Travel Health Information Sheets
Updated December 2012
Rabies
Introduction
Rabies virus is a member of the genus Lyssavirus, of the family Rhabdoviridae, or bullet-shaped viruses. The virus attacks the central nervous system, causing progressive paralysis, encephalitis and coma. Once symptoms are present, rabies is almost always fatal.
Rabies occurs in warm-blooded mammals (both domestic and wild) and is transmitted to man, usually by a bite from an infected animal.
Epidemiology
Global epidemiology
Rabies: Countries at risk 2012
Click here to view bigger map (opens in a new window 134KB PDF)
Map courtesy World Health Organization (International Travel and Health, 2012).
According to WHO data, rabies is present in over 100 countries with at least 55,000 deaths reported in rural Africa and Asia. However the true burden of disease is considered to be largely underestimated with more than 3 billion people considered to be at risk of acquiring rabies worldwide. Most parts of the African and Asian continents and many parts of Latin America are endemic for rabies. An estimated 10 million people, particularly children aged less than15 years, receive post-exposure treatments each year after being bitten by a suspected rabid animal, usually a dog [1].
Most deaths occur in regions where stray dog populations are ineffectively controlled. This, combined with limited availability of human post-exposure prophylaxis in some countries, contributes to the high mortality rates.
The UK is considered free of rabies in terrestrial animals; cases of rabies in bats are occasionally reported.
Most of Western Europe is rabies-free due to the success of co-ordinated wildlife oral vaccination programmes, together with the availability of effective commercial vaccination for domestic animals [2]. However, an outbreak of rabies in wild animals occurred in the Friuli-Venezia Giulia region of north-east Italy, the first outbreak of rabies in Italy since 1995 [3].
More recently, rabies has been reported in a fox and a domestic dog in Western Macedonia, Northern Greece. These are the first cases reported in Greece since 1987 [4, 5].
Incidents involving imported animals also occur, such as a rabid dog imported into France from North Africa in 2011 [6] and a rabid puppy imported into the Netherlands from Morocco via Spain in 2012[7].
Rabies is endemic in wild animals of North America and in parts of Eastern Europe and Turkey.
Rabies in UK Travellers
The last case of indigenous terrestrial animal rabies occurred in Great Britain in 1922. The last recorded cases of animal rabies outside quarantine occurred in 1969 and 1970 when two imported dogs died soon after completing six months quarantine. Since then, nearly all cases of rabies in the UK have occurred in quarantined animals or in people who were infected abroad. The exception was human rabies in a bat handler infected with European Bat Lyssavirus 2 (EBLV2) in Scotland in 2002 [8]. It is recognised that UK bats can carry EBLV2. Confirmed cases of EBLV2 in bats have been reported in Newhaven in 1996, Lancashire in 2002 and 2003, Surrey in 2004, Oxfordshire in 2006, Shropshire in 2007 and 2008, Surrey in 2008 and Scotland in 2009 [9].
There have been 25 human deaths in the UK from imported rabies since 1902. All but two of these resulted from a dog bite (one was from a cat and the other exposure was unknown): 63% of deaths were after a bite that occurred on the Indian Sub-Continent. The five cases imported since 2000 are:
- an overseas visitor from Nigeria who sustained a dog bite on the lower leg five months prior to clinical symptoms [10]
- a UK resident who was bitten by a dog whilst in the Philippines [11]
- a British woman who sustained a dog bite during a two week holiday to Goa, India and died of rabies in the UK in 2005 [12]
- a British woman who had worked in an animal sanctuary in South Africa and died of rabies in Northern Ireland in January 2009 [13]
- a British woman bitten by a dog whilst visiting Asia [14]
None of these cases were known to have received pre-or post-exposure rabies prophylaxis.
Risk for travellers
Most deaths from rabies occur in Asia, Africa and Latin America, and follow a bite from an infected dog. Each of these regions are reported to have large stray dog populations that pose a risk to humans if they are bitten or have other trans-cutaneous or mucosal exposure to infected saliva. Other mammalian hosts of rabies in these regions include bats, monkeys, mongoose and jackal.
In North America and Europe the disease is mainly confined to wild animals (particularly bats, and foxes in Europe and coyote, skunks and racoons in North America); in North America human cases have usually followed exposure to an infected bat.
Transmission
Rabies virus is found in the saliva of an infected animal. The virus is transmitted to humans by a bite, or when saliva from an infected animal comes into contact with broken skin or mucous membranes (eyes, nose, or mouth). Rarely, rabies has been contracted following laboratory exposure or after transplantation of organs from an infected individual [15, 16].
Signs and symptoms
The incubation period of rabies is between 20 and 90 days; in rare cases it can be as short as a few days or as long as several years. In more than 90% of patients, the onset is within one year of exposure. The prodrome is often non-specific with symptoms of fever, headache, myalgia, and fatigue. Paresthesiae can occur at the site of the bite. The disease progresses to the more common furious rabies, or the less common paralytic or ‘dumb’ rabies.
