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ORIGINAL ARTICLE

Incidence of Potential Rabies Exposure Among Japanese Expatriatesand Travelers in Thailand

Wataru Kashino, MD,∗ Watcharapong Piyaphanee, MD,∗ Chatporn Kittitrakul, MD,∗

Noppadon Tangpukdee, PhD,∗ Suda Sibunruang, MD,† Saranath Lawpoolsri, PhD,‡

Hiroaki Yamashita, MD,§ Sant Muangnoicharoen, PhD,∗ Udomsak Silachamroon, MD,∗ andTerapong Tantawichien, MD||

∗Department of Clinical Tropical Medicine, Mahidol University, Bangkok, Thailand; †Queen Saovabha Memorial Institute, ThaiRed Cross Society, Bangkok, Thailand; ‡Department of Tropical Hygiene, Mahidol University, Bangkok, Thailand; §MedicalDivision, Embassy of Japan in Thailand, Bangkok, Thailand; ||Department of Medicine, King Chulalongkorn University,Bangkok, Thailand

DOI: 10.1111/jtm.12124

Background. Rabies has become a forgotten and neglected disease in Japan. In 2006, there was a slight increase in social awarenessof rabies when Japan had two reported cases of human rabies, originating in the Philippines. Although the number of Japanese eithertraveling or living in other Asian countries has been increasing, the exact risk of this population contracting rabies is unknown.Thus, this study utilized a questionnaire to investigate the incidence of rabies exposure, as well as the knowledge, attitude, andpractice toward rabies prevention among Japanese expatriates and travelers in Thailand.Methods. Japanese travelers and expatriates were asked questions related to knowledge, attitude, practice toward rabies risk, andexperiences of potential rabies exposure such as animal bites, licks, and scratches. Questionnaires were either completed at theBangkok Suvarnabhumi International Airport and other tourist areas or distributed within Japanese associations in Thailand.Results. A total of 1,208 questionnaires from Japanese expatriates and 590 from Japanese travelers were collected and analyzed.We found high incidence rates of potential exposure events among these populations. In particular, Japanese travelers had thehighest incidence rate compared to previous studies of international travelers in Thailand. While expatriates’ incidence rates ofanimal bites, licks, and scratches were 1.7, 6.9, and 1.8/1,000 person-months, travelers have much higher incidence rates of 43.1,136.1, and 33.0/1,000 person-months. Generally, travelers, compared to expatriates, tended to have less accurate knowledge andless often had the pre-exposure prophylaxis vaccination. Moreover, survey answers indicated that 55.0% of expatriates and 88.9%of travelers who were bitten would not seek proper treatment.Conclusions. Since rabies is a preventable disease as long as one has the appropriate knowledge, attitude, and practice, it is essentialto promote prevention activities for the Japanese population in Thailand to avert serious consequences of this disease.

Until 2006, rabies was a neglected and almost for-gotten disease in Japan, owing to its nationwide

elimination in 1957.1 In 2006, two Japanese travelersdied of rabies after returning from the Philippines.2–4

These imported cases temporarily increased socialawareness, which led to a shortage of domestic Japaneserabies vaccine (purified chick embryo cell rabiesvaccine–Kaketsuken) because many Japanese goingoverseas consulted medical facilities for vaccinations.5To prevent further cases, healthcare workers need to

Corresponding Author: Wataru Kashino, MD, Departmentof Psychiatry, National Center of Neurology and Psychia-try, 4-1-1 Ogawa-Higashi, Kodaira, Tokyo 187-8551, Japan.E-mail: wkashino@ncnp.go.jp

advise travelers, including the recommendation ofpre-exposure prophylaxis (PrEP), based on accuraterisk assessments. Nevertheless, to our knowledge, nostudy has estimated the risk of rabies among Japanesetravelers and expatriates in rabies-endemic regions.

