• It is especially crucial for tourists to be vaccinated for rabies before traveling to Southeast Asia
  • A study by doctors are SGH found a lack of pre-travel vaccination
  • Rabies has no specific treatment once clinical symptoms set in

Millions of tourists visit Southeast Asia (SEA) – a rabies hotspot – every year. A majority of these visitors often do not seek pre-travel vaccination as they believe there is only a small possibility of contracting rabies.

Other than complacency, low awareness about the consequences of rabies and the need for prompt treatment upon potential rabies exposure can put one at risk of the deadly disease.

Rabies is one of the most feared human diseases as there is no specific treatment once clinical symptoms set in. The World Health Organisation estimates that between 23,000 to 25,000 people die of rabies in SEA each year.

It causes human encephalitis, the inflammation of the brain which can present itself in a wide range of symptoms: from headaches with fever to vomiting, fits, numbness, paralysis and even loss of consciousness.

Thus, it is especially crucial for tourists to seek pre-exposure prophylaxis (PrEP), and be aware of the availability of post-exposure prophylaxis (PEP) before travelling to the region.

A study by Dr Chua Ying Ying, Dr Wijaya and two other clinicians from the Department of Infectious Diseases at SGH found a deficiency in rabies PEP for travellers exposed to high-risk animal injuries in rabies-endemic countries.

The team reviewed the profiles of travellers to SEA seeking rabies PEP in SGH from December 2010 to December 2013. During this study period, the travel clinic saw an average of 1,060 travellers. Of these, there were 37 travellers who visited for rabies PEP.

The study revealed that almost one-third (n=12) of the patients did not receive PEP in the country of rabies exposure, with the first dose given only after consultation in the travel clinic.

All of them either sustained category II or III injuries, and 84 per cent (n=31) of these injuries were unprovoked encounters. The sources of exposure were mainly from monkeys (n=17) and dogs (n=16).

In addition, majority of them (n=35) did not have PrEP, seek pre-travel health consultations or vaccinate themselves before travel.

The poor uptake of PrEP is often attributed to cost, insufficient time for full vaccine administration and a general lack of rabies knowledge.

“It takes a minimum of three weeks to complete a pre-exposure vaccination. But as any vaccine will take time to build an immune response, we advise everyone to seek pre-travel advice and vaccination at least six weeks before embarking on their travel,” said Dr Wijaya.

At SGH, patients with possible rabies exposure are assessed if they require Rabies Immunoglobulin (RIG). The RIG is a pooled antibody against rabies, and it is administered to patients who have never received rabies vaccination.

“Any vaccine we give after exposure to a potentially rabid animal will take time to develop an antibody response before there is protection against the illness. The RIG, which already has the antibody, will protect the person until the body can produce its own antibodies against the virus,” explained Dr Wijaya.

While the travel clinic routinely offers RIG, RIG is not as easily accessible and available in most SEA countries.

The team found that only five out of the 28 patients who required RIG received it in the country of visit. More importantly, failure to medicate wounds with RIG has been associated with the development of rabies despite proper active immunisation.

All in all, the team stressed the need to improve pre-travel health seeking behaviour among travellers, as well as to educate the general population of the risk and consequences of rabies.

This article was first published in Proceedings of Singapore Healthcare Vol. 23, No. 4.

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