UKC

Following the July thread on the advisability (or not) of having rabies jabs before travelling to a high risk area, did any of you see the TV documentary on leopards, ferrell dogs and declining vulture population in India last night?

The vacuum caused by the decline in vultures (due to a drug given to cows which is fatal to vultures when they eat carcasses) has now been filled by packs of ferrell dogs in the cities scavanging off dead animals, which in turn is attracting leopards to hunt them. The leopards unfortunately eat the occasional human too.

The Indian vulture population is declining so rapidly that there is a danger of the species becoming extinct. Not good news for cults which rely on sky burials.

Rabies is now rapant amongst ferrell dogs who also bite humans, and human deaths from rabies in India now number 20,000 a year. The programme emphasised that rabies is a horrible death and once someone is infected, death is inevitable.

I would definitely have a rabies jab if visiting the Indian sub continent or anywhere else with a high incidence of rabies.

In reply to Trangia:

Death is not inevitable as long as you catch in early enough.

In reply to Trangia:

it's not inevitable, you just have to act quickly.

Probably said repeatedly in the previous thread, but if you're going to be near to somewhere where you can be treated then there's no benefit to the jab. It's useful though if you're off the beaten track or far enough away for that extra time it gives you to potentially save your life. Depends on what type of trip you're doing.

Saying that I hadn't heard of the problem with the vulture population and knock on effects and am sad not to have seen the program.

In reply to Scarab9:


http://www.birdlife.org/action/science/species/asia_vulture_crisis/diclofen...

Looks like its been known about for many years (Pre 2004)

In reply to Removed User:

This discussion has been seen before on UK Climbing and with the same degree of false information. I hope to stop this rubbich early on this occasion. It simply illustrates how misinformation can be spread on the web. I note that Mr Hardonicus quotes no references, evidence or case studies to support his comments.

Excuse my long quotes but:-

"Globally, Rabies is the tenth most common couse of death from infectious disease.......The World Health Organisation (WHO) currently estimates the number of rabies deaths globally at 40,000 to 70,000 a year, an average of approximately one death every ten minutes"

"Rabies in humans, once it has become clinically apparent, is uniformly fatal. No other infection is so lethal or progresses so rapidly. In the 1970s intensive support allowed three humans with clinical rabies to survive. Three rabies survivors have been reported subsequently...at least three of the five survivors had severe residual neurological deficits, severe enough to be fatal 34 months later in one person"

I take this information from Paul Auerbach's "Wilderness Medcine" 5th Edition published 2007 the relevant chapter is writtn by James Wilkerson and backed with multiple references from peer reviewed journals and data from the WHO.

Personally I do not want to be one of the 40.000 people a year who die of this disease. Even less do I want to be a survivor with severe neurological problems. I keep my immunisations up to date for foreign travel

I currently declare no conflict of interest in this E mail but did, in the late 1970s when a medical student, receive free samples of the "new" rabies vaccine for my first Himalayan trip.

Yours,

David Hillebrandt

In reply to David Hillebrandt:

Interesting stuff.


Morbid I know but I suspect that few other diseases would give rabies a good run for its money in both departments. Pneumonic plague must be a candidate; it's apparently pretty much uniformly fatal if unreated within 24 hours and it can kill in under a day. New variant creutzfeldt-jacob disease is absolutely 100% lethal as I understand it (in fact unless there's been a change recently I think it's only even been diagnosed posthumously).

Oh and for what it's worth everything I've read and heard says you're right about the fatality rate for rabies. A number of my relatives worked in very remote areas of africa since the 50s and rabies was one of the diseases they worried about most.

In reply to Scarab9:

Poorly stored, out of date and fake drugs are common in the subcontinent. You feel the need take the risk of being close to somewhere that has one of the above?

Regards

D

In reply to David Hillebrandt:

I meant that assuming you get bitten by something, you take the precaution of getting the jab(s) straight away as opposed to hanging out for the 'clinical signs'.

As a scientist I appreciate you rigour however squire...

In reply to Removed User:

im off to asia in less than a week to go climbing, i opted for the rabies jab as they said one of the biggest threats out there is monkeys and bats, who tend to hang out where climbers like poking their fingers in things.

Apparently by the time the symptoms have manifested, its too late. So either you rush and get treatment (i think you have something like a 24-48hr window) or die. The problem being, sometimes the animal wont show symptoms either, and you can catch it from something as minor as a dog licking broken skin.

The age old balance of hypercondria vs risk

In reply to Kemics:


>The age old balance of hypercondria vs risk.

It's not though is it. It's coming from a society with an advanced healthcare system where most deadly infectious diseases are eradicated by childhood vaccination or through access to good quality drugs and well trained staff - you have no good perspective on the risk. If you knew a few people in your village that had died of rabies then you would feel a tad differently about paying the hundred and whatever notes it costs. If it cost nothing would you get it?

Regards

D

In reply to David Hillebrandt: I'm with you on this. I'm no expert but given what is generally known about rabies I am not prepared to take the chance; after all it only takes one bite. Even having had the course of three prophylactic(sp) injections, if you are bitten by a suspect animal apparently you still require urgent follow up treatment.

I stumped up £100 for three jabs - a minor amount compared with the cost of a trip. What price your life?

In reply to David Hillebrandt: Before making such assertive statements that may mislead others you should perhaps explain the difference between vaccine and pre-exposure prophylaxis (as that is what is commonly given in the UK).

In reply to MJH:

Dear Mr Hale,

I trust that my statment will not mislead anybody. It is simply a statement of the facts based on reputable sources. I fail to follow your statement but to quote the British National Forumulary Number 59 published March 2010 Section 14.4 Page 737:

"Rabies Vaccine contains inactivated rabies virus cultured in either human diploid cells or purified chick embryo cells. Vaccines are used for pre- and post-exposure prophylaxis"

Hence there is no difference.

