Rabies is a deadly animal disease caused by a virus. It can happen in wild animals, including raccoons, skunks, bats and foxes, or in dogs, cats or farm animals. People get it from the bite of an infected animal.

In people, symptoms of rabies include fever, headache and fatigue, then confusion, hallucinations and paralysis. Once the symptoms begin, the disease is usually fatal. A series of shots can prevent rabies in people exposed to the virus. You need to get them right away. If an animal bites you, wash the wound well; then get medical care.

To help prevent rabies

• Vaccinate your pet. Rabies vaccines are available for dogs, cats and farm animals
• Don't let pets roam
• Don't approach stray animals. Animals with rabies might be aggressive and vicious, or tired and weak

Rabies is a preventable viral disease most often transmitted through the bite of a rabid animal. The rabies virus infects the central nervous system of mammals, ultimately causing disease in the brain and death. The vast majority of rabies cases reported to the Centers for Disease Control and Prevention (CDC) each year occur in wild animals like bats, raccoons, skunks, and foxes, although any mammal can get rabies.

The Rabies Virus

Rabies virus belongs to the order Mononegavirales, viruses with a nonsegmented, negative-stranded RNA genomes. Within this group, viruses with a distinct “bullet” shape are classified in the Rhabdoviridae family, which includes at least three genera of animal viruses, Lyssavirus, Ephemerovirus, and Vesiculovirus. The genus Lyssavirus includes rabies virus, Lagos bat, Mokola virus, Duvenhage virus, European bat virus 1 & 2 and Australian bat virus.

Structure

Rhabdoviruses are approximately 180 nm long and 75 nm wide. The rabies genome encodes five proteins: nucleoprotein (N), phosphoprotein (P), matrix protein (M), glycoprotein (G) and polymerase (L). All rhabdoviruses have two major structural components: a helical ribonucleoprotein core (RNP) and a surrounding envelope. In the RNP, genomic RNA is tightly encased by the nucleoprotein. Two other viral proteins, the phospoprotein and the large protein (L-protein or polymerase) are associated with the RNP.

The glycoprotein forms approximately 400 trimeric spikes which are tightly arranged on the surface of the virus. The M protein is associated both with the envelope and the RNP and may be the central protein of rhabdovirus assembly. The basic structure and composition of rabies virus is depicted in the longitudinal diagram below.

Rabies is an RNA virus. The genome encodes 5 proteins designated as N, P, M, G, and L. The order and relative size of the genes in the genome are shown in the figure below. The arrangement of these proteins and the RNA genome determine the structure of the rabies virus.

Replication

The fusion of the rabies virus envelope to the host cell membrane (adsorption) initiates the infection process. The interaction of the G protein and specific cell surface receptors may be involved.

After adsorption, the virus penetrates the host cell and enters the cytoplasm. The virions aggregate in the large endosomes (cytoplasmic vesicles). The viral membranes fuse to the endosomal membranes, causing the release of viral RNP into the cytoplasm (uncoating). Because lyssaviruses have a linear single-negative-stranded ribonucleic acid (RNA) genome, messenger RNAs (mRNAs) must be transcribed to permit virus replication.

A viral-encoded polymerase (L gene) transcribes the genomic strand of rabies RNA into leader RNA and five capped and polyadenylated mRNAs, which are translated into proteins. Translation, which involves the synthesis of the N, P, M, G and L proteins, occurs on free ribosomes in the cytoplasm. Although G protein synthesis is initiated on free ribosomes, completion of synthesis and glycosylation (processing of the glycoprotein), occurs in the endoplamsic reticulum (ER) and Golgi apparatus. The intracellular ratio of leader RNA to N protein regulates the switch from transcription to replication. When this switch is activated, replication of the viral genome begins. The first step in viral replication is synthesis of full-length copies (postive strands) of the viral genome. When the switch to replication occurs, RNA transcription becomes “non-stop” and stop codons are ignored. The viral polymerase enters a single site on the 3’ end of the genome, and proceeds to synthesize full-length copies of the genome. These positive strands of rabies RNA serve as templates for synthesis of full-length negative strands of the viral genome.

During the assembly process, the N-P-L complex encapsulates negative-stranded genomic RNA to form the RNP core, and the M protein forms a capsule, or matrix, around the RNP. The RNP-M complex migrates to an area of the plasma membrane containing glycoprotein inserts, and the M-protein initiates coiling. The M-RNP complex binds with the glycoprotein, and the completed virus buds from the plasma membrane. Within the central nervous system (CNS), there is preferential viral budding from plasma membranes. Conversely, virus in the salivary glands buds primarily from the cell membrane into the acinar lumen. Viral budding into the salivary gland and virus-induced aggressive biting-behavior in the host animal maximize chances of viral infection of a new host.

Overview

Rabies is a virus that infects wildlife, especially bats, raccoons, skunks and foxes in the US. It can spread to people and pets when they are bitten or scratched, causing fever, agitation and death. Rabies is 100% preventable with post-exposure prophylaxis (PEP) that includes rabies vaccine and medications to fight infection, as long as people get PEP before symptoms start. Understanding the risk of rabies and knowing what to do after contact with wildlife can save lives.

