Scratched by a monkey, how to prevent rabies and herpes B

Monkeys may be cute but I came to know first hand how greedy and nasty they can be. While visiting one of the Hindu temples at Batu Caves, near Kuala Lumpur in Malaysia, the priest blessed me with white/red powder on my forehead and a flower behind my ear. Filled with serenity, I proceeded to walk up the stairs to explore the temple/cave.

Unfortunately this feeling was short lived. Suddenly I felt a sharp pain in my ear. My flower gone and my ear bleeding, a monkey had come out of nowhere and stolen my flower, and proceeded to eat it in front of me, a face full of defiance, challenging me to come get him, if I dared.

The monkey that stole and ate my flower
The truth is, monkey bites and scratches are quite common in travellers. If you've travelled in Asia you would no doubt have seen them in rural areas, temples, even beaches and hot springs! They're not shy and will often try and steal food from the unsuspecting.

Unfortunately even the smallest monkey bites or scratches can be quite nasty as they have the potential of transmitting rabies and herpes B virus. Most people are not aware of this danger so hopefully this post will provide some information about what to do in the event of a bite or a scratch, and explain why rabies vaccination is a good idea for ALL travellers going to developing countries.


Rabies

Rabies is a virus that can be transmitted by bites, scratches or licks over broken skin from dogs, cats, monkeys, raccoons, bats - any mammal really! It is present in most of the world, especially Asia and Africa. Even in countries declared rabies free eg Australia, a closely related virus called lyssavirus can be present in bats and flying foxes, and can cause an equally serious disease.

Once the rabies virus gets into the wound after a bite or scratch, it travels silently towards the brain; this process may take weeks, months, or even years! Symptoms include fever, headache, weakness, abnormal behaviours, paralysis, seizures, hydrophobia (fear of water) and aerophobia (fear of air). Once symptoms develop though, it is almost 100% fatal.

The good news? There is something we can do before rabies kills us. Wash the wound thoroughly in water and soap for 10-15 minutes, then see a doctor as soon as possible to start post exposure prophylaxis which includes HRIG (human rabies immunoglobulin, ie antibody) injection locally into the wound as well as a course of four rabies vaccines into the arm (on day 0, 3, 7  and 14). The HRIG gives us some immediate protection while waiting for the rabies vaccines to start working. (Note, if your immune system doesn't function normally you need a fifth rabies vaccine on day 28.)

So we can go get jabs after the bite to protect us from rabies - that's great news! But the problem? HRIG is very expensive (can be over $1000!) and is not available everywhere, which means having to interrupt your journey and maybe even fly elsewhere (eg in South East Asia it's available in Singapore and Bangkok) or home where this is available. Some places only have ERIG - (equine [horse] rabies immunoglobulin) which may be associated with a higher risk of allergic reaction. Also HRIG injections can be very painful - a 70kg adult requires about 10mL of it. Imagine trying to inject the whole amount into a finger if that is where you are bitten! Ouch!

The other option is to have a course of rabies vaccines before you travel (and before you're bitten), ie pre exposure prophylaxis - a course of three vaccines over a month (on day 0, 7 and 21 or 28). This will offer lifelong protection but two booster vaccines 3 days apart will still be required in the event of a bite or scratch. You won't need HRIG in this case and these booster vaccines are much more readily available overseas. 

I think this is definitely a good idea for ALL travellers especially those who spend time in developing countries or rural areas where access to medical care may be delayed. Kids, because of their inquisitive natures, are more at risk of animal bites and therefore vaccination should be considered. There is no lower age limit - even babies can be vaccinated. 

More monkeys outside Batu Caves


Herpes B Virus

It is a virus carried by macaque monkeys that are often found in popular Asian travel destinations. Surveys indicate over 80% of monkeys carry this virus, although human infection is extremely rare – about 50 cases reported world wide. Symptoms include vesicles (blisters) at the site of exposure, flu like symptoms (fevers, headache, fatigue) and this may eventually progress to encephalitis (infection in the brain, neurological symptoms, paralysis etc). Many will die despite treatment.

First aid includes washing the wound thoroughly with water, soap or antiseptic for at least 15 minutes. Deep puncture wounds or wounds not washed adequately may be at risk so some may be given an antiviral drug. Unfortunately there is no vaccine available. 

A monkey outside Angkor Wat, Cambodia


Other nasties - tetanus and infection

Monkey bites can also transmit tetanus and other bacterial infections so it is important that you receive a booster tetanus vaccine if you're not up to date. Deep bites may require antibiotics to prevent bacterial infections. 

Avoid the monkeys

These monkeys are not afraid of humans, and are too clever for their own good, often working in teams to try and steal food from the unsuspecting. And yes, they can work zippers (remember opposable thumbs!). Don't bring food (or keep them in air tight containers) when around monkeys. If a monkey picks on you, don't make eye contact or smile with your teeth showing, as it can be interpreted as a sign of aggression. Stay calm, don't show fear, and don't run away. Give them what they want. If it can't be eaten they will soon leave it alone.



The Aftermath...

My next stop after my scratch was Singapore so when I got there the next day I called around to try and find doctors with rabies vaccines available. No such luck. They all advised going to the emergency department; fortunately where I stayed was only 5 minutes walk from Singapore General Hospital. After waiting for 2 hours I was given my first rabies vaccine and sent home. After I came home I finished my course of rabies vaccines and it's nice to know that I'll have some protection against rabies in the future.

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