Swiss adventurer, athlete, travel writer and photographer Ella Maillart said “You do not travel if you are afraid of the unknown, you travel for the unknown.” When it comes to international travel, excitement and the unknown are both on the itinerary.

Travel offers many health benefits including increased mental well-being and happiness from new experiences, creating fun, new memories, breaking routine, meeting new people and taking in the endless sights the world has to offer. However, fear of being attacked by a wild animal generally isn’t a blip on the radar of those inevitable travel emotions - even when considering the possibilities of the unknown.

In parts of Africa and Asia, wild animal attacks are a very real threat, though they are rare enough that pre-travel vaccination against rabies is not on the short list of preparedness to-do’s.

A northern Nevada woman knows all of this all too well.

The importance of international travel preparedness

You never know when you might face the unexpected, especially while traveling and venturing into the unknown. Being prepared is a travel truism, but even the best-laid plans can go awry.

Reno residents Dr. Lisa Leiden and her husband had planned their upcoming vacation in South Africa by the book. A long-time patient of Dr. Steven Zell, AAHIVS / CTH, Professor of Internal Medicine at the University of Nevada, Reno, School of Medicine (UNR Med) and travel medicine expert, Leiden thoroughly consulted with Zell before her departure.

Zell says that travel medicine is so much more than looking up where a patient will be traveling to and administering the required or recommended vaccinations. He says it’s a lot like being a travel agent. “You look at past medical history, what recreational activities are on the agenda and risks. Especially as people age and are on multiple medications, an expert in internal medicine can best advise the client on possible drug interactions that might make them prone to specific tropical diseases.”

Primed for a successful South African vacation, methodical medications and first aid kits carefully packed inside their luggage, the couple excitedly arrived in Cape Town, a port city on South Africa’s southwest coast with sweeping ocean views from majestic mountains, exotic wildlife and all around natural splendor.

Their international travel excitement soon turned to disappointment as they learned their meticulously prepared luggage had been stolen almost as soon as they arrived at their destination.

Making the best of the situation, however, the couple set out for a tour of Victoria Falls, one of the greatest attractions in Africa and one of the most spectacular waterfalls in the world.

Monkey see. Monkey bite.

Cute, anthropomorphic and mischievous, monkeys of various types and sizes are a common encounter in South Africa with the macaque being one of the most common. Making their way through the main entrance of the falls, Leiden and her husband enjoyed capturing the macaque’s adorable antics and carefree frolicking on camera.

It didn’t take long before a small group of monkeys, seemingly innocently, started following Leiden. The formerly serene scene turned into trouble as one macaque monkey bolted from the group, bounding onto Leiden’s shoe. Unprovoked, the monkey latched onto her leg, sinking four teeth through her jeans and into her flesh, drawing blood.

According to Zell, animal bites that cause puncture wounds are more likely to become infected, and animals who attack without provocation are more likely to be infected with a virus that can cause rabies. While rabies in humans is rare, it is most often deadly if contracted.

The couple reported the monkey bite at the park entrance. Although they were told it was not a risk, Leiden located an antiseptic wash in the park’s first aid kit. Returning to the hotel with just the clothes she was wearing, no luggage and no familiar first aid supplies from home, the concierge assured Leiden 100 percent that she would never have a problem from the monkey bite.

Viruses know no boundaries, nor does good medical care.

Unconvinced, Leiden reached out to Zell, now half a world away from her. “Like most UNR Med faculty members, I live on email, so it was very easy for Lisa to get ahold of me,” said Zell. Immediately, he knew rabies exposure was looming, as did his resident, Dr. Khazi Nayeemuddin. Nayeemuddin is a native of India and has seen rabies there. “Without capturing the monkey, you don’t know if it is ill,” Nayeemuddin said.

“This was my first time coordinating medical care for a wild monkey bite,” said Zell. “I networked with Dr. Robert Dedmon in Wisconsin, a retired global expert in rabies. He called me back immediately and told me in addition to rabies, there is a Simian Herpes Type B virus that can be transmitted from a macaque monkey.”

Leiden’s monkey bite incident was classified as a category III rabies exposure which includes transdermal bites, such as puncture wounds, lacerations and avulsions, or scratches and abrasions with spontaneous bleeding.

Assuming the unprovoked wild monkey could be rabid, Zell’s first recommendations were basic first-aid measures: (1) scrubbing the wound or bitten area with soap under a running tap water for at least 15 minutes; (2) removing foreign material from the site; (3) rinsing with plain water; and (4) irrigating with a virucidal agent, such as alcohol or povidone iodine.

The dedicated UNR Med doctor immediately made contact with a colleague at the International Society of Travel Medicine (ISTM) to arrange care in Africa. While international communication between Zell and Leiden, and between Zell and his ISTM contacts remained constant, progress for Zell’s next step unexpectedly ceased. The dedicated physician learned that the country of Zambia had zero readily-available rabies immune globulin (RIG) for his patient.

Getting both RIG and administration of rabies vaccine simultaneously is preferred. Rabies can take weeks to establish infection, allowing a window timeframe of up to a week to get proper treatment. Leiden’s treatment was delayed for three days while Zell worked from across the globe to coordinate the international medicine delivery that Leiden needed.

