Incidence of Potential Rabies Exposure Among Japanese Expatriates and Travelers in Thailand

I S T M 240 ORIGINAL ARTICLE Incidence of Potential Rabies Exposure Among Japanese and 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, and Terapong Tantawichien, MD Department of Clinical Tropical Medicine, Mahidol University, Bangkok, Thailand; Queen Saovabha Memorial Institute, Thai Red Cross Society, Bangkok, Thailand; Department of Tropical Hygiene, Mahidol University, Bangkok, Thailand; Medical Division, 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 awareness of rabies when Japan had two reported cases of human rabies, originating in the Philippines. Although the number of Japanese either traveling 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, and practice 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, and experiences of potential rabies exposure such as animal bites, licks, and scratches. Questionnaires were either completed at the Bangkok 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 the highest incidence rate compared to previous studies of international travelers in Thailand. While expatriates incidence rates of animal 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 and less 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 essential to promote prevention activities for the Japanese population in Thailand to avert serious consequences of this disease. Until 2006, rabies was a neglected and almost forgotten disease in Japan, owing to its nationwide elimination in 1957. 1 In 2006, two Japanese travelers died of rabies after returning from the Philippines. 2 4 These imported cases temporarily increased social awareness, which led to a shortage of domestic Japanese rabies vaccine (purified chick embryo cell rabies vaccine Kaketsuken) because many Japanese going overseas consulted medical facilities for vaccinations. 5 To prevent further cases, healthcare workers need to Corresponding Author: Wataru Kashino, MD, Department of Psychiatry, National Center of Neurology and Psychiatry, 4-1-1 Ogawa-Higashi, Kodaira, Tokyo 187-8551, Japan. E-mail: wkashino@ncnp.go.jp advise travelers, including the recommendation of pre-exposure prophylaxis (PrEP), based on accurate risk assessments. Nevertheless, to our knowledge, no study has estimated the risk of rabies among Japanese travelers and expatriates in rabies-endemic regions. Rabies is endemic worldwide. The World Health Organization estimates that 55,000 people worldwide die of rabies and at least 15 million doses of anti-rabies postexposure prophylaxis (PEP) are administered annually to avert the onset of disease. 6 Several studies have investigated the risk of potential rabies exposure among international expatriates or travelers in Asian countries such as Thailand and Nepal, 7 9 but Japanese citizens should be investigated separately because of their 2014 International Society of Travel Medicine, 1195-1982 Journal of Travel Medicine 2014; Volume 21 (Issue 4): 240 247

Rabies Exposure Among Japanese in Thailand 241 unawareness of and lack of preparedness for infectious disease risks outside Japan. 10,11 The main objective of this study was to estimate the incidence rates of potential rabies exposure among Japanese expatriates and travelers in Thailand, and to describe the knowledge and attitudes for preventing rabies and practices (KAP) after risky contacts with animals. The results can provide information to help promote further prevention activities against this lethal but preventable disease. Methods Study Design and Eligibility Criteria This study was a questionnaire-based cross-sectional study. The questionnaires were distributed to eligible Japanese: those who were of Japanese nationality and over 18 years old. Japanese expatriates were classified as those who had stayed in Thailand for more than 3 months. Japanese travelers were classified as those who had stayed in Thailand for more than 3 days, and this did not include transit-only travelers. This study and the questionnaires used were approved by the Ethics Committee of the Faculty of Tropical Medicine, Mahidol University. Sample Size Estimation The sample size was determined using the estimated risk of potential rabies exposure and the estimated Japanese population in Thailand in 2009. 