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Rabies early symptoms in humans: Rabies – Symptoms and causes

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Rabies: Signs, Symptoms, and Complications

Despite being rare in the United States, rabies remains a frightening prospect due to the speed neurological symptoms can develop and progress. Early infection may be marked only by a mild fever and headache. Symptoms developing after the incubation period (30 to 90 days) will invariably be severe and include confusion, excessive salivation, seizures, paralysis, delirium, and coma. Once symptoms appear, death is, sadly, almost inevitable.

This type of virus, known the lyssavirus, moves through the network of nerve cells, causing progressive symptoms as it gradually infiltrates the brain and central nervous system. That’s why, unlike some infectious diseases, you cannot wait for signs of the illness to appear. You must seek treatment the moment you come you are bitten or scratched by an animal that has or is suspected to have rabies.

The symptoms of rabies can be characterized by the stages of infection, broadly described as the incubation period, the prodromal period, the acute neurologic period, and coma preceding death. 

© Verywell, 2018 

Incubation Period

The incubation period is the time between exposure to the virus and the first appearance of symptoms. The period can run anywhere 30 to 90 days on average but may be shorter or longer based on the host and viral factors.

Symptoms of rabies during the incubation period may include:

  • Fever
  • A headache
  • Tingling or burning sensation at the site of the exposure (known as paresthesia)

Prodromal Period

The prodromal period is described by the first appearance of symptoms. This is when the virus first enters the central nervous system and begins to cause damage.

The prodromal phase tends to run from two to 10 days on average and may cause such symptoms as:

  • Fatigue
  • A general feeling of unwellness (malaise)
  • Loss of appetite (anorexia)
  • A sore, swollen throat (pharyngitis)
  • Nausea
  • Vomiting
  • Diarrhea
  • Agitation
  • Insomnia
  • Anxiety and depression

Acute Neurologic Period

The acute neurologic period lasts anywhere from two to ten days and will almost invariably end in death. The types and characteristics of symptoms can vary, depending largely on how severe or mild the initial exposure was.

Furious rabies is the type most people with experience. As its name suggests, this form of rabies is characterized by violent physical and neurologic symptoms. Symptoms may come and go, and will often be interspersed with moments of calm and lucidity. Death will most often be caused by cardio-respiratory arrest.

Paralytic rabies affects up to 20 percent of people and will cause muscles to gradually weaken, starting from the site of the exposure and expanding outward. Paralysis and death will eventually ensue (usually by respiratory failure). Most paralytic cases are believed to be caused by a minor injury, such as a nip, that has gone unnoticed.

Atypical rabies is a type most often associated with bat bites. It may involve symptoms from both furious and paralytic forms of the disease. The variations in symptoms and severity can often make it hard to recognize a case as rabies.

Symptoms of rabies occurring during the acute neurologic period may include:

  • Hyperactivity
  • Excessive salivation
  • Hydrophobia (a distressing symptom characterized by an unquenchable thirst, an inability to swallow, and panic when presented with fluids to drink)
  • Priapism (persistent and painful erection of the penis)
  • Extreme sensitivity to light (photophobia)
  • Paranoia
  • Confusion and incoherence
  • Aggression (including thrashing and biting)
  • Hallucinations
  • Seizures
  • Partial paralysis
  • Delirium

These symptoms will soon to lead to a coma as the rabies infection causes massive brain inflammation. Without intensive supportive care, death will usually occur within hours or days.

When to See a Doctor

Once rabies symptoms begin to appear, the infection is almost always fatal. To this end, you need to seek care the moment you are bitten by a wild animal—or even a domestic one.

Start by washing the wound thoroughly with soap and warm water. While a doctor should be seen as a matter of urgency, the condition is not considered to be a medical emergency at this stage. It is simply important to see a physician, ideally on the same day, and to provide as much information as you can about the attack. Even if you’ve been previously vaccinated for rabies, you should still have your wound looked at.

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If the animal has been captured (or the suspected pet quarantined), tests can be performed to determine whether it has rabies. But, even then, treatment wouldn’t necessarily be delayed pending the results. This is because the only sure way to confirm rabies is to euthanize the animal and obtain two tissue samples from the brain. Clearly, with a domestic animal, this may be less of an option if the symptoms are vague, non-specific, or nonexistent.

Whatever the circumstance, if there is a genuine suspicion of exposure, treatment should be started without delay.

On the other hand, if you have been scratched by a suspicious animal or have come into contact with body fluids from a sick or dead animal, you should still see a doctor if only for your peace of mind. This is especially true if you live in an area where animal rabies has been identified.

While rabies can only be transmitted through saliva or brain/nerve tissues, any potential exposure, however small, should be taken seriously. If anything, it may provide you the impetus to get the rabies vaccine and reduce your future risk.

Severe Abdominal Pain as the First Manifestation of Rabies

Jundishapur J Microbiol. 2014 Aug; 7(8): e11671.

Jamshid Ayatollahi

1Infectious and Tropical Diseases Research Center, Shahid Sadoughi University of Medical Sciences, Yazd, IR Iran

Mohammad Reza Sharifi

1Infectious and Tropical Diseases Research Center, Shahid Sadoughi University of Medical Sciences, Yazd, IR Iran

Seyed Hossein Shahcheraghi

1Infectious and Tropical Diseases Research Center, Shahid Sadoughi University of Medical Sciences, Yazd, IR Iran

1Infectious and Tropical Diseases Research Center, Shahid Sadoughi University of Medical Sciences, Yazd, IR Iran

*Corresponding author: Seyed Hossein Shahcheraghi, Infectious and Tropical Diseases Research Center, Shahid Sadoughi University of Medical Sciences, Yazd, IR Iran. Tel: +98-9132531389, Fax:+98-3518224100, E-mail: [email protected]

Received 2013 Apr 20; Revised 2013 Jun 6; Accepted 2013 Jul 7.

Copyright © 2014, Ahvaz Jundishapur University of Medical Sciences; Published by Kowsar Corp.

This is an open-access article distributed under the terms of the Creative Commons Attribution License, which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited.

This article has been cited by other articles in PMC.

Abstract

Introduction:

Rabies is an acute fatal viral disease that is generally transmitted from animals to humans following wild and domestic animal bites. The rabies virus enters the body from the area where the individual is bitten, and then the virus moves towards the brain and involves the nerves.

Case Presentation:

During the years 2001-2011, there have been 73 reported rabies cases. About 50,000 reported human deaths are annually due to rabies. The actual number of human deaths due to rabies in Asia especially India, Pakistan and Bangladesh are more than these numbers, since there is no advanced surveillance system for disease control to determine the actual number of infected and fatal human cases. According to the World Health Organization (WHO) reports, more than 10 million people who are bitten by animals are annually treated by prophylactic treatment regimens for rabies, worldwide.

Conclusions:

This paper reports on a case of human rabies with the first disease manifestation (severe abdominal pain). The patient reported extensive biting on his left leg by a dog. He had a slight fever of 38.1°C. It has been recommended that a careful history should be taken from patients for diagnosis of rabies disease. A complete history should be taken from patients for diagnosis of disease, because rabies could be wrong with various diseases with atypical symptoms. because various diseases with atypical symptoms or long incubation periods can visit.

Keywords: Rabies, Humans, Iran

1. Introduction

Zoonosis or common diseases between humans and animals can be transmitted from both domesticated and wild animals to individuals. The transmission of common diseases is related to many factors including: an available agent, the amount of exposure, mechanisms related to transferring and host sensitivity. These factors have principal roles in the epidemiology of fatal viral diseases in humans. The rabies virus (genus Lyssavirus, family Rhabdoviridae) is present in the saliva of infected mammals and is most commonly transmitted via a biting incident (1-4). The present study was performed to evaluate a case of human rabies with severe abdominal pain from Iran.

Rabies is an encephalitis agent in mammals, which causes a fatal viral zoonotic disease. It has been suggested that there are approximately 55000 victims per year of whom 30-50% are below 15 years of age. Nevertheless rabies is commonly diagnosed after the onset of neurological complaints and controlled by wound care, administration of rabies immune globulin (RIG) and vaccine, which are almost 100% successful in inhibiting human rabies following disclosure. The rabies virus is present in the saliva of unhealthy mammals and is normally transferred via a biting incident (5).

Non-bite sources of rabies transmission are including: unhealthy mucous membranes with other possibly infectious components (such as tracheal, nasal secretions and brain tissues, cerebrospinal fluid and tears), scratches, corneal transplantation or disclosure of membranes to aerosols. Unhealthy mucous membranes with other possibly infectious components (such as tracheal, nasal secretions and brain tissues, cerebrospinal fluid and tears), scratches, corneal transplantation or disclosure of membranes to aerosols have been reported as non-bite sources of rabies transmission (6).

The first signs of rabies disease in humans include: a common feeling of illness, pain at the bite site, nausea, vomiting, depression and headache. This virus begins to reproduce and multiplies in the brain or spinal cord; neurological signs appear, including anxiety, stun, hallucinations, production of abundant saliva, high-level of agitation, insomnia, paralysis of lower legs, fidgetiness, voice box spasms and problems swallowing due to a painful throat. In Iran, the Ministry of Health and Medical Education has established the WHO Collaborating Center for Reference and Research on Rabies, as the only testing laboratory in Iran, to follow rabies cases. In Asia, most mortality cases of human rabies were reported from underdeveloped countries such as India, Pakistan and Bangladesh which have large populations and no specific strategies for controlling rabies (7).

2. Case Presentation

On the 2nd of March 2013, a 26-year-old man resident of Rafsanjan (Kerman province, south-eastern, Iran) was admitted to Shahid Sadoughi Hospital of Yazd, Iran with symptoms of severe abdominal pain. The patient reported extensive biting on his left leg by a dog showing marked aggressiveness, on the 22nd of September 2012, eight months before symptomatic disease onset. The dog had bitten four people who had received rabies immune globulin (RIG) and vaccine while our study patient had not received this treatment. The dog died three days after the biting incident. On admission, our study patient stayed at the surgery unit for one day because of his severe abdominal pain followed by two days at the neurology unit because of behavioral changes. After consultation, he was transferred to the infectious diseases ward.

On the first day of hospital admission, the patient had malaise, diplopia, headache, depression, vomiting and severe abdominal pain in the hypogastria. He also had a five-year history of consumption of narcotic substances (opium) but had quit use since six months ago. Complete blood count revealed a normal count of leucocytes (9200/μL). Blood had a slight increase of glucose (111 mg/dL). Wright and Widal tests were negative. Cerebrospinal fluid (CSF) was analyzed and showed 100% lymphocytes, two white blood cells (WBC), 159 red blood cells (RBC) and protein 40 mg/dL.

On the 3rd and 4th of March 2013, the patient had a slight fever (38.1°C), malaise, headache, abdominal pain and abnormal behavior. Finally, the patient died on the 4th of March 2013. Cerebrospinal fluid sample was submitted to the Pasteur Institute of Tehran, Iran. The polymerase chain reaction (PCR) test was performed. This test was positive and proved rabies disease.

3. Discussion

Our patient was admitted with symptoms of severe abdominal pain, as the first and most severe manifestation. Therefore, it is necessary to obtain information from patients for diagnosis of disease, because rabies could be wrong with various diseases with atypical symptoms. because various diseases with atypical symptoms or long incubation periods can visit.

One of the most important diseases in developing countries, especially in poor rural communities, is rabies viral disease. Despite the production of several secure and effective human vaccines against the disease virus, virus victims continue to grow in many countries. The bite of a rabid animal is the main agent of virus transmission. Also, transmission can be via the saliva that is the major source of virus spread (5). Rabies disease is endemic in the wild life of our country, therefore domestic animals are frequently infected while, enhancing cases of animal bite and scattering of disease virus in most provinces of Iran, declare a need to pay more attention to controlling this disease (8).

In a study in Kerman province of Iran, 10 individuals were infected with rabies disease, two of them being females and eight males, and half of them were attacked by dogs. The incubation period was 54 days (9). A fatal case of human rabies was an Indian man in his forties, who had been a resident of Italy for 10 years. He was admitted with fever (40.4°C), malaise, headache, diplopia, unilateral ptosis (left eye), whole body paraesthesia, ataxia, myalgia and flaccid paresis of the arms, especially of the left arm. His behavior appeared abnormal, with signs of anxiety and agitation (the incubation period was one month). Finally, the patient died (10).

Another study, reported a 27-year-old male with hypochondriasis. This patient had contracted rabies. He refused to respond correctly to several questions in the hospitalization time. The patient had severe rabidity and bitted himself and attacked individuals by biting them. He was been bitten by a dog (the incubation period was eight years). He had a common feeling of sickness, depression, and pain at the bite site, nausea and headache. Finally, the patient died (7).

The difference of our patient with other reported cases is the length of the incubation period (eight months). The first manifestation of the disease is severe abdominal pain.

Acknowledgments

We would like to thank the staff of the Infectious and Tropical Diseases Research Center of Yazd Shahid Sadoughi University of Medical Sciences and the Pasteur Institute of Iran for their cooperation with this study.

Footnotes

Authors’ Contributions:Dr. Jamshid Ayatollahi developed the original idea and the protocol. Dr. Mohammad Reza Sharifi contributed to the development. Seyed Hossein Shahcheraghi prepared the manuscript.

Funding/Support:This study was financially supported by the Infectious and Tropical Diseases Research Center, Shahid Sadoughi University of Medical Sciences, Yazd, IR Iran.