• The best way to avoid rabies is to stay away from wildlife.
• Contact with infected bats is the leading cause of rabies deaths in people in the US.
• Rabid dogs outside the US are the second leading cause of rabies deaths in Americans, who are exposed during travel abroad.
• Whether in the US or abroad, seeing a healthcare provider quickly after an animal bite or scratch can ensure people get PEP if needed.

Common carriers of rabies by location in the US.

Then & Now: Changes in Rabid Animals Reported

Problem

People may not know about rabies.

• Once the leading cause of human rabies deaths in the US, dogs are no longer as much of a risk, thanks to the use of rabies vaccines. Dogs are only 1% of rabid animals reported each year.
• People might worry about rabies in animals that don’t often carry the virus, like opossums or squirrels. But these animals hardly ever have rabies.
• People may not recognize a scratch or bite from a bat, which can be smaller than the top of a pencil eraser. But these types of contact can still spread rabies!
• It’s not only in the woods – rabid animals can be found in people’s yards and homes too!

The Way Forward

Everyone Can:

• Leave all wildlife alone.
• Wash animal bites or scratches immediately with soap and water.
• If you are bitten, scratched or unsure, talk to a healthcare provider about whether you need PEP.
• Vaccinate your pets to protect them and your family.
• If you find injured wildlife, don’t touch it; contact local authorities for assistance.

Healthcare Providers Can:

• Contact local/state health departments for help with risk assessments and PEP recommendations.
• Ask patients if they had recent animal bites or scratches.

International Travelers Can:

• Get health recommendations for your destination: www.cdc.gov/travel.
• Know if rabies is present in dogs or wildlife where you are going.
• While abroad, avoid contact with all animals.
• Seek medical care ASAP if you are bitten or scratched.

Rabies prevention by the numbers

• About 55,000 Americans get post-exposure prophylaxis (PEP) each year to prevent rabies infection after being bitten or scratched by an infected or suspected infected animal.
• Each year, CDC and its public health partners respond to 175 mass bat exposures (events where more than 10 people are exposed to a potentially rabid bat).

What animals get rabies?

Rabies affects only mammals. Mammals are warm-blooded animals with fur. People are also mammals. Birds, snakes, and fish are not mammals, so they can’t get rabies and they can’t give it to you. But any mammal can get rabies, including people. While rabies is rare in people in the United States, with only 1 to 3 cases reported annually, about 60,000 Americans get post-exposure prophylaxis (PEP) each year to prevent rabies infection after being bitten or scratched by an infected or suspected infected animal.

In the United States, more than 90% of reported cases of rabies in animals occur in wildlife. The wild animals that most commonly carry rabies in the United States are raccoons, skunks, bats, and foxes. Contact with infected bats is the leading cause of human rabies deaths in this country; at least 7 out of 10 Americans who die from rabies in the US were infected by bats. People may not recognize a bat scratch or bite, which can be very small, but these types of contact can still spread rabies.

Pets (like cats and dogs) and livestock (like cattle and horses) can also get rabies. Nearly all the pets and livestock that get rabies had not received vaccination or were not up to date on rabies vaccination. Most pets get rabies from having contact with wildlife.

Because of laws requiring dogs to be vaccinated for rabies in the United States, dogs make up only about 1% of rabid animals reported each year in this country. However, dog rabies remains common in many countries. Exposure to rabid dogs is still the cause of nearly all human rabies deaths worldwide. Exposure to rabid dogs outside the US is the second leading cause of rabies deaths in Americans.

How can you tell if an animal has rabies?

You can’t tell if an animal has rabies by just looking at it—the only way to know for sure if an animal (or a person) has rabies is to perform laboratory testing. However, animals with rabies may act strangely. Some may be aggressive and try to bite you or other animals, or they may drool more than normal. (This is sometimes shown in movies as animals “foaming at the mouth.”) But not all animals with rabies will be aggressive or drooling. Other animals may act timid or shy, move slowly or act tame, or let you get close to them. Because that’s not the way wild animals usually act, you should remember that something could be wrong. Some animals may not appear ill. For the health and safety of wildlife, your pets, and yourself, leave wild animals alone, including baby animals.

The best thing to do is to never feed or approach a wild animal. Be careful of pets that you do not know. If you see a stray dog or cat, don’t pet it. This is especially important if you are traveling in a country where rabies in dogs is common. And if any animal is acting strangely, call your local animal control officer for help. Some things to look for are:

• General sickness
• Problems swallowing
• Excessive drool or saliva
• An animal that is overly aggressive
• An animal that bites at imaginary objects (sometimes called “fly biting”)
• An animal that appears tamer than you would expect
• An animal that’s having trouble moving or may even be paralyzed
• A bat that is on the ground

How can you prevent rabies in animals?

