Rabies in Europe: Epidemiology, Clinical Management, and Prevention.

Abstract

Background: Rabies is one of the oldest known zoonoses. In Europe, because cases are rare and medical experience is limited, there is often uncertainty about the indications and modalities of pre- and post-exposure prophylaxis (PrEP, PEP).

Methods: This review is based on studies of the epidemiology, diagnosis, treatment, and prophylaxis of rabies that were published from January 2000 to October 2025 and retrieved by a selective search in PubMed, supplemented by data from the WHO, CDC, ECDC, RKI, and FLI and the current recommendations of the German Standing Committee on Vaccination (STIKO).

Results: The WHO reports that approximately 60 000 persons die of rabies each year around the world, mainly in southern Asia and Africa, and that dogs are the source of the infection in more than 99% of cases. Once the disease has become manifest, its lethality is nearly 100%. Terrestrial rabies is considered to have been largely eliminated in the member states of the European Union (EU) since 2008, although zoonotically relevant bat lyssaviruses are still being regularly documented. As a result, even in Germany, a low risk of infection remains through contact with bats and through importation of infected animals from endemic areas abroad. The use of modern cell-culture vaccines for PrEP yields protection rates of 96-100%, with rare severe side effects (< 1:10 000). PEP is highly effective: after its administration in more than 29 million cases per year around the world from 1980 to 2022, only 122 breakthrough infections were registered, mainly because of faulty administration of rabies immunoglobulin, inadequate wound cleansing, and a late start of PEP. The main preventive measures are PrEP, avoidance of exposure, rapid wound disinfection, early PEP, and counseling by specialists in travel medicine.

Conclusion: Despite the favorable epidemiological situation, the possibility of rabies should be considered early on for anyone in Europe who has had an unclear animal exposure-especially to bats-or a potential rabies exposure abroad. When questions remain about the indication or modalities of PEP, expert advice should be obtained from an infectious disease unit or a rabies information center.