References

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The myth of the bite

Can J Infect Dis. 2002 Mar-Apr; 13(2): 121–125.

, MD,1, MD FRCPC,1, MD,2, MD,2, MD FRCPC,4 and , MD FRCPC3

Olivier Despond

1Pediatric Intensive Care Unit, Department of Pediatrics

Marisa Tucci

1Pediatric Intensive Care Unit, Department of Pediatrics

Hélène Decaluwe

2Department of Pediatrics

Marie-Claude Grégoire

2Department of Pediatrics

Jeanne S Teitelbaum

4Department of Medicine, Maisonneuve-Rosemont Hospital, Université de Montréal, Montréal, Québec

Nathalie Turgeon

3Department of Microbiology and Immunology,
Sainte-Justine Hospital, Université de Montréal, Montréal, Québec

1Pediatric Intensive Care Unit, Department of Pediatrics

2Department of Pediatrics

3Department of Microbiology and Immunology,
Sainte-Justine Hospital, Université de Montréal, Montréal, Québec

4Department of Medicine, Maisonneuve-Rosemont Hospital, Université de Montréal, Montréal, Québec

Correspondence and reprints: Dr Marisa Tucci, Sainte-Justine Hospital, 3175 Côte Ste-Catherine, Montréal, Québec h4T 1C5. Telephone 514-345-4931 ext 3261, fax 514-345-4822, e-mail [email protected]

Received 2001 Mar 30; Accepted 2001 Aug 31.

Copyright © 2002, Pulsus Group Inc. All rights reservedThis article has been cited by other articles in PMC.

Abstract

A nine-year-old boy died from rabies encephalitis caused by a rabies virus variant associated with insectivorous bats. The patient was most likely infected in the Laurentian Mountains of western Quebec, but neither the patient nor his parents remembered any direct contact with an animal. The diagnosis was made seven days after the start of symptoms. After examining the most recent cases of rabies in North America, it is obvious that rabies following bat exposure can occur without history of a documented bite. The present case report emphasizes that the general public and medical care providers need better information about the risks associated with exposure to bats.

Key Words: Bat, Children, Encephalitis, Prophylaxis, Rabies

Rabies is a zoonosis responsible for more than 50,000 human deaths every year worldwide, as reported by the World Health Organization. In North America and Europe, human rabies has become a very rare disease, because of the systematic vaccination of domestic animals, massive vaccination campaigns of wild animals, efficacy of rabies postexposure prophylaxis (RPEP) and education programs (1,2). While knowledge about the risk of rabies associated with a bite from a terrestrial animal seems relatively adequate among the general public and medical care providers, a lack of information may exist regarding the risk of human rabies following contact with a bat. Between 1980 and 1996, 32 cases of human rabies were diagnosed in the United States, 17 of which occurred after a contact with an indigenous bat (of which only two patients had a definite bite), 14 cases after a dog bite and one after a skunk bite (3). In Canada, three of the four cases of human rabies that have occurred since 1970 followed exposure to bats, the last case dating to 1985 (4). Since September 2000, five cases of human rabies have been reported in the United States (5). One was consecutive to a dog bite contracted in Africa and four have been attributed to bats; in the latter cases, a definite history of a bite was noted in only one case. In 1996, the National Association of State Public Health Veterinarians of the United States stated that “since rabies is endemic in bats, bats should be excluded from houses and surrounding structures to prevent direct association with humans” (6). Possible measures to reduce the bat population to a critical threshold below which the virus might be unable to propagate or to induce immunity in the vector via vaccination seem physically, economically and ecologically impractical (7). The case that we report emphasizes that the bite or the scratch of a rabid bat can go unnoticed and may lead to the development of human rabies.

CASE PRESENTATION

In late September 2000, a nine-year-old boy with no significant past medical history complained of pain over the upper third of his left arm, associated with a fever of 38. 2°C. His pain was associated with numbness and progressed over the subsequent three days, radiating to the left wrist, left shoulder and lateral aspect of his neck. The pain was worse on palpation, with active movement and at night, causing insomnia. Four days after the onset of symptoms, the patient developed uncontrolled tremors of his left arm, increasing with voluntary movements and stress. The next day, the child presented for medical assessment and was hospitalized.

While his pain remained localized over the left arm, the tremor progressed to the right arm in the next 12 h. He also started complaining of a sore throat and difficulty swallowing cold liquids. The subsequent night was complicated by an intense pruritus over the scalp, neck and torso, with minimal response to diphenhydramine. On day 1 after admission, still conscious and oriented, he exhibited bilateral arm-beating tremors with choreiform and myoclonic movements of the fingers, toes and calves. Deep tendon reflexes were symmetrical, and strength and sensory examinations were normal. At that time, an electroencephalogram revealed a diffuse slowing of cerebral activity with rapid dysrythmia but no epileptic activity. An electromyogram of the left deltoid muscle and computed tomography of the head were normal. Later that day, the patient developed hydrophobia and aerophobia, and he became dysarthric. An evanescent macular rash was noted over the posterior aspect of the neck and back, associated with intense pruritis. He became agitated and experienced transient visual hallucinations. He had significant difficulty drinking but was still able to swallow his saliva.

The following day, the patient developed severe tremor and myoclonus of the face and all extremities, priapism, drooling, pharyngeal spasm, and a feeling of suffocation. He was intubated, heavily sedated and transferred to a tertiary care facility with a presumptive diagnosis of rabies.

Procedures to confirm diagnosis were undertaken, and human rabies immune globulin, rabies vaccine and acyclovir were administered immediately. During the following 24 h, extreme agitation and constant tremors required aggressive analgesia and sedation. On day 3, high fever, intense keratoconjunctivitis and swollen hyperemic lips were noted; these signs remained present for the next six days. A nonpurpuric maculopapular rash appeared over the face, neck and upper torso, and was confirmed by skin biopsy to be erythema multiforme. A possible right coronary aneurysm was identified by echocardiography, and the patient received intravenous immunoglobulin infusion for a Kawasaki-like syndrome. Over the ensuing two days, his neurological status progressively deteriorated. On day 5, he developed decerebrate posturing as well as a marked pharyngolaryngeal spasm. The following day, his pupils became dilated and unequal, and he presented transient hemodynamic instability. On day 7, his pupils became fixed and dilated, priapism disappeared and gasping movements were noted. Sedation was gradually decreased as the patient lost bulbar reflexes and progressed to a profound flaccid coma. Evoked potentials revealed abnormal conduction in the left suprabulbar tract. On day 9, 14 days after the onset of his initial symptoms, the patient presented a clinical picture compatible with brain death, was extubated and died.

A nuchal skin biopsy, cerebrospinal fluid (CSF), saliva and tears were sent to the Animal Disease Research Institute in Nepean, Ontario. The skin biopsy was positive for rabies virus antigen by direct fluorescent antibody test. All samples, except CSF, were positive for rabies virus by reverse-transcriptase polymerase chain reaction (RT-PCR) assay. Molecular analysis of rabies virus isolated from saliva revealed infection by a variant associated with silver-haired and eastern pipistrelle bats. Rabies virus grew from the saliva but not from the other samples. Immunofluorescence testing did not reveal rabies antigen on corneal impression smears, and rabies serology, sent to the Central Public Health Laboratory in Etobicoke, Ontario, was negative. Cerebral magnetic resonance imaging revealed no abnormality. White blood cell count on admission was 6.7×109/L with a sedimentation rate of 4 mm/h; CSF white blood cell count was 5×106/L, CSF protein level was 0.56 g/L and CSF glucose concentration was 4.5 mmol/L.

The principal findings on autopsy revealed subacute encephalomyelitis with numerous Negri bodies found principally in the hippocampus, thalamus and brain stem; subacute, multifocal inflammation of the dorsal root ganglia of the spinal cord and of the autonomous ganglionic ramifications related to the myocardium, epicardium, esophagus, gut, adrenal gland and retroperitoneum; and subacute myocarditis without coronary aneurysm.

History revealed no travel outside the province of Quebec. The family had spent five days at a cottage in a wildlife sanctuary in the Laurentian Mountains of western Quebec four weeks before the onset of symptoms of the patient. On the evening of their arrival, while the patient and his younger brother were asleep in their bedroom, the parents noticed a bat flying in the kitchen and removed it promptly. That same night, a bat standing still in the bathroom scared the younger brother. The bat had difficulty flying and was easily grasped by the father and thrown out. Subsequent recollections obtained from the parents after the confirmation of the diagnosis revealed that three days after this event, the patient had showed his mother a small erythematous lesion on his left upper arm with a linear aspect at its centre. No further action was undertaken because the origin of the lesion was unknown at the time.

RPEP was given to the family, 12 close playmates and 44 health care workers with possible percutaneous or mucous exposure to the patient’s saliva before confirmation of the diagnosis.

DISCUSSION

The clinical course of human rabies is classically divided into four stages: incubation period; prodrome; acute neurological phase; and coma. The length of the incubation period presumably depends on the location of the bite, the amount of virus inoculated, and the age and immune status of the patient. The virus is believed to multiply in muscle fibres at the site of the wound, a process that is not painful and does not seem to delay wound healing (8). The virus then seems to bind to nicotinic acetylcholine receptors at the neuromuscular junction, acting like a neurotoxin (9). Before entering into the nerve endings adjacent to the site of viral multiplication, the virus is highly sensitive to the active or passive immune response of the host. If not destroyed at the site of infection, the neurotropic virus migrates centrally via peripheral unmyelinated nerves at a rate estimated between 10 and 400 mm/day (10). Once in nervous tissue, the virus is protected from the immune system, making immunization inefficient. The incubation period usually lasts between 20 and 90 days, but intervals as short as four days or as long as 19 years have been reported (7).

In the prodromal period, the patient develops the early symptoms of rabies. Pruritus, pain and paresthesia at the site of inoculation or involving the whole limb are classical symptoms that occur in 50% to 80% of cases as the virus spreads toward the central nervous system by retrograde axonal transport. Nonspecific symptoms such as fever, chills, fatigue, malaise and insomnia may be present. At this stage, it may remain difficult to diagnose rabies and it is not unusual for patients to be treated with cortisone, antibiotics, acyclovir or quinine. The prodrome usually lasts for two to 10 days.

The acute neurological phase occurs as the virus reaches the brain stem, diencephalon and limbic system, and then moves centrifugally from the central nervous system, infecting those tissues and organs that are most densely innervated.

Two clinical forms of rabies have been described (11). In 80% of cases, the encephalitic or furious form develops with classical symptoms such as hydrophobia, aerophobia, pharyngeal spasms, hypersalivation and autonomic instability. Periods of visual hallucinations are frequent, but generally awareness remains present. Other clinical signs, such as muscle spasms, rigidity, opisthotonos, anisocoria, seizure and priapism, most of which occurred in our patient, are described in the literature. In 20% of the cases, a paralytic form of rabies develops, resembling a Guillain-Barré syndrome, which makes the diagnosis of rabies more difficult. In all cases, neurological status progressively deteriorates, aggressive supportive care is necessary to counteract hemodynamic instability and death almost always ensues.

Rabies virus antibody does not appear until late in the clinical course, and viral cultures require much time and rarely allow for early diagnosis; therefore, the most useful diagnostic tests are for viral antigen or nucleic acid. However, intravitam diagnosis is often difficult to make and negative results early in the disease should not rule out the diagnosis of rabies (12). Fluorescent antibody test in a skin biopsy from the nape of the neck just above the hairline, which is a densely innervated area, is considered to be one of the best diagnostic tools for early detection. This assay is easily feasible, has a high sensitivity up to 86% and requires only a few hours to provide a result. Moreover, this method is very specific (13). Rabies virus antigen can be less reliably detected in corneal impression smears, yielding positive results in only 14% to 41% of cases. Furthermore, it can cause significant ocular complications and should be performed by an ophthalmologist (14,15). While RT-PCR assay using saliva has been shown to have reasonable sensitivity (56% to 100%) and can permit rapid identification of the virus in the early phase of the disease, RT-PCR using CSF has a lower sensitivity (22%) (16). More information about laboratory testing is provided by Elmgren and al (17), found in the present issue of The Canadian Journal of Infectious Diseases.

RPEP has been proved very efficient in preventing the disease. However, the prognosis of patients who develop neurological symptoms is grim. Survival has occurred in only four well-documented cases, where all patients had received some form of prophylaxis, albeit inadequate, before the onset of symptoms (18-21). Therapy with interferon-alpha, ribavirin and intrathecal rabies immune globulin has been attempted, and has not proved efficacious (8,22-24). Our patient was given rabies immune globulin and rabies vaccine on the day that the diagnosis was suspected; an attempt at RPEP was considered worthwhile because the rarity of adverse effects associated with this treatment far outweighed the very poor prognosis associated with the disease.

A few hours after RPEP administration, our patient developed a high fever, a bilateral nonexudative conjunctival hyperemia, swollen and fissured lips, and a polymorphous exanthem; moreover, a right coronary aneurysm was suspected on echocardiography. These clinical signs were considered suggestive of atypical Kawasaki disease (25), and consecutively, nonspecific immune globulins were administered. A biopsy confirmed that the skin lesions were compatible with erythema multiforme, but no coronary aneurysm was found at autopsy. Although no diagnostic certainty was possible in our patient, several potential explanations for the rash were considered. While it was deemed possible that such a reaction could be drug-associated, our patient received neither antibiotics nor anticonvulsants, which might be associated with erythema multiforme and certain clinical features of Kawasaki disease. Furthermore, acyclovir, which our patient did receive, has not been reported to cause such skin lesions (26,27). Secondly, infectious etiologies were considered. Numerous viral infections including herpes simplex and Epstein-Barr virus are known triggers of erythema multiforme (28,29). In addition, adenovirus, enterovirus and measles infections are known causes of Kawasaki-like syndrome (30), and streptococcal and staphylococcal toxin-mediated illness can induce similar skin reactions (31). In our patient, viral and bacterial cultures were positive only for rabies virus, and we could find no case report associating rabies virus with erythema multiforme or Kawasaki-like disease. Finally, it remains possible that these lesions were secondary to a systemic reaction to RPEP.

