Rabies in Travelers

Tropical, Travel and Emerging Infections (L Chen, Section Editor)
Part of the following topical collections:
  1. Topical Collection on Tropical, Travel and Emerging Infections


Most cases of rabies in travelers are associated with dog bites and occur in adults who are commonly migrants. The incidence of injuries to travelers caused by potentially rabid animals is approximately 0.4 % per month of stay. Dogs account for 51 % of cases, but nonhuman primates are the leading animals responsible for injuries in travelers returning from Southeast Asia. Travel to Southeast Asia, India and North Africa, young age, and traveling for tourism are risk factors for potential exposure. More than 70 % of travelers are not immunized prior to departing and do not receive adequate care when injured. The intradermal vaccination route has been proven economical, safe and immunogenic in travelers. The immunity provided by the three-dose series is long-lasting and should be considered an investment for future travel. Abbreviated schedules may be used for last-minute travelers.


Rabies Rabies exposure Travel Vaccine 


Papers of particular interest, published recently, have been highlighted as: • Of importance •• Of major importance

  1. 1.
    World Health Organization. Rabies vaccines. WHO Expert Consultation on Rabies. Second report. WHO Technical Report Series. Geneva: World Health Organization; 2013.Google Scholar
  2. 2.
    Wunner WH, Briggs DJ. Rabies in the 21 century. PLoS Negl Trop Dis. 2010;4(3):e591.PubMedCentralPubMedCrossRefGoogle Scholar
  3. 3.
    Freedman DO, Weld LH, Kozarsky PE, et al. Spectrum of disease and relation to place of exposure among ill returned travelers. N Engl J Med. 2006;354:119–30.PubMedCrossRefGoogle Scholar
  4. 4.
    Leder K, Torresi J, Libman MD, et al. GeoSentinel surveillance of illness in returned travelers, 2007-2011. Ann Intern Med. 2013;158:456–68.PubMedCrossRefGoogle Scholar
  5. 5.
    Malerczyk C, Detora L, Gniel D. Imported human rabies cases in Europe, the United States, and Japan, 1990 to 2010. J Travel Med. 2011;18:402–7.PubMedCrossRefGoogle Scholar
  6. 6.••
    Carrara P, Parola P, Brouqui P, Gautret P. Imported human rabies cases worldwide, 1990–2012. PLoS Negl Trop Dis. 2013;7:e2209. This paper describes 60 cases of rabies in travelers, highlighting potential problems in the diagnosis and management of patients.PubMedCentralPubMedCrossRefGoogle Scholar
  7. 7.
    International Society for Infectious Diseases. ProMED-mail. Rabies - Taiwan: ex Philippines. Archive Number: 20130515.1715913. Published date: 15 May 2013. http://www.promedmail.org. Accessed 15 Jan 2014
  8. 8.
    International Society for Infectious Diseases. ProMED-mail. Rabies - USA (11): (Texas) ex Guatemala, human. Archive Number: 20130616.1775355. 16 Jun 2013. http://www.promedmail.org. Accessed 15 Jan 2014
  9. 9.
    International Society for Infectious Diseases. ProMED-mail. Rabies - Netherlands: ex Haiti, canine, human. Archive Number: 20130625.1791201. 25 Jun 2013. http://www.promedmail.org. Accessed 15 Jan 2014
  10. 10.
    Dacheux L, Wacharapluesadee S, Hemachudha T, et al. More accurate insight into the incidence of human rabies in developing countries through validated laboratory techniques. PLoS Negl Trop Dis. 2010;4:e765.PubMedCentralPubMedCrossRefGoogle Scholar
  11. 11.
    Rossi IA, Genton B. The reliability of pre-travel history to decide on appropriate counseling and vaccinations: a prospective study. J Travel Med. 2012;19:284–8.PubMedCrossRefGoogle Scholar
  12. 12.
    Lankau EW, Montgomery JM, Tack DM, et al. Exposure of US travelers to rabid zebra, Kenya, 2011. Emerg Infect Dis. 2012;18:1202–4.PubMedCentralPubMedCrossRefGoogle Scholar
  13. 13.••
    Gautret P, Parola P. Rabies vaccination for international travelers. Vaccine. 2012;30:126–33. This paper present a meta-analysis of more than 1 270 000 travelers injured by potentially rabid-animals.Google Scholar
  14. 14.
    Gautret P, Schwartz E, Shaw M, et al. Animal-associated injuries and related diseases among returned travellers: a review of the GeoSentinel Surveillance Network. Vaccine. 2007;25:2656–63.PubMedCrossRefGoogle Scholar
  15. 15.
