Rabies

Rabies is a viral infection of the central nervous system. Dogs are the most common source of rabies, especially in Latin America, Africa and Asia (except Taiwan, Hong Kong, Singapore, Brunei, Maldives and Japan). More than 30% of rabies cases in the USA occur in returning travelers and immigrants that received dog bites while abroad. Almost 60% of the human cases of rabies diagnosed in the USA have been associated with bat variants. In the case of a bat bite, inhalation of aerosolized bat secretions (e.g., spelunkers), scratch or mucous membrane exposure, post-exposure treatment is recommended even if evidence of exposure is not visible but there is reasonable probability that an exposure may have occurred. Other sources of rabies are skunks, raccoons, foxes, jackals, groundhogs, domestic cats, mongooses and, particularly in countries in southwestern Asia, wolves. It is rare to find rabies in rabbits, squirrels, gerbils, rats, mice, chipmunks, or guinea pigs.

In the USA, rabies vaccine is indicated for international travelers venturing into areas of possible rabies exposure, particularly if post-exposure treatment is not available. Be aware Rabies Immune Globulin (RIG) may be very difficult to find abroad, and if found, it may be very expensive.

Our general recommendations for the prevention of rabies is the following:

• Avoid all contact with animals
• If you have any exposure to animal bites or wounds seek attention immediately
• If you begin rabies treatment abroad but return to the USA before your treatment is complete, document the type of vaccine used
• If you are concerned about rabies, but decide not to receive the vaccine here (it is quite expensive!), strongly consider purchasing appropriate supplemental medical insurance to assure your ability to return home as quickly as possible and begin therapy. Also, make every attempt to ascertain if RIG is available in the host country.

The primary series of rabies vaccine is a total of three injections given at 0, 7, and 21 or 28 days. A single booster dose is recommended for persons in high-risk categories every two years. Recently, some authorities recommend a three-dose primary series and a single booster dose a year later. This yields very high antibody titers that will persist for at least 10 years.

What To Do Following an Exposure

All animal bites should be thoroughly cleansed immediately with soap and water. If available, a virucidal agent such as a poviodone-iodine (BETADINE®) solution should be used to irrigate the wound.

The pre-exposure rabies immunization does not eliminate the need for further immunization after an exposure incident; however, it does eliminate the need for RIG, which is often very difficult to access abroad and is extremely expensive. Without pre-exposure rabies vaccine an exposed person requires a single dose of RIG on day 0 and rabies IM on days 0, 3, 7, 14, and 28. Pre-exposure rabies vaccine reduces the post-exposure vaccine schedule to a single injection of rabies vaccine IM at days 0 and 3. This regimen is applicable for all age groups, including children.

Based on CDC, Health Information for International Travel 2001-2002, DHHS, Atlanta, GA, 2001; WHO, International Travel and Health, 2002, Geneva; and Dr. Richard Thompson's book Well on the Road - A Practical Guide for the International Traveler, 2002.