Rabies is endemic worldwide. The World HealthOrganization estimates that 55,000 people worldwidedie of rabies and at least 15 million doses of anti-rabiespostexposure prophylaxis (PEP) are administered annu-ally to avert the onset of disease.6 Several studies haveinvestigated the risk of potential rabies exposure amonginternational expatriates or travelers in Asian coun-tries such as Thailand and Nepal,7–9 but Japanese cit-izens should be investigated separately because of their

© 2014 International Society of Travel Medicine, 1195-1982Journal of Travel Medicine 2014

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unawareness of and lack of preparedness for infectiousdisease risks outside Japan.10,11

The main objective of this study was to estimatethe incidence rates of potential rabies exposure amongJapanese expatriates and travelers in Thailand, and todescribe the knowledge and attitudes for preventingrabies and practices (KAP) after risky contacts withanimals. The results can provide information to helppromote further prevention activities against this lethalbut preventable disease.

Methods

Study Design and Eligibility CriteriaThis study was a questionnaire-based cross-sectionalstudy. The questionnaires were distributed to eligibleJapanese: those who were of Japanese nationality andover 18 years old. Japanese expatriates were classifiedas those who had stayed in Thailand for more than3 months. Japanese travelers were classified as thosewho had stayed in Thailand for more than 3 days,and this did not include transit-only travelers. Thisstudy and the questionnaires used were approved by theEthics Committee of the Faculty of Tropical Medicine,Mahidol University.

Sample Size EstimationThe sample size was determined using the estimatedrisk of potential rabies exposure and the estimatedJapanese population in Thailand in 2009.12–14 A sur-vey at Bangkok International Airport showed that 1.3%of the 1,882 international travelers surveyed had experi-enced a dog bite and 8.9% had experienced a dog lick.8Therefore, exposure risk was set at 10.2%, and it wasassumed that up to 25% of exposure events went unre-ported. Utilizing those data, we estimated 535 expa-triates and 541 travelers needed to determine the riskof potential rabies exposure, such as dog bites and doglicks, with 95% confidence. The sample size calcula-tion was performed with epi info program version 3.5.3(CDC, Atlanta, GA, USA).

QuestionnaireEach participant was asked to fill out a four-pagequestionnaire once. The questionnaire was written inJapanese and English, and consisted of three parts: gen-eral information (age, gender, purpose of stay, placesand durations of stay, occupation, educational back-ground, acquisition of travel health information); atti-tudes toward, and knowledge about, rabies prevention(acquisition of information on rabies, PrEP status andits type if vaccinated, reason for not being vaccinatedif unvaccinated, questions about rabies transmissionand prevention, and treatment after an animal bite);potential rabies exposure, and practices after an animalbite (animal bites, licks, and scratches experienced inThailand, practices after an animal bite, animal speciescontacted, and their ownership status). The question-naire could be completed in 4 to 8 minutes.

Data Collection and Study SiteFor the eligible expatriates, the questionnaire was dis-tributed by direct or indirect personal contact. For thedirect contacts, the study team attended meetings heldin Japanese residential and business districts of Thai-land, and handed out the questionnaire to participants.For the indirect contacts, the team asked Japanese orga-nizations in Bangkok and other provinces to distributequestionnaires to their members.

For the travelers, the team distributed the question-naires directly at three tourist areas. Travel agencies anda medical facility in Bangkok were also asked to cooper-ate in the survey.

Statistical AnalysisThe characteristics of the participants in each groupwere described. The t-test or Mann–Whitney U-testwas used for continuous data, while the Chi-square testor Fisher’s exact test was used for categorical data. Toestimate incidence rates of potential rabies exposure,we divided the total number of each type of potentialrabies exposure (bites, licks, and scratches) by the totalduration of stay (the sum of each individual’s period ofrisk). Prevalence was estimated by dividing the numberof participants exposed by the number of study subjectsin each group. Univariate Poisson regression analysiswas used to compare differences in the incidence ratesbetween the two groups. Statistical significance was setat p≤ 0.05, with a two-tailed test. For statistical analyses,spss software version 17.0 for Windows (SPSS Inc.,Chicago, IL, USA) was used.

