Rabies Vaccine for Travel – who needs it?
November 25th, 2012Rabies vaccine is a dilemma to many Australian travellers. Travellers seek advice from many sources, (eg doctors, Google, travel agents, fellow travellers etc) and often receive conflicting information about rabies. Some sources say have rabies vaccine, some say do not have rabies vaccine… Below is a typical question I receive..
My daughter, leaves for a GAP year placement in 8 weeks. She will be on her placement in Malawi for 7 months and possibly travelling within Africa afterwards. I am receiving mixed messages from our local GP and the travel doctor we have consulted in about the need for vaccination for rabies.I am wondering if you can give me your opinion on this issue?.
I act as an advisor to one of the GAP placement organisations, and this question came from one of the parents.
I will try to answer the question (of whether to have rabies vaccine or not ) in an unbiased fashion, but, in my clinic, I must declare that I see too many persons who have been bitten by potentially infected animals, to be very relaxed about travelling without the rabies vaccine into the poorer parts of the world.
Dogs are common in Asia (this is Bhutan).
Rabies-infected dogs may look healthy.
The local GP (…with greatest respect as I love GP’s and the work they do) … will probably not have the expertise necessary to advise on this rabies – he or she do not get the special training, and will seldom be exposed to patients who have had animal bites in Africa, so they often underestimate the problem. The GP’s may also not realize that the required treatment for a potential rabies bite is not readily available in most parts of the developing world, especially Africa.
In Summary
My opinion on the above question is I would not send my child to Malawi for 7 months without rabies vaccine (.. For the record, I have two daughters aged 17 and 19)
Rabies Treatment is not easy to access
If a traveller is bitten or licked by an animal and has NOT had rabies vaccine in the past, then in order to treat them they requires TWO things; rabies vaccine and ‘RIG’ (Rabies Immune Globulin)- ideally within 24 hours.
The Rabies vaccine takes two weeks to be effective so RIG is like a quick infusion of instant antibodies. RIG keeps you safe while the vaccine helps your immune system to makes its own antibodies. RIG is a blood product ( scary thought in Africa ) and costs big dollars, so is not readily available in Malawi, or many other parts of the world where resources are poor. (RIG is sometimes in short supply even in Australia.)
If complete rabies treatment is not given correctly and on time, i.e. immediately after a bite, and a traveller were to wait until rabies symptoms develop – it would be too late…. established rabies is untreatable and universally fatal. We have no drugs that work against rabies. The only thing that stops the rabies virus is a well trained immune system.
Risky Bites are not uncommon
The odds of being bitten are hard to estimate – A recent study found the risk of being bitten in Asia was 1.11 per 100 travelers per month and the risk of being licked was 3.12 per 100 travelers per month. Both bites and licks are potential risks for rabies. The odds of being bitten are low but not zero. For the record, our figures show the highest risk age group for rabies exposures are 20-29 year old travellers. Most people I see bitten in my clinic are not ‘patting dogs’ – they are just being tourists ….walking in a temple or in the street, lying on a beach, sitting in a restaurant, taking a photo etc. If you have the rabies vaccine before you go, you are pre immunised for life.
The pre immunisation rabies vaccine course is three doses over a month, ( day 0, 7 and 28). That means if you ever receive an animal bite or lick, you would only need two doses of vaccine ( relatively easy to access ) in order to be safe. Persons who have had vaccination in the past have a head start. They have a ready made supply of rabie-killing-‘bullets’ so they do not need RIG ( the blood product ) if they are bitten.
Persons who are pre immunised only need two booster doses of vaccine – which is relatively easy to access in most parts of the world. Pre immunisation makes treatment of an animal exposure much simpler, safer, and less disruptive of ones travel plans.
So the choice is
2-3 vaccines before you go and if bitten while away – have 2 booster doses of vaccine
OR
no vaccine before you go, and if bitten while away – travellers need an injection of RIG into the wound ( if they can find some on the day of the bite ) and 4-5 vaccines: one each – given on the day of the bite, 3 days later, 7 days later, 14 days later and possibly 28 days later.
