Should travellers to rabies-endemic countries be pre-exposure vaccinated? An assessment of post-exposure prophylaxis and pre-exposure prophylaxis given to Danes travelling to rabies-endemic countries 2000-12

The occurrence and extent of anxiety and distress among Dutch travellers after encountering an animal associated injury

BACKGROUND

Prompt administration of post-exposure prophylaxis (PEP) is crucial to prevent a fatal rabies infection after an animal associated injury (AAI), preferably within 24 h. PEP, especially in case of a type III injury for which rabies immune globulin (RIG) is needed, is difficult to obtain abroad. This, along with the fear of potentially having contracted a lethal disease, might be an important source for anxiety and distress. We investigated the occurrence and extent of self-reported anxiety and distress at different timepoints among Dutch travellers after encountering an AAI, and the involved factors.

METHODS

A retrospective quantitative observational study was conducted including insured Dutch travellers who actively contacted Eurocross Assistance after encountering an AAI abroad. An online questionnaire was designed to measure anxiety and distress levels, using the HADS (Hospital Anxiety and Depression Scale) and distress thermometer at three time points: departure from home (T1), post-AAI (T2), and treatment administration (T3). Statistical analyses included T-tests, Chi-square tests, and ANCOVA analyses.

RESULTS

We showed a significant increase in mean anxiety and distress scores at T2, and a significant decrease at T3. Women were more often anxious and distressed. Between T1 and T2, PrEP, and being aware of the risks were positively associated with anxiety levels, and PrEP and WHO region Africa with distress levels. Between T2 and T3, anxiety levels remained higher for monkey-induced injury, thoracic injuries, and WHO region Southeast Asia. PEP-delay between 24-48 h resulted in decreased distress levels at this time period, while type II injury elevated distress levels.

CONCLUSIONS

This study showed significant anxiety and distress levels after an AAI among the vast majority of travellers, which is detrimental to their health-related quality of life (HR-QOL). This highlights the importance of proper pre-travel information. In the context of rabies prevention, these results suggest that pre-travel advice and policy makers should also take aspects of HR-QOL into consideration.

Infectious diseases and predominant travel-related syndromes among long-term expatriates living in low-and middle- income countries: a scoping review

Introduction

Expatriates working in low-and middle-income countries have unique health problems. Migration leads not only to an increase in individual health risk but also a risk of global impact, such as pandemics. Expatriates with no prior experience living in tropical settings have expressed greatest concern about infectious diseases and appropriate peri-travel consultation is essential to expatriates. The objective of this review is to describe infections and travel-related syndromes among expatriates living in low-and middle-income countries.

Methods

MEDLINE database since the year 2000 was searched for relevant literature. Search terms were “long-term travel”, “expatriate”, and “health problems”. The additional references were obtained from hand-searching of selected articles.

Results

Up to 80% of expatriates suffered from gastrointestinal problems followed by dermatologic problems (up to 40%), and febrile systemic infection/vector-borne/parasitic infection (up to 34%) Expatriates living in Southeast Asia were at risk of vector-borne diseases including dengue and non-Plasmodium falciparum (pf) malaria while expatriates living in South Asia had a high prevalence of acute and chronic diarrhea. Staying long-term in Africa was related to an elevated risk for pf malaria and gastrointestinal infection. In Latin America, dermatologic problems were commonly reported illnesses among expatriates.

Conclusion

Certain health risks for expatriates who are going to depart to specific regions should be the focus of pre-travel consultation. Specific health preparations may reduce the risk of disease throughout their time abroad. Disease and symptom awareness is essential for screening, early diagnosis, and better health outcomes for ill-expatriates.

Rabies risk behaviour in a cohort of Dutch travel clinic visitors: A retrospective analysis

BACKGROUND

Travellers to rabies endemic countries should be counselled on rabies risk and, in case of high-risk, pre-exposure vaccination is advised. However, it is not clear which travellers exactly are at high risk. In this study we determined the incidence of possible rabies exposure in travel clinic visitors and compliance with pre-travel advice.

METHODS

Travellers to rabies endemic countries who visited a Dutch travel clinic between September 2017 and May 2018, were invited to participate.

RESULTS

Of 980 travellers, one percent was injured by a potentially rabid animal. Compliance with advice was low as 59% reported proximity to a potentially rabid animal and only half of those exposed sought medical advice. The most important predictors of proximity to a potentially rabid animal were young age, long travel duration, visiting a monkey forest and hiking for more than one day. Travel for business was associated with lower risk.