Furious rabies is characterised by laryngeal spasms, which occur in response to attempts to drink water; these can be accompanied by a feeling of terror. Following deterioration, coma and death ensue over several days.
The paralytic form of rabies is often misdiagnosed. Paresthesiae and weakness often first occur around the bite site and begin to ascend the bitten limb. The paralysis results in respiratory failure and inability to swallow. Death usually occurs within 1-3 weeks.
Treatment
All travellers who have a possible exposure to the rabies virus, whether by bites, scratches, or other means, should seek medical advice without delay. Seeking medical care also applies to travellers in areas considered low risk for rabies as other infections may be transmitted by the bite, or the animal may have been imported or crossed the border from an endemic country. Medical advice should be sought without delay even if pre-exposure vaccine was received.
During 2011, over 1300 enquiries were made to the HPA relating to potential rabies exposures for which rabies PEP was issued for 1100 people in England and Wales. Exposures requiring PEP are commonly related to dog, cat, monkey and bat bites. Most of the bat exposures occur in the UK [17].
Although a few patients have survived rabies [18], the disease is considered fatal once symptoms manifest themselves.
Prevention
Contact with wild or domestic animals during travel should be avoided. Travellers should be advised:
- not to approach animals
- not to attempt to pick up an unusually tame animal or one that appears to be unwell
- not to attract stray animals by offering food or by being careless with litter
- to be aware that certain activities can attract dogs (e.g. running, cycling)
Pre-exposure vaccine should be given to travellers at continuous, frequent or infrequent risk, according to UK guidance [19]. A record of vaccination should be carried and shown to those administering emergency treatment in a post-exposure situation
Receiving rabies vaccine prior to travel does not eliminate the need for post-exposure medical evaluation and additional doses of rabies vaccine.
Advice should be given to all travellers regarding first aid in the case of a possible rabies exposure:
- This is an emergency. Treatment should be commenced as soon as possible after the exposure.
- Immediately wash the wound with detergent or soap and running water for several minutes.
- Apply a disinfectant to the wound such an iodine solution (tincture or aqueous solution of povodone-iodine) or 40-70% alcohol.
- Apply a simple dressing to the wound.
- Seek immediate medical advice about the need for PEP and/or rabies vaccination and possible antibiotics to prevent a bite wound infection.
- Tetanus vaccine may be necessary if the traveller is not up-to-date.
- Primary suturing of the wound should be postponed until post exposure prophylaxis has started [19].
Rabies Pre-Exposure Vaccine
Indications for use of vaccine
This should be determined by the risk (continuous, frequent or infrequent) category of the individual [19].
All those who are at continuous or frequent risk of exposure should be offered pre-exposure vaccine. Groups in these risk categories include:
- laboratory workers routinely handling rabies virus
- bat handlers who regularly handle bats
- those who regularly handle imported animals
- animal workers who regularly travel to rabies enzootic areas
- health workers in rabies enzootic areas who have direct contact with rabies infected patients
Most international travellers to rabies enzootic areas are considered to be at infrequent risk, but may require pre-exposure rabies vaccine if they are:
- unable to access rabies vaccine, immunoglobulin and medical care easily at their destination
- undertaking activities considered at higher risk of exposure e.g. cycling and running
- at risk for more than one month
The rationale for receiving pre-exposure vaccine is to give the individual time to reach medical treatment in the event of an animal bite or scratch; it may also protect an individual who has an unapparent exposure. Those who have received a pre-exposure course of rabies vaccine will require two further doses of vaccine post-exposure (according to UK schedules), rather the full course of five vaccines. In addition, rabies immune globulin (RIG) will not be necessary.
Accessing safe and effective rabies vaccine products in low income countries may be difficult, and vaccine derived from animal brain tissue may be the only type available. In some areas modern tissue culture rabies vaccines may only be obtained privately or in rabies treatment centres. RIG is frequently difficult to locate and only available in major cities [20].
All travellers should be advised to perform first aid treatment on a wound and to seek medical advice as soon as possible.
Availability of vaccine (in the UK)
There are two rabies vaccines licensed for use in the UK, both of which are inactivated. Unlicensed products are occasionally available when licensed products are in short supply (please refer to manufacturer/distributor).
Details of licensed vaccines are found in the Table:
Table. Vaccine schedules
| Vaccine | Manufacturer /distributor |
Route of admini- stration |
Schedule | Pre-exposure recommend-ations [19] |
Age Range |
| Rabies Vaccine BP (Human diploid cell vaccine) (HDCV) | Sanofi Pasteur MSD | Intra- muscular |
3 doses. Day 0, 7 and 28* | Continuous risk:
if titre falls below (0.5 IU/ml)
10 years post primary course if travelling again to a high risk area |
No minimum age stated in SPC. Children are often bitten around the face or head. This type of bite is considered to be high risk. |
The SPC should be consulted prior to the administration of any vaccine.
