Rabies and
the traveller
 Rabies is an almost invariably fatal disease. You are at
risk of this infection in almost every destination. It
is a rare disease in tourists who are only at risk if
exposed to the saliva of an infected animal (any
mammal). The onset of disease after the bite may be days
to over a year after the exposure and presents as a
brain infection with bizarre symptoms. Once symptoms
develop there is no available effective treatment and
death is almost inevitable.
If you are not vaccinated against rabies before you
travel you will need 6 injections over the next month.
The 1st of these is a human blood product. And as this
is most likely to be while you are in a developing
country there is possibly an increased risk associated
with its safety.
Two scenarios
I will present two scenarios of a traveller ('you') who
has gone to Morocco (or India or Thailand or Bolivia ...)
and while walking through a market is bitten on the leg
by a dog. The dog runs away and as is recommended you
wash the wound thoroughly and use ample antiseptic.
Scenario A - is if you haven't been vaccinated before
travel.
You should call your travel health insurance
company (or embassy) to seek advice. They will direct
you to urgently (within 24 – 48hours) go to a major
hospital which is luckily only a 4 hour drive away.
After arriving at the hospital the following is needed.
Day 0 Human Rabies Immune Globulin (HRIG) injected into
the wound and synthetic vaccine, and one dose of the
vaccine should be administered on days 0, 3, 7, 14 and
30 (this may vary from country to country).
Scenario B - is if you had pre exposure vaccination.
In
this situation the first aid is the same with urgent and
thorough cleaning of the wound and call to travel
insurance company. However, this traveller needs only
two
more doses of the synthetic vaccine a few days apart and
it is not quite so urgent (though the sooner the
better).
Issues
- The un-vaccinated traveller needs 5 visits to the
clinic for the 4 week course of post exposure
vaccination, thus he/she will likely have to abandon the
itinerary in order to stay close to that supply of
vaccine.
- Rabies immune globulin is not available in all
countries and if it is available may be very costly
(perhaps $100's).
- The greatest risk of rabies to Western travellers is
in developing countries where blood products may carry a
higher risk of contamination with blood borne viruses.
- For some, the above points will require the traveller
to abandon their travels to fly to a developed country
(or home) for safer vaccine.
Rabies vaccine is expensive and requires three intramuscular
doses of vaccine at Day 0, 7 and 21- 28. It is normally
well tolerated, though minor side effects are not
uncommon.
A less expensive option is to give 0.1 ml of vaccine via
intra-dermal route which is offered by some travel
clinics (because it is cheaper for the traveller) but is
"off license" and requires a blood test to be performed
after the course to confirm seroconversion
(effectiveness). You will need more time pre-departure
for this option.
It is now thought that after a primary course of vaccine
no further booster doses are required except if exposed
to saliva of a warm blooded animal in a rabies endemic
country. (Vaccine boosters for high risk travellers e.g.
vets / animal handlers are different.)
... prepared by
Dr Mark Sweet, Travel
Medicine Alliance Surrey
Hills, Victoria
Case study
A 22 year old traveller who had been holidaying on
the islands of Southern Thailand was walking back to her
hotel in the late afternoon. Near the main tourist strip
it is common for locals to have monkeys which they offer
to tourists to hold while they have a photo taken.
This woman who had been given travel advice in a TMA
clinic was aware that she should avoid contact with
mammals. However after refusing the offer from the
monkey handler the man thrust the monkey upon her.
Instinctively the traveller panicked and the monkey bit
her.
She did as she was told and attended the local hospital
for advice and received post exposure vaccination.
Three days later and back in Melbourne she was referred to
the Local Infectious Diseases Clinic where she was given
Rabies Immune Globulin and she completed the course of
her vaccines.
... prepared by
Dr Mark Sweet, Travel
Medicine Alliance Surrey
Hills, Victoria
Travellers
diarrhoea vaccine
Dukoral is an oral vaccine that provides about three months
protection from the most common cause of travellers
diarrhoea – the germ called ETEC (Entero Toxic E Coli).
The vaccine is taken as two drinks, given one week apart
and the course should be completed two weeks before
departure. Protection lasts about three months so the
vaccine is best taken in the last month before
departure. It is not a guarantee and travellers still
need to be careful what they eat and carry medication
for travellers diarrhoea in case they get sick. However
studies show that in some of those vaccinated, even if
they get gastro, the illness is milder.
Dukoral tastes a bit like ENO and is generally well
tolerated. Mild and transient gastrointestinal
side-effects, such as abdominal cramping and loose
stools can occur in some people. 1 million doses have
been given in Scandinavia with no serious adverse
effects. The vaccine is only available by prescription.
Shingles
vaccine
Good News! A vaccine for shingles has just been
released - ZOSTAVAX. 20% of persons will develop shingles
sometime in their life and the disease can be quite
severe. Shingles sufferers feel tired and unwell plus
they develop a blister like rash in a patch on one side
of the body. About 15% of sufferers will develop with
persisting pain
which may last for some weeks to months afterward.
Shingles is
caused by the same virus that causes chickenpox.
Shingles is most severe in persons over 60 years but the
vaccine works best if given a little earlier, so the
vaccine is recommended for persons over the
age of 50. This vaccine is a great idea for everyone,
whether
travelling or not. Ask at your TMA clinic for more
information.
Outbreak
Information
Dengue fever
Almost 6000 cases of Dengue have been reported in
Thailand in the first two months of 2008.
This is is 77% higher than the same period last year.
More cases are occurring in the central region of the
country. A public health campaign is underway in Thailand
to help curb the spread. Meanwhile, travellers need to
take precautions.
Dengue is carried by day biting mosquitoes and
travellers need to regularly use repellents containing
30% DEET.
Flu
It is not too late to have a flu shot - but you need to
do it soon as the cold weather is starting to occur. The
flu vaccine covers the three most common strains of
influenza;
A Solomons, A Brisbane and B Florida. The vaccine has
been proven to save persons from losing days off work - that's why so many work places now have flu programs. The
vaccine cannot give you symptoms of the flu, but does
make your arm sore for a day or so.
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Do you have a holiday
story to tell, especially one with a medical
event?
Send it to
info@travelmedicine.com.au,
and we will send you one of our mini TMA
torches to put on your key ring - a great
help when finding your lock at night.
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The Travel Medicine Alliance