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Travel health – Rabies

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Travel health – Rabies



Introduction 

Rabies is a very serious viral infection that targets the brain and nervous system. You can catch rabies if you are bitten by an infected animal and haven't been vaccinated.

It's almost always fatal unless treated very early.

In the UK, rabies has largely been eliminated from the animal population and infections are almost always picked up during travel abroad.

When to seek medical help

Seek immediate medical advice if you're worried that you or your child may have been infected by an animal while abroad. 

Although rabies is almost non-existent in the UK, you should also seek immediate medical help if you're bitten or scratched by a bat or a pet without a known vaccination history.

If you've been bitten or scratched, you should:


wash the wound thoroughly with soap and water under a running tap for 15 minutes

apply antiseptic or alcohol to clean the wound

leave the wound open

go to the nearest hospital or medical centre and explain that you've been bitten


 

How rabies spreads

Rabies can spread to humans from infected animals through a bite, a scratch, or a lick to broken skin or the eye. You may also be at risk if an animal spits in your face. In very rare cases, rabies can be spread during an organ transplant.

Once it enters the body, the rabies virus multiplies before spreading into nerve endings. It then travels to the spinal cord and brain (the central nervous system). Once the virus is in the central nervous system, it multiplies rapidly and spreads to the salivary glands, lungs, kidneys and other organs.

 

Animals that carry rabies

All mammals can carry the rabies virus, but the following species are more commonly infected:


dogs

bats

raccoons

foxes

jackals

cats

mongooses

monkeys


What are the symptoms?

It can take a while for symptoms to develop, but when they do the condition is almost always fatal.

Symptoms in humans can include:


tingling and itchiness at the site of infection

high temperature (fever)

an irrational fear of water (hydrophobia)

sensitivity to light (photophobia)

fear of drafts of air (aerophobia)

aggressive behaviour


An animal with rabies may also have some of these symptoms, although some symptoms – such as hydrophobia – only occur in humans.

Treating rabies

If there is a high risk that you have rabies in its early stages (soon after exposure, before you have any symptoms), you'll be given a course of treatment known as post-exposure prophylaxis.

This usually involves cleaning the site of contamination and administering a course of the rabies vaccine, in an attempt to prevent the infection spreading to the brain and nervous system. In most cases, post-exposure prophylaxis is effective.

If rabies reaches a stage where it causes symptoms, it's almost always fatal. In these cases, treatment will usually focus on making you as comfortable as possible.

There are currently no tests to identify rabies before it reaches a fatal stage. A diagnosis is based on the likelihood that you have the infection – for example, whether you've visited somewhere with high rates of the disease and if you may have been bitten by a potentially infected animal.

Various tests, including a skin biopsy, saliva tests or blood tests, can be used to diagnose rabies in its later stages.

Vaccination

A number of vaccines can be used to prevent a rabies infection developing.

Routine vaccination is usually only recommended if you regularly work with potentially infected animals or are travelling to a part of the world known to have high levels of rabies and limited medical care.

Public Health England provides a detailed list of countries that have rabies on the GOV.UK website.

Most people going on a standard holiday (as opposed to trekking or living and working in rural areas) won't need a rabies vaccine.

Avoiding rabies

When travelling in countries that aren't rabies-free, don't touch unknown animals and educate your children about the dangers of petting them. Examine your children regularly for cuts and scratches following contact with any animal, and ask how they got them. Make sure they know that being bitten by an animal is dangerous and they need to tell you about it.

Quarantine and the Pet Travel Scheme (PETS)

To keep countries rabies-free, it's important that there are strict public health measures to control stray animals, such as foxes. The movement of potentially infected animals across borders into uninfected regions is controlled by strictly enforcing quarantine regulations. Animals that don't have a licence shouldn't be brought into the UK.

The Pet Travel Scheme (PETS) is a system that allows pet dogs, cats and ferrets from certain countries to enter the UK without going into quarantine, as long as they have been vaccinated. It also means that people in the UK can take their dogs, cats and ferrets to other European Union (EU) countries and return with them to the UK.

How common is rabies?

There are an estimated 55,000 deaths from rabies each year worldwide. Most cases occur in the developing world, particularly in Africa and Asia.

As a result of strict UK quarantine laws in regards to transporting animals, as well as the introduction of the PETS, the UK has been rabies-free since the beginning of the 20th century, with the exception of a rabies-like virus in a single species of bat.

It's rare for bat rabies viruses to infect other animals, and the risk of human infection is thought to be low. Nevertheless, if you find an injured bat or a bat that needs to be moved, don't touch it. Call the Bat Conservation Trust helpline on 0845 1300 228 for advice.

The last recorded case of rabies in the UK was in May 2012. The patient, who died, contracted the disease after being bitten by a dog in India.

Symptoms of rabies 

The initial symptoms of rabies are mild, but they quickly become serious.