Results

Data Collection and Baseline Characteristics of the StudyPopulationData were collected from November 15, 2010 untilMarch 31, 2011. To collect expatriate data, we coop-erated with associations in Thailand. These associa-tions were the Embassy of Japan in Thailand, the Thai-land Office of the Japanese International CooperationAgency, eight Japanese primary schools, a Japaneseelementary school, a Japanese junior high school, aJapanese high school in Bangkok, the dispensary of aJapanese School in Chonburi, four local Japanese asso-ciations, eight private enterprises, and Bangkok andChiang Mai Christian churches. To collect data fromJapanese travelers, we randomly interviewed travel-ers in Bangkok’s Suvarnabhumi International Airport,Khaosan Road area, and Chatuchak Weekend Market.We also cooperated with the Queen Saovabha Memo-rial Institute and two travel agencies in Bangkok to col-lect data from Japanese travelers who visited each asso-ciation. The response rate was 56% for the expatriategroup and 64% for the traveler group.

In all, 1,208 questionnaires were collected from expa-triates and 590 from travelers. Most travelers (70.9%)were male, while most expatriates (61.1%) were female.

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Table 1 Baseline characteristics of the study population

Expatriates Travelers

Characteristics n % n % p-Value

Total participants 1,208 100 590 100Age (years)

Median (range) 39 (18–82) 42 (18–89) <0.001Gender N = 1,204 N = 588

Female 736 61.1 171 29.1 <0.001Educational background N = 1,201 N = 432

Junior high/high school 210 17.5 89 20.6 0.151College/university* 859 71.5 283 65.5 0.019Graduate school 95 7.9 46 10.6 0.082Others 37 3.1 14 3.2 0.870

Expatriates n % Travelers n %

Reason for stay N = 1,205 Reason for travel N = 589Companion with family 599 49.7 Tourism 434 73.7Business 448 37.2 Business 103 17.5Immigration/long-term stay 79 6.6 Visit acquaintances 34 5.8Education/research 26 2.2 Education/research 16 2.7Studying in Thailand 12 1.0 Other reasons 2 0.3Other reasons 41 3.4Residence in Thailand† N = 1,208 Have traveled to†, ‡ N = 590Bangkok 1,107 91.6 505 85.6Central besides Bangkok 19 1.6 30 5.1Northern 19 1.6 71 12Northeastern 3 0.2 17 2.9Eastern 55 4.6 79 13.4Western 1 0.1 15 2.5Southern 4 0.3 60 10.2Length of stay (months) Length of stay (days)Median (range) 32 (3–601) Median (range) 6 (3–360)

N = total number of respondents; n= the number of persons responding positively per category.*Including junior college.†We adopted the six-region division system by the National Geographic Committee.‡Travelers visited multiple places.

The median duration of stay was 32 months for expatri-ates and 6 days for travelers. Detailed baseline charac-teristics are summarized in Table 1.

Attitudes Toward Risk of Rabies and PrEP StatusThe results for “attitudes toward risk of rabies” andPrEP status are summarized in Table 2. Generally,compared with expatriates, travelers were less preparedfor health problems in Thailand, were less vacci-nated with PrEP, and were less aware of the risk ofrabies. The proportions for participants who receiveda complete PrEP vaccination course were low in bothgroups (8.6% of expatriates vs 2.2% of travelers,p< 0.001). Furthermore, 65.5% of expatriates and40% of travelers who were vaccinated were unawareof which PrEP vaccine they received, although theJapanese domestic rabies vaccine has PEP schedulesdifferent from those of internationally standard rabiesvaccines.

Knowledge About Rabies Transmission and PreventionResults of knowledge about rabies transmission andprevention are summarized in Table 3. We found that

the knowledge of travelers was less accurate than thatof the expatriates. While most of the study participantsrecognized that animal bites have potential risk ofrabies transmission, animal licks and scratches tendednot to be recognized as one of the possible rabiestransmission routes, and 47.6% of the expatriates and74.8% of the travelers did not know the fact that licksby infected animals on mucous membranes can causerabies transmission. Over 97% of the study participantsrecognized that dogs could carry rabies, while manywere unaware that cats, bats, and monkeys are alsopossible transmission sources.

