Rabies vaccination in Ecuador
No RIG rabies treatment in Ecuador

Do I need a rabies vaccination before traveling to Ecuador?

If you come from a western country, like myself. And if you asked your countries Health Department about the recommended vaccinations before your travels to a developing country, there is a good chance that they recommended you to take an anti-rabies vaccination.
Years ago my own Dutch Health Department (GGD) recommended me for my travels to Latin America to also have 3 preventive vaccinations against rabies. These would be about 100 Euro each plus consultation costs. These three injections would then give me 24 hours extra in case I got bitten by a suspicious animal.
Normally if you get bitten by a suspicious animal you have 24 hours to start your anti-rabies treatment. But with these 3 preventive vaccinations I would have 48 hours. This would be good in case I travel to very remote areas and won’t be able to reach a clinic within 24 hours of being bitten. But I didn’t plan such travels. So I decided that 300+ Euro was too much for just 24 hours extra (prices can vary).
However, I wasn’t informed of one important detail; If you don’t have a pre-vaccination and you get bitten by a dog with rabies, then you also need a so called RIG vaccination. This vaccination is expensive and not everywhere available…

Bat in Amazon EcuadorNow I’ve been about 16 years on and off in Latin America. I’ve been bitten 3 or 4 times by (street) dogs and also a few times by other (wild) animals. The ‘wild animal’ bites were at the animal refuges where I worked. All animals looked and were healthy, so I was never worried about getting any rabies. I would have been if this animal had been a bat, or a really wild animal (not one that lives in an enclosure), but this never happened.

The main reason I’ve never been really worried about rabies is as followed:
People can get rabies only via a bite from a rabid animal or possibly through scratches, abrasions, open wounds or mucous membranes in contact with saliva or brain tissue from a rabid animal.
Dogs with rabies may only shed the rabies virus three to six days before they show clinical signs of rabies and only live for a few days after the clinical signs appear.

What to do when attacked by dogs in Ecuador?

If you go hiking/ biking and/ or running in Latin America, you will likely meet some barking dogs. They either live on the streets, or ‘escape’ from their property when you pass by. Luckily most of these dogs aren’t really aggressive. They bark at you, because you enter their territory, or because they’re scared of you. An effective local trick in Latin America is to pick up a small pebble and throw it in their direction. Usually you don’t even actually throw the pebble, or actually hit the dogs, because they will already run away when you make the movement. If they’re not impressed (rarely happens) then feel free to hit them with the pebble. If they really come close, then you might have to kick them, but that hardly happens. On a bicycle this might be needed sometimes when dogs try to bite your ankles. If it is just one dog you can also step of you bike, hold the bike between you and the dog and walk slowly out of his territory.
NEVER turn your back at the barking dogs, or run away! Once they start barking at you, you will have to keep eye contact with them until you’re past, or else they think that you’re afraid and they’re ‘the boss’. It’s best to keep eye contact and slowly walk out of his territory. Almost all dogs have a for us invisible territory and will not follow you out of there. For more safety tips.

Rabies in Ecuador

After my experiences from the past weekend in Ecuador, I’m happy that I was never bitten by any suspicious animal. If so, I might have actually died. Or at least in Ecuador, but I suspect that other Latin American countries might handle similar procedures.
Luckily Ecuador does have a good preventive vaccination program against rabies. Dog owners are obligated to vaccinate their dogs against rabies and each year there is a monthly campaign to give out free rabies vaccinations. Once a year the government of Ecuador even sends workers out to visit dog owners and check if their dogs have valid vaccinations.
According to the following Ecuadorian website from ODA (a national organization that helps animals in Ecuador), there hasn’t been any case of rabies in Ecuador for over more than 20 years. On the other hand a spokeswoman from the official Dutch Health Department just told me that this information isn’t completely reliable. According to her there have been some suspected cases in the past 20 years. However, lack of adequate knowledge could mean that these cases weren’t about rabies. Unfortunately, it can also mean that there were actually even more infected cases, but they weren’t recognized.
The World Health Organization (WHO) writes that there have been less than 4.5 deaths due to rabies in Ecuador between 2013 and 2016. Peru had between 4.5 to 20 deaths in the same period, but is also 5x bigger.
The World Organization for Animal Health also still considered rabies to be present in Ecuador in 2019.