The incubation period

The incubation period is the time it takes for symptoms to develop after a person is infected with the virus. The incubation period for rabies is usually two to 12 weeks, although it can be as short as four days. It would be highly unusual for the incubation period to last for more than a year.

The closer the site of infection is to your brain, the shorter the incubation period. For example, a bite to your face, head or neck will have a shorter incubation period than a bite to your arm or leg.

The length of the incubation period is important, because it's the only period in which treatment can be successful.

Initial symptoms

The initial symptoms of rabies are often vague, and it can be easy to mistake them for other less serious types of infection. They include:


a high temperature of 38C (100.4F) or above

chills

extreme tiredness

problems sleeping

lack of appetite

headache

irritability

anxiety

sore throat

vomiting


Around half of people also experience pain and a tingling sensation at the infection site.

Advanced symptoms

Initial symptoms of rabies last for two to 10 days before more severe symptoms start to develop. There are two types of advanced rabies:


furious rabies – which accounts for around two-thirds of cases 

dumb or paralytic rabies – which accounts for the remainder of cases


Furious rabies

Furious rabies is characterised by episodes of increasingly odd and hyperactive behaviour, separated by periods of relative calm. During these episodes, a person may have some or all of the following signs and symptoms:


aggressive behaviour – such as thrashing out or biting

agitation

hallucinations – seeing or hearing things that aren't real

delusions – believing things that are obviously untrue

excessive production of saliva

high temperature (fever)

excessive sweating

the hair on their skin stands up

a sustained erection (in men)


People with furious rabies also develop hydrophobia (a fear of water). This initially begins as a pain in the throat or difficulty swallowing. On attempting to swallow, the muscles in the throat go into a brief spasm, lasting for a few seconds. Subsequently the sight, sound or even the mention of water (or any other liquid) can trigger further spasms. There will also be a fear of bright light (photophobia) and fear of breezes (aerophobia).

A few days after these symptoms develop, the affected person will fall into a coma and die, usually as a result of heart or lung failure.

 Dumb or paralytic rabies 

Dumb rabies, sometimes called paralytic rabies, is characterised by muscle weakness, loss of sensation and paralysis (inability to move one or more muscles). This usually begins in the hands and feet, before spreading throughout the body.

Hydrophobia is unusual in cases of dumb rabies, although muscles may go into spasm. As with furious rabies, someone with dumb rabies will fall into a coma and eventually die from heart or lung failure.

 When to seek medical advice 

If you're in a part of the world known to be affected by rabies, always seek medical advice as soon as possible if you're bitten or scratched by an animal, particularly a dog. You can also catch rabies if you have an open wound that is licked by an infected animal.

If you don't seek medical help while abroad, you should do so as soon as you're back in the UK.

In the UK, rabies is almost non-existent. However, always seek medical attention if you're bitten by a bat, or if you think that someone in your care who is unable to report a bite may have been bitten (for example, if you find a bat in a young child's room).

 Symptoms of rabies in an animal 

As with humans, the symptoms of rabies in an animal follow a number of stages.

The first stage is marked by initial vague symptoms, such as:


loss of appetite

a change in normal behaviour – such as appearing unusually tame around strangers


The second stage is known as the "mad dog" stage and usually lasts for two to four days. It's characterised by aggressive and erratic behaviour, such as:


constantly barking or growling

no fear of normal natural enemies

attempting to attack and bite anything that comes near, including inanimate objects


The final stage, known as the "paralytic" stage, lasts for two to four days and is characterised by symptoms such as:


the animal appearing to be choking

foaming at the mouth

the dropping of the lower jaw (in dogs)

paralysis of the jaw, mouth and throat muscles


 Treating rabies  

The treatment given for rabies depends on whether you've started to show signs or symptoms.

If you show no signs or symptoms, but infection is suspected, a course of treatment called post-exposure prophylaxis (PEP) is used. This can usually prevent a rabies infection from becoming established and producing symptoms.

If you have symptoms of rabies, treatment usually focuses on making you as comfortable as possible. This is because rabies is almost always fatal when it reaches this stage.

These two types of treatment are described in more detail below.

 Post-exposure prophylaxis 

Post-exposure prophylaxis involves three stages:


cleaning the wound

administering rabies immunoglobulin – a special preparation of antibodies

administering a course of the rabies vaccine


Cleaning the wound

Immediately after being bitten, you should:


wash the wound thoroughly under a running tap

use antiseptic or alcohol to clean the wound and apply ethanol, tincture or aqueous solution of iodine, if available

leave the wound open – use a simple dressing, but don't try to stitch it, because this could expose your nerve endings to the rabies virus

go to the nearest hospital or medical centre and explain that you've been bitten


If you think your eye may have been infected with the saliva of an animal, wash it thoroughly with clean water and seek medical help.