Results of a descriptive question about rabies pre-vention after an animal bite are summarized in Table 4.With regard to disease prevention after potential rabiesexposure, few participants knew the appropriate treat-ments, although they were aware of the need to washbitten wounds immediately, go to hospital, and be vacci-nated for PEP (plus injection of rabies immunoglobulin,if available). The proportion of participants who gavecorrect answers for all questions about the appropriatetreatments was low (8.4% of expatriates and 1.2% oftravelers, p< 0.001) (Table 4).

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Table 2 Attitudes toward rabies risk and pre-exposure vaccination status

Expatriates Travelers

Question n % n % p-Value

Sought travel health information before your stay in Thailand? N = 1,207 N = 585Yes 718 59.5 191 32.6 < 0.001

Source of travel information N = 718 N = 169Travel medicine specialist 114 16.7 13 7.7General practitioner/family doctor 156 22.9 12 7.1Relatives/friends 125 18.3 34 20.1Retrieved information on the Internet 532 78.0 119 70.4Guide book/news/television 331 48.5 62 36.7Medical department of a company 44 6.5

Received rabies information before your stay in Thailand? N = 1,205 N = 586Yes 682 56.6 169 28.8 < 0.001

Received vaccines against rabies? N = 1,203 N = 584Yes, all three doses 104 8.6 13 2.2 < 0.001*Yes, 1–2 doses 203 16.9 22 3.8No 896 74.5 549 94

Reasons for not being vaccinatedI think it is not necessary 479 39.8 322 55.1 < 0.001After animal bites, I will be vaccinated 122 10.1 7 1.2 < 0.001I did not know about rabies or vaccination 82 6.8 162 27.7 < 0.001No time or chance to be vaccinated 52 4.3 13 2.2 0.002It is too expensive 48 4 17 2.9 0.044Doctors did not recommend rabies vaccination 42 3.5 0 0Lack of vaccines in Japan 29 2.4 4 0.7 0.002Other reasons 42 3.5 24 4.1 0.780

Type of vaccination N = 307 N = 35Japanese vaccine (PCEC-K) 72 23.5 11 31.4Internationally standardized vaccine 34 11.1 10 28.6Unsure 201 65.5 14 40

N = total number of respondents; n= the number of persons responding positively per category; PCEC-K= purified chick embryo cell rabies vaccine–Kaketsuken.*Compared the rates of participants receiving at least one dose of vaccine and unvaccinated.

Risk of Potential Rabies Exposure in ThailandThe results for “risk of potential rabies exposure” aresummarized in Table 5, which shows the frequency ofcontacts with dogs, cats, and monkeys, because thesethree animals are major sources of rabies transmissionin Thailand.15 The incidence rates of animal bites (per1,000 person-months) were 1.7 for expatriates and 43.1for travelers. The incidence rates of animal licks were6.9 for expatriates and 136.1 for travelers. The incidencerates of animal scratches were 1.8 for expatriates and33.0 for travelers. On the other hand, the prevalenceof animal bites, licks, and scratches (per 1,000 persons)was 86.9, 325.9, and 92.0 for the expatriates (averagestay, 55.4 months), respectively, and 15.3, 53.0, and 11.9of the travelers (average stay, 13.0 days), respectively(Table 5).

Among all participants, 118 were bitten, 441 werelicked, and 124 were scratched by mammals. Over95% of these episodes were exposure to dogs, cats,and monkeys. Of the 782 potential rabies exposure tomammals, 65.7% (514/782) had been with dogs, 28.1%(220/782) with cats, and 1.4% (11/782) with monkeys(data not shown).