I think that the information from the websites above show sufficient proof that cases of rabies in Ecuador are very, very rare, but nonetheless still possible.
So what do you do when you get bitten by a wild animal or (street) dog in Ecuador? The World Health Organization recommends the following steps:

Official WHO rabies treatment recommendation

Get as soon as possible to a hospital and start with a Post-exposure prophylaxis (PEP) treatment. This PEP is the immediate treatment of a bite victim after possible rabies exposure. This treatment prevents virus entry into the central nervous system, which results in imminent death.

Post-exposure prophylaxis (PEP) consists of:

1- Extensive wound washing; This involves first-aid of the wound that includes immediate and thorough flushing and washing of the wound for a minimum of 15 minutes with soap and water, detergent, povidone iodine or other substances that kill the rabies virus. If possible it is also best to keep the wound open to the air. So try to limit stitches and even tight bandage on the wound. If you don’t have a valid tetanus vaccination, it might be recommended to also receive one of those.
2- Depending on the severity of the contact with the suspected rabid animal, administration of PEP is recommended as follows (see table below):
Categories of contact and recommended post-exposure prophylaxis (PEP):

Category I
Touching or feeding animals, animal licks on intact skin (no exposure)
2A – Recommended PEP treatment: None

Category II
Nibbling of uncovered skin, minor scratches or abrasions without bleeding (exposure)
2B – Recommended PEP treatment: Local treatment of the wound and immediate vaccination

Category III
Single or multiple transdermal bites or scratches, contamination of mucous membrane or broken skin with saliva from animal licks, exposures due to direct contact with bats (severe exposure)
2C – Recommended PEP treatment: Local treatment of the wound and immediate administration of rabies immunoglobulin (RIG) and immediate vaccination with the anti-rabies vaccine.

All category II and III exposures assessed as carrying a risk of developing rabies require PEP.

Rabies vaccination details

First you need a fast-acting shot of rabies immune globulin (ERIG or HRIG), to prevent the virus from infecting you. Both products are produced by vaccinating either horses (ERIG) or humans (HRIG) and harvesting their plasma which contains antibodies against rabies virus. The dose of ERIG is twice as high (40 IU/Kg of body weight) as the dose needed if you receive HRIG (20 IU/Kg of body weight). Don’t give too much, as the shots can then work counterproductive.
Both globulin treatments (RIGs) are good and consist of different shots given near the area where the animal bit you. It is best to receive these shots as soon as possible after you got bitten (within 24h), but it can still be given until maximal 7 days after the bite. The purpose of these shots is to give your body a direct boost to help producing antibodies and fighting the rabies virus. If you already had a preventive rabies vaccination in the past 5 years, you don’t need these RIG shots, because your body has already produces some antibodies against rabies. However, it is still recommended to get an extra boost of the anti-rabies vaccination.

After receiving your RIG shots, you will receive the first of your 5 shots of anti-rabies vaccination. In Ecuador they use VERORAB.
Ideally you receive your fist VERORAB injection on the day you got bitten in the muscle of your upper arm, at the opposite location of where you received your RIG shots. This will be the start of your treatment for the nest 3 to 4 weeks.
A common schedule is that you receive your first treatment on day 0, then you receive one on day 3, then day 7, day 14 and day 28 (or day 21).
If you need to travel, it is good to know that you could also receive these VERORAB vaccinations at other locations. They don’t have to come from the same bottle. Still it is good to take a picture of the medicine that you received.
It is also important to verify if the same medicine is available at your next location.

Although the risk to get infected with rabies in Ecuador is very small it increases if:
• The biting mammal is a known rabies reservoir or vector species
• The exposure occurs in a geographical area where rabies is still present
• The animal looks sick or displays abnormal behavior
• A wound or mucous membrane was contaminated by the animal’s saliva
• The bite was unprovoked
• The animal has not been vaccinated.

Ideally the vaccination status of the suspect animal should not be the deciding factor when considering initiating PEP. It can happen that local vaccination programs aren’t sufficiently regulated, or followed out of lack of resources and/ or priority.