12 14 Asurvey at Bangkok International Airport showed that 1.3% of the 1,882 international travelers surveyed had experienced a dog bite and 8.9% had experienced a dog lick. 8 Therefore, exposure risk was set at 10.2%, and it was assumed that up to 25% of exposure events went unreported. Utilizing those data, we estimated 535 expatriates and 541 travelers needed to determine the risk of potential rabies exposure, such as dog bites and dog licks, with 95% confidence. The sample size calculation was performed with epi info program version 3.5.3 (CDC, Atlanta, GA, USA). Questionnaire Each participant was asked to fill out a four-page questionnaire once. The questionnaire was written in Japanese and English, and consisted of three parts: general information (age, gender, purpose of stay, places and durations of stay, occupation, educational background, acquisition of travel health information); attitudes toward, and knowledge about, rabies prevention (acquisition of information on rabies, PrEP status and its type if vaccinated, reason for not being vaccinated if unvaccinated, questions about rabies transmission and prevention, and treatment after an animal bite); potential rabies exposure, and practices after an animal bite (animal bites, licks, and scratches experienced in Thailand, practices after an animal bite, animal species contacted, and their ownership status). The questionnaire could be completed in 4 to 8 minutes. Data Collection and Study Site For the eligible expatriates, the questionnaire was distributed by direct or indirect personal contact. For the direct contacts, the study team attended meetings held in Japanese residential and business districts of Thailand, and handed out the questionnaire to participants. For the indirect contacts, the team asked Japanese organizations in Bangkok and other provinces to distribute questionnaires to their members. For the travelers, the team distributed the questionnaires directly at three tourist areas. Travel agencies and a medical facility in Bangkok were also asked to cooperate in the survey. Statistical Analysis The characteristics of the participants in each group were described. The t-test or Mann Whitney U-test was used for continuous data, while the Chi-square test or Fisher s exact test was used for categorical data. To estimate incidence rates of potential rabies exposure, we divided the total number of each type of potential rabies exposure (bites, licks, and scratches) by the total duration of stay (the sum of each individual s period of risk). Prevalence was estimated by dividing the number of participants exposed by the number of study subjects in each group. Univariate Poisson regression analysis was used to compare differences in the incidence rates between the two groups. Statistical significance was set at 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 Study Population Data were collected from November 15, 2010 until March 31, 2011. To collect expatriate data, we cooperated with associations in Thailand. These associations were the Embassy of Japan in Thailand, the Thailand Office of the Japanese International Cooperation Agency, eight Japanese primary schools, a Japanese elementary school, a Japanese junior high school, a Japanese high school in Bangkok, the dispensary of a Japanese School in Chonburi, four local Japanese associations, eight private enterprises, and Bangkok and Chiang Mai Christian churches. To collect data from Japanese travelers, we randomly interviewed travelers in Bangkok s Suvarnabhumi International Airport, Khaosan Road area, and Chatuchak Weekend Market. We also cooperated with the Queen Saovabha Memorial Institute and two travel agencies in Bangkok to collect data from Japanese travelers who visited each association. The response rate was 56% for the expatriate group and 64% for the traveler group. In all, 1,208 questionnaires were collected from expatriates and 590 from travelers. Most travelers (70.9%) were male, while most expatriates (61.1%) were female.

