Source: Health Canada" />

Source: Health Canada

Know before you go!
Infectious diseases not necessarily common in Canada can occur and may even be widespread in other countries. Standards of hygiene and medical care may differ from those at home. Before departure, you should learn about the health conditions in the country or countries you plan to visit, your own risk of disease and the steps you can take to prevent illness.

The risk is yours
Your risk of acquiring a disease depends on several factors. They include: your age, gender, immunization status and current state of health; your itinerary, duration and style of travel (e.g., first class, adventure) and anticipated travel activities (e.g., animal contact, exposure to fresh water, sexual contact); as well as the local disease situation.

Risk assessment consultation
Health Canada strongly recommends that your travel plans include contacting a travel medicine clinic or physician 6 to 8 weeks before departure. Based on your individual risk assessment, a health care professional can determine your need for immunizations and/or preventive medication (prophylaxis) and advise you on precautions to avoid disease. We can help you locate a travel medicine clinic closest to your home.

Some facts from the experts
The information below has been developed and is updated in consultation with Health Canada's Committee to Advise on Tropical Medicine and Travel (CATMAT). The recommendations are intended as general advice about the prevention of rabies for Canadians travelling internationally.

Disease profile
Rabies is a viral infection of animals that can be transmitted to humans. It is caused by a virus of the Rhabdoviridae family, which attacks the central nervous system and eventually affects the brain. The virus is usually found in the saliva of an infected animal. Rabies is almost always fatal once symptoms occur.

Transmission
Rabies can occur in any warm-blooded animal, domestic and wild. Commonly, rabies has been transmitted to humans from dogs, cats, foxes, raccoons, skunks, monkeys, wolves and bats. As well, animals having potential interactions with people such as cattle, horses and deer can acquire rabies and may transmit the disease to humans.

The virus is transmitted through close contact with the saliva of infected animals, most often by a bite or scratch or by licks on broken skin or mucous membranes, such as the eyes, nose or mouth. In very rare cases, person-to-person transmission has occurred when saliva droplets were dispersed in the air.

Injury to the upper body or face poses the greatest risk of transmission. The risk of children is estimated to be four times greater than adults, and boys are at greater risk than girls.

Geographic distribution and incidence trends
The World Health Organization (WHO) reports that more deaths occur worldwide from rabies than from other common infections such as dengue fever, polio, meningococcal meningitis or Japanese encephalitis. Of the 50,000 human rabies deaths reported annually, it is estimated that over 30,000 deaths occur in the Indian Sub-Continent with most of the remaining cases occurring in South-East Asia (particularly, the Philippines), Africa and Latin America.

In most countries of Africa, Asia and Latin America, infected dogs are responsible for most of the rabies deaths. India has a dog population of 50 million. Thailand has 10 million dogs for its population of 58 million. In Bangkok it is estimated that one in 10 stray dogs is infected.

In developed countries, rabies is found mainly in wild animals, from which infection can spread to domestic animals and humans. In Canada, the incidence of human rabies has substantially decreased, which is associated with the increase of rabies vaccination in domestic animals. However, rabies among wildlife - especially bats, raccoons and skunks - has become more prevalent in North America.

Although rabies is rare in international travellers overall, a significant proportion of deaths caused by rabies is reported among people in the developed world who acquired the disease while travelling. Over a period of 17 years, 33% of rabies cases reported in the United States acquired their infection in other countries. The UK reported 12 cases of rabies over 20 years, 10 of which came from the Indian Sub-Continent. In France, 18 of the 19 cases of rabies reported over a 20-year period were acquired abroad, the vast majority in Africa. There has been one Canadian case of rabies acquired abroad in the seven decades since statistics have been kept.

Symptoms
The time from exposure to first symptoms (i.e., incubation period) for rabies varies. It can be as short as 5 days, or as long as several years, usually taking 20 to 60 days. The first symptoms are usually non-specific, flu-like symptoms - fever, tiredness, headache that may last for a few days. In the acute stage, which quickly follows, an individual exhibits anxiety, confusion, insomnia, agitation, hallucinations and hyperactivity (furious rabies) or paralysis (dumb rabies). The acute period usually ends after 2 to 10 days. In both furious and dumb rabies, a complete paralysis develops, followed by coma. Death occurs during the first 7 days of illness without intensive care.