There are several things you can do to protect your pet from rabies. These include making sure your pets get regular rabies vaccines, keeping pets away from wild animals, spaying or neutering pets, and calling animal control to remove stray animals from your neighborhood. Many states also are vaccinating wild animals (mainly raccoons) to prevent the spread of rabies. Instead of trying to catch every animal and give it a shot, they use a vaccine in a special type of food that works when the animal eats it. The food is put out where animals are likely to find it. Sometimes airplanes and helicopters are used to get the food into places that are hard to reach on foot or with a truck.

When should you see a doctor?

If you’ve been in direct physical contact with any wildlife or unfamiliar animals, particularly if you’ve been bitten or scratched, you should talk with a healthcare or public health professional to determine your risk for rabies or other illnesses. One important factor in deciding if you should receive rabies vaccination (post exposure prophylaxis) will be if the animal you were exposed to can be found and tested for rabies or held for observation. If you need rabies vaccination, it should be started soon after exposure; so talk to a healthcare provider right away to determine if you need it.

Rabies virus is transmitted through direct contact (such as through broken skin or mucous membranes in the eyes, nose, or mouth) with saliva or brain/nervous system tissue from an infected animal.

People usually get rabies from the bite of a rabid animal. It is also possible, but rare, for people to get rabies from non-bite exposures, which can include scratches, abrasions, or open wounds that are exposed to saliva or other potentially infectious material from a rabid animal. Other types of contact, such as petting a rabid animal or contact with the blood, urine or feces of a rabid animal, are not associated with risk for infection and are not considered to be exposures of concern for rabies.

Other modes of transmission—aside from bites and scratches—are uncommon. Inhalation of aerosolized rabies virus is one potential non-bite route of exposure, but except for laboratory workers, most people won’t encounter an aerosol of rabies virus. Rabies transmission through corneal and solid organ transplants have been recorded, but they are also very rare. There have only been two known solid organ donor with rabies in the United States since 2008. Many organ procurement organizations have added a screening question about rabies exposure to their procedures for evaluating the suitability of each donor.

Bite and non-bite exposures from an infected person could theoretically transmit rabies, but no such cases have been documented. Casual contact, such as touching a person with rabies or contact with non-infectious fluid or tissue (urine, blood, feces), is not associated with risk for infection. Contact with someone who is receiving rabies vaccination does not constitute rabies exposure, does not pose a risk for infection, and does not require postexposure prophylaxis.

Rabies virus becomes noninfectious when it dries out and when it is exposed to sunlight. Different environmental conditions affect the rate at which the virus becomes inactive, but in general, if the material containing the virus is dry, the virus can be considered noninfectious.

Which animals carry rabies?

All mammals can get rabies, but only a few species are important as reservoirs for the disease. In the United States, distinct strains of rabies virus have been identified in bats, raccoons, skunks, foxes, and mongooses. In many other parts of the world, rabies in dogs is still common.

The Virus Travels through the Body

From numerous studies conducted on rabid dogs, cats, and ferrets, we know that when the rabies virus isintroduced into a muscle through a bite from another animal, it travels from the site of the bite to the brain by moving within nerves. The animal does not appear ill during this time.

The time between the bite and the appearance of symptoms is called the incubation period and it may last for weeks to months. A bite by the animal during the incubation period does not carry a risk of rabies because the virus has not yet made it to the saliva.

The Virus Reaches the Brain

Late in the disease, after the virus has reached the brain and multiplied there to cause an inflammation of the brain, it moves from the brain to the salivary glands and saliva.

Also at this time, after the virus has multiplied in the brain, almost all animals begin to show the first signs of rabies. Most of these signs are obvious to even an untrained observer, but within a short period of time, usually within 3 to 5 days, the virus has caused enough damage to the brain that the animal begins to show unmistakable signs of rabies.

Extensive studies on dogs, cats, and ferrets show that the rabies virus can be excreted in the saliva of infected animals several days before illness is apparent. Such extensive studies have not been done for wildlife species, but it is known that wildlife species do excrete rabies virus in their saliva before the onset of signs of illness. The excretion of virus may be intermittent, and the relative amount of excreted virus may vary greatly over time, before and after the onset of clinical signs.

The reason there is so much variation in the time between exposure and the onset of the disease is that many factors come into play, including the site of the exposure, the type of rabies virus, and any immunity in the animal or person exposed.

The Infectious Path of the Rabies Virus

1. An animal is bitten by a rabid animal.
2. Rabies virus from the infected saliva enters the wound.
3. Rabies virus travels through the nerves to the spinal cord and brain. This process can last approximately 3 to 12 weeks. The animal has no signs of illness during this time.
4. When it reaches the brain, the virus multiplies rapidly and passes to the salivary glands. The animal begins to show signs of the disease.
5. The infected animal usually dies within 7 days of becoming sick.

After a rabies exposure, the rabies virus has to travel to the brain before it can cause symptoms. This time between exposure and appearance of symptoms is the incubation period. It may last for weeks to months. The incubation period may vary based on

• the location of the exposure site (how far away it is from the brain),
• the type of rabies virus, and
• any existing immunity.

