Possible Rabies Exposure

Rabies Exposure

(Since rabies risk depends on location, please check out this page to look up individual countries and you can find a rabies risk world map here)

Risk of Exposure

In Rabies Endemic Countries: 🦔🦔🦔/5

In Rabies non-Endemic Countries: 🦔/5

Severity if Exposed: 🦔🦔🦔🦔/5 (While easily preventable within 72 hours, Developed Rabies has a 99.9% mortality rate)

When most people think of Rabies they think of raccoons or bats, but unfortunately in many parts of the world (take a look at the map above) cats and dogs could be that rabies carrier.  So that adorable puppy on the street that plays with you and nips your hand? The cute kitty that gives you a little scratch? Bad news: you might be exposed to rabies.

And rabies has no cure.  As of the time I’m writing this, I can count the number of people who have survived active rabies on one paw. And they had to be put into a medically induced coma. So basically: you get rabies, you die.

What counts as rabies exposure? Most of us assume the bite of a rabid (mammalian) animal. It’s actually a bit more complicated. The World Health Organization splits it into three categories: I, II, and III.

Category I is touching an animal or an animal licking you on fully intact skin. This isn’t rabies exposure. But wash your hands anyway.

Category II is a small bite, nip, or nibble on your uncovered skin, small scratches that don’t cause bleeding.  This is Rabies Exposure and you will need an immediate vaccine and local treatment.

Category III is a bite or scratch that breaks the skin, contact with a mucous membrane, or anything involving bats. This is severe Rabies Exposure and you will need an immediate vaccine, local treatment, and HRIG which is a whole new level of unpleasant.

Most people don’t think a scratch can carry rabies since it’s in saliva, but remember: animals groom and lick and chew their paws! Rabies is too dangerous of a risk.

Finally, some animals almost never carry rabies.  North american field mice and opossums, for example.  But if you don't know for sure, assume the animal might be dangerous.  The hospital can also advise you.

The good news is exposure isn’t rabies, and this is something you can get through with relatively minor pain!

How Can You Prevent Rabies Exposure?

There are lots of ways that you can help fully or partially prevent a rabies exposure.

Get the Rabies PrEP! Ask your doctor to get the Rabies PrEP vaccine. You might need to get it from a specialized travel doctor. PrEP stands for “Pre Exposure Prophylaxis”. Essentially, it’s a vaccine.  Unlike other vaccines though, this isn’t stand-alone.  We’ll get into that in the “What if it happens” section, so don’t stop reading! You aren’t in the clear yet. 

Wait, if it isn’t fully preventative, why get it? First of all, it reduces your risk of getting rabies if you are exposed. So if you get this and the post exposure boosters, you are safer than someone who just got the post exposure treatments. Secondly, if you do get exposed, you are in for a much easier follow up treatment than someone without the PEP. To read about that that nightmare, check out the “It happened to me” section.

It is especially important to get the PrEP if you will ever be somewhere that is more than 48 hours travel to the nearest hospital with rabies treatment. 

Avoid mammals! Ugh, I hate giving this advice because I don’t follow it myself (plus, I'm a hedgehog! we're mammals and I don't want you to avoid me, even if I do have bubonic plague). There are so many pitiful street dogs and adorable street cats everywhere. I would like to snuggle all of them! But unfortunately, they might have rabies.

Buy Travel Insurance! Okay, technically this can’t do anything to prevent your rabies exposure, but it will make what follows a lot easier. Especially on your pocket. Rabies treatment is expensive!

Have an emergency fund or someone willing to loan you money! Again, this won’t prevent rabies exposure, but treatment isn’t cheap. And it’s better to be down a few thousand dollars than to be dead. Having insurance obviously can prevent the “down a few thousand dollars” bit but depending on your insurance, you might still need to pay up front. This is a big enough emergency that if you can't build in an emergency fund, you will almost certainly qualify for assistance from your embassy.

What do you do if it happens to you?

Gosh darn it, you got scratched or bit by an animal or had direct, unintended contact with a wild bat. This is a Category II or Category III exposure.  Whether minor or severe, you need to take action NOW. Rabies doesn’t wait. Neither can you.

Clean the wound! Soap and water and a solid 15 minutes of washing. If you have something like Hydrogen peroxide or rubbing alcohol (yes, alcohol will hurt) use that too.  Then you can bandage it, if you feel it’s necessary.

Call a hospital! If it’s the middle of the night, feel free to wait until morning, but contact as soon as you can.  International travel hospitals are really familiar with this scenario, so try and contact one of them. If you can’t, any hospital will do. Arrange an appointment for as soon as possible.

Now go to the hospital and get your first treatment(s)! Tell the doctor if you’ve had the Rabies PrEP.  If you have, you’re in luck! All you will need is a series of follow up Rabies PEP (Post Exposure Prophylaxis). And don’t worry! It’s not like a few decades ago when it was a series of awful shots in the stomach. It’s going to be a few shots in the upper arm and hurts a bit more than a flu shot.  Usually it’s one on the day of exposure and one 3 day later, so it may effect your travel schedule but your life is far more important!  If your tetanus shot is out of date or soon in need of a booster (more than 7 years past the shot) you will also need a tetanus booster.

