Should i get pre-exposure rabies shots before traveling?

What i’ve learned about rabies prophylaxis after being attacked by a dog on a long-term cycle tour


A dog bite during long-term travel is not a problem until it becomes one. When it does become one, what to do about it might not be immediately clear, and local customs and perceptions might not necessarily be the best source of guidance. I felt like greater “rabies awareness” might be warranted, and it shouldn’t be that much of an extra effort to promote it. I hope travelers planning to be on the road for a long time and/or going to regions where rabies is present will find this article useful  —  especially those coming from places where rabies is not an issue, who might not have a good enough intuition of how big of a deal it can become.

Now, i am not a rabies or dog expert myself, and this article is for your information only  —  the following is based on my personal, anecdotal experience being attacked by a dog on a cycle tour, the conversations with doctors and Internet research in that context, and my personal travel and life philosophies. By continuing to read, you acknowledge that i am not liable under any circumstances for what you decide to do or not to do in reaction to this article. My only recommendation is that you inform yourself about the risk, and consult with your doctor and local health authorities before making any decision.

Sometimes dogs can be real bitches!

I’m currently out on a long-term cycle tour. Among other things, this means i spend much of my time on the bicycle riding secondary roads in the countryside, where farm dogs abound, or entering/leaving villages/towns/cities, which in many cases also means dealing with packs of stray dogs. So far, i hadn’t had any problems with them besides their unpleasant, persistent chasing and barking after you until you leave their imaginary territory. Having traveled by bicycle unharmed through more than 20 countries, including some notorious for their dogs such as Serbia, Romania, Bulgaria and Turkey, i had already come to terms with that annoyance, and pretty much internalized the belief that, as long as i kept my cool and didn’t provoke them any further, or at least their owner was present, they would never bite  —  until one of them did bite!  —  in Lithuania, in front of their owner, while i was pulling near a house to ask for information outside the city of Alytus.

My first mistake

“Fuck  —  i don’t want to have to go to the doctor  —  it’s too much responsibility!  —  can you imagine how much time this might take!?  —  and i’m not even worried about how much money it might cost yet.” I was up to date with my tetanus shots, and the wound was seemingly superficial, there was not much blood in the picture. So, i was not particularly concerned about bacterial infections, and it definitely didn’t look like i might need stitches or whatever. The puncture was indeed a bit painful, and in a way i don’t think i’d quite experienced before. But it was nevertheless tolerable. Rabies was quickly singled out as my only potential concern, and i seemed determined to get away from having to deal with it in the most stupid possible way.

“Might i get sick from this bite?” In the cacophonous haze i was eager to get myself away from as soon as possible  —  the dogs continuing to bark at me, their hopeless owner haphazardly yelling at them, presumably trying to contain them from biting me again, while also trying to give me the attention i was asking for, and mutually unintelligible utterances in Lithuanian, Russian, English and Portuguese  —  that’s what i came up with to type into my phone and have translated into Russian, which the owner said she could understand  —  i had no access to the Internet, and had forgotten to download the Lithuanian package for use offline. Although reading cyrillic seemed to be a bit of a challenge for her, i got the sense that she understood my question, which she quickly dismissed  —  “no, no, no.” Despite the language barrier, i felt validated enough, and moved on to what i had really pulled in to ask them about  —  “alright, so, may i camp near the river for one night?”  —  “sure, do you know how to get there?”  —  “i’ll figure it out, thanks!”  —  like i said, i just wanted to get out of there as soon as possible. But, one last time  —  “do i need to go to the doctor for this?”  —  “no, you don’t need to go to the doctor, wait a minute”  —  she then came back with some hard liquor and cotton, with which she cleaned up the wound, and then applied a bandaid.

Whatever. I’ll clean it up again with my first aid kit once i find my campsite.

Folks, that’s not how you ask if the dog has been vaccinated against rabies. Here’s how you ask if the dog has been vaccinated against rabies: “has the dog been vaccinated against rabies?  —  do you have the documentation?  —  can we please exchange contact information?”

