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Fangs for the memory…..a guide to rabies post exposure treatment.

What is Rabies?

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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!

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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

 

Posted January 26, 2016
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