North Sulawesi is an endemic area of rabies and boasts the highest number of deaths in Indonesia. Dog population that exceeds the number of vaccines and low public awareness are to blame for the prevalence of the disease.
“Your son will not live longer than 24 hours.”
Jimmy Dapar (29) was stunned after listening to the doctor’s pronouncement. His only son Gio (5), diagnosed with rabies, could not be saved. Gio died on January 20th, 2021 at the Kandou Malalayang Public Hospital in Manado City, North Sulawesi.
On December 24th, 2020, the little boy was playing with friends in front of their house in Bahu, Manado city. A dog unexpectedly approached them and Gio chased it. In return, the dog bit him on his cheek.
On January 19th, 2021, Gio showed abnormal behavior such as anxiety, salivation, and acted as if he wanted to bite others. When Jimmy realized that his son was showing rabies symptoms, he took his son to the hospital again. But it was too late.
“The doctor immediately said he cannot be saved. Less than 24 hours at the (state) Kandou Hospital, my son died. He was treated in his own room, his symptoms worsened and eventually he died,” Jimmy said.
At the time of writing this article, Jimmy and his wife do not know the whereabouts of the dog that bit their son. How it came from and its condition now. Jimmy voiced hope that people look after their dogs and urged them to get them vaccinated.
“Likewise, if someone is bitten by a dog, whether adults or children, they must immediately get the anti-rabies vaccine. Especially, anyone who does not know where the dog comes from. Don’t take it for granted, so what happened to my son, won’t happen again,” he said.
Rabies in dog meat trade
In his old age, Herni Sumilat (79) is still slaughtering dogs in Langowan Market, Minahasa, 50 kilometers away from Gio’s house in Manado City. He is the oldest butcher in this market and says he has slaughtered many animals in the 65 years doing this job. He can’t recall how many.
Over the decades of selling dog meat for consumption, Herni has been attacked by dogs many times. His hands and feet are covered with scars from dog bites and attacks. In fact, a wound on his leg had not yet healed, when he was interviewed by Tribunmanado at the market on Saturday, 16 October 2021.
Herni admitted that he has not yet been vaccinated against rabies and has never been diagnosed with rabies following all the dog bites she experienced. He claimed he can distinguish which dogs have rabies and which do not. If it was only a small wound, he would leave it to heal on its own. If the wound was worrying, Herni would seek treatment from a nurse at the local health center. However, Herni added, he would receive a tetanus shot, instead of rabies vaccine.
“There are no dogs with rabies here. I never get rabies. If there’s an open wound, it will heal itself,” said Herni.
Maxi Sumilat (69), Herni’s younger brother, is also a dog meat trader. He too tells a similar story. In his 56 years of selling dog meat, he has never had rabies and his response to dog bites in the past is the same as his older sister’s.
Steven Manopo (54), another trader, lost a finger on his left hand after he was attacked by a dog he was about to trade. His right hand is deformed from repeated dog bites.
But, after 30 years of selling dog meat in the Langowan market, Steven claimed he never had rabies, nor was he vaccinated, and he would only be given the tetanus injection. “If a dog bites, I take an avocado then I put it on where the bite marks are,” he said. Many locals in Manado believe that avocado can help treat dog bite wounds and heal them faster.
For Minahasa People in North Sulawesi, consuming domestic animals is a habit that has passed down generation to generation.
Traditional markets that sell dog and cat meat are spread across six districts, but the majority are found in Tomohon, Minahasa, and Manado. Some sell them butchered, while some sell them live. Dogs and cats are kept in a metal cage and are ready to be slaughtered when a sale is made.
Ahmad Gozali, Senior Technical Advisor Food and Agriculture Organization of the United Nations (FAO) Emergency Centre for Transboundary Animal Diseases (ECTAD) in Indonesia, said that one of the highest risks of spreading the zoonotic disease in the dog trade for consumption is in the transportation process.
Christian Waltzer, Executive Director for Health in the Global Conservation Program of the WCS (Wildlife Conservation Society), quoted in Live Science, said zoonoses are infectious diseases caused by bacteria, viruses, fungi or parasites that spread from animals to humans.