242 Kashino et al. Table 1 Baseline characteristics of the study population Characteristics n % n % p-value Total participants 1,208 100 590 100 Age (years) Median (range) 39 (18 82) 42 (18 89) <0.001 Gender N = 1,204 N = 588 Female 736 61.1 171 29.1 <0.001 Educational background N = 1,201 N = 432 Junior high/high school 210 17.5 89 20.6 0.151 College/university* 859 71.5 283 65.5 0.019 Graduate school 95 7.9 46 10.6 0.082 Others 37 3.1 14 3.2 0.870 n % n % Reason for stay N = 1,205 Reason for travel N = 589 Companion with family 599 49.7 Tourism 434 73.7 Business 448 37.2 Business 103 17.5 Immigration/long-term stay 79 6.6 Visit acquaintances 34 5.8 Education/research 26 2.2 Education/research 16 2.7 Studying in Thailand 12 1.0 Other reasons 2 0.3 Other reasons 41 3.4 Residence in Thailand N = 1,208 Have traveled to, N = 590 Bangkok 1,107 91.6 505 85.6 Central besides Bangkok 19 1.6 30 5.1 Northern 19 1.6 71 12 Northeastern 3 0.2 17 2.9 Eastern 55 4.6 79 13.4 Western 1 0.1 15 2.5 Southern 4 0.3 60 10.2 Length 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. visited multiple places. The median duration of stay was 32 months for expatriates and 6 days for travelers. Detailed baseline characteristics are summarized in Table 1. Attitudes Toward Risk of Rabies and PrEP Status The results for attitudes toward risk of rabies and PrEP status are summarized in Table 2. Generally, compared with expatriates, travelers were less prepared for health problems in Thailand, were less vaccinated with PrEP, and were less aware of the risk of rabies. The proportions for participants who received a complete PrEP vaccination course were low in both groups (8.6% of expatriates vs 2.2% of travelers, p < 0.001). Furthermore, 65.5% of expatriates and 40% of travelers who were vaccinated were unaware of which PrEP vaccine they received, although the Japanese domestic rabies vaccine has PEP schedules different from those of internationally standard rabies vaccines. Knowledge About Rabies Transmission and Prevention Results of knowledge about rabies transmission and prevention are summarized in Table 3. We found that the knowledge of travelers was less accurate than that of the expatriates. While most of the study participants recognized that animal bites have potential risk of rabies transmission, animal licks and scratches tended not to be recognized as one of the possible rabies transmission routes, and 47.6% of the expatriates and 74.8% of the travelers did not know the fact that licks by infected animals on mucous membranes can cause rabies transmission. Over 97% of the study participants recognized that dogs could carry rabies, while many were unaware that cats, bats, and monkeys are also possible transmission sources. Results of a descriptive question about rabies prevention after an animal bite are summarized in Table 4. With regard to disease prevention after potential rabies exposure, few participants knew the appropriate treatments, although they were aware of the need to wash bitten wounds immediately, go to hospital, and be vaccinated for PEP (plus injection of rabies immunoglobulin, if available). The proportion of participants who gave correct answers for all questions about the appropriate treatments was low (8.4% of expatriates and 1.2% of travelers, p < 0.001) (Table 4).

Rabies Exposure Among Japanese in Thailand 243 Table 2 Attitudes toward rabies risk and pre-exposure vaccination status Question n % n % p-value Sought travel health information before your stay in Thailand? N = 1,207 N = 585 Yes 718 59.5 191 32.6 < 0.001 Source of travel information N = 718 N = 169 Travel medicine specialist 114 16.7 13 7.7 General practitioner/family doctor 156 22.9 12 7.1 Relatives/friends 125 18.3 34 20.1 Retrieved information on the Internet 532 78.0 119 70.4 Guide book/news/television 331 48.5 62 36.7 Medical department of a company 44 6.5 Received rabies information before your stay in Thailand? N = 1,205 N = 586 Yes 682 56.6 169 28.8 < 0.001 Received vaccines against rabies? N = 1,203 N = 584 Yes, all three doses 104 8.6 13 2.2 < 0.001* Yes, 1 2 doses 203 16.9 22 3.8 No 896 74.5 549 94 Reasons for not being vaccinated I think it is not necessary 479 39.8 322 55.1 < 0.001 After animal bites, I will be vaccinated 122 10.1 7 1.2 < 0.001 I did not know about rabies or vaccination 82 6.8 162 27.7 < 0.001 No time or chance to be vaccinated 52 4.3 13 2.2 0.002 It is too expensive 48 4 17 2.9 0.044 Doctors did not recommend rabies vaccination 42 3.5 0 0 Lack of vaccines in Japan 29 2.4 4 0.7 0.002 Other reasons 42 3.5 24 4.1 0.780 Type of vaccination N = 307 N = 35 Japanese vaccine (PCEC-K) 72 23.5 11 31.4 Internationally standardized vaccine 34 11.1 10 28.6 Unsure 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 Thailand The results for risk of potential rabies exposure are summarized in Table 5, which shows the frequency of contacts with dogs, cats, and monkeys, because these three animals are major sources of rabies transmission in Thailand. 