The most dramatic aspect of this case is the manner in which virus transmission occurred. This patient clearly had no recollection of a bat bite or scratch, and the parents never realized that a significant contact might have happened. Such a lack of suspicion is not uncommon. Among the 24 cases of human rabies transmitted by bats in the United States since 1990, a definite history of a bite was established in only two cases (8.3%) (3,5). The virus strains from most patients without a history of a bite were similar to the virus typically isolated from the silver-haired bat and rarely found in other bat species (32). The silver-haired bat is an uncommon species, representing less than 1% of the bat population, and is found throughout North America. In New York State, 8% of captured silver-haired bats were shown to be rabid, while less than 1% of the entire bat population seems to be infected with rabies virus (33). It is hypothesized that the silver-haired bat variant of rabies virus might have unique biological properties that enhance its transmissibility to humans (34). Such a virus might have a higher infectiousness due to a more effective replication in the dermis at lower temperature. Although human contamination through airborne droplets of bat secretions can rarely be a mode of transmission (35), most rabid animals transmit the virus via a break in the skin following a bite or a scratch (36). The teeth from certain bat species are so small and sharp that scrutinizing the wound with an otoscope (6x magnification) may be necessary to visualize the pinpoints of a bite (37). This might explain why, in most cases of human rabies related to a contact with a bat, no trace of a bite could be found when patients were examined several days later. Moreover, scratches are a frequent finding in children, particularly during the summer months, and generally do not raise any suspicion.

RPEP prevents the development of rabies efficaciously if given correctly and early after exposure (38). Indeed, if given correctly within five days after exposure, protection against the development of the disease is close to 100% (39). Although in 1999, the Advisory Committee on Immunization Practice published guidelines for proper administration of RPEP (40), its administration is often inappropriate due to insufficient physician education, misinformation within the general public and poor coordination with public health officials (41). Practically, RPEP begins with immediate and thorough washing of all bite wounds and scratches with soap and water to reduce the viral load at the site of inoculation. Then, RPEP involves the administration of both rabies immune globulin at the site of inoculation and a vaccination schedule that must be respected (). Some cases of failure associated with immune globulin administration distant from the wound emphasize why rabies immune globulin should be thoroughly infiltrated into the wound and the area surrounding it (42).

TABLE 1

Rabies postexposure prophylaxis

• Immediate and thorough washing of the wound with soap and water, and if possible, with a povidone-iodine solution.
• Passive immunization with rabies immune globulin 20 U/kg infiltrated in the area around and into the wound, as soon as possible.
• Active immunization with rabies vaccine injected intramuscularly on day 0, 3, 7, 14 and 28, in the deltoid area for adults or the anterolateral thigh for infants and young children, commencing as soon as possible after initial contact or bite

Contact with a bat must be considered significant if a bite, a scratch or a mucous membrane exposure has clearly occurred or cannot be reliably excluded, for example, if a bat was found in the room of a sleeping person, a previously unattended child, a mentally disabled person or an intoxicated person (43). If the bat is caught, it should be taken to a veterinarian, euthanized and tested for rabies as soon as possible. Unless the animal can be proven negative for rabies within 48 h after contact, RPEP should be immediately initiated (44). In most cases, however, the animal is unavailable; it then has to be considered rabid and RPEP should be administered. Despite recent criticism (45), the dramatic circumstances surrounding our patient’s history, as well as increasingly frequent reports of human rabies contracted in North America, support the current Canadian guidelines which state that RPEP is appropriate in cases where a significant contact with a bat cannot be excluded (46). The notion that a bite or an overt break in the skin needs to be seen or felt for rabies to be transmitted by a bat is a myth in many cases.

References

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Rabies : OSH Answers

Workers who have contact with animals must know how to deal with rabid animals and how to protect themselves from the rabies virus.

With the development of an oral vaccine for animals, vaccinating of local wildlife has become a common way to manage outbreaks.  

Dealing with rabid animals

Do not approach or kill an animal suspected of having rabies except to defend yourself, other people, or other animals. If an animal must be killed, try to avoid damaging its head. An undamaged brain is important for a quick laboratory diagnosis. If an animal suspected of having rabies is responsive or manageable, keep it alive and away from other animals or people. Do not touch it with bare hands. If an animal is unmanageable and dangerous and cannot be restrained or killed, observe its movements and seek help from qualified experts as soon as possible. If you must handle the animal or carcass, wear protective gloves to prevent infectious material from having contact with cuts or rashes on the skin. Also wear protective masks and goggles to protect against infectious aerosols. When there is a need for personal protective equipment (PPE), then there should be a PPE program in place where you work.

Responsibility for the management of rabies is shared by the public, the veterinary profession and all levels of government. Canadian federal regulations requires all pets, livestock or wild animals that may be rabid, or had contact with a potentially rabid animal, to be reported to a veterinarian, veterinary clinic, local medical health officer or public health authority immediately. These professionals or agencies will in turn report the incident to the Canadian Food Inspection Agency (CFIA).

Protection for workers who have had contact with the rabies virus

Workers who have come into contact with saliva, body fluids, or tissue of animals suspected of having rabies must take the following steps without delay.

Immediately clean and flush their skin (even if there is no obvious bite or scratch) with water for several minutes. Cleaning will help wash out the virus. If available, use soap or detergent to help kill the virus. Washing the area or wound is probably the most effective procedure in the prevention of rabies. While cleaning is being done, shield the eyes, nose, and mouth from spray. After cleaning, follow by 70% ethanol or an iodine containing solution when available.

Remove any clothing that may be contaminated, place it in a plastic bag properly labelled and wash it promptly and separately from other clothing. Get medical advice as soon as possible.

Contact the police, your local health unit and district veterinarian or local office of the Canadian Food Inspection Agency. If possible, provide the following information:

  • the name and address of all persons attacked or exposed to the animal’s saliva, body fluids or tissues
  • the time and place of the incident
  • any other information to help find and identify the offending animal

Laboratory precautions for rabies

Biosafety containment level 3 is recommended when working with the rabies virus (includes full coverage protective clothing, front gowns with tight fitting wrists, gloves, respiratory protection, and eye protection (if risk of splashes)).   Additional precautions may be necessary. Please see the Rabies Virus – Pathogen Safety Data Sheet (2011) from the Public Health Agency of Canada for more information. 

About Rabies- Minnesota Dept. of Health

On this page:
Signs and symptoms
Cause (transmission)
Rabid animals
Diagnosis
Treatment
Prevention
Fact Sheet

Signs and symptoms

The rabies virus infects the central nervous system, ultimately causing disease in the brain and death.

  • The first symptoms of rabies may be very similar to other illnesses. These symptoms may last for days.
    • fever
    • headache
    • and general weakness or discomfort.
  • As the disease progresses, more specific symptoms appear including: insomnia, anxiety, confusion, slight or partial paralysis, excitation, hallucinations, agitation, hypersalivation (increase in saliva), difficulty swallowing, and hydrophobia (fear of water), Death usually occurs within days of the onset of these symptoms.
  • With rabies, the incubation period may be a few days to several weeks or longer. That means there is typically a period of time between getting bitten and experiencing symptoms of rabies.

Cause (transmission)

  • The rabies virus cannot penetrate intact skin.

Rabid animals

  • In Minnesota, rabies is found mainly in skunks and bats.
    • Pets generally develop the disease following a bite from a rabid skunk.
    • People are generally exposed to rabies by bats, or unvaccinated pets and livestock.
    • Almost three quarters of human rabies cases in the U.S. between 1990 and 2001 came from contact with bats.
  • Bites from wild carnivores and large rodents such as muskrats, groundhogs, and beaver are also of concern.
  • Animals that are not a rabies risk in Minnesota include mice, hamsters, guinea pigs, gerbils, squirrels, chipmunks, rats, voles, and rabbits.
    • Animals of Concern for Rabies

      Species of concern for rabies in Minnesota: Domestic animals, wild animals, captive wild or hybrid animals; and species are not a rabies concern in Minnesota.
  • Because of widespread vaccination programs in the United States, transmission from dogs and cats to people is very rare.

    Outside the United States, exposure to rabid dogs is the most common cause of transmission to humans.
  • For questions regarding animals that have been bitten by a suspect rabid animal in which there is no human exposure, please contact the Board of Animal Health (BAH) at 651-201-6808.

Diagnosis

  • Rapid and accurate laboratory diagnosis of rabies in humans and other animals is essential for timely administration of postexposure prophylaxis. 
  • The only test for rabies in animals that may be used to guide human rabies risk analysis is the direct fluorescent antibody (DFA) test.
    • There is no live animal test for rabies.
    • The animal’s brain, specifically sections of the medulla, cerebellum, and hippocampus are required to perform the test.
    • The brain must be relatively fresh and in good condition, as the test cannot be done reliably if the different regions of the brain are not discernable.
    • Rabies Testing

      Guidelines for submitting suspect animals for rabies testing, laboratory testing, result reporting, result follow-up, rabies testing in humans.

  • Testing for diagnosis of rabies in humans is performed at the Centers for Disease Control and Prevention.
    CDC: Diagnosis in Animals and Humans

Treatment

  • Once a person begins to exhibit signs of the disease, survival is rare.
  • To date less than 10 documented cases of human survival from clinical rabies have been reported and only two have not had a history of pre- or postexposure prophylaxis.

Prevention

  • Vaccinate your pets.

    Dogs, cats, and ferrets can be infected by rabies.
  • Never approach any stray or wild animals.

Fact Sheet

Minnesota’s Rabies Facts

Fact sheet with frequently asked questions about rabies.

Rabies Questions and Answers Page


Questions and
Answers about Rabies

What is rabies?

Rabies is a viral
infection that affects the nervous system of mammals. It invariably causes
swelling of the brain and death after a relatively short illness. 

How is rabies
transmitted?

The rabies virus is
found in the nervous tissue of infected mammals. As the virus works its way
to the brain, it begins to be secreted in the saliva of the animal. People
and mammals get rabies when infectious saliva is introduced into the body,
usually through a bite from an infected animal. Rabies transmissions from
other types of exposures are extremely rare. These types of exposures include
saliva or nervous tissue entering an open wound or saliva or nervous tissue
coming into contact with a mucous membrane such as the eyes, nose or mouth.

What are the symptoms of
rabies in people?

After an average of 30 to
50 days (as short as 14 days or longer than a year) from exposure to a rabid
animal, a person develops an illness that may include fever, sore throat,
stiff muscles, headache, tiredness, restlessness, nausea, and itching or
tingling at the site of the bite. As the disease progresses, a person may
become agitated, with periods of calm. Fear of water caused by severe throat
spasms when trying to drink may occur. Paralysis then starts in the legs and
moves towards the head. Most people die from cardiac arrest or respiratory
failure within a short period after onset of illness.

What are symptoms of
rabies in animals?

The animal may have a
change in personality or behavior. For example, wild animals may lose their
fear of humans or pets may become aggressive or withdraw. Often the animal
does not eat, may fear water, and have an unsteady gait. Paralysis may start
in the rear quarters and progress to the front of the body.

What should I do if I am
bitten by an animal or exposed to the saliva of a possibly rabid animal?


NDDoH Rabies Exposure Assessment Algorithm (PDF)

First, thoroughly
wash the wound with soap and running water. Gather as much information about
the animal as possible. Contact your physician as soon as possible and notify
your local public health unit or the state health department as well as local
law enforcement.  

How long is the rabies
virus infectious after it is outside of the rabid animal?

The rabies virus is a very
fragile virus. As soon as the saliva dries, the virus is no longer
infectious. The virus is easily killed by soaps, detergents, bleach, alcohol
and ultraviolet light.

What will happen to the
animal after a person has been bitten or otherwise exposed?


  • NDDoH Rabies Exposure Assessment Algorithm (PDF)
  • If the animal is a healthy domestic dog, cat or ferret it should be
    confined and held for observation for 10 days. A licensed veterinarian
    must examine the animal at the beginning and end of the 10-day observation
    period.  If the animal develops symptoms suggestive of rabies, it should
    be humanely destroyed and the brain sent for testing. If the animal is
    healthy at the end of the 10-day period, then no rabies exposure occurred and
    the person bitten will not need rabies vaccination.

  • If the animal is not a domestic dog, cat or ferret, it should be captured, humanely destroyed and the brain sent for rabies testing. If the animal is a domesticated farm
    animal (cow, horse, etc.), consult with your physician and veterinarian. 

  • “Other biting animals that might have exposed a person to
    rabies should be reported immediately to the local health department.
    Management of animals other than dogs, cats, and ferrets depends on the
    species, the circumstances of the bite, the epidemiology of rabies in the
    area, the biting animal’s history, current health status, and the animal’s
    potential for exposure to rabies. Previous vaccination of these animals
    might not preclude the necessity for euthanasia and testing.”
    What to do with an animal that has bitten a person. (2011). Retrieved from http://www.cdc.gov/rabies/specific_groups/veterinarians/person_bitten. html

What is meant by
confinement?

