Rabies Pre-Exposure Vaccine: Will Not Getting One Come Back To Bite You In The Butt?

Recently, a well-traveled friend of mine, whom I’ll call Jules, went to Belize on vacation. While on an idyllic, live-aboard sailing trip, Jules, her husband, and mother decided to explore some cays by sea kayak. What happened next is one of my worst developing nation nightmares.

While poking around what appeared to be an abandoned cay (this is why poking sans guide isn’t recommended, but few true travelers can resist), two semi-feral dogs “jumped out from beneath an overturned rowboat, barking ferociously.” Jules explains, “They were tied up, and we immediately headed back to our kayaks, when we saw a man. He told us the cay was ‘privado (private),’ and I started apologizing in Spanish as we pointed at our kayaks and picked up our pace. The next thing I knew, one of the dogs was let loose, and barreling after us. I started to run, and it bit the back of my right calf.”

The dog released her leg after Jules’ husband waved his arms at it while yelling, “NO, NO, NO, NO!” Then it re-launched itself at her, so she employed the same tactic, and eventually they made their way to their boats and escaped.

As if this story isn’t harrowing enough, the really terrifying part is that they were 10 miles out to sea and had four days left aboard ship. Fortunately, Jules’ mom is a medical professional. Immediately following the attack, she soaked her leg in sea water to flush the wound, then her mom accessed their first-aid kit and cleaned it with hydrogen peroxide, and applied antibiotic ointment. For the remainder of the trip, her mother repeated this procedure, changing the bandages up to three times a day.

I asked Jules why she didn’t insist upon returning to land immediately and seeking medical treatment.

“That’s an emotionally hard question to answer,” she explained. “The dogs weren’t foaming at the mouth, they didn’t look rabid, but rather in aggressive/protective mode. My mother was on the boat with us and she nursed my wound and kept checking my vital signs for any dangerous symptoms. Luckily, nothing bad came of it. There were no clinics in Placenia where we were, so I made the decision to go to the hospital as soon as I returned home six days later.”

There, she was advised to get rabies shots, which had to be administered through the ER (general practitioners apparently won’t provide them). Jules said the series of four treatments – eight shots the first visit, and one per follow-up – was awful. “I got one in each shoulder, one in each upper thigh, one in my butt, and three directly into the wound. The serum they inject feels thick and made my blood feel sluggish. I couldn’t think clearly and needed to nap every day.” She also wasn’t up-to-date on her tetanus, so that was the first shot she received.

Since Jules is one of the most energetic people I know, the shots really affected her ability to work, and she had to take a number of sick days on top of her two weeks vacation. That, of course, is the least concern in this scenario, and I asked my infectious disease doctor, John Szumowski, a fellow at the University of Washington, what the best course of action would be in such a situation.

“Once a person has symptoms of rabies, there’s little that can be done,” he says. “Only a handful of persons have survived even with intensive care. But the rabies pre-exposure prophylaxis vaccine series is felt to be very effective if administered to a person who doesn’t have symptoms.”

I’ve been telling myself for years that I should get rabies prophylaxis (a series of three recommended vaccinations) because I’m in what’s considered a high-risk group when I travel. I have a lot of exposure to animals, and I spend extended periods in rural areas where a delay in medical evaluation is likely. Thus, it’s a safe generalization to say that most adventure travelers would do well to get the series, even if they’re not animal lovers (for the record, despite my crazy dog/cat lady tendencies, I usually give creatures in developing nations a wide berth for this reason). I know I’m going to do it before my next big trip.

Getting the series, says Dr. Szumowski, “Also allows for a simpler course of post-exposure prophylaxis following a bite: fewer vaccinations and immunoglobin (which may not be readily available or of good quality internationally) isn’t needed. The pre-exposure series is available in travel clinics, but can be easily given in a primary care setting, too. Clinics may not have it immediately available, so calling the office ahead of time is a good idea.”

Dr. Szumowski is quick to point out that getting the pre-exposure series does NOT mean medical evaluation should be skipped after an animal bite. Aside from rabies, bites can transmit other, primarily bacterial, infections. “Thorough cleansing of the bite site is an important step, regardless of vaccination status,” he adds. “Animal bites, even those that took place some time in the past, should be discussed with your medical provider because the incubation period for rabies can be up to years afterward.”

