Understanding the risks and management of rabies exposure for UK travellers 

We are concerned to hear about the recent death from rabies of a UK traveller returning home from abroad. The traveller was holidaying in Morocco and had been scratched whilst playing with a puppy that led to transmission of the virus.

Terrestrial rabies cases have not been recorded in the UK for 120 years, although cases of returning travellers potentially infected while abroad have continued to rise. The above case has been reported widely in the media and consequently, demand has risen for appointments following potential post-exposure situations.

Patient awareness in the UK of rabies infection is low. Many do not realise that the rabies virus upon entering the body will replicate in muscle tissue before moving along the peripheral nerves towards the spine and the central nervous system. Upon reaching the brain the virus continues to replicate, and the case fatality rate rises to greater than 99%. 

Essentially rabies is an infection of the central nervous system and practitioners have a responsibility to make travellers going to areas of high risk for rabies aware of the potential severity of the disease.

Community clinicians and practice staff need to understand the difference between rabies vaccination requests for pre-travel (not allowed on the NHS) and post-exposure treatment (allowed and free on the NHS). 

Treatment of post-exposure rabies varies according to pre-travel vaccinations⁽¹⁾. A completed pre-travel course of  rabies vaccine is treated by a short course of additional rabies vaccines to maintain antibody levels. While post-exposure treatment of rabies without any pre-travel vaccinations needs an assessment ⁽²⁾ of the bite wound. If this is considered to be high, then the rabies immunoglobulin (RIG) may be started with additional rabies vaccines. 

In the UK the MHRA have issued interim guidelines for the use of RIG and highlight that it is now restricted for use only in severe (category 3 cases) and not to be used 7 days⁽³⁾ after a rabies vaccine has been given. 

Ensuring patients are aware of the risk of rabies and other life-threatening diseases before they travel remains a top priority for our Faculty of Travel Medicine. Our College offers a range of travel medicine courses, including our upcoming Annual Conference or Professional Development Certificate (PDC) in Travel Medicine, to help clinicians make informed risk assessments, recommend immunisation and prophylactic medication when needed and educate travellers on how to minimise exposure.