Hedgehogs Without Borders: Vaccinations and the Question of Rabies

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Posted by Tim on Jan 20, 2005

About three million.

Thatâ€™s the number of people who die every year of malaria. Three million. Thatâ€™s roughly double the population of our beloved Philadelphia.

So, letâ€™s talk about vaccinations and medications, shall we?

We knew from the beginning that weâ€™d need to get vaccinated for all sorts of things. We just didnâ€™t know how to go about getting it done. And more to the point, we didnâ€™t have the foggiest idea of how much it was going to cost. We spent a lot of time crawling the BootsnAll forums and reading through every travel website we came across, but we couldn't find anything to give us even a ballpark figure. So we made one up, picked $800 for no particular reason, and plugged that into our budgets.

Our first problem was that there was just so much to figure out, we didnâ€™t know where to start. We put together lists of vaccinations we thought we might need, and tried to figure out when weâ€™d need to get our shots. I googled â€œtravel clinic Philadelphiaâ€ and got a list of phone numbers, and then basically went down the list, calling each office and pestering them with questions. And we had a lot of questions.

When the time came for us to choose a travel clinic, we went with the one that was always the nicest to me on the phone: Executive Health Services. Our first visit was an hour-long consultation with our travel doctor, Dr. Emil Sdefu. We talked him through the trip we were planning, giving him as much of an itinerary as we could. He asked us if we'd had the standard MMR (measles-mumps-rubella) vaccinations as children, and if we'd ever had chicken pox. He wanted to know how long we thought we'd be spending in each place, how long we thought we'd be in rural areas, whether we expected to mostly stay in private rooms or dorm situations. And he came up with a list of recommended vaccinations (see below), with a total price tag of over $3,000!

*cough*

Three thousand dollars?! Gah! It was so much more than we'd expected that we went into a kind of "sticker-shock". We went over how much everything cost, and came up with three that we weren't sure we needed:

Japanese Encephalitis – This is mostly a risk if you're planning on spending more than a month in rural areas of the infected countries, which we were not. It's also mostly transmitted only between May and October, and we wouldn't be in Southeast Asia until December. In the end, although we completely understand why Dr. Sdefu recommended it to us, we elected not to get this vaccination. That saved us a few hundred dollars.

Meningococcal Meningitis – Epidemics of this disease generally only occur in the so-called "Meningitis Belt" of sub-Saharan Africa, so we were at first reluctant to get the vaccine. The concern, we gather, is mainly of picking it up from other travelers. Coincidentally, there was a Meningitis outbreak in a Philadelphia school right at that moment, and we were spooked into getting the vaccine. Maybe that's for the best.

Rabies – This is a big one. See below.

The vaccine for rabies comes in three shots, which cost $184 each. That's $1104 total for the two of us! That plus the fact that if you get bitten by an animal you still need treatment anyway, plus the fact that we aren't planning on getting all that close to rabid animals, and all of a sudden we'd talked ourselves out of getting the rabies shots.

Or at least we had, until the time comes to tell our doctor that. He didn't blink when we said we didn't want the Encephalitis shots, but with rabies he had concerns. (And, important point, that's very much how it came across – as genuine concern for our well-being. This wasn't someone just trying to sell us something.) And in the process of explaining why he encourages us to reconsider, he made sure we'd noticed all of the articles on the wall he'd written for the New England Journal of Medicine and the Journal of the American Medical Association – articles about rabies. This was a man who knew what he's talking about.

Fact #1: Rabies is the deadliest disease in the world. Deadlier than Ebola, deadlier than Lassa, deadlier than malaria and cholera and the bubonic plague combined.
Fact #2: While the vaccination won't prevent us from needing treatment if we get infected, it will buy us time (see fact #1).
Fact #3: If you haven't been vaccinated and you get infected, one of the first steps in treatment is an injection of human rabies immune globulin (HIRG), which may not be available in smaller, more rural hospitals abroad.

All of this got us to thinking. For one thing, we didn't want to have to be terrified of animals. If we're in rural Cambodia, and the owner of our guesthouse has a fairly mangy-looking cat, we didn't want to have to be afraid to pet it. But the thing that really changed our mind was this question: if the vaccine for Yellow Fever cost $1,100, would we choose not to get it? Of course not. We were balking here just because it was rabies, and rabies isn't such a big deal in the US. And with that realization, we knew we were getting the rabies shots.

