Exposure, prevention and treatment

Exposure

Prevention

Treatments


Exposure

Have I been exposed to rabies? 

If you been bitten or scratched by an animal that is unknown to you and/or that appears unwell, you may have been exposed to rabies. 

Please take any potential exposure seriously. Throughly wash the wound with soap and water and seek urgent medical attention.

90% of human rabies cases are caused by a bite (or scratch) from a rabid dog.

The rabies virus becomes noninfectious when it dries out and when it is exposed to sunlight.

If rabies is passed through saliva, why are scratches a risk?

Scratches from an infected animal may cause infection because saliva is sometimes present on claws - particularly if the disease is causing the animal to drool excessively (hyper-salivation).

However, you can only get rabies by coming in contact with saliva and nervous bodily tissues of an infected animal.

You have not been exposed if

•   the animal that doesn't have rabies itself, for example, not all dogs have rabies

•   you have petted or handled an animal

•   you have had contact with blood, urine or feces 

None of these situations constitute exposure to rabies.

As well as saliva, rabies is also passed through nervous tissue membranes.

Can I get rabies from an animal showing no clinical signs of rabies?

Experiments on dogs, cats, and ferrets have shown that rabies virus can be excreted in the saliva of infected animals several days before they show signs of illness. Extensive studies have not been done for wildlife species, but it is known that wildlife species also excrete rabies virus in their saliva before the onset of signs of illness. This means that animals can transmit rabies to other animals and people even if they are not yet sick because of their infection.

I am not sure if I have been exposed

In general, any mammal that bites you without being provoked should be tested for rabies. Rabies prophylaxis is then offered based upon the laboratory test results. 

If testing the animal is not possible, see a doctor or local medical practitioner to discuss whether you need rabies post-exposure prophylaxis.

Can I get rabies if I drink milk from an animal that has rabies?

There are no scientifically documented cases of rabies transmission by drinking the raw milk of an animal that has rabies. However, such transmission is theoretically possible and drinking raw (unpasteurized) milk and raw milk products from an animal that has clinical rabies is considered to be a risk. 

Because heat kills the virus, pasteurized milk from an animal with clinical rabies does not contain infectious rabies virus and is not a risk. Nevertheless, it is recommended that you avoid consuming milk or other products from rabid animals.

Can I get rabies by preparing or eating raw meat from a rabid animal?

Both preparing or ingesting raw animal products from a rabid animal are both considered a high risk. There are documented cases of rabies transmission to butchers cutting meat from a rabid animal.

Preparing meat from wildlife is also considered a high risk activity for rabies transmission and hunters are encouraged to wear protective clothing and barriers, such as gloves, face masks and coats, when butchering animals they have killed. 

In some countries it is prohibited to slaughter animals that are known to have been exposed to rabies in the recent past.

Can people transmit rabies to other people?

Bites or contact with saliva from a person infected with rabies during the symptomatic stage of the disease could theoretically transmit rabies and people who have been exposed to rabies patients should be offered post-exposure prophylaxis. 

Casual contact with a person infected with symptomatic rabies (touching unbroken skin or contact with non-infectious tissues or bodily fluids) cannot transmit the rabies virus to another person.

Puncture wounds due to needle sticks penetrating neural tissue during the care of a rabies patient does constitute an exposure to rabies and requires treatment.  

It may be possible to transmit the virus from a symptomatic rabies patient through mouth-to-mouth contact or kissing. The virus has been reported to be present in sperm or vaginal secretions, so transmission through sexual intercourse with an infected person may be possible. Oral sex with a person infected with the rabies virus may also carry a risk. 

There are documented cases of human-to-human rabies transmission in the recipients of transplanted corneas and other solid organs where rabies infection in the donor was not suspected.

If you have had risky contact with an infectious person 14 days prior to the onset of clinical symptoms, post-exposure prophylaxis is recommended.  Risky behaviors include: bites, kisses or other direct contact between saliva and mucous membranes or broken skin, sexual activity, and sharing eating or drinking utensils or cigarettes.

If I am receiving rabies vaccinations after an exposure, can I transmit rabies to other people?

No. Patients who are undergoing preventative vaccinations against rabies are not able to transmit the virus to others. The vaccine does not contain live virus but rather a killed form of the virus and is non-infectious.

Prevention

How can I protect my family and myself?

There are three main ways to protect you and your family from rabies.

  1. Reduce risk of exposure. In high-risk areas, avoid wild animals and stray dogs – particularly if they appear in distress or are behaving unusually. Try to keep bats out of homes and public buildings. Bat bites are very small and there have been cases where people have been unknowingly bitten while asleep.

  2. Vaccinate pets and animals

  3. Vaccinate yourself

There are two types of rabies vaccine courses:

  • pre-exposure prophylaxis (PrEP) - a preventative treatment before exposure to the virus
  • post-exposure prophylaxis (PEP) - a treatment to stop the onset of rabies after exposure to the virus

 

What is PrEP and should I have it?

PrEP is a preventative series of rabies vaccinations. They are usually given to people considered to be at a high risk of exposure. This may be because of their job (e.g. animal control officer, veterinarian) or because they live in, or are traveling to, a rabies endemic area.

This is particularly important if you are, or will be, far away from medical services.

If you have PrEP and are exposed to rabies you still need post-exposure prophylaxis (PEP). But, in this case, the PEP number of doses is reduced.

How often are routine boosters needed after pre-exposure immunization?

A full course of rabies vaccine (prEP or PEP) will induce long lasting immunity to rabies virus, but antibody levels will decline over years.

