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Rabies vaccination and traffic accidents
Travel Medicine and Infectious Disease (2008) 6, 326e327
available at www.sciencedirect.com
journal homepage: www.elsevierhealth.com/journals/tmid
CORRESPONDENCE
Rabies vaccination and traffic accidents Rabies in travelers returning to western countries is rare but inevitably fatal. In a retrospective study, Menachem et al. found a poor understanding of the consequences of rabies and a low rate of pre-exposure prophylaxis (PreEP) in travelers who were injured by a potentially rabid animal. The authors concluded that PreEP should be considered more often. Improvement of pre-travel advice concerning rabies is mentioned just secondarily.1 We think this order of priority is inadequate. Specific advice concerning rabies is crucial. Post-exposure prophylaxis (PoEP) in resource poor settings is often unsafe and difficult to access and failures do occur.2,3 In view of these disadvantages of PoEP, PreEP should be recommended in addition to comprehensive advice. It remains unclear whether a traveler might benefit from PreEP in terms of lifesaving or just from facilitating PoEP. Menachem et al. suggest the exposure risk rate (ERR) for assessment of actual risk of acquiring rabies. The ERR varies widely and is defined imprecisely. Studying 815 travelers retrospectively Menachem et al. found 13 travelers exposed (ERR Z 2,7/1000 travelers/month). The majority of those, nine travelers, were not seeking medical attention. Postexposure prophylaxis (PoEP) in context of this study for exposed and untreated travelers was not mentioned nor discussed. No human rabies case was reported.1 This suggests that the ERR is not taken as an indicator of true rabies exposure. Regarding the low incidence of imported human rabies in western countries against the background of extensive travel of poorly prepared persons, the ERR obviously overestimates the actual risk of true rabies exposure. Thus, the ERR is no measure of the actual risk of acquiring rabies, but for the risk of requiring PoEP. In absence of a reliable measure for actual rabies risk in travelers, perception of the magnitude of this risk is helpful. For this purpose we draw a daring comparison with a daily life risk: road traffic. From 2000 to date, three travelers died from imported rabies in Germany. None received PoEP before onset of symptoms. Two returned from India and one from Morocco.4e6 Considering some main travel destinations endemic for rabies: India, Thailand, China, Turkey, Egypt, Tunisia, Morocco and South Africa, 8.8 million people were taking a rabies risk in 2006 by traveling from German airports to countries endemic for rabies.7 German road traffic in
2006 was afflicted with 480 casualties and 7.4 deaths per 109 km.8 Considering these numbers, the average risk for these travelers to acquire rabies equals the chance of being killed in a road accident when traveling 6 km in common traffic at home. This fictitious scenario suggests that lifesaving effects of PreEP could be counteracted by disadvantages in some travelers. However, it leaves the risk of requiring PoEP and the facilitating effects of PreEP unconsidered. Risks and benefits of measures against travel related human rabies have to be weighed. The effects of PreEP in facilitating a safe post-exposure treatment should be distinguished from its lifesaving effects. We stress the German consensus on rabies vaccination in travelers: comprehensive advice concerning rabies is crucial and PreEP should be considered additionally.2 We agree with Menachem et al. that PreEP should be recommended strongly to long-term travelers, but any visitor of rabies endemic regions may benefit from PreEP, particularly in destinations which are likely to have inadequate facilities for post-exposure treatment.
References 1. Menachem M, Grupper M, Paz A, Potasman I. Assessment of rabies exposure risk among Israeli travelers. Travel Med Infect Dis 2008;6:12e6. 2. Scho ¨nfeld C, Burchard G, Dittmann S, Fru ¨hwein N, Hu ¨lsse C, Idel H, et al. Consensus paper on rabies vaccination for travelers [in German]. MMW Fortschr Med 2003;145:125e9. 3. Wilde H. Failures of post-exposure rabies prophylaxis. Vaccine 2007;25(44):7605e9. 4. Schmiedel S, Panning M, Lohse A, Kreymann K, Gerloff C, Burchard G, et al. Case report on fatal human rabies infection in Hamburg, Germany, March 2007. Euro Surveill 2007;12(5). E070531.5. 5. Robert Koch Institut. Rabies from transplantation [in German]. Epid Bull 2005;(7):52e4, http://www.rki.de/cln_049/nn_504562/ DE/Content/Infekt/EpidBull/Archiv/2005/07__05,templateIdZraw,propertyZpublicationFile.pdf/07_05.pdf; 2005 [accessed 04.03.08]. 6. Friedrich Loeffler Institut. Rabies information system of the WHO collaboration centre for rabies surveillance and research, http://www.rbe.fli.bund.de/Queries/Distribution.aspx; 2008 [accessed 04.03.08]. 7. Statistisches Bundesamt. Flight passengers in 2006 [in German], http://ims.destatis.de/luftverkehr/Default.aspx; 2007 [accessed 04.03.08].
1477-8939/$ - see front matter ª 2008 Elsevier Ltd. All rights reserved. doi:10.1016/j.tmaid.2008.05.003
Correspondence 8. Bundesanstalt fuer Strassenwesen. Traffic accidents [in German], http://www.bast.de/cln_007/nn_39814/DE/Statistik/Unfa lldaten/downloads/Strassenverkehrsunfaelle,templateIdZraw, propertyZpublicationFile.pdf/Strassenverkehrsunfaelle.pdf; 2007 [accessed 4.03.08].