Anyway, these are the shots and whatnot that we got, and how much they cost:

Vaccination	Delivery	Cost	Notes
Yellow Fever	1 shot	$129/person	This one is a biggie, as you need to get it to travel to a number of countries (or more to the point, to travel back out from them). It was probably the most painful injection we received: more so than the infamous tetanus. The pain doesn't come when you get the shot, it comes on an hour or so later, and then lingers for a couple of days. It hit Jessica harder than Tim: she had difficulty raising her arm during this period. Even so, it wasn't as painful as people had led us to believe it would be.
Typhoid/Typhus	4 pills	$74/person	This one is funny: they give you a box of pills that comes labeled "Caution: Contains live pathogen. Handle with Care." We put it next to the eggs (you need to refrigerate it). You take one every other day, in the morning on an empty stomach.
Tuberculosis (TB)	PPD test	$18/person	You get a PPD (purified protein derivative) skin test to see if you've ever been infected by the bacteria that causes TB. It's called a "skin-prick", because the antigens are injected under the top layer of skin, rather than into the bloodstream. After two days, you come back to the clinic, and they check for the presence of a red lump over the injection site. Our tests both came up negative: we'll want to be tested again when we get back, to see if we picked it up on our trip (in which case we'll want treatment).
Influenza	1 shot	$29/person	This being a year when there was a huge shortage and the local news was encouraging everyone to leave what we had for the elderly, we both felt a little guilty. But hey, doctor's orders!
Hepatitis-B	3 shots	$75/shot	This one had caused us some stress when we were preparing for our trip. You get three HepB shots: the second and third shot are given 1 and 6 months after the first shot. But... when we were going in for our shots, there were only a few months left until our departure, not enough time to get all three. Were we supposed to get the third shot while abroad? Was that safe? As it turns out, we needn't have worried. The third shot is a booster, which ensures lifetime immunity. We can safely get it after we return, a year after getting our first shot. Tim had no adverse reactions to this shot, but Jessica developed hives all over her body and an odd discoloration around the injection site that lasted for several weeks. (She's a freak, that one.)
Hepatitus-A	2 shots	$82/shot	Similar story to HepB, except that you only get two shots, 6 months apart. We each got one, and we'll get the other when we return.
Polio	1 shot	$42	No one wants polio.
Meningococcal Meningitis	1 shot	$131/person	Again, this one wasn't so much because we'd be traveling in areas where it was a risk, so much as the worry of picking it up from other travelers. We hesitated on this one when we were dealing with our sticker-shock, but in the end decided to get it.
MMR	N/A	N/A	We'd both had the whole Measles/Mumps/Rubella regimen of shots as kids, so we were fine here.
Chicken Pox	Blood titer	$95	If you never go through chicken pox when you're a kid, it can be extremely dangerous to you as an adult. Tim was fine here, but Jessica's situation was more unclear, so a blood titer was run on her to make sure she had the required antibodies. She did, and was spared the vaccination.
Tetanus	1 shot	$40/person	The tetanus shot is infamous. We'd both heard horror stories about excruciating pain, about limbs being damn near paralyzed for days. Both of us had a history of strong reactions to it in our families. But in the end, it wasn't so bad, not even as painful as the Yellow Fever (although Jessica again had trouble raising her arm the next couple of days).
Rabies	3 shots	$184/shot	Other than the painful cost (see above), the rabies shots didn't hurt much. They did, however, make the two of us very bitchy with each other for a day or two after the injection. (It took us until after the second time to realize that was happening). You get the second shot 1 week after the first shot, and the third shot 2 or 3 weeks after that.

So, in total (and including $65 each for that initial consultation), that comes to $1,312 for Tim and $1,407 for Jessica (the difference being that $95 chicken pox titer). Ouch.

"But wait," I hear you saying. "What about malaria? Three million people and all that?"

Well, my friends, it turns out there isn't a vaccine for malaria. There's pills. But that's the subject of another entry...