The recommended booster schedule depends upon the potential risk of exposure.
Persons at high risk of exposure, (rabies laboratory workers etc.) should have a blood test to evaluate the presence of rabies neutralizing antibodies. The time interval between blood tests is determined by the degree of risk.  Directors of rabies laboratories should have specific requirements in place to monitor the presence of rabies neutralizing antibodies in the workers.  In the event that the serological titre of someone working in a rabies laboratory falls below 0.5 IU/mL, they should receive one routine booster injection. Others that have received rabies cell culture vaccine previously and are at low risk of exposure, do not need a routine booster.

Treatment of exposures

I might have been exposed to rabies. What should I do?


If you are bitten or scratched by a rabid animal, you must:

Wash the wound thoroughly with soap and water for at least 15 minutes.
Apply ethanol or a similar antiseptic to prevent secondary infection.
Seek urgent medical attention. You need to start post-exposure prophylaxis as soon as possible.
If you have already had pre-exposure prophylaxis, you still need further treatment.

Modern vaccines are the only way to prevent the onset of rabies after exposure. Traditional remedies, such as jackfruit gum and chilli powder do not stop the rabies virus.

Please treat any potential exposure to rabies seriously. Once clinical symptoms appear, death is almost inevitable.

 

What is post-exposure prophylaxis and should I have it?

PEP is a course of vaccinations that protect you against rabies after you have been exposed to the virus.

It consists of immunoglobulin injections into the wound (these are antibodies against the rabies virus), and a series of rabies vaccinations. The number of vaccine doses and the days on which you receive them may follow a different regimen, but 1 dose on each of days 0,3,7,14 and 28 is the most common. For healthy people, the last dose can be dropped and the course is still considered complete.

For PEP to be effective, you must have both the vaccination and the immunoglobulin treatment.

If you have previously had PrEP, you you will still need two additional doses of vaccine, on day 0 and 3 after the exposure. You will not need immunoglobulin injections.

I have been vaccinated against rabies, but then got exposed, do I still need treatment?

Yes, you will need two booster doses of vaccine, to make sure that your immune system is prepared to fight off the virus. You do not need to have rabies immunoglobulin if you have been pre-vaccinated.

I missed one of my PEP shots - do I need to start again?

No, you do not need to start again if you deviated from the vaccine dosage schedule but you should contact your doctor if a PEP injection is missed. The next dose should be given as soon as possible.

Tell you doctor in you know in advance that you will miss one or more does of PEP. In order to be protected against rabies, you need the full series of vaccines. All doses, particularly at the start of of the course, should be given at the recommended intervals wherever possible.

I didn’t seek PEP after a potential exposure some months ago. What should I do now?

You should seek advice about post-exposure vaccination. If you have been exposed to rabies, even if it was some time ago, it is still worth getting PEP treatment as long as you do not have any symptoms. But seek treatment as soon as possible.

I was bitten a number of years ago. Can I still get rabies? Should I be vaccinated?

Yes, it is possible though very rare to develop rabies after an incubation period of several years. Typically, the incubation period for rabies is between one and three months, however, the length of the time to onset of disease can be as short as a few days to as long as several years. So long as there are no symptoms of rabies after an exposure, PEP can still prevent clinical rabies from developing.

If there is a suspicion of rabies exposure, even as long as several years ago, victims can still benefit from PEP and should immediately consult a medical expert. 

Can I give PEP to a baby?

Yes. Both the rabies vaccine and the rabies immune globin (RIG) should be administered for a suspected rabies exposure and are considered safe for pediatric use. The recommended site of injection is the thigh for very young children and in the deltoid of older children.

Rabies vaccines are used extensively worldwide in children, who are the largest population of exposed individuals.

Do the vaccinations hurt?

Vaccination against rabies used to involve many painful injections to the stomach.

Modern vaccines are given into the muscle or under the skin of the arm and are not as painful.

Can vaccination cause rabies?

No. The World Health Organization approves rabies vaccines. Modern vaccines are very safe and effective. 

No cases of rabies have been documented from receipt of WHO-approved rabies vaccine.

Do the vaccinations have side effects?

With WHO-approved vaccine, side effects are mild.

There may be some pain at the site of injection, swollen glands, headache, aching muscles, malaise, and shivering.

In rare cases, allergic reactions occur. This can include a rash, wheezing and hives, swelling of the upper respiratory tract. Serious complications very rare.

The risks of death from rabies are far higher than potential health problems from vaccination.

In some countries, they use locally produced vaccines which are not WHO approved. While many of these are safe and effective, there have been (very rare) cases of ineffective vaccines causing serious side effects.

Do traditional remedies work to prevent rabies?

No. None of the remedies used in traditional medicine, such as jackfruit gum and chilli powder, stop rabies from developing.

Rabies specific vaccines are the only way to stop the onset of clinical symptoms and to prevent death.

What can be done for a patient with rabies?

If a patient has symptoms of rabies there is very little that can be done.

Medical teams can use sedation and tranquilizers to prevent the patient suffering from the distressing symptoms, but there is no cure.

What about the Milwaukee Protocol?

In 2005, Jeanna Giese became the first person to survive rabies with a procedure that is now known as the Milwaukee Protocol.

Since then a handful of people with early symptoms of rabies have recovered using this procedure.

The Milwaukee Protocol involves inducing a coma to protect the brain whilst the body fights off the rabies virus.

However, even with intensive care facilities, the success rate remains very low and the protocol is impractical for most rabies endemic areas.