The first symptoms of rabies may be similar to the flu, including weakness or discomfort, fever, or headache. There also may be discomfort, prickling, or an itching sensation at the site of the bite. These symptoms may last for days.

Symptoms then progress to cerebral dysfunction, anxiety, confusion, and agitation. As the disease progresses, the person may experience delirium, abnormal behavior, hallucinations, hydrophobia (fear of water), and insomnia. The acute period of disease typically ends after 2 to 10 days. Once clinical signs of rabies appear, the disease is nearly always fatal, and treatment is typically supportive. Less than 20 cases of human survival from clinical rabies have been documented. Only a few survivors had no history of pre- or postexposure prophylaxis.

The signs, symptoms, and outcome of rabies in animals can vary. Symptoms in animals are often similar to those in humans. These include early nonspecific symptoms, acute neurologic symptoms, and ultimately death.

If you’ve been in contact with any wildlife or unfamiliar animals, particularly if you’ve been bitten or scratched, you should talk with a healthcare or public health professional to determine your risk for rabies or other illnesses. Wash any wounds immediately with soap and water and then plan to see a healthcare provider. (It’s important to know that, unlike most other animals that carry rabies, many types of bats have very small teeth which may leave marks that disappear quickly. If you are unsure, seek medical advice to be safe.)

Remember that rabies is a medical urgency but not an emergency. Decisions should not be delayed.

See your doctor for attention for any trauma due to an animal attack before considering the need for rabies vaccination. After any wounds have been addressed, your doctor – possibly in consultation with your state or local health department – will help you decide if you need treatment known as rabies postexposure prophylaxis (PEP). Decisions to start PEP will be based on your type of exposure, the animal you were exposed to, whether the animal is available for testing, and laboratory and surveillance information for the geographic area where the exposure occurred.

In the United States, PEP consists of a regimen of one dose of immune globulin and four doses of rabies vaccine over a 14-day period. Rabies immune globulin and the first dose of rabies vaccine should be given by your health care provider as soon as possible after exposure. Current vaccines are relatively painless and are given in your arm like a flu or tetanus vaccine; rabies vaccines are not given in the stomach.

Any mammal can get rabies. The most common wild reservoirs of rabies are raccoons, skunks, bats, and foxes. Domestic mammals can also get rabies. Cats, cattle, and dogs are the most frequently reported rabid domestic animals in the United States.

You should seek medical evaluation for any animal bite. One important factor in deciding if you should have postexposure prophylaxis will be if the animal can be found and held for observation.

Rabies is transmitted only when the virus is introduced into a bite wound, open cuts in skin, or onto mucous membranes such as the mouth or eyes.

Other factors to consider when evaluating a potential rabies exposure include the natural occurence in the area, the biting animal’s history and current health status (e.g., abnormal behavior, signs of illness), and the potential for the animal to be exposed to rabies (e.g., presence of an unexplained wound or history of exposure to a rabid animal).

A currently vaccinated dog, cat, or ferret is unlikely to become infected with rabies.

When an exposure has occurred, the likelihood of rabies infection varies with the nature and extent of that exposure. Under most circumstances, two categories of exposure — bite and nonbite — should be considered.

Bite

Any penetration of the skin by teeth constitutes a bite exposure. All bites, regardless of body site, represent a potential risk of rabies transmission, but that risk varies with the species of biting animal, the anatomic site of the bite, and the severity of the wound.

Bites by some animals, such as bats, can inflict minor injury and thus be difficult to detect.

Was the bite from a provoked or an unprovoked attack? Bites inflicted on a person attempting to feed or handle an apparently healthy animal should generally be regarded as provoked. If it was an unprovoked attack, that’s more likely to indicate that the animal is rabid.

Nonbite

The contamination of open wounds, abrasions, mucous membranes, or theoretically, scratches (potentially contaminated with infectious material from a rabid animal) constitutes a nonbite exposure.

Nonbite exposures from terrestrial animals rarely cause rabies. However, occasional reports of rabies transmission by nonbite exposures suggest that such exposures should be evaluated for possible postexposure prophylaxis administration.

Other contact by itself, such as petting a rabid animal and contact with blood, urine, or feces of a rabid animal, does not constitute an exposure and is not an indication for postexposure vaccination.

A healthy domestic dog, cat, or ferret that bites a person should be confined and observed for 10 days. Any illness in the animal during the confinement period or before release should be evaluated by a veterinarian and reported immediately to the local public health department.

If signs suggestive of rabies develop, postexposure prophylaxis should be initiated. The animal should be euthanized and its head removed and shipped, under refrigeration, for examination by a qualified laboratory.

If the biting animal is stray or unwanted, it should either be confined and observed for 10 days or be euthanized immediately and submitted for rabies examination.

Skunks, raccoons, foxes and bats that bite humans should be euthanized and tested as soon as possible. The length of time between rabies virus appearing in the saliva and onset of symptoms is unknown for these animals and holding them for observation is not acceptable.

After exposure to wildlife in which rabies is suspected, prophylaxis is warranted in most circumstances. Because the period of rabies virus shedding in wild animal hybrids is unknown, these animals should be euthanized and tested rather than confined and observed when they bite humans.

