Sussex Travel Clinic

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01273 749100

Worthing Clinic

01903 254774

What is Rabies?

dog-india2-300x200

 

Rabies is a virus transmitted through the saliva of infected animals. It can be spread to humans if an infected animal bites or scratches the skin, or licks an open cut. Once symptoms have manifested, rabies is nearly always fatal.

Rabies can be carried by any living mammal, but dogs are the source of the vast majority of human rabies deaths.

 

Global_Rabies_ITHRiskMap 2013

Some worrying statistics!

In the UK, we seldom hear about rabies, but latest estimates put the global death toll at close to 60,000 human deaths every year. (1)

Each year more than 15 million people worldwide seek treatment following rabies exposure. (2)  More than 1000 people in the UK each year seek rabies post-exposure treatment (PEP). Most of these are travellers who seek this treatment on return to the UK. Contact with dogs has shown to be the commonest exposure that results in PEP, this is closely followed by contact with cats, monkeys and bats. (3)

The recent Public Health England report highlighted that “since 2000 there have been five human deaths from rabies in UK citizens; four of these in travellers following exposure in rabies endemic countries, and the fifth in a bat handler infected in Scotland. None of these individuals had received post-exposure prophylaxis.” (3)

A study of travellers who had a high risk bite injury in Africa and Asia showed that only 24% received both post exposure rabies vaccination and immunoglobulin in the country they were visiting. Many travellers have to return home to complete or obtain the full course of rabies post exposure treatment. (4)

What a cute puppy? Knowing about rabies and your risks of exposure is important. Remember an animal infected with rabies may not always look ill!

iStock_000004440071_Large

In another study of backpackers travelling to Thailand it showed that 4% of them had a potential exposure from dogs that appeared healthy, and only a few knew about the transmission risks from bites, scratches and licks to broken skin. Only a very small percentage of this group had pre-exposure rabies courses before travel. (5)

Travellers may not always be aware of the poor availability of post exposure rabies treatment when travelling, particularly in Africa and Asia. It may not always be possible to complete a full World Health Organisation (WHO) recommended post exposure schedule in these countries.

So for travellers a bite from a dog or contact with monkeys, cats or bats becomes a worrying race against time to access life-saving post exposure treatment within 24 hours of the bite/scratch or lick to broken skin. Even a delay of a few days before receiving post exposure treatment can be deadly.

 True or false?

I won’t go near dogs on my trip and so I won’t get bitten.

False – It is a good idea not to go near dogs or animals in countries where rabies is present. However, in most circumstances exposure to rabies is a result of an unprovoked attack.

So what should I do if I get bitten by an animal?

This advice is the same even if you have had rabies vaccines before you travel.

If you are in a country with rabies and are bitten, scratched, licked on open skin (a cut or open eczema) or an animal spits in your face you are at risk of rabies and should seek medical advice immediately (preferably within 24 hours).

Never assume in a rabies risk country that the contact animal isn’t infected.

  • Wash the wound thoroughly with soap and running tap water for at least 15 minutes.
  • Do not scrub the wound.
  • Apply disinfectant – neat alcohol or iodine solution
  • If an animal spits in your face immediately splash your face with lots of water to stop the saliva getting into your eyes, mouth or nose.
  • Seek medical help without delay – never waste time, whether or not you have received any rabies vaccine before you have travelled.
  • Avoid getting bites or scratches stitched, this can damage the skin and increase the risk of the virus reaching your nerves.

True or false?

If I get bitten I will just go to hospital

True – if you get bitten you should go straight to hospital. However, in many countries rabies treatment and vaccines are in short supply. In some countries there have even been counterfeit rabies vaccines administered.

What post exposure rabies treatment should I have?

It’s important that you know what post exposure treatment you should expect to receive. Studies have shown that local understanding and knowledge of rabies post exposure treatment can be sketchy and very limited. Travellers should not automatically accept the word or advice of local non-medical trained staff about what to do after possible rabies exposure.

If you have had pre-exposure rabies vaccinations, it is a good idea to take a copy of this vaccination history with you, so that you can show this to the hospital or clinic that you are attending for your post exposure treatment. Vaccine brands are interchangeable and don’t need to be the same as the ones you have already had.