Practices After an Animal Bite, and Animal OwnershipStatusThe results for “practices after an animal bite” are sum-marized in Table 6. Among the 105 expatriates who werebitten, 48 (45.7%) received PEP, while only 1 of 9 trav-elers (11.1%) received PEP. Of the 744 total potentialrabies exposure to dogs, cats, and monkeys (122 bites,494 licks, and 128 scratches), 74.9% (557/744) had con-tact with domestic animals, 18.4% (137/744) with wildanimals, and 6.7% (50/744) had contact with animalsof unclear ownership status. None of the travelers whowere bitten knew whether the animals that bit them hadbeen vaccinated against rabies.

Discussion

To our knowledge, this is the first study investigating therisk of potential rabies exposure among Japanese citizensliving or traveling in Thailand. Furthermore, no otherstudies have been conducted to compare KAP on rabiesbetween expatriates and travelers. We found a high inci-dence of potential rabies exposure, especially amongtravelers. Two previous studies investigated the risk of

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Table 3 Knowledge about rabies transmission and prevention

Expatriates Travelers

Question n % n % p-Value

1. You may get rabies if you: N = 1,207 N = 587Are bitten by an animal* 1,187 98.3 561 95.6 <0.001Are licked on broken skin* 876 72.6 206 35.1 <0.001Are licked on a mucous membrane like your eyes or mouth* 633 52.4 148 25.2 <0.001Are scratched deeply by an animal* 867 71.8 172 29.3 <0.001Are scratched shallowly* 525 43.5 109 18.6 <0.001Are licked on normal skin 1,087 90.1 547 93.2 <0.001Eat contaminating food or drinks 1,036 85.8 532 90.6 0.004

Participants who chose all correct answers 199 16.5 30 5.1 <0.0012. Correctly identified animals that could carry rabies N = 1,208 N = 587

Dog* 1,187 98.3 576 97.6 0.839Cat* 840 69.5 150 25.4 <0.001Monkey* 613 50.7 140 23.7 <0.001Bat* 466 38.6 106 18 <0.001

Correctly identified animals that could not carry rabiesSnake* 1,130 93.5 570 97.1 0.002Chicken* 1,062 87.9 540 92 0.009

Participants who chose all correct answers. 232 19.2 23 3.9 <0.0013. If you have finished complete course of rabies vaccines and you are

bitten by a dog or cat, there is no need to have boosters†952 78.8 415 70.3 <0.001

Unsure 215 17.8 125 21.24. A bite of a healthy-looking dog or cat poses no risk of rabies?† 842 69.7 263 44.6 <0.001

Unsure 286 23.7 226 38.3

N = total number of respondents; n= the number of participants who chose correct answers.*Correct answers.†Questions 3 and 4 are TRUE/FALSE questions. The correct answers are “FALSE.” The numbers and percentages shown counted the numbers of participants who chosethe correct answers.

Table 4 Knowledge about rabies prevention after ananimal bite

Expatriates Travelers

Question Yes % Yes % p-Value

If you are bitten by an animal,what are you going to do toprevent rabies onset?

N = 1,208 N = 590

Clean the wound (1)* 343 28.4 91 15.4 <0.001Go to hospital (2)* 1, 060 87.7 394 66.8 <0.001Receive vaccination (3)* 378 31.3 50 8.5 <0.001Observe the animal (4)* 16 1.3 5 0.8 0.486Tie the upper part of thewound to prevent toxincirculation

23 1.9 9 1.5 0.569

Suck out toxins from thewound

4 0.3 6 1 0.089

Nothing to do 17 1.4 39 6.6 <0.001Unsure 117 9.7 122 20.7 <0.001

Participants who gave allcorrect answers†

101 8.4 7 1.2 <0.001

N = total number of respondents.*Correct answers.†The number of participants who answered (1), (2), and (3) with or without (4).

potential rabies exposure among international travel-ers in Thailand. Phanuphak and colleagues found thatamong 1,882 foreign travelers at Bangkok InternationalAirport, the prevalence of animal bites was 12.6/1,000

people and the prevalence of animal licks was 89.1/1,000people (average stay in Thailand, 17.0 days).8 Piyapha-nee and colleagues investigated 870 foreign backpackersin the Khaosan Road area, Bangkok; and the prevalenceof being bitten was 6.9/1,000 people, while the preva-lence of being licked was 35.6/1,000 people (average stayin Southeast Asia, 30.6 days).9 Considering the shorteraverage stay for travelers in our study (13.0 days), theprevalence of animal bites among Japanese travelers wasthe highest of the three studies.