CONCLUSION

Despite pre-travel advice, rabies risk behaviour was high. Therefore, we would recommend to keep the threshold for pre-travel vaccination low. Pending more data on rabies exposure risk, the identified predictors of proximity to potentially rabid animals could be used to tailor indications for pre-travel rabies vaccination.

Delayed rabies post-exposure prophylaxis treatment among Dutch travellers during their stay abroad: a comprehensive analysis

BACKGROUND

After an animal-associated injury (AAI) in rabies-endemic regions, post-exposure prophylaxis (PEP) is needed to prevent infection.1,2 PEP consists of rabies vaccinations (RV) and in some cases also additional rabies immune globulins (RIG). Not always PEP medication, and RIG in particular, is accessible. Along with an increased number of exposure notifications among Dutch travellers, this might lead to treatment delay and thus to increased health risks. Until now, research mainly focused on factors associated with exposition, but none on which factors are associated with PEP delay. This study aimed to identify which general sample characteristics are associated with PEP delay while being abroad.

METHODS

A quantitative retrospective observational study was conducted. The study population consisted of insured Dutch international travellers who actively contacted their medical assistance company (2015-2019) because of an animal-associated injury (AAI) (N = 691). The association between general sample characteristics and delay of different PEP treatments was studied using survival analysis.

RESULTS

Travellers without pre-exposure prophylaxis (PrEP) had an increased hazard, and therefore a shorter delay, for receiving their first RV as compared to travellers with PrEP (HR:1.11, 95%CI:1.01-1.22). The travellers needing both RV and RIG had a decreased hazard, and therefore a longer delay, as compared to travellers only needing RV (HR:0.81, 95%CI:0.67-0.96). General sample characteristic associated with RIG administration delay was travel destination. Travellers to Central and South America, East Mediterranean and Europe had a decreased hazard, and therefore a longer delay, for receiving RIG treatments relative to travellers to South East Asia (HR:0.31, 95%CI:0.13-0.70; HR:0.34, 95%CI:0.19-0.61; HR:0.46, 95%CI:0.24-0.89; HR:0.48, 95%CI:0.12-0.81, respectively).

CONCLUSIONS

Our results suggest that the advice for PrEP should be given based on travel destination, as this was found to be the main factor for PEP delay, among travellers going to rabies-endemic countries.

Preventable public health challenge: Rabies suspected exposure and prophylaxis practices in southwestern of Turkey

BACKGROUND

Rabies is found in many countries of the eastern Mediterranean and is one of the most important zoonotic diseases in the world. The study aims to describe rabies suspected exposures (RSE) and rabies prophylaxis practices in Antalya-Turkey between 2010 and 2013.

METHODS

All 2513 RSE cases presenting to a rabies vaccination center in Antalya, southwestern Turkey, were retrospectively investigated.

RESULTS

The mean age of the RSE cases was 30.04±19.63 years with male predominance (63.6%). The vast majority was from urban areas (91.7%), and a postexposure rabies vaccination program was applied to 79.7% of participants. Dogs were the primary source of RSE cases (61.2%). The 39.2% of animals were under observation, and 9.53% of them died. Forty-two animals (1.7%) were laboratory confirmed rabid; 61.9% of them were cows. The rabid animal rate in the rural area was significantly higher than the urban area (18.2% versus 0.2%; p=0.001).

CONCLUSIONS

This study includes a large number of RSE cases and prophylaxis practices in southwestern Turkey. Most RSE cases had dog or cat contact. As most RSE cases were in urban areas; more focused efforts should be made for elimination and vaccination of feral dog and cat population in Turkey.

A risk scoring system to identify travellers who qualify for pre-exposure rabies vaccination

We want to introduce a free online scoring system to identify high risk travellers who qualify for pre-travel rabies vaccination. The system uses evidence based risk predictors and the probable availability of HRIG at the destination.

Rabies exposure in travellers to Asia, the Middle East, Africa, South and Central America-a German Airport study

BACKGROUND

Rabies causes thousands of deaths worldwide and trips to rabies endemic countries are popular. Travellers are often uncertain whether pre-exposure prophylaxis (PrEP) is advisable since they find it difficult to estimate the exposure risk during travel and the availability of post-exposure prophylaxis in endemic regions. The aim of this study was to determine the potential rabies exposures in travellers and to assess their knowledge on rabies. Secondly, we explored the access to appropriate post-exposure medical care in respective countries.

