Rabies Without Borders

On the 17th of July, a 5 year old girl died of rabies in the Sarawak General Hospital in Kuching, the capital of Sarawak in Malaysia. This little girl became the fourth child victim of rabies from this small area this month, all of them bitten by dogs around the town of Serian, near to the Sarawak border with Indonesia (see map). The first victims, a 6 year old girl and her 4 year old brother died on July 4th. A third case, a 7 years old child was under intensive care observation, but died on July 13th. These are the first human rabies deaths in Malaysia in 20 years and naturally are of great concern.

Other children initially suspected of having contracted rabies from dog bites have tested negative and so far havent shown any symptoms, but on July 18th a 52 year old man was confirmed as having contracted rabies after being bitten by a dog in early May. This man died on July 23rd .

An official report dated July 10th sent to the World Organisation for Animal Health (OIE) indicated that 32 rabies cases in dogs and cats had been found from two villages near Serian. This was updated with a total of 23 more cases from 9 more villages in a report dated July 18th . Highly concerning in this second report is one rabid dog reported in Taiping, Perak, in peninsular Malaysia. This is a great distance from the Serian area (see the map), and it is not yet clear how the outbreaks are connected. A news report on July 23rd stated that a total of 20 areas in Sarawak had been declared as rabies-infected with one of the new areas in the state capital, Kuching. Clearly the situation is evolving daily as more investigations are completed and further reports will likely increase the number of infected areas.

Since 1954, Malaysia has been one of very few rabies-free areas in Asia, but rabies-carrying dogs crossing its borders have been an ongoing battle. A dog rabies outbreak that crossed into the far northern states of Malaysia from Thailand removed the countrys rabies-free status in 2015. This previous outbreak was detected only in dogs and brought under control without any reports of human rabies cases. The current situation would appear to be much more serious, as rabies has clearly been present in dogs in Southern Sarawak at least since May when the victims were bitten. This outbreak will need to be stopped and no rabies-positive dogs identified for two years before Malaysia can claim that it is rabies-free once again.

As of a news report on July 18th when just seven villages had been declared rabies infected areas the Sarawak Veterinary Services Department had vaccinated 7,655 pets, and 73 stray dogs have been captured. More intense efforts are now underway to vaccinate both owned dogs and strays and seem to be having a good uptake, but 70% of the dogs need to be vaccinated to be sure that the virus can no longer spread. Rabies awareness campaigns are urging people to get their pets vaccinated and seek treatment for dog bites, and at least 250 people have received Post Exposure Prophylaxis to prevent the symptoms of rabies. Tougher animal movement controls are being enforced and further vaccination efforts and surveillance outside the affected zones will be increased.

These situations are similar to an incursion into the Arequipa region of Peru from Bolivia which occurred in 2015, and the introduction of rabies onto the historically rabies-free Indonesian islands of Flores in 1997 and Bali in 2008 . Recent genetic analysis suggests that Flores and Bali were also infected following the introduction of rabid dogs from the Kalimantan region of Indonesia, likely transported on fishing boats.

Such incursions into previously rabies free areas are a continuing threat to rabies-free areas whilst any country in a region harbors ongoing rabies transmission. Land borders between countries may be very rural, remote from the capital, and sometimes disputed territory, making rabies control programs especially difficult to carry out. Much of the interior of Sarawak is rugged, dense rainforest for example. Such areas may have very low levels of routine vaccination and surveillance activities. Although islands have the advantage of their natural ocean borders, where fishing or other boats frequently travel across them there are dangers. It is clear that human transportation of rabid animals, by land or by sea, is a huge risk with potentially devastating consequences, especially to rabies-free countries where animal vaccination is not routine.

Cross-border threats undermine efforts of individual countries to gain and to maintain rabies freedom, a fact that underlines the need for regional cooperation. Regional networks can support coordinated rabies control efforts across whole regions, and highlight countries that need extra assistance to building the capacity to reduce the burden of rabies. As travel increases exponentially, support for rabies control in all countries is necessary for the global public good.

This piece was based on an article originally posted on the GARC website and updated with more recent information. It is part HuffPosts Project Zero campaign, a yearlong series on neglected tropical diseases and efforts to eliminate them. This series is supported, in part, by funding from the Bill & Melinda Gates Foundation. All content is editorially independent, with no influence or input from the foundation. If you'd like to contribute a post to the series, send an email to ProjectZero@huffingtonpost.com . And follow the conversation on social media by using the hashtag #ProjectZero.