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Treatment and Prevention

Once a rabies infection is established, there's no effective treatment. Though a small
number of people have survived rabies, the disease is usually fatal. For that reason, if you think
you've been exposed to rabies, you must get a series of shots to prevent the infection from taking
hold.

Treatment for people bitten by animals with rabies
If you've been bitten by an animal that is known to have rabies, you'll receive a series of
shots to prevent the rabies virus from infecting you. If the animal that bit you can't be found, it
may be safest to assume that the animal has rabies. But this will depend on several factors, such
as the type of animal and the situation in which the bite occurred.
Rabies shots include:
 A fast-acting shot (rabies immune globulin) to prevent the virus from infecting you. Part
of this injection is given near the area where the animal bit you if possible, as soon as
possible after the bite.
 A series of rabies vaccines to help your body learn to identify and fight the rabies virus.
Rabies vaccines are given as injections in your arm. You receive four injections over 14
days.
Determining whether the animal that bit you has rabies
In some cases, it's possible to determine whether the animal that bit you has rabies before beginning
the series of rabies shots. That way, if it's determined the animal is healthy, you won't need the
shots.
Procedures for determining whether an animal has rabies vary by situation. For instance:
 Pets and farm animals. Cats, dogs and ferrets that bite can be observed for 10 days to see
if they show signs and symptoms of rabies. If the animal that bit you remains healthy during
the observation period, then it doesn't have rabies and you won't need rabies shots. Other
pets and farm animals are considered on a case-by-case basis. Talk to your doctor and local
public health officials to determine whether you should receive rabies shots.
 Wild animals that can be caught. Wild animals that can be found and captured, such as
a bat that came into your home, can be killed and tested for rabies. Tests on the animal's
brain may reveal the rabies virus. If the animal doesn't have rabies, you won't need the
shots.
 Animals that can't be found. If the animal that bit you can't be found, discuss the situation
with your doctor and the local health department. In certain cases, it may be safest to
assume that the animal had rabies and proceed with the rabies shots. In other cases, it may
be unlikely that the animal that bit you had rabies and it may be determined that rabies
shots aren't necessary.
Pre-exposure Prophylaxis (PrEP) and Post-exposure Prophylaxis (PEP)

Pre-exposure Vaccination
People work with rabies in laboratory settings and animal control and wildlife officers are just a
few of the people who should consider rabies pre-exposure vaccinations.
If you are traveling to a country where rabies is widespread, you should consult your doctor about
the possibility of receiving preexposure vaccination against rabies.

Consider pre-exposure vaccination if:

 Your planned activity will bring you into contact with wild or domestic animals, for
example if you are a biologist, veterinarian, or agriculture specialist working with
animals.

 You will be visiting remote areas where medical care is difficult to obtain or may be
delayed, for example, hiking through remote villages where dogs are common.

 Your stay is longer than 1 month in an area where dog rabies is common. The longer
your stay, the greater the chance of an encounter with an animal.
Although pre-exposure vaccination does not eliminate the need for additional therapy after a rabies
exposure, it simplifies management by eliminating the need for rabies immune globulin and
decreasing the number of doses of vaccine needed. This is of particular importance for persons at
high risk for exposure to rabies in areas where immunizing products might not be available or
where lesser quality biologics might be used which would place the exposed person at increased
risk for adverse events.
Pre-exposure prophylaxis may also protect people whose post-exposure therapy is delayed and
provide protection to people who are at risk for unapparent exposures to rabies.
Rabies Pre-exposure Prophylaxis Guide
Risk Preexposure
Nature of Risk Typical Population
Category Recommendations
Virus present
continuously, often in
Primary course. Serologic
high concentrations.
Rabies research laboratory testing every 6 months;
Specific exposures
Continuous workers; rabies biologics booster vaccination if
likely to go
production workers. antibody titer is below
unrecognized. Bite, non-
acceptable level.
bite, or aerosol
exposure.
Exposure usually
Rabies diagnostic lab workers,
episodic, with source Primary course. Serologic
spelunkers, veterinarians and
recognized, but testing every 2 years;
staff, and animal-control and
Frequent exposure also might be booster vaccination if
wildlife workers in rabies-
unrecognized. Bite, non- antibody titer is below
enzootic areas. All persons
bite, or aerosol acceptable level.
who frequently handle bats.
exposure.
Veterinarians and terrestrial
animal-control workers in
areas where rabies is
Exposure nearly always
uncommon to rare. Veterinary Primary course. No
episodic with source
Infrequent students. Travelers visiting serologic testing or booster
recognized. Bite or non-
areas where rabies is enzootic vaccination.
bite exposure.
and immediate access to
appropriate medical care
including biologics is limited.

Exposure always U.S. population at large,
Rare
episodic with source including persons in rabies-
(population No vaccination necessary.
recognized. Bite or non- epizootic areas.
at large)
bite exposure.

Primary vaccination
Three 1.0-mL injections of HDCV or PCEC vaccine should be administered intramuscularly
(deltoid area) — one injection per day on days 0, 7, and 21 or 28. Vaccine preparations for
intradermal administration are no longer available in the United States.
Booster doses
Continuous risk
People who work with rabies virus in research laboratories or vaccine production facilities are at
the highest risk for unapparent exposures. Such persons should have a serum sample tested for
rabies antibody every six months. Intramuscular booster doses of vaccine should be administered
to maintain a serum titer corresponding to at least complete neutralization at a 1:5 serum dilution
by the RFFIT.
Frequent risk
This group includes other laboratory workers such as those performing rabies diagnostic testing,
spelunkers, veterinarians and staff, and animal-control and wildlife officers in areas where animal
rabies is enzootic. The frequent-risk category also includes persons who frequently handle bats,
regardless of location in the Unites States. Persons in the frequent risk group should have a serum
sample tested for rabies antibody every 2 years; if the titer is less than complete neutralization at a
1:5 serum dilution by the RFFIT, the person also should receive a single booster dose of vaccine.
Infrequent risk
Veterinarians, veterinary students, and terrestrial animal-control and wildlife officers working in
areas where rabies is uncommon to rare (infrequent exposure group) and at-risk international
travelers fall into this category and do not routine preexposure booster doses of vaccine after
completion of primary preexposure vaccination
All cases of suspected rabies exposure should be treated immediately to prevent the onset of
clinical symptoms and death. Post-exposure prophylaxis (PEP) consists of wound treatment,
the administration of rabies vaccines based on WHO recommendations, and if indicated, the
administration of rabies immunoglobulin (See table below).

Recommended post-exposure prophylaxis for rabies infection
Category of exposure to suspect rabid
animal Post-exposure measures

Category I – touching or feeding animals,
licks on intact skin (i.e. no exposure) None

Category II – nibbling of uncovered skin,
minor scratches or abrasions without Immediate vaccination and local treatment
bleeding of the wound

Immediate vaccination and administration
Category III – single or multiple
of rabies immunoglobulin; local treatment
transdermal bites or scratches, licks on
of the wound
broken skin; contamination of mucous
membrane with saliva from licks,
exposures to bats.

Rabies Post-exposure Vaccinations
For people who have never been vaccinated against rabies previously, post-exposure anti-rabies
vaccination should always include administration of both passive antibody and vaccine.
The combination of human rabies immune globulin (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 pr-eexposure 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 with your doctor or
state or local public health officials if you will not be able to have shot at the recommended
interval. Rabies prevention is a serious matter and changes should not be made in the schedule of
doses.
People cannot transmit rabies to other people unless they themselves are sick with rabies. The
prophylaxis you are receiving will protect you from developing rabies, and therefore you cannot
expose other people to rabies. You should continue to participate in your normal activities.
Rabies pos-texposure prophylaxis consists of a dose of human rabies immune globulin and rabies
vaccine given on the day of the exposure, and then a dose of vaccine given again on days 3, 7, and
14.
If a person has previously received post-exposure vaccinations or received pre-exposure
vaccinations, only two doses of vaccine (on the day of exposure and then 3 days later) are needed.
Human rabies immune globulin is not required. Your doctor and local health department will be
able to guide you through the process.
Human Rabies Vaccine

Biologic Product name/ Manufacturer Potency

Human diploid cell vaccine Imovax®/ Sanofi Pasteur > 2.5 international units (IU) of
(HDCV)*,†,‡ rabies antigen

Purified chick embryo cell vaccine RabAvert®/ Novartis Vaccines >2.5 IU of rabies antigen
(PCECV)*,†,‡ and Diagnostics

*Dose: Single dose vial of vaccine should be reconstituted with accompanying sterile diluent to
final volume of 1mL before administration.
†Administration Route: Intramuscular in the deltoid area for adults, in the deltoid area or the
anterolateral aspect of the thigh for children. DO NOT use the gluteal area for HDCV or PCECV.
‡Indications: Pre-exposure2 AND post-exposure prophylaxis.

Rabies Immunoglobulin

Biologic Product name/ Manufacturer Potency Dose

Human Imogam® Rabies-HT / Sanofi Pasteur 150 IU/mL 20 IU/kg
immunoglobulin*,†

Human KEDRAB™3 / Kedrion Biopharma and Kamada 150 IU/mL 20 IU/kg
immunoglobulin*,† Ltd

Human HyperRab™ S/D / Grifols3 150 IU/mL 20 IU/kg
immunoglobulin*,†

Human HyperRab®3,4 / Grifols3 300 20
immunoglobulin*,† IU/mL4 IU/kg4

*Administration Route: Local infiltration around wound, with remaining immunoglobulin
administered intramuscularly in an anatomical site distant from where vaccine was placed.
†Indications: Post-exposure prophylaxis with human rabies immunoglobulins is indicated
for ONLY those persons who 1) did not receive appropriate pre-exposure prophylaxis2 and 2)
have not previously received post-exposure prophylaxis for rabies in accordance with ACIP
recommendations.

Prevention
Rabies is a serious disease, but individuals and governments can and do act to control and prevent,
and, in some cases, wipe it out completely.
Strategies include:
• regular anti-rabies vaccinations for all pets and domestic animals
• bans or restrictions on the import of animals from some countries
• widespread vaccinations of humans in some areas
• educational information and awareness

Individual precautions
Individuals should follow some safety rules to reduce the chance of contracting rabies.

 Vaccinate pets: Find out how often you need to vaccinate your cat, dog, ferret, and other
domestic or farm animals, and keep up the vaccinations.

 Protect small pets: Some pets cannot be vaccinated, so they should be kept in a cage or
inside the house to prevent contact with wild predators.

 Keep pets confined: Pets should be safely confined when at home, and supervised when
outside.

 Report strays to the local authorities: Contact local animal control officials or police
departments if you see animals roaming

 Do not approach wild animals: Animals with rabies are likely to be less cautious than usual,
and they may be more likely to approach people.

 Keep bats out of the home: Seal your home to prevent bats from nesting. Call an expert to
remove any bats that are already present.
In 2015, a woman died from rabies after being bitten by a bat during the night. She did not realize
she had been bitten.
People are encouraged to seek medical help after an encounter with a wild animal, even if they do
not have bite marks or other outward signs of injury.
The World Health Organization (WHO) calls rabies a "100-percent vaccine-preventable disease."
They note that at least 70% of dogs in an area must be vaccinated to break the cycle of transmission.
In the U.S., vaccinations control rabies in domestic dogs. Nevertheless, between 30,000 and 60,000
people seek rabies postexposure prophylaxis every year, following contact with suspect animals.
Hundreds of thousands of animals undergo tests and observation.
Between 60 and 70 dogs and around 250 cats are reported rabid each year in the U.S. Most of these
have not been vaccinated, and they were exposed to the virus through wild animals, such as bats.

Sources:
(2018, September 19) Treatment, World Health Organization Retrieved from:
http://www.who.int/rabies/about/home_treatment/en

(2017, November 15) Rabies: Symptoms, causes, treatment, and prevention, Medical News Today
Retrieved from: https://www.medicalnewstoday.com/articles/181980.php

(2016, November 04) Rabies, Mayo Clinic, Retrieved from: https://www.mayoclinic.org/diseases-
conditions/rabies/diagnosis-treatment/drc-20351826

(2011, April 22) Rabies, Centers for Disease Control and Prevention Retrieved from:
https://www.cdc.gov/rabies/exposure/index.html