*see interrupted/accelerated courses
**see Immunisation against infectious diseases: Rabies, for information on serological testing [19].
| Vaccine | Manufacturer /distributor |
Route of admin-istration |
Schedule | Pre-exposure recommend-ations [19] |
Age Range |
Rabipur® (Purified chick embryo cell vaccine) PCECV) |
MASTA | Intra- muscular |
3 doses. Day 0, 7 and 21 or 28* | Continuous risk 10 years post primary course if travelling again to a high risk area |
Can be given from any age. be considered for children as bites may be higher risk as they often occur around the face or head |
The SPC should be consulted prior to the administration of any vaccine.
* see interrupted/accelerated schedules
**see Immunisation against infectious diseases: Rabies, for information on serological testing [19].
It is good practice to continue a course of rabies with the same brand of vaccine. However, should this not be possible, the vaccines can be used interchangeably.
Intradermal route of administration
The intramuscular route is the preferred route to administer rabies vaccines. Pre-exposure rabies vaccination using the intradermal (ID) route is approved by the WHO [1], however the route is not licensed in the UK for any rabies vaccine. The technique requires expert practised technique [19].
Clinicians who choose to administer rabies vaccine intradermally must assume responsibility for using this method. The use of one vial to vaccinate more than one individual carries a risk of contamination and is not recommended [19].
Interrupted or accelerated courses
Ideally, those at risk should receive pre-exposure vaccination with three doses of rabies vaccine before travel. The 0, 7 and 21 day schedule can be given using either product, where there is less than four weeks before departure [19].
If there are time constraints to the full pre-exposure course, a single dose is likely to prime the immune system; travellers should complete the pre-exposure course of vaccine during their travels. A record of vaccination should be carried as this will be useful during post-bite evaluation.
Travellers need to understand that if less than the recommended three doses of vaccine have been administered pre-exposure, in the event of a possible exposure, a full post-exposure course of vaccine will be required. However, RIG will not usually be necessary.
Expert advice may be needed for individuals who have previously received an interrupted or incomplete course of vaccine and who are travelling to an area where they may be at risk.
Contraindications
- Acute febrile or other infectious illness
- Allergy to any constituent of the vaccine
- Individuals who develop symptoms suggestive of hypersensitivity after vaccination should not receive further doses of the same vaccine
- Rabipur vaccine is propagated on chick embryo cell, and is therefore contraindicated for those with have a known anaphylaxis to egg
Post vaccination serology
Post vaccination serology, to determine the level of rabies neutralizing antibody is recommended for those at continuous risk. It can be considered for those at frequent risk to determine whether a booster at three to five years is required. It is used as a guide to determine whether a booster of rabies vaccine is required. Most travellers are at infrequent risk and do not require serological testing.
Adverse events
Adverse events to rabies vaccine tend to be mild and transient and include itching, pain, and erythema at the injection site. Less commonly fever, malaise, headaches, dizziness, and urticaria occur. Delayed hypersensitivity reactions and neurological problems such as Guillain Barre have been reported [21, 22].
Post exposure management
This includes treatment of the wound and detailed risk assessment to determine necessary post exposure prophylaxis with rabies vaccine and in some circumstances human rabies immunoglobulin. Necessary details of the exposure incident to be considered are:
- site and severity of the wound
- circumstances of the bite
- species, behaviour and appearance of the animal involved
- health of the animal following the bite
- vaccination status of the animal
- country the exposure occurred and origin of the animal
- vaccination status of the individual at risk
A guide to post exposure prophylaxis following risk assessment is available here.
Specialist advice should be sought for all individuals requiring post exposure rabies management including possible bat exposures in the UK.
Advice regarding post-exposure prophylaxis in England and Wales is from the Health Protection Agency (HPA) Virus Reference Division, Colindale on 020 8200 4400. If they are not available, the duty doctor at the HPA Colindale should be consulted (020 8200 6868).
In Scotland, contact the local on-call infectious diseases consultant (20) and in Northern Ireland the Regional Virology Service on 02890240503 or Public Health Agency Duty Room on 02890553994 (20).