PREVENTION OF RABIES INFECTION AFTER CONTACT WITH AN ANIMAL

IF HAD FULL COURSE OF 3 RABIES BEFORE POTENTIAL RABIES EXPOSURE THEN 2 DOSES OF RABIES VACCINE ARE NEEDED AFTER EXPOSURE

Rabies Pre-exposure

True or false?

Rabies injections are painful and given in the stomach. I don’t fancy that!

False – rabies vaccinations are no longer given in the stomach and haven’t been for a considerable amount of time. They are generally given into a muscle in the upper arm. If you require HRIG this may be injected around the site of the wound depending upon the risk of the rabies contact.

Having the rabies vaccine before you travel just gives you more time to get to hospital if you are bitten.

False – it gives you antibodies. Receiving the pre-exposure vaccine also ensures that the follow up vaccines will work straight away, as your immune system has already produced antibodies to rabies. You must still get to hospital as soon as possible within 24 hours.

What’s the best way to protect myself from rabies?

The best way to prevent rabies is to have the pre-exposure course of the vaccine before you travel. You still need to get post exposure treatment after animal contact but because your body has already produced antibodies, when you complete the course of vaccine you can have peace of mind that you will not get rabies. There have been no reports of any travellers who have received a pre-exposure course ever dying following exposure to the rabies virus.

Who should get a rabies vaccine?

Hopefully you will know the answer to this now

  • Vaccination is advised for all those travelling to risk areas, especially those that will be remote and more than 24 hours away from a reliable source of vaccine.
  • The risk of exposure increases with the length of stay, and if you are staying for 4 weeks or more in a rabies endemic country you should consider having rabies pre-exposure vaccine before your trip, even if you will have access to medical facilities. Even when pre-exposure vaccines have been received urgent medical advice should be sought after any animal bite. If you have not had a course of pre-exposure rabies you will need a treatment called Rabies Immunoglobulin (RIG) within 24 hours of being bitten. In many countries the availability of rabies RIG is scarce, therefore it is recommended you get a full course of rabies vaccines before you travel.
  • Those doing bike rides or runs in risk countries.
  • Those who are working with animals abroad.
  • You are going to live, travel frequently to or spend long periods in countries with rabies.
  • Those at occupational risk. E.g. bat workers.
  • Children, who may lack awareness of the need to avoid animals or to report an animal bite

Rabies Vaccine Schedule

Three doses given on Day 0, Day 7 and Day 21 or 28

Booster                –             every 10 years or if bitten, scratched or licked on an open wound when travelling.

Children               –             can be given to infants and children of any age

Cost Per Dose
£52.00 ( ID) or £80.00 (IM)

 

Watch this video produced by Jane Chiodini – Travel Nurse Specialist to see the benefits of having a course of rabies vaccine before you travel.

 

Post Exposure Rabies Vaccines- What to do if you have had a rabies exposure when travelling and recently returned to the UK.

Sussex Travel Clinic does not routinely offer post exposure rabies treatment. If you have had a rabies exposure when travelling and need to complete a course of rabies vaccine on return to the UK, you can get rabies post exposure treatment free of charge via the NHS. You should contact your NHS GP as soon as possible and tell them that you have had a rabies exposure when travelling. Your GP will be able to access advice and vaccines from the Rabies Reference Laboratory. If you do not have an NHS GP then you can access the same advice and treatment via your local A & E department.

Don’t forget I can pass on rabies too! Please don’t touch or play with me, however adorable I look. It’s just not worth the risk!

To book a course of rabies vaccinations please call the clinic on 01273 749100 or 01903 254774 or book ONLINE

 

Written by Nicki Harrison- Lead Nurse

Sussex Travel Clinic

References

Hampson K. et al. (2012) Estimating the Global Burden of Endemic Canine Rabies.

http://www.ncbi.nlm.nih.gov/pmc/articles/PMC3459869/

Green Book – Immunisation against infectious disease

(https://www.gov.uk/government/uploads/system/uploads/attachment_data/file/85762/Green-Book-Chapter-27-v3_0.pdf)

Public Health England (2015)

(https://www.gov.uk/government/publications/health-protection-report-volume-9-2015/hpr-volume-9-issue-35-news-2-october)

 (Ridding the world of rabies Sarah Cleaveland Adapted from Hampson et al. (2015))

Piyaphanee W. et al. (2010) Rabies Exposure Risk among Foreign Backpackers in Southeast Asia. The American Journal of Tropical Medicine and Hygiene. 82(6):1168- 1171. doi:10.4269/ ajtmh.2010.09-0699 (http://www.ncbi.nlm.nih.gov/pmc/articles/PMC3459869/)

Bibliography

Nathnac – http://travelhealthpro.org.uk/rabies/

TRAVAX – http://www.travax.nhs.uk/diseases/vaccine-preventable/rabies.aspx

Fit For Travel – http://www.fitfortravel.nhs.uk/advice/disease-prevention-advice/rabies.aspx

 

Today is World Rabies Day – 28 September 2012

World Rabies Day is an initiative of the Global Alliance  for Rabies Control  set up with the aim to raise awareness about the impact of human  and animal rabies.

55,000 people worldwide die from rabies every year, most cases are in Africa and Asia. Rabies is spread through the bite, scratch or lick on broken skin, from an infected wild or domestic animal. The most  important source of rabies throughout the world is uncontrolled rabies in dogs, with children at particular risk of exposure.

The inaugural World Rabies Day was held in 2007, and  continues annually with events being held in 150 countries. A total of 182  million people have been educated and 7.7 million dogs have been vaccinated  against rabies as a result.

Advice for Travellers

  • If you are travelling to a rabies risk area you should avoid contact with any wild or domestic animals, including bats.
  •  Pre – exposure Rabies vaccination should be given to adults and children at increased risk of  rabies including those who are travelling to remote areas where medical care  and post-exposure prophylaxis with rabies vaccine and rabies immunogloblin may not be available.
  • You should seek urgent medical advice if you receive a potential rabies exposure when travelling in a rabies risk country.

To find out more and watch videos about Rabies, symptoms and prevention visit the World Rabies Day site.

To book a rabies vaccine please call 01273 749100.

 

 

 

TYPHOID VACCINE

Our supplier Sanofi Pasteur has informed us that currently they are out of stock of injectable typhoid vaccine and will be until January 2013. Sussex Travel Clinic is offering the Oral Typhoid Vaccine Vivotif as an alternative during this time.

Vivotif is taken on day 0, day 2, and day 5. Cost – £30 per course.

Vivotif is a live vaccine but can be given with other live vaccines and does not need to be separated by 4 weeks like other live vaccines do.

RABIES VACCINE

Both UK suppliers of rabies vaccine Novartis and Sanofi Pasteur are  currently out of stock of rabies vaccine and normal supplies will not start until November 2012.

Sussex Travel Clinic have made the decision to administer rabies vaccine intraderamally(ID) to ensure our rabies supply lasts through the shortage period.

ID Rabies is given on day 0, 7 and 21 or 28.

Please note: Rabies vaccine administered by ID technique should only be administered by those trained in ID technique. All nurses at Sussex Travel Clinic are trained to give ID injections.

FLU VACCINATIONS

Sussex Travel Clinic now has flu vaccines in stock for those not eligible for an NHS flu vaccine. Cost £18

We also offer an onsite flu vaccine service for businesses with 10 or more employees.

To Book please call 01273 749100 or use our ONLINE booking via our website.

A 50 year old woman has died of rabies following a dog bite whilst on holiday in Goa, India. The lady, of Indian origin, did not have pre- exposure rabies vaccinations before travel and did not seek any medical advice for 2 months after the dog bite. Unfortunately, the woman who did not present to the medical profession until symptoms of rabies had appeared was at first turned away from A & E at a Kent hospital. A spokesman for the hospital  said that as the UK is rabies-free, if a patient went to a hospital with vague symptoms, a doctor was unlikely to consider rabies as a diagnosis unless the patient highlighted wild animal contact in an at-risk country. “The hospital responded to the information supplied by the patient at the time,” he said.

The UK is rabies free; however, travelling to an area of high risk can pose a risk. In the last 10 years there have been four cases of imported rabies:

  1. 2001 – Nigeria – a visitor from Nigeria died after a dog bite overseas five months previously.
  2. 2001- Philippines- a traveller died who had contracted rabies whilst on holiday in the Philippines.
  3. 2005- India – a traveller died after being bitten by a puppy on a 2 week holiday in Goa.
  4. 2008- South Africa – a UK traveller died after being bitten whilst working in an animal sanctuary.

