Why the disconnect?
What do you need to know about rabies vaccine?
It’s hard to advise patients about rabies when our own personal experience is so limited. Typically there are only 1-3 cases per year in the USA. Many of these are ‘imported’ (the bite occurred outside of the country) All are fatal.
It’s a different story worldwide where over 150 people die each day from rabies. That’s over 55,000 people per year, mostly in Africa and Asia, including India. Of those, sadly 40% are children under age 5.
If you have patients traveling to India, Asia, or Africa or any other country the CDC identifies as having outbreaks you must talk about it your travelers about rabies. Surprisingly many travelers are completely unaware of their risk.
- Rabies is a uniformly fatal viral infection spread by the bite of animals with fur (mammals).
- It can be prevented by timely care with biologics after the bite occurs, including Human Rabies ImmunoGlobulin (HRIG) and 4 doses of vaccine.
- Many countries do not have proper rabies wound care available, putting your travelers at significant risk of disease.
- Children due to their small size and proximity to animals, especially dogs, are far more likely to suffer animal bites than adults.
For all these reasons many travelers opt to invest in pre-exposure rabies prophylaxis
And I say invest because it is very expensive. Typical costs for 3 doses of rabies vaccine runs $1200-1400 USD for the series. Ouch!
The problem with rabies protection is not the cost of the vaccine; it’s the worldwide scarcity of Human Rabies ImmunoGlobulin (HRIG).
I know it’s hard to believe that a vaccine which costs over $1200 USD is not the real problem. But it’s true.
In many countries rabies vaccines is available but HRIG is often in short supply. It’s this lack of HRIG that puts your patient at risk.
HIRG is expensive and fragile. For these reasons it’s unavailable throughout most of the developing world. If your patient gets bitten they need to locate both HRIG and rabies vaccine, quickly.
This is such a big deal that the International Society of Travel Medicine (ISTM) keeps a database for its members about the availability of HRIG, just to help travel medicine specialists give accurate advice about the availability of care at a particular destination.
How does getting the rabies vaccine solve the HRIG problem?
If your patient is bitten and hasn’t had prior rabies vaccine, they will need HRIG plus 4 doses of vaccine. But if you can’t get HRIG your patient is now in a race against the clock.
Finding HRIG can be stressful; often it requires many phone calls and travel to another country.
If, however, your patient has completed their primary series of rabies vaccine, they do not need HRIG. Of course, they still need wound care and two more rabies vaccines according to schedule.
This is much easier problem to solve; even in developing countries rabies vaccine is relatively easy to locate. Getting treated often requires only local travel, which can save the trip.
Which travelers might benefit from rabies vaccine?
The short answer: Any traveler at risk for a bite from a rabid animal.
The practical answer: Anyone who anticipates a lot of travel over his or her lifetime.
- humanitarian trips
- adventure tips
- traveling with children
- travel to remote locations
It’s a good idea to discuss investing in a series of rabies vaccine for anyone with increased risk of a bite or trouble locating HRIG. Spread out over a lifetime of traveling it’s rather affordable.
This is especially true when you consider rabies vaccines can be ‘trip saving’. Meaning when bit, people can find local sources of good wound care and the final two doses of rabies vaccine instead of abruptly ending the trip in search of proper care.
Are there any other options besides expensive rabies vaccine when traveling to areas where HRIG is not available?
For most patients, the combined prohibitive cost of rabies pre-exposure prophylaxis and shortage of HRIG can be addressed by purchasing travel health insurance with evacuation coverage.
This is a particularly satisfactory solution for short-term travelers not planning on going too far off the beaten path.
Travel health insurance can be purchased for a fraction of the cost of even one dose of rabies vaccine. In the event of an animal bite, the insurance usually covers the cost of traveling to the closest country with proper treatment as well as the medical care.
Of course you’ll want to encourage your patients to check their policy for details prior to departure.
Have ‘the talk’ with your patients.
Rabies is not something we are used to worrying about in the USA. When a potentially rabid animal bites our patients HRIG is readily available, and proper care is started immediately. For this reason we do not routinely recommend pre-exposure rabies vaccine for our patients, even in areas where there are a lot of rabid skunks, foxes and raccoons.
But when you are advising your patients for travel to places where rabid animals are common but proper care isn’t, you will need to develop a plan with your patients.
Remind them that any bite is potentially rabid and should be properly cared for. Discuss whether rabies vaccine or travel health insurance is a better strategy for managing a potential bite. Most patients have very definite ideas about which solution works best for them.
How do you manage rabies in your travelers? Leave a comment below: