title: Should travellers to rabies-endemic countries be pre-exposure vaccinated? An assessment of post-exposure prophylaxis and pre-exposure prophylaxis given to Danes travelling to rabies-endemic countries 2000-12.
abstract: BACKGROUND
  Since 2000, a steady increase of vaccines used for both rabies Post-exposure prophylaxis (PEP) and rabies Pre-exposure prophylaxis (PrEP) given to Danish travellers was observed. This study aims to evaluate whether the increase of PEP and PrEP was due to increased travelling, increased awareness of the need for PrEP, or more animal bites per travel, leading to more PEP being administered, in order to assess the need for changing the recommendations. We also described in which countries Danish travelers most frequently reported possible exposure to rabies, and evaluated the timeliness of rabies PEP, including rabies immunoglobulin (RIG).
  
  
  METHODS
  We included all Danes reported to the National Database for Rabies Treatment as having started rabies PEP either abroad or after returning to Denmark, between 2000 and 2012. Data on the yearly number of Danish travelers from 2004 to 2012 to Thailand were collected to calculate the incidence of animal bites at this destination. We also included data on rabies vaccines sold for PrEP or for booster vaccination in Denmark.
  
  
  RESULTS
  PEP after possible exposure to rabies abroad increased yearly by 8.8 %. Likewise vaccines sold for PrEP increased by 8.2% annually. The number of Danish travelers to Thailand increased by 7.3% per year, resulting in a stable incidence of animal bites per 100,000 travelers. Seventy-five % started PEP in the country of exposure, while only 10 % received RIG.
  
  
  CONCLUSIONS
  The yearly increase in PEP and PrEP are parallel to the yearly increase in number of travelers, and can thus be explained by the increased rate of traveling, and not by a rise in awareness of rabies risk or more bites per traveler.Even short term travelers should be given the option of including PrEP in their travel immunisation program, as PEP and especially RIG is not always available in rabies-endemic countries.
authors.affiliation: Department of Infectious Disease Epidemiology, Division of National Health Surveillance & Research, Statens Serum Institute, Denmark ahc@ssi.dk.
authors.forename: Annette H
authors.initials: AH
authors.lastname: Christiansen
authors.affiliation: Department of Infectious Disease Epidemiology, Division of National Health Surveillance & Research, Statens Serum Institute, Denmark.
authors.forename: Anna B
authors.initials: AB
authors.lastname: Rodriguez
authors.affiliation: Department of Infectious Disease Epidemiology, Division of National Health Surveillance & Research, Statens Serum Institute, Denmark.
authors.forename: Jens
authors.initials: J
authors.lastname: Nielsen
authors.affiliation: Department of Infectious Disease Epidemiology, Division of National Health Surveillance & Research, Statens Serum Institute, Denmark.
authors.forename: Susan A
authors.initials: SA
authors.lastname: Cowan
mesh_terms: D000818:Animals; D001733:Bites and Stings / Q000453:epidemiology; D016208:Databases, Factual; D003718:Denmark; D006801:Humans; D015994:Incidence; D056990:Post-Exposure Prophylaxis / Q000639:trends*; D065129:Pre-Exposure Prophylaxis / Q000639:trends*; D011818:Rabies / Q000453:epidemiology* / Q000517:prevention & control*; D011819:Rabies Vaccines / Q000627:therapeutic use*; D012044:Regression Analysis; D013785:Thailand; D014195:Travel
chemical_list: D011819:Rabies Vaccines
keywords: Postexposure prophylaxis; Rabies; Rabies exposure