Rabies

[cheeryble]

Can anyone tell the price for a course of rabies shots?

(My regular hospital is Ram CM.)

Day before yesterday I got a nip which drew blood from an unknown dog which joined my dog and I for a walk.

He was certainly not showing symptoms and was nervous but quite pleasant. I felt sorry for him and fed him at my house with my dog and afterward when he came when I called my dog with tail wagging I gave them both a tousle of the head but he nipped me.

I washed it well in water then put the finger in a half glass of Sangsom for a couple of minutes.

I think this all reduces any chances of rabies to very small indeed, but a friend tells me the incubation is long, so am interested in the cost of shots.

Edited October 6, 2013 by cheeryble

[Gsxrnz]

Had a friend that went through with the injections. I seem to recall he got 5 shots over the space of about 10 or 12 days and paid about 8k Baht for the course.

He mentioned he had a choice of 3 or 5 injections - not sure what that was all about.

[Sheryl]

It depends on whether you have ever had the pre-exposure rabies vaccine, if you have then a shorter course needed . If not, then 5 injcetions, plus you need a dose of the immunoglobulin. The immunoglobulin and 1st does of vaccine should be given as soon as possible, preferrably on day 0.

Thoroughly washing the wound with soap and water immediately =after the bite reduces but does nto eliminate the risk. I doubt putting it in Sangsom helps.

[cheeryble]

Thanks for the replies!

I have come to the wobbly conclusion the risk is very low indeed and haven't bothered getting inoculated.

It's not like the shots are particularly cheap, they are a real expense.

The dog is still hanging around the gardens where I live.

I feel sorry for it and had thought of at least feeding it regularly, but it tends to bark at people in the night and so I'm shooing it away I have great trouble getting back to sleep. Sorry dog.....but you did bite the hand that fed you!

[wpcoe]

As long as you are comfortable with the odds, good on you. However, you do realize that rabies is 100% fatal (and very unpleasant while killing you) if it develops, right?

[ross163103]

Listen to what the previous poster said about the fatality rate and get the shots.....8k baht is cheap compared to your life. Good luck!

[hanno]

Get the shots now!!!!! Rabies is prevalent in SE Asia and it is not a pleasant way to go.

[cheeryble]

Thanks for all your concern.......

but i think the odds are very slim and am willing to take my chances.

Funnily enough the same dog has been hanging around in the background at our garden......a sort of forested community of rentals.....and today he was the same slightly nervous but amiable slowly tail wagging chap who approached when I was going to feed my dog (and I still feel sorry for him may arrange for him to get food somewhere far enough away I can't be woken up).

I think the little snap he gave me was just reaction pretty typical of a nervous dog to overconfident petting.

I also noted today that from a distance of a few yards there are no obvious wounds on him where he may have himself contracted rabies.

I read that the virus is pretty fragile and susceptible to alcohol, so add to the above the washing in water then soaking in whisky I gave the two tiny and surface wounds (which bled just a few drops), and I think I can not justify the expense of shots to myself.

Again, thanks!

(holds throat, froths, and grimaces )

Edited October 9, 2013 by cheeryble

[Dr Robert]

cough up the money, get the shots or risk an ugly painful end. simple really.

[cheeryble]

Again thanks for the concern Dr.R....

but unless you can convince me I'm thinking irrationally about some step in my considerations I'll add to the above that I'd be willing to bet that the transmissable viral load is much less if an infected dog is not showing symptoms.

Edited October 9, 2013 by cheeryble

[wooloomooloo]

You've made your mind up, cheeryble. If you survive then maybe you can think about longer term protection.

[offset]

No need to go to a hospital I had mine carried out by a normal doctor and if my memory is good it was only 500 baht an injection

[hanno]

A dog does not have to have "obvious wounds" to have rabies as it can be passed on by saliva. anyway, you have made up your mind; good luck.

[Sheryl]

Again thanks for the concern Dr.R....

but unless you can convince me I'm thinking irrationally about some step in my considerations I'll add to the above that I'd be willing to bet that the transmissable viral load is much less if an infected dog is not showing symptoms.

Even the smallest amount of the virus will do it, and an aysmptomatic animal can certainly transmit it.

I would say that all your thinking on this has been irrational (or perhaps more accurately, a rationalization).