15 The incidence rates of animal bites (per 1,000 person-months) were 1.7 for expatriates and 43.1 for travelers. The incidence rates of animal licks were 6.9 for expatriates and 136.1 for travelers. The incidence rates of animal scratches were 1.8 for expatriates and 33.0 for travelers. On the other hand, the prevalence of animal bites, licks, and scratches (per 1,000 persons) was 86.9, 325.9, and 92.0 for the expatriates (average stay, 55.4 months), respectively, and 15.3, 53.0, and 11.9 of the travelers (average stay, 13.0 days), respectively (Table 5). Among all participants, 118 were bitten, 441 were licked, and 124 were scratched by mammals. Over 95% of these episodes were exposure to dogs, cats, and monkeys. Of the 782 potential rabies exposure to mammals, 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 Ownership Status The results for practices after an animal bite are summarized in Table 6. Among the 105 expatriates who were bitten, 48 (45.7%) received PEP, while only 1 of 9 travelers (11.1%) received PEP. Of the 744 total potential rabies exposure to dogs, cats, and monkeys (122 bites, 494 licks, and 128 scratches), 74.9% (557/744) had contact with domestic animals, 18.4% (137/744) with wild animals, and 6.7% (50/744) had contact with animals of unclear ownership status. None of the travelers who were bitten knew whether the animals that bit them had been vaccinated against rabies. Discussion To our knowledge, this is the first study investigating the risk of potential rabies exposure among Japanese citizens living or traveling in Thailand. Furthermore, no other studies have been conducted to compare KAP on rabies between expatriates and travelers. We found a high incidence of potential rabies exposure, especially among travelers. Two previous studies investigated the risk of

244 Kashino et al. Table 3 Knowledge about rabies transmission and prevention Question n % n % p-value 1. You may get rabies if you: N = 1,207 N = 587 Are bitten by an animal* 1,187 98.3 561 95.6 <0.001 Are licked on broken skin* 876 72.6 206 35.1 <0.001 Are licked on a mucous membrane like your eyes or mouth* 633 52.4 148 25.2 <0.001 Are scratched deeply by an animal* 867 71.8 172 29.3 <0.001 Are scratched shallowly* 525 43.5 109 18.6 <0.001 Are licked on normal skin 1,087 90.1 547 93.2 <0.001 Eat 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 <0.001 2. Correctly identified animals that could carry rabies N = 1,208 N = 587 Dog* 1,187 98.3 576 97.6 0.839 Cat* 840 69.5 150 25.4 <0.001 Monkey* 613 50.7 140 23.7 <0.001 Bat* 466 38.6 106 18 <0.001 Correctly identified animals that could not carry rabies Snake* 1,130 93.5 570 97.1 0.002 Chicken* 1,062 87.9 540 92 0.009 Participants who chose all correct answers. 232 19.2 23 3.9 <0.001 3. If you have finished complete course of rabies vaccines and you are 952 78.8 415 70.3 <0.001 bitten by a dog or cat, there is no need to have boosters Unsure 215 17.8 125 21.2 4. 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 chose the correct answers. Table 4 Knowledge about rabies prevention after an animal bite Question Yes % Yes % p-value If you are bitten by an animal, what are you going to do to prevent rabies onset? N = 1,208 N = 590 Clean the wound (1)* 343 28.4 91 15.4 <0.001 Go to hospital (2)* 1, 060 87.7 394 66.8 <0.001 Receive vaccination (3)* 378 31.3 50 8.5 <0.001 Observe the animal (4)* 16 1.3 5 0.8 0.486 Tie the upper part of the 23 1.9 9 1.5 0.569 wound to prevent toxin circulation Suck out toxins from the 4 0.3 6 1 0.089 wound Nothing to do 17 1.4 39 6.6 <0.001 Unsure 117 9.7 122 20.7 <0.001 Participants who gave all correct 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 travelers in Thailand. Phanuphak and colleagues found that among 1,882 foreign travelers at Bangkok International Airport, the prevalence of animal bites was 12.6/1,000 people and the prevalence of animal licks was 89.1/1,000 people (average stay in Thailand, 17.0 days). 8 Piyaphanee and colleagues investigated 870 foreign backpackers in the Khaosan Road area, Bangkok; and the prevalence of being bitten was 6.9/1,000 people, while the prevalence of being licked was 35.6/1,000 people (average stay in Southeast Asia, 30.6 days). 9 Considering the shorter average stay for travelers in our study (13.0 days), the prevalence of animal bites among Japanese travelers was the highest of the three studies. Regarding the incidence of animal exposure among expatriates, although accurate data on the risk among local Thais do not currently exist, we estimate that between 270,000 and 400,000 people per year are potentially exposed to rabies in Thailand, based on the number of PEP in national Thai hospitals. 