oPatientPlus articles are written by UK doctors and are based on research evidence, UK and European Guidelines. They are designed for health professionals to use, so you may find the language more technical than the condition leaflets.
Rabies is a fatal viral infection, which is usually acquired in humans from the bite of an infected animal. Nearly all deaths from rabies in humans worldwide result from the bite of a rabid dog.
Since 2000 there have only been four cases of rabies in the UK.
Active and passive immunisation are available and schedules have been developed for pre-exposure and post-exposure prophylaxis. There is no specific treatment for rabies.
- Currently cell-culture derived vaccines are used. There are two licensed for use in the UK:
- Human diploid cell vaccine (HDCV), or Rabies Vaccine BP Pasteur Mérieux®.
- Purified chick embryo cell (PCEC) rabies vaccine, or Rabipur®.
- New, more potent DNA vaccines are being developed.
- Human rabies-specific immunoglobulin (HRIG) is available and is derived from the plasma of immunised human donors for passive immunisation.
- Other cell-culture derived vaccines are available in other countries but these are no longer recommended.
Recommendations: pre-exposure prophylaxis
This is available free on the NHS to:
- Laboratory workers handling the virus.
- Workers handling imported animals.
- Any handlers of species of bats.
- Workers in at-risk jobs, in at-risk areas.
- Health workers likely to have contact with infected patients.
It is also recommended, but not free on the NHS, to:
- Travellers to high-risk areas for stays of more than one month where there is also limited access to medical care and particularly to easy post-exposure prophylaxis. Up-to-date information on other countries to assess - this can be found on the NaTHNaC website - see under 'Internet and further reading', below.
- Travellers to high-risk areas for stays of less than one month who may be exposed to rabies because of their travel activities and limited access to post-exposure medical care.
- Rabies prevention in travellers is a controversial issue.
- According to experts, the decision to vaccinate results from an individual risk assessment based on the duration of stay, the likelihood of engagement in at-risk activities, the age of the traveller, the rabies endemicity and access to appropriate medical care in the country of destination.
- The majority of patients who have sustained a high-risk injury abroad were not vaccinated against rabies before travelling and were not properly treated abroad.
- Primary, pre-exposure protection: give three doses, 1 mL - intramuscular deltoid region - at days 0, 7 and 28. The third dose can be given on day 21.
- A single reinforcing dose is then given, one year after the primary course has been completed, to those at regular and continued risk.
- For those who are travelling again to a high risk area, a booster dose can be considered at ten years after the primary course has been completed.
- For those at intermittent risk or who are travelling again to rabies-enzootic areas without ready access to safe, medical care, a booster dose should be given, from two years after the primary course has been completed.
- The Joint Committee on Vaccination and Immunisation recommends the intramuscular rather than the intradermal route for rabies vaccine. The use of the intradermal route is not covered by the manufacturers' product licence and, if it is used, becomes the doctor's own responsibility.
- Serological testing is only advised for those who work with the live virus:
- Antibodies should be tested every three to six months. Those people with low levels of antibodies should be given a reinforcing dose of vaccine as necessary to maintain their immune status.
- The World Health Organization (WHO) currently considers a minimal acceptable antibody titre to be 0.5 IU/mL.
Recommendations: post-exposure prophylaxis
Post-exposure prophylaxis is nearly 100% effective at preventing rabies.
The schedule used depends on:
- Level of risk (low, medium or high) in the country.
- Type of exposure (history of the animal/stray, likelihood of infection, etc).
- The individual's immunity (details of previous vaccinations, if any).
If possible, expert advice on the appropriate management and schedule should be sought with this outline of information from the Health Protection Agency Virus Reference Department, Colindale, London (Tel: 020 8200 4400) or the Communicable Disease Surveillance Centre (Tel: 020 8200 6868).
Immediate action at the time
- Clean the wound with soap or detergent under running tap water for several minutes. Then treat with a suitable disinfectant (eg 40-70% alcohol, topical iodine).
- Information gathering: name and address of the animal's owner to allow follow-up. This may require enlistment of help from local officials.
- It is important to determine the vaccination status of the animal.
- Local medical advice should be sought. They are likely to know the level of risk locally and be able to advise on the need for vaccination.
- Primary suturing of the wound should be avoided or postponed.
- As the incubation period for rabies can be prolonged, treatment should still be considered even if the interval from exposure is lengthy.
Human rabies-specific immunoglobulin (HRIG)
- HRIG (passive immunisation) is used after exposure to rabies, for rapid protection until the rabies vaccine (active immunisation) becomes effective.