METHODS

We conducted a cross-sectional study at Frankfurt Airport. Returning adult travellers arriving from Asia, the Middle East, Africa, South and Central America were invited to participate in this questionnaire-based study while waiting in the baggage claim area.

RESULTS

Over a one-month recruitment phase in March 2019, we enrolled 3066 travellers; 2929 were included in the analysis. The gender ratio was balanced; the median age was 42 years (range 18-83 years). Participants arrived from Asia (46%), Africa (29%), Central/South America (13%), the Middle East (8%) and the Caribbean (8%). Forty-five per cent sought pretravel advice and 22% received ≥2 injections of rabies PrEP. Travellers with pretravel advice from tropical medicine specialists reached significantly higher knowledge scores than others. We found that potential rabies exposure occurred in 2.0% (57/2915) of travellers with 31% (13/42) of the contacts being unprovoked; 19% (8/42) of the exposed sought medical care and 3/8 were adequately treated before returning to Germany. Risk factors for animal exposure were: male sex, young age, trips to Asia and a long stay abroad (>4 weeks).

CONCLUSIONS

A total of 2% of returning travellers (n = 2915) experienced a potential rabies exposure during their journey. A majority of the exposed individuals did not seek medical care; those seeking medical care were often treated inadequately. Rabies information must be emphasised during pretravel counselling and PrEP should be offered generously, especially to travellers with high exposure risks.

Vaccines for International Travel

The pretravel management of the international traveler should be based on risk management principles. Prevention strategies and medical interventions should be based on the itinerary, preexisting health factors, and behaviors that are unique to the traveler. A structured approach to the patient interaction provides a general framework for an efficient consultation. Vaccine-preventable diseases play an important role in travel-related illnesses, and their impact is not restricted to exotic diseases in developing countries. Therefore, an immunization encounter before travel is an ideal time to update all age-appropriate immunizations as well as providing protection against diseases that pose additional risk to travelers that may be delineated by their destinations or activities. This review focuses on indications for each travel-related vaccine together with a structured synthesis and graphics that show the geographic distribution of major travel-related diseases and highlight particularly high-risk destinations and behaviors. Dosing, route of administration, need for boosters, and possible accelerated regimens for vaccines administered prior to travel are presented. Different underlying illnesses and medications produce different levels of immunocompromise, and there is much unknown in this discipline. Recommendations regarding vaccination of immunocompromised travelers have less of an evidence base than for other categories of travelers. The review presents a structured synthesis of issues pertinent to considerations for 5 special populations of traveler: child traveler, pregnant traveler, severely immunocompromised traveler, HIV-infected traveler, and traveler with other chronic underlying disease including asplenia, diabetes, and chronic liver disease.

Perceptions of rabies risk: a survey of travellers and travel clinics from Canada, Germany, Sweden and the UK

BACKGROUND

Extensive global experience shows that rabies pre-exposure prophylaxis (PrEP) through vaccination is effective and well tolerated, yet many travellers opt not to be vaccinated when travelling to rabies-endemic countries. Previous research has identified several factors influencing the choices travellers make to reduce the risk of rabies, including cost, time constraint and perspective on the importance of vaccination. The objectives of this study were to assess travellers' awareness of rabies and advice-seeking attitudes and to evaluate travel clinics practices regarding rabies pre-travel advice.

METHODS

We surveyed individuals aged 18-65 years residing in the UK, Germany, Canada and Sweden who had travelled to rabies-endemic countries between 2013 and 2016 and defined this as the rabies visit-risk sample. The first 850 respondents from the visit-risk sample who had undertaken pre-defined at-risk activities (e.g. contact with animals during the trip) completed an additional 15-min online questionnaire and were included in the activity-risk subsample. We also interviewed travel clinic personnel using a 25-min online or phone questionnaire.

RESULTS

The visit-risk sample included 4678 individuals. Many sought pre-travel health information online (33%) or talked to a family doctor (24%). Within the activity-risk subsample, 83% of travellers were aware of at least a few basic facts about rabies, and 84% could identify at least one correct rabies prevention measure; 49% were aware of a rabies vaccine, however, only 8% reported receiving PrEP vaccination within the past 3 years. Among 180 travel clinic respondents, 21% reported recommending PrEP against rabies to all travellers to rabies-endemic countries. Travel clinics estimated that 81% of travellers complete their travel vaccination schedules and reported sending reminders by e-mails (38%), text (38%), phone calls (37%) or by using vaccination cards (37%).

CONCLUSIONS

These findings suggest that although travellers had frequently heard of rabies, awareness of the risks of this serious infectious disease was relatively low. 5975671594001tay062media15975671594001.

