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Rabies and monkey bites, is it a concern, what should I do?

Lombok, Indonesia
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Rabies and monkey bites, is it a concern, what should I do?

Rabies is a neurotropic virus that can cause fatal disease in humans, it is transmitted to them by infective animals who have themselves contracted Rabies. A common infection route is established by a bite, or by saliva from an infected animal entering through a skin wound or lesion.

At the outset it should be made clear that there is NO established evidence that any monkey on the island of Bali has ever transmitted a Rabies infection to a human.

Monkeys are just not in the current disease vector on Bali. However dogs are.

Some people feel understandable concern that the disease vector may change and that monkeys may become infective.

This no doubt stimulates the concern to administer post-exposure treatment for potential Rabies infection in the event of a monkey bite from a non-captive Balinese monkey, such as in the Ubud 'Monkey Forest'.

That is location popular with visitors and a notorious site for monkey bite injuries on the island, as are many of the temple sites.

A monkey bite is very unlikely to give rise to a Rabies infection.

If it did occur then it would create a medical, veterinary and public health precedent on the island.

The prevailing concept appears to be that Rabies 'might' become apparent in Monkeys.

That is somewhat stretching a hypothetical. However the concept that it 'might' happen has now become so engrained in popular mythology that many people are reacting as though it is known fact. They are mistaken.

A few media reports have inflamed this by reporting monkey bites as being "suspected" of bearing a possible Rabies infection.

However the media reporting has often provided some emphasis to the hypothetical 'suspicion' rather than an actual medical or virological reality.

At times this has been presented in a quite sensationalistic reporting style. This has made the misunderstanding a lot worse.

The media have possibly been reporting their own statements, not anything based on medical or veterinary fact.

In mid-May 2012 a man died following a primate attack in the village of Tengah Nongan. The man's naked body was found 50 m from a river bank with multiple bite wounds and a severed artery.

Concerns were raised that the animal or animals that attacked him may have done so due to being effected by a Rabies infection. Local villages reported that several weeks earlier the same monkey had attacked a dog. It was reported that after the attack the dog exhibited suspected symptoms of rabies causing its owner to put the animal down. The nature of these symptoms was not reported.

The Karangasem health agency apparently sent out personnel to catch some of the suspect monkeys and examine them to determine if they had a rabies infection. No verifiable evidence was presented to support that concern, and none has emerged in the months since.

There have been issues in the past on Bali with Rabies infection in the wild dog population and a limited number of domesticated or 'kampung' dogs that also became infected.

That situation is generally considered to be under control now. There have been both animal culling and animal vaccination programs run to acheive that end.

There have been human fatalities in recent years, 26 people were reported to have died of rabies in 2010, a significant decline from the 83 deaths in 2010. Most of them have arisen from a lack of suitable medical and disease awareness, lack of access to appropriate treatment, or a reluctance to receive appropriate treatment. There are around 4 million people on Bali, not all have sufficient awareness, access or the means to seek appropriate medical intervention.

That the rabies issue appears to be controlled should not reduce a visitors vigilance.

The risk is certainly reduced but is still potentially present.

Avoid animals, especially wild ones. Do not pet animals, feed them or interact in other ways, just ignore them, or avoid them as appropriate to the circumstances.

Do most certainly avoid sick looking dogs wandering around the island, don't approach them and do not interact with them. If they are sleeping, then let them alone.

A Rabies infection may not be identifiable by casual observation, so while some animals will display obvious warning signs such as foaming at the mouth or unpredictable and aggressive behaviour, many others can seem completely normal.

So let sleeping dogs and cats lie, just leave them be.

The WHO (World Health Organization have a statement on Criteria for application withholding of post-exposure treatment for potential Rabies infection available here www.who.int/rabies/human/generalconsid/en/

Key wording in that statement is "the animal involved is a recognized rabies vector in the area where the contact occurred". It must be understood that in the Bali context monkeys are NOT in the "rabies vector", in other words they are not known to be transmitting rabies, indeed there has never been a known case of that happening in Bali.

So what is happening with these vaccinations in Bali is that guidelines for bites from known vector animals are being applied also to animal bites from animals such as monkeys that are known to NOT be in the transmission vector.

For some information this WHO Rabies Fact Sheet N°99 September 2012 is good… www.who.int/mediacentre/factsheets/fs099/en/ and would be a very good thing to read if concerned about Rabies in Bali, or elsewhere.

