5 facts about rabies every GP should tell travellers

The risks may be greater than you think
ad_pn_article_3.jpg

Promoted

aswzf

This content is produced by Australian Doctor Group in partnership with GSK.

Travellers to popular destinations in Asia and Africa may be at risk of exposure to rabies if they come into contact with animals such as dogs, monkeys or bats – and it’s almost always fatal once symptoms appear.1,2

Even though rabies pre-exposure prophylaxis (PreP) is recognised to be an effective preventive measure against rabies, the uptake among Australian travellers appears to be low.2–5

Here are the key must-know facts about rabies to tell travellers.

1. 95% of human deaths from rabies occur in Asia or Africa1

Areas at risk of rabies

shfdx

Adapted from World Health Organization (WHO). International Travel and Health, 2014 update.6

Rabies exists in more than 150 countries, but 95% of human deaths occur in regions of Asia and Africa.1

Bali, considered rabies-free until 2008, is now a potentially risky destination – about 700,000 people visit the four main monkey temples in Bali each year and at least 6% of them are bitten by the macaque monkeys.7

And it’s not only long-stay visitors who are at risk. Two cases of reported rabies occurred in tourists taking a two-week trip to India and Kenya.8

2. Bites and scratches from dogs, cats, bats and monkeys can transmit rabies1

jfh

 

Travellers should be informed that monkey and dog bites put them most at risk of rabies – but they should also beware of bats everywhere, including Australia.1,2,9,10

Classical rabies virus is one of 12 known lyssavirus species and is closely related to Australian bat lyssavirus and European bat lyssaviruses.2

Of the 497 Australians in NSW assessed for post-exposure prophylaxis (PEP) due to exposure to either rabies or Australian bat lyssavirus in 2015, 49% of the 230 cases exposed in Southeast Asia were due to monkey bites or scratches, 36% from dogs, and 9% from cats – predominantly while travellers were in Indonesia or Thailand. However, 38% of the local cases were due to exposure from bats in Australia.9

Children are especially vulnerable – 40% of those who are bitten by potentially rabid animals are younger than 15.1 The height of young children makes them a target for bites to the face and head.2

The Australian Immunisation Handbook advises the following risk reduction measures for travellers to rabies endemic regions:2

• Avoid bats in any area, including Australia
• Avoid feeding or approaching wild or domestic animals
• Don’t allow young children to feed, pat or play with animals
• Avoid contact with stray dogs or cats and be alert when walking, running or cycling
• Don’t carry food, and don’t feed or pat monkeys, even in popular areas where travellers may be encouraged to interact with them
• Avoid focusing attention on monkeys carrying their young, as they may feel threatened and bite suddenly.

3. Rabies is almost 100% fatal once symptoms appear1

sdxg

 

The incubation period for rabies is typically one to three months but may vary from as little as one week, up to a year.1

Initial symptoms may be vague and non-specific and include a fever with pain and unusual or unexplained tingling, prickling, or burning sensation at the wound site.1,10 

There are two forms of the disease:
1. Furious rabies: Symptoms include hyperactivity, agitation, hydrophobia (fear of water) and sometimes aerophobia (fear of draughts or fresh air). After a few days, the patient will die due to cardio-respiratory arrest.1
2. Paralytic rabies: In this form, the muscles gradually become paralysed, starting at the site of the bite or scratch, followed by a coma and eventual death. This form is slow to progress and is often misdiagnosed.1

4. Rabies can be prevented by vaccination2

dzg

 

The Australian Immunisation Handbook recommends pre-exposure prophylaxis (PreP) for “travellers and expatriates who will be spending time in rabies-enzootic areas” following a risk assessment that accounts for likelihood of contact with animals and the accessibility of post-exposure vaccines.

Even though rabies pre-exposure prophylaxis (PreP) is recognised to be an effective preventive measure against rabies, the uptake among Australian travellers appears to be low.2–5 

A study of backpackers travelling in Thailand showed that out of the 98 travelling from Australia and New Zealand, only 19% had received PreP.3

A three-dose course of Rabipur (Inactivated Rabies Virus Vaccine) PreP can be completed in 21 days and is administered at days 0, 7 and 21 or day 28.

Clinical trials show 100% of people achieved an adequate immune response (antibody titres of 0.5 IU/mL)* by day 28 or earlier when Rabipur was administered according to the approved regimen.4,5

PreP does not eliminate the need for urgent medical care following possible rabies exposure.1,2,10

*There is no specific level of rabies virus-neutralising antibodies that is recognised as being “protective” against rabies in humans. The World Health Organization (WHO) recommends a specific antibody level of 0.5 IU/mL as indicative of adequate immune response after vaccination.

5. Access to rabies immunoglobulin is unreliable and potentially unsafe2,10

dzsa

 

Travellers need to know what to do immediately if they are bitten or scratched by a potentially rabid animal.

