Initiation of appropriate treatment is often delayed and is a concern to those without preexposure rabies immunization. In view of the scarcity of RIG, travelers need to be aware of the risks, consider preexposure immunization, and present early for PEP. Rabies is a viral zoonosis caused by rabies virus of Lyssavirus genus and the family Rhabdoviridae. The term rabies in Latin means “madness.”1 It causes acute encephalitis and is typically transmitted from the saliva of a rabid animal via a bite, scratch, or mucous membrane exposure. Rabies is almost invariably fatal if postexposure prophylaxis (PEP) is not administered before the development

of symptoms. Prevention relies on a combination of Epigenetic signaling pathway inhibitor interventions including the control of rabies in the animal population, administration of preexposure immunization to individuals at risk, and administration of PEP to exposed individuals. Most of the burden of rabies is in Asia and Africa: mortality from rabies is estimated at 55,000 per year and PD0325901 results in 1.74 million disability adjusted life years per year.2 In 2009, 58.6

million UK residents traveled abroad. Of these, 49.5 million (84.5%) visits were to Europe and to North America and 9.1 million (15.5%) to other parts of the world. Of these, 2.8 million (4.8%) were to Asia, predominantly to India, Pakistan, and Thailand.3 The UK has been free of rabies in carnivore host species since 1922. However, it is recognized that UK bats carry lyssaviruses (European bat lyssaviruses) types 1 and 2, with one bat handler dying of rabies in 2005.4–6

There have been 24 cases of human rabies in the UK since 1902, with 5 cases in the last 10 years.7–10 Four of these cases were imported and none had received PEP (Table 1). In the UK, PEP with vaccine and immunoglobulin is administered by different health science care providers, including general practitioners, accident and emergency departments, and specialized services. Liverpool School of Tropical Medicine (LSTM) is one of the major travel centers that administer PEP. The Health Protection Agency (HPA) provides guidance and a centralized supply of human rabies immunoglobulin (HRIG) and postexposure vaccine for PEP, based on individual risk assessment, which takes into account the nature of injury, the immune status of the traveler, and the risk of rabies in the country involved.11 Approximately 3,500 vials of vaccines and 1,200 doses of immunoglobulin are used per year for PEP in the country, with a 50% increase registered between 2006 and 2008 [3,062 vials of vaccine in 2006 to 4,622 vials in 2008 and 1,020 doses of rabies immunoglobulin (RIG) in 2006 to 1,476 doses in 2008] (H. Kirkbride, personal communication, September 2009). It is important that appropriate PEP is given to those who are at risk. This study examined the rabies PEP service at the LSTM in the last 10 years.