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Background: Timely administration of post-exposure prophylaxis (PEP) can prevent rabies. For non-vaccinated persons, PEP consists of multiple vaccinations and rabies immunoglobulin (RIG) on indication. Since RIG is scarce, the need for PEP could be restricted through preventing animal contact and pre-exposure vaccination. We aimed to identify determinants for possible rabies exposure among travellers to provide more targeted pre-travel advice., Method: A case-control study was performed. Cases were defined as persons with a possible rabies exposure (category II or III injury according to WHO classification guidelines) in a rabies endemic country. Controls did not report exposure during travel. Multivariable logistic regression was performed., Results: 229 cases and 1427 controls were included. Predictors (p < 0.05) of possible rabies exposure were young age, male sex, travelling to Western or Southeastern Asia, visiting a monkey park, pet ownership, previously visited the same country and considering oneself an experienced traveller. Negative predictors were travelling for business, visiting friends and relatives, and fear of animals., Conclusions: Pre-travel advice should take the identified predictors into account to provide better targeted information and pre-exposure prophylaxis., (Copyright © 2022 The Authors. Published by Elsevier Ltd.. All rights reserved.)

Background: Travellers to rabies endemic countries should be counselled on rabies risk and, in case of high-risk, pre-exposure vaccination is advised. However, it is not clear which travellers exactly are at high risk. In this study we determined the incidence of possible rabies exposure in travel clinic visitors and compliance with pre-travel advice., Methods: Travellers to rabies endemic countries who visited a Dutch travel clinic between September 2017 and May 2018, were invited to participate., Results: Of 980 travellers, one percent was injured by a potentially rabid animal. Compliance with advice was low as 59% reported proximity to a potentially rabid animal and only half of those exposed sought medical advice. The most important predictors of proximity to a potentially rabid animal were young age, long travel duration, visiting a monkey forest and hiking for more than one day. Travel for business was associated with lower risk., Conclusion: Despite pre-travel advice, rabies risk behaviour was high. Therefore, we would recommend to keep the threshold for pre-travel vaccination low. Pending more data on rabies exposure risk, the identified predictors of proximity to potentially rabid animals could be used to tailor indications for pre-travel rabies vaccination., (Copyright © 2021 The Authors. Published by Elsevier Ltd.. All rights reserved.)

BackgroundThe risk of contracting rabies is low for travellers. However, the number of Dutch travellers potentially exposed abroad following an animal-associated injury and needing post-exposure prophylaxis (PEP) has increased, resulting in increased costs.AimHere, we evaluated the costs and the cost-effectiveness of different pre- and post-exposure interventions in the Netherlands, taking into account the 2018 World Health Organization (WHO) recommendations for the prevention of rabies.MethodsA decision tree-based economic model was constructed. We calculated and compared the cost of different WHO pre-exposure prophylaxis (PrEP) recommendations, intramuscular vs intradermal vaccination and PEP subsequent to increased vaccination coverage in risk groups. We estimated cost-effectiveness, expressed as incremental costs per rabies immunoglobulin (RIG) administration averted, using a societal perspective. Statistical uncertainty regarding number of travellers and vaccination coverage was assessed.ResultsTotal costs at the national level were highest using previous WHO recommendations from 2012, estimated at EUR 15.4 million annually. Intradermal vaccinations in combination with the current recommendations led to the lowest costs, estimated at EUR 10.3 million. Higher vaccination uptake resulted in higher overall costs. The incremental costs per RIG administration averted varied from EUR 21,300-46,800.ConclusionsThe change in rabies PrEP and PEP recommendations in 2018 reduced total costs. Strategies with increased pre-travel vaccination uptake led to fewer RIG administrations and fewer vaccinations after exposure but also to higher total costs. Although larger scale intradermal administration of rabies vaccine can reduce total costs of PrEP and can positively influence vaccination uptake, it remains a costly intervention.

In February 2012 a rabid puppy dog was imported into Amsterdam, the Netherlands from Morocco via Spain. In a joint action between the Netherlands’ Food and Consumer Product Safety Authority, the Public Health Service of Amsterdam and the Centre for Infectious Disease Control all exposed human and animal contacts were traced and, when necessary, provided with post-exposure prophylaxis. During the importation, the international legislations with respect to vaccination requirements were not fully obeyed by veterinarians and custom services.