Rabies post-exposure prophylaxis started during or after travel: A GeoSentinel analysis

BACKGROUND

Recent studies demonstrate that rabies post-exposure prophylaxis (RPEP) in international travelers is suboptimal, with only 5-20% of travelers receiving rabies immune globulin (RIG) in the country of exposure when indicated. We hypothesized that travelers may not be receiving RIG appropriately, and practices may vary between countries. We aim to describe the characteristics of travelers who received RIG and/or RPEP during travel.

METHODOLOGY/PRINCIPAL FINDINGS

We conducted a multi-center review of international travelers exposed to potentially rabid animals, collecting information on RPEP administration. Travelers who started RPEP before (Group A) and at (Group B) presentation to a GeoSentinel clinic during September 2014-July 2017 were included. We included 920 travelers who started RPEP. About two-thirds of Group A travelers with an indication for rabies immunoglobulin (RIG) did not receive it. Travelers exposed in Indonesia were less likely to receive RIG in the country of exposure (relative risk: 0.30; 95% confidence interval: 0.12-0.73; P = 0.01). Travelers exposed in Thailand [Relative risk (RR) 1.38, 95% Confidence Interval (95% CI): 1.0-1.8; P = 0.02], Sri Lanka (RR 3.99, 95% CI: 3.99-11.9; P = 0.013), and the Philippines (RR 19.95, 95% CI: 2.5-157.2; P = 0.01), were more likely to receive RIG in the country of exposure.

CONCLUSIONS/SIGNIFICANCE

This analysis highlights gaps in early delivery of RIG to travelers and identifies specific countries where travelers may be more or less likely to receive RIG. More detailed country-level information helps inform risk education of international travelers regarding appropriate rabies prevention.

Intradermal pre-exposure rabies vaccination in a Canadian travel clinic: 6-year retrospective observational study

BACKGROUND

The intradermal route of vaccine administration for pre-exposure rabies prophylaxis, endorsed by the Canadian National Advisory Committee on Immunization, was implemented at a large travel clinic in Montréal in 2008. We evaluated the effect of intradermal vaccination availability on uptake of pre-exposure rabies prophylaxis and rates of seroconversion with intradermal vaccination.

METHODS

We conducted a retrospective cross-sectional study using data from December 2008 to December 2014. The number of travellers who received pre-exposure rabies prophylaxis before and after the introduction of intradermal vaccination was compared. Postvaccination antibody titres were measured in intradermal vaccination recipients. We compared demographic and travel characteristics between vaccinated and unvaccinated travellers and between travellers in the intradermal and intramuscular groups using univariate and multivariate analyses.

RESULTS

The proportion of travellers who received pre-exposure prophylaxis increased after the introduction of intradermal vaccination (annual average of 300 travellers from December 2009 to December 2014 v. 183 travellers from December 2006 to December 2007). Seroconversion occurred in 99.9% of those in the intradermal group. Travellers who received pre-exposure prophylaxis were older (mean age 35.8 yr v. 32.1 yr) and had longer travel duration than those who did not receive pre-exposure prophylaxis. Travellers to Asia were more likely to receive pre-exposure prophylaxis, and travellers visiting friends and relatives were less likely to receive it. Travellers in the intradermal group were younger than those in the intramuscular group and were more likely to be travelling for tourism.

INTERPRETATION

The introduction of intradermal vaccination for pre-exposure rabies prophylaxis was associated with an increase in vaccination uptake. Reduced cost may be responsible for the increased coverage among younger travellers and those travelling for tourism. The high seroconversion rate after intradermal vaccination supports the effectiveness of this route of administration for pre-exposure rabies prophylaxis in immunocompetent people.

Emerging Zoonotic and Vector-Borne Viral Diseases

Many vector-borne and zoonotic diseases are considered to be emerging; since they are either newly reported to cause human disease, or are causing disease in geographical locations or species not previously documented. In the past 15 years, significant outbreaks of Severe Acute Respiratory Syndrome (or SARS) and Middle Eastern Respiratory Syndrome (or MERS), Nipah and Hendra, Ebola virus disease and Zika fever and others have been reported. In this chapter the clinical characteristics, epidemiological aspects, treatment and prevention and information related to the laboratory investigation of important zoonotic and vector-borne diseases that have emerged in the past 10 years, and how this affects children, will be discussed. Furthermore rabies, considered a neglected viral disease with the majority of victims in Africa being children, will also be addressed.