What is Rabies?

Rabies is a virus found in the salvia of an infected animal and is transmitted from the bite or scratch of an infected domestic or wild animal. Dog bites account for 99% of human rabies deaths. Initial symptoms of rabies include fever, pain and tingling at the wound site. As the virus spread through the nervous system inflammation of the brain and spinal cord occurs. Rabies is always fatal. The incubation period is usually 1-3 months, but can be from as little as 1 week up to 1 year.

Rabies is present in 150 countries worldwide and it is estimated that 55,000 people die from rabies every year.

Advice for Travellers

There is a very effective vaccine that can protect you against rabies. The vaccine should be given before you travel. Three doses of vaccine are required on days 0, 7 and 21 or 28. In the event of a bite or scratch you will need to seek medical advice and get two more top up vaccines.

If you have not had any rabies vaccine before you travel and you get bitten by an animal you will need to seek immediate medical treatment. In this instance you will need to receive a full course of rabies vaccine and a treatment called rabies immune globulin (RIG). RIG is a blood product and is not readily available in many countries, so if you are at risk it is recommended that you receive pre -exposure rabies vaccines before travel.

Am I at risk?

Your nurse will do an assessment to see if you need for pre-exposure rabies vaccine.

Assessment includes:

  • The incidence of rabies in the countries you are travelling to.
  • The availability and quality of rabies vaccine and rabies immune globulin (RIG).
  • The planned activities you may be doing on your trip..
  • The length of stay in a risk country.
  • The possibility of unrecognised or unreported exposure (e.g. young children).

Rabies pre-exposure vaccine should generally be given to adults and children who are at risk of rabies. These include:

  • If you are  travelling to remote areas where medical care is not readily available
  • If you are undertaking higher risk activities (e.g. cycling, running)
  • If you are travelling for long periods through rabies risk countries
  • If you are at occupational risk e.g. vets, animal handlers, and laboratory workers who handle the virus.

 

To book an appointment for a rabies vaccine please call 01273 749100 or book online

 

References

  1. http://www.who.int/mediacentre/factsheets/fs099/en/
  2. http://www.promedmail.org/
  3. http://www.nathnac.org/pro/factsheets/rabies.htm#indications

 

 

 

 

 

 

 

 

In the second part of our question and answer posts we look at Rabies vaccination.

Q: I am planning to back pack around South East Asia for 2 months should I have the rabies vaccine?

A: Yes we would definitely recommend a course of rabies vaccine. Rabies is spread through a bite, scratch or a lick on broken skin from an infected animal. It is estimated that there are between 50000 and 60000 deaths from rabies worldwide each year. Over half these deaths occur in South East Asia and rabies is almost always fatal.

If you do not have pre-exposure rabies vaccine before you travel you would require a treatment called rabies immune globulin (RIG). This must be administered within 24hrs following a bite/lick/scratch from a potentially infected animal. Human RIG is manufactured from the blood of immunized volunteers. Receiving any blood product abroad is never recommended unless you can be certain it has been screened for blood borne diseases such as H.I.V.  RIG is not always available in many developing countries.

Having three doses of rabies vaccine pre-travel eliminates the need for R.I.G and primes your immune system so that treatment after exposure would be successful.

If you are travelling to a rabies endemic country for 4 weeks or more, or likely to be more than 24 hours away from good medical facilities and a reliable source of RIG, you should consider getting a course of rabies before you travel. The vaccine is given on days 0, 7 and 21 or 28.

To book an appointment at Sussex Travel Clinic call 01273 749100 or book ONLINE

The rabies virus is spread through the bite or scratch of an infected warm –blooded animal, most commonly dogs, and is nearly always fatal.  The virus attacks the central nervous system, causing paralysis, encephalitis and coma.

The World Health Organisation estimate that, more than 3 billion people are at risk of contracting rabies in at least 85 countries worldwide, with the annual number of deaths worldwide caused by rabies is estimated to be between 50,000 and 60,000. [1].

In this weeks post we look at countries reporting rabies in 2011.

 

 Countries Reporting Rabies cases in 2011 (June – December)

 

Angola

Angola is reporting an increase in rabies in animals during 2011. 405 people have been bitten by potentially rabid animals with 12 deaths since the beginning of the year.

