Latest version (26/06/2017 – Patrick Soentjens)

RABIES

General information

Rabies distribution map - WHO disease distribution maps

The rabies virus causes a severe, acute inflammation of the brain. It can give rise in animals to a “raging” form, in which frenzy is prominent, but it can also lead to a paralytic form in which the affected animal appears weak, paralysed and pathetic. Stroking 'tame' animals in the wild (including temple monkeys and foxes) is strongly discouraged.

In developing countries the disease is usually transmitted to humans by (stray) dogs, but also by cats, monkeys and bats. Transmission by many other mammalian species is, however, also possible. Rabies is a major problem in many developing countries. Once symptoms of the disease have appeared, the outcome is fatal in all cases. There is no treatment or cure.

When abroad, do not stroke (tame) wild animals, stray animals and pets you do not know. You should never touch dead animals. Keep a special eye on children.

Every traveller should be aware of the serious risks involved and know what to do in the event of an animal bite. The risks are low for ordinary tourists, however, and preventive vaccination is not recommended.

Vaccination

The current vaccine (based on human cells or cell culture [e.g. Vero cells) is safe and no longer has the dangerous side effects of earlier vaccines (based on sheep or goat brains). It is used for both preventive vaccination and for vaccination after exposure (post-exposure prophylaxis or PEP). Preventive vaccination offers partial protection by priming the immune system and making it 'boostable', but revaccination is required after any bite. The number of injections required in the case of preventive vaccination is lower than it would be without pre-vaccination, and rabies-specific immunoglobulins (RIG) are not necessary in this case. The vaccine is injected into the upper arm muscle.

Preventive vaccination (pre-exposure prophylaxis - PreP)

Vaccination plan: 3 inoculations on day 0, 7, 21 or 28.

After receiving the full basic vaccination as a health precaution for travel abroad, there is no need for further booster injections for tourists or expats. An antibody production test is only required in people with reduced immunity or on immunosuppressants. It can be performed by the Department of Contagious and Communicable Diseases, Wetenschappelijk Instituut voor Volksgezondheid (WIV/IPV, Belgian Scientific Institute of Public Health), from 10 days after the third injection (ideally after 4 to 6 weeks).

Other guidelines under occupational health regulations apply to persons at increased risk of exposure because of the nature of their work (e.g. vets, bat researchers).

The rabies vaccine is readily available at pharmacies with a prescription from any doctor (Rabipur (Novartis Pharma) & HDC Merieux rabies vaccine (Sanofi Pasteur MSD) can be supplied to pharmacies by wholesalers).

What to do following a bite

In the event of being bitten by a potentially infected animal when abroad, it is extremely important to wash the wound immediately with soap and water for 15 minutes (because the virus is very sensitive to cleaning agents), and then to disinfect the wound thoroughly with iodine/isobetadine or 60-80% ethanol. You should consult a doctor at your location as soon as possible with regard to further care and to evaluate the need for vaccination.

A decision will then be taken as to whether or not rabies vaccination (PEP) is required, possibly in combination with specific anti-rabies immunoglobulins (RIG).

The decision on whether or not to vaccinate depends on the following:

  • The country you are in when bitten (or the country the animal originated from in the case of imported animals)
  • The type of wound 
  • The type of animal (bats are always considered high-risk)
  • The patient’s medical history

In case of a possible exposure, wash the wound with soap and water and desinfect it with a povidone iodine solution. Assess the risk category to the patient, establishing the possible need for rabies PEP with or without immunoglobines.

This new procedure is described in detail in the manual available on this website.

Rabies has a high mortality rate. If you suspect infection, we advise you to contact the experts of the Institute of Tropical Medicine for advise on the diagnosis, treatment and follow-up.

  • During working hours, call 03 247 66 66 or 03 247 64 05 or e-mail us.
  • After working hours and during the weekend, contact the emergency ware of the University Hospital Antwerpen (UZA) by calling 03 821 30 00.

Post-exposure prophylaxis (PEP) for unvaccinated patients

  • Scheme with 4 vaccinations on day 0 (administer twice), day 7 and day 21. Check the antibody titre 10 days after completing the scheme (day 31).
  • Scheme with 5 vaccinations on day 0, 3, 7, 14 and 28 with an antibody titre test 10 days after the end of the vaccination plan (i.e. from day 38). If the antibody titre has risen sufficiently, an additional vaccination is not needed.
  • The scheme with 5 vaccinations is combined with HRIG, "antiserum" 20 IU/kg, in and around the wound. There are vials of 2 ml (300 IU) and 5 ml (750 IU). Administration of these specific immunoglobulins is only useful up to eight days after the start of vaccination.

Post-exposure prophylaxis (PEP) for pre-vaccinated patients

  • 2 vaccinations (each of 1 dose) on day 0 and day 3, no HRIG

It is strongly recommended to start the vaccination treatment as quickly as possible and preferably within 24 hours. In case of a suspect bite, treatment (vaccination and/or immunoglobines) can be however be initiated after returning home because the incubation time is usually quite long. 

The request for a full reimbursement of the immunoglobines and their administration can only be handled by a medical doctor of the Institute of Tropical Medicine. Any travel clinic or treating practitioner can administer the PEP rabies vaccine without immunoglobines. The reimbursement procedure of this vaccine is unchanged.

The operating procedures of the National Reference Centre of the WIV for the analysis of samples of humans (mainly blood and cerebrospinal fluid) or animal (blood or brain) regarding rabies remains unchanged.

The problem in developing countries is that vaccines are sometimes of a lower quality (since they are prepared on the basis of animal brains) and the correct immunoglobulins are not available.

In the event of a suspect bite the traveller may decide to return home at once or to try to obtain the correct vaccine or immoglobulins with the help of the travel insurance company.

The following people should consider a vaccination against rabies before travelling:

  • The classical risk groups, such as veterinary surgeons, hunters, foresters, cattle dealers, agricultural experts, etc., but also archaeologists and speleologists.
  • Tourists undertaking a long cycle trip or who jog very often form a risk group and should always be vaccinated.
  • Individuals travelling to, or intending to live for long periods in remote rural areas in developing countries high-risk areas and who cannot have access within 24 hours to a vaccine (prepared on human cells or Vero cells) and within 48 hours (or at the most up to 8 days, see further) to human or modern purified equine specific antirabies immunoglobulins (RIG), “antiserum”.
  • Parents of children who are going to live in a high-risk area – depending on the local circumstances – must seriously consider having their children preventively vaccinated. Pets or domestic animals must always be vaccinated.

N.B. All illegal import of animals and non-respect of the official vaccination guidelines regarding, implicate a risk of importing rabies in mammals.