The death of a four-year-old child is the fifth rabies fatality in Bali this year, according to local authorities, underlining an ongoing public health challenge for the Indonesian resort island.
Officials said the child had experienced symptoms such as fever, hallucinations and hydrophobia — a fear of water — which are indicative of the rabies virus.
The child had been bitten by a stray dog the month prior in Gianyar, the local area encompassing Ubud, according to the local health office.
While rabies is non-existent in Australia, it still poses a significant public health risk in Indonesia.
And as Australians continue to flock to Bali in record numbers, the island is still struggling in its fight against the deadly virus.
Bali has highest rate of rabies in Indonesia
Bali's provincial health ministry reports more than 39,000 people have been bitten by rabies-carrying animals this year.
About 90 per cent — more than 36,000 of them — were bitten by dogs.
Stray dogs are less common in Muslim-majority regions because many Indonesian Muslims believe keeping dogs is forbidden.
Hindu-majority Bali is thus the epicentre of Indonesia's rabies cases.
"Bali is home to many dogs, with Bali dogs being an integral part of many communities," said Matt Backgouse, head of stray animal care in South-East Asia with Four Paws.
"Many of them are not officially owned but live communally with the general population."
The World Health Organization wants to end human deaths from dog-mediated rabies by 2030.
Last year, however, it noted rabies remained endemic across 26 Indonesian provinces despite the disease being preventable by vaccination.
The stray dog bite that claimed the child's life this month was not reported to health workers, authorities said in their report.
While available data shows only 54.9 per cent of the Balinese population has been vaccinated against rabies, experts say free vaccines from the Balinese government have led to improved immunity in recent years.
Rabies prevention efforts in Bali
Ni Nyoman Sri Budayanti, head of the One Health Collaborating Centre at Udayana University in Bali, said the mindset of local communities remained a challenge in fighting rabies.
"What's difficult are the children who do not tell their parents that they were bitten by a dog," Dr Budayanti told the ABC
"[They are often] people from a lower socio-economic background.
"They think that rabies has been around for a while so it's fine to get bitten."
She said the relaxed attitude had contributed to five people dying this year.
The number of rabies cases and bites from rabies-carrying animals had decreased because of government efforts according to Dr Budayanti, who has worked on the issue since the island's first recorded case in 2008.
A new task force established in 2022 treats bite wounds and provides anti-rabies vaccines to residents, while also delivering educational programs to the community.
But the final step needed to curb Bali's rabies cases, Dr Budayanti said, was greater buy-in from the community.
"Rabies is a community-based disease so the community should be active," she said.
However, Bali Animal Welfare Association founder Janice Girardi said the high cost of animal vaccination meant it remained unaffordable for many locals.
Many residents did not understand what to do when their dog got sick, she said, explaining they often assumed a dog had rabies whenever it showed signs of illness and promptly abandoned the animal out of fear.
"So they throw their sick dogs away, they get on their motorbikes … they leave them at the markets, beaches, temples."
This was why the number of unvaccinated stray dogs stayed high and Bali's rabies threat remained, she said.
"People need to be taught that rabies is 100 per cent preventable with vaccines."
The Australian Department of Agriculture is working with Indonesian authorities to implement a rabies control program.
Since 2022, they have administered 200,000 vaccines per year provided by the World Organization for Animal Health.
But Ms Girardi said vaccination efforts would be ineffective if unvaccinated dogs continued to be sold informally.
"Breeders are one of the main problems and I think if the government is serious they want to stop rabies, they need to insist that people stop breeding dogs," she said.
"They're selling the dogs on the side of the road and we're asking them, 'Are your dogs vaccinated?'"
