When we went to Ubud, Bali, one of the main attractions was seeing the monkeys at the Sacred Monkey Forest. My three year old daughter was thrilled to see them walk around us and eat the food that people brought for them. I remember that our biggest concern was to make sure the monkeys didn’t swipe our hats, drinks, and sunglasses. There were signs everywhere warning people to keep your valuables safe from the monkeys. In fact, I witnessed a monkey take off with an elderly tourist’s eyeglasses and promptly broke them in several pieces. I felt really sorry for this woman since I knew it would be impossible for her to find a replacement for the rest of her trip. We felt lucky to take some good photos of the monkeys, feed them some bananas, and leave with all of our belongings. In retrospect, we were also very lucky not to get scratched or bitten by any monkeys. I learned recently that about 40% of workers at this temple have reported getting bitten by these monkeys.
One of the many informative seminars I attended at a recent travel medicine conference was on the deadly diseases that wild animals can spread to humans. I learned that monkeys, dogs, bats, and other wild animals in developing countries can harbor terrible viruses, like rabies, which is extremely fatal without treatment. Bites from macaques can transmit another deadly virus, called herpesvirus B, which is just as terrible. About 50,000-55,000 people die from rabies worldwide each year. And about half of these deaths are in India alone. Mostly all were bitten by a rabid dog. In the United States, rabies is only a concern with bites from animals such as bats, skunks, foxes, coyotes, and raccoons. Dog and cat bites in the U.S. almost never carry rabies. I consider this yet another huge success story of vaccinations, this time in pets.
Children under age 5 are particularly high risk for animal bites since they are smaller and usually love animals. Bites to the face and neck, which are higher risk bites, are more common in children. Children may also not tell the parent that a dog scratched or bit them. About 40% of all human rabies occur in kids younger than 14 years of age. Animal bites are the 7th most common health problem in travelers, with children 3-4x higher risk. There is an approximately 1.3% chance of a dog bite in travelers who stay in an endemic country for a month or more.
The full treatment of animal bites to prevent rabies can be difficult to obtain in some developing countries. It is important to wash the wound thoroughly with soap and water and apply a povidone-iodine solution directly to the wound. But more importantly, the post-exposure treatment involves getting human rabies immunoglobulin (HRIG)and starting a series of 4 rabies vaccine shots as soon as possible, preferably within 72 hours, after an animal bite or scratch. Since most rural areas do not carry HRIG, an animal bite or scratch would mean that you would have to scrap your entire trip, go to the nearest hospital or clinic that actually has this life-saving treatment, or go home ASAP! This is an important reason why I recommend all families traveling to developing countries AVOID touching or feeding wild or stray animals, no matter how cute or harmless they look. This is why I will never let my child go near a wild animal again the next time we travel to a developing country.
In the U.S. there is a vaccine against rabies that people can get before the trip to help prevent rabies in case they get an animal bite. The CDC recommends the rabies vaccine for people who will be outdoors a lot like campers or cavers, those who have occupations like veterinarians, long-term travelers (>1 month), and young children get this vaccine series. However, the rabies vaccine series involve 3 separate doses over the course of 21-28 days. The timing of this vaccine series is difficult since most patients are not seeking pre-travel advice until the week or two before their trip. Also, each of these 3 vaccines is extremely expensive, about $200-300 each! In addition, getting this pre-exposure rabies vaccine series does not mean that you don’t need treatment after an animal bite. You won’t need the difficult to find HRIG shot, but you would still need an additional 4th dose of rabies vaccine. Most developing countries have a good supply of rabies vaccine, even rural areas. So getting the 3 rabies vaccines before your trip would not completely ruin your trip, which you probably have waited all year for.
When I discuss the rabies issue with families, it is a difficult decision for families to make. Rabies is a scary and deadly disease. Luckily, travelers rarely come down with rabies (1 study reported 22 cases over 10 years). Perhaps this is because travelers tend to seek medical advice after an animal bite. My recommendation is that if you choose not to get the rabies vaccine series before your trip and you are traveling to a highly endemic area, like Asia or Africa, with a small child, be sure to BUY travel health insurance and medical evacuation insurance. This could save you a tremendous amount of money, time, and worry!