There have been over 120 deaths in Bali since an outbreak of rabies was first reported in November 2008. This has been newsworthy in Australia because Bali is such a popular destination for Australian tourists and it was previously considered rabies-free. To put these numbers in perspective however, rabies is present in the animal population of most islands of Indonesia, as well as continental Asia, including most places where Australians holiday. India is especially risky, with the WHO estimating up to 60 000 rabies deaths per year. In short, in most locations, if a traveller is bitten by a mammal (usually dogs, monkeys, or cats) and the wound bleeds, this is a rabies exposure.
The bad news is this: The disease rabies is essentially always fatal. The first certain exception was a young woman in the USA in 2004 by the name of Jeanna Giese, who against all odds survived (and in fact recently graduated from college!) The good news is this: Rabies vaccination is very safe and effective. The initial course is 3 shots over a month. Subsequent boosters are just a single shot, lasting at least 2 years.
The World Health Organization (WHO) recommends vaccinating those who are at high risk of the disease, such as children who live in areas where it is common. Other groups may include veterinarians, researchers, or people planning to travel to regions where rabies is common. Three doses of the vaccine are given over a one-month period on days zero, seven, and either twenty-one or twenty-eight. For individuals who have been potentially exposed to the virus, four doses over two weeks are recommended, as well as an injection of rabies immunoglobulin with the first dose. This is known as post-exposure vaccination.
For people who have previously been vaccinated, only a single dose of the rabies vaccine is required. However, vaccination after exposure is neither a treatment nor a cure for rabies; it can only prevent the development of rabies in a person if given before the virus reaches the brain. Because the rabies virus has a relatively long incubation period, post-exposure vaccinations are typically highly effective. Immunity following a course of doses is typically long lasting, and additional doses are usually not needed unless the person has a high risk of contracting the virus. Those at risk may have tests done to measure the amount of rabies antibodies in the blood, and then get rabies boosters as needed. Following administration of a booster dose, one study found 97% of immunocompetent individuals demonstrated protective levels of neutralizing antibodies after ten years.
Rabies vaccines are safe in all age groups. About 35 to 45 percent of people develop a brief period of redness and pain at the injection site, and 5 to 15 percent of people may experience fever, headaches, or nausea. Because of the certain fatality of the virus, receiving the vaccine is always advisable. Vaccines made from nerve tissue are used in a few countries, mainly in Asia and Latin America, but are less effective and have greater side effects. Their use is thus not recommended by the World Health Organization.
So, why get rabies vaccination before travel? Consider these two ‘Bali’ scenarios (though it could be almost anywhere):
You’ve had your course of rabies vaccinations, and you get bitten by a dog in Bali. You need to thoroughly wash the wound and get two rabies vaccine boosters to optimise protection. The rabies vaccine is available in most countries. Having done this you are certain to be OK. You can relax!
You’ve never had rabies vaccination and get bitten by a dog in Bali. This is a medical emergency. You need to thoroughly wash the wound and seek reliable medical care. You need HRIG (Human Rabies Immune Globulin.) HRIG is a blood product containing the antibodies to immediately neutralise the virus and is given by injection around the bite site. There is a worldwide shortage of HRIG so it is very hard to obtain and indeed may not be available in Bali. It is also very expensive, costing up to $4000 when available overseas. You also need a course of 5 rabies vaccinations over a month. Vaccination alone is not sufficient as it may take a month to become fully immune, which is too slow after a bite. The best advice may be to seek initial medical care at a reliable centre locally and then cancel the trip and return home as soon as possible to complete the full post-exposure prophylaxis course. Once all that is completed, and the anxiety has passed, you are certain to be OK. You too can relax! Pity about the holiday though.
But in Bali, in the current circumstances, even vaccinated travellers are advised to bear in mind the old Travel Health aphorism.
Individuals with WHO category II or III exposures should receive PEP without delay. The PEP rabies vaccine will need to be given several times, so it is important to talk to your healthcare professional to plan a regimen that suits you. For severe category III exposures, Rabies Immunoglobulin (RIG) should also be administered alongside the PEP. Adverse reactions to rabies vaccine and immunoglobulin are not common, and newer vaccines in use today cause fewer adverse reactions than previously available vaccines.
Unless an individual is sick with rabies, it is not transferable from person to person. PEP will protect you from developing rabies, ensuring you cannot expose other people to the virus. So if you feel like you have been exposed, and are managing it through the correct course of precautions as recommended by the WHO, you can continue to participate in your usual activities.
RABIES VACCINATION is available at HydroMedical Bali. You will note two types of vaccine.
“Intramuscular course” is the standard and preferred course. The vaccine is given in a dose of 1ml as a deep IM injection, on three occasions, usually Day 0, 7 and 28.
“Intradermal course”, while not standard, is accepted by the NH&MRC as an alternative way of giving the same vaccine less expensively. It means that backpackers, volunteers and students, who tend to be at high risk and broke, may be able to afford the vaccine. The same vaccine is given as a smaller dose with a tiny needle, as a bleb just under the skin. Again, three shots are required, usually Day 0, 7 and 28. For those having likely contact with animals, a blood test at the end of the course can make absolutely sure you have become immune. If injection technique is correct, (and it will be at my clinic cos I give them all!), success rates should be 100%.