were surprised that the doctors did not administer this immediately as this follows Canadian, United Kingdom and International standards . The following day I went to the Ubud Clinic and saw the doctor there. He was also surprised that the PEP shots were not administered. When I asked if I need to use the antibiotics, he looked at them and said that they were way too strong and that I wouldn’t need to take them.
Luckily, I was smart enough to get a second opinion. If not, it could have resulted in my death if the dog was rabid which further evidence by locals indicates that it is. Further I was charged 360,000 Indonesia Rupiah for seeing the doctors and for the antibiotics (which I know is not much at all, but it still is inconvenient and can affect your budget if you are backpacking).
It is believed that rabies was introduced by a dog illegally brought to Bali by two men from Flores, where rabies has been endemic since 1998. The dog then bit the two men and then transferred the disease to other animals. Prior to 2008, Bali was rabies free and completely unprepared to fight a rabies epidemic. There were no vaccines, emergency plans or funding.  On November 17th, 2008, the first human death following a dog bite from rabies occurred in Ungasan, Bali. By 2009, 27 cases had occurred in several different parts of the island, but mostly in the southern region. By 2010, the number of rabies related deaths surpassed 40 [3, 4].
Culling in the 16th century.
The government at the time decided the best way to fight rabies was a mass culling of Bali’s street dogs. They used Strychnine, a poison, in baits and then darts. This resulted in 150,000 dogs dying, in extreme pain. Rabies then continued to spread as people moved their pets to avoid the culling, unaware that unvaccinated dogs could already be incubating the viral disease. Currently, 160 people have died because of rabies on Bali.
Though Indonesia is high risk, Bali has gotten better for rabies. In 2011, the organization Bali Animal Welfare Association (BAWA) has worked with the Balinese government to establish an effective Vaccination program which has dropped the rate of transmission of rabies. Through awareness and education, they have also helped teach the general public about signs of rabies in animals and humans and what to do should they encounter an infected animal. Instead of culling, BAWA advocates for a cruelty-free sterilization method which has been proven scientifically to be more effective in reducing the rate of transmission of rabies. In addition, they have even developed a vaccination program that gives the pre-vaccine to people living in poverty and tourists. 
Rabies is a difficult battle to fight and though the Bali government and BAWA have worked hard to eradicate it, there are still cases popping up sporadically. In March 2015, an Australian man was bitten by a monkey that had rabies . In September 2016, another local Balinese man was bitten by a rabies positive dog even though it did not exhibit any symptoms such as aggression, foaming at the mouth or fear of water (hydrophobia). Luckily, both men sought immediate medical attention and survived .
So, what can we learn from all of this? Personally, I hope that when people read this, they will seriously consider getting vaccinated against rabies and other preventable diseases. Doing so reduces the likelihood of transmission and spread of the disease. Second, I hope this makes people aware of what they need to do if they are bitten by any warm-blooded animal. Lastly, I recommend getting travel insurance to cover medical expenses such as emergencies similar to this one. Let’s hope 2017 is a good year for rabies eradication in Bali.
 Centers for Disease Control and Prevention. (Mar 2016) Rabies. Retrieved from: http://www.cdc.gov/rabies/medical_care/
 Bali Animal Welfare Association. Rabies and Response Control. Retrieved from: http://bawabali.com/our-programs/rabies-response-control/
 Clifton M. Rabies, canine, human – Indonesia (21): Bali. ProMED-mail 2009, 29 December: 20091229.4373. http://www.promedmail.org. Accessed 11 January 2017.
 Clifton M. Rabies, canine, human – Indonesia. ProMED-mail 2009, 13 March: 20100313.0816. http://www.promedmail.org. Accessed 11 January 2017.
 Cronshaw, D. (March 2015). The Sydney Morning Herald. Retrieved from: http://www.smh.com.au/nsw/nsw-man-faces-rabies-risk-after-monkey-bites-in-bali-20160315-gnjbpd.html
 Coconuts Bali. (October 2016). Retrieved from: http://bali.coconuts.co/2016/10/06/tabanan-man-bitten-rabies-positive-dog
If any information is ever incorrect, please let me know! Science is about learning from mistakes, improving and moving forward!