    Gautret P, Shaw M, Gazin P, et al. Rabies postexposure prophylaxis in returned injured travelers from France, Australia, and New Zealand: a retrospective study. J Travel Med. 2008;15:25–30.PubMedCrossRefGoogle Scholar
  16. 16.
    Gautret P, Lim PL, Shaw M, Leder K. Rabies post-exposure prophylaxis in travellers returning from Bali, Indonesia, November 2008 to March 2010. Clin Microbiol Infect. 2011;17:445–7.PubMedCrossRefGoogle Scholar
  17. 17.
    Mills DJ, Lau CL, Weinstein P. Animal bites and rabies exposure in Australian travellers. Med J Aust. 2011;195:673–5.PubMedCrossRefGoogle Scholar
  18. 18.
    Carroll HJ, McCall BJ, Christiansen JC. Surveillance of potential rabies exposure in Australian travellers returning to South East Queensland. Commun Dis Intell Q Rep. 2012;36:E186–7.PubMedGoogle Scholar
  19. 19.
    Gautret P, Adehossi E, Soula G, et al. Rabies exposure in international travelers: do we miss the target? Int J Infect Dis. 2010;14:e243–6.PubMedCrossRefGoogle Scholar
  20. 20.
    Boggild AK, Costiniuk C, Kain KC, Pandey P. Environmental hazards in Nepal: altitude illness, environmental exposures, injuries, and bites in travelers and expatriates. J Travel Med. 2007;14:361–8.PubMedCrossRefGoogle Scholar
  21. 21.
    Pandey P, Shlim DR, Cave W, Springer MF. Risk of possible exposure to rabies among tourists and foreign residents in Nepal. J Travel Med. 2002;9:127–31.PubMedCrossRefGoogle Scholar
  22. 22.
    Menachem M, Grupper M, Paz A, Potasman I. Assessment of rabies exposure risk among Israeli travelers. Travel Med Infect Dis. 2008;6:12–6.PubMedCrossRefGoogle Scholar
  23. 23.
    Piyaphanee W, Shantavasinkul P, Phumratanaprapin W, et al. Rabies exposure risk among foreign backpackers in Southeast Asia. Am J Trop Med Hyg. 2010;82:1168–71.PubMedCentralPubMedCrossRefGoogle Scholar
  24. 24.
    Piyaphanee W, Kittitrakul C, Lawpoolsri S, et al. Risk of potentially rabid animal exposure among foreign travelers in Southeast Asia. PLoS Negl Trop Dis. 2012;6:e1852.PubMedCentralPubMedCrossRefGoogle Scholar
  25. 25.
    Meslin FX. Rabies as a traveler's risk, especially in high-endemicity areas. J Travel Med. 2005;12 Suppl 1:S30–40.PubMedGoogle Scholar
  26. 26.
    Blanton JD, Rupprecht CE. Travel vaccination for rabies. Expert Rev Vaccines. 2008;7:613–20.PubMedCrossRefGoogle Scholar
  27. 27.
    Altmann M, Parola P, Delmont J, Brouqui P, Gautret P. Knowledge, attitudes, and practices of French travelers from Marseille regarding rabies risk and prevention. J Travel Med. 2009;16:107–11.PubMedCrossRefGoogle Scholar
  28. 28.
    Gautret P, Tantawichien T, Vu Hai V, Piyaphanee W. Determinants of pre-exposure rabies vaccination among foreign backpackers in Bangkok, Thailand. Vaccine. 2011;29:3931–4.PubMedCrossRefGoogle Scholar
  29. 29.
    Gautret P, Parola P. Rabies pretravel vaccination. Curr Opin Infect Dis. 2012;25:500–6.PubMedCrossRefGoogle Scholar
  30. 30.
    Shaw MT, O'Brien B, Leggat PA. Rabies postexposure management of travelers presenting to travel health clinics in Auckland and Hamilton, New Zealand. J Travel Med. 2009;16:13–7.PubMedCrossRefGoogle Scholar
  31. 31.
    Wijaya L, Ford L, Lalloo D. Rabies postexposure prophylaxis in a UK travel clinic: ten years' experience. J Travel Med. 2011;18:257–61.PubMedCrossRefGoogle Scholar
  32. 32.
    Sibunruang S, Tepsumethanon S, Raksakhet N, Tantawichien T. Rabies immunization of travelers in a canine rabies endemic area. J Travel Med. 2013;20:159–64.PubMedCrossRefGoogle Scholar
  33. 33.
    Hemachudha T, Ugolini G, Wacharapluesadee S, et al. Human rabies: neuropathogenesis, diagnosis, and management. Lancet Neurol. 2013;12:498–513.PubMedCrossRefGoogle Scholar
  34. 34.
    Jentes ES, Blanton JD, Johnson KJ, et al. The global availability of rabies immune globulin and rabies vaccine in clinics providing direct care to travelers. J Travel Med. 2013;20:148–58.PubMedCrossRefGoogle Scholar
  35. 35.••
    Warrell MJ. Current rabies vaccines and prophylaxis schedules: preventing rabies before and after exposure. Travel Med Infect Dis. 2012;10:1–15. This paper review the existing data about intradermal vaccination against rabies.Google Scholar
  36. 36.
