Rabies is a form of brain infection caused by a virus that is transmitted in the saliva of infected animals. Nepal and India are countries with a high risk of rabies due to the large population of stray dogs in the cities. Monkeys can also transmit rabies to humans, and most other animals are thought to be capable of transmitting rabies. Therefore, any contact with an animal in Nepal that results in a wound, a bite or a scratch should lead the person to seek a medical opinion as to whether rabies immunoprophylaxis is necessary. In Nepal, most animal exposures to travelers occur in Kathmandu and monkey bites/scratches account for 43% of all exposures in tourists in a study done at CIWEC Clinic. Monkey bites are sustained most commonly at the monkey temple (Swyambu) and a smaller number in the Pashupati temple area. Contrary to popular belief, trekking in Nepal does not pose any added risk to the traveler.

There is no way to kill the rabies virus with antibiotics. Treatment is based on immunizing a person who has been bitten with a combination of borrowed antibodies from other humans (human rabies immune globulin), and vaccines that stimulate the production of large amounts of antibodies that can kill the wild virus before it reaches the brain. Thus, rabies is the only disease of humans that is treated with a vaccine after exposure has occurred. There is another strategy for helping to prevent rabies which involves taking three injections of rabies vaccine before you travel. These "pre-immunized" travelers, if they are bitten, need only two shots of the vaccine, 3 days apart, as a booster. Otherwise, travelers who have not been pre-immunized require injections of human rabies immune globulin (HRIG) and 5 injections of the vaccine over a one month period. Both strategies are effective at preventing rabies after an exposure. Here is a summary of the approach to rabies prevention in travelers:

CIWEC Clinic had always made HRIG available to treat patients with animal bites in the past but lately due to world-wide shortage of HRIG, the supply of HRIG at CIWEC is not consistent. We are therefore, recommending most travelers to Nepal to be pre-immunized. If you are not pre-immunized and get animal bite in a country where HRIG is not available, start the series of rabies vaccine shots as soon as possible. If you have a high risk wound, which means deep wounds around the face, or neck, or on the hands, or multiple deep wounds, the traveler should try to obtain HRIG as soon as possible even if that means traveling to another country where HRIG is available. If it is more than 8 days since the vaccine was started (not since the bite occurred), then HRIG should no longer be given, as it may interfere with the immune response to the vaccine.

Most rabies exposures in travelers result in trivial wounds that may be at very low risk to transmit rabies, such as minor abrasions of the skin that barely drew blood. Any exposure should be evaluated by a doctor familiar with rabies, and in almost all instances, post-exposure immunoprophylaxis will be recommended. However, HRIG works best when injected around the wound within a short time of the bite or scratch. The overall level of antibodies produced in the blood from an HRIG injection is low, and is surpassed by one’s own antibody production 7-10 days after starting the rabies vaccine injections. Therefore, always start the rabies vaccine, and then try to obtain HRIG if it is deemed necessary by your doctor.

There are several acceptable rabies vaccines available around the world, and they can be used interchangeably during the same rabies treatment series, if necessary. The acceptable vaccines are all referred to as "tissue culture vaccines," and are significantly more powerful and freer from side effects than the older "neurotissue vaccines." Avoid vaccines that have been derived directly from sheep or mouse brain. Acceptable vaccines include the following: Human Diploid Cell Vaccine (HDCV); Purified Verocell Rabies Vaccine (PVRV); Purified Chick Embryo Vaccine (PCEC).

Remember, if you are traveling overseas and are exposed to a possibly rabid animal, make sure you contact a medical practitioner who is familiar with rabies prophylaxis. Carry with you the phone number of the travel clinic that gave you your pre-travel immunizations, or contact your local embassy. It is always recommended to receive rabies post-exposure immunoprophylaxis no matter how much time has elapsed from a possible exposure.