Confinement in North
Dakota, as it pertains to rabies, means separation of an animal from humans (other than the owner, caretaker, a member of the owner’s family or the
caretaker’s employees) and from other animals, by means of a building, cage,
fence, pen or other secure enclosure that restricts the animal’s movement
within definite boundaries and prevents the animal from exiting the
enclosure.  

Why can a healthy
domestic dog, cat, or ferret be held for ten days?

Studies have shown that
dogs, cats, and ferrets only shed the rabies virus in their saliva for a short
period of time (usually 4 to 5 days) before they develop symptoms.  If the
animal has not developed symptoms by the tenth day after the exposure then the
animal would not have been shedding the virus at the time of the exposure.

Why can’t the ten-day
observation period be used for other animals?

Only domestic dogs,
cats, and ferrets have been studied enough to determine with certainty the
period of viral shedding.  Although this period of viral shedding may be
similar for other species of animals, without more studies, there is too much
uncertainty and too great of risk for error. 

What if the animal is not
available for observation or testing?


NDDoH Rabies Exposure Assessment Algorithm (PDF)

If you have been bitten or
otherwise exposed to the saliva of an animal that is not available for
observation or testing, contact your physician, local public health unit or
state public health department and local law enforcement. If it was a
domestic dog, cat, or ferret, try to locate the animal or the owner of the
animal.  If the animal cannot be located, speak with your physician, as you may
need to start preventive treatment for rabies which will include the rabies
vaccine.

Does an animal have to be
destroyed to be tested for rabies?

Yes, the only proven test
is to examine the brain for the rabies virus. Blood tests have proven not to
be reliable. Because rabies is so serious, the test needs to be as accurate
and reliable as possible.

What if the owner of an
animal who has bitten someone refuses to have it evaluated for rabies?

In situations where the
owner refuses to have an animal evaluated for rabies, you should contact local
law enforcement officials.

How can I protect myself
from rabies?

  • Vaccinate your domestic dog,
    cat, or ferret (and be sure to keep the animal’s vaccinations up-to-date).

    For more information on each state’s vaccination laws, please see the

    American Veterinary Medical Association website.

  • Avoid contact with wild or stray animals, and domestic/wild hybrid
    animals.

  • Do not touch dead
    animals.  

  • Keep wild animals out of
    homes, workplaces and other dwellings. 

  • Report stray, sick,
    and injured animals to local animal control authorities or law enforcement
    officials.

What is a domestic/wild
hybrid?

A domestic/wild
hybrid is the offspring of a domestic animal crossed with a wild animal. The
most common example is a domestic dog/wolf hybrid. Although wolves may be
raised in captivity, they are still considered wild animals.

Are there any vaccines
for wild or hybrid animals?

At this time no
vaccines have been approved for wild or hybrid animals.  Although some zoos
vaccinate their animals for rabies, this is only done to try to protect the
animals from rabies. A wild or hybrid animal that bites a person should be
humanely destroyed and the brain submitted for rabies testing. If the animal
is a valuable specimen (at a zoo, for example) then rabies shots can be given
to the exposed person instead of destroying the animal.

What happens if my dog,
cat, or ferret is bitten or fights with a wild animal or another animal that may
have rabies?

  • If the animal that bit your pet can be captured, have the animal’s brain
    tested for rabies. If the test is negative for rabies and your pet has not
    been vaccinated, you should vaccinate your pet immediately.

  • If the biting animal tested
    positive for rabies and the pet is current on its rabies vaccination, the pet
    should be given a booster vaccine immediately. Observe
    your pet for 45 days for any symptoms of rabies after the booster shot. 

  • If the biting animal tested positive for rabies and your pet has never been vaccinated, the recommendation is to put the pet down. If you are
    unwilling to euthanize the pet, it must be confined for 6 months and vaccinated
    against rabies (the rabies vaccine must be administered at least
    1 month prior to release).  

  • If the biting animal tested
    positive for rabies and the pet is NOT current on its rabies vaccination (i.e., it was vaccinated against rabies in the past, but is now overdue for a booster vaccination), it should be evaluated based on severity of exposure, time elapsed since last vaccination, number of previous vaccinations, current health status, and local rabies epidemiologic factors to determine need for euthanasia or immediate revaccination and observation with isolation. 

 If the animal
cannot be captured, assume it is rabid and proceed as described above.


Our dog killed a skunk and when I handled the dog after the
attack it was all wet. Could I have been exposed to rabies by handling the dog?


Although there may have
been skunk saliva on the dog, the risk of an actual exposure is very low. The
saliva has to enter an open wound or get onto mucous membranes. If this did
not happen, there was no rabies exposure. If you think you were exposed,
call your health care provider. You will want to test the skunk to see
if it was rabid in this situation. The test results will be needed by you and your veterinarian
to determine what to do with your dog, and it can be used by you and your
health care provider to make a determination about your possible exposure.



What if I have livestock
exposed to rabies?


All species of livestock are susceptible to rabies. As with domestic pets,
livestock that have been vaccinated for rabies (with a vaccine approved by
USDA for that species) should be revaccinated immediately and observed
for 45 days. If the animal has not been vaccinated, it should be
euthanized. The animal can be used for human consumption if
it is slaughtered within 7 days of exposure, provided liberal amounts of the
tissue around the exposed area (bite) are discarded. Consult with your
veterinarian.



What if I am bitten by a
mouse or gopher?


Small rodents, including
mice, rats, gophers, chipmunks, squirrels, rabbits and hares, rarely have
rabies and are not known to have transmitted rabies to humans. You should
always consult with your physician regarding bites from these animals.
Depending on the circumstances, the animal may need to be humanely destroyed and
the brain tested for rabies. Bites or saliva exposure from other larger
rodents such as muskrats or groundhogs may result in a rabies exposure.



What animal serves as the
reservoir for rabies in North Dakota?


The skunk serves as
the primary reservoir for rabies in North Dakota. Any bite from a skunk should be
considered an exposure to rabies until a laboratory test indicates otherwise. 



Do bats in North Dakota
get rabies?


Any mammal, including bats
can get rabies. Bites from bats may not be easily noticed. Bats have small
teeth and bites may cause very little discomfort. You should contact your
physician or a public health department if you come into contact with a bat or
find a bat in your home.



Can a person get rabies
shots before they are exposed?


Pre-exposure rabies vaccines
are recommended only for people at increased risk of coming into contact with
rabies. Such people include rabies laboratory workers, veterinarians, animal
control officers, and cave explorers. Some people may get pre-exposure shots
when they travel to developing countries. Consult your health care provider or
public health department for more information.



I work in a high risk
occupation where I have a greater risk of being exposed to rabies.  What is
recommended for me?


The Advisory Committee on
Immunization Practices (ACIP) and the Centers for Disease Control and
Prevention (CDC) recommend that you receive pre-exposure vaccination. This
consists of three doses of vaccine administered on days 0, 7 and 21 or 28. You should be tested for protective antibody every 2 years and booster
vaccination is recommended for unacceptable antibody levels. If you are
working in a rabies research laboratory or are a rabies biologic production
worker then you should have your antibody level checked every 6 months.



If I need rabies shots,
what should I expect?


  • If you never had rabies
    shots before, then you can expect to receive four doses of vaccine over a 14
    day period and a dose of rabies immunoglobulin (RIG) on the same day as the
    first dose of vaccine. Rabies immunoglobulin provides immediate protection
    against rabies until your body has responded to the vaccine and makes its own
    antibodies to rabies.  

  • If you have been
    vaccinated previously with one of the currently licensed vaccines, you
    will still need two booster doses of rabies vaccine. The first dose should be given as
    soon as possible and the second dose three days later. Rabies
    immunoglobulin should NOT be given.


What are the side effects
of the vaccine?


As with most vaccines the
most common side effect is soreness and redness at the site of the injection.  
More severe reactions are rare and often related to allergies to the
ingredients in the vaccine.  Contact your health care provider if you are
having any health effects which you think might be related to the vaccine.



Are the rabies shots
given in the stomach?


No, the rabies vaccine has not been given in the stomach since the 1980s.
For adults, it should only be given in the deltoid muscle of the
upper arm (administration to the gluteal area is NOT recommended, as studies
have shown this can result in a less effective
immune response). For children, the anterolateral aspect of the thigh is also an acceptable site (depending on the child’s age and body mass). Rabies immunoglobulin is recommended to be given at the site
of the bite, if possible.



When is it too late to
start rabies vaccinations after an exposure?


Ideally, the vaccination series should begin as soon as possible after an exposure has occurred and a health care provider has determined
rabies vaccination is warranted.  Usually you can wait for test results
from a healthy domestic animal to see if rabies shots are needed. Bites and
exposures from wild animals should be treated as if the animal were rabid
until rabies has been ruled out. There have been instances when a person did
not start rabies shots for months after an exposure because the exposure was
never suspected.



Once a person develops rabies symptoms it is too late to vaccinate against
rabies!


How much does rabies
vaccine cost?


Rabies vaccine and
immunoglobulin is very expensive. A typical vaccination series with the
rabies immunoglobulin can cost anywhere from $2,000 to $7,000+ per person. 



As a local law
enforcement official, what can I do protect the public from rabies?


If your jurisdiction has
rabies vaccination ordinances and leash laws, enforcing these ordinances will
help reduce the risk of rabies in your communities.  Enforcing the proper
confinement of animals that have bitten a person helps ensure that the animal
will not escape during the observation period, so a veterinarian can declare
the animal in question healthy. It also minimizes the risk for other
people or animals to be exposed to the confined animal and helps prevent
people from getting unneeded rabies shots.



Where can I send an
animal brain for rabies testing?

  • The brain can be sent to the North Dakota Department of Health Division of
    Laboratory Services or to the North Dakota State University Veterinary
    Diagnostic Laboratory for testing. Please contact one of the labs for
    more information.

How should I collect and
ship the specimen?


Humanely destroy the animal, avoiding damage to the skull and brain. This
should be done by a professional such as a veterinarian. Only a veterinarian
or other trained professional should remove the head and extract the brain
leaving the brain stem intact. Contact the
NDDoH
Division of Laboratory Services (701.328.6272) or the
NDSU Veterinary Diagnostic
Laboratory (701.231.7527) for further
instructions.



The animal that I was
exposed to has been dead for a while, can it still be tested?


Consult with your
veterinarian to determine if the animal can still be tested. If it has been
cold, the animal may still be testable. However, brain tissue decomposes rapidly,
especially in warm temperatures, and it may be too decomposed to test.



If you have any
other questions about rabies submit them
here or call 800.472.2180.

Rabies | Clinical Infectious Diseases

Even in these days of modern plagues such as AIDS and Ebola virus disease, rabies is regarded with terror. Undoubtedly much of the terror derives from the inexorable death that follows after the development of symptoms and the long incubation period that leaves dangling the risk of rabies for months and even years. Although we are now very successful at preventing rabies after known exposure, neither the pathogenesis of disease nor the mechanism of protection is completely understood, which adds interest for the scientist. Moreover, for the public health professional, rabies is a headache both in developed countries where the occasional case causes panic and in developing countries where control of the disease in dogs is elusive. Rabies is an ancient disease that remains a modern problem in much of the developing world and in the United States, where the disease is enzootic in bats and wild terrestrial mammals.

Clinical Description

The incubation period of rabies in humans is generally 20–60 days. However, fulminant disease can become symptomatic within 5–6 days; more worrisome, in 1%–3% of cases the incubation period is >6 months. Confirmed rabies has occurred as long as 7 years after exposure, but the reasons for this long latency are unknown.

The first signs of illness are nonspecific: fever, anxiety, and malaise. Often there is tingling and severe pruritus at the site of the animal bite. After 2–10 days, frank neurological signs become manifest, ranging from hyperactivity to paralysis. Indeed, the disease is usually divided into encephalitic and paralytic forms. In the former form, signs of irritation of the CNS predominate, including agitation, confusion, hydrophobia, aerophobia, hyperventilation, hypersalivation, priapism, and convulsions. These symptoms reflect both cerebral dysfunction and autonomic dysfunction. The unnerving aspect of this hyperactivity, both to the patient and to the physician, is its episodic nature, between which the patient is cooperative and oriented.

In some cases, paralysis involving the peripheral nerves is the presenting sign, which is usually accompanied by fever but in the absence of sensory involvement. Eventually, however, patients who present with signs of encephalitis also become paralyzed. The principal differential diagnosis in paralytic cases includes rabies and Guillain-Barré Syndrome. In the latter form, there is sensory involvement, absence of fever, and absence of encephalitic signs in oxygenated patients. Specific diagnostic tests for rabies, which are discussed below, are valuable in making the distinction between rabies and Guillain-Barré syndrome.

Within 2–12 days, coma begins, and cardiorespiratory failure is only a matter of time. A handful of recoveries from rabies have been claimed, although these recoveries are associated with severe neurological disabilities (and almost always occur in patients who have been partly vaccinated). No known treatment is of avail.

Virology

Rabies virus is serotype 1 of 7 serotypes of the genus Lyssavirus, which belongs to the larger classification of rhabdoviruses. At least 6 of these viruses have been found in bats, and it is possible that rabies virus itself is really a bat virus that has crossed species. The lyssaviruses are bullet-shaped, with the core containing the viral RNA, a nucleocapsid protein, a phosphoprotein, and a viral transcriptase. The outer part of the cartridge contains the matrix protein and a glycoprotein on which are located the epitopes that induce neutralizing anti-bodies.