If you have not had the PrEP, you are in for a bad time. First you will get your first Rabies PEP injection. You will be given a non-negotiable schedule for the follow up PEP series, and its a longer series than the folks who go the PrEP: one on the day of exposure, one 3 days later, one 7 days later, and one 14 days later. This will almost certainly effect your travel plans, but again, better than death.  If your tetanus shot is overdue or almost overdue, you will need a booster there too.

Time to do the HRIG! The doctor will ask your weight, and no matter how shy you may be about this Do Not Lie! Your life depends on this information! The doctors will then measure out HRIG (Human Rabies Immunoglobulin) based on your weight. This will be injected directly into the open wound site or sites. This hurts badly. In fact, especially if the wound is on a sensitive area such as the hand, I highly recommend seeing if you can get a sedative prior to the injections.

Finally, Go Home, Calm Down, and Organize Your Medical Paperwork. Nightmare is over. You are almost 100% guaranteed to be safe from this rabies exposure. Photograph or scan your medical papers immediately and especially the bills for treatment. Insurance will need these later! And get yourself a treat. You’ve had a rough day. You deserve it.

"It Happened to Me: My Rabies Exposure"

CW: Pain. Lots of it.

(2018, Nepal)

I love cats. And usually they love me. But the one time that really wasn’t true was a total nightmare.

I had just started renting a new flat in Nepal and I hadn’t fully set it up yet.  I woke up in the night, around 1 am, to a strange sound and got up to investigate.  There, in my open, half unpacked suitcase, was a rummaging movement.  A closer look revealed a scrawny, adorable, wild kitten.

Maybe it was my previous luck with cats making me cocky. Maybe I was too sleepy to think logically. But I tried to shoo the cat out with my hand. Sharp kitty, as I now call her, did not take it kindly. She yowled and slashed and scratched to high heaven before eventually sprinting out the gap in the door.

A quick evaluation in the bathroom showed me that this was definitely a Cat III (pun intended) exposure.  I had 6 wounds: four on my left palm, one on the back of my left hand, and one on my right wrist. All were bleeding profusely.  I washed them out as best I could, but I knew that wouldn’t be enough. I hadn’t unpacked fully yet and I didn’t have wound disinfectant. 

But I did have an alcohol based hand sanitizer.

I poured that into my bleeding palm and held it.  It hurt like hell. I couldn’t make any noise because it was the middle of the night, but I held it in my palm for 30 seconds. Then I repeated on the back of the hand and the wrist before bandaging the wound as best I could.  I called the international hospital emergency line and told them the situation and how I had cleaned the wound. They advised that I could wait to come in until morning.

In the morning I called CIWEC travel hospital in Kathmandu and took a taxi over.  After a weigh-in they explained what they would be doing.  I was given my first Rabies PEP injection and a schedule for the next 3 shots.  Since my tetanus shot was 7 years prior, I wasn’t overdue but to be safe I was given another tetanus shot. 

Unfortunately, I didn’t have the PrEP so I needed the HRIG.  Let's talk about HRIG.  First of all, normal injections go into nice, squishy parts of your body, like your arm.  HRIG goes wherever the wound is.  That means that unless the wound is on a squishy part, it's going to be a lot of pressure. Secondly, for the average adult, the dose of HRIG is twice as large as a standard vaccine, so a heckuva lot is going in.  Finally, HRIG is a thick liquid, so not only does it require a large needle, you feel it going in.

If I had known what I was in for, I would have requested sedatives or even local anaesthesia.

I was brought into a room and asked to lie down on a stretcher.  Two nurses were called in, in addition to the doctor who would be administering the shots.  I’d never gotten a shot like this before.

The doctor warned me it would be uncomfortable, then the nurses helped me lie down, arms outstretched, and gently pinned me to the stretcher.  

And that was when the doctor started the first injection of HRIG directly into the first open wound on my palm.

At only one other time in my life have I have uncontrollably screamed from pain. And this was far worse. I had to be held down as I screamed and sobbed for each and every one of the injections. The one on the base of my finger was worst, but even the one on the back of my hand had me screaming so loudly that patients in the waiting room were horrified.  I don’t know what I can compare it to, but from my own experience I can tell you that I would rather have 5 cortisone shots than a single HRIG injection. It was worse than trying to stand on a shattered ankle. It was worse than steam burns.  It was worse than sliding down a gravel hill on my shins.  And I’ve done all those things.

I’m sure my experience was worse being on the palm, a major nerve center, but even on other parts of the body, HRIG is described as an unusually painful injection. The doctor told me he once had to do it on a child’s tongue, but I don’t like to think about that.

When it was all done, I was brought into a quiet room and given some water. I had to be helped into the bathroom because I could hardly walk, being near fainting, and I also nearly vomited from the pain.  My hand was so swollen that I couldn’t use it for n two days. Eventually I was able to walk to the counter and get my bill.  More than $2000, two times the average annual income in Nepal. I’ve heard its more expensive in other countries.

I took a taxi home and curled up on my bed and sobbed.

I would not wish the experience of the HRIG on my worst enemy. I now tell all my friends and anyone interested in travel: please get the PrEP! I don’t want anyone to experience what I had to experience. It is preventable 

But if I could go back in time to the moment I got slashed and I knew then what I know now about how much it would hurt and how much it would cost: would I do it again?  Yes. Not a question in my mind.  It hurt. It was horrible. Even thinking of it causes me pain and makes my heart race.

But I’m alive.  And that’s what matters.