Rabies Vaccine may be a very a good idea
Whether or not the rabies vaccine is recommended depends on where you visit in the world, and what you plan to do, and how far you will be from medical care, your medical history, and your risk tolerance.
Rabies vaccine before a trip is not mandatory, ( mandatory vaccines are designed to stop diseases spreading from place to place eg like Yellow Fever )
Rabies vaccine is merely ‘recommended’ for some travellers for protection and peace of mind.
Some travellers say they hate needles – but if you get an animal bite overseas and are not pre immunised you may need 10 mls of RIG injected into the wound – that could be your your finger – that is a lot worse than a needle in the upper arm.
Some travellers complain that the vaccine is too expensive. Travel clinics can give the vaccine by a special technique – into the surface of the skin ( intradermally ) which makes the course cost roughly $180. Which is really not so bad when you consider how dangerous the disease is.
It really boils down to your appetite for risk….mine is very low when it comes to preventable problems, especially with my kids.
Don‘t forget the humble soap
An interesting thing about the rabies virus is that soap kills it, so anyone bitten by an animal in a rabies endemic country, needs to gently wash the wound with soap and water (never scrub), and then seek skilled medical attention to get rabies vaccine.
Dr Deb,
Thanks for the very clear info on rabies vaccine. We plan to get the vaccine before going to Brazil in August this year. Quick question: if we were exposed, could we get away with waiting a few days for the first post-exposure booster? (ie, must we immediately find a hospital ?, as it may take a few days when we are in the Amazon)
Thanks
Craig
Hi Craig,
The great thing about being immunised before you go, is that you have more time to safely wait if you are bitten and need post exposure vaccine . It is recommended to be ASAP but the average person takes about 4 days to get to a booster vaccine. You can also afford to wait for really good quality vaccine.
Regards Dr Deb
Hi I had the three rabies vaccines in 05 do they need booster shots or am I ok still??
HI Sarah. If you are a traveller, and have completed 3 pre exposure rabies vaccines, and your immune system is normal, you only need boosters if you have an animal exposure. Regards Dr Deb
Thank you for your very informative information. My husband and I were told not to have. Watching fishing show on tv monkeys came into the room. I also remembered Bali and girls holding monkeys. I made an appointment with dr next day, took 2 days for vaccine to come in, we have had fist injection next Wednesday 2 nd, 3rd in 21 days. day we leave for Africa this Dr was all for it and has see rabies before. Cost $290.00 Aust. Dr giving yellow fever injection said not need. Glad we have had, giving us peace of mind.
Thanks for your comment. Yes it is very nice to know you are covered for all future trips as well, regards Dr Deb
Hi Deb,
I had the rabies pre-exposure treatment through the travel doctor in australia a few months ago. I am now travelling in Sri Lanka on its east coast. Today (7 hours ago on 11 September) I was patting the young puppy of a local business owner. Yes, very stupid I realise now! I didn’t know until I started patting him, but the puppy is going through that milk teeth chew everything it touches phase and had a little nibble on my hands. No bleeding, but a couple of minor scratches on the back of my hands. The puppy appeared healthy but I don’t know it it has been vaccinated for rabies.
I don’t return to Australia until 19 September. I also don’t reach.Colombo until 18 September. Do I need to have post exposure treatment before then?
Many thanks!
Regards
Hello Jen
Thank you for your question
The World Health Organisation grades rabies contacts as follows
Types of contact are:
category I – touching or feeding animals, licks on the skin
category II – nibbling of uncovered skin, minor scratches or abrasions without bleeding, licks on broken skin
category III – single or multiple transdermal bites or scratches, contamination of mucous membrane with saliva from licks; exposure to bat bites or scratches
For your described exposure ( level II exposure) , it would be recommended to have two boosters. It would be safer for you to access reliable rabies vaccine on your return to Australia, than to try and access possibly dubious quality vaccine in rural Sri Lanka.
