Rabies is a viral disease transmitted to humans usually by a bite or scratch from an infected animal (usually a dog). The virus attacks the central nervous system causing, progressive damage to the brain and spinal cord. Once symptoms are present, rabies is almost always fatal.

Human rabies cases are often unreported so it is difficult to provide reliable figures on the incidence worldwide. The disease is estimated to cause 59,000 human deaths annually. Rabies is rare in travellers with only 25 human deaths in the UK from imported rabies since 1946.

Although rabies cases are rare in travellers, animal bites and scratches are common. It is important that travellers visiting areas where rabies occurs are aware of the risk and know what to do if they are bitten or scratched. The disease is preventable if the correct post-exposure treatment (PET) is provided quickly. PET can be expensive and difficult to obtain in some areas.

Prevention

Contact with wild or domestic animals during travel should be avoided. Travellers should also 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
• Be aware that certain activities may attract dogs (e.g. running, cycling)

The following advice can be given regarding first aid following a possible rabies exposure:

• Urgent action is required; 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 as an iodine solution (tincture or aqueous solution of povodone-iodine) or 40-70 percent alcohol
• Apply a simple dressing to the wound
• Seek immediate medical advice about the need for PET and possible antibiotics to prevent a wound infection
• Tetanus vaccine may be necessary if the traveller is not up-to-date
• Suturing of the wound should be postponed until PET has started

Rabies vaccine

Individuals considered at risk of exposure to rabies viruses within the UK include:

• laboratory workers routinely handling rabies virus
• workers at Defra-authorised quarantine premises and carriers
• bat handlers who regularly handle bats, including on a voluntary basis, in the UK
• veterinary and technical staff who due to their employment maybe at increased rabies risk

Individuals considered at risk of exposure to rabies travelling outside the UK include:

• animal workers who regularly travel to rabies enzootic areas
• travellers to rabies enzootic areas especially if:
  - those visiting areas where access to post-exposure treatment and medical care is limited
  - those planning higher risk activities such as cycling and running
  - long-stay travellers (more than one month)
  - health workers in rabies enzootic areas who may have direct contact with rabies infected patients

See our Country Information pages to see individual recommendations for each destination.

A course of pre-exposure vaccines simplifies PET when this is required, two further rabies vaccines are administered on days 0 and 3 - 7 in the event of a possible rabies exposure. These vaccines should be obtained as soon as possible after the exposure. For individuals who have not had pre-exposure rabies, four doses of rabies vaccine are usually recommended over one month plus rabies immunoglobulin may be recommended in the event of a high risk exposure. Immunoglobulin is in short supply worldwide, and may not be available in many countries.

Vaccine schedules

The Summary of Product Characteristics (SPC) should be consulted prior to the administration of any vaccine.

*A third dose can be given from day 21 if insufficient time before travel.

**Routine booster doses are not recommended for most travellers. See Rabies. Chapter 27. Immunisation against infectious disease.

***Although the vaccine can be given at any age, the risk of animal bites may be higher once the child is independently mobile. Children are often bitten around the face or head, a type of bite considered to be a higher risk due to the expected shorter incubation period.

Interrupted or accelerated courses

Ideally, those at risk should receive pre-exposure vaccination with three doses of rabies vaccine before travel. Both the 0, 3, 7, 365 (i.e. a fourth dose at 1 year) schedule and the 0, 7 and 21 day schedule can be given using either product, where there is less than four weeks before departure. The 0,3,7, 365 schedule is 'off license' in some age groups and with some vaccine brands but can be given according to Ch 27 immunisation against infectious disease 'Green book' guidance.

In some vaccine shortage situations, the Medicines and Healthcare products Regulatory Agency (MHRA) and the Department of Health (DH) allow vaccine companies to import alternative vaccine products for use. See information on vaccine supply shortages and use of unlicensed medicines. Please contact the vaccine suppliers for information.

A risk assessment should always be undertaken when considering rabies immunisation.

Resources

• More detailed information can be found in our rabies factsheet
• Public Health England: Immunisation against infectious disease. Rabies
• Public Health England: Rabies: risk assessment, post-exposure treatment, management
• Public Health England: Rabies post-exposure administration of vaccine and immunoglobulin
• Further details on the vaccines can be found in the SPC on the electronic Medicines Compendium