Rabies exposure in international travelers: do we miss the target?

Background: Little data exist about the spatial distribution of the risk for travelers of being injured by a potentially rabid animal. Methods: Over the last 14 years, animal-associated injuries in 424 international travelers presenting to a travel medicine clinic in Marseille, southern France, were investigated. Results: The majority of cases were reported from North Africa (41.5%) and Asia (22.2%). Most countries where at-risk injuries occurred (Algeria, Morocco, Tunisia, Thailand, and Turkey) were those for which travelers do not usually seek advice at a specialized travel clinic, because these countries are not at risk for specific travel-associated diseases like malaria or yellow fever. The probability of travelers being attacked by each animal species varied significantly according to the destination country. Dogs were more frequently involved in Algeria, cats in Tunisia and the Middle East, and non-human primates in sub-Saharan Africa, Madagascar, and Asia. Conclusions: We suggest that rabies pre-exposure vaccination should be offered to individuals traveling regularly to North Africa to visit their relatives and who are at high risk of exposure to potentially rabid animal attacks. Pre-travel advice when addressing rabies prevention should consider the specific epidemiology of animal-related injuries in the traveled country, as well as the traveler's characteristics. Travelers should be advised about which species of animal are potentially aggressive in their destination country so that they can more easily avoid risk-contacts. (C) 2009 Published by Elsevier Ltd on behalf of International Society for Infectious Diseases.