The difference between vaccination on the 18th in Colombo and 19th in Australia, would be extremely unlikely to make any difference, provided you sought advice immediately on your return.
Regards Dr Deb
Dear Dr. Deb,
some dog bit me in the arm (he missed – so no deep wound, merely a little scratch, but a little blood came out). I am currently in Costa Rica. I consulted a doctor who told me they ran out of vaccine (rural area) but it would be ok because the bite wasn’t deep and the dogs in Costa Rica should be vaccinated. I will get to see a doctor in San Jose tomorrow (26h after the bite), is this to late?
HI Benedikt,
if the skin was broken, there is potential risk. Thankfully dog rabies is rare in Costa Rica.
One more day to get advice is not a problem
Average time to access post exposure rabies is 4 days
regards Dr Deb
Dear DrDeb,
I was bitten (only one small puncture wound that drew no blood, but did ever so slightly break the skin) by a house dog in Bali (not a street dog), that was on a Monday, on the following Wednesday I went to the hospital to start the rabies treatment. The doctor explained that I only needed 4 shots for the course of treatment, on visiting her tonight for my 4th (and final…i thought) shot, she flirtingly explained that I now needed a 5th shot….for my safety. I don’t want to question this Indonesian doctor, however during the times I saw her she said it was only 4 shots for the treatment….and now she adds a 5th (because she liked me, she said) Is this a money grab? Or is this normal? It was the smallest puncture, I washed with soap and antiseptic as soon as it happen and it was from a dog that has had the rabies vaccination which is compulsory for Bali, as I have spoken with the dogs owners. My question is, is the treatment 4 or 5 shots…is 4 enough?? Any advice would be appreciated.
Best regards,
Thomas
Hi Thomas,
If you are in Australia, you can have a blood test to check the vaccine has worked after 4 doses, but a 5th dose will do you no harm.
A 5th dose is recommended if the vaccine given in the first 4 doses was not of a good quality.
Regards Dr Deb
Hi Dr Deb,
I was bitten by a dog in Thailand in January 2007 and had 5 post-exposure vaccinations over a course of a month (in an international hospital) and the RIG vaccination within 24 hours of the bite. I’m going to Sri Lanka next month followed by Thailand – about 10 days in each country. Do I need any further pre-exposure vaccinations before I leave?
Many thanks in advance for your help,
Matt.
HI Matt,
no you dont need further pre-exposure vaccines, just boosters if you are bitten,
regards Dr Deb
Thank you for your advice Dr Deb – much appreciated! 🙂
Hi Dr Deb,
Just been reading your advice about rabies and a little concerned about the decision I made in regards to protection.
I am taking a trip through Laos with my girlfriend (who is vaccinated). The journey will involve cycling from Vientiane to Luan Prabang, but the duration will only be 2 weeks.
I made the call not to get vaccinated because of this short period for potential exposure and obviously taking care not to go near any dogs and the minimal risk of a random bite.
Could you provide advice about how to respond if bitten/licked by an infected animal (dog probably) in Laos.
I understand from reading the blog that I would need to get the RIG shot into the wound within 24 yours. I imagine this means getting back to Vientiane post haste to get that particular shot and then the appropriate 4/5 shots.
My big concern is that the capital might not have RIG- do you know if it does? Second: if it doesn’t stock the RIG then what are my options? Some sort of emergency flight to Bangkok in the hope of finding a hospital with the RIG?
Also: I have only three weeks before I go. I’m starting to think it would have been wiser to have had the course of shots. But is there any use in only getting 2 or 3 shots? Is this better protection than none at all?
Many thanks
Nico
Hi Nico
Sorry to inform you but duration of trip is not a reliable predictor of exposure. Rabies deaths have been observed in travellers after short trips of two weeks or less(1). Another study (2) reported the mean time to injury was 15.3 days after departure from Australia and 88% were exposed within 30 days of arrival.
RIG is very hard to access in Laos – you would probably have to fly to Bangkok to access appropriate treatment.