Regarding the incidence of animal exposure amongexpatriates, although accurate data on the risk amonglocal Thais do not currently exist, we estimate thatbetween 270,000 and 400,000 people per year arepotentially exposed to rabies in Thailand, based on thenumber of PEP in national Thai hospitals.16 On thebasis of these data, over 0.6% of the Thai populationis estimated to be potentially exposed annually. There-fore, the incidence for Japanese expatriates is far greaterthan the incidence for local Thais since 2% of Japaneseexpatriates are estimated to be bitten by potentiallyrisky animals annually, according to the incidence ratesin this study. However, the incidence of animal expo-sure among Thais is likely an underestimate, becausethe incidence is based only on data from public hos-pitals and does not include those seeking treatmentat private hospitals or those not seeking treatmentat all.

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Table 5 Risk of potential rabies exposure in Thailand

Expatriates Travelers

Risk of potential rabies exposure n/N % n/N % p-Value

Number of bitten participants 105/1,208 8.7 9/590 1.5Number of licked participants 393/1,206 32.6 31/585 5.3Number of scratched participants 111/1,206 9.2 7/586 1.2

n n

Total number of animal bites 111 11Total number of animal licks 461 33Total number of animal scratches 120 8Prevalence (per 1,000 persons)

Animal bites 86.9 15.3Licks 325.9 53.0Scratches 92.0 11.9

Incidence rates (per 1,000 person-months)Animal bites 1.7 43.1 <0.001

Licks 6.9 136.1 <0.001Scratches 1.8 33.0 <0.001

Total number of exposures, counting multiple exposures of study participants.N = total number of the respondents; n= the number of persons with exposure.

Table 6 Practices after an animal bite

Expatriates TravelersAfter an animal bitewhat did you do? n % n % p-Value

N = 105 N = 9Cleaned the wound 62 59 3 33.3 0.170Went to hospital immediately 56 53.3 1 11.1 0.032Were vaccinated

(post-exposure prophylaxis)48 45.7 1 11.1 0.075

No treatment 19 18.1 6 66.7 0.001

The results are shown for the first animal bite episode for each individual.Participants could choose more than one of the practices.N = total number of respondents; n= the number of persons responding positivelyper category.

It is difficult to explain exactly why the Japanese,especially travelers, have such high incidences of animalexposure in Thailand. It may be due to the lack ofappropriate knowledge and attitudes among Japanesetravelers, as several studies have shown.10,11 The inter-national travelers in the Khaosan Road study, mostlyEuropeans and North Americans, had a much higherPrEP rate (18.1%) than the Japanese travelers inthe current study (2.2%). In addition, other interna-tional travelers were found to have more knowledgeabout rabies than the Japanese travelers in our study.9Although the number of the participating travelersshould have reached sufficient sample size, the rela-tively small number of the travelers and the relativelyshort duration of their stay in Thailand (duration oftravelers’ stay in Thailand: median 6.0 days, average13.0 days) might affect the results and lead to a highincidence of potential exposure.

Theoretically, when we collect information aboutnumber of exposure events and duration at risk for each

participant, the rates of exposure can be estimated retro-spectively, based on the results of a cross-sectional study.This is a practical and low-cost method.17,18 One previ-ous study suggested that the length of stay was related tothe risk of exposure, that is, travelers who stayed morethan 20 days had a higher risk than travelers who stayedless than 5 days (5% vs 1.3%, adjusted relative risk 7.78,95% confidence interval 4.71–13.01).19 Therefore, weassume that longer stay should be one of the risk factorsto potential rabies exposure, and calculate the rates ofpotential rabies exposure to compare differences in riskbetween two groups with different durations of stay,assuming that the risk of animal exposure had a linearassociation with duration of stay. However, the calcu-lated rates of exposure might not be a good estimator,and might be overestimated if the actual relationshipwas nonlinear. Although another potential limitationof this method is recall bias, incidents of animal bitesand scratches are likely not easily forgotten, and thusthe data obtained have minimal recall bias. However,episodes of animal licks might not be as obvious,so the number of reported licking episodes may bean underestimate.