Vaccination should be discontinued if tests of the involved animal are negative for rabies infection.

In animals, rabies is diagnosed using the direct fluorescent antibody (DFA) test, which looks for the presence of rabies virus antigens in brain tissue. In humans, several tests are required.

Rapid and accurate laboratory diagnosis of rabies in humans and other animals is essential for timely administration of postexposure prophylaxis. Within a few hours, a diagnostic laboratory can determine whether or not an animal is rabid and inform the responsible medical personnel. The laboratory results may save a patient from unnecessary physical and psychological trauma, and financial burdens, if the animal is not rabid.

In addition, laboratory identification of positive rabies cases may aid in defining current epidemiologic patterns of disease and provide appropriate information for the development of rabies control programs.

The nature of rabies disease dictates that laboratory tests be standardized, rapid, sensitive, specific, economical, and reliable.

Several tests are necessary to diagnose rabies ante-mortem (before death) in humans; no single test is sufficient. Tests are performed on samples of saliva, serum, spinal fluid, and skin biopsies of hair follicles at the nape of the neck. Saliva can be tested by virus isolation or reverse transcription followed by polymerase chain reaction (RT-PCR). Serum and spinal fluid are tested for antibodies to rabies virus. Skin biopsy specimens are examined for rabies antigen in the cutaneous nerves at the base of hair follicles.

A diagnosis of rabies can be made after detection of rabies virus from any part of the affected brain, but in order to rule out rabies, the test must include tissue from at least two locations in the brain, preferably the brain stem and cerebellum.

The test requires that the animal be euthanized. The test itself takes about 2 hours, but it takes time to remove the brain samples from an animal suspected of having rabies and to ship these samples to a state public health or veterinary diagnostic laboratory for diagnosis.

In the United States, the results of a rabies test are typically available within 24 to 72 hours after an animal is collected and euthanized. Because rabies exposure to suspect animals is a medical urgency, but not an emergency, testing within this period is more than adequate for determining if a person was exposed to a rabid animal, and requires rabies postexposure vaccinations.

Approximately 120,000 animals or more are tested for rabies each year in the United States, and approximately 6% are found to be rabid. The proportion of positive animals depends largely on the species of animal and ranges from <1% in domestic animals to >10% of wildlife species.

Based on routine public health surveillance and pathogenesis studies, we have learned that it is not necessary to euthanize and test all animals that bite or otherwise potentially expose a person to rabies. For animals with a low probability of rabies such as dogs, cats, and ferrets, observation periods (10 days) may be appropriate to rule out the risk of potential human rabies exposure.

Consultation with a local or state health official following a potential exposure can help determine the best course of action based on current public health recommendations.

What medical care will I receive if I may have been exposed to rabies?

Postexposure prophylaxis (PEP) consists of a dose of human rabies immune globulin (HRIG) and rabies vaccine given on the day of the rabies exposure, and then a dose of vaccine given again on days 3, 7, and 14. For people who have never been vaccinated against rabies previously, postexposure prophylaxis (PEP) should always include administration of both HRIG and rabies vaccine. The combination of HRIG and vaccine is recommended for both bite and non-bite exposures, regardless of the interval between exposure and initiation of treatment.

People who have been previously vaccinated or are receiving preexposure vaccination for rabies should receive only vaccine.

Adverse reactions to rabies vaccine and immune globulin are not common. Newer vaccines in use today cause fewer adverse reactions than previously available vaccines. Mild, local reactions to the rabies vaccine, such as pain, redness, swelling, or itching at the injection site, have been reported. Rarely, symptoms such as headache, nausea, abdominal pain, muscle aches, and dizziness have been reported. Local pain and low-grade fever may follow injection of rabies immune globulin.

The vaccine should be given at recommended intervals for best results. Talk to your doctor or state or local public health officials if you will not be able to have your shots at the recommended interval. Rabies prevention is a serious matter and changes should not be made in the schedule of doses. Patient assistance programs that provide medications to uninsured or underinsured patients are available for rabies vaccine and immune globulin.

People cannot transmit rabies to other people unless they themselves are sick with rabies. PEP will protect you from developing rabies, and therefore you cannot expose other people to rabies. You can continue to participate in your normal activities.

Wound Care

Regardless of the risk for rabies, bite wounds can cause serious injury such as nerve or tendon laceration and infection. Your doctor will determine the best way to care for your wound, and will also consider how to treat the wound for the best possible cosmetic results.

For many types of bite wounds, immediate gentle irrigation with water or a dilute water povidone-iodine solution has been shown to markedly decrease the risk of bacterial infection.

Wound cleansing is especially important in rabies prevention since, in animal studies, thorough wound cleansing alone without other postexposure prophylaxis has been shown to markedly reduce the likelihood of rabies.

You should receive a tetanus shot if you have not been immunized in ten years. Decisions regarding the use of antibiotics, and primary wound closure should be decided together with your doctor.