However the reality of rabies treatment in Ecuador is different

Two different dog bites in the past 5 months in combination with the personal explanation of a vaccination doctor in Ecuador, show that their policies differ from those of the WHO.
It is likely that because RIGs are limited available (supposedly only in Quito), their standard emergency procedure doesn’t include the use of RIGs.
This isn’t ideal, but according to the following WHO health study (page 3) the treatment can still be effective. In most of the cases the survival rate is still almost 100%. This is as long as the victim does receives directly his/ her anti-rabies vaccination on the day he/ she got bitten by a suspicious animal..
Sadly, and here it comes, the current (January 2020) policy in Ecuador is NOT to give any vaccinations until there is proof that either the dog/ animal is sick, or you start showing the first symptoms.
According to the official Ecuadorian governmental policy, victims of dog bikes are recommended to observe the dog for 8 till 10 days.
If the dog doesn’t get sick you don’t need treatment.
If you can’t observe the dog, then you have to keep a close eye on your own health. If you start to feel sick then come back and get your rabies vaccination (VERORAB).
If you’re observing that the dog is getting sick, you can also start with your VERORAB treatment.

The problem is that this will be too late. It takes about 7 to 10 days for the anti-rabies vaccination to actually start producing antibodies and fight the rabies virus. Even if they agree to give you the RIG vaccinations, it can take 2 to 3 days before it arrives at your location. Without the RIG vaccinations to cover the first 7 to 10 days, the treatment is likely not to work fast enough to prevent death.

So what to do when you get bitten by a dog/ wild animal in Ecuador?

->  Get as soon as possible to a hospital and get the wound cleaned (PEP 1 treatment).
->  Try to find the dog and its owners and ask them if the dog has recently been vaccinated against rabies. Officially this is obligated by law. If the dog has recently been properly vaccinated against rabies, then there is no risk for contaminations. If you can’t find the dog/ animal, or it isn’t sure if it has been properly vaccinated in the past years, you will have to make a decision. Do you want to take the risk and believe that it is very unlikely that the animal has rabies, or do you not want to take that risk? If you don’t want to take that risk then;
->  Try if you can also get the PEP 2 treatment.
->  Contact the emergency number of your health insurance, or if you don’t have a health insurance, then contact the health department of your government and/ or your Embassy/ Consulate. Explain them your situation as detailed as possible and also tell them about the official governmental policy around dog bites. After explaining the details, see how much these institutions can do for you in trying to get the right PEP treatment.
->  As I wrote above, even if you can’t get the RIG vaccination, it is still important to get at least the first VERORAB vaccination on the day you were bitten, or at least as soon as possible. To receive this vaccination already on the day you got bitten, you will need to be able to discuss in Spanish and/ or have good help.

Important: if possible always keep an eye on the dog that bit you for at least 10 days.
After an animal is exposed to rabies and the virus has spread to its salivary glands, the animal may be able to shed (or excrete) the rabies virus in its saliva; this means that the animal is infectious. Shedding occurs in the last stages of the disease and you can only receive rabies when saliva or brain tissue of the infected animal enters an open wound. Clinical signs of infection appear in these last stages, followed closely by death. Dogs, cats and domestic ferrets with rabies may shed the rabies virus three to six days before they show clinical signs of rabies and only live for a few days after the clinical signs appear. This is why it is so important to observe animals that have bitten or otherwise potentially exposed a person to rabies. If a dog, cat or domestic ferret is healthy 10 days after the incident, it can be concluded that the rabies virus could not have been in the animal’s saliva at the time of the incident and it could not have exposed the person to rabies.
The animal still could possibly be incubating rabies, but it could not have been at the point of transmitting the virus in its saliva.

Other positive information is that the whole rabies treatment in Ecuador is for free.

More information about rabies you can find at:

What is rabies.
Facts about rabies.
Rabies vaccinations.
VERORAB.
Rabies treatment.
RIG.
With and without RIG.

Important note: The information above are written based on real life experiences in a developing country, Ecuador. The general recommendations come from experts, but personally I’m just a traveller. Also each case and each person is different; therefore I like to recommend travellers to use the information above as guide lines, but not as exact knowledge. In case you got bitten, it is always best to contact the emergency number of your own (health) insurance.

About Author

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Martijn Steijn
Martijn Steijn, founder and General Manager of Fairtravel4u.