That would have made it possible to monitor the dog. But i didn’t do any of that then, nor did i think about going back there next day in the morning for it. I did remember from a previous dog bite back in Brazil when i was a teenager that one typically has about ten days to start taking the rabies shots though, and that i had already completed a post-exposure rabies vaccination program in that occasion. So, i figured instead of rushing into an emergency room close to dark, i could leisurely look up on the Internet the next day how long the vaccine is supposed to last, the risk of getting rabies from a dog bite in a place like Lithuania, and perhaps swing by a doctor on my way to Kaliningrad.

But let’s figure this out

According to the World Health Organization’s Human rabies transmitted by dogs: current status of global data, 2015, the phenomenon is currently not observed in Lithuania. So, my risk of having been exposed to the virus was slim. But as far as i understand the data, it only tells us that there have not been any recently reported deaths by human rabies transmitted by dogs in the country  —  it doesn’t say anything about potential cases where the dog was eventually found to rabid, and the victim survived because of the vaccines. I could not find anything about that on the Internet, and decided a visit to the doctor was warranted after all  —  if only for the peace of mind and what i might learn from the experience of having to seek medical care on a cycle tour  —  how much trouble would that really be? —  how much would it cost?  —  would my travel insurance be useful, would i get reimbursed?  —  would that be the kind of disruption i’d find interesting dealing with?  —  let’s just do this  —  that’s precisely why i left my previous career, hopped on a bicycle, and started riding around the world, isn’t it?

So, what have i learned about rabies?

The one thing about this disease that has always intrigued me was one of its infamous clinical symptoms  —  hydrophobia, or the “fear of water.” I find it tragically fascinating how a virus can trigger such complex behavior in its host. If you think you can handle it, this heartbraking video of a man suspected to have rabies in a hospital in Vietnam shows what that fear of water might look like. This other video shows a man in Russia confirmed to have had rabies describing his condition to the doctors throughout the development of the clinical disease.

Apart from that, i must admit i’m not terribly interested in all the details though  —  as far as the practicalities of cycle touring/long-term travel are concerned, there doesn’t seem to be a whole lot one needs to know about rabies:

  1. It’s a viral disease that can be transmitted to humans through bites, licks and scratches by infected dogs, bats and other animals carrying the virus.
  2. After the onset of clinical symptoms, it is universally fatal.*
  3. This tragic outcome can be prevented with a relatively simple and inexpensive** post-exposure protocol.
  4. Keeping up with the underlying post-exposure vaccination schedule can be a challenge while on the move, especially if you’re crossing international borders along the way.
  5. Pre-exposure vaccination or a completed post-exposure prophylaxis does not confer life-long immunity, but nevertheless greatly simplifies the post-exposure protocol.

Besides the information i got from talking to doctors in Lithuania, Poland and Sweden, i’ve also consulted the World Health Organization, the Centers for Disease Control and Prevention, and the Brazilian Health Ministry (in Portuguese) websites. There’s much agreement and some discrepancy across their recommendations. For the purposes of writing this article, i decided to follow the WHO guidelines, which i briefly summarize below, and can be read in more detail here, here and here. You should, of course, consult with your own available health specialists and authorities before making a decision.

Post-exposure prophylaxis. The WHO recommends immediate washing and flushing of the wound for 15 minutes with soap and water and other virucidal substances such as alcohol or iodine. If there’s bleeding, or in the case of bites in the head, neck, hand or genitals, which have high density of nerve terminations, along which the virus travels until it reaches the central nervous system, the administration of rabies immunoglobin at the wound site is also recommended. This should be done before suturing the wound. One intramuscular dose of the vaccine should be administered on days 0, 3, 7, 14 and 28 after the suspected exposure to the virus. (Alternative vaccination schedules and delivery methods are available, but they all require three to five visits to the doctor and take three to four weeks to complete.)

Pre-exposure prophylaxis. Consists of one intramuscular dose of the vaccine on days 0, 7, 21 and 28, and is recommended to people in risk of exposure to the rabies virus, including travelers to areas where the disease is endemic. Different delivery methods are available.