[Issangeorge]

Years ago I was bit by a dog on Samui and went for the shots @ the time I needed four shots and had two on Samui and then one in Bangkok, the price was less than ฿1,000 a shot. I then returned to Toronto and had the final shot, it was covered by my medicare, but I was told the shot would have been ฿3,000. The doctor also told me that if the dog was still alive a week later then it didn't have rabies. I asked him if that wouldn't be to late to start the shots and he said no. I still find it hard to believe.

Sent from my i-mobile IQ 6 using Thaivisa Connect Thailand mobile app

[cheeryble]

Years ago I was bit by a dog on Samui and went for the shots @ the time I needed four shots and had two on Samui and then one in Bangkok, the price was less than ฿1,000 a shot. I then returned to Toronto and had the final shot, it was covered by my medicare, but I was told the shot would have been ฿3,000. The doctor also told me that if the dog was still alive a week later then it didn't have rabies. I asked him if that wouldn't be to late to start the shots and he said no. I still find it hard to believe.

Sent from my i-mobile IQ 6 using Thaivisa Connect Thailand mobile app

Thankyou Issangeorge,

What your doctor told you sounds like rubbish.

As everyone on this forum, all my friends and my wife all told me I should not even think of not having post exposure prophylaxis (jabs) I followed The Wisdom of Crowds and took a course of action today.

I went to the vet behind Nimmanhemin who has sewn my dog together a few times.

I asked him how much rabies was around Chiangmai. He said it is very rare. I told him what happened to me and he said "Practically, i wouldn't worry about it."

As there was another vet on my route I stopped there a minute to compare.

He also said about rabies "Little" but in a formulaic manner said "But you must get injections".

I succumbed to this and aforesaid peer pressure and went to the hospital for an injection.

Saw the doc, and he asked me how many injections I'd like. Said five was normal first time if previously vaccinated then three.

It had occurred to me that maybe the later injections are only to ensure longterm immunity like HepB, and as he was asking me rather than telling me I said I'll take one for now and think about (which means learn) how many more.

I had the injection, 1330bt plus reduced 20% for family of staff.

I heard at the pharmacy about immunoglobulin (apparently much more expensive) only being for deep wounds, didn't ask the doctor about it and he didn't mention it.

I now read this which leaves me confused and slightly concerned:

What is the difference between rabies vaccine and HRIG?

A course of rabies vaccines (given into the shoulder muscle) works to develop long term immunity, but this may take seven days to begin providing protection. For this reason, HRIG is usually given into the wound or site of injury to provide immediate short term protection while the rabies vaccines start to work. Long term protection is essential as rabies infection can take a long time to develop. Not everyone potentially exposed to rabies or ABLV will be advised to have HRIG. For example, HRIG is generally not required for people who have been previously vaccinated against rabies. When recommended, it is important to have the HRIG as well as the vaccine to ensure complete protection against rabies or ABLV.

Edited October 10, 2013 by cheeryble

[cheeryble]

ps: I read that a 5 jab course in the US cost $3000, for a normal worker.

90,000 baht.

Imagine a country where that sort of thing happens as a matter of course.

Edited October 10, 2013 by cheeryble

[Sheryl]

Years ago I was bit by a dog on Samui and went for the shots @ the time I needed four shots and had two on Samui and then one in Bangkok, the price was less than ฿1,000 a shot. I then returned to Toronto and had the final shot, it was covered by my medicare, but I was told the shot would have been ฿3,000. The doctor also told me that if the dog was still alive a week later then it didn't have rabies. I asked him if that wouldn't be to late to start the shots and he said no. I still find it hard to believe.

Sent from my i-mobile IQ 6 using Thaivisa Connect Thailand mobile app

That is untrue. rabies has a very long incubation.

Also - the immunoglobulin and vaccined should be given ASAP. No use to give the immunoglobulin late and effectiveness of vaccine will also be less.

[Sheryl]

As everyone on this forum, all my friends and my wife all told me I should not even think of not having post exposure prophylaxis (jabs) I followed The Wisdom of Crowds and took a course of action today.

I went to the vet behind Nimmanhemin who has sewn my dog together a few times.

I asked him how much rabies was around Chiangmai. He said it is very rare. I told him what happened to me and he said "Practically, i wouldn't worry about it."