Human rabies immune globulin (HRIG) is administered only once, at the beginning of anti-rabies prophylaxis, to previously unvaccinated persons. This will provide immediate antibodies until the body can respond to the vaccine by actively producing antibodies of its own. If possible, the full dose of HRIG should be thoroughly infiltrated in the area around and into the wounds. Any remaining volume should be injected intramuscularly at a site distant from vaccine administration.

HRIG should never be administered in the same syringe or in the same anatomical site as the first vaccine dose. However, subsequent doses of vaccine in the four-dose series can be administered in the same anatomic location where the HRIG dose was administered.

If HRIG was not administered when vaccination was begun, it can be administered up to seven days after the administration of the first dose of vaccine. Beyond the seventh day, HRIG is not recommended since an antibody response to the vaccine is presumed to have occurred.

Because HRIG can partially suppress active production of antibody, no more than the recommended dose should be administered. The recommended dose of HRIG is 20 IU/kg body weight. This formula is applicable to all age groups, including children.

A regimen of four 1-mL doses of HDCV or PCEC vaccines should be administered intramuscularly to previously unvaccinated persons.

The first dose of the four-dose course should be administered as soon as possible after exposure. Additional doses should be administered on days 3, 7, and 14 after the first vaccination. For adults, the vaccination should always be administered intramuscularly in the deltoid area (arm). For children, the anterolateral aspect of the thigh is also acceptable. The gluteal area should never be used for rabies vaccine injections because observations suggest administration in this area results in lower neutralizing antibody titers.

Postexposure Prophylaxis for Non-immunized Individuals

* A 5th dose on day 28 may be recommended for immunocompromised persons.

Postexposure Prophylaxis for Previously Immunized Individuals

If exposed to rabies, previously vaccinated persons should receive two IM doses (1.0 mL each) of vaccine, one immediately and one three days later. Previously vaccinated persons are those who have received one of the recommended preexposure or postexposure regimens of HDCV, RVA, or PCECV, or those who received another vaccine and had a documented rabies antibody titer. RIG is unnecessary and should not be administered to these persons because an anamnestic response will follow the administration of a booster regardless of the pre-booster antibody titer.

There are several things you can do to protect your pet from rabies.

First, visit your veterinarian with your pet on a regular basis and keep rabies vaccinations up-to-date for all cats, ferrets, and dogs.

Second, maintain control of your pets by keeping cats and ferrets indoors and keeping dogs under direct supervision.

Third, spay or neuter your pets to help reduce the number of unwanted pets that may not be properly cared for or vaccinated regularly.

Finally, call animal control to remove all stray animals from your neighborhood since these animals may be unvaccinated or ill.

The importance of vaccinating your pet

While wildlife are much more likely to be rabid than are domestic animals in the United States, people have much more contact with domestic animals than with wildlife. Your pets and other domestic animals can be infected when they are bitten by rabid wild animals, and this type of “spillover” increases the risk to people.

Keeping your pets up to date on their rabies vaccination will prevent them from acquiring the disease from wildlife, and thereby prevent possible transmission to your family or other people.

Moving out of the United States

If you are bringing your pet into the United States, you may be subject to CDC regulations that govern the importation of animals capable of causing human disease. (For example, dogs coming from countries considered high risk for importing dog rabies must have a valid rabies vaccine certificate to enter.)

If you are planning to move out of the country and take your pets with you, you should consult with the embassy of your destination country to see what regulations they have for importing pets.

Understanding your rabies risk and knowing what to do after contact with animals can save lives. Any mammal can get rabies, but the most commonly affected animals in the United States are raccoons, skunks, bats, and foxes — so the best way to avoid rabies in the U.S. is to stay away from wildlife. Leave all wildlife alone, including injured animals. If you find an injured animal, don’t touch it; contact local authorities for assistance.

Rabies in dogs is still common in many countries outside the United States, so find out if rabies is present in dogs or wildlife at your destination before international travel.

Because pets can get rabies from wildlife and then could spread it to humans, preventing rabies in pets is also an important step in preventing human rabies cases.

If you do come into contact with a rabid animal, rabies in humans is 100% preventable through prompt appropriate medical care. If you are bitten, scratched, or unsure, talk to a healthcare provider about whether you need PEP.

Preventing rabies around the globe

Although dog rabies is no longer a problem in the United States, the most important global source of rabies in humans is from uncontrolled rabies in dogs. Children are often at greatest risk from rabies. They are more likely to be bitten by dogs, and are also more likely to be severely exposed through multiple bites in high-risk sites on the body. Severe exposures make it more difficult to prevent rabies unless access to good medical care is immediately available.

This major source of rabies in humans can be eliminated through ensuring adequate animal vaccination and control, educating those at risk, and enhancing access of those bitten to appropriate medical care. The annual World Rabies Day campaign, first observed in 2007, brings together researchers and partners to accomplish these goals by mobilizing awareness and resources in support of human rabies prevention and animal rabies control around the world.

Bats play key roles in ecosystems around the globe. They also can carry diseases, including rabies. The best way to protect yourself and bats is to stay away from them and get medical care if you come in contact with them.

