[10] In spite of avoidance behavior, a traveler may still be bitten by an animal in the developing world where there is a reasonable risk of exposure to rabies infection. If the traveler has a contingency plan to deal with such a scenario, she/he will know to go to the nearest center of safe medical care within a

few days or as soon as possible for appropriate rabies PEP. Unfortunately, many cases of travel-related rabies infection were associated with the exposed person grossly underestimating the significance of the incident and not seeking medical care until the onset of rabies symptoms.[17-20] Prior to the onset of symptoms, some travelers also died of rabies as a result of seeking but not receiving timely rabies PEP even at sites of medical selleck chemicals llc excellence.[21-24] In addition, recent studies document inadequate Belnacasan cost rabies PEP and animal bite aftercare provided to travelers following high-risk exposures in various developing countries.[25-27] Knowing

this, it may be more prudent in some high-risk travel environments (eg, India or Africa) to offer rabies PrEP to any concerned traveler.[10] Where cost is a barrier, the intradermal method of administration is a cost-effective alternative to intramuscular injections.[28] Unlike animal avoidance, rabies immunization is a passive act and does not require active participation of the traveler. In general, passive interventions tend to be more successful than active ones that require the client’s adherence throughout the trip. If the properly primed traveler [eg, with post-series rabies virus neutralizing antibodies (RVNA) titer ≥0.5 IU/mL] is potentially exposed to rabies, then the management becomes an urgent and not an emergent matter.[14] Rabies PrEP may be seen as addressing a manageable risk, because it simplifies post-exposure aftercare. Rabies immune globulin (RIG) is not required for PEP in an adequately “PrEPed” traveler; and RIG is often unavailable in many developing countries.[10,

12-14, 25-27] However, rabies PrEP may also be seen as addressing rabies exposure as a preventable risk rather than simply a manageable one. Veterinarians and other animal handlers receive rabies PrEP for occupational reasons, because they may experience inapparent BCKDHB rabies exposure during the course of their careers.[12, 14] As a precaution, these individuals are tested at regular intervals to assure having adequate RNVA (>0.5 IU/mL) as a surrogate for protection against rabies infection, because inapparent exposures would never result in post-exposure rabies vaccination. This has been an accepted occupational health practice for several decades.[13] To our knowledge, there have been no reported cases of rabies among animal handlers who have received a proper rabies PrEP series using a World Health Organization (WHO)-recommended vaccine of cell-culture origin.