Rabies: guidance on pre-exposure and post-exposure measures for humans in Scotland
SHPN easy-read guide

Overview

This Scottish Health Protection Network (SHPN) easy-read guide is a supporting resource to the SHPN Rabies: guidance on pre-exposure and post-exposure measures for humans in Scotland.

This guide highlights key information that may be useful to health protection professionals when approached for advice on rabies. The full SHPN guidance should be used in the management of all cases.

The guidance was developed in line with the agreed SHPN good practice guidance method by a Guidance Development Group (GDG).

Intended audience

The guidance is for health protection professionals only.

Other people who require advice should contact their local health protection team.

What the guidance covers

The guidance covers:

• background information on rabies virus
• pre-exposure measures
• post-exposure measures
• imported pets
• roles and responsibilities
• key contact details

Background information

Rabies is caused by one of 14 lyssaviruses which includes rabies virus.  

Almost all cases occur in Africa or Asia with Europe contributing less than 1% of all recorded infections. The only recorded death in the last 100 years of UK-acquired rabies occurred in a bat worker in Scotland in 2002.

The disease is almost certainly fatal in those infected who have not received pre-exposure prophylaxis (PrEP) or post-exposure treatment (PET).

Transmission

Transmission of the virus usually occurs following a bite or scratch from an infected animal. Less often, it can be transmitted through an open wound or mucous membrane – for example, mouth, nasal cavity or eyes.

The virus will not pass through intact skin.

Rabies has also been contracted by inhalation – in laboratories where highly concentrated Lyssavirus is being studied or in caves where high densities of rabies-infected bats exist.

Such circumstances do not typically exist in the UK.

Incubation period

The incubation period is highly variable ranging from a few days to as long as a few years.

Treatment arrangements: pre and post-exposure

The Chief Medical Officer (CMO) letter, SGHD/CMO(2023)10 outlines arrangements in Scotland for rabies:

• assessment
• antibody testing
• vaccination
• treatment

This includes vaccination payment information.

Rabies vaccine used as part of post-exposure treatment (PET) is provided free of charge to the patient.

NHS boards should:

• ensure there are arrangements for assessment and provision of pre-exposure prophylaxis (PrEP) to persons at risk who have no employer – this includes travellers (who can be charged) and volunteer bat workers who should receive PrEP free of charge
• have a clear pathway in place in order to access post-exposure assessment and vaccination, as well as any post-exposure care and testing that may be required.

Pre-exposure measures

The recommendation for pre-exposure prophylaxis (PrEP) should be arrived at after a risk assessment considering the individual’s occupation or activities.

The purpose of pre-exposure rabies vaccination is to reduce the:

• risk of developing rabies
• need for the number of doses of vaccine and/or administration of human rabies immune gobulin (HRIG) post-exposure where required

Any individual at risk for rabies – whether they have received vaccination or not – must be advised that they carry out immediate first aid and promptly seek assessment or advice on PET if they:

• are scratched, bitten or licked by any animal abroad
• suspect a bat exposure in the UK or abroad

Who is PrEP indicated for?

PrEP is indicated for those with occupations (voluntary or paid) that involve frequent exposure to the rabies virus or potentially infected animals.

This includes:

• laboratory workers who routinely handle rabies virus
• workers at Department for Environment, Food and Rural Affairs (DEFRA)
• authorised quarantine premises and carriers
• those who regularly handle bats, including on a voluntary basis, in the UK
• veterinary and technical staff who, by reason of their employment, encounter enhanced risk
• certain inspectors appointed under the Animal Health Act.1981 (but not dog wardens for whom the risk of exposure is low and for whom the rapid PrEP schedule would be more appropriate where required) – see section 3.1.4 of the SHPN guidance
• occupations which may result in continual or frequent exposure – for example:
  • animal control and wildlife workers
  • veterinary staff or zoologists who regularly work in rabies enzootic areas

PrEP should also be considered for some people travelling to some areas outside of the UK.

Up-to-date advice is available for health professionals from TRAVAX and the general public from fitfortravel.

PrEP is not indicated for those not described above.

Summary of Rabies PrEP recommendations

Table 1: Summary of Rabies PrEP recommendations

Post-exposure measures

Potential rabies prone exposures (PRPE) occur when there is contact between a person and potential rabies-infected mammal that could result in transmission, for example a bite or scratch from a bat.

Immediate actions

For all PRPEs:

• advise immediate wound care
• undertake risk assessment

Wound care for post-exposure management involves:

• cleaning the wound with soap or detergent
• flushing with running water
• applying a virucidal agent – for example, povidone-iodine solution or 40–70% alcohol
• covering with a dressing

Wound washing is the most effective first-aid treatment against rabies.

Refer to section 5.4 of the SHPN guidance for full details.

Risk assessment

Further public health actions are determined through risk assessment based on the:

• category of exposure, for example, a bite (see Table 2 of the SHPN guidance)
• country where the exposure occurred, for example, the UK/Ireland or overseas
• animal involved, such as a bat or a dog
• patient’s vaccination status (see Table 4 of the SHPN guidance)

For up-to-date information on country and animal risk, view the UKHSA rabies risks in terrestrial animals by country.

Who performs the risk assessment?

Unless the health professional providing immediate care to the exposed person is confident about being able to perform a full, expert risk assessment, then the person should be referred to their local pathway for risk assessment.

Contact details to access risk assessment and management in Scotland are available in the key contact details section of this guide and in Appendix 3 of the SHPN guidance.

People who are outside of Scotland

If a person seeks help from Scotland from abroad, they should be advised to make their way to a local medical facility for assessment without delay.

Access to assessment and treatment is variable by country.

In some circumstances travel to another country or even returning home may be necessary for treatment.

Post-exposure treatment (PET)

Post-exposure rabies treatment is usually given in infectious disease (ID) units where healthcare practitioners:

• have experience in assessing risk
• know how and where to access human rabies immune gobulin (HRIG) and rabies vaccine
• know how to administer treatment

Since PET should be instituted as soon as possible after a PRPE, if delay is likely then patients should be referred to the local ID physician for immediate management.

Key contact details

PET assessment and management in Scotland

To access pre-exposure treatment use the appropriate contact details. 

Health Protection Teams

Access up-to-date contact information for local HPTs.

Additional relevant contacts

View the guidance

The guidance should be used together with our easy-read guide.