References
1. World Health Organization. Rabies vaccines: WHO position paper: Wkly Epidemiol Rec 6 August 2010;85: 309-320. [Accessed 11 December, 2012].Available at http://www.who.int/wer/2010/wer8532.pdf
2. Department of Health. Memorandum on Rabies Prevention and Control. February 2000. [Accessed 11 December 2012]. Available at http://www.dh.gov.uk/prod_consum_dh/groups/dh_
documents/digitalasset/dh_4080657.pdf
3. NaTHNaC Clinical Update : Rabies in Italy- update. 27 November 2009. [Accessed 11 December, 2012]. Available at : http://www.nathnac.org/pro/clinical_updates/
nathnacrabiesinitalyfriuli-veneziagiuliaandveneto27nov09healthprofessionals.htm
4. World Organisation for Animal Health. Rabies, Greece. 19 October 2012. [Accessed 11 December, 2012]. Available at: http://www.oie.int/wahis_2/public/wahid.php/Reviewreport/
Review?page_refer=MapFullEventReport&reportid=12455
5. World Organisation for Animal Health. Rabies, Greece. 19 November 2012. [Accessed 11 December, 2012]. Available at: http://www.oie.int/wahis_2/public/wahid.php/Reviewreport/
Review?page_refer=MapFullEventReport&reportid=12589
6. Mailles A. Rabid dog illegally imported to France from Morocco, August 2011. Eurosurveillance, Volume 16, Issue 33, 18 August 2011 [Accessed 11 December, 2012]. Available at : http://www.eurosurveillance.org/ViewArticle.aspx?ArticleId=19946
7. Van Rijckevorsel GG. Rabid puppy-dog imported into the Netherlands from Morocco via Spain, February 2012. Eurosurveillance, Volume 17, Issue 10, 08 March 2012. Accessed 11 December, 2012]. Available at: http://www.eurosurveillance.org/ViewArticle.aspx?ArticleId=20112
8. Crowcroft NS. Possible rabies-like infection in Scotland. Eurosurveillance 2002; (6) 47. [Accessed 11 December, 2012]. Available at: http://www.eurosurveillance.org/ViewArticle.aspx?ArticleId=1969
9. Health Protection Agency. European Bat Lyssavirus: Frequently Asked Questions
[Accessed 11 December, 2012]. Available at: http://www.hpa.org.uk/Topics/InfectiousDiseases/Infections
AZ/Rabies/GeneralInformation/RabiesEBLVFAQs/
10. Johnson N, Lipscomb DW, Stott R et al. Investigation of a human case of rabies in the United Kingdom. J Clin Virol. 2002;25:351-56
11. Smith J, McElhinney L, Parsons et al. Case report: rapid ante-mortem diagnosis of a human case of rabies imported into the UK form the Phiippines. J Med Virol. 2003 Jan;69(1):150-155
12. Solomon T. Marston D. Mallewa M et al. Paralytic rabies after a two week holiday in India. BMJ. 2005;331:501-3
13. Health Protection Agency. Wildlife centre traces volunteers following death from rabies. 13 January 2009 [Accessed 11 December, 2012]. Available at: http://www.hpa.org.uk/webw/HPAweb&HPAwebStandard/HP
Aweb_C/1231836544247?p=1231252394302
14. Health Protection Agency. Confirmed case of rabies in London. 23 May 2012. Press Release. [Accessed 11 December, 2012]. Available at: http://www.hpa.org.uk/NewsCentre/NationalPressReleases
/2012PressReleases/120523ConfirmedcaseofrabiesinLondon/
15. Srinvarsan A. Burton EC. Kuehnert MJ et al.Transmission of rabies virus from an organ donor to four transplant recipients. N Engl J Med. 2005;352:1103-11.
16. Hellenbrand W. Meyer C. Rasch G.Cases of rabies in Germany following organ transplantation. EuroSurveill. 2005; 10(2):E050224.6.
17. Dr Kevin Brown, Consultant Medical Virologist, Virus Reference Department, Health Protection Agency [Personal Communication, 6 December 2012].
18. Willoughby RE, Kelly S. Tieves, D.O.et al. Survival after Treatment of Rabies with Induction of Coma. N Engl J Med 2005. 352(24): 2508-2514
19. Rabies. Ch 27. In: Salisbury D, Ramsay M, Noakes K (eds). Immunisation against infectious disease 2006. The Stationary Office, London. [Accessed 11 December, 2012]. Available at: https://www.gov.uk/government/uploads/system/uploads
/attachment_data/file/85762/Green-Book-Chapter-27-v3_0.pdf
20. Meslin FX. Rabies as a traveler's risk, especially in high-endemicity areas. J Travel Med 2005;12 Suppl 1:S30-40.
21. Sanofi Pasteur MSD. Rabies BP. Summary of Product Characteristics. [Accessed 11 December, 2012]. Available at: http://www.medicines.org.uk/EMC/medicine/7589/SPC/
22. Novartis. Rabipur. Summary of Product Characteristics. [Accessed 11 December, 2012]. Available at: http://www.medicines.org.uk/EMC/medicine/14933/SPC/Rabipur/
Links
Health Protection Agency: Clinical Rabies Service
Health Protection Agency: Rabies.
NaTHNaC: Product information and alerts
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