Testing and Treatment
It is very important to act quickly if an individual thinks he/she may have been exposed to rabies. Treatment for rabies is effective, but only if an individual begins treatment early.

Immediately following an exposure to a suspected rabies carrier through a bite, scratch or lick, an individual should:

• vigorously wash and flush the wound or point of contact with soap and water and apply alcohol or iodine, if available
• seek medical attention for post-exposure vaccination and, if necessary, wound care.
  
  

Vaccines
One vaccine against rabies is licensed for use in Canada. The vaccine is very effective, causes few adverse reactions, and is fairly expensive. The vaccine provides immunity to rabies when administered for protection before an exposure (pre-exposure prophylaxis) or after an exposure (post-exposure prophylaxis).

1- Vaccination before travel
Pre-exposure vaccination includes three doses given over 1 month. If an individual is subsequently exposed to rabies, two further doses will be needed.

Determining the need for pre-travel vaccination is complex: a personal risk assessment prior to travel will weigh an individual's risk of exposure with other factors such as itinerary, planned activities, rabies occurrence in countries to be visited, availability of vaccine in country of travel and the cost of the vaccine. Pre-exposure rabies vaccination is not usually recommended for the general traveller. It may be considered for those with the greatest risk of animal exposure, such as:

• veterinarians,
• farm workers,
• spelunkers (cave explorers),
• young children who may not understand the need to stay away from animals or to report any bite,
• travellers in areas of high rabies activity where there is limited access to post-exposure prophylaxis.
  
  

2- Vaccination following an exposure
If an individual was not vaccinated before travel with three doses, a full course of five vaccine doses, plus one dose of the rabies immunoglobulin (RIG) are needed following exposure. Both the vaccine and RIG can be hard to obtain in some developing countries.

Once a post-exposure vaccine series has been started, the traveller should obtain as much information about the vaccine used as possible (e.g., manufacturer, type of doses, vaccination schedule used), so that treatment may continue without delay on his/her return to Canada. This information is important; without it, the traveller may have to restart the complete series, as partial vaccination may not prevent a fatal case of rabies.

Prevention and personal precautions
Taking personal precautions to avoid close contact with animals is the best means of preventing exposure to the rabies virus. As well, rabies is a vaccine-preventable disease.

Recommendations
Health Canada strongly recommends all travellers obtain an individual risk assessment from a physician or travel medicine clinic before departure to determine their particular risk for rabies exposure. The need for vaccination is difficult to assess. A thorough risk assessment takes into consideration a traveller's proposed activities and itinerary, the cost of the vaccine and the availability of the vaccine while travelling.

Health Canada further recommends that travellers take personal precautions to avoid rabies exposure by:

• avoiding direct contact with unfamiliar wild or domestic animals, especially dogs in developing countries;
• not handling, feeding, or unintentionally attracting wild animals with open garbage cans or litter;
• instructing children to avoid unfamiliar wild or domestic animals, even if they appear friendly;
• preventing bats from entering living quarters.
  
  

If exposed to a potentially rabid animal:

• wash the area or wound thoroughly with soap and water, and
• seek medical attention immediately.
  
  

Domestic pets may be a risk for rabies exposure. If travelling with a pet:

• keep pets' rabies vaccinations up-to-date;
• keep pets under tight control to avoid contact with wild and/or other animals.
  
  

If travellers encounter any difficulty in obtaining a post-exposure vaccine, they should contact the nearest Canadian embassy or consulate.

Some things to think about...
Given the unpredictable nature of a potential rabies exposure, consider all stray animals to be infected with rabies and avoid contact. As well, be aware that should contact occur, treatment for rabies exposure is not available everywhere.

For more information...

• For more Know before you go! information, click here.

• For world rabies trends information provided by the WHO, go to CCDR Canada Communicable Disease Report - Volume 26-02, 15 January 2000: Click here
  
  
• Communicable Disease Surveillance and Response Division of the WHO offers more info on post-exposure treatment and surveillance of rabies worldwide at: Click here
  
  
• To see a listing of the most current global incidence rates for rabies, go to the Table by WHO CSR's World Survey of Rabies for the year 1997 at: Click here

Sources: Division of Quarantine of the Centers for Disease Control and Prevention; World Health Organization