The cost of survival

The rabies vaccine is given for prevention to people who are at higher risk of coming in contact with rabies, such as veterinarians, wildlife workers, lab workers doing rabies research, etc. It’s also given to people after an animal bite if the animal could have rabies. For those not receiving vaccine prior to travel, RIG must be given at the site of a bite with the first dose of rabies vaccine at a distant second site.

Though painful upon injection, the rabies vaccine is well-tolerated with minimal side-effects. But it’s the cost of the vaccine that is even more painful and prohibitive. A serious rabies bite is capable of taking a serious bite out of the bank account.

According to the CDC, although the cost varies across locations, a course of rabies immune globulin and four doses of vaccine given over a two-week period typically exceeds $3,000. The medical cost of saving a human life from rabies ranges from approximately $10,000 to $100 million, depending on the nature of the exposure and the probability of rabies in a region.

“It was an act of urgency, and I was able to arrange for her an appointment with some of my friends with the ISTM at a district global clinic that has expertise in travel medicine,” said Zell.

“We had to get money by going to the head of the hotel and giving him our debit card. He sent a driver across the border to Zambia to get money out from a Zambian ATM machine. We then took a cab to the pharmacy in this very small town,” said Leiden.

In spite of the cost, being vaccinated against rabies may be one of the best investments of Leiden’s life.

“A lot of people have a laissez-faire attitude on safety and preparedness, when it comes to travel. If Lisa would have taken the advice from the park and her hotel, she may have become very ill and may have died. Wild animal bites, especially rabies bites, are all serious. You don’t want to take ‘you’ll be fine’ for an answer. Lisa didn’t and she is better for it,” said Zell.

Leiden and her husband flew to Johannesburg, South Africa’s biggest city, to continue treatment which included injecting seven milliliters of rabies-immune globulin around her leg bite. She also received four doses of the rabies vaccine, Rabavert, in her arm – one dose right away, and additional doses on the 3rd, 7th, and 14th days after exposure.

World Rabies Day: September 28

September 28 marks the anniversary of the death of Louis Pasteur, the French chemist and microbiologist, who developed the first rabies vaccine. It’s no wonder the same date was chosen to celebrate World Rabies Day, an annual global health observance to raise awareness about rabies, prevention and control efforts.

Although rabies cannot be cured, it can be prevented. One of the best ways to do so is to avoid being bitten by a rabid animal.

For Leiden, the unprovoked monkey bite was unavoidable, and she never dreamed of being attacked on her well-planned African vacation. Luckily, Zell was able to coordinate her medical care, ironically enough, during the month of World Rabies Day.

International travel preparedness tips

Vaccinations are an important part of international travel preparedness. Planning for a safe and successful vacation involves more than getting all of the required and recommended immunizations and medications.

Zell recommends five health/safety steps to take when planning international travel.

1.     Make a phone call to the consulate of the country you’re planning to visit. Make certain there are no vaccines required at customs. There are two designated by the World Health Organization (WHO): Yellow Fever and, in certain areas of sub-Saharan Africa and Saudi Arabia, proof of meningitis vaccine may be required for entry.

2.     Make an appointment to see a good travel clinician. This is especially important if you are older and are on medicines for dual diagnosis conditions such as heart disease plus diabetes. A travel clinician will do an analysis of your itinerary, risk assessment and recommend/administer vaccines for preventable diseases, such as travelers’ diarrhea or malaria.

3.     Get vaccinations from your travel clinician at least six weeks before departing. Some vaccines take time to kick in.

4.     Prepare an adequate first aid kit. Zell equips his travel medicine patients with a 40-page handout on various levels of first aid kids, depending on location. Information included entails nonprescription drugs, medicines to have on hand, such as acetaminophen, anti-diarrheal, creams, steroids, sunblock, and mosquito repellent, as many viruses are carried by mosquitos, wound care supplies for abrasions, cuts, deep puncture wounds, antiseptics to clean wounds, rubber gloves to prevent contamination and a mask.

5.     Pre-identify a source you can go to for help in a third world country. Ensure the source can speak your native language and offer expert medical advice should you need during your travels abroad. The ISTM global directory lists experts in foreign countries who specialize in travel medicine.

Rabies is not only an international concern

The rabies problem is as old as mankind, dating back in written records to the Romans, Greeks and Egyptians. The term “rabies,” came from the Sanskrit word rabhas, which means “to do violence.”

While rabies is a 100 percent preventable disease, Centers for Disease Control and Prevention (CDC) estimates that rabies kills more than 59,000 people worldwide, every year. To help prevent and control rabies, vaccinate pets and learn how to stay safe from the animals that commonly spread rabies in the U.S., including raccoons, bats, skunks, and foxes.

And they traveled happily ever after

Lisa Leiden’s health and even life were saved from potentially deadly misinformation, thanks to Zell’s expertise and Certification in Travel Health (CTH), which allows him to connect patients to medical providers anywhere in the world.

“UNR Med and Dr. Zell are at the forefront of delivering comprehensive travel health services, enabling people to travel and return home safely,” said Dr. Thomas L. Schwenk, dean of the University of Nevada, Reno School of Medicine. “We are extremely proud our UNR Med faculty like Dr. Zell and his team, whose health care services address real-world needs and improve the quality of life for the people of Nevada, the nation and the world.”

Zell’s travel services are available to the general public. Those interested do not have to be an established patient of UNR Med to be seen for a pre-travel consultation. To make a travel consultation appointment, call (775) 982-5000.