16 On the basis of these data, over 0.6% of the Thai population is estimated to be potentially exposed annually. Therefore, the incidence for Japanese expatriates is far greater than the incidence for local Thais since 2% of Japanese expatriates are estimated to be bitten by potentially risky animals annually, according to the incidence rates in this study. However, the incidence of animal exposure among Thais is likely an underestimate, because the incidence is based only on data from public hospitals and does not include those seeking treatment at private hospitals or those not seeking treatment at all.

Rabies Exposure Among Japanese in Thailand 245 Table 5 Risk of potential rabies exposure in Thailand Risk of potential rabies exposure n/n % n/n % p-value Number of bitten participants 105/1,208 8.7 9/590 1.5 Number of licked participants 393/1,206 32.6 31/585 5.3 Number of scratched participants 111/1,206 9.2 7/586 1.2 Total number of animal bites 111 11 Total number of animal licks 461 33 Total number of animal scratches 120 8 Prevalence (per 1,000 persons) Animal bites 86.9 15.3 Licks 325.9 53.0 Scratches 92.0 11.9 Incidence rates (per 1,000 person-months) Animal bites 1.7 43.1 <0.001 Licks 6.9 136.1 <0.001 Scratches 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. n n Table 6 Practices after an animal bite After an animal bite what did you do? n % n % p-value N = 105 N = 9 Cleaned the wound 62 59 3 33.3 0.170 Went to hospital immediately 56 53.3 1 11.1 0.032 Were vaccinated 48 45.7 1 11.1 0.075 (post-exposure prophylaxis) 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 positively per category. It is difficult to explain exactly why the Japanese, especially travelers, have such high incidences of animal exposure in Thailand. It may be due to the lack of appropriate knowledge and attitudes among Japanese travelers, as several studies have shown. 10,11 The international travelers in the Khaosan Road study, mostly Europeans and North Americans, had a much higher PrEP rate (18.1%) than the Japanese travelers in the current study (2.2%). In addition, other international travelers were found to have more knowledge about rabies than the Japanese travelers in our study. 9 Although the number of the participating travelers should have reached sufficient sample size, the relatively small number of the travelers and the relatively short duration of their stay in Thailand (duration of travelers stay in Thailand: median 6.0 days, average 13.0 days) might affect the results and lead to a high incidence of potential exposure. Theoretically, when we collect information about number of exposure events and duration at risk for each participant, the rates of exposure can be estimated retrospectively, based on the results of a cross-sectional study. This is a practical and low-cost method. 17,18 One previous study suggested that the length of stay was related to the risk of exposure, that is, travelers who stayed more than 20 days had a higher risk than travelers who stayed less than 5 days (5% vs 1.3%, adjusted relative risk 7.78, 95% confidence interval 4.71 13.01). 19 Therefore, we assume that longer stay should be one of the risk factors to potential rabies exposure, and calculate the rates of potential rabies exposure to compare differences in risk between two groups with different durations of stay, assuming that the risk of animal exposure had a linear association with duration of stay. However, the calculated rates of exposure might not be a good estimator, and might be overestimated if the actual relationship was nonlinear. Although another potential limitation of this method is recall bias, incidents of animal bites and scratches are likely not easily forgotten, and thus the data obtained have minimal recall bias. However, episodes of animal licks might not be as obvious, so the number of reported licking episodes may be an underestimate. Several studies have shown that males are more at risk of potential rabies exposure than females. 20,21 On the basis of gender ratio of Japanese travelers to Thailand in 2007, 72.5% of Japanese travelers were male. 22 The ratio was nearly the same in the current study, indicating that our sample of travelers is similar to Japanese travelers in general in terms of gender. On the other hand, in 2009, 66.2% of Japanese expatriates were male. 14 In our sample, the majority of expatriates were female, which may partially explain the lower incidence of potential exposure in expatriates compared with travelers.

