Rabies: There are no short cuts

By Dr Eddy Bajrovic*

She thought she’d avoided the terrible disease.
Bitten by a stray dog at a market near her North Bali village in July, the local woman twice tried to obtain the rabies vaccine without success. At the time, stocks were critically low across the island.
Instead, she had to content herself with cleaning the wound.
It wasn’t enough: Two months after the lethal virus lurking in the dog’s saliva began its relentless journey through her nervous system to her brain, the mother of three suddenly fell ill and died – Bali’s fifteenth rabies victim of 2015.
A brief report in local media told the tragic story on the eve of World Rabies Day (Monday, Sept 28).
Her needless death was another grim reminder that there are no short cuts with rabies. Fail to get effective treatment and rabies is fatal - always.

A unique travel health risk

For Australian travellers, rabies is the only health risk that’s 100% deadly and 100% preventable through vaccination.
The virus is passed on in the saliva of an infected animal, usually via a bite from a dog. It can also be transmitted through the animal licking broken skin or via a scratch from paws that have been in contact with its saliva.
Once the virus reaches the brain, the damage is irreversible and the disease is quickly, and often agonisingly, fatal.
Rabies kills an estimated 59,000 people annually, more than half of them children under 15.
Among the victims are a relatively small number of travellers who fail to get effective treatment quickly enough – if at all.

After a bite, every step is critical

There are 2 rabies vaccines available in Australia, each involving three intramuscular doses (0, 7, 21 or 28 days). Both are highly effective and long-lasting.
However, preventing rabies infection also involves a series of potentially life-saving steps after any possible exposure to the virus.
All of these steps need to be taken immediately and in the right order.
- Step one is to cleanse the wound thoroughly with lots of soap and water. Cleaning the wound may prevent infection, but is no guarantee.
- Next, if available, apply alcohol or iodine. But, don’t bind the wound tightly – just cover it with gauze to prevent secondary infection or leave it uncovered.
- Finally (critically), seek expert medical attention as a matter of urgency. (Don’t wait to find out of the dog was in fact infected. That could take days, even weeks, wasting precious time.)

Find the right medical expertise

It’s important to find a medical facility experienced in rabies treatment which stocks (or can obtain quickly) both Human Rabies Immune Globulin (HRIG) and the first dose of a suitable cell culture rabies vaccine.
Injected at the site of the wound, HRIG contains rabies antibodies that quickly control the virus until the vaccine begins its work of generating protective antibodies.
Beginning this post-exposure treatment regime without delay may mean cutting short the holiday and flying to another country, or heading home if there is no suitable local facility.
Treatment is a must even if you’ve already been vaccinated against rabies.

Definite pluses to pre-travel vaccination

So, why bother getting vaccinated beforehand, you ask?
Simply, because you can’t take any chances with a deadly disease like rabies.
However, there are distinct advantages to pre-exposure immunisation, including:
- You don’t require the initial HRIG, which is notoriously difficult to obtain overseas (and is almost always very expensive when it is).
- You’ll need only 2 injections, not the 4-5 required if you haven’t been vaccinated.

Rabies risk paradigm is changing

There are more compelling reasons to consider pre-travel rabies vaccination and they are becoming increasingly relevant.
POPULAR DESTINATIONS HAVE RABIES: The majority (67%) of exposures occur in Asia, especially India, Thailand, Indonesia, China, Nepal, and Vietnam. (Which is not surprising given they are among the most popular destinations with international travellers, including tens of thousands of Australians each year).
YOUNGER TRAVELLERS ARE MOST VULNERABLE: Two thirds of rabies patients are leisure travellers aged 20–50 years.
RABIES IS A RISK ON SHORT STAYS, TOO: As the number of travellers grows each year and adventure travel gains in popularity, short-stay travellers are being more exposed to rabies than used to be the case. A major review of returned travellers bitten during their trip revealed that more than half (53%) of those who sought post-travel treatment for rabies had been travelling for less than 3 weeks when bitten. Of these, 12% were less than 7 days into their journey.)

Monkeys see, monkey bite

Globally, bites are typically delivered by dogs (51%), followed by monkeys (21%), and cats (8%).
However, in a review of Australian travellers bitten overseas, monkeys (56%) accounted for almost twice as many attacks as dogs (30%) – probably reflecting the popularity of Asian destinations. A surprising 7% of travellers reported bites from either a rodent, squirrel, mule, tiger, or antelope.
But, attacks on people that result in rabies are almost entirely by dogs – a whopping 98%. The exception is developed countries. In regions such as North America and Europe high levels of vaccination among domestic pets means that most animals cases occur in wild animals – bats, racoons, foxes, skunks, and coyotes – and human exposures to rabies usually occur after these animals bite domestic pets. (Bats are a major reservoir of rabies worldwide.)
So the rule is: Don’t pat, feed or touch any animals – domestic or wild – unless you are 100% certain they’ve been vaccinated against rabies.

Delaying treatment could be fatal

In reality, Aussie travellers are naïve about the risk of rabies.
Because it doesn’t occur in our country, we don’t give it much thought when we travel to countries where it does. (We do have the closely related Australian Bat Lyssavirus or ABL, which is carried by bats - most commonly flying foxes in Queensland. The rabies vaccine protects against ABL.)
If they do see a doctor after a bite, most travellers wait until after their holiday, which may result in long delays that can compromise treatment.
The good news is that as long as no symptoms have appeared it’s never too late to begin treatment after a potential brush with rabies.
The bad news is that, once the virus reaches the brain and symptoms become apparent, rabies is invariably fatal.

Who needs rabies vaccination?

Whether or not rabies vaccination is right for a particular traveller or trip is another of the complex pre-travel consultation issues best discussed with a doctor experienced in travel medicine.
Factors to be weighed up include the region/s to be visited, length of stay, activities planned, type of internal travel (bicycle riders are at greater risk that those in a car, bus or train), and just how readily accessible professional medical attention is likely to be.
Generally speaking, the travellers who should consider rabies vaccination are those:
- Staying in an infected country for longer than a month.
- Planning to live overseas – especially in a high-risk country – for an extended period.
- Shorter stay travellers who will be far from good medical care or where facilities lack rabies HRIG and potent vaccines.
Kids are at higher risk of rabies: they are more prone to animal bites by virtue of their smaller stature and may be reluctant to report a possible exposure.

A healthy travel investment

Rabies vaccine is relatively expensive at around $115 per dose.
Some travellers want the peace of mind of knowing they have both the protection and advantages immunisation offers, regardless of the extra cost.
(Vaccination using a smaller intradermal (ID) dose is usually considerably cheaper as it involves drawing a number of doses from a single vial to immunise a group of travellers. However, giving the vaccine by this route is generally not recommended in Australia as antibody levels are lower and protection wanes more rapidly.)
On the plus side, once the IM course is completed, no booster dose is required - ever. The only exception is a person at risk of ongoing exposure, such as someone who working with bats in Australia or with animals overseas.
If you travel regularly or are concerned about the risk of rabies, my advice is to get the protection vaccination provides. Think of it as a lifetime investment in healthy travel.

* Dr Bajrovic is the Medical Director of Travelvax Australia.

Find out more about the risk of rabies on your next overseas trip by calling Travelvax Australia’s travel health advisory service (1300 360 164). You can also arrange a one-stop consultation to receive any recommended or required vaccinations and personalised illness prevention advice.