Rabies immunoglobulin

If there is a high risk of you being infected with rabies, you should be given an injection of rabies immunoglobulin. This should help to protect you against the virus and prevent it travelling to your nervous system.

The immunoglobulin works by providing ready-made antibodies designed to neutralise the rabies virus and prevent it from spreading.

Aside from some temporary soreness at the injection site, rabies immunoglobulin doesn't usually cause any side effects.

Vaccination

The rabies vaccine should be given in every case of suspected exposure to rabies. The length of your vaccination course will depend on whether you have previously been vaccinated.

If you've never been vaccinated, you should receive five doses of the vaccine. The first dose is given at the beginning of the treatment, followed by four further doses, which are given three, seven, 14 and 30 days after the start of treatment.

If you've previously been vaccinated, you should receive two doses of the vaccine. The first dose is given at the start of your treatment, followed by a second dose three to seven days later. The doses are given by injection into the shoulder muscle.

A common side effect of the rabies vaccine is redness, swelling and pain at the injection site, which occurs 24 to 48 hours after the injection has been given.

Choice of vaccine

There are three types of rabies vaccine:


human diploid cell vaccine (HDCV), which is created by using samples of human cells

purified chick embryo cell rabies vaccine (PCEC), which is created by using samples of chicken embryos 

nerve tissue vaccine, which is created using samples of nerves taken from animal brains


The World Health Organization (WHO) recommends that only purified cell culture or embryonated egg-based vaccines (CCEEVs), which include HDCV or PCEC, should be used. This is because there are safety concerns over the nerve tissue vaccine. Researchers have found that this type of vaccine has a one in 650 chance of causing serious complications that can result in permanent disability, such as muscle paralysis.

A small number of countries have not followed the WHO recommendation and still use the nerve tissue vaccine. They include Ecuador, Peru, Myanmar (Burma) and Pakistan.

In many developing countries, the HDCV or PCEC vaccine may only be available if you're willing to pay for private treatment.

If you're offered the nerve tissue vaccine, it's recommended that you refuse and ask for one of the alternative vaccines.

Supportive treatment

If a person who is infected with rabies isn't treated and they have developed symptoms, rabies is said to be established.

In this situation, there is almost nothing that can be done apart from keeping them comfortable. This is usually done by using powerful tranquilisers and sedatives to keep them free from physical pain and emotional upset.

To date, there have been no reported cases of human-to-human transmission of rabies. However, it's theoretically possible, so anyone who has been in close contact with someone who has a rabies infection may be advised to have post-exposure prophylaxis as a precaution.

Rabies vaccination 

A vaccination offering protection against rabies is recommended for people who are felt to be at risk.

Who should be vaccinated?

In the UK, rabies vaccination is recommended for:


laboratory workers who may be required to handle samples of the rabies virus

people handling bats

people travelling to an area for one month or more where rabies is common in animals, and where there is no access to prompt and safe medical care

people travelling to an area where rabies is common and carrying out activities exposing them to rabies, such as trekking in a jungle

people working abroad in close contact with animals, such as vets or animal handlers at zoos


Rabies can be found throughout the Middle East, Africa, Asia, Central America and in some parts of Eastern Europe.

Public Health England provides a detailed list of countries that have rabies on the GOV.UK website.

The vaccine

Two rabies vaccines are available in the UK. Vaccination usually requires a course of three doses for protection. The second dose is given seven days after the first. The third dose is given 21 or 28 days after the first, depending on which vaccine is used.

The injections aren't painful and are given into your upper arm. There are usually no serious side effects.

Vaccination should be completed before your departure to allow your body to develop full immunity.

Bat handlers who regularly handle bats are entitled to a free pre-exposure vaccine on the  your GP will order this from Public Health England.

For other groups, the vaccine is not available on the  and should be obtained through their employer’s occupational health department.

If you need to pay for the vaccination privately, you can either visit your GP surgery or a travel clinic. The price for the complete course of three doses ranges from £120 to £170.

As a general rule, pregnant women are usually advised to avoid rabies vaccinations. The vaccine is usually only recommended if the potential risk of exposure to rabies is thought to be high and there is limited access to medical care.

Further doses

For people who continue to be at risk of rabies exposure (because of their job, for example), further doses of the vaccine are needed to maintain immunity.

In these cases, a single reinforcing dose of vaccine should be given one year after the first course is completed. Further doses should be given at three- to five-year intervals after that.

Further doses aren't usually recommended for travellers, unless it has been more than 10 years since you were first vaccinated and you're visiting an area with a high risk of rabies.

Side effects

After having the rabies vaccine, some people experience temporary soreness, redness and swelling at the injection site for 24-48 hours after the vaccination. In rare cases, some people may also experience:


a mild fever

headache

muscle aches

vomiting

a rash


Severe reactions are very rare.