246 Kashino et al. Even though the provinces in which the expatriates in this study stayed were relatively the same as the overall Japanese population in Thailand, 13 the number of participants was only adequate in Bangkok to estimate our results with our desired precision. If more questionnaires were obtained from expatriates living in other provinces, the expatriate incidence rates may increase because the incidence of potential rabies exposure might be greater in rural than urban areas. After an animal bite, 54.3 and 88.9% of the expatriates and travelers, respectively, who were bitten, were at risk of not receiving appropriate treatment with an anti-rabies PEP. Above all, the vaccination statuses of the dogs and cats that had bitten the travelers were unclear. Some of the expatriates and most of the travelers who were bitten were unaware of their risk for rabies, even after an animal with an unclear vaccination status bit them. The majority of risky animal contact was with domestic animals (74.9%). This was one major reason why expatriates who were bitten did not receive PEP after a potential exposure. In China, domestic dogs remain the major cause of the over 2,000 annual deaths due to human rabies. 23 We assume that countries like Japan, which eliminated rabies, experience decreased awareness of the dangers of rabies exposure. One review article found 42 imported human rabies cases worldwide from 1990 to 2010, and the greatest number of deaths were reported in European Union countries (n = 22), followed by the United States (n = 13), the former Union of Soviet Socialist Republics (n = 5), and Japan (n = 2). 24 Inappropriate care or ineffective care in countries where risk exposure occurred was the cause of several of these cases. 24 Healthcare workers in rabies-endemic countries need to be appropriately trained to prevent rabies; however, travelers and expatriates should also have sufficient KAP before international travel. Nonetheless, as our study and the other studies indicate, expatriates and travelers from countries that are not rabies endemic may have insufficient KAP. In conclusion, we found a high incidence of potential rabies exposure, particularly among Japanese travelers. This survey indicates that Japanese expatriates and travelers are at high risk of potential rabies exposure and have the potential to contract rabies, because of the low rate of appropriate treatment after potential exposure. Anti-rabies PrEP vaccination for Japanese expatriates and travelers is worthy of consideration, because of the high incidence rates for potential rabies exposure. Rabies is a preventable disease with appropriate KAP and PEP. Therefore, the dissemination of knowledge regarding rabies prevention among Japanese expatriates and travelers in Thailand needs to be promoted urgently through healthcare providers, media, and public organizations before Japanese citizens 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 Research Unit, Mahidol University, and Queen Saovabha Memorial Institute, for their exceptional support for data collection. This study was supported by Faculty of Graduate Studies, Mahidol University, and Infectious Diseases Unit, Department of Medicine, King Chulalongkorn University. Declaration of Interests The authors state they have no conflicts of interest to declare. References 1. Takayama N. Rabies control in Japan. Jpn J Infect Dis 2000; 53:93 97. 2. Takahashi H, Sagara H, Fujita S. Rabies as of 2006, Japan. IASR 2007; 28. Available at: http://idsc.nih.go.jp/iasr/28/325/inx325.html. (Accessed 2010 Sep 1). 3. Tamashiro H, Matibag GC, Ditangco RA, et al. Revisiting rabies in Japan: is there cause for alarm? Travel Med Infect Dis 2007; 5:263 275. 4. Yamamoto S, Iwasaki C, Oono H, et al. The first imported case of rabies into Japan in 36 years: a forgotten life-threatening disease. J Travel Med 2008; 15:372 374. 5. 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