Delays in rabies post-exposure prophylaxis abroad

Many travellers sustain an animal-associated injury (AAI) that may lead to rabies. To avert infection the WHO recommends starting post-exposure prophylaxis (PEP) within 24 hours of the AAI. Many travellers experience PEP delay (60%). The reason for this is unclear, but delay leads to unnecessary health risks, anxiety, and potentially death. Therefore, this study aims to analyse which factors contribute to PEP delay while abroad.

A quantitative observational study was conducted among Dutch travellers between 2019 and 2024 using case records from the Eurocross Assistance database. The records consisted of information provided by the traveller during the trip. A multivariable logistic regression analysis with backward selection was performed to identify the factors contributing to PEP delay.

Of the 1410 AAI notifications, 838 travellers required PEP of whom 59.4% experienced PEP delay. The analysis showed higher odds of delay for travellers requiring rabies immunoglobulins (RIG) (OR:6.46; 95%-CI:4.26-9.79), and those travelling to South America (OR:22.39; 95%-CI:9.78-51.21), Central America (OR:11.54; 95%-CI:4.57-29.16), North America (OR:5.53; 95%-CI:2.04-14.96), Europe (OR:4.08; 95%-CI:2.17-7.67), Africa (OR:3.34; 95%-CI:1.59-7.02), Eastern Mediterranean (OR:2.54; 95%-CI:1.38-4.67), and the Western Pacific (OR:2.37; 95%-CI:1.36-4.12) compared to Southeast Asia.PEP delay was mainly due to conflicting medical advice and unavailability of treatment. Absence of RIG led to repatriation of 65 (7.8%) travellers to the Netherlands. The median delay for RIG was 2 days (range: 0-10), and 0 days for rabies vaccinations (range: 0-15). The highest median delay for RIG was observed in Central and South America (4.5 days; range: 1-10 and 1-7, respectively), while no delay was observed in Southeast Asia.

Travellers to Central- and South America are at particularly high risk of PEP delay, primarily due to conflicting medical advice and unavailability of RIG. Our findings suggest that destination-specific pre-exposure prophylaxis advice may reduce preventable delays and improve rabies prevention outcomes.