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 between 1902 and 2005.

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 prophylaxis (PEP) is provided quickly. PEP 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 PEP 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 PEP has started

Rabies vaccine

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 risk areas
• health workers in rabies risk areas who may have direct contact with rabies infected patients

Most international travellers to rabies affected areas are considered to be at ‘infrequent risk’, but pre-exposure vaccines are recommended for those whose activities put them at increased risk.

For countries with rabies in domestic and wild animals these travellers include:

• those visiting areas where access to PEP and medical care is limited
• those planning higher risk activities such as cycling and running
• long-stay travellers (more than one month).

In countries where rabies has only been reported in wild animals or bats, pre-exposure vaccines are recommended for a smaller group of travellers. See our Country Information pages to see individual recommendations for each destination.

A course of pre exposure vaccines simplifies PEP when this is required, two further rabies vaccines are administered on days 0 and 3 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, five 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 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.

** see Rabies. Chapter 27. Immunisation against infectious disease. Table 27.1

***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. 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
• Further details on the vaccines can be found on the Summary of Product Characteristics (SPC) on the electronic Medicines Compendium