Both the glycoprotein and the nucleocapsid protein induce protection against rabies in experimental animals, the former through the induction of neutralizing antibodies and the latter through the induction of cytotoxic T cells. The glycoprotein contains 524 amino acids, and changes in the sequence have a strong influence on viral virulence. The glycoprotein alone has been used successfully to protect animals against rabies.

Cases of rabies caused by Lyssavirus serotypes 2–7 are rare, and protection by standard rabies vaccine has thus far been uniform in humans; however, because animal experiments sometimes reveal vaccine failures, there is still speculation as to whether antigens from additional viruses need to be added to the vaccine.

Pathogenesis

Although much is known about the pathogenesis of rabies, some essential points yet remain mysterious. Clearly, early after implantation the virus is cell-free, since both washing of the wound and injection of antiserum reduce infection. However, in the absence of specific prophylaxis, the virus becomes hidden, only to invade the CNS weeks, months, or years later. Where is the virus during this period? There is some evidence for slow replication in muscle cells and for latency in macrophages, but there is no certainty that these account for the long incubation periods.

The next clear point is that the rabies virus glycoprotein has homologies to neurotoxins and that the virus attaches to neural axons through lipoprotein receptors, including that for acetylcholine. Other receptors, such as the neutral cell adhesion molecule (NCAM), may also be involved. The virus then enters the axon and travels passively to the nucleus of the neuron at rates variously estimated as 1–40 cm/d. The virus replicates in neurons and passes to other neurons through the fiber connections. Virus also passes down axons to the skin and to the salivary glands, where it is released into the saliva.

Damage in the brain is curiously limited. Neuronal death is not pronounced, but neuronal dysfunction is considerable, perhaps mediated through inhibition of the synthesis of neural transmitters. The Negri body is in fact a virus-induced cytoplasmic inclusion, which contains considerable amounts of viral antigen. Anatomically, most of the damage is in the hypothalamus, but it is interference with cardiorespiratory control that results in death.

Immune Responses

During the incubation period, rabies virus is evidently segregated from the immune system, since no antibody responses are seen. Only after neurological symptoms develop do antibodies appear in the serum and later in the CSF. Antibodies in the CSF reflect active local production in the CNS, as well as passive transfer, and are absent after vaccination. Demonstration of antibodies is thus useful diagnostically only in late phases of the disease. Prior vaccination of a patient with rabies may confuse the issue, but in disease, titers increase to levels not seen in vaccinees.

Immunopathologic studies in mice show that neutralizing antibodies are an essential component of the protective response. However, “knockout” mice who are unable to mount a T cell-mediated IFN response do less well than control mice, despite the presence of antibodies, and it is evident that cellular immunity plays at least a minor role in protection.

Diagnosis

As in many diseases, clinical suspicion is critical to a timely diagnosis of rabies. Rabies should be included in the differential diagnosis of any case of encephalitis of unknown origin, particularly when the patient has a history of an animal bite and signs of autonomic disturbance in the absence of coma. Thus, hyperventilation, hypersalivation, aerophobia, and hydrophobia are all part of the clinical picture. Flaccid paralysis and localized paresthesias may also be signs of rabies. Clinically, rabies may be confused with Guillain-Barré syndrome, poliomyelitis, and other viral encephalitides.

Postmortem diagnosis is relatively easy and is based on demonstration of rabies virus antigens in brain tissue specimens by fluorescent antibody techniques or ELISA and, more recently, by demonstration of rabies virus nucleic acid by reverse transcriptase (RT)-PCR analysis. Eosinophilic intracytoplasmic inclusions, called Negri bodies, may also be seen during routine histological examination, but this technique may have false-positive and false-negative results. Virus isolation in cell culture or from animals can be used as a confirmatory technique, but it takes time.

Intravitam diagnosis depends on the demonstration of antibodies to rabies virus in serum or CSF specimens from patients with a prolonged clinical course, viral antigen in touch impressions from the cornea, viral antigen in highly innervated hair follicles obtained by biopsies along the hairline of the neck, and virus isolation from or nucleic acid detection in saliva. However, negative results early in the disease do not rule out the diagnosis of rabies, and in most cases rabies is diagnosed clinically at autopsy.

Noah et al. [1] summarized the diagnostic and epidemiological findings of 32 United States cases of human rabies that occurred during 1980–1996. The median incubation period from bite to symptoms was 85 days, with hospitalization following usually 1–10 days later. As shown in table 1, the test that gave the best results (positive in 100% of cases) was RT-PCR analysis, which revealed viral RNA in saliva. The next best test for antemortem diagnosis was nuchal skin biopsy (positive in 67% of cases).

Table 1

Antemortem diagnostic test results for 20 human patients with rabies in the United States, 1980–1996.

Table 1

Antemortem diagnostic test results for 20 human patients with rabies in the United States, 1980–1996.

Epidemiology

The epidemiology of human rabies is an exact reflection of the epizootiology of the disease in animals. From the viewpoint of public health, the dog or other canid species are the only important vector for humans, being responsible for most infections in Asia, Africa, and Latin America. However, with the retreat of canine rabies from most of the developed world, rabies transmitted by wild mammals, including bats, has become more prominent.

Thus, in the United States at this point, raccoons and skunks account for most rabies virus-infected animals. However, in terms of risk to humans, bats, dogs, and cats are the most likely threats to transmit rabies to Americans. The distribution of major terrestrial reservoirs of rabies in the United States is shown in figure 1 [2]. The major change in recent years has been the extension of raccoon rabies into the northeast.

Figure 1

Distribution of major terrestrial reservoirs of rabies in the United States. Reprinted with permission from W. B. Saunders [2]. The skunk and the fox are infected with several geographic variants.

Figure 1

Distribution of major terrestrial reservoirs of rabies in the United States. Reprinted with permission from W. B. Saunders [2]. The skunk and the fox are infected with several geographic variants.

Rabid bats have become the predominant rabies risk to humans in the United States because of a combination of virological, biological, and ecological factors. In particular, the silver-haired and eastern pipistrelle bats have been prominent recently because the virus recovered from them may infect human skin more easily than other rabies virus strains and because the small teeth of the bat may leave little evidence of a bite. Moreover, human exposures appear to be more frequent, perhaps because of increasing encroachment of human habitation in formerly rural areas. From 1980 to 1996, 21 of 36 cases of domestic human rabies could be attributed to bats by nucleic acid analysis; of these 21 patients, only 1 had a firm history of a bite [4]. These facts have led to new recommendations relative to prophylaxis for rabies, which are given below.

Bats are the source of another type of human rabies, aerosol infection, that is fortunately rare; aerosol infection may occur in caves inhabited by millions of bats. Rabies in research laboratory workers who are accidentally exposed to aerosols of the virus is also rare but well documented.

Although dogs and cats are uncommonly rabid in the United States owing to the widespread use of prophylactic vaccines and other public health measures, these pet animals may frequently expose humans to rabies, particularly along the border with Mexico.

Corneal transplants from donors who died of unspecified encephalitis have transmitted rabies in the past, but transplantation practice now forbids the use of tissues from such donors.

The major foci of rabies in the world today are the Indian subcontinent, Southeast Asia, and most of Africa. Data from India suggest that there are 30,000 cases each year in that country, and one estimate of the death rate associated with rabies is 35. 5 deaths per 1 million people. Although rabies vaccination services in Thailand are well organized, ∼75 Thai people still die of rabies each year. The World Health Organization estimates that there are 50,000 cases of fatal rabies in the world each year. On a list of worldwide causes of mortality, rabies ranks ahead of yellow fever, polio, and meningococcal meningitis. However, some countries, particularly islands, are free of rabies. The prominent vectors for rabies in various regions of the world are listed in table 2; this list may be useful in assessing the risk for travelers.

Table 2

Principal animal vectors of rabies.

Table 2

Principal animal vectors of rabies.

Vaccination

The principles of prophylaxis for rabies have not changed for many years, but there have been important recent modifications that deserve emphasis. The basic principles are to remove free virus from tissues by both washing and neutralization and to induce a rabies virus-specific immune response in the exposed individual before rabies virus can replicate in the CNS.

The history of vaccine development for rabies is a colorful one. It starts with the well-known and dramatic story of Louis Pasteur and his rabbit spinal cord vaccine and continues to this day with the demonstration of protection in animals by rabies virus reverse transcriptase DNA plasmid vaccination or by feeding them plants that contain chimeric plant viruses that code for rabies virus glycoprotein. However, in terms of use in humans, vaccines may be divided into nerve tissue vaccines, avian embryo vaccines, and cell culture vaccines.

Regrettably, nerve tissue vaccines are still the most widely used type for prophylaxis for rabies. They are dangerous in terms of induction of autoimmune CNS disease, require multiple injections, and are not always efficacious. The Fuenzalida vaccine, which is produced from rabies virus grown in suckling mouse brain, is an improvement over prior vaccines with regard to reduced myelin content, but it still provokes neurological problems. The vaccines originally produced from rabies virus grown in duck embryo contained no myelin, but the potency of the unconcentrated vaccine was low.

Today the optimal rabies vaccine is one produced by the growth of virus in cell culture or culture of avian embryos, followed by inactivation, purification, and concentration. The first one commercially developed, which is still the standard, was human diploid cell culture vaccine (HDCV). The advantages of HDCV and the cell culture vaccines that followed are freedom from heterologous protein, a high level of immunogenicity that permits a rational dosing schedule, and efficacy demonstrated in trials that were not placebo-controlled but were at least done with careful observation. The disadvantage of these vaccines is cost of production, particularly for the original HDCV. Subsequently developed vaccines have used less expensive cellular substrates to reduce their price.

The cell culture vaccines are considered equivalent in terms of efficacy and freedom from serious allergic reactions (table 3). If necessary (although it is not recommended), these vaccines may be used interchangeably in the same patient, at least for the intramuscular regimens.

Table 3

Important past and present rabies vaccines for humans.

Table 3

Important past and present rabies vaccines for humans.

Preexposure Vaccination

The advent of cell culture rabies vaccines has allowed safe immunization of people likely to be exposed to rabies, according to the same principles that govern the use of other vaccines. As summarized in table 4, 2 doses of a cell culture vaccine are given 1 week apart, and a third booster dose is given 2–3 weeks later. Antibody response is virtually 100%, and the individual remains sensitized indefinitely.

Table 4

Regimens for preexposure and postexposure vaccination with rabies vaccines.

Table 4

Regimens for preexposure and postexposure vaccination with rabies vaccines.

If a person who has been vaccinated previously is exposed to rabies, 2 doses of vaccine are administered 3 days apart. An anamnestic response is seen within 1 week. A vaccinated person at continuous risk should receive a single booster dose 1 year after primary immunization. We have observed that a titer of antibody to rabies virus that is measured 14 days after this fourth dose is useful in predicting the need for further booster doses: titers >30 IU indicate prolonged seropositivity, whereas subjects with lower titers should undergo more frequent retesting to be certain that their titers remain >0.5 IU, which is generally considered to be an acceptable level [3].

Preexposure vaccination is recommended for people who will be exposed to rabies virus in the laboratory or who will have contact with mammals, including bats. Included on this list are veterinarians, trappers, dog catchers, speleologists, biologists who work with mammals, and laboratory workers likely to come in contact with rabies virus-infected specimens. Individuals with less certain indications for preexposure vaccination, which should be influenced by geography and by information from veterinary authorities, include hunters, mail carriers, and travelers to countries where rabies is enzootic. Travelers who keep to the usual tourist routes are probably not in much danger. However, those travelers who remain in remote areas, particularly children, are at risk; vaccination is recommended for peace corps workers. One survey conducted in Thailand showed that 0.5% of travelers needed rabies vaccination because of exposures to potentially or proven rabid animals; therefore, there is ample justification for preexposure immunization.

Children living in areas where rabies is enzootic can be easily immunized against rabies (even as part of routine infant vaccination), although such practice is not yet recommended, in part for financial and logistic reasons.

Postexposure Prophylaxis

Optimal postexposure treatment consists of local cleansing, administration of passive antibody, and active immunization. All 3 elements are essential, since rabies has occurred when 1 of the elements was omitted.

The choice of cleaning solution is probably less important than the copiousness of the fluid administered. Soap and water are fine, although 0.1% benzalkonium chloride, 70% alcohol, or 1% povidone-iodine may be usefully applied to the wound after washing. Tetanus vaccine, tetanus antiserum, and antibiotic treatment should be provided as indicated.

After a wound has been cleansed, the physician can decide whether the threat of rabies justifies vaccination. The factors influencing that decision include the following:

  1. If there is high suspicion that the biting animal has rabies on the basis of compatible clinical signs, prophylaxis should be started immediately.

  2. If the biting animal has always been a domestic pet, such as a dog, cat, or ferret, it can be quarantined and observed for rabies for 10 days. Dogs and cats are still potential vectors in a few areas of the United States, particularly along the southern border. If the animal remains healthy, no vaccination is needed. In countries where dog rabies is enzootic, prophylaxis should be started immediately and should be discontinued if the animal remains healthy.

  3. If the biting animal is wild and has been killed, the brain can be examined for signs of rabies. This step is particularly important for raccoons, skunks, foxes, bats, and woodchucks (groundhogs). The fluorescent antibody test for rabies virus antigen in the brain is highly sensitive and specific.

