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Published Date: 2011-06-20 15:35:56
Subject: PRO/AH/EDR> Rabies - Indonesia: (NT) vaccination policy
Archive Number: 20110620.1885

RABIES - INDONESIA: (EAST NUSA TENGGARA) VACCINATION POLICY
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Date: Mon 20 Jun 2011
From: Wilf Mentink <wilfmentink@yahoo.com>, via Omesh Bharti
<bhartiomesh@yahoo.com> [edited]

Some news from Flores
------------------------------
I visited Maumere last week [week of 13 Jun 2011] and called in at
the Dinas Kesehatan [provincial health department]. Kab Sikka
[regency] has had no rabies vaccine for at least a month. Unofficial
report says that Maumere has had 800 reported dog bite cases so far
this year [2011]. The [health] staff are just waiting for the 1st
rabies deaths to be reported from last month's [May 2011] bite cases
who could not receive vaccine.

Maumere usually borrows from Ende [capital of the East Nusa Tenggara]
when stock runs out. The present situation suggests that Ende is also
short of vaccine. Maumere has been using the better intradermal
(intrakutan) delivery of VAR [anti-rabies vaccine] for more than a
year. An official in Maumere said that some other kabupatens
[regencies] had also changed to intradermal, but this has not been
confirmed.

A quick calculation suggests that if around 800 patients had been
given VAR intradermally, this would require around 1000 vials of
vaccine (Verorab). Used intramuscularly, this amount of vaccine would
treat just 250 people.

Last week in the RSUD Maumere [hospital] a small boy from the Bola
region was diagnosed in the terminal stages of rabies infection, but 5
days after admission he was still alive. At the time of writing his
progress is not known. Most people on Flores die within 48 hours of
the onset of final symptoms.

A health official in Maumere was asked about the progress of the
program to vaccinate dogs in Sikka. Of course he did not know. This
situation, which exists throughout Flores, is unacceptable. The main
reason for vaccinating dogs against rabies is to eradicate the disease
and protect humans. Dog rabies vaccine is very cheap compared to human
vaccine.

Health officials should be intimately familiar with dog vaccination
especially in areas where human rabies infection has been reported. In
fact dog vaccination seems to be very simple. The vaccine must be kept
in cold chain, and is delivered subcutaneously -- a simple matter of
lifting up a loose fold of its skin and sticking the needle in. This
could be performed by medical staff at local health clinics in the
distant villages with the dog restrained by its owner, a mouth guard
fitted, and there is little else for the nurse to do. The puskesmas
[health center] with its refrigerator is the logical centre for
delivering dog vaccine and registering vaccinations, but it is not the
logical place to deliver VAR to humans using the intradermal method.
This is because efficient pooling of patients is necessary to keep
costs down by reducing the amount of reconstituted vaccine that must
be discarded at the end of the day. Such vaccine could also be
effectively used to vaccinate health and animal workers
intradermally.

The puskesmas which receives more than one dog bite case a day might
temporarily stock VAR, but a system should be used so that VAR in cold
chain can go to the puskesmas and be returned to the central delivery
point before the expiry date (VAR: shelf life 3 years in cold chain).

Rabies remains a problem ever on the verge of serious outbreaks on
Flores. Dog vaccination has not worked, responsibility for it should
be placed in other hands closer to health authorities.

Omesh Kumar Bharti, MBBS, DHM, MAE (Epidemiology)
OSD, Emergency Medical Response and Transport,
Directorate of Health, Kasumpati,
Shimla, Himachal Pradesh, India
<bhartiomesh@yahoo.com>

--
communicated by:
Wilf Mentink
<wilfmentink@yahoo.com>

[ProMED-mail is grateful for this constructive report on current
vaccination strategy in Flores.

Maumere is the largest town of Flores Island, East Nusa Tenggara
province. It lies on the north coast of the island and can be located
using the HealthMap/ProMED-mail interactive map
http://healthmap.org/r/0_gB. - Mod.CP]

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