They should immediately flush and wash the wound thoroughly with soap and water for at least 15 minutes, apply a virucidal solution such as povidone-iodine, and seek medical help for post-exposure prophylaxis (PEP).1,2,10 This could save a person’s life.1

Some travellers may wonder why they should have pre-exposure vaccination when PEP is available. 

For unvaccinated people, PEP usually involves four or five doses of the rabies vaccine and rabies immunoglobulin is required for individuals who receive a Wound Exposure Category III or Wound Exposure Category II where there is uncertainty of category rating.1,2,10 

However, rabies immunoglobulin can be very difficult to obtain while overseas, especially in developing countries, and its safety cannot be guaranteed.2,10  

In a case series of 45 travellers to Bali between 2008 and 2010 who had contact with a potentially rabid animal, less than half received PEP in Bali – and only two received the necessary rabies immunoglobulin.7

PreP eliminates the need for administration of rabies immunoglobulin, and simplifies the PEP vaccination schedule – people who have been fully immunised need two doses of Rabipur as PEP, at days 0 and 3.2,4

As Professor Nick Zwar, Dean of Medicine at the University of Wollongong, noted in an article published in Australian Doctor: “Given the complexity of PEP and the difficulty of access, for people who plan to travel to rabies-endemic areas on repeated occasions over the course of their lives, rabies PreP could be viewed as an investment in healthy and relatively hassle-free travel.”11 

For more information on GSK vaccines and medicines, register now at www.health.gsk.com.au

 

PBS Information: This product is not listed on the National Immunisation Program or the PBS.

 

Please review Rabipur Product Information before prescribing.
Product information is available at
au.gsk.com

RABIPUR MINIMUM PRODUCT INFORMATION (Inactivated Rabies Virus Vaccine) Indications: Active immunisation against rabies virus, including pre-exposure immunization and post-exposure treatment following exposure to rabies virus. Contraindications: Pre-exposure: Hypersensitivity to any vaccine component, including chicken eggs/protein, bovine gelatin, neomycin, chlortetracycline and amphotericin B. Acute severe febrile illness. Post-exposure: Unless an alternative vaccine is available, those with severe hypersensitivity should be vaccinated and monitored with the availability of emergency treatment. Precautions: Intramuscular injection (IM) only. Not for intragluteal injection. Temporal association of anaphylaxis and neurological events reported with Rabipur administration. Anticipate potential syncope. Immunocompromised patients, pregnancy (category B2), lactation. Interactions: Administer concomitant vaccines or immunoglobulins at different injection sites. Avoid immunosuppressive therapy during post-exposure treatment. Anti-rabies immunoglobulins may attenuate the effects of concomitant rabies vaccine. Adverse events: Clinical Trials: Injection site reactions (erythema, induration and pain), asthenia, fatigue, fever, headache, myalgia, arthralgia, influenza-like illness, rash, urticaria and gastrointestinal symptoms. Dosage and Administration: Pre-exposure: 1.0ml given IM at days 0, 7, and 21/28. Boosters: Every 2 to 5 years for those with ongoing risk. Depending on risk of exposure, serological testing may be recommended. Post-exposure: Refer to the PI. Storage: Store between +2oC and +8oC. DO NOT FREEZE. For more information, please refer to the PI. [Rabipur min PI v02] 

References 1. World Health Organization (WHO). Rabies Factsheet no.99. Available online: www.who.int/mediacentre/factsheets/fs099/en/. Accessed September 2017. 2. Australian Technical Advisory Group on Immunisation (ATAGI). The Australian Immunisation Handbook 10th ed (2016 update). Canberra: Australian Government Department of Health, 2016. 3. Gautret P et al. Vaccine 2011; 29:3931-34. 4. Rabipur Approved Product Information, May 2017. 5. Briggs DJ et al. Vaccine 2001; 19: 1055–60. 6. World Health Organization (WHO). International Travel and Health 2012. Updated 2014. Available online: www.who.int/ith/en. Accessed September 2017. 7. Gautret P et al. Clin Microbiol Infect 2011; 17: 445–447. 8. Carrara P et al. PLoS Negl Trop Dis 2013; 7(5): e2209. 9. NSW Health. 2015 NSW Zoonoses Annual Report. 10. Centers for Disease Control and Prevention (CDC). CDC Health Information for International Travel 2016 (Yellow book). New York: Oxford University Press; 2016. 11. Zwar N. Managing rabies exposure. Australian Doctor, 16 July 2014.
 

For information on GSK products or to report an adverse event involving a GSK product, please contact GSK Medical Information on 1800 033 109. GlaxoSmithKline Australia Pty Ltd. ABN 47 100 162 481. Melbourne, VIC. Trade marks are owned by or licensed to the GSK group of companies ©2017 GSK group of companies or its licensor. AUS/RIR/0006/17 Date of Approval: November 2017.