  4. If the biting animal has escaped, reference to veterinary authorities should be made to determine whether the species involved may possibly be infected with rabies in that particular geographic area.

  5. If the biting animal was a bat, prophylaxis for rabies should always be given (see the section on bats below).

  6. Provocation of the bite or lack of it is not a good criterion for decision.

  7. Exposure of mucous membranes to secretions of a rabid animal is not as dangerous as a bite but is associated with the risk of rabies. Exposure of intact skin is not a risk (see the section on bats below).

If a decision is made to proceed with prophylaxis for rabies, rabies immune globulin (RIG) should be administered. Two forms of RIG exist: human RIG and equine RIG. However, only human RIG is available in the United States. The currently used equine RIGs are purified products and are associated with relatively few allergic reactions and only rarely with anaphylaxis. Unfortunately, because strict regulation to eliminate extraneous viral contamination, human RIG is in short supply.

The dose of human RIG is 20 IU/kg, whereas that for equine RIG is 40 IU/kg. United States and WHO recommendations call for local infiltration of the total dose at the site of the bite to the extent that is anatomically feasible, rather than 50% of the dose formerly recommended. The change in recommendation was made because blood levels of antibodies to rabies virus are not high after parenteral administration of RIG, and local neutralization of the virus is key.

Active immunization against rabies should be started simultaneously with administration of antiserum. Although no effort should be made to induce active immunization and passive immunization at different times, if one product is available before the other, it should be administered promptly, and the second product should be given when it becomes available. However, if RIG is available >1 week after vaccination has been started, it is probably unnecessary as an active antibody response will have begun.

A 5-dose schedule for postexposure vaccination against rabies is internationally accepted, and im injection is the only route acceptable in the United States. (However, see the section on intradermal vaccination below.) Doses are given at 0, 3, 7, 14, and 28 days (table 4). After the fifth dose, antibodies are always present, usually at a titer of >10 IU. Another vaccination schedule, called 2-1-1, is used in some countries, but this schedule is not as immunogenic if used together with human RIG. Vaccine and antiserum should never be mixed or injected in the same limb.

In the United States, there is a choice of 3 vaccines (table 5): HDCV, purified chick embryo cell culture vaccine, and fetal rhesus lung cell culture vaccine (or rabies vaccine adsorbed, which is temporarily unavailable). They are interchangeable, but it is normal practice to use 1 for the complete vaccination series. Outside of the United States, there are other choices, including primary hamster kidney cell culture vaccine, monkey vero cell vaccine, purified duck embryo vaccine, and numerous nerve tissue vaccines. If a traveler returns to the United States after having received 1 of the cell culture vaccines, the vaccination schedule may be completed with 1 of the 3 licensed vaccines, but if the patient has received a nerve tissue vaccine, rabies vaccination should be started without reference to the prior doses.

Table 5

Human rabies vaccines—United States, 1999.

Table 5

Human rabies vaccines—United States, 1999.

Titers should be measured in immunosuppressed persons, including those with HIV infection, after vaccination, to ensure that seroconversion has occurred.

There has been concern that vaccination might not protect against Lyssavirus serotypes 2–7, but fortunately, experimental studies suggest that there should be sufficient cross-neutralization with most strains to give protection.

The 1999 recommendations concerning postexposure prophylaxis for rabies by the Advisory Committee on Immunization Practices [4] are summarized in tables 6 and 7.

Table 6

Guide for postexposure prophylaxis for rabies in the United States, 1999.

Table 6

Guide for postexposure prophylaxis for rabies in the United States, 1999.

Table 7

Schedule of postexposure prophylaxis for rabies in the United States, 1999.

Table 7

Schedule of postexposure prophylaxis for rabies in the United States, 1999.

Intradermal Vaccination

The higher cost of cell culture vaccines has induced physicians to look for ways of reducing doses. Accordingly, Warrell et al. [5] and Wilde and et al. [6] have developed vaccination schedules by using the intradermal route. In the United States, the intradermal route is approved only for preexposure vaccination. Details of the intradermal immunization schedules are provided in table 4. The principles that allow intradermal vaccination are the better response to an equal volume of antigen when placed in contact with the Langerhans’ cells of the epidermis and the use of multiple sites of vaccination to obtain maximum drainage of antigen-presenting cells to the lymph nodes. The intradermal regimens have had remarkable success, particularly in Thailand. However, some expertise is necessary for correct intradermal injection, and the choice of vaccine is important. The intrasdermal dose is one-fifth of a vial for inteded intramuscular injection, which may be 0.1 mL or 0.2 mL, depending on the brand of vaccine.

Individuals receiving antimalarial prophylaxis with chloroquine or related compounds should be vaccinated by the im route, since their antibody responses to intradermal vaccination may be lower than normal.

Bats or the Return of Dracula

Rabies virus is only one of a number of lyssaviruses enzootic in bats and indeed may have been the original source of the virus for other species. Bat rabies is an important problem for the Americas, including the United States, where it occurs in all 49 continental states. Although <1% of bats screened for rabies are positive, in Colorado, 30% of bats who bit people and 50% of bats found in houses by wakening individuals were rabid [7].

In recent years, insectivorous bats have been the predominant source of human infections in the United States, in particular the silver-haired bat, Lasionycteris noctivagans, and the eastern pipistrelle bat, Pipistrellus subflavus. The virus indigenous to these bats is a genetic variant of Lyssavirus serotype 1 that adapts to epithelial and fibroblast cells in culture and may be more infectious than other strains. Disturbingly, most human patients with rabies caused by the virus variant from these bats give no history of contact with bats or only a history of contact without a bite. However, bat bites may be small or may be inflicted on a sleeping person who does not awaken. Therefore, a new recommendation by the Advisory Committee on Immunization Practices [4] states the following: “Consequently, post-exposure prophylaxis should be considered when direct contact between a human and a bat has occurred, unless the exposed person can be certain a bite, scratch, or mucous membrane exposure did not occur. In instances in which a bat is found indoors and there is no history of bat-human contact, the likely effectiveness of postexposure prophylaxis must be balanced against the low risk such exposures appear to present. In this setting, postexposure prophylaxis can be considered for persons who were in the same room as the bat and who might be unaware that a bite or direct contact had occurred (e.g., a sleeping person awakens to find a bat in the room or an adult witnesses a bat in the room with a previously unattended child, mentally disabled person, or intoxicated person) and rabies cannot be ruled out by testing the bat. Postexposure prophylaxis would not be warranted for other household members. ” Vampire bats in Latin America also may transmit rabies. Fortunately, standard rabies vaccination elicits good neutralizing antibody to viruses from bats.

Human-to-Human Transmission

Aside from transmission through transplanted tissues, human-to-human transmission lies largely in the realm of folklore. However, rabies virus may be present in the saliva of humans with rabies, and possible contact transmission has been reported recently and in the past. Thus, bites, scratches, and mucous membrane exposures to a rabid patient are considered indications for vaccination. The latter indication includes sexual exposure shortly before the onset of symptoms.

Reactions and Contraindications to Vaccination

Reactions to human RIG are uncommon. Currently, manufactured equine RIGs are associated with relatively few allergic reactions: serum sickness in only 1% of cases and very rare cases of anaphylaxis. Nerve tissue vaccines may induce local, systemic, or neuroparalytic reactions. The latter reactions are based on the induction of antibodies to myelin proteins or gangliosides. Reactions to cell culture vaccines are relatively mild, although local pain, erythema, and swelling at the injection site are commonly seen. Systemic reactions with headache and malaise occur less frequently. Guillain-Barré syndrome has been rarely reported after receipt of modern rabies vaccine, but its association with the vaccine is uncertain.

The most significant problem is type I or III allergic reactions consisting of urticaria, arthritis, and angioedema, which are seen in about 6% of patients who receive a booster dose of HDCV. These reactions have been attributed to the formation of antibodies to the human albumin stabilizer chemically altered by β-propiolactone. These reactions can be treated with the usual drugs employed for allergic reactions, and another rabies vaccine can be substituted for HDCV. The use of steroids should be avoided, but if these agents are administered, titers of antibody should be measured after completion of the vaccine series.

There are no true contraindications, and vaccination is safe in pregnancy. HIV-infected patients with CD4+ cell counts below 300/µL respond poorly, and may need additional doses of vaccine. Antibody titers can be monitored to verify responses.

Treatment Failures

In nearly all cases of rabies occurring despite vaccination, some aspect of the treatment did not follow the guidelines. The common faults are late start of prophylaxis, insufficient cleansing of the wound, total omission of antiserum administration, or failure to inject antiserum into all wound sites. One treatment failure did occur in a person prevaccinated by the intradermal route; in that case, concomitant chloroquine medication may have suppressed the patient’s response. However, it should be recognized that the size and placement of the challenge dose of rabies virus are influential on the outcome. A highly contaminated bite on the face, for example, may allow for rapid CNS invasion, and failures of protection have been reported in that situation despite standard treatment.

The best solution to human rabies still lies in the suppression or vaccination of animal reservoirs where feasible, particularly among domestic animals. More than 2000 years after the description of hydrophobia by Celsus, human rabies is far from extinct.

Acknowledgments

I thank Dr. Charles Rupprecht and Dr. Henry Wilde for critical reading of the manuscript.

A supplemental reading list reading appears in the online edition of CID (http://journals.uchicago.edu.CID/journal/).

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© 2000 by the Infectious Diseases Society of America

90,000 Human rabies: symptoms, signs, treatment

Contact with aggressive wild or domestic animals carries the risk of contracting rabies. This extremely dangerous disease is caused by the Rabies virus, which affects the cells of the human nervous system and brain. In the active phase, it proceeds quickly and with severe symptoms, and the probability of death is almost 100% in the absence of preventive measures.

General information about the

pathogen

Wild and stray animals, mainly predators, some rodent species, as well as horses and livestock serve as the reservoir for the virus.The main means of transmission of the virus is animal saliva, the method of infection is a human animal bite. Infection does not develop in every case: with a bite of a limb, the risk of developing the disease is about 23%, and in case of damage to the neck or face, it reaches 90%.

Penetrating into the human body, the virus spreads along the nerve fibers, and can also be carried by the blood and lymph flow. It destroys nerve cells and leaves specific formations in their place, called Babesh-Negri bodies.After some time, the virus reaches the brain, in which it causes an inflammatory process characterized by severe symptoms. Due to the degeneration of cells of nerve fibers, functional disorders of internal organs and systems develop.

In the external environment, the virus remains poorly viable. It instantly dies in direct sunlight and when dried, within ten minutes – when heated to 60 ° C. Gastric juice destroys it within 20 minutes, alcohol and other disinfectants – almost instantly.At low temperatures, the virus can persist for several weeks, but it loses its virulence.

External manifestations of the disease

The incubation period for rabies infection can range from 1.5 weeks to 3 months, depending on the location of the bite site and the depth of penetration of the infected animal’s saliva. With multiple bites to the head and neck, the disease develops quickly, with a single injury to the leg, as a rule, signs of rabies in a person appear after 2-3 months.

In the development of the disease, the following periods are clearly traced:

  • incubation, during which there are no symptoms of rabies;
  • prodromal, which is characterized by a slight increase in temperature, sleep disturbances, depressed or restless behavior, an itching sensation in the area of ​​the bite;
  • aggressive, characterized by hypersensitivity to external stimuli, hydrophobia, delirium and inappropriate behavior;
  • paralytic, with drooping of the lower jaw, unnatural appetite and degradation of the patient’s personality.

Then comes paralysis of the respiratory tract, which usually ends in the death of the patient.

In some cases, patients do not have a prodromal stage, and sometimes the first symptoms of rabies in humans appear with the development of paralysis. Because of this, doctors do not have time to determine the disease in time and provide the necessary assistance. Therefore, for any animal bites, you must immediately consult a doctor. Delay can lead to irreversible consequences.

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Diagnostic Methods

In the case when a patient consults a doctor immediately after contact with an aggressive animal, an external examination of the bite site is of great importance. The doctor determines the characteristic features of the wounds, the depth of puncture of tissues with the teeth of the animal, assesses the degree of salivation. All this is necessary to determine the expected duration of the incubation period.

Upon further observation, the doctor notes the presence of visual signs of rabies – changes in behavior, pupil size, etc. Laboratory diagnostics in ordinary clinics is not carried out, since almost all tests are specific and can only be performed in laboratories engaged in the study of dangerous infections. Lifetime research tends to be useless because the results appear too late.Currently, physicians can:

  • Determine viral antigens in the occipital skin biopsy by the method of fluorescent antibodies;
  • starting from the seventh day of illness, determine the presence of antibodies to the virus;
  • Perform a PCR test on cerebrospinal fluid.

Most often, in the absence of severe symptoms of rabies in a person and too late seeking medical help, postmortem examinations have to be performed in order to reliably establish the cause of death:

  • Histological analysis of brain tissue for the detection of Babesh-Negri bodies;
  • infection of laboratory animals with saliva taken from humans, and in the event of their death, detection of Babesh-Negri bodies in the brain tissue;
  • PCR and ELISA studies of corneal and brain tissues, as well as saliva.

The listed methods make it possible to establish rabies as the cause of the disease with one hundred percent accuracy.

Modern methods of treatment

After the onset of obvious symptoms, effective treatment of rabies becomes impossible, the efforts of doctors are aimed only at reducing the patient’s suffering. He is prescribed anticonvulsants and hypnotics, placed in a darkened ward with good noise isolation, painkillers and tranquilizers are administered.Scientists are currently testing new techniques based on the use of specific immunoglobulins, intensive care, and cerebral hypothermia. However, at the current level of development of medicine, after the appearance of clinical symptoms, death occurs in all cases.