Post-exposure prophylaxis for previously vaccinated individuals. Rabies vaccines to not confer long-term immunity to the disease. The wound gets otherwise the same washing and disinfecting treatment. But for those who have previously completed a pre-exposure or post-exposure vaccination schedule, fewer doses of the vaccine are required, and the administration of rabies immuglobin is not needed. One intramuscular dose of the vaccine should be administered on days 0 and 3 after exposure. An alternate, single visit, 4-site intradermal vaccination is also possible.

According to the doctor who saw me at the Pomeranian Center for Infectious Diseases and Tuberculosis in Gdańsk, Poland, where i took my second shot, most doctors will treat you as if you have not been vaccinated before unless you can produce documentation specifying the drug, dosage, delivery method and schedule.

Getting vaccinated while on the move

Now back to my personal experience. Before you read it, i want to first admit to my embarrassent for having taken so much of the time of so many people at so many hospitals  —  but i would have been even more embarrassed, if not plain guilty, had this happened somewhere in the world with already precarious health care available to their own population. So, not to be unnecessarily inflammatory here, but the question of whether or not to take pre-exposure rabies shots before long-term travel might well be an ethical one.

I could not  —  i mean, i didn’t want to consider the possibility of staying in Lithuania for four weeks until completing my series of rabies shots  —  at that point i had still not learned that, because i’d been previously vaccinated, i could potentially get away with a single visit. “Can i take the first shot with you here, and then continue my treatment in Poland?” The first doctor i spoke with, in the Emergency Room at the Marijampolė Hospital, didn’t really know what to say about that  —  he implied that my chances of catching rabies from that dog bite were minimal, and that taking the shots or not was eventually my decision  —  but his professional mandate was still to recommend the 0–3–7–14–28 WHO schedule, and that he could not guarantee that i’d be able to take the next shot elsewhere. I don’t think he ever looked at my wound, though i had told him it had been a superficial one on my left calf. He never mentioned the rabies immunoglobin.

With another nine days to decide whether or not to start taking the shots, i decided to sleep on it one more night. Next day, my last day in Lithuania, i figured that consulting with another specialist on my way to Kaliningrad wouldn’t hurt. I first went to a pharmacist in Vilkaviskis, who then referred me to the town hospital. I explained the situation to them, and it seemed like they were actually interested in whether this transnational rabies vaccination program could be successfully carried out! They finally looked at the wound, gave me the first rabies shot, as much paperwork as it made sense, including marking my international immunization card, and wished me good luck.

After crossing Kaliningrad, i reentered Schengen two days later in Poland, in time for my second shot the next day. Getting it took me almost two whole days though, and proved to be quite a hassle. First of all, not every hospital in Poland has rabies shots, and it seems like most of them don’t even know where you can really get it, or seem willing to make one or two phone calls to help you find out  —  each hospital i visited on my way through Elblag, Gdańsk and Gdynia would refer me to the next one  —  not even the University Center for Maritime and Tropical Medicine in Gdynia had the shots! (Rabies is considered a Neglected Tropical Disease.) It was not until the eighth hospital visit back in Gdánsk that i was finally able to get my second shot.

Would that be easier in Sweden? It wouldn’t have been. Dog-transmitted rabies is nonexistent in Sweden, so not many hospitals in the country have the vaccine either, as i found out after my visit to the first of them in Lenhovda  —  Sandra and Julia were very generous with their time to help me find a hospital further down my route where i’d be able to take that third shot, though i’d definitely not be able to do it on day 7, which was slowly coming to an end. Julia consulted with a specialist on the phone, who said i could wait up to another four days until Monday, which would have in fact been the date of the third shot according to the Swedish schedule. On the one hand, that was good to hear. But this discrepancy led me to take a closer look into the WHO’s recommendations  —  that’s when i found out that previously vaccinated people, no matter how long ago, need only take the two shots on days 0 and 3.

