Rabies Pretravel Vaccination

Philippe Gautret; Philippe Parola

Disclosures

Curr Opin Infect Dis. 2012;25(5):500-506. 

In This Article

The Epidemiology of Rabies and Exposure to Potentially Rabid Animals in Travelers: Recent Data and Risk Factors

From 1990 ( Table 1 ) through May 2012, 48 confirmed cases of rabies in international travelers were reported in the literature, and most of these cases involved travelers who returned to Europe and the USA.[6–12] The exposures occurred in Asia, Africa, Central America, the Caribbean and Eastern Europe, and the four areas with the most cases were India and Sri Lanka (8 cases), the Philippines (6 cases), north Africa (6 cases), and Mexico (5 cases). Most patients were older than 15 years (85.4%) and men (65.5%). Of the rabies cases, most were associated with dog bites, but two bat-related cases and one fox-related case were also reported. One-third of cases occurred in individuals traveling for 3 months or less, including three cases for which travel lasted no more than 2 weeks. A significant number of cases were observed in recent migrants or migrants visiting friends or relatives in their countries of origin (44.8% since 2000). Additional, confirmed travel-associated rabies cases are likely to be unpublished or published in sources that are not available to an international audience. Moreover, rabies may be misdiagnosed, notably when death occurs abroad.[13] This figure of two cases per year therefore most likely underestimates the true incidence of rabies in travelers.

The incidence of injuries to travelers caused by potentially rabid animals has been estimated to be 0.4% per month of stay, according to a meta-analysis of more than 1 270 000 individuals[6]; however, the data are very heterogeneous in terms of methodology, and no comparison can be made between available studies. Dogs, which are responsible for almost all rabies cases in developing countries, accounted for only 51% of cases in the largest available multicentric survey on animal-related injuries requiring PEP in travelers; the remaining animals carry a lower risk of rabies transmission.[14] Monkeys were the leading animal responsible for injuries leading to rabies PEP in travelers returning from Southeast Asia, notably from Bali in several recent studies.[3,4,15] In a survey conducted in Nepal, monkey bites were 13 times more likely to occur in tourists than expatriates, suggesting that tourists pursue activities with greater potential for human–monkey interaction.[16] Although experimentally infected monkeys develop rabies, there is no published data about wild Asian monkeys carrying rabies. Nevertheless, given the 100% fatality rate of the disease and the safety of the preventive treatment, rabies PEP is usually provided to mitigate rabies risk following monkey bites. At least 42 000 visitors are bitten by monkeys yearly in Balinese monkey temples.[17] Given the continuous growth of tourism in Southeast Asia, the number of patients seeking care for rabies PEP following monkey bites may accordingly increase. The risk of a potential shortage of rabies immunoglobulin because of an unplanned increase in demand or because of limited supply is shared by many countries in Europe and countries in other continents.[18] To decrease the number of rabies PEP following monkey bites, it is crucial that travelers to Asian countries and notably to Bali should be fully informed that monkey bites are extremely frequent in the monkey temples visited by tourists and that they should be very careful when approaching monkeys.

Finally, based on recent studies,[3,14,16,19–21] the following risk factors for injury caused by potentially rabid animals may be identified: traveling to Southeast Asia, India, and north Africa, young age, and traveling for tourism. Notably, the duration of travel does not appear to be a risk factor in these studies; in a survey of backpackers in Bangkok, 54% of exposures occurred within the first 10 days after arrival in Southeast Asia.[21] Additionally, traveling to visit friends and relatives appears to be a risk factor for rabies; this finding suggests that if migrants become injured while traveling, they are less likely to seek care for rabies PEP compared to tourist travelers.

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