Zoonoses can be transmitted through direct physical contact, through the air or water, or through an intermediate host such as insects. Often these zoonotic pathogens do not affect the animals in which they live, but they can pose an enormous risk to humans who have no natural immunity to them.
The movement of dogs from one place to another has the potential to spread the rabies virus. The risk also exists in the processing of dogs into food.
“The dog’s communication tool is the mouth. If it feels uncomfortable, it will bite. It might bite another dog or the operator. Then the slaughtering process, we don’t know to what extent the operator protects himself during the process. If there’s an open wound and that gets exposed to the saliva of an infected dog, then we can be sure the operator will be infected. If the saliva enters the human body, he will be infected,” explained Gozali, who is also a veterinarian.
Awareness of behavioral change in dogs
Once bitten by a dog, a person should be aware that there is a high risk of contracting rabies, said Gozali. If after the bite there is a change in the dog’s behavior, one should be increasingly suspicious of the presence of the rabies virus.
“A dog that used to be fierce, then became less fierce, or vice versa. Or those who are usually active, now just hide. Or when they usually run straight to you when you call, and they no longer respond – that is reason to be more suspicious. You must act by taking the rabies vaccine,” said Gozali.
Dog bites that are close to the brain further accelerate the risk that the rabies virus will enter the brain. The rabies vaccine protects the brain from the virus. If one has not been vaccinated and the virus reaches the brain, then clinical symptoms will appear in humans. Once that happens, the fatality rate of the individual is 100 percent, he confirmed.
“For example, if you are bitten in the mouth, it is close to the brain. With bites on the legs, people may take more time to develop symptoms. If a person is vaccinated before the virus’ journey to the brain, the person has a chance to recover,” he said.
Gozali said people who keep dogs should also have their dogs vaccinated twice a year. This is so that the rabies virus does not lodge in the dog’s body. Gozali noted a dog must be first vaccinated at three months old. The second vaccination is to be administered a year after and ideally, they are to be vaccinated every year or every three years after that.
“Rabies virus is invisible to the eye. This means that this virus can be anywhere. The safest way to prevent rabies is to vaccinate pet dogs,” said Gozali.
The highest number of deaths in Indonesia
Despite repeated urging from the FAO and public health officials, North Sulawesi has the highest cases of recorded deaths from rabies in Indonesia. According to a statement released by the Ministry of Health on 20 September 2020, the national death rate due to rabies virus is still high, with 100-156 deaths per year. There is no data on how many stray dogs exist, but it is clear that rabies remains a threat to public health, particularly in North Sulawesi.
The ministry further explained that in the last five years (2015-2019) there were 404,306 cases of animal bites that transmitted rabies, with 544 fatalities throughout the country. The five provinces with the highest number of deaths were North Sulawesi, West Kalimantan, South Sulawesi, North Sumatra and East Nusa Tenggara.
Arthur Troy, Head of Infectious Disease Control and Prevention at the North Sulawesi Public Health Department, said the biggest challenge is in the coverage of rabies-carrying animal vaccination (HPR) in North Sulawesi. “If the rabies vaccination rate among animals is high, the fatality rate will be lower,” he said.
Hanna Tioho, Head of the Regional Technical Implementation Unit (UPTD) of the Animal Health and Veterinary Public Health Laboratory at the North Sulawesi Agriculture and Animal Husbandry Department, which is responsible for carrying out the vaccination drives, added that cases of rabies in animals in North Sulawesi are still high despite their efforts. In 2021, of the 500 cases of animal bites tested, 80 percent of the samples tested positive for rabies.
Tioho said the vaccine supply for dogs – provided free by the government — is far less than 70 percent of the total population of dogs in North Sulawesi. According to Indonesia’s rabies elimination target set by the Agriculture Ministry, ideally, at least 70 percent of the dog population should be vaccinated by 2030.
Tioho added that for the total number of 270,000 dogs’ population based on data collected by the North Sulawesi Agriculture Department, there are only 10,000 vaccines available. “The supply of 20 percent vaccine isn’t enough. Much of the [local administrative] budget has been shifted to the mitigation of Covid-19 [also a zoonotic disease, like rabies],” Tioho explained.
However, the availability of vaccines has been extremely limited even in the years preceding the pandemic. Hanna Tioho admits that the government’s budget for the procurement of rabies vaccine is not sufficient, adding that animal health is an optional program, not priority compared to public health, education, and others. In 2021, the North Sulawesi Agriculture Department allocated Rp375 ($26,000) million for the procurement of rabies vaccine.
According to Tioho, public awareness about the importance of pet vaccination is also low. Many still undermine vaccination and believe their dog is just fine without it. “If there are no rabies cases, everyone is quiet. But, when there is a rabies case that surfaces, then they panic,” said Tioho.
Tioho added that if people want to get free vaccines for dogs, they can immediately contact the animal health department in their respective district and city. Meanwhile, paid vaccines are available at veterinary clinics.
For humans, both provincial and district administrations offer free and paid vaccinations.
“In fact the rabies vaccine is accessible in health facilities. It’s in the community health centers, also at the health department. If the district runs out, they can go to the provincial level outlets. If clinical symptoms appear in humans, no amount of money can help. It’s just a matter of time (to die),” she said.
Currently, pet owners are able to get free vaccines in state-run outlets and community health centers. They can also obtain vaccines at pet clinics for a nominal price, between Rp50,000 – Rp250,000. Meanwhile, rabies vaccinations for humans are only administered when they are bitten by animals, and are free.
One Health in rabies control
In 2017, Minahasa was appointed as a pilot district for a zoonoses control program with a One Health approach that concentrates on rabies in Indonesia.
The Indonesian Health Ministry defines the concept of One Health as a collaborative effort from various sectors, especially human, animal and environmental health, both at local, national, and global levels to achieve optimal health. With this approach, the Indonesian government targets the elimination of rabies in humans and animals by 2030.
Veterinarian Louise Kumaunang, Head of the Animal Health, Animal Husbandry and Health of the Minahasa Agriculture department said, through the One Health approach, public health, animal health, and wildlife health officers report to each other events that occur in all areas in Minahasa.
Before One Health was implemented, it was very difficult for the public to get information about animal and human rabies. Information only spreads quickly when a death occurs due to rabies.
Before the initiative, information-sharing was hampered because there was no coordination, said Kumaunang. The Minahasa administration has only been able to implement a rabies management model like this since the One Health program was launched here in 2017.
Louise acknowledged that controlling rabies with the One Health approach is still limited to treatment. Steps to fully prevent rabies through vaccination have not yet been able to be implemented because of the number of available vaccines is inadequate for the growing dog population.
Didik Budijanto, Director of Prevention and Control of Vector and Zoonotic Diseases at the Ministry of Health, said that apart from animal and human health, the role of community in efforts to control rabies using the One Health method is very important.
He said there must be close cooperation among stakeholders. The public should be educated about what to do if they get a dog bite. It is also important to increase the capacity of the government and experts in the management of cases of animal bites carrying rabies.
“With One Health we can handle cases faster. The target is no deaths in humans, while in dogs the rabies rate can be decreased. Rabies in dogs has been a challenge. In addition to vaccine availability, [another implementation challenge is] dogs always bite. Especially if they get provoked,” she said.
Arthur Tooy, Head of the Communicable Disease Prevention and Control of the North Sulawesi Health Department, said that the implementation of One Health in Minahasa has had a big impact. He added, the province has seen a decrease in death cases. Apart from Minahasa, through the local administration budget, his department also implements the One Health approach in other districts and cities.
However, when the Covid-19 pandemic hit in 2020, the provincial government shifted the budget to more urgent Covid-19 counter-measures.
Still, Tooy is hopeful. “We are actually optimistic that rabies cases will continue to decline, but the Covid-19 pandemic has affected the prevention of rabies in North Sulawesi, especially from a human health perspective,” he said.
This story was first published in Indonesian by Tribun Manado on 17 February 2022 and has been edited for length and context.
This story was produced with support from Internews’ Earth Journalism Network.