Key Facts

• Bats are one of the most commonly reported rabid animal in the United States.
• Bats are the leading cause of rabies deaths in people in the United States.
• If you find a bat in your home, try to capture it for testing. By testing the bat for rabies, you can find out if you need to be vaccinated.
• Bat bites can be very small. If you’ve been in contact with a bat – even if you aren’t sure you’ve been bitten or scratched – talk to a healthcare or public health professional about your risk and whether or not you need to be vaccinated.

Rabies and Bats

Bats are the leading cause of rabies deaths in people in the United States. Rabid bats have been found in all 49 continental states. Only Hawaii is rabies-free. The good news is that most bats don’t have rabies. But you can’t tell if a bat has rabies just by looking at it. Rabies can only be confirmed in a laboratory.

Any bat that is active during the day or is found in a place where bats are not usually seen – like in your home or on your lawn – might be rabid. A bat that is unable to fly and is easily approached could be sick.

What should I do if I encounter a bat?

If you come into contact with a bat, you might need medical care. What you should do around bats depends on where you encounter them and what type of contact you have. Infants, young children, and people with reduced mental function due to medication, alcohol, illness, or age are at higher risk since they may not know or be able to tell others if they were bitten or scratched.

• If you know you’ve been bitten or scratched by a bat — or if infectious material (such as saliva or brain material) from a bat gets into your eyes, nose, mouth, or a wound — wash the wound thoroughly with soap and water and seek medical attention immediately. Whenever possible, the bat should be captured and sent to a laboratory for rabies testing.
• If you are outdoors:
  • Seeing bats outside is common and normal, especially at dusk and through the night. Avoid intentional contact with bats outside. Use screens, tents, or mosquito netting when sleeping outside.
  • If you are outside and have direct contact with a bat, you should talk to a healthcare or public health professional to decide if you need to be vaccinated to prevent rabies. If you’re not sure if contact occurred but find a bat on or near you (for example, if you wake up with a bat near or on you), then you may need vaccination.
• If you are in your home: If you find a bat in your house, talk to a healthcare or public health professional and have the bat captured for possible rabies testing. Call animal control, wildlife conservation, or a public health agency for assistance. If professional assistance is not available, safely capture the bat in case testing is needed. Testing the bat may help you and your doctor decide if you need rabies vaccination.

Capture a bat for testing

1. Find a container like a box or a can large enough for the bat to fit in, and a piece of cardboard large enough to cover the container opening. Punch small air holes in the cardboard.
2. Put on leather work gloves. When the bat lands, approach it slowly and place the container over it. Slide the cardboard under the container to trap the bat inside.
3. Tape the cardboard to the container to secure the bat inside. Contact your local health department to have the bat tested for rabies.

Keep bats out of your house

You can contact an animal-control or wildlife conservation agency for assistance with “bat-proofing” your home, or you can take steps to bat-proof on your own.

• Examine your home for holes that might allow bats entry. Caulk any openings larger than a dime. Use window screens, chimney caps, and draft-guards beneath doors to attics. Fill electrical and plumbing holes with stainless steel wool, caulk, or other material rated for pest exclusion. Ensure that all doors to the outside close tightly.
• If you already have bats in your home, observe where they exit at dusk. Make note of how many there are. Prevent them from coming back by loosely hanging clear plastic sheeting or bird netting over the areas where they exit. This lets any remaining bats crawl out and leave but prevents them from re-entering. When all the bats are gone, the openings can be permanently sealed.
  • Bat sightings may increase early in the exclusion process, as bats try to find other entrances and exits into your home. Make sure all residents and visitors are aware of the bat-proofing efforts and report any contact between bats and people or pets to your local health department.
• Most bats leave in the fall or winter to migrate, so these are the best times to bat-proof your home. In most of the U.S., avoid bat-proofing from May through August, because you could trap young bats inside and cause them to die or to make their way into your living areas.
• Always be mindful of local rules or laws about removing bats . Some bats are endangered and may require special care if they are found in your home.

The majority of people in the United States have a low risk of coming in contact with the rabies virus. However, a small subset has a higher level of risk, such as those who work directly with animals that could have rabies, or those who travel to parts of the world where rabies is common and access to medical care is limited. These people should receive rabies pre-exposure prophylaxis (PrEP), a series of rabies vaccine doses given before coming into contact with the rabies virus.

The Advisory Committee on Immunization Practices (ACIP) develops the U.S. recommendations about how to use vaccines to prevent disease in the United States, including how to prevent rabies in people. ACIP updated rabies vaccine recommendations in May 2022, which are summarized below:

Updates to the ACIP recommendations to prevent human rabies, 2022

• A 2-dose PrEP schedule has replaced the 3-dose PrEP schedule to protect for up to 3 years. Options for maintaining protection beyond 3 years are also described.
• Risk categories have been redefined into 5 risk groups.
• The minimum acceptable laboratory value (antibody titer) used to determine whether rabies vaccine booster doses are needed was revised and standardized.
• Many people for whom serial titers were recommended every 2 years now require only a one-time titer (and booster if below a certain level) OR a one-time booster.
• Clinical guidance for administering PrEP to people with weakened immune systems has been outlined and includes recommendations to confirm that the vaccine was effective.

