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Rabies

Disease

Rabies is an acute, invariably fatal, encephalitis caused by the rabies virus.

Transmission

  • Via the saliva of an infected mammal - introduced by a bite, scratch, or lick of broken skin/mucous membrane.
  • It cannot be transmitted through intact skin.
  • Aerosol spread is rare but may occur in bat caves.
  • Organ transplantation from an undiagnosed donor may result in rabies in the recipient

Epidemiology

  • Rabies occurs on all continents except Antartica. Individual countries within continents may be reported to be disease free - please consult country specific pages for country specific risk and/or the Rabies FAQs.
  • All mammals are susceptible, wild and domestic; carnivores and bats act as reservoirs of disease.
  • In endemic areas dogs account for the majority (95%+) of human fatalities.
  • More than 15 million people exposed to potentially rabid animals annually - 40-70,000 deaths reported; this is likely to be a significant underestimate.
  • More than 95% of human deaths occur in the Indian subcontinent, Asia and Africa.
  • Bats may carry a Lyssavirus that is closely related to rabies virus and causes a similar disease. It is endemic in bat populations in countries otherwise considered free from rabies, including the United Kingdom.

Clinical Aspects

  • Incubation - 20 - 60 days (range 5 days up to 1 year).
  • Invariably fatal once symptoms develop.

Risk of severe illness

  • Incubation periods often shorter when bites sustained on the head rather than on the extemities.

Signs and symptoms

  • Clinical Illness begins with prodrome of fever, headache, malaise, anorexia and pain/paraesthesia at bite site.

Clinical Rabies can present in two forms:

  • Furious rabies:
    • most common form
    • characterised by fluctuating consciousness, hydrophobic spasms, signs of autonomic dysfunction
    • death occurs after a few days due to cardiorespiratory arrest.
  • Paralytic rabies:
    • muscle paralysis gradually develops from bite site
    • slow development of coma that results in death.

Diagnosis

  • During the clinical course of the disease the virus can be isolated from saliva, brain, CSF, and urine.
  • Often made post mortem by immunofluorescence of skin or brain biopsy material.

Treatment

  • There is no effective treatment for rabies once clinical signs develop.
  • Prevention of rabies following a potential exposure depends upon the type of exposure and vaccination status of the individual. Post exposure care includes:
    • immediate wound care
    • passive immunisation with human rabies immunoglobulin (HRIG)
    • active immunization with rabies vaccine.

Advice to Travellers

  • Any animal contact in a rabies endemic area poses a potential risk of infection.
  • All travellers to rabies endemic areas should be aware of the risk of rabies and advised to avoid contact with animals (both wild and domestic), particularly dogs and cats.
  • Children are more vulnerable to rabies than adults as they are less likely to comprehend the risk of animal contact, less able to defend themselves from an animal attack and may not report a potential exposure.
  • All travellers to endemic areas should be aware of immediate wound care and advised to seek medical attention immediately, see Post-Exposure Rabies Advice.
When to consider pre-exposure vaccination Vaccination should be considered for all travellers to endemic areas under the following circumstances and dependant on the individual risk assessment:
  • Travel to regions where HRIG and/or modern rabies vaccines may not be available or cannot be accessed within 24 hours post-exposure. A reliable, safe source of HRIG may not be available in many endemic countries.
  • Those at higher risk of contact with animals or bats: veterinary surgeons, volunteers in animal sanctuaries, children, cave explorers, cyclists/runners, zoologists, botanists, etc.]

Pre-exposure Vaccination

Pre-exposure rabies vaccination:
  • Removes the need for the administration of HRIG post-exposure.
  • Reduces the number of doses of vaccine given post-exposure.
It does not remove the need for urgent medical attention and further doses of vaccine. Information also available in DH Green Book. This book is produced by the JCVI (Joint Committee for Vaccines and Immunisations). Their guidance may vary slightly from that of the manufacturers but should be followed by UK practitioners. Available vaccines Rabies Vaccine BP (Sanofi Pasteur MSD) Summary of product characteristics for Rabies Vaccine BP Rabipur (Chiron/Novartis) Summary of product characteristics for Rabipur These vaccines may be used interchangeably for primary courses, boosters and post-exposure vaccination. Vaccine for pre-exposure use should not be prescribed on an NHS subsidised prescription but should be written on a private prescription or ordered directly from the supplier and charged to the traveller. Those at occupational risk may be eligible to receive this vaccine subsidized by the NHS. Post exposure treatment is covered under the NHS.
     
     
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