Under these conditions, the prevention of rabies is of vital importance, which consists not only in vaccinating healthy people, but also in the mandatory implementation of a set of measures for animal bites:

  • deep and thorough washing of wounds with medical alcohol;
  • treatment of wounds with antiseptic preparations;
  • conducting a course of rabies vaccination using dry rabies vaccine and rabies immunoglobulin.

The scheme of administration of the vaccine and immunoglobulin in each case is determined individually, depending on the site of the bite, the severity of the wounds and the degree of salivation. When all the above measures are taken, the likelihood of the disease can be reduced to almost zero.

Frequently Asked Questions

How is rabies transmitted from person to person?

Theoretically, the transmission of the virus from one person to another is possible through a kiss, if the patient already has it in the saliva, and the healthy person has wounds in the mouth.However, in practice, such cases are not known to medicine. It is possible for the fetus to become infected from an infected mother during pregnancy, as well as from organ transplant donors, but these cases are extremely rare.

Is rabies transmitted by scratching a cat?

Infection is possible when:

  • Injury to the skin by the claws of an infected animal;
  • contact of the damaged skin area with the saliva of a sick animal;
  • salivation by sick animals of the mucous membrane of the mouth, nose or eyes of a person;
  • butchering the carcass of an infected animal without special clothing and protective equipment;
  • airborne contact in a dark, damp room (for example, in a cave that is home to infected bats).

However, the overwhelming majority of infections occur in the bites of sick animals.

What animals are most often affected by rabies?

The most common reservoirs for the virus are wild foxes, wolves and jackals. They infect humans directly or through contact with pets, which in turn transmit the infection to humans.

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90,000 First symptoms and signs of rabies in humans

Rabies is an acute zoonotic disease of viral etiology that develops after a person is bitten by an infected animal.

The disease is manifested by severe damage to the central nervous system and death. The rabies vaccine for a person bitten by a sick animal is the only chance of survival. Therefore, vaccination must be carried out immediately.

Most cases of rabies development in patients are caused by late seeking for specialized help, as well as with violation of the recommended regimen during the period of preventive vaccination or with non-completion of the course of specific immunization.

Incubation period of rabies in humans

In most cases, the incubation period is one to 3 months. However, in some cases, this period can be shortened to one week. The maximum incubation period for rabies virus does not exceed one year.

If possible, examine the animal that has bitten the patient. The animal is monitored for ten days. At the same time, laboratory tests are carried out to detect rhabdoviruses in the animal.

If negative test responses are received and the animal remains healthy within ten days of observation, the rabies prophylaxis carried out to the bitten person is terminated.

In this situation, the initiation of rabies vaccines pending the results of the study is justified by the fact that no cure for rabies has been developed at this time. The disease is characterized by absolute lethality. All treatment, with the manifestation of symptoms of rabies in a person, is reduced only to alleviating his condition until the moment of death.

How can you get infected?

Infection with rhabdoviruses occurs after being bitten by an infected animal. Also, infection can occur as a result of infected saliva getting on the affected skin.

In most cases, infection of urban residents occurs after a dog bite. Cases of infection after cat bites are much less common. You can become infected after being bitten by any infected animal (bat, rat, squirrel, horse, fox, wolf, etc.)e).

Basic facts about rabies

Rural rabies accounts for 2/3 of all cases. This is due to the fact that the risk of being bitten by a rabid animal is higher for residents of rural areas than for urban residents.

The bites of dogs, bats and cats are the most common causes of urban rabies. Outbreaks of natural rabies are usually associated with fox and wolf attacks.

After a bite in the hand, the incidence of rabies is about seventy percent.The maximum probability of infection and the rapid development of the disease with a minimum incubation period falls on bites in the neck and face (the probability of infection is more than 95%).

Rabies is more common in children than in adults. This is because children often play with stray animals and may receive small bites that they do not report to adults. Bats are especially dangerous at the moment. In this regard, it is categorically not recommended to try to catch with your bare hands a mouse that has flown into an apartment or onto a balcony.

It should be noted that in countries where there are strict restrictions on the import of animals and mandatory vaccinations have been introduced for them, there is practically no rabies. Such preventive measures are common in Japan, Great Britain, etc.

Is rabies transmitted from person to person?

The rabies virus is transmitted to humans only from an infected animal.

Upon contact with a bitten person, the transmission of the virus does not occur.There have been isolated cases of infection during corneal transplantation from a person who died of rabies.

In theory, transmission of the virus from a person with terminal rabies to another person is possible. However, for this, a sick patient must not only bite another person, but also bite through the skin. Or, a large amount of saliva from a patient in the terminal stage of rabies should get onto the affected area of ​​the skin (open wounds).

In practice, people with rabies do not pose an epidemiological danger.

By airborne droplets or by kissing, the rabies virus is not transmitted from person to person.

Can you get rabies without a bite

In addition to a bite, infection can occur after contact with open lesions of the skin or mucous membranes, saliva of a sick animal. Infection does not occur if the animal’s saliva gets on intact skin, for example, the animal could not bite through the tight sleeve of a coat, trousers, etc., but at the same time the tissue was saturated with saliva that got on the skin.

Examination of an animal and a course of prophylaxis (injections from rabies to humans) after a bite or salivation of open wounds is mandatory.

In isolated cases, vertical transmission of the virus from a mother bitten by an animal to a child is possible.

Signs of rabies in humans

Severe damage to the central nervous system results in:

  • development of convulsive contractions of the respiratory and swallowing muscles;
  • a sharp increase in salivation (salivation and profuse sweating;
  • severe disorders of the respiratory and cardiovascular systems.

Further migration of the rabies virus throughout the body, accompanied by its penetration into all organs and the development of multiple organ failure.

The first signs of rabies in humans are the appearance of a scar phenomenon, vague fears, depression.

The phenomenon of a scar consists in the appearance of a strong burning sensation, as well as pulling and aching pains at the site of the bite. Soreness spreads along the nerve fibers located at the site of the bite. There is also severe redness and swelling of the scar.

Paroxysms of rabies are the specific reactions of the patient to the action of any stimuli. Patients shudder, stretch their trembling hands forward (the body also pierces a small tremor) and throw their heads back. The appearance of inspiratory dyspnea (inability to take a full breath) is also characteristic.

The most indicative phobias (fears) in case of rabies will be the occurrence of hydrophobia (fear of water), aerophobia (fear of air), acousticophobia (fear of various sounds), photophobia (fear of light).

Doctor-surgeon Kovalenok V.T.

90,000 Rabies: symptoms and first aid for a bite

In humans, the disease is characterized by convulsions of the pharyngeal and respiratory muscles, which are subsequently replaced by paralysis, leading to death. Convulsions occur at the slightest external stimuli (bright light, noise, air movement, concussion, etc.). Especially characteristic is such a symptom as hydrophobia, expressed in a spasm of the larynx at the sound or form of pouring water. With increasing excitement, patients become aggressive, rushing about in bed.The stage of arousal is then replaced by paralysis, which leads to the death of the patient. The disease, if its development was not prevented by vaccinations, always ends in death. This circumstance determines the importance and responsibility of combating the sources of infection with this disease and the obligation of specific prevention of the disease in people bitten by rabid or suspicious animals, as well as the need for active immunization of the most sensitive domestic (dogs) and some types of farm animals, for example, reindeer.

All cases of rabies must be reported to the district (city) veterinary station. Laboratory confirmation of the diagnosis is usually not required, but it is possible, including using the recently developed method of detecting rabies virus antigen in prints from the surface of the eye. Animals that have bitten people are immediately isolated and kept under strict veterinary supervision for 10 days. If during this period they do not show signs of rabies, they are considered healthy, and the affected person is not infected.

Treatment of patients with the appearance of clinical signs of the disease is reduced only to pathogenetic and symptomatic therapy. Anticonvulsant therapy is widely used. For nutrition and restoration of fluid loss, saline solutions, plasma substitutes, glucose solutions and vitamins are injected intravenously. Patients with rabies often require intensive therapy, for example, the introduction of curariform drugs (diplacin, condelfin, etc.) to relax the muscles. At the same time, compulsory apparatus breathing is being established.

What if you get bitten?

The first thing to do is immediately wash the bite with soap. You need to wash it quite intensively, for 10 minutes. It is recommended to flush deep wounds with a stream of soapy water, for example with a syringe or catheter. No need to cauterize wounds or stitches. After that, you need to immediately contact the nearest emergency room, because the success of rabies vaccination strongly depends on how quickly you turned to a doctor for help.It is advisable to inform the doctor in the emergency room the following information – a description of the animal, its appearance and behavior, the presence of a collar, the circumstances of the bite. This is followed by a course of vaccinations prescribed by a doctor. Nobody has given forty injections in the stomach for a long time, they will inject you with the vaccine and let you go home. And so five or six times. A bitten person can be left in the hospital if his condition is especially severe, those who are vaccinated again, as well as people with diseases of the nervous system or allergic diseases, pregnant women, as well as people who have been vaccinated with other vaccinations within the last two months.At the time of vaccination and 6 months after it, it is necessary to refrain from drinking alcohol. In addition, if you are undergoing a course of vaccination against rabies, you must not overwork, overcool or, on the contrary, overheat.

Rabiology – Surgut Clinical Trauma Hospital

What is rabies?

Rabies is a contagious disease caused by a virus that is transmitted through saliva when bitten by sick animals.

Infection is also possible when contaminated saliva gets on the skin and mucous membranes, through scratches and other injuries.

Not every animal or person bitten by a rabid dog is bound to get sick.

Much depends on the depth of the wound and the strength of the bleeding. If the wound is superficial but bleeding heavily, the virus is often washed away by the blood stream and does not enter the body. But, even after getting into the blood, it can die before it has time to attach to the nerve cell.

From the moment of infection until the first symptoms appear, it takes from 2 weeks to 3 months.

The behavior of a dog with rabies changes: it becomes restless, later it can run away for a while, it can hide in dark corners.

Sometimes the voice also changes: the barking becomes with a howl. Due to the defeat of various parts of the body, nervousness, fits of rage, and various types of paralysis may appear. Dogs have difficulty in taking food and water. The lower jaw hangs down, saliva flows from the mouth, squint, hallucinations appear: the dog can bark at a familiar object, catch missing flies in the air.Seizures are noted, the desire to bite dogs and people. The dog begins to gnaw on the ground, iron, rags, his own body.

After a while, aggressiveness is replaced by apathy, sharp oppression. To the paralysis of the muscles of the pharynx, tongue and other organs, the growing paralysis of the limbs and tail is added, and salivation increases. On days 6-11, the dog dies.


A dog’s bite is only dangerous when it is sick.

The rabies virus is found in saliva 8 days before the first signs appear; a dog that bites must be isolated for 2 weeks in order to exclude rabies with complete confidence.Otherwise, not only dogs, but also people may be at risk of infection.

There are 3 stages of human disease with rabies: I – initial (depression), II – agitation, III – paralysis.

The first stage – the disease begins with the appearance of unpleasant sensations in the area of ​​the bite (burning, pulling pains, itching, skin hypersthesia), although the wound may already be completely healed. Face bites cause olfactory and visual hallucinations. The body temperature becomes 37.2-37.3 ° C.The first symptoms of a mental disorder appear: unexplained fear, melancholy, anxiety, depression, less often – increased irritability. The patient is depressed, withdrawn, refuses to eat.

After 1-3 days, the second stage begins. Anxiety, anxiety and attacks of hydrophobia appear. When trying to drink, and soon even at the sight and sound of pouring water, there is a feeling of horror and spasms of the muscles of the pharynx and larynx. Breathing becomes noisy, accompanied by pain and cramps.

At this stage of the disease, a person becomes irritable, excitable, very aggressive.

During seizures, patients scream and rush, they can break furniture, displaying superhuman strength, and throw themselves at people. There is an increased sweat and salivation, it is difficult for the patient to swallow saliva and he constantly spits it out. This period lasts 2-3 days.

Then comes the third stage of the disease, the onset of which is characterized by calming – fear, attacks of hydrophobia disappear, and there is hope for recovery.

After that, the body temperature rises above 42 ° C, paralysis of the limbs and cranial nerves of various localization occurs, impaired consciousness, convulsions.Death occurs from respiratory paralysis and cardiac arrest. The duration of the disease rarely exceeds a week.

There is no cure for rabies. If the disease is already in the first stage, most likely there will be no other outcome as fatal.

However, there is a way to prevent the disease – this is a method of specific prevention – the introduction of a special vaccine against rabies no later than the 14th day from the moment of the bite.

The vaccine is administered in 1 ml 5 times: on the day of infection (or treatment), then on 3,7,14 and 28 days.With this scheme, good immunity is created. Therapy may be discontinued if the animal is found to be healthy during the 10-day follow-up period or if the animal has not been found to have rabies virus.


What if you get bitten?

The first thing is to immediately wash the bite with soap.

You need to wash it quite intensively, about 10 minutes.

It is recommended to wash deep wounds with a stream of soapy water.No need to cauterize wounds or stitches. After that, you must immediately contact the emergency room. In this case, it is advisable to inform the doctor the following information: a description of the animal, appearance and behavior, the presence of a collar, the circumstances of the bite.