Risk categories and PrEP recommendations

*The typical characteristics described may not include the characteristics of all activities that fall within the described risk group.

What is rabies?

Rabies is a deadly disease caused by a virus. You can get rabies if you are bitten or scratched by an animal with rabies.

In the United States, rabies is mostly found in wild animals like bats, raccoons, skunks, and foxes. However, in many other countries around the world, bites from dogs (including puppies) are the main source of rabies infections in people. Most people who die of rabies were bitten by a dog with rabies.

Rabies affects the central nervous system (the brain and spinal cord). Without appropriate medical care, rabies causes brain disease and death. Once symptoms of rabies appear, the disease is nearly always fatal. For this reason, preventing animal bites and receiving prompt medical care is especially important.

Early rabies symptoms include weakness or discomfort, fever, and headache. There may be discomfort or a prickling or itching sensation at the place of the bite. Within days, an infected person may become anxious, confused, and agitated. As a person gets sicker, they may become delirious, hallucinate, be unable to sleep, and unable to swallow or quench their thirst.

Who is at risk?

Rabid dogs are a problem in many countries around the world, including most of Africa, Asia, and parts of Central and South America. Although any mammal can transmit rabies, dog bites are how most travelers get rabies.

Activities that may increase a traveler’s chances of rabies infection include:

• Camping or exploring caves (spelunkers)
• Working with animals (veterinarians, animal handlers, field biologists, or laboratory workers handling animal specimens)
• Long-term travelers and expatriates

Children are more likely to get infected because they often play with animals and may not report bites.

Rabies in dogs is rare in the United States, Australia, Canada, Japan, and most European countries.

What can travelers do to prevent rabies?

Travelers can protect themselves from rabies by taking the following steps:

Avoid animals when traveling

• Don’t touch dogs, puppies, or other animals. This goes for strays as well as pets. Not all countries require pets to be vaccinated against rabies. Even animals that appear healthy can spread rabies.
• Supervise children closely, especially around dogs and puppies, cats and kittens, and wildlife.
• If you travel with your pet, watch it closely. Do not allow it around other local pets or wild animals.
• Avoid bringing animals home to the United States. Dogs and cats may be infected with rabies but not show signs until several days or months later. If you do decide to bring an animal with you to the United States, be aware of CDC’s and USDA’s animal importation regulations.
• If you are traveling to work with animals, bring and wear appropriate protective gear.
• For more information, see Be Safe Around Animals.

Act quickly if you are bitten or scratched by a dog or other animal

• Immediately wash all bites and scratches well. Use plenty of soap and running water.
• Seek medical care immediately, even if you don’t feel sick or the wound does not look serious.
• To prevent rabies, start treatment immediately. Treatment for rabies includes getting a vaccine after you have been bitten. Even if you were vaccinated before your trip, you still need to seek care if you get bitten or scratched by an animal.
• Be prepared to travel back to the United States or to another area to receive treatment. Vaccination and medicine for rabies exposure is not available everywhere in the world.

Pre-travel rabies vaccine

For some travelers, it may make sense to get the rabies vaccine before your trip. Check if rabies vaccine is recommended for your destination.

The rabies vaccine is given in two shots. The second dose is given seven days after the first dose. Even if you are vaccinated against rabies, if you are bitten or scratched by an animal that may have rabies while traveling, you need to seek medical care immediately and get two booster doses of the vaccine.

Consider medical evacuation insurance

Rabies vaccine is not available in all countries. Medical evacuation insurance can cover the cost of transferring you home or to the nearest destination where care can be obtained.

If you traveled and feel sick, particularly if you have a fever, talk to a healthcare provider and tell them about your travel. Avoid contact with other people while you are sick.

Rabies is found on all continents except Antarctica. In most countries, the risk of rabies in an encounter with an animal and the precautions necessary to prevent rabies are the same as they are in the United States. When traveling, it is always prudent to avoid approaching any wild or domestic animal.

In certain areas of the world, including but not limited to parts of Africa, Asia, and Central and South America, rabies in dogs is still a major problem, and access to preventative treatment may be hard to get. The importance of rabid dogs in these countries, where tens of thousands of people die of the disease each year, cannot be overstated.

Unlike programs in developed countries, dog rabies vaccination programs in developing countries have not always been successful. Rates of postexposure prophylaxis in some developing countries are about 10 times higher than in the United States, and rates of human rabies are sometimes 100 times higher.

Before traveling abroad, consult your doctor, a travel clinic, or your local or state health department about your risk of exposure to rabies and how to handle an exposure should it arise.

If traveling to a country where there is an increased incidence in rabies, especially in canine populations, rabies pre-exposure vaccination may be recommended. Rabies vaccination should also be considered if you will be spending lots of time outdoors in rural areas or plan to handle animals.