Australia

A women from Brisbane in Queensland, Australia received rabies post-exposure prophylaxis following an attack by three foxes or fruit bats while she was on her balcony.

Bhutan

In 2011 it has been reported that five people have died from rabies in Bhutan. Dogs accounted for 39% of the cases, while the main transmitters of rabies in Bhutan are cattle 55%

Bolivia

Bolivia had reported at 60% increase in cases of canine rabies in 2011. There have been 208 confirmed cases of canine rabies with three human deaths reported in 2011.

China

In Shanghai  it has  been reported I that during 2011 there has been an increase of dog attacks on residents.40,000 people have been bitten by a pet, a 40% increase from 2010. In 2010 there was 1 case of rabies, this year 6 cases have been reported. Beijing reported six human deaths from rabies in the first six months of the year and in Chongqing in Southern China there were a total of 38 deaths from rabies in the first half of the year.

Ecuador

A total of nine human deaths from rabies were reported by the ministry of Health of Ecuador on 28 Nov 2011. An on-going mass vaccination programme is being conducted in the affected communities in canton Taisha, Morona-Santiago.

India

In Chennai at least 20 people have died of rabies in the first half of 2011. General hospitals in Tamil Nadu reported 12 deaths due to rabies in 2010. In Visakhapatnam, sea port on the south east coast of India a rabies death was reported in July 2011 and a boy died in the Khammam district. also in July 2011.

Indonesia

The rabies epidemic continues in Bali, as of June 2011, over 100 deaths caused by rabies have been reported. In Borneo at least 858 rabies cases have been reported, including one death. In east Nusa Tenggara a total of 800 dog bites have been reported this year.  An on-going shortage of rabies vaccine has been reported in Kab Sikka regency and in other areas of the province.

Kazakhstan

In July 2011 a 10-year-old boy was hospitalized in the KyzylordaOblast with suspected rabies.

Pakistan

Rawalpindi city has reported an increase of dog attacks on residents.  Every month more than 100 dog-bite cases are being with the number continuously on the rise.

Peru

In 2011 a total of 20 human rabies cases have been reported so far. Of the 20 deaths 19 were in natives of the Amazonas region who were bitten by bats. In a remote village in the Atalaya province a rabid cattle had to be slaughtered and a total of 87 people consumed the infected meat in November 2011. All persons involved received rabies post-exposure prophylaxis.

Russia

In the first nine months of 2011 in Russia ten people contracted rabies, of which three cases were reported in the Tverskaya province. In 2010 there were 17 cases of human rabies in the Russian Federation.

Svalbard and Jan Mayen (Norway)

Three reindeer were reported to have tested positive for rabies on 27 Sept 2011.

Ukraine

Ukraine has reported 5 cases of human rabies in 2011. 100,000 – 120,000 people seek medical treatment for animal bites every year in the Ukraine.

USA

There have been reports of rabies cases in racoons in Florida in 2011 and in Texas they are reporting a rise in the cases of animal rabies with 591 reported in the first six months of the year. In Jul 2011, a 73-year-old woman tested positive for rabies. She was bitten by a dog in her native Haiti in Apr 2011. Animal rabies was also reported in Illinois and New York.

Vietnam

In June 2011 an outbreak of rabies amongst domestic dogs in the Si Ma Cai District of northern Lao Cai Province was reported.

 Zambia

In October 2011 an outbreak of rabies was reported in Mansa district with 14 cases. One human death was reported in Mwang’uni , the person had become infected after being bitten by a dog.

Advice for Traveller’s

If you are travelling to country where rabies is present for 4 weeks or more, or if you are likely to be more than 24 hours away from a reliable source of vaccine and treatment, then you should consider having a course of rabies vaccines pre travel. Many countries do not have a supply of rabies immunoglobulin, the treatment you need if you have not had any rabies vaccines, so you should consider having the vaccine before you go.

To book a rabies vaccine please call 01273 749100 or book ONLINE

References

1. www.nathnag.org

There is currently a short supply of rabies vaccine in the UK. Sussex Travel Clinic currently has rabies vaccine in stock. Cost £48 per dose – 3 doses required for pre exposure on days 0 , 7 and 21 or 28.

To book a rabies vaccine please call 01273 749100 or use our online booking system.