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Travel health advice in brief: rabies

Rhona Aikman
RGN BA
Practice Nurse
Gourock Medical Practice

Rabies kills more than 55,000 people each year and remains a serious global problem. However, it is a preventable disease and practice nurses are in an ideal position to give advice to travellers about risk reduction and immunisation, as Rhona Aikman explains

Rabies (Lyssa) is an acute viral encephalomyelitis caused by members of the lyssavirus. It is one of the oldest known zoonotic diseases, which is transmissible to humans through exposure to infected saliva via a bite or scratch from an infected animal.

More than 55,000 people die from rabies each year and, of these, around 30-50% will be children, who are more likely to play with animals, and less likely to report scratches or bites.
The true figures, however, are likely to be considerably higher, as many deaths in developing countries happen in the home.
About 95% of these deaths are in Africa and Asia.1

Rabies in animals occurs in all continents except Antarctica, although some individual countries are, in fact, reported to be rabies free.

Rabies is a uniformly fatal infection, and once clinical symptoms have appeared the patient will die. At this point, there is no specific treatment other than supportive care. The incubation period for rabies is generally between three and 12 weeks, and in more than 93% of cases the onset is within one year of exposure. Since rabies cannot be treated, prevention and post-exposure prophylaxis are essential.

In 2008, the number of UK residents travelling abroad was 58.5 million. The majority visited Europe and North America; however, 8.9 million people travelled further afield, and many would have travelled to destinations that warrant individualised health advice before departure.2

The extreme consequences of infection with rabies mean that it is important for travellers to understand the risks, and what to do if they have been exposed. Post-exposure vaccination is almost 100% if started within a few days.

Many travellers will present expecting solely to have immunisations, but it is vital that a full risk assessment is performed. A travel health consultation takes time - more than the 10 minutes usually allocated for appointments in general practice. Health promotion is a significant part of the consultation and this has been shown to significantly reduce morbidity and illness in travellers.3 It is impossible to predict whether or not a traveller will be exposed to a rabid animal, but the patient must be made aware of prevention measures and what to do if they believe that exposure has taken place (see Box 1).

[[Box 1 rabies]]

While vaccination before exposure does not eliminate the need for treatment after exposure, it does simplify treatment and avoids the need for immunoglobulin. This can be important as rabies immunoglobulin is expensive and may be in short supply in many developing countries. Equine (horse) immunoglobulin may be all that is available in some countries and allergic reactions can occur. In India rabies vaccine derived from sheep brain is sometimes still used and this also can have serious adverse effects, for example, encephalitis. In developed countries human rabies immunoglobulin is the standard treatment.

The most cost-effective strategy to prevent rabies in humans is by eliminating it in dogs through vaccination. Several countries, including Japan and Malaysia, have been successful in using this approach. In some countries where wildlife is responsible for cases of human rabies, oral immunisation using vaccine loaded bait has been very successful, and Switzerland, Belgium and France are all now free of rabies. In Canada, a tremendous reduction in the number of rabies cases in wild animals has been achieved through large-scale use of oral immunisation of coyotes over the last 20 years.

[[Tab 1 rabies]]

Summary
A survey by the Post Office Travel Insurance group in 2009 found that almost half of holidaymakers going abroad did not seek advice about appropriate immunisations and, just as worryingly, nearly a third did not remember what disease they had been immunised against or when they last received them. Rabies is a preventable disease and it is important that healthcare professionals give advice to travellers about risk reduction and immunisation. Practice nurses are in an ideal position to do this.

References
1. World Health Organization (WHO). Rabies Fact Sheet No. 99. Available from: www.who.int/mediacentre/factsheets/fs099/en/
2. Office for National Statistics. Travel and tourism: international travel. Available from: www.statistics.gov.uk/cci/nugget.asp?id=178
3. Kassianos G. Immunisation: Childhood and Travel Health (4th edn). Oxford: Blackwell Science; 2001.
4. Department of Health. Immunisation Against Infectious Disease (Green Book). London:
HMSO; 2006.

Resource
Travax
W: www.travax.nhs.uk