RABIES - Medicine for Mountaineering and Other Wilderness Activities - page 489

proximately 25 percent of exposures, commonly monkeys leaping for food held by tourists
visiting the Swayambunath Temple.
Individuals exposed to rabies while visiting developing countries cannot depend upon
local physicians or institutions for reliable treatment. In many areas vaccine prepared from
infected animal brains is used to immunize individuals exposed to rabid animals because it
is inexpensive. This vaccine has been described as the “crudest” biological preparation ad-
ministered to humans. It varies considerably in its potency and effectiveness and probably
is not effective for severe exposures with multiple bites about the head and neck. Twenty-
four injections are required and are quite painful, and the vaccine is associated with a high
incidence of side effects, a number of which are disastrous. Vaccination should be refused
unless the recipient is certain the preparation is one of the WHOapproved vaccines.
The amount of rabies immune globulin being produced worldwide is estimated to be
about one-third the quantity needed for treating all individuals exposed to rabies. In de-
veloping countries, immune globulin is rarely administered. Travelers to those countries
treated in local facilities are not given immune globulin unless they know enough about
rabies postexposure therapy to insist upon its administration.
If a reliable source of therapy, such as the CIWEC Clinic in Kathmandu, Nepal, or the
Queen Saovabha Memorial Institute in Bangkok, Thailand, is not available, U.S. citizens
exposed to rabies should go immediately to the nearest American embassy. These em-
bassies have physicians on their staffs or available to them and are required to be able to
obtain reliable immune globulin and vaccine within an appropriate period of time. (Cit-
izens should not allow themselves to be turned away in off-duty hours by uninformed duty
personnel.) In addition, the embassies of Canada and Britain have usually welcomed the
opportunity to assist citizens of the United States in an emergency.
PREEXPOSURE RABIES VACCINATION
Preexposure rabies vaccination of humans consists of the three intramuscular injections of
1.0 ml of vaccine on days zero, seven, and twenty-one or twentyeight. Rabies vaccines are
so reliable that serologic testing for antibody levels is recommended only for individuals
known to be immunodeficient.
In 1987 the Food and Drug Administration (FDA) approved vaccinations with only 0.1
ml of vaccine intradermally on the same schedule. (The volume injected is only one-tenth
that administered intramuscularly.) However, the antibody level produced by intradermal
injections is not as high, and does not last as long, as that produced by intramuscular in-
jections. Some authorities are recommending that only intramuscular injections be admin-
istered, and the vaccine for intradermal injections has not been available for a number of
years.
If a vaccinated individual subsequently has contact with a rabid animal, treatment with
vaccine is still necessary. However, rabies immune globulin is not needed, and only two