Rabies Exposures in International Travelers: A Review

Up to 2% of international travelers report an animal contact which raises the possibility of rabies exposure. Travelassociated rabies is rare; however, infection is essentially fatal once expressed yet death is preventable by timely postexposure prophylaxis (PEP) -- thorough wound cleansing, local injection of rabies immune globulin (RIG) and a vaccine series. To begin to provide initial guidance if contacted by a patient potentially exposed to rabies while abroad, key questions the clinician should ask in a stepwise fashion are: (1) What animal was involved? (2) What was the actual exposure and in what country did it occur? (3) How many wounds, location (including mucosal surfaces), severity and what wound care performed? (4) Is the traveler immunocompromised? (5) Was either preexposure rabies prophylaxis or PEP previously given? (6) Is rabies PEP clearly indicated and/or is expert advice and guidance needed? (7) Where is the traveler, what level of acceptable care is accessible and how long to access it? And (8) What formulation of rabies immune globulin and vaccine is available and what injection protocol is in-use? Framed here by experience with four travelers, answers to these and additional questions set the stage for the clinician’s initial guidance and action. The goal and clinical relevance of this review is straightforward – to maximize the opportunity for travelers who warrant rabies PEP to promptly receive it.