Rabies caused by lyssavirus is a fatal condition affecting the nervous system. The virus resides in the saliva of infected animals and is transmitted most commonly through a bite or contact between bodily fluids and broken human skin. Infected canines such as dogs are usually associated with the transmission of infection in endemic regions worldwide (World Health Organization (WHO), 2017).
It is estimated that almost 59 000 deaths a year occur worldwide due to rabies (WHO, 2017), mainly in Africa and South East Asia. With immigration and tourism, it is not unrealistic to expect that rabies acquired from endemic regions will be seen occasionally in the UK. This is reflected in the fact that Public Health England (PHE) treats around 2000 people every year with post-exposure treatment, 88% being exposed to an animal bite overseas and about 12% bitten by bats in UK. The PHE stated that the last death from rabies contracted from a bat in the UK was in 2002 (Shaw, 2018).
In Western Europe, dog-transmitted rabies has been eliminated (WHO, 2017). However, lesser recognised hosts continue to pose a risk in the UK. For example, Daubenton's bats, foxes and badgers have been found to carry the European bat lyssavirus type 2 (EBLV2) strain (Singer and Smith, 2012). A recent news report highlighted the detection of the EBLV1 strain for the first time in the UK in a dead Serotine bat, native to Dorset (Shaw, 2018).
By the nature of their job, certain professionals such as veterinarians, veterinary nurses, animal handlers, forest officials, and laboratory staff working with the rabies virus may be at increased risk (PHE, 2018). These high-risk professionals are usually offered pre-exposure prophylactic rabies vaccines.
Symptoms of rabies in the early stages are usually nonspecific and may mimic a flu-like illness ranging from fever, headache, malaise, nausea and vomiting. It then progresses to agitation, confusion, hyperactivity, excessive salivation and difficulty in swallowing, leading to a fear of water and, finally, may lead to paralysis and death, if left untreated (PHE, 2018).
All bats should be considered as potential carriers. Bat bites are often felt but not seen as they may not bleed and may not leave visible signs. Anyone in direct contact with a bat should be assessed at the earliest opportunity so that post-exposure prophylaxis can be offered. Since the incubation period for rabies can be long, a full pre-assessment should be done even if the history of exposure to bats dates to a few months previously.
Nurses working in GP surgeries and emergency departments play a vital role in early diagnosis as they are likely to manage the largest number of patients as frontline health professionals. Nurses should take a detailed history regarding contact with bats or other wild animals such as foxes, badgers, etc, and, if there is a strong suspicion of contact, a risk assessment should be undertaken (PHE, 2019). Liaising with the PHE doctors is necessary to decide on the level of exposure and risk posed to an individual. Rabies vaccination needs to be arranged when post-exposure treatment is required (PHE, 2018).
There are two types of vaccines available in the UK—neither contain any live organisms (PHE, 2018). The only contraindication is a history of anaphylaxis to the vaccine or its components and immunisation in such cases may be considered under close medical supervision (PHE, 2018). If exposure is strongly suspected or if a wound is present, immediate wound care should be performed. This includes, washing the wound with running water and applying a suitable disinfectant. For all high-risk exposures to the rabies virus, human rabies immunoglobulin should be administered to provide immediate and quick protection (PHE, 2018).
Given the fatal nature and non-specific early symptoms, a high index of suspicion about rabies is needed for susceptible populations. It is important that immediate post-exposure vaccination is started and appropriate follow-up ensured. The disease and its complications are preventable only through enhanced vigilance and prompt therapy.