Rabies

Rabies is a relatively rare, but dangerous viral infection, which attacks the brain and nervous system. It is carried by a variety of wild and domestic mammals, including dogs, cats, wolves, foxes, jackals, civets, mongooses, racoons and bats. The greatest risk in most countries is from domestic dogs, although vampire bats are a significant risk in parts of South America.

Image of a cute-looking campsite puppy in Laos.

Rabies is usually transmitted to humans through the saliva of an infected animal, through bites, licking of broken skin or scratches. However, being spat in the face by a startled bat also counts as a significant exposure.

Rabies is especially common in parts of Africa, India, SE Asia and China, causing 59,000 human deaths each year and untold fear and suffering.

A recent outbreak on Bali, which until 2008 had been rabies-free, has so far claimed the lives of at least 160 people (and countless more dogs). The outbreak continues with 9 human deaths reported in the first 7 months of 2015 alone. Many hospitals on the island have now simply run out of rabies vaccine.

Overall, the risk to travellers of rabies itself is very small, but the consequences potentially major. Without pre- or post-exposure vaccination, rabies is universally fatal.

By contrast, the risk of a potentially rabid bite when travelling in an endemic country is relatively common: It is now more than 30x the risk of hepatitis A; 20x the risk of typhoid in the Indian Sub-continent (and between 63-400x the risk in Africa and South America); and 40-95x the risk of hepatitis B (source: Robert Steffen, 2016).

Prevention

OK, it's not a common vampire bat, but my web designer's away and I don't know how to change it...  The commonest, reported clinical indication for rabies post-exposure vaccine worldwide since 2010 has been: 'monkey bite in Bali' (source: GeoSentinel).

Rabies vaccination

Pre-exposure vaccination consists of a course of three vaccinations, typically on days 0, 7 and 28.

Rabies vaccination can be given by either the intra-dermal or intra-muscular routes. Both are equally effective, but the intra-dermal route is cheaper and less painful. TrExMed is one of the only Edinburgh travel clinics which offers intra-dermal vaccination.

The current Scottish and international guidelines are that no further, 'routine' boosters are required for most travellers following a full, intra-dermal or intra-muscular course, except in the event of a significant exposure (see below).

Treatment - what to do if you are bitten, scratched or spat in the eyes/mouth by a suspect animal:

If you HAVE had three pre-exposure vaccines previously:

You would probably be advised by the doctor you see locally to have a booster. This would mean either 4 intra-dermal vaccinations on the same day, or 2 intra-muscular ones, 3 days apart. While the immunity from a full course is now considered to be life-long, it is generally thought safest practice to re-alert the immune system's memory cells in the event of a possibly rabid bite.

No-one who has had a complete pre-exposure course, followed by a booster after an exposure has ever gone on to develop rabies. No other vaccine can compare with this 100% record!

If you HAVE NOT had a full, pre-exposure vaccination course:

You may need to have BOTH:

AND:

*Please note: HRIG is often in short supply in rabies-endemic countries, and where available, usually only in a major or capital city.

Expeditions and other 'extremely remote' travel:

Rabies vaccination is considered by most Expedition/Wilderness Medicine professionals to be a pre-requisite for people going on expedition to a high risk region. It can also work out more cost-effective to arrange this as a group.

For travellers planning to be in extremely remote areas (i.e. more than 48 hours away from a hospital) additional, special arrangements may be advisable, e.g. carrying a dose of rabies vaccine with you, or having a precautionary booster just before you travel. If you feel you might fall into this category, please speak to Jim or Nicky to arrange training, supplies etc.

Rabies immunity testing

There are some people who have a high occupational risk of unnoticed rabies exposure, e.g. laboratory workers working with the virus, or people working with wild or stray animals.

For such people and/or for extra peace of mind, TrExMed offers a rabies immunity testing service. This consists of a simple blood test to see if you have significant levels of rabies neutralising antibody in your blood.

Jim Bond and Nicky Armstrong, updated April 2017

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