    Gherardin AW, Scrimgeour DJ, Lau SC, et al. Early rabies antibody response to intramuscular booster in previously intradermally immunized travelers using human diploid cell rabies vaccine. J Travel Med. 2001;8:122–6.PubMedCrossRefGoogle Scholar
  37. 37.
    Lau C, Sisson J. The effectiveness of intradermal pre-exposure rabies vaccination in an Australian travel medicine clinic. J Travel Med. 2002;9:285–8.PubMedCrossRefGoogle Scholar
  38. 38.
    Roukens AH, Vossen AC, van Dissel JT, Visser LG. Reduced dose pre-exposure primary and booster intradermal rabies vaccination with a purified chick embryo cell vaccine (PCECV) is immunogenic and safe in adults. Vaccine. 2008;26:3438–42.PubMedCrossRefGoogle Scholar
  39. 39.
    Shaw MM, Leggat PA, Williams ML. Intradermal pre-exposure rabies immunisation in New Zealand. Travel Med Infect Dis. 2006;4:29–33.PubMedCrossRefGoogle Scholar
  40. 40.
    Lau CL, Hohl N. Immunogenicity of a modified intradermal pre-exposure rabies vaccination schedule using a purified chick embryo cell vaccine: an observational study. Travel Med Infect Dis. 2013;11:427–30.PubMedCrossRefGoogle Scholar
  41. 41.
    Mills DJ, Lau CL, Fearnley EJ, Weinstein P. The immunogenicity of a modified intradermal pre-exposure rabies vaccination schedule – a case series of 420 travelers. J Travel Med. 2011;18:327–32.PubMedCrossRefGoogle Scholar
  42. 42.
    Suwansrinon K, Wilde H, Benjavongkulchai M, et al. Survival of neutralizing antibody in previously rabies vaccinated subjects: a prospective study showing long lasting immunity. Vaccine. 2006;24:3878–80.PubMedCrossRefGoogle Scholar
  43. 43.
    Brown D, Featherstone JJ, Fooks AR, et al. Intradermal pre-exposure rabies vaccine elicits long lasting immunity. Vaccine. 2008;26:3909–12.PubMedCrossRefGoogle Scholar
  44. 44.
    Fayaz A, Simani S, Janani A, et al. Antibody persistence, 32 years after post-exposure prophylaxis with human diploid cell rabies vaccine (HDCV). Vaccine. 2011;29:3742–5.PubMedCrossRefGoogle Scholar
  45. 45.
    Strady A, Lang J, Lienard M, et al. Antibody persistence following preexposure regimens of cell-culture rabies vaccines: 10-year follow-up and proposal for a new booster policy. J Infect Dis. 1998;177:1290–5.PubMedCrossRefGoogle Scholar
  46. 46.
    World Health Organization. The immunological basis for immunization series, module 17: Rabies. Geneva: World Health Organization; 2011.Google Scholar
  47. 47.•
    Leder K, Chen LH, Wilson ME. Aggregate travel vs. single trip assessment: arguments for cumulative risk analysis. Vaccine. 2012;30:2600–4. This paper highlights the interest of rabies vaccination in travelers who visit rabies endemic countries frequently, given its long-term efficacy.Google Scholar
  48. 48.••
    Wieten RW, Leenstra T, van Thiel PP, et al. Rabies vaccinations: are abbreviated intradermal schedules the future? Clin Infect Dis. 2013;56:414–9. This paper reviews the published literature about abbreviated schedules for rabies pre-exposure vaccination.Google Scholar
  49. 49.
    Khawplod P, Wilde H, Benjavongkulchai M, et al. Immunogenicity study of abbreviated rabies preexposure vaccination schedules. J Travel Med. 2007;14:173–6.PubMedCrossRefGoogle Scholar
  50. 50.
    Khawplod P, Jaijaroensup W, Sawangvaree A, et al. One clinic visit for pre-exposure rabies vaccination (a preliminary one year study). Vaccine. 2012;30:2918–20.PubMedCrossRefGoogle Scholar
  51. 51.
    Lembo T, Attlan M, Bourhy H, et al. Renewed global partnerships and redesigned roadmaps for rabies prevention and control. Vet Med Int. 2011;2011:923149.PubMedCentralPubMedCrossRefGoogle Scholar
  52. 52.
    Lankau EW, Cohen NJ, Jentes ES, et al. Prevention and control of rabies in an age of global travel: a review of travel- and trade-associated rabies events – United States, 1986-2012. Zoonoses Public Health. 2013. doi:10.1111/zph.12071.PubMedGoogle Scholar

Copyright information

© Springer Science+Business Media New York 2014

Authors and Affiliations

  1. 1.Aix Marseille Université, Unité de Recherche sur les Maladies Infectieuses et Tropicales Emergentes (URMITE)UM63, CNRS 7278, IRD 198MarseilleFrance
  2. 2.Institut Hospitalo-Universitaire Méditerranée Infection, Pole Maladies InfectieusesAssistance Publique Hôpitaux de MarseilleMarseilleFrance
  3. 3.Aix Marseille UniversitéURMITEMarseilleFrance

Personalised recommendations