Global Health Update
January 19, 2011
Ann Settgast, MD, DTM&H
Center for International Health
For which of these patients would you
recommend rabies PrEP (Pre-exposure
Prophylaxis) and why?
A. Adult male backpacking across India for 6 months
B. Toddler child moving to Costa Rica for the year with her
missionary parents
C. Adult female working with MSF in Angola for 4 months
D. Adult female working in Tanzania for 2 weeks on a filming
project about HIV awareness
E. Adult male visiting Mumbai for 5 days for business
F. Adult female PhD candidate spending one month in
Bangladesh to do diarrhea research
G. Adult female bikeriding around the island of Bali for 3 weeks
H. Adult male med/peds resident doing a two-month rotation in
Bolivia
Why rabies discussion is important
in travel medicine
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~ 55,000 human rabies deaths per
year world-wide
Likely under-reported, especially due
to misdiagnosis of paralytic form
Only way to guarantee survival in an
exposed unimmunized patient is to
give post-exposure prophylaxis (PEP)
PEP= vaccine plus RIG
Where in the world
is rabies?
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Over 100 countries and all continents
Vast majority of deaths in Africa & Asia
20,000 deaths in India
China second to India in # of deaths
24,000 deaths in Africa
80% in rural areas
Bangladesh
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Highest per capita
death rate from rabies
- one in every 30,000
This would = 100
rabies deaths per year
in the Twin Cities!!
Bali – rabies free
Until…
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Sept 2008, two adults died two
months after being bitten, “… it
would be a major concern if the
dogs were infected with rabies,
because no vaccine … is stored on
the island.” (Jakarta Post)
Dec 2008, the Indonesian
authorities reported a rabies
outbreak in dogs on Bali
Jan 2009, “Commendable efforts
being made … to achieve control by
culling and (dog) vaccination.
Strangely, medical authorities seem
reluctant to employ post-exposure
vaccination to protect human
population.”
Mar 2009, “Little precise information
has been reported concerning the
course of the outbreak and…
consequent human fatalities. In
particular, there is concern about
the extent of the dog vaccination
program and the availability of
vaccine and immunoglobulin for
PEP.”
•Sept 2009, 21 y/o female bitten by dog; rushed to regional hospital;
wound was cleaned and sutured. 15 days later presented with inability to
move legs, restlessness, and phobic to water. Given two rabies vaccines.
Died. 9th fatality.
•Oct 2009, Indonesia MOH reported 15 deaths - most cases near popular
tourist destinations on the southern tip of Bali
•April 2010, “…important for patients and families to seek medical advice as
soon as any of the classic rabies symptoms are exhibited…They should get
anti-rabies vaccines immediately," he said.
•September 2010, 93 deaths (165 people bitten by dogs daily)
•As of last week, 118 deaths recorded
How many do NOT die of rabies?
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Estimated that in the absence of PEP
(post-exposure prophylaxis),
327,000 persons in Africa and Asia
would die each year
Manufacturer data suggest that > 15
million people receive PEP annually
(majority in India and China)
“Rabies vaccines: WHO position paper”, No. 32, 2010
Rabies Immune Globulin (RIG)
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Produced by a limited # of companies in
the developing world
In the developing world, < 1% of those w/
serious exposures receive it!
Human (HRIG) preferred (longer half-life)
Newer Equine formulations (ERIG): potent,
highly purified, safe, much less $$
• Small, but real risk of anaphylaxis and serumsickness
J Travel Med 2005; 12:s30-s40
Vaccine
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All cell culture vaccines induce prompt
and high neutralizing Ab response
• Intradermal regimens well-proven
(assuming proper administration) and
widely used
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Nerve tissue vaccines (still used in a
few countries): less immunogenic
+more severe reactions
“Rabies vaccines: WHO position paper”, No. 32, 2010
Not all travelers need PrEP
(Pre-Exposure Prophylaxis)
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But all need education!
Rabies vaccine at Health Partners Travel
Clinic is $329 + admin fee
But…once correctly immunized w/ PrEP, no
need for RIG
76% of 300 surveyed German and Swiss
GPs seeing patients (going to developing
countries) for pre-travel advice did not
discuss rabies with the traveler (J Trav Med
1999; 6:163-167)
Factors to consider in pre-travel
consultation…
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Probability of exposure:
• Incidence of rabies in the area
• Probability of contact with infected animal
*Children
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Ability to access local after-care
(remoteness of travel and time to reach
medical care)
Competence of local after-care
Back to Bali
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One million tourists visited Bali Jan
to June 2009
PrEP for all would cost $750,000,000
(at U.S. rates)
If risk of being bitten is 1 in 6000
(based on study of tourists in Nepal),
then total cost of giving PEP to only
those who exposed would be 166
times $4000, which equals $664,000
However…
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Sometimes decision to give PEP is a
no-brainer, but process can still be
very stressful for patient and
provider
Situation is much easier if PrEP has
been given (especially when severity
of exposure is less obvious).
How do you know where RIG is available?
You don’t!
Mumbai, India – H
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Most other cities in India - E
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Costa Rica
Islamabad, Pakistan – H
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Cuzco, Peru
Kathmandu, Nepal – H
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Bali
Bangkok – H
64% of 500 Thai Hospitals surveyed (J
Trav Med 1998)
Hong Kong
Singapore
HCMC and Hanoi, Viet Nam only at Int’l
SOS clinic
Beijing, China – “controlled & limited”
Ulanbatter, Mongolia
Lagos, Nigeria – “occasionally E, but none
at the moment”
Acra, Ghana
Durban, South Africa
Large cities in Brazil – B
Lima, Peru – E
Source: informal email survey sent to 40 clinics (ISTM)
Medellin, Columbia – E
in 20 developing countries ~ 75% response rate
Counseling a traveler
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Avoid stray or unknown domestic
animals
If bitten, immediately flush wound
with soap/water
Seek urgent medical attention,
preferably in specialized center
Request cell culture vaccine only
Insist on RIG
Now, for which of these patients would
you recommend rabies PrEP (Preexposure Prophylaxis) and why?
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A. Toddler child moving to Costa Rica for the year with her
missionary parents
B. Adult female bikeriding around Bali for 3 weeks
C. Adult female PhD candidate spending one-month in
Bangladesh to do diarrhea research
D. Adult male backpacking across India for 6 months
E. Adult female working with MSF in Angola for 4 months
F. Adult female working in Tanzania for 2 weeks on a
filming project about HIV awareness
G. Adult male visiting Mumbai, India for 5 days for business
H. Adult male med/peds resident doing a two-month
rotation in Bolivia