Yes it is worth getting 3 shots: You can have rabies vaccine given day 0,7,21 and it will be effective pre exposure immunisation
regards
Dr Deb
1 Carrara, P., Parola, P., Brouqui, P., Gautret, P., 2013. Imported Human Rabies Cases Worldwide, 1990–2012. PLoS Neglected Tropical Diseases 7, e2209.
2. Mills, D.J., Lau, C.L., Weinstein, P., 2011. Animal bites and rabies exposure in Australian travellers. Med. J. Aust. 195.
Hi Nico,
I appreciate your question was for Dr Deb, but I can offer some good advice having lived in Thailand for 2 years and also travelled through Laos.
When I was bitten by a dog in Phuket I was just walking down the street, not doing anything to annoy the animal. The dog just ran out of a side-street and bit me. There are a lot of stray dogs throughout S E Asia, so it’s a real problem.
Even though it was early evening, I cleaned the wound with soapy water and rushed straight to the nearest hospital, where I had the first of 5 vaccinations over the next month. The hospital didn’t have the RIG vaccine and I rushed around the town to different hospitals until I was able to obtain it at the Phuket International hospital. It cost AUS $1000 and it was very painful – but fortunately I was insured, at least for the pain in the wallet!
You would definitely not want to find yourself in a similar situation and especially not in Laos. It’s a lot less developed than Thailand and as Dr Deb says, you’d probably need to fly back to Bangkok to get the RIG shot, by which time it may be too late to have any effect.
If you don’t have time to get all 3 vaccinations before you leave, you could get a couple and then the last one when you arrive from a reputable clinic in Vientiane. The rabies vaccine appears to be easily obtainable throughout S E Asia, as it’s obviously a serious health risk for the locals too, although the quality may not always be up to Australian standards.
Having done a lot of cycle touring myself, the one piece of advice you should definitely take is wear lightweight trousers while cycling – not shorts – as dogs will often chase you when you’re on your bike, so this is when you’re most vulnerable.
Hope you have a great trip – it’s beautiful part of the world 🙂
Matt.
Thanks for the comment Matt
Many thanks for the reply Dr Deb
Very helpful information.
Im going to try for those three shots before departure
Nico
Hi Dr Deb,
My hand has recently been bit, quite strongly, by a neighbour’s yard cat. Considering we live next to a forrest where the cat could have come into contact with wild animals, I decided to have the post-exposure vaccine. The doctor at the hospital advised me to only have 3 out of the 5 vaccines in case the cat lives for more than the next 10 days. If the cat will die or disappear during this period I’m supposed to go ahead with all the 5 shots. The vaccine I had is Verorab.
I didn’t have any other side effects but, I’ve felt quite weakened in the days since receiving my first shot; I’m supposed to go in for my second shot later today. My question is, if I only have 3 out of the 5 post-exposure shots, will this provide me with any immunity? As I don’t want to go ahead with the full treatment if I don’t have to. Will I only need booster shots in case I travel to areas of increased risk (SE Asia)? Or will I need to proceed the same way as if I hadn’t received the shots?
Many Thanks,
Ana
HI Ana
THree rabies vaccines will usually result in good antibody levels, however you can have a blood test to check this. If you have positive antibodies on blood test you would only need a booster if you were bitten etc
Regards Dr Deb
Hi Dr Deb
just to clarify – I have had 3 initial rabies vaccines in 2010 – do I need a booster to keep it up to date or only if I get exposed?
Hello Dr Deb,
Along the same lines as Lyn’s question, how long is the rabies vaccine good for?
Hi Ange
The pre exposure rabies vaccine course is ‘good’ until you get a potentially rabies infected bite, then you need a booster. You don’t need routine boosters.
regards
Dr Deb
Dear Dr Deb,
I am leaving to India next month and decided to go for the Rabies vaccine. I chose a clinic that charged 25£/ shot instead of 65£, and that’s because they do it intradermally. (Didn’t know difference at the time)
After getting it I started reading about the vaccine and it says how specialists need to do it the ID route or it may not work. How do I know if mine was administered correctly? A little bubble popped up on my upper arm after he did it (skin colour) and he said that would probably last 7 days. However, a few hours later it is now completely gone. Do you know what this means?
