Bali rabies epidemic

"Once the signs and symptoms of rabies start to appear, there is no treatment and the disease is almost always fatal."  - World Health Organization
Bites from stray dogs have recently led to the death of many people in Bali.   Bali Discovery (h/t Odinius):
The latest death of a 45 year-old woman, Ni Ketut Ardini, on Monday, March 8, 2010 has brought to 40 the number of fatalities tied to the continuing scourge of rabies in Bali.
A day prior to her death the woman still managed to work in family farming lots. Approximately 1.5 months prior to her death Ardini suffered a dog bite from a family pet on the fingers of her left hand.  Refusing medical treatment the woman only washed the wound with soap and water.
Odinius blogs:
Bali's main general hospital at Sanglah is reporting a daily rate of 60 dog bites, with other satellite general hospitals across the island treating an average of between 25-30 cases a day. Authorities estimate around 85 dog bites are taking place island-wide on a daily basis. Since November 2008, a total of 31,000 dog bite injuries have occurred in Bali with 28,000 people being given anti-rabies serum. The current count estimates that there have been 59 cases of rabies of which 28 have been clinically confirmed as resulting from the disease.
Rabies cases have been reported in every metropolitan center in Bali.

 Even tourist areas of Bali are populated with nasty stray dogs.  For peace of mind, getting a rabies shot would seem advisable prior to vacationing in Bali.  Needless to say,  if you get bitten by a dog -- or any other animal such as a bat in Bali -- you will need to be treated.

What kind of treatment should you seek?

Here's some information from the CDC in Atlanta:
In the United States, postexposure prophylaxis consists of a regimen of one dose of immune globulin and four doses of rabies vaccine over a 14-day period. Rabies immune globulin and the first dose of rabies vaccine should be given by your health care provider as soon as possible after exposure. Additional doses or rabies vaccine should be given on days 3, 7, and 14 after the first vaccination. Current vaccines are relatively painless and are given in your arm, like a flu or tetanus vaccine.
Also according to my reading of the CDC website, it would not be advisable even to touch any animal in Bali capable of carrying the rabies virus:  "... transmission has been rarely documented via other routes such as contamination of mucous membranes (i.e., eyes, nose, mouth..."   The WHO would undoubtedly consider touching a dog in Bali a "Category I" rabies risk.  This means that if you have any skin contact with a dog you would be advised to wash your hands immediately. According to CDC, soap and water washing is considered an important step in rabies prevention.    

Also from the CDC: Information about peexposure vaccinations:
Although preexposure vaccination does not eliminate the need for additional therapy after a rabies exposure, it simplifies management by eliminating the need for rabies immune globulin and decreasing the number of doses of vaccine needed. This is of particular importance for persons at high risk for exposure to rabies in areas where immunizing products might not be available or where lesser quality biologics might be used which would place the exposed person at increased risk for adverse events.

Preexposure prophylaxis may also protect people whose postexposure therapy is delayed and provide protection to people who are at risk for unapparent exposures to rabies.
From personal experience, I can assure readers that Bali's medical system is not up to international standards.  I would not assume that any Bali medical facilities have access to the highest "quality biologics."

CDC answers the question: What if I receive treatment outside the United States?
Postexposure therapy outside the United States may include materials not used in the U.S. such as purified vero cell rabies vaccine (Verorab ™, Imovax - Rabies vero ™, TRC Verorab ™), purified duck embryo vaccine (Lyssavac N ™), or different formulations of PCEC (Rabipur ®) or HDCV (Rabivac ™).

If these materials have been used, it might be necessary to provide additional therapy when the patient returns to the United States.  
Bottom line:  If you suffer an animal bite in Bali -- or have any other cause for concern about any infection for that matter -- get yourself to Singapore or Australia.

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