Dog and monkey bites in Vietnam: what to do about rabies risk

Act today. Rabies is one of very few travel health topics where the correct response is not to monitor and see. Once symptoms begin there is no treatment that changes the outcome, and the illness is fatal. Before symptoms begin, prevention after exposure works reliably — which is why everything on this page is about speed.

The other thing worth saying at the start: the dose of urgency here is not meant to frighten anybody out of a trip. Vietnam has an enormous number of friendly street dogs and almost nobody who meets them has a problem. The point is simpler than that. If you do get bitten, the response is same-day and standardised, not a judgement call. Nothing on this page replaces being examined; the category a wound falls into is decided in person.

What to do in the first few minutes, and when to go to hospital

Wash the wound first. That is not tidying up before treatment. It is the first and most effective step of treatment, and the clock on it is immediate. Then go to a clinic or hospital the same day, whatever the hour. Call 115 or go straight to the nearest hospital emergency department if any of these apply:

• Bleeding that firm pressure does not bring under control
• A bite to the face, head, neck, hand or genitals, where nerves are dense and the route is short
• A deep puncture, a crush injury, or a wound you cannot see the bottom of
• A bite from an animal behaving strangely — unprovoked aggression, staggering, drooling, unable to swallow, or paralysed
• A bite from a bat, or waking in a room where a bat has been flying
• Swelling, spreading redness or fever developing in the hours and days afterwards
• Any bite in a child, where the wound is closer to the central nervous system simply because the child is small

A small bite from a dog you know and whose vaccination certificate you have seen is a different conversation from an unprovoked bite in the street. Both still get washed, and both still get assessed the same day.

Washing the wound properly

Thorough washing removes and inactivates a large part of the virus at the entry point. It is the measure most often done for thirty seconds when it needs fifteen minutes.

• Soap and running water, for a full fifteen minutes by the clock. Not a rinse
• Work the water into the depth of the wound rather than over the surface. A tap squeezed through a bottle gives useful pressure
• Follow with povidone iodine or an alcohol-based antiseptic if there is any to hand
• Do not suture a bite closed at this stage, do not cauterise it, and do not apply chilli, lime, herbs, engine oil or any of the traditional remedies that will be suggested
• Do not try to squeeze the wound to make it bleed more
• Keep it open and covered loosely. Take it to be assessed rather than dressing it and carrying on

What counts as an exposure

This is where people talk themselves out of going, usually because there was no blood. The categories used internationally are worth knowing, because they decide what treatment follows.

Touching or feeding an animal, or being licked on intact skin, is not an exposure and needs nothing. Nibbling on uncovered skin, a minor scratch or graze without bleeding, is an exposure and needs vaccination. A single bite or scratch that breaks the skin, a lick on broken skin or on a mucous membrane, and any contact with a bat, is the category that needs both vaccination and rabies immunoglobulin.

That third category is the one that surprises people. A lick on an existing graze counts. A scratch from a cat that drew a bead of blood counts. The absence of a dramatic wound tells you nothing about the risk.

Monkeys at the temples and the parks

Macaques are the exposure most travellers here actually experience, and it is almost always because of food. A monkey that has learned to associate plastic bags with lunch will take one out of a hand. The hand gets scratched or bitten in the process. The sites where this happens are predictable. The temple complexes, the headland parks, and anywhere a viewpoint has a snack vendor.

Macaques can carry rabies. They also carry herpes B virus, which is a separate and serious consideration with monkey bites specifically, and it is a reason a monkey scratch is assessed rather than washed and forgotten.

Prevention is behavioural. Do not feed them, do not carry visible food, do not make eye contact with a large male, do not photograph a mother with an infant at close range, and let go of a bag rather than contesting it. Nothing in a bag is worth the course of injections.

The vaccination timetable

Post-exposure vaccination is a short course given over a couple of weeks. The first dose should be on the day you present. The exact schedule depends on which regimen the clinic uses, whether the vaccine goes into muscle or into the skin, and whether you have had a rabies course before.

• Someone with no previous rabies vaccination gets a course of several doses spread across roughly two weeks, with the first on day zero
• Someone who completed a pre-exposure course before travelling needs only two doses, a few days apart, and does not need immunoglobulin
• Immunoglobulin, where it is indicated, is infiltrated into and around the wound itself and is given at the start of the course, not later
• Starting late is better than not starting. There is no cut-off after which it is pointless to begin, because the incubation period can run for months
• Finish the course. Travellers routinely leave a country mid-schedule, and the remaining doses can be given elsewhere if you carry the record
• Keep the vaccination card with the product name, batch and dates. A clinic in another country cannot continue a course it cannot verify

The practical reason to go the same day is immunoglobulin. It has to be given early to be useful. It is the component most often missed when somebody waits a week to see whether anything happens.

Where to go in Vietnam

Rabies prophylaxis in Vietnam is handled through the preventive medicine system rather than through general clinics. Every province has a centre for disease control with a vaccination unit, and the larger cities have Pasteur Institute branches. Those are the places that reliably hold both the vaccine and the immunoglobulin. Large public hospitals also provide it.

The supply question is the reason to ask before travelling across town: vaccine is widely available, immunoglobulin is less so, and knowing which unit has it saves a day. A general practitioner or a house call can assess the wound, wash and dress it properly, work out which category the exposure falls into, deal with the tetanus question and start antibiotics if the wound needs them — and then send you to the right vaccination unit with a letter rather than leaving you to find one.

The bacterial problem, which is separate

Rabies gets the attention and bacterial infection is the thing that will actually make your week unpleasant. Animal mouths are dirty. Bites inject bacteria deep rather than depositing them on the surface. And bites to the hand become infected at a much higher rate than bites elsewhere, because there is so little tissue between skin and tendon.

That is why a bite is often not stitched, why antibiotics are frequently given for hand and deep bites rather than waiting for signs, and why a bite needs looking at again after a couple of days. Watch for increasing pain, spreading redness, discharge, a red line tracking up the limb, or difficulty moving a finger — any of those means being seen again rather than finishing the tablets and hoping.

Tetanus is the third item on the list. A bite counts as a dirty wound, so the date of your last booster is worth knowing before anyone asks.

If you are already home

People realise on the plane, or a week after getting back, that the scratch they ignored was a category that needed treatment. The answer is still to act rather than to decide it is too late.

Contact a travel clinic or your own doctor. Describe the exposure honestly, including the date, the animal and the depth. Incubation can be weeks to months, occasionally longer, and a course started after returning home still prevents the disease. Nobody will be impressed by having waited, and nobody will refuse to start.

The short version

Wash it with soap under running water for a full fifteen minutes, then be seen the same day. That combination is what prevents rabies. Any bat contact, and any bite that broke the skin, needs immunoglobulin as well as vaccine, and immunoglobulin only works if it is early. Deep wounds, facial bites, uncontrolled bleeding or a strangely behaving animal mean 115 or the nearest hospital now.