Rabies

Definition
Rabies is a disease humans may get from being bitten by an
animal infected with the rabies virus. Rabies has been recognized for over
4,000 years. Yet, despite great advances in diagnosing and preventing it,
today rabies is almost always deadly in humans who contract it and do not
receive treatment.

Rabies can be totally prevented. You must recognize the exposure and
promptly get appropriate medical care before you develop the symptoms
of rabies.

 Where rabies is found: Human rabies is quite rare in the United

States. Only 27 cases have been reported in people in the United
States since 1990. Yet in some areas of the world (for example,
Southeast Asia, Africa, and Latin America), human rabies is much more
common. The incidence of rabies in people parallels the incidence in
the animal kingdom. The great strides that have been made in
controlling the disease in animals in the United States and in other
developed countries is directly responsible for this decline in human
rabies. 

o Although rabies in humans is very rare in the United

States, between 16,000 and 39,000 people receive preventive
medical treatment each year after being exposed to a potentially
rabid animal. 

o Some regions of the country have more cases of rabies

than others do. 

o Rabies in wildlife accounts for greater than 85% of animal

rabies in the United States.
 Animals that carry rabies: Raccoons are the most common wild
animals infected with rabies in the United States. Skunks, foxes, bats,
and coyotes are the other most frequently affected. 

o Bats are the most common animals responsible for the

transmission of human rabies in the United States, accounting for
more than half of human cases since 1980, and 74% since 1990.
Rabid bats have been reported in all states except Hawaii. 

o Cats are the most common domestic animals with rabies in

the United States. Dogs are the most common domestic rabid
animals worldwide. 

o Almost any wild or domestic animal can potentially get

rabies, but it is very rare in small rodents (rats, squirrels, chipmunks)
and lagomorphs (rabbits and hares). Large rodents (beavers,
woodchucks/groundhogs) have been found to have rabies in some
areas of the United States. 

o Fish, reptiles, and birds are not known to carry the rabies
virus

Rabies Causes
 For a human to get rabies, 2 things must happen.
o First, you must have contact with a rabid animal.
o Second, the contact must allow for the transmission of
infected material, which will involve exposure to the saliva of the
infected animal usually through a bite or scratch.
 Contaminated tissue in the rabid animal includes saliva. Other
potentially infectious tissue is in the brain or nerve tissue. The virus is
transmitted only when the virus gets into bite wounds, open cuts in your
skin, or onto mucous membranes (for example, into your eyes or your
 mouth). The virus then spreads from the site of the exposure to your
brain and eventually spreads throughout your body's major organs.
 Ways the virus is transmitted
o Bites are the most common source of transmission.
o Scratches by infected animals are far less likely to
cause infection but are still considered a potential source of rabies
transmission.
o Bites or scratches are often not confirmed in cases of
human rabies traced to bats. Therefore, treatment might be
necessary after a close encounter with a bat.
o
o In the 20 cases (since 1990) of human rabies associated
with a bat, a definite history of a bat bite could be confirmed in only 1
case. It is unclear how the virus was transmitted in the other cases-
perhaps by an undetectable bite.
o Rabies has rarely been transmitted by other means.
Examples include inhaling a large amount of bat secretions in the air
of a cave by 2 cave explorers and inhaling the concentrated virus
in laboratory workers studying rabies.

Rabies Symptoms
 Signs and symptoms in animals 
o Animals infected with rabies may appear sick, crazed, or
vicious. This is the origin of the phrase "mad dog." However, animals
infected with rabies may also appear overly friendly, docile, or
confused. They may even appear completely normal. 

o Seeing a normally nocturnal wild animal during the day (for

example, a bat or a fox) or seeing a normally shy wild animal that
appears strange or even friendly should raise suspicion that the
animal may have rabies.
 Signs and symptoms in humans 
o The average incubation period (time from infection to time
of development of symptoms) in humans is 30-60 days, but it may
range from less than 10 days to several years. 

o Most people first develop symptoms of pain, tingling,

or itching shooting from the bite site (or site of virus entry). 

o Nonspecific complaints of fevers,

chills, fatigue, muscle aches, and irritability may accompany these
complaints. Early on, these complaints may seem like any virus,
except for the shooting sensations from the bite site. 

o Gradually, however, you will become extremely ill,

developing a variety of symptoms, including high fever, confusion,
agitation, and eventually seizures and coma. 

o Typically, people with rabies develop irregular contractions

and spasms of the breathing muscles when exposed to water (this is
termedhydrophobia). They may demonstrate the same response to a
puff of air directed at them (termed aerophobia). By this point, they
are obviously extremely ill. 

o Eventually, the various organs of the body are affected,

and the person dies despite support with medication and a
respirator.

 A rarer form of rabies, paralytic rabies, has been linked to vampire

bat bites outside of the United States. In this form, the person who was
bitten develops a paralysis, or inability to move the part of the body that
was bitten. This spreads gradually throughout the body, and the person
ultimately dies. Hydrophobia is less common in paralytic rabies than in
classic rabies.
 When to Seek Medical Care
If you think an exposure to a rabid animal has occurred, call your doctor
immediately.

 The doctor should discuss both the animal's risk for having rabies
and the risk of the exposure for transmission of the virus.

 The doctor also should know if you have previously

received vaccination against rabies, either because you're in a high-risk
profession (for example, a veterinarian or zoo worker) or you have
been exposed to a potentially rabid animal before. If you have been
vaccinated previously, it will change the treatment that will follow after a
new potential exposure.

 Because rabies is such a rare disease, the doctor may be

unfamiliar with the need for treatment or may not have the vaccine in
the office for prompt administration. The local public health department
is a good source of information in these cases, and a
hospital's emergency department is a good place to seek medical care.

Any serious animal bite should be cared for as soon as possible in a

hospital's emergency department.

 In addition to the potential for transmission of rabies, other medical

issues need to be checked: 

o Transmission of regular bacterial germs from the mouth of

the biting animal 

o Need for an injection to maintain protection, or immunity,

against tetanus (another type of infection that can be transmitted by
bites or to open wounds) 

o Issues of wound repair

 Even the most trivial bite can transmit rabies. Any bite or scratch
by a rabid animal warrants the administration of rabies shots. Whether
or not that animal is at risk for rabies depends somewhat on the region
of the country and on the species of the animal. Any exposure to a bat
where a bite cannot be ruled out is a significant exposure.

Diagnostic Examination and Laboratories

 Testing: No specific testing is needed because there is no way to
detect if the rabies virus has been passed to you. It is not necessary to
bring the animal itself to the emergency department because the
doctors do not have the ability to test animals for rabies. The local
health department will coordinate testing of the animal in question.

 Examination: Your vital signs will be taken (temperature, heart

rate, breathing rate, andblood pressure). You will be asked a series of
questions about the animal and the exposure. The doctor will also ask
questions about immunization you may have been given before against
rabies andtetanus.
o Certain medications used for the treatment of rheumatoid
arthritis and the prevention and treatment of malaria(for
example, chloroquine andmefloquine) can interact with the rabies
vaccine should it be given. Bring a medication list or the pill bottles of
all current medications you are taking to the emergency department.
o If there is a concern that you may actually have rabies, it is
important to tell the doctor about any history of jobs, hobbies, recent
international travel, and exposure to animals.
 Other illnesses: The diagnosis of rabies is complex and cannot be
determined in the emergency department. Rabies can look very much
like other serious illnesses, such as meningitis (infection of the fluid
surrounding the brain andspinal cord). If the doctor is concerned about
rabies or another form of central nervous system infection, you may be
admitted to the hospital. You would be given a number of tests: blood
and x-ray tests and a spinal tap to examine spinal fluid for evidence of
infection.

Rabies Treatment
Self-Care at Home

When bitten by an animal, you should always care for the wound
immediately by washing it out with soap, water, and some sort of
commercial antiseptic iodine solution, if available. This will help kill the
common bacterial germs that may be passed by the bite but also has
been shown to decrease the likelihood of transmission of the rabies virus,
should the animal be rabid.

 If the animal is a pet, get the owner's name, address, and phone
number, if possible. This information will aid the local public health
authorities as they monitor the animal.
 If the animal is a wild animal, or stray dog or cat, contact the local
animal control authorities (your local humane society or city or county
public health office) immediately. They will attempt to safely capture the
animal for examination. The victim or other bystanders should not
attempt to capture or subdue the animal. This might lead to further bites
or exposures.
 If the animal is a bat, and the exposure occurred in a building, the
doors and windows should be shut in the room containing the bat after
all other people are evacuated. If this cannot be done without risk of
repeat exposure to the bat, then the most important thing is to minimize
the chance of contact between that bat and other people. Once again,
call local animal control authorities, and they will capture the bat. 
 o Bat exposures are different from any other animal. There
does not necessarily have to be a detectable bat bite to constitute a
significant exposure.
o If a bat bite or direct contact cannot be ruled out, then there
may have been a significant exposure, such as in the following
circumstances:
 A sleeping person awakens to find a bat in the
room.
 An adult sees a bat in the room of a previously
unattended child, mentally disabled person, or intoxicated person.

Medications
There are 2 types of rabies vaccine injections. 

 Injection of the human rabies immune globulin (HRIG) for

immediate protection is based on exact weight. This is not a situation
where more is better. Therefore, you should not overestimate your
weight. If the exact weight is not known, you will be weighed at the
hospital. 

o Once the dose is determined, as much as possible is

injected into and around the bite site. If the entire volume does not fit
into the tissue in that area (for example, the tip of the finger), then
the remaining volume will be injected into some other site in your
body, such as the arm, leg, or buttocks. The doctor may use
numbing medicine to decrease the pain associated with injection of
HRIG into the tissues at the bite site. 

o If you have been previously immunized adequately against

rabies, then the HRIG is not needed. You would need only the
vaccine described next.

 Injection of the vaccine will begin during this initial visit to the
emergency department and will proceed on a schedule over the next
28 days, with a total of 5 small injections. 
o There are 3 different types of rabies vaccines licensed for
use in the United States (human diploid cell [HDCV], rabies vaccine
absorbed [RVA], and purified chick embryo cell culture vaccine
[PCEC]). If given properly and on schedule, any of these 3 types will
protect you against rabies. 

 The dose for each is 1 cc, or milliliter, delivered into

the muscle. This vaccine must be delivered into the deltoid,
or shoulder muscle, in adults or older children. The front, outside
aspect of the thigh muscle is acceptable in younger children. It
must never be injected into the buttocks. Injection into the proper
site ensures absorption. It must be administered in a site different
from the remainder of the immune globulin that is not injected into
the bite site. 

 If you have never been vaccinated against rabies,

then vaccine shots will be given on the day of the visit (day zero),
and again on days 3, 7, 14, and 28. If you have already been
adequately immunized against rabies, a series of 2 booster
vaccine injections will be given on day zero and again on day 3
only. This is sufficient to stimulate your body's immune system, or
memory, and provide protection against rabies.

Prevention
Prevention of rabies depends on decreasing the disease in the animal
kingdom. Avoid contact with wild animals and strays. Have your pets
vaccinated against rabies. Keep pets under control and away from wild
animals and strays.