Yours,

David Hillebrandt

In reply to David Hillebrandt: OK, you picked up on Hardonicus's statement that death was not certain from rabies if caught quick enough. You then went on to talk about vaccination without mentioning that in many cases all vaccination does is give an amount of extra time to get further treatment, which was why I said you were potentially being misleading.

In reply to MJH:
If the patient has had a full course of pre exposure vaccinations further treatment is IMMEDIATE very thorough wound cleansing and the possible use of antibiotics to cover potential non rabies bacterial infections, and then one post exposure rabies vaccination booster, to "reawaken" the viral immune response, as soon as possible after the bite. You are correct that one has more time to get this post exposure vaccination.

If you have not had the pre exposure vaccination course the time available for post exposure vaccination is considerably less.

In many countries modern Rabies vaccination is unavailable or, at best, very difficult to get, very expensive and may involve cutting short one's planned trip.

Yours,

David Hillebrandt

In reply to Trangia:
Not much to add to David's info, apart from to add that I have great confidence in his knowledge of all things expedition medicine. It's often difficult to separate the crap from the useful advice on this site and as always check info from a reputable source, in this case your local travel clinic or a decent online resource like patient.co.uk

DOI, I know David from the Diploma Mountain Medicine

Damian

In reply to Dauphin:
. If it cost nothing would you get it?

Indeed, it cost me nothing* - I got it.

I was lucky I suspect, but worth asking your GP.

Tom

*(This was about five or six years ago)

In reply to Trangia: failing the Prophylactics you could pin your hopes on this!

http://en.wikipedia.org/wiki/Milwaukee_protocol

In reply to higherclimbingwales: Interesting stuff!

To the other posters, how much extra time does the prophylactic vaccination actually give you? It seems to me if you are anywhere other than near a city your chances of survival are slim.

In reply to sebrider:

I'm not sure but it could be up to about ten days.

In reply to sebrider: I'm a UK Pharmacist working in Asia and have been closely involved with treatment of patients exposed to rabies, with availability of vaccines and with testing of animals (brains) to see if they carried the rabies virus. My comments are;

1) if you are exposed (not only bitten)and require vaccine and have had no prior rabies shots then protective levels of antibodies from the vaccine aren't reached until after two weeks depending on the rabies vaccine used.
2) it means that for the worst category of exposure antibodies are also given directly at the same time as the vaccine to try to give immediate proection. That's called rabies immunoglobulin.
3) it means that if you haven't received prior vaccine (pre-exposure course) you can still be protected by this combination of vaccine and immunoglobulin and you'd likely be ok.

But;

while you might find vaccine in large centres (and may have to travel for it) you may not find the immunoglobulin easily available and therefore won't be protected for 2 to 3 weeks with vaccine alone.

The expats I meet are always very, very worried after being bitten. They are usually very very worried if their children have been bitten or licked by dogs (s). If they are lucky we have the dog, take off its head and can get a result one week later to see if its rabid or not. In most cases we don't have the dog and therefore no idea if it was rabid or not. We assume it was and treat according to the type of exposure (there is a classification of types).

By having the pre-exposure course and if you are exposed you are a) protected immediately after the first shot in the post exposure course. Your antibody levels go sky high within a day or so. That's enough to stop any rabies virus from getting into your nervous system. You are immediately protected and you don't need the immunoglobulin which can be more expesnive that the pre-exposure course...if you can find it.

So anyone traveling outside of big city holiday destinations and off the beaten track in Asia should have the pre-exposure course. You only need it once and then periodic boosters. If you lapse on the boosters your body will still respond rapidly to a future full course should you later be exposed and have post-exposure vaccine at that time.

Rabies is a horrible death. I followed a 16 year old boy in hospital in Thailand from his admission to death one week later. We filmed it for teaching purposes. Very sad.

regards, andrew

In reply to andrewm1000: Very interesting comments Andrew and ones which, from a layman's angle I would endorse.

I feel much happier now that I've had the three pre-exposure jabs. As I said before, what price your health? For most of us £100 for the three injections is little to pay for some reassurance.

In reply to andrewm1000:
Thank you for words of wisdom based on good science combined with clinical experience.
David Hillebrandt

In reply to Trangia:

For the Good Scientists amongst you only.

Before going to Nepal 17 years ago, I had a course of rabies jabs- no problem. In 1999, before going to Bolivia, I started another course. After the first jab, I felt slightly odd. After the second one, I went into melt down. Hot, crawling flesh, agitated etc. The GP was fascinated- much more interesting than signing sick notes for people who wanted a few days off because the weather was good. After consulting his specialist pals, he decided that if I ever had another jab of vaccine, it might well be my last! He said that should I ever be bitten I should have 'anti-rabies immunoglobulin' only [and not rabies vaccine].
My query is, if I should be bitten, would countries I am likely to be bitten in have anti-rabies immunoglobulin and would it be any use in preventing a nasty exit?
Experts views please.

George

In reply to George Allan: George. yhm

In reply to higherclimbingwales: that's pretty cool isn't it? i was going to post it but you saved me the trouble...

In reply to Trangia: As an example, I'm now in Jakarta. Government has confirmed rabies in almost all of the provinces. Bali was rabies free until 2008 but now there are some new cases there. Vaccine is available in main centres but people who require the rabies immunolobulin (eg bitten and having no prior pre-exposure vaccine) need to fly to Singapore to get it. Another example of supply problems for the immunoglobulin and reinforcing the recommendations to have the pre-exposure prophylaxis course before traveling. regards, andrew