As there was another vet on my route I stopped there a minute to compare.

He also said about rabies "Little" but in a formulaic manner said "But you must get injections".

I succumbed to this and aforesaid peer pressure and went to the hospital for an injection.

Saw the doc, and he asked me how many injections I'd like. Said five was normal first time if previously vaccinated then three.

It had occurred to me that maybe the later injections are only to ensure longterm immunity like HepB, and as he was asking me rather than telling me I said I'll take one for now and think about (which means learn) how many more.

I had the injection, 1330bt plus reduced 20% for family of staff.

I heard at the pharmacy about immunoglobulin (apparently much more expensive) only being for deep wounds, didn't ask the doctor about it and he didn't mention it.

I now read this which leaves me confused and slightly concerned:

What is the difference between rabies vaccine and HRIG?

A course of rabies vaccines (given into the shoulder muscle) works to develop long term immunity, but this may take seven days to begin providing protection. For this reason, HRIG is usually given into the wound or site of injury to provide immediate short term protection while the rabies vaccines start to work. Long term protection is essential as rabies infection can take a long time to develop. Not everyone potentially exposed to rabies or ABLV will be advised to have HRIG. For example, HRIG is generally not required for people who have been previously vaccinated against rabies. When recommended, it is important to have the HRIG as well as the vaccine to ensure complete protection against rabies or ABLV.

The later shots are not "just to ensure long term immunity" and are needed.

I suyspect when he asked you how many shots you'd like he was getting at whether or not you had had prior immunization for rabies which I gather you had not. So you need at least 4, i.e. 3 more.

Yes, you should have received HIG.

A vet is not the appropriate source if rabies prophylaxis for humans!!!

[midas]

cheeryble do you mean after i have taken note of your comments over in the” financial crisis " and " where is gold going " threads i now discover that you don't regard your life as being worth even 8,000 baht ( or even more if necessary - however much rabies shots cost ) ?

Edited October 11, 2013 by midas

[cheeryble]

Without wishing to extend a thread where I thought enough had been said....

Yes, you should have received HIG.

A vet is not the appropriate source if rabies prophylaxis for humans!!!

Thankyou for advice on the number of shots Sheryl.

As far as not getting HIG and now learning it's required......this is so typical of my Thai medical experience.

My best guess is that the doctor after hearing the story and possibly knowing more than we do about rabies incidence around CM reckons there's no chance of me having contracted the virus and is keeping me happy........which I'm now not!

What other reason could there possibly be apart from gross incompetence?

As for the vet......I visited not to be injected but because I thought a vet might be the best source of knowledge about rabies incidence.

Straight from the horse's mouth one might say.

However it does occur to me that if I only have to go through the motions of getting injections with no need for assessment I may as well go to the cheapest source of vaccine possible......as long as it is proper quality. Any ideas? I just heard the Sripat has an outpatients in the new building on the other side. Anyone know about that and if the prices are substantially less than Ram?

Thanks!

[Sceptict11]

Here is what the CDC say !

http://www.cdc.gov/rabies/medical_care/vaccine.html

http://www.cdc.gov/rabies/medical_care/hrig.html

Note

The Immunoglobulin is always required in "at risk" individuals who have never previously been vaccinated.

[cheeryble]

Here is what the CDC say !

http://www.cdc.gov/rabies/medical_care/vaccine.html

http://www.cdc.gov/rabies/medical_care/hrig.html

Note

The Immunoglobulin is always required in "at risk" individuals who have never previously been vaccinated.

Thankyou Skeptic

Again, not wishing to make an epic out of this or turn a mystery into an enigma, but:

I called by Suan Dok hospital pharmacy today and learned the list price for vaccine is 331baht at the hospital next door, but isn't sold at the pharmacy. Thus I would save nearly two thirds for the next shots.

As I was asking some sort of more senior pharmacist came out.

I asked him about immunoglobulin and that I hadn't been given it.

Ah, he said, that is much more expensive but is only needed for deep wounds.

This is exactly what the Ram pharmacist said and it may be the doctor's basis for not using HIG.

My tentative half-assed theory is that if you get a lot of virus transferred (big wound) you need an instant hit of resistance which will work quickly (HIG). If the transfer is tiny however, presuming the virus replicates based on an exponential curve, the tiny start means it takes a lot more time for the viral load to become damaging. I theorise that after a few days the regular vaccine has stimulated antibodies and you then have your resistance before the viral load has climbed to dangerous levels. So an instant hit isn't needed.