- It is given at the same time but at a separate site as part of post-exposure prophylaxis.
- The dose is HRIG 20 IU/kg body weight. It is administered around the cleansed wound or intramuscularly (anterolateral thigh) if the wound has healed or is not visible.
- It can be given for up to seven days after starting the vaccination course (active immunisation).
Post-exposure prophylaxis following risk assessment
Level of risk in country
Unimmunised or not completely immunised*
|None||No immunisation||No further immunisation|
|Low||5 doses human diploid cell vaccine (HDCV) on days 0, 3, 7, 14 and 30||2 doses on days 0 and 3|
|High||5 doses rabies vaccine on days 0, 3, 7, 14 and 30|
PLUS human rabies-specific immunoglobulin (HRIG) on day 0 only
|2 doses on days 0 and 3|
- Rabies vaccine may cause local reactions such as redness, swelling or pain at the site of injection within 24 to 48 hours of administration.
- Systemic reactions, such as headache, fever, muscle aches, vomiting and urticarial rashes, are rare.
- Reactions may become more severe with repeated doses.
- HRIG may cause local pain and low-grade fever, but no serious adverse reactions have been reported.
- Pre-exposure rabies vaccine should not be given to those who have had:
- A confirmed anaphylactic reaction to a previous dose of rabies vaccine.
- A confirmed anaphylactic reaction to any component of the vaccine.
- There are no absolute contra-indications to post-exposure rabies vaccine.
- In the event of a hypersensitivity reaction to a dose of a pre-exposure course, these patients should still receive post-exposure vaccination if indicated, because the risks of rabies outweigh the risks of hypersensitivity.
- When a hypersensitivity reaction occurs during post-exposure immunisation, further doses should be given under close medical supervision.
- Pregnant women and breast-feeding mothers should only be given pre-exposure vaccination if the risk of exposure to rabies is high and rapid access to post- exposure prophylaxis would be limited.
- Post-exposure treatment should be given to pregnant women when indicated.
- Individuals with immunosuppression and HIV infection (regardless of CD4 count) should be given rabies vaccines in accordance with the recommendations above.
- Re-immunisation should be considered after treatment has finished and recovery has occurred.
- Individuals who are immunosuppressed or with HIV, who are exposed, may require a different regime for post-exposure management. Specialist advice should then be sought urgently.
Supplies of vaccine
- Rabies Vaccine BP is available from Sanofi Pasteur MSD (Tel: 0800 085 5511).
- Rabipur® is available from Novartis Vaccines (Tel: 08457 451500) or MASTA (Tel: 0113 238 7500).
- Post-exposure-centres in the Health Protection Agency (HPA) Directory - also advise re HRIG availability.
- Supply centres for rabies vaccine and HRIG are listed in the Department of Health's Memorandum on rabies: prevention and control.
Further reading & references
- National Travel Health Network and Centre (NaTHNaC)
- No authors listed; Meeting of the Immunization Strategic Advisory Group of Experts, November 2007--conclusions and recommendations. Wkly Epidemiol Rec. 2008 Jan 4;83(1):1-15.
- No authors listed; Rabies vaccines. WHO position paper. Wkly Epidemiol Rec. 2007 Dec 7;82(49-50):425-35.
- Gompf SG et al, Rabies, Medscape, Dec 2011
- Meslin FX; Rabies as a traveler's risk, especially in high-endemicity areas. J Travel Med. 2005 Apr;12 Suppl 1:S30-40.
- Rabies: Frequently Asked Questions, Health Protection Agency (HPA)
- Bahloul C, Taieb D, Diouani MF, et al; Field trials of a very potent rabies DNA vaccine which induced long lasting virus neutralizing antibodies and protection in dogs in experimental conditions. Vaccine. 2006 Feb 20;24(8):1063-72. Epub 2005 Sep 21.
- Gautret P, Parola P; Rabies vaccination for international travelers. Vaccine. 2012 Jan 5;30(2):126-33. Epub 2011 Nov 12.
- Immunisation - The Green Book; Dept of Health
- Memorandum on rabies: prevention and control, Dept of Health, 2000
Disclaimer: This article is for information only and should not be used for the diagnosis or treatment of medical conditions. EMIS has used all reasonable care in compiling the information but make no warranty as to its accuracy. Consult a doctor or other health care professional for diagnosis and treatment of medical conditions. For details see our conditions.
Dr Richard Draper
Dr Louise Newson
Dr Adrian Bonsall