Several studies have shown that males are moreat risk of potential rabies exposure than females.20,21

On the basis of gender ratio of Japanese travelers toThailand in 2007, 72.5% of Japanese travelers weremale.22 The ratio was nearly the same in the currentstudy, indicating that our sample of travelers is similarto Japanese travelers in general in terms of gender. Onthe other hand, in 2009, 66.2% of Japanese expatriateswere male.14 In our sample, the majority of expatriateswere female, which may partially explain the lowerincidence of potential exposure in expatriates comparedwith travelers.

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Even though the provinces in which the expatri-ates in this study stayed were relatively the same asthe overall Japanese population in Thailand,13 thenumber of participants was only adequate in Bangkokto estimate our results with our desired precision.If more questionnaires were obtained from expatri-ates living in other provinces, the expatriate incidencerates may increase because the incidence of poten-tial rabies exposure might be greater in rural thanurban areas.

After an animal bite, 54.3 and 88.9% of the expatri-ates and travelers, respectively, who were bitten, wereat risk of not receiving appropriate treatment with ananti-rabies PEP. Above all, the vaccination statuses ofthe dogs and cats that had bitten the travelers wereunclear. Some of the expatriates and most of the trav-elers who were bitten were unaware of their risk forrabies, even after an animal with an unclear vaccinationstatus bit them. The majority of risky animal contactwas with domestic animals (74.9%). This was one majorreason why expatriates who were bitten did not receivePEP after a potential exposure. In China, domestic dogsremain the major cause of the over 2,000 annual deathsdue to human rabies.23

We assume that countries like Japan, which elim-inated rabies, experience decreased awareness of thedangers of rabies exposure. One review article found42 imported human rabies cases worldwide from1990 to 2010, and the greatest number of deathswere reported in European Union countries (n= 22),followed by the United States (n= 13), the formerUnion of Soviet Socialist Republics (n= 5), and Japan(n= 2).24 Inappropriate care or ineffective care incountries where risk exposure occurred was the causeof several of these cases.24 Healthcare workers inrabies-endemic countries need to be appropriatelytrained to prevent rabies; however, travelers andexpatriates should also have sufficient KAP beforeinternational travel. Nonetheless, as our study andthe other studies indicate, expatriates and travelersfrom countries that are not rabies endemic may haveinsufficient KAP.

In conclusion, we found a high incidence of potentialrabies exposure, particularly among Japanese travelers.This survey indicates that Japanese expatriates andtravelers are at high risk of potential rabies exposureand have the potential to contract rabies, because ofthe low rate of appropriate treatment after potentialexposure. Anti-rabies PrEP vaccination for Japaneseexpatriates and travelers is worthy of consideration,because of the high incidence rates for potential rabiesexposure. Rabies is a preventable disease with appro-priate KAP and PEP. Therefore, the disseminationof knowledge regarding rabies prevention amongJapanese expatriates and travelers in Thailand needs tobe promoted urgently through healthcare providers,media, and public organizations before Japanese cit-izens depart to Thailand, to avert serious, even fatal,consequences.

Acknowledgments

We express sincere gratitude to Mr D. Oguchi, Mr Y.Odahara, Mr Y. Saita, Mrs N. Oka, Mr K. Nakaoka,Miss H. Aoyama, Miss I. Nakamura, Miss M. Yamada,and all of the staff in the Travel Medicine ResearchUnit, Mahidol University, and Queen Saovabha Memo-rial Institute, for their exceptional support for data col-lection. This study was supported by Faculty of Gradu-ate Studies, Mahidol University, and Infectious DiseasesUnit, Department of Medicine, King ChulalongkornUniversity.

Declaration of Interests

The authors state they have no conflicts of interest todeclare.

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