The Pharmaceutical Journal Vol 266 No 7153 p848
June 23, 2001

Rabies — time to enforce the protocols at airports

After the distressing experience of two friends, one of whom had been bitten by a vicious dog in Turkey, Diane Langleben discovered that the post-bite immunisation protocol at Heathrow failed

Rabies is perceived as a rare condition. In the United Kingdom, the last indigenous case was diagnosed almost a century ago, in 1902. However, in the past six weeks two patients have been diagnosed with rabies and a third is still undergoing tests in this country. One of the patients has already died. Worldwide, there are 35,000–40,000 cases a year. As travel to destinations where the disease is endemic increases, more people face the risk of contracting rabies. The Public Health Laboratory Service (PHLS) advice is to “seek advice immediately for an animal bite” and to “stay away from stray dogs and cats”. The PHLS also advises travellers to seek advice before travel and to be vaccinated, but says that this is “usually only necessary for those planning longer visits to developing areas, especially where rural travel is likely”.

Is PHLS advice to “stay away from stray dogs and cats” adequate?

Attacked

Several weeks ago, two good friends of mine left for a trip to central Turkey exploring the area of Cappadocia. A week into the holiday, having just arrived at their hotel for the night, the husband decided to take a walk in the gardens, whereupon he was attacked by an Alsatian dog. He sustained serious bites, one of which was close to the femoral artery in the groin area. He was taken to the small local hospital where he was patched up and given the first dose of rabies vaccine.

My friends had to curtail their holiday and arrangements were made to return them to the UK. This took a couple of days, by which time the second dose of rabies vaccine was due. Indeed, they could have had the dose administered at Istanbul Airport, but, anxious to be on the way home, and confident that Heathrow Airport would readily offer the facility, they decided to wait. The pilot radioed ahead to alert staff that a suspected rabies victim was on board and arrangements were made to meet him on arrival. My friends assumed that the rabies vaccine would be administered at an on-site clinic.

On arrival, they were met by airport personnel and hustled through to the taxi rank with the instruction to go to the accident and emergency department at Ashford Hospital but not to tell the driver why they needed to go there. Allegedly, if he had known that he could be carrying a possible rabies victim he could have refused the fare.

At Ashford Hospital, the closest hospital to one of the busiest international airports in the world, the staff in the A&E department had not been alerted, and moreover, had no stock of rabies vaccine. Nor did they have any success at locating any.

By now my friends were frantic and the victim of the dog’s attack was shivering due to the onset of a blood infection. Fortunately, his wife was able to contact a relative who is a doctor. A hospital close to the couple’s home was alerted, and by the time they had taken a taxi from Ashford to North London, the vaccine had been delivered to the hospital from the PHLS in Colindale.

The story has a happy ending in that my friend is making a good recovery after several weeks of receiving high-dose antibiotic therapy and further rabies injections. The wounds are healing well, although some cosmetic surgery may be necessary. Most importantly, it was reported from Turkey that the dog was found not to be rabid.

However, the episode raises several questions, especially in light of advice from the PHLS. We live in an age when foreign travel is the norm; it is also an age when rabies, far from being a disease of the past, is prevalent in most areas of the world. With holiday-makers seeking ever-more exotic locations for their vacations, is it enough for them to be advised to “stay away from stray dogs and cats”?

Given that rabid animals do not differentiate between the indigenous population and passing tourists, and that some of these tourists could well be from the UK, why is it that one of the major airports of the world and its closest hospital could not provide vaccines but a small hospital in a remote part of Turkey could?

Protocol

When I contacted the health control department at Heathrow, I was informed by a spokesman that a protocol is in place and that stocks of rabies vaccine and rabies immunoglobulin are held there. The Department of Health memorandum on rabies advises travellers with a suspected rabies infection that on arrival at Heathrow or Gatwick airports they must consult the duty port medical officer at the health control unit before passing through customs and immigration controls.

I am assured that the pilot of the British Airways flight notified Heathrow about the rabies suspect on board his plane but it would appear that ground staff meeting the plane were not aware of the protocol and on-site facilities. In the case of serious communicable diseases such as rabies it is not enough simply to have a protocol; staff working in all places of entry into the UK must be aware of it and able to act on it. At Gatwick, for example, although vaccine and immunoglobulin are stocked, they cannot be administered by the medical staff on site. A spokesman told The Journal that their protocol is currently being updated.

The situation appears to be even less satisfactory for travellers arriving in the UK at other ports of entry, for example, at Dover by sea or Manchester by air. The advice in the memorandum on rabies is to seek medical advice as soon as possible, normally through a GP. This, of course, assumes that it is possible to contact the GP immediately. Such advice does not help the long-haul traveller in urgent need of the vaccine to comply with the rabies protocol as stated in the BNF.

Advice on prophylactic vaccination

The British National Formulary advises that pre-exposure, prophylactic immunisation with rabies vaccine should be offered to those at high risk — laboratory staff who handle the rabies virus, those working in quarantine stations, animal handlers, veterinary surgeons and field workers who are likely to be exposed to bites of possibly infected wild animals, certain port officials, licensed handlers and health workers who are likely to come into close contact with patients with rabies. Pre-exposure immunisation is also recommended for those living ore travelling to enzootic areas who may be exposed to unusual risk: telephone the PHLS on 020 8200 4400 for further information.

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Diane Langleben is on the staff of The Pharmaceutical Journal