Well, that was my case  —  even though i could not quite document it, i’d been attacked by a dog when i was a teenager back in Brazil, and completed a full post-exposure vaccination program on the occasion. I decided that, if i couldn’t trust that, i might as well not trust the transnational vaccination program i was now undertaking either. But before stopping the vaccines, i still wanted to hear the opinion of a doctor, and even that was very difficult to get in Sweden. At the Medical Center in Eksjö, they were not very friendly, telling me that “it was my decision to come to Sweden with that problem, and that they could not help me there”  —  “are you telling me that it’s not possible to sign me in and put me in line to talk to a doctor?”  —  “we cannot help you here, you need to go to Jönköping, they have the vaccine there”  —  “that’s the point, i might not need the vaccine, that’s why i’d like ask a doctor about” — “we cannot help you here, it was your decision to come to Sweden with this problem, you have to go to Jönköping.” I didn’t want to go through the same hospital-hopping i’d experienced in Poland, so i asked them for that hospital’s number. They didn’t pick it up. Although i’d already tried that before, i figured i’d call 1177 again, the number in Sweden for medical non-emergencies, and express a bit more frustration. I’m really glad Renée was the one who picked it up  —  she kindly and patiently helped me settle the matter. I gave her all the information i had, and she connected me with a specialist who finally confirmed that i didn’t need to continue with the shots afther the first two i’d already taken on days 0 and 3. That was a huge relief.

So, should i take pre-exposure shots?

What are the disadvantages of taking the pre-exposure shots? It costs a lot of time, and probably a fair amount of money  —  i’ve seen figures from $100 to $1000, on the Internet, depending on where you are taking the shots.

On the other hand, not taking the shots can make adequate post-exposure prophylaxis challenging to carry out on the road  —  not to mention the potentially harmful waste of the time of the health care professionals you’re going to need attention from.

I am retrospectively very grateful for that dog bite when i was a teenager, and how it has inadvertently made my present life a lot simpler  —  i was not looking forward to finding out what getting a fourth rabies shot in Sweden and a fifth one in Norway might have looked like. Furthermore, i’m at the mere beginning of my world exploration, which will inevitably take me to areas of greater risk of exposure to rabies in the future  —  the fact that i’ve been vaccinated before gives me the same peace of mind about dealing with potential dog bites as my TBE shots have given me about dealing with ticks.

You may read accounts and thoughts from other long-term/cycle touring travelers and health care specialists here, here, and here.

What would you do?

If you’ve considered this, i’d be very glad to hear your thoughts and experience as well. Please feel especially invited to share your own dog/wild animal/human bite story in the comments below, and how you’ve dealt with it, if you have one.

Acknowledgements

Special thanks to Antanas, the pharmacist i talked to in Vilkaviskis, Lithuania who connected me with their town hospital, Vitalija and Vilija, who helped me with the paperwork at the hospital, the doctor who saw me, the nurse who administered the first shot, and all other anonymous staff involved in the affair. Many thanks to Tomasz, who appeared out of thin air to offer me help as a translator in the Elblag Hospital, and to Simon, the guy who offered to guide me on his bike to four different hospitals in Gdynia, doubling as a translator at each of our stops  —  i cannot possibly imagine what it would have been like to deal with this without their help. I also appreciate the kindness of the doctor and staff at the Pomeranian Center for Infectious Diseases and Tuberculosis in Gdańsk, Poland, where i finally got my second shot. I will thank Sandra and Julia from the Medical Center in Lenhovda, Sweden once again for their time and interest, and Renée from the 1177 service, who helped me bring this to a closure.


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Footnotes

* A few non-vaccinated patients have been known to survive rabies through the Milwalkee protocol. But this expensive treatment has only worked in about 10% of the cases where it was applied, and is certainly not something to rely on — especially for a disease where adequate post-exposure prophylaxis almost never fails.

** By ‘inexpensive,’ i mean, ‘to a typical person with enough resources to be traveling abroad,’ as the $50 or so that adequate post-exposure prophylaxis costs can still be an enormous financial burden to those most in need in poor communities around the world where the disease is still endemic.

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