This is followed by a course of vaccinations prescribed by a doctor. For a long time no one has given forty injections in the stomach, you will be given a vaccine and sent home.

A bitten person can be left in the hospital if his condition is especially severe, as well as persons with diseases of the nervous system or allergic diseases, pregnant women.

At the time of vaccination and 6 months after it, it is necessary to refrain from drinking alcohol. In addition, if you are undergoing a course of vaccination against rabies, you must not overwork, overcool or, on the contrary, overheat.

During vaccinations, you must carefully monitor your health. And for any complaints of deteriorating health, you must consult a doctor, and temporarily stop vaccinations. Only after examination by a neuropathologist, therapist and a rabiologist is the issue of continuing vaccinations resolved in consultation.

Symptoms of rabies in animals and humans.

Rabies virus infects the central nervous system of animals and humans. Rising along the nerve pathways, it reaches the brain and causes its inflammation (specific encephalitis). Rabies is a deadly infection for animals and humans. Only a few cases of people curing from this terrible infectious disease are known. However, a timely vaccination or certain measures, which will be discussed further, can save the patient’s life.

The main carriers of the rabies virus:

1. Wild animals (wolves, foxes, wild cats, lynxes, bats, hedgehogs, rodents).
2. Farm animals.
3. Pets.

Recently, due to the spread of rabies among wild animals, the virus penetrates simultaneously into several biological species. For example, it is transmitted from a wolf to a fox or marten. Therefore, in the forest you need to be especially careful and attentive.

Approximately half of all rabies cases are domestic and farm animals in contact with wild animals. The most dangerous wild animals in terms of rabies infection are foxes. Moreover, you can meet rabid foxes both in the forest and in the city. When infected with rabies, foxes can manifest themselves in two ways. Some can behave aggressively and attack people. Others, on the contrary, reach out to people and show affection, like domestic cats. This behavior is not typical for a healthy fox.

After a dog or cat is infected with rabies, it usually takes about 15 days before the animal begins to behave aggressively.

The following symptoms are most common in pets:

1. Begins to chew or lick the bite.
2. The pupils of the dog dilate, at the same time begins to behave aggressively and even runs away from home.
3. Keeping appetite, the dog may swallow inedible things.
4. The animal may have severe salivation with foam and vomiting (doctors attribute this to the main symptom of rabies).
5. Hydrophobia (may not appear).

After the manifestation of these signs, as a rule, on the third day, paralysis of all muscles and death of the animal occur. In cats , salivation and intense arousal are most common.

What to do if you are bitten by a rabid animal or a stray dog?

1. At the first symptoms of rabies, it is almost impossible to save a person. Therefore, if you have been bitten by a forest or stray animal, as well as an unvaccinated pet, you should immediately seek medical help.
2. If the rabid animal is a pet, then you need to tie and isolate it.
3. Before the arrival of the ambulance team, wash the wound with water and laundry soap and cause profuse bleeding from the wound, so there is a possibility that the virus will come out of it with blood (virus penetration 3 mm per hour)
4. Do not sew up the wound, treat it with alcohol , iodine go to another antiseptic.
5. Do not drink alcohol after being bitten.
6. Animals bitten by humans must be examined by a veterinarian.
7. If the animal is aggressive and there is no way to tie it, then it is necessary, without touching it, to call the department of anti-rabies Kiev, st. Volynskaya, house 12, phone 044-245-76-74.

Prevention of rabies

Compliance with the rules of keeping pets by the owner is very important in the prevention of rabies. The very first thing to do when you decide to take an animal into your home is to find out if it has been vaccinated against rabies.
Rabies vaccination is given at an early age. Re-vaccinations must be carried out every year.

If you want to sell, buy or transport dogs, you must issue a veterinary certificate stating that the animal was vaccinated against rabies.

90,000 symptoms, first signs, prevention and vaccination

What is rabies and what is the danger of this disease?

Rabies is an acute infectious disease of warm-blooded animals and humans, usually with a fatal outcome.

The disease is caused by the Rabies virus, which affects the brain, causing irreversible changes in it.

Rabies is registered in almost all countries – according to the World Health Organization, more than 55,000 people die from rabies every year.

This disease has been known since ancient times, and although it was described as early as the 5th century BC, by 2005 only three documented cases of recovery were known.

In 2005, a successful cure for rabies was recorded in the United States for the first time – a group of American doctors developed an experimental treatment called the Milwaukee Protocol, and Gina Gies, a bat-bitten girl, who received this treatment, recovered.

Subsequently, this technique was used in different countries in the treatment of 35 more people who fell ill with rabies, but only 4 of them recovered.

According to experts, the effectiveness of treatment according to the “Milwaukee Protocol” is not fully proven, and in general the effectiveness of this method is recognized as no more than 20%, moreover, this method is still experimental and very expensive.

That is why, at the moment, rabies is considered to be an incurable disease with almost 100% fatal outcome.

Many residents of large cities mistakenly think that this danger does not concern them. Unfortunately, this is not at all the case – according to Rospotrebnadzor, the epizootic situation in Moscow due to rabies is constantly tense. This is due to the fact that there are many active natural foci of rabies around the capital. So, only in 2013-2016, about 50 cases of this disease in animals were registered in Moscow, and according to Rosselkhoznadzor, only for the period from February 1 to February 18, 2016, 166 cases of rabies were recorded in Russia.

What animals can get rabies?

All mammals and birds can get rabies. The main reservoir of rabies in nature is wild predatory animals – foxes, wolves, raccoon dogs; there is also a hypothesis that rodents are the natural reservoir of the virus. Less often bears, lynxes, moose are ill.

Foxes and hedgehogs are the most dangerous for our region.

How do you get rabies?

Infection of a person or a pet occurs when a sick animal bites or when infected saliva comes into contact with damaged skin or mucous membranes.Dangerous contact not only with a “rabid” animal, but also with an animal carrier. The virus in saliva is detected 8-10 days before the manifestation of obvious clinical signs of the disease.

One of the most common routes of infection is when unvaccinated dogs are taken out into the countryside, where they attack infected hedgehogs.

Not only “summer residents” are at risk, but also those who are never taken out of the city. After all, about 800 wild foxes live on the territory of Moscow, as well as hedgehogs, rodents and other representatives of the fauna that your pet may encounter not only in the park, but also just walking in the yard.

Incubation period

The incubation period (the latent period from the moment the virus enters the body until the manifestation of signs of the disease) lasts from 9 days to several months and depends on the virulence (strength) and the amount of the virus that entered the body, the site of the bite, the age of the animal, and the state of its immune system. Usually, clinical signs appear 15-25 days after infection.

The deeper and more extensive the wound, the more the virus could get into it with saliva.And the more rich in nerve endings the bite site is, the faster the disease manifests itself, since the virus enters the brain through nerve fibers.

The most dangerous bites are in the head and hands, since there are a significant number of nerves, and the path of the virus to the brain is shorter, and the incubation period is correspondingly shorter.

Once in the body, the virus fixes itself on the nerve cells, begins to multiply and moves along the nerve trunks in the spinal cord and further into the brain. The virus can also spread through the bloodstream, as evidenced by infection of fetuses in pregnant animals with rabies.

The multiplied virus enters the salivary glands along the nerve fibers and is excreted with saliva, and it has been established that the virus is detected in saliva 8-10 days before the first clinical signs appear, which is why preventive measures after a bite should be started as early as possible.

How does the disease manifest itself?

Different types of animals can show different clinical signs of rabies. Dogs usually do not have hydrophobia. Most often, cats have a violent form of rabies – they become aggressive towards people and other animals, tend to run away from home and die within 3-6 days.But foxes, on the contrary, often lose their caution, cease to be afraid of a person, reach out to people and behave like tame.

Remember that if a wild animal does not run away from a person and behaves in an unusual way, you can suspect that it is sick with rabies.

Dogs show the most typical symptoms of rabies. It is customary to distinguish five forms of the disease:

  1. Violent – lasts 6-11 days and passes in three stages, turning one into another. In the first, prodromal or melancholic, minor changes in behavior appear, the dog becomes apathetic, avoids people, hides or, on the contrary, becomes overly affectionate, its appetite worsens, swallowing may be difficult and drooling may appear.At this stage, the dog is already contagious. The second stage, the stage of excitement or manic, is characterized by a sharp change in behavior: the dog is aggressive, appetite perversion is often observed, the dog swallows inedible objects, sticks, stones, etc., bites people and animals that come across it, laryngeal paralysis develops; the dog is unable to eat and drink and the disease flows into the third, last, paralytic stage, which is characterized by progressive paralysis and ends with the death of the animal.
  2. Silent, or paralytic – lasts 2-4 days, the dog is not aggressive, paralysis of the lower jaw, pharynx and hind limbs is expressed.
  3. Atypical – characteristic symptoms are not expressed, the stage of excitement is absent, exhaustion, gastroenteritis can be observed.
  4. Abortive, in which at the beginning of the second stage the disease suddenly stops and the animal is cured. This rare and poorly studied form of the disease accounts for only 1-2% of all cases.
  5. The relapsing form is characterized by the fact that after an apparent recovery, the symptoms of the disease reappear, and such alternations are observed 2-3 times at short intervals. The returnable form also ends with the death of the animal.

It is known that not all those bitten by rabid animals get sick, but do not delude yourself – this percentage is small from 1 to 8%

After the manifestation of symptoms of the disease, a person dies in 5-8, sometimes 10-12 days, the life of a sick animal is even shorter – 2-6 days.

Diagnosis and treatment

There is no cure for rabies and sick animals are destroyed.

The final diagnosis is usually made after postmortem examination of the brain of an animal that died from the disease for the presence of Babesh-Negri bodies – cellular inclusions found in the cytoplasm of nerve cells during rabies.

If you suspect that the animal is sick with rabies, then you must notify the state veterinary service at your place of residence or the regional station for the fight against animal diseases, and by the decision of the veterinarian, the animal is sent to quarantine, which takes place within the established time limits in accordance with the sanitary and veterinary rules and regulations.

Since rabies is one of the most dangerous diseases, the delivery of an animal to quarantine and subsequent quarantine is free.

Restrictive measures are imposed on areas that are not favorable for rabies – you cannot take out dogs and cats, hold exhibitions, etc.

The restrictions are lifted 2 months after the last case of the disease.

Prevention. How to keep your pet safe?

The only remedy that can protect your pet from rabies disease is timely vaccination.

When clinical signs of the disease appear, vaccination is no longer effective.

In our country, only inactivated rabies vaccines are allowed for use, such vaccines do not contain live viruses, therefore, the disease of an animal with rabies as a result of the use of such a vaccine, contrary to common “horror stories”, is basically impossible.

Currently, there are quite a large number of rabies vaccines, both domestic and foreign.They are both monovalent – only against rabies, and polyvalent (complex), protecting against rabies and a number of other diseases. All rabies vaccines are highly effective, the doctor will advise which vaccine is best for your pet.

Dogs and cats are usually vaccinated from 12 weeks of age. However, if there is a real threat of the disease, the animal can be vaccinated earlier than the specified age, with repeated vaccination after reaching 3 or 6 months.

Subsequent revaccination is carried out annually.Immunity after vaccination is formed in 3-4 weeks.

Undesirable side reactions of the body to the administration of the rabies vaccine are possible, but fortunately, they are quite rare and in this case the benefits of the vaccine are many times greater than the risks.

Despite the fact that the instructions for some imported vaccines indicate the possible terms of revaccination against rabies in 2-3 years, according to the legislation of our country, it is necessary to vaccinate animals annually, otherwise problems may arise when the animal is exported abroad, or if your dog is -or bite.

Only a clinically healthy animal can be vaccinated; 10-14 days before vaccination, deworming must be carried out.

It is necessary to vaccinate animals against rabies only in licensed veterinary clinics, since only in this case you will receive the necessary vaccination documents.

During the initial vaccination, a veterinary passport is issued for an animal, indicating the timing of vaccinations, the name and series of the introduced vaccine; in the future, information about subsequent vaccinations is also entered there.This is a necessary document for any trips with a dog, visiting exhibitions, it is on the basis of a veterinary passport that an animal is issued a certificate No. 1 for transporting animals in public land and air transport.

To obtain a certificate of form No. 1, the animal must be vaccinated against rabies at least 30 days before the planned date of departure, but not more than one year.

This certificate is valid for 5 days.

In accordance with the law of the Russian Federation and the rules for keeping dogs and cats, all these animals must have a veterinary passport with notes on all the necessary vaccinations, and regardless of whether they are taken out somewhere or just kept at home.

What if you or your dog / cat are bitten?

Any bites from wild animals should be perceived as potentially dangerous due to rabies.

The most important thing that needs to be done immediately after the bite is immediately or as early as possible to thoroughly wash the wound with soap and water, which kills the virus, destroying its shell, and treat it with 40-70 degree alcohol or iodine solution; then you should URGENTLY contact the veterinary clinic.

People who have been bitten by suspicious rabies or unknown animals are also immediately treated for the wound; they urgently need to contact the nearest emergency room for further treatment and preventive measures.

If the owner of a bitten dog or cat cannot provide a vaccination certificate, then the dog is subject to quarantine (usually at home) for 10 days, and if during this time the animal does not show symptoms of rabies, then it is considered healthy.

Elena Filina

Rabies – symptoms and treatment

Rabies is a disease of a viral
nature, arising after the bite of an infected animal, characterized by
severe damage to the nervous system and usually ending in
fatal.Rabies virus (Neuroryctes rabid) belongs to the group
mixoviruses of