Andreas Gunther* Department of Medicine, Municipal Hospital, Wolfenbuttel, Germany *Corresponding author. E-mail address: [email protected]
327 Gerd-Dieter Burchard Clinical Department, Bernhard-Nocht-Institute for Tropical Medicine, Hamburg, Germany Christian Schoenfeld Travel Clinic, Institute for Tropical Medicine, Berlin, Germany
22 April 2008 Available online 1 August 2008
available at www.sciencedirect.com
journal homepage: www.elsevierhealth.com/journals/tmid
CORRESPONDENCE
Rabies vaccination and traffic accidents Rabies in travelers returning to western countries is rare but inevitably fatal. In a retrospective study, Menachem et al. found a poor understanding of the consequences of rabies and a low rate of pre-exposure prophylaxis (PreEP) in travelers who were injured by a potentially rabid animal. The authors concluded that PreEP should be considered more often. Improvement of pre-travel advice concerning rabies is mentioned just secondarily.1 We think this order of priority is inadequate. Specific advice concerning rabies is crucial. Post-exposure prophylaxis (PoEP) in resource poor settings is often unsafe and difficult to access and failures do occur.2,3 In view of these disadvantages of PoEP, PreEP should be recommended in addition to comprehensive advice. It remains unclear whether a traveler might benefit from PreEP in terms of lifesaving or just from facilitating PoEP. Menachem et al. suggest the exposure risk rate (ERR) for assessment of actual risk of acquiring rabies. The ERR varies widely and is defined imprecisely. Studying 815 travelers retrospectively Menachem et al. found 13 travelers exposed (ERR Z 2,7/1000 travelers/month). The majority of those, nine travelers, were not seeking medical attention. Postexposure prophylaxis (PoEP) in context of this study for exposed and untreated travelers was not mentioned nor discussed. No human rabies case was reported.1 This suggests that the ERR is not taken as an indicator of true rabies exposure. Regarding the low incidence of imported human rabies in western countries against the background of extensive travel of poorly prepared persons, the ERR obviously overestimates the actual risk of true rabies exposure. Thus, the ERR is no measure of the actual risk of acquiring rabies, but for the risk of requiring PoEP. In absence of a reliable measure for actual rabies risk in travelers, perception of the magnitude of this risk is helpful. For this purpose we draw a daring comparison with a daily life risk: road traffic. From 2000 to date, three travelers died from imported rabies in Germany. None received PoEP before onset of symptoms. Two returned from India and one from Morocco.4e6 Considering some main travel destinations endemic for rabies: India, Thailand, China, Turkey, Egypt, Tunisia, Morocco and South Africa, 8.8 million people were taking a rabies risk in 2006 by traveling from German airports to countries endemic for rabies.7 German road traffic in
2006 was afflicted with 480 casualties and 7.4 deaths per 109 km.8 Considering these numbers, the average risk for these travelers to acquire rabies equals the chance of being killed in a road accident when traveling 6 km in common traffic at home. This fictitious scenario suggests that lifesaving effects of PreEP could be counteracted by disadvantages in some travelers. However, it leaves the risk of requiring PoEP and the facilitating effects of PreEP unconsidered. Risks and benefits of measures against travel related human rabies have to be weighed. The effects of PreEP in facilitating a safe post-exposure treatment should be distinguished from its lifesaving effects. We stress the German consensus on rabies vaccination in travelers: comprehensive advice concerning rabies is crucial and PreEP should be considered additionally.2 We agree with Menachem et al. that PreEP should be recommended strongly to long-term travelers, but any visitor of rabies endemic regions may benefit from PreEP, particularly in destinations which are likely to have inadequate facilities for post-exposure treatment.
References 1. Menachem M, Grupper M, Paz A, Potasman I. Assessment of rabies exposure risk among Israeli travelers. Travel Med Infect Dis 2008;6:12e6. 2. Scho ¨nfeld C, Burchard G, Dittmann S, Fru ¨hwein N, Hu ¨lsse C, Idel H, et al. Consensus paper on rabies vaccination for travelers [in German]. MMW Fortschr Med 2003;145:125e9. 3. Wilde H. Failures of post-exposure rabies prophylaxis. Vaccine 2007;25(44):7605e9. 4. Schmiedel S, Panning M, Lohse A, Kreymann K, Gerloff C, Burchard G, et al. Case report on fatal human rabies infection in Hamburg, Germany, March 2007. Euro Surveill 2007;12(5). E070531.5. 5. Robert Koch Institut. Rabies from transplantation [in German]. Epid Bull 2005;(7):52e4, http://www.rki.de/cln_049/nn_504562/ DE/Content/Infekt/EpidBull/Archiv/2005/07__05,templateIdZraw,propertyZpublicationFile.pdf/07_05.pdf; 2005 [accessed 04.03.08]. 6. Friedrich Loeffler Institut. Rabies information system of the WHO collaboration centre for rabies surveillance and research, http://www.rbe.fli.bund.de/Queries/Distribution.aspx; 2008 [accessed 04.03.08]. 7. Statistisches Bundesamt. Flight passengers in 2006 [in German], http://ims.destatis.de/luftverkehr/Default.aspx; 2007 [accessed 04.03.08].
1477-8939/$ - see front matter ª 2008 Elsevier Ltd. All rights reserved. doi:10.1016/j.tmaid.2008.05.003
Correspondence 8. Bundesanstalt fuer Strassenwesen. Traffic accidents [in German], http://www.bast.de/cln_007/nn_39814/DE/Statistik/Unfa lldaten/downloads/Strassenverkehrsunfaelle,templateIdZraw, propertyZpublicationFile.pdf/Strassenverkehrsunfaelle.pdf; 2007 [accessed 4.03.08].
Andreas Gunther* Department of Medicine, Municipal Hospital, Wolfenbuttel, Germany *Corresponding author. E-mail address: [email protected]
327 Gerd-Dieter Burchard Clinical Department, Bernhard-Nocht-Institute for Tropical Medicine, Hamburg, Germany Christian Schoenfeld Travel Clinic, Institute for Tropical Medicine, Berlin, Germany
22 April 2008 Available online 1 August 2008