(No qualifications to say this other than an active mind).

According to my theory however, as I have left it for some days I may need the HIG as virus would have time to replicate a bit.

There is another part to the equation, that the dog in question is still around the area just saw him and apart from a poorly poor he looks fit as a fiddle.

Edited October 11, 2013 by cheeryble

[Patsycat]

So, in the end. You're just scared of needles?!!

[cheeryble]

cheeryble do you mean after i have taken note of your comments over in the” financial crisis " and " where is gold going " threads i now discover that you don't regard your life as being worth even 8,000 baht ( or even more if necessary - however much rabies shots cost ) ?

The point is Midas it's not as if I'm going to save my life for 8000 baht.

I'm saving a fraction, a chance, of losing my life.

The whole question is what is the fraction, what is the risk?

The factors that led me at first to neglect treatment are all in my posts, but include

Very low rabies incidence.

Symptomless dog who nipped not attacked.

Very small wounds indeed.

Immediate cleaning and whisky dip.

If I were to take a wild stab at the odds of infection I'd put them at one in the thousands, probably in the many thousands.

BTW I'm sure dog bites happen really a lot. Over a lifetime wouldn't there be several for each typical person.....there would for me, I may be overconfident but doesn't everyone get bitten once or twice or more. Is anyone dogbite free for a lifetime?

That makes an enormous n of dog bites. It would be surprising not to get a few exceptional infections.

However I've been overruled and am happy to be advised...........the only problem being I've got three Chiangmai medical professionals advising me differently to what we can read on the internet!

Edited October 11, 2013 by cheeryble

[jrtmedic]

An interesting article here which perhaps puts the risk into perspective .

http://www.hindawi.com/journals/apm/2011/383870/

Speaking personally if I were nipped / bitten by a street dog I would seek vaccination ASAP !

[cheeryble]

An interesting article here which perhaps puts the risk into perspective .

http://www.hindawi.com/journals/apm/2011/383870/

Speaking personally if I were nipped / bitten by a street dog I would seek vaccination ASAP !

Thankyou JRTMedic

That clears up he business about HIG......it is indeed recommended for deep bites and scratches as suggested by the pharmacists, regular vaccination only for lesser wounds.

It also confirms that the incidence is very low indeed and reinforces an earlier post which speaks of 20something human cases nationwide witht none in the north.

The other thing reinforced is my suggestion about the very high n of dogbites......ca 400kpa which I would guess maybe a low estimate......perhaps that's hospital cases.

As it happens my dog just ran out to welcome me home running through the trees and was joined by his little gang of friends from the other houses all I've known for years.....and guess who joined in the fun. The culprit, looking just fine. He was standing on the edges but wagging gently wanting to be part of the gang. I took the trouble to get my torch and checked him out from some feet away. I could see no wounds at all.

None of these are guarantees, but they are all odds-reducers in an uncertain world.

Edited October 11, 2013 by cheeryble

[cheeryble]

Another interesting assumption from the WHO data:

19m people in The region bitten annually.

4m get vaccinated afterwards.

That leaves 15m people who get bitten by dogs and don't get treatment.

Yet the rabies incidence is under 25,000.

This suggests if you get bitten by a dog and don't get vaccinated you stand a 1/600 chance of infection.

But this is including rabies-heavy areas like India.

If you supplanted the same assumptions (upping the PEP rate to 25%) to Thailand the ballpark chance of infection would be under 1/10,000 with no vaccination. Previously vaccinated people would raise the odds a bit, but my guess is not more than a modest fraction of the population are immunised here. Low-rabies areas inside the country would of course reduce the odds further.

That includes all types of bites including very nasty difficult to clean deep ones, and some that just get ignored.

[apetley]

No need to go to a hospital I had mine carried out by a normal doctor and if my memory is good it was only 500 baht an injection

 

Same for me. Went to a local clinic and paid 2500 for a course of 5 injections.

[Dr Robert]

I think the whisky dip did it-effected your thinking, not cleanse the wound.

Are you depressed? have you thought through how much you think your life is worth to you and your loved ones? is this a call for help?