Also – it was a white/clear liquid, not pink, as I’ve read elsewhere that it should be – is that ok?
Many thanks for your help,
A worried traveller to India
HI Traveller to India,
The presence of the bubble is the important point, it is not really important how long it persists. Most bubbles go away within a few hours but then there may be some redness at the spot for up to a month later.
The course is always three doses of vaccine, so when you go back to get the next dose, you should discuss your concerns with the doctor at the clinic.
The pink vaccine is one version of rabies vaccine (HDCV vaccine) , but there are some good rabies vaccines that are not pink.
The best way to ensure the vaccine has worked is to have a blood test for rabies antibodies, at the end of the course. This blood test is routine in Australia, but not sure about UK.
regards
Dr Deb
Lab testing determined that I have a .48 titre level, while <.5 is not immune. The doctor recommended one booster shot. I am seeking a second opinion. Will the one shot be enough to bring me to acceptable immunity levels or should I complete a 3 shot series?
Thank you.
HI Brett,
It is extremely likely that a single further dose of vaccine will be sufficient to increase your antibody levels to over the official cutoff of 0.5. Sometimes it just takes a little longer for antibody levels to rise. A repeat blood test would be recommended if you are having the vaccine intradermally. You are most unlikely to need any more than one extra dose.
Regards
Dr Deb
Thanks,
One detail I omitted is that when I was vaccinated last year I only received one of the normal three shots. After 14 months, I had the 0.48 level. Does this effect your advice?
Hi,
I had two questions about the rabies vaccine that I was wondering if you could help me with.
1) I understand that we need the two boosters if we get bitten or scratched. (contact II or III). Do we also need the two boosters if we get licked, or do we just need to wash it with soapy water? I’ll be travelling with my children, the youngest is 5, so he is not necessarily going to mention a lick to me soon enough.
2) My daughter and I have previously had antibody tests for seroconversion after hep b and rubella immunisations. Despite additional shots, we have not recorded any antibody titre to these shots (e.g. I had 11 hep b without any seroconversion). I am worried that we do not “take” to vaccines.
a) Is there any way that I will know if the rabies vaccine has “worked”?
OR
b) Should we just get the pre-exposure vaccines, and then if we have a lick/scratch/bite act as though we have not had the pre-exposure vaccine?
OR
c) Get the pre-exposure vaccine and just assume it’s all good. (not so comfortable with this).
Cheers
Dear Sarah
Any bite or scratch that breaks the skin, or lick over broken skin requires two boosters if you have been pre immunised.
There is minimal correlation with lack of antibodies to Hep B vaccine, and lack of antibodies to Rabies vaccine
You can get antibodies to rabies vaccine measured in the blood in Australia, so if you have the course, and check the titre and it is above 0.5IU/ml you know pre-immunisation has been successful.
regards DrDeb
I am going on a last minute holiday to central america in 2 weeks so I would not have time to get all 3 shots, is there any point to only receiving 2 shots?
HI Brittany
No point having just 2
regards
Dr Deb
Dear Dr Deb,
I am going to Thailand in one week.
I had my pre-exposure rabies vaccines in 2003. I had a blood test in 2010 which showed 1.36 IUs/ml. I was advised that this means I have lifelong pre-immunisation.
Last week I visited my local GP who told me that the above advice was wrong and that rabies requires a booster every 2-3 years.
What is going on here? Do I have lifelong pre-immunisation or not?
Thanks so much for your advice Dr Deb.
HI Scott
What is going on… is your GP does not have current information – that is the nature of specialised clinics, we have the specialised up to date knowledge. Boosters every 2-3 years were discovered to be unnecessary years ago.
Dr Deb