It is essential reading for someone who may think they are at risk of infection form a bite.

This Indian article is a little more complex to read and understand, however it has a good chart (Fig. 2: Algorithm for post-exposure prophylaxis (PEP) of rabies.) that is a handy tool to understand if a vaccine treatment is required.http://medind.nic.in/jac/t06/i1/jact06i1p39.pdf

This link... who.int/rabies/en/WHO_guide_rabies_pre_post_… is to the current WHO guide r=fro Rabies post exposure treatment in humans.

This is a link to the data sheet for VERORAB Purified inactivated rabies vaccine, prepared on VERO cells …govt.nz/profs/datasheet/v/verorabinj.pdf that is the vaccine of choice used in Indonesian (Bali) for a post exposure treatment where Rabies is suspected.

Who should receive the vaccine post-exposure?

✭ Vaccination after exposure (post-exposure) is recommended for all individuals who have had contact with an animal (e.g., bites or abrasions) that they believe may be, or which is proven to be, Rabid.

✭ Vaccination should be initiated as soon after exposure as possible and should be accompanied by proper wound management and the administration of Rabies Immune globulin, human (HRIG).

Pregnant women who are exposed to rabies may receive the vaccine.

What should you do if bitten by a rabid or suspicious animal?

✭ Wash all bites and scratches immediately and thoroughly and for an extended period with soap and water and a solution that kills viruses (such as Betadine or any other Povidone-iodine solution). Wound cleansing alone will markedly reduce the chances of getting rabies, and other potential infections.

✭ Go to a health care provider such as AEA SOS Medika or BIMC hospital, both on Jalan By-Pass, for a medical assessment regarding the need for a tetanus shot (if it needs to be updated), rabies vaccination, and administration of RIG (Rabies immunoglobulin). If possible delay suturing the wound until the question of the appropriateness of Rabies immunoglobulin administration has been resolved.

✭ Vaccination and appropriate immune globulin therapy can protect you after you have been bitten. Vaccination before exposure merely simplifies therapy by eliminating the need for RIG and decreasing the number of vaccine doses needed.

Pre-exposure vaccination for Rabies in anticipation of a visit to the island is really only appropriate in a very narrow range of circumstances. Unless likely to be interacting with vector species in Bali then it unlikely to be required.

Perth, Australia
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1. Re: Rabies and monkey bites, is it a concern, what should I do?

Thank you j_

A most informative post. I was wondering a bit about the safety of monkeys after several posts recently regarding bites at the monkey forest. Certainly one from an American seemed a bit over the top but it still got me thinking. During my many visits to Bali I've never been to the Monkey Forest. Not because I've been concerned, just because I never have. I'm spending a couple of days in Ubud in April so I will take a look with some confidence following the information you've provided.

Once again thanks for the information.

Cranbourne...
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2. Re: Rabies and monkey bites, is it a concern, what should I do?

Thanks Hurc

This may ease a few fears, yet always the need to be viligant.

Greg

(BTW what do you know about Doctor Fish?)

Lombok, Indonesia
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3. Re: Rabies and monkey bites, is it a concern, what should I do?

I hope it helps inform and also allay some of the fears and concerns surrounding the Rabies issue on Bali. I really do wish I could go back and edit some of the minor spelling errors and keyboard typos.

Sorry about them and I hope it all makes some sense.

Some of those links are very informing and the Indian sourced flow chart for treatment/vaccination management is quite good medind.nic.in/jac/t06/i1/jact06i1p39.pdf Fig. 2: Algrithm for post-exposure prophylaxis (PEP) of rabies is on the 4th page of that article and it does a good job of indicating what should be done, and when.

As Greg mentions above, vigilance is important.

Edited: 27 November 2012, 22:41
Bali, Indonesia
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4. Re: Rabies and monkey bites, is it a concern, what should I do?

I am a person who's raised in Bali for years though not born there - enough to know a lot about the local news.

The rabies tend to be more of a danger in the more rural parts of Bali so if you're staying near those areas, you may want to watch out. You can't always tell whether a stray dog has it, though I suggest in general don't get too near stray dogs, especially those that are wounded.

For monkeys, I don't really have an opinion on them as they aren't very well populated in general tourist areas besides some parts in Uluwatu and of course the monkey forest.

5. Re: Rabies and monkey bites, is it a concern, what should I do?

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