Need more compelling reasons for why adventure travelers should get pre-exposure shots? I’ve witnessed a puppy play-biting (drawing blood) a fellow traveler while we were visiting a Myanmar refugee camp in Thailand. I’ve seen a late-stage rabid dog staggering down the main street of a small village in Ecuador. I’ve been chased down an alleyway by a pack of mangy Vietnamese dogs, and had to scale a fence to escape. Gadling contributor Kyle Ellison has been chased by a dog while going for a run in a developing nation. I’ve been attacked and bitten two separate times by seemingly friendly cats here in the States, and still had to go to the ER, while animal control was required to quarantine and test the animals.

Rabies definitely isn’t limited to developing nations, nor is it restricted to dogs and cats. You should never get to close to wildlife, wherever you may be, for any number of safety reasons. But animals like raccoons, opossums, and bats are also frequent carriers of this deadly disease domestically.

For more information on rabies and other infectious diseases related to travel, the CDC’s Yellow Book is an excellent resource. And don’t let fear of rabies make you paranoid about indulging your fondness for animals when you travel.

Says Jules, “I’m an animal lover, and even after this horribly scary incident, I’ll continue to look for the wagging tails of approaching dogs. This was a minor blip on our trip, and will in no way stop me from continuing to see the world. It’s a part of traveling that makes us stop and re-evaluate taking precautions. We’re very protected in the U.S., and take that for granted. We need to respect the places that we visit and be our own advocates to protect ourselves and fellow travelers. From now on, I’ll also always consider travel insurance when visiting developing nations.”

[Photo credits: German shepherd, Flickr user State Farm; dog bite, Jules; dog, Laurel Miller]

Rabies: what to do if you’re bitten

Katerina I were enjoying a beautiful afternoon on a Central American beach, swimming and body surfing the day away. As the sun dipped below the horizon, we finished up with a trip for dinner. In the small town near the restaurant, a man had a pet monkey that he was allowing the tourists to take pictures with for a few bucks. Who doesn’t like monkeys? Of course we went to get a picture with the spider monkey on our shoulder.

Unfortunately, the cute little monkey got excited and bit Katerina on the hand. In that instant, many thoughts flashed through my mind — first and foremost: rabies. After a very close inspection of the wound and a thorough cleaning with soap and water, we saw that the skin was not broken. This, combined with a detailed questioning of the monkey’s handler, made me feel much better about the situation.

Some basic knowledge of rabies, including treatment and prevention, is necessary for any traveler who might come into contact with animals. Rabies is a viral disease carried by warm blooded animals. This is primarily a neurological illness that effects the brain. In North America, bats, raccoons, and skunks are most common carriers. Dogs and cats from all corners of the world are also potential carriers.

Transmitted through saliva, often during a bite, the virus ascends the nerves to the brain. Thus, a bite on the leg will take longer to show effects than, say, a bite to the face. The CDC states that exposure to urine, feces or blood of an infected animal does not constitute an exposure. But an infected animal that licks an open wound can transmit the virus. Symptoms of rabies in humans includes weakness, agitation, fever, headache, and itching at the location of the bite are the most common. A few days later, hyperactivity and hallucinations can occur.

Rabies is a killer, literally. There has been at least one case of a person who had documented rabies and survived, without pre or post exposure treatment. Fortunately, there is an effective treatment if given in time. There’s even a vaccine!

If you’re bitten from an unknown animal, a good, aggressive cleansing with soap and water is first. The next step is to obtain the rabies “shots.” This is a combination of HRIG (Human Rabies Immune Globulin) and HDCV (Human Diploid Cell Vaccine). The first is given as soon as possible after the bite, while the latter is given five times over 30 days.

For those at high risk, such as animal handlers, a vaccine exists. A three shot series, given over 28 days, the pre-exposure vaccine still means you need more injections if bitten. A person who has received the rabies vaccine still requires two addition injections if bitten.

There can be a few problems if bitten in a remote or developing area. Some locations use rabies anti-serum made from duck or horse product, which can cause severe reactions in humans. Of course, this is better than no rabies treatment, but riskier than Human Rabies Immune Globulin. In the event of a bite or exposure in a developing area, notify your consulate and ask where you can get HRIG. Some consulates even stock it, themselves. The International Society of Travel Medicine may also be of help locating a clinic.

Having a game plan is key. Bites often occur unexpectedly and in unprovoked circumstances. This is also an unfortunate complication of a curious child who is raised to not be scared of other animals. If bitten, especially by an unknown animal…seek help immediately.


CDC Traveler’s Health Rabies