Bitten or Scratched by an Animal Abroad? What to Do in the First 24 Hours

Why this is the one travel problem where you do not wait

The CDC chapter is blunt about it: rabies is a fatal, progressive infection of the brain; once symptoms appear there is no evidence-based treatment and survival is incredibly rare; and yet it is completely preventable by appropriate care after a bite. CDC puts the rate of exposures at somewhere between 16 and 200 per 100,000 travellers, with deaths in travellers averaging about two a year worldwide. The gap between those two numbers is what this page is about.

Dogs are the main reservoir in many low and middle income countries; bats can transmit rabies in any destination; cats, though not a reservoir, are increasingly reported; and monkeys, CDC notes, are a common source of bites in Asia, often around tourist sites, and usually cannot be followed up, so post-exposure treatment is recommended after a monkey bite.

Step one: wash the wound, properly, now

CDC's instruction is to clean all animal bites and scratches with copious amounts of soap and water, povidone iodine, or other products with virucidal activity, and to do it immediately or as soon as possible. CDC's own rabies guidance elsewhere describes washing for a full 15 minutes. The chapter states that cleaning the wound immediately substantially reduces the risk of rabies virus infection, especially when followed by timely post-exposure treatment. It also says that for unvaccinated people, stitching the wound should be delayed for a few days unless needed to stop bleeding or for function.

Step two: get assessed for post-exposure treatment, and do not sleep on it

Post-exposure prophylaxis, in CDC's description, means wound care plus a course of rabies vaccine, and for people who were never vaccinated before, an injection of rabies immune globulin around the wound as well. The vaccine course runs over about two weeks. For people who completed a pre-travel rabies vaccination, treatment is shorter: two doses, three days apart, and no immune globulin. Pregnancy is not a reason to withhold treatment, and children get the same vaccine dose as adults.

The reason not to wait for symptoms is in the chapter: rabies virus can persist in tissue for a long time before it reaches a nerve, which is why CDC says an unvaccinated traveller with a suspicious bite should receive full treatment even if considerable time has passed. The converse is also true: treatment started promptly is what prevents the disease. CDC observes that abroad the animal can rarely be observed for the ten days that would clear it, so post-exposure treatment is commonly given out of an abundance of caution. That is the right default.

Bats, monkeys, cats, and the dog you just stepped over

• Bats: CDC says many bats have tiny teeth and the wounds might not be visible, failure to find the bite has led to deaths, and any contact with a bat on bare skin or in the hair is grounds for post-exposure treatment. Do not handle bats; consider protection before entering caves.
• Dogs: in many countries dogs roam freely. CDC advises avoiding contact, not approaching puppies with the mother near, not stepping on sleeping dogs, and, with an aggressive dog, avoiding eye contact, staying still and backing away slowly. Shouting or running is likely to provoke a bite.
• Cats: not a reservoir, but CDC notes a small and increasing number of deaths from cat bites and scratches, and says bites and scratches from unfamiliar cats should be reported to a medical professional for assessment.
• Monkeys: rarely rabid, but a common source of bites around tourist attractions in Asia; CDC recommends post-exposure treatment for bite victims because the animal cannot be followed up. Do not carry food near habituated monkeys.
• Children: at greater risk, CDC says, because of curiosity, inability to read animal behaviour, and a tendency to take bites to the head and face, and they may not report it. Ask them directly.

If you were vaccinated before the trip

Pre-travel vaccination does not remove the need for care after a bite, but it simplifies it: CDC says previously vaccinated people receive two vaccine doses three days apart and do not need immune globulin. The current US schedule for pre-travel vaccination is two doses a week apart; CDC notes protection from that series is well supported for about three years, after which a booster or a blood test is advised for people with continuing risk. If that sounds like your situation and you are not sure where you stand, a doctor can work it out with you from your vaccination record.

Abroad, the treatment you are offered can differ

CDC's chapter is useful here in a way few patient pages are. Human rabies immune globulin is in short supply worldwide and unavailable in many countries; equine immune globulin or monoclonal antibody products may be offered instead, and CDC says those are preferable to none. If immune globulin is delayed but modern vaccine is available, CDC says to start the vaccine and add the immune globulin within seven days. Different vaccine schedules and brands are used abroad and are acceptable. CDC advises travellers to photograph the products they receive and note the schedule, so that a doctor at home can tell whether anything needs topping up.

One warning CDC gives plainly: some countries still use old vaccines made from animal brain tissue, recognisable as a large daily injection for two to three weeks. CDC advises declining those and travelling to somewhere that has modern vaccine.

You are already there: what this means in practice

Everything above is the CDC chapter. This section is ours. The countries we write about are all places where this applies: street dogs in Morocco and Egypt, monkeys at tourist sites, cats everywhere, bats in caves and roofs. The practical picture from the chapter, if it happens to you: wash for 15 minutes under a tap with soap; do not stop to debate whether the animal looked healthy; take a photo of the wound; and, per CDC, seek post-exposure treatment as soon as possible. On our country guides you will find the emergency numbers and what FCDO says about local care for Egypt, Morocco and the Dominican Republic.

What a video doctor can and cannot do about this

After a bite abroad, in-person care comes first: the injections have to be given in person, as soon as possible. A video consultation can sit alongside that, for example while you are on your way, but never instead of it and never as a reason to wait. On that call a doctor can look at the wound and at you, give a view on how urgent this is, coach you through washing it properly, ask about the animal and the circumstances, check whether you were vaccinated before the trip and what that changes, and tell you exactly what to ask for and what to refuse when you get to the injections. That can save hours and a great deal of worry. A doctor can also, where clinically appropriate and local rules permit, advise on the wound itself.

What a video doctor cannot do is give you the vaccine or the immune globulin. Those are in-person, and soon. A bite from a mammal abroad cannot be managed entirely by video, and nothing on this page should be read as suggesting it can; CDC's guidance is wound washing and post-exposure prophylaxis as soon as possible.