Monkey see, monkey bite, urgent flight

By Dr Jennifer Sisson*

A sign at Bali’s Monkey Forest in Ubud warns tourists “Don't stare at or tease the monkeys!”
It’s very good advice. It would be even better if it told them “Don’t feed the monkeys! Don’t pat them! Stay well clear!”
But, then the woman who sits nearby selling bananas to tourists to feed the ever-hungry macaques would probably be out of business.
As it turns out she does a brisk trade. So do local doctors.
By now, you’ve probably guessed how this story goes: Aussie traveller buys bananas. Monkey jumps onto man’s shoulder to eat banana. Monkey suddenly ‘freaks out’ and bites man on head. Hard. Twice.
Anthony Wallace recently brought home his monkey memento – nasty scalp wounds. After getting basic first-aid in Bali, Mr Wallace returned to East Gosford in New South Wales to have rabies immunoglobulin injected around the wound and to begin a post-exposure course of four rabies vaccine injections to prevent infection.

After dogs, monkey bites most common

Mr Wallace’s story is far too common.
An Australian study found that between 2007 and 2011, an average 13 Aussies a month returned home to face the long series of injections.
Of the 780 possible rabies exposures in that period, 78.3% occurred in Southeast Asia – mainly Indonesia (47.6%). Of these, almost all (95.2%) occurred in Bali and most involved monkeys (49.4%) or dogs (35.8%).
(Besides rabies, there is the added potential for macaques to transmit herpes B virus infection during an attack. It is important to thoroughly cleanse the wound with clean water for more than 5 minutes after a bite and get medical treatment as soon as possible so the risk can be assessed.) 
Hundreds of animal bites occur each day in Bali and despite attempts to eradicate rabies on the island, the virus continues to claim victims – often young children, who are particularly vulnerable. Earlier this month a 9-year-old boy from East Bali died 2 weeks after being bitten by his neighbour’s pet dog, according to a media report

Things to know about rabies

Rabies is present in almost every country on earth, but most human cases occur in South Asia – particularly India. While dogs are responsible for most of the estimated 55,000 deaths each year, virtually any mammal can carry the virus, typically passing it on by biting another animal – or a person.
When you’re overseas, patting, feeding or even approaching animals – domestic or wild, healthy, sick or injured – is problematic: The virus is always fatal once its symptoms manifest themselves so you can’t ignore a potential exposure.
You know all this, right? Well, here are a few things you might not know about rabies…
You don‘t have to be bitten to get infected – Though rare, transmission can occur through infected saliva contacting the mucous membranes of your nose or eyes, or via a lick on a scratch or other break in the skin.
Infection isn’t immediate – After multiplying in the wound, the virus inevitably reaches nerve tissue. It then travels via the nervous system to the brain, where it continues to multiply with progressively more gruesome and painful clinical symptoms. If rabies post-exposure prophylaxis (PEP) is administered before the virus enters the nervous system, death can be prevented. 
Animals may not appear rabid – The Hollywood image of a dog foaming at the mouth is a far less common sign of rabies than sudden, unexplained paralysis or a change in behaviour. A friendly cat may suddenly be very aggressive, while a normally playful puppy becomes shy and withdrawn. Not eating, eating strange (non-food) objects, pawing the mouth, appearing to choke, difficulty swallowing, chewing the bite wound, seizures, hypersensitivity to touch or sound are among the other sign an animal is infected.
Rabies incubation periods can vary – It usually takes 3-8 weeks for the rabies virus to incubate, but human cases have ranged from just days to years. That’s why it is important to receive PEP as soon as possible and start within 48 hours. If medical care was not sought at the time of the bite it is still possible to get PEP well after the potential exposure, because if the incubation period is at the protracted end, the PEP may still be effective. Only this week I initiated post-exposure treatment for someone bitten by a monkey 4 years ago because she did not realise that treatment was needed at the time.

Rabies is 100% preventable

While it’s 100% deadly, rabies is also 100% preventable. But, a series of steps needs to be taken in the right order to prevent infection.
1 – The wound needs to be cleansed thoroughly with lots of soap and water.
2 – If available, alcohol or iodine should be applied. The wound should be covered with gauze to prevent infection (but not bound), or left uncovered.
3 – It is critical to seek expert medical attention as soon as possible. (Don’t wait for confirmation that the animal was infected. That could take days – even weeks.) It’s important to find a medical facility experienced in rabies treatment that stocks (or can obtain quickly) both Human Rabies Immune Globulin (HRIG) and the first dose of rabies cell culture vaccine. Injected at the site of the wound, HRIG contains rabies antibodies that immediately inactivate and control the rabies virus until the vaccine begins to work.
4 - Have a tetanus booster, if one is required.
5 - Observe the wound for redness and discharge. Bacterial infection may occur after animal bites and antibiotics may be required.

Vaccination provides lifelong protection

Discuss pre-travel rabies vaccination with your travel doctor or GP if you are:
– Staying in an infected country for longer than a month, especially children.
– Planning to live overseas – especially in a high-risk country – for an extended period.
– Wanting the protection that immunisation offers.
The course of rabies vaccine is relatively expensive. On the plus side, no booster is required – ever – in the future unless you will be at risk of regular exposure.
The advantages of pre-exposure vaccination are:
- If bitten or potentially exposed to the virus you will need only 2 injections over 3 days, not the 4-5 over 14-28 days required if you haven’t been vaccinated.
- The HRIG is not necessary, greatly simplifying treatment after a potential exposure. (HRIG is notoriously difficult to obtain overseas and always very expensive when you can.)
For regular travellers, rabies vaccination is a life-long investment in peace-of-mind travel.

* Dr Sisson is the acting Medical Director of Travelvax Australia.

For more advice on rabies and other vaccinations that may be recommended or required for your journey, call Travelvax Australia’s obligation free travel health advisory service on 1300 360 164 (toll-free from landlines). You can also make an appointment for a pre-travel medical consultation at a Travelvax clinic to receive vaccines, any medication required, accessories, and personalised advice tailored to your itinerary and your medical history.