Dr Aidan Perse

Rabies is present in most countries in the world. A relatively new regime may boost uptake of vaccination.

Issues that need to be discussed with travellers to developing countries include food and water-borne diseases (e.g. Hep A and typhoid), mosquito-borne infections (dengue, zika, chikungunya, malaria, Japanese encephalitis, yellow fever) and airborne diseases such as flu and measles. And then there is rabies, a virus spread from bites or scratches of infected mammals. If not properly treated and rabies symptoms develop, the disease progresses swiftly and is virtually always fatal.

Girl feeding monkey in Bali.

Countries posing most risk to Australian travellers include India, Thailand and Bali. Tens of thousands of deaths occur in the developing world annually. Rabies is vaccine preventable, but traditionally the course has cost over $300 for the three doses in Australia and is given over a period of three to four weeks.

High risk travellers include those working with animals (vets and wildlife volunteers), ecotourists, travellers to remote places (treatment difficult to find), long term or frequent travellers, and children, who are more likely to pat animals without alerting parents. For all these people rabies vaccination is recommended.

At our clinic, post exposure rabies treatment is needed a couple of times a week – monkey bites from Ubud (Bali) are the commonest reason. Most require full post exposure rabies treatment, involving wound infiltration with 10 ml of human rabies immunoglobulin, and four to five IM vaccine doses over two to four weeks. Treatment is uncomfortable for the patient (as well as expensive and difficult to source).

Travellers to rabies affected countries should always avoid close contact with either wild, stray or domestic animals; in particular dogs, cats, monkeys and bats. No tests diagnose rabies infection in humans before the onset of disease, so potential exposure must always be treated. Ideally, we would vaccinate travellers more often but cost, and sometimes time, are barriers to greater uptake.

New options

Traditional pre-travel vaccination is three IM injections over 3 to 4 weeks before departure. If exposure occurs, two quick booster vaccine doses are given three days apart. Once vaccinated, the schedule is for life, provided booster doses are given after exposure. There is no need for immunoglobulin.

Variations to this schedule have been endorsed by the WHO (Australia is yet to). A cheaper, shorter course of two intradermal doses of rabies vaccine, injected at separate body sites at the same time, and repeated one week later. This requires less time and is substantially cheaper, facilitating potentially wider uptake. Trials show 98–100% effectiveness. Check serology prior to departure, some two weeks after the final doses, to ensure effectiveness. To have enough time to confirm immunity, see travellers 6 to 8 weeks before departure.

The vaccine must be given intradermally and subcutaneous administration (i.e. accidentally too deep) will render it ineffective. It is imperative that the nurse giving the intradermal vaccinations is trained and experienced in the technique.

Key messages:

  • Rabies is a serious life-threatening risk for travellers to developing countries.
  • Cost and time have been barriers to vaccination.
  • A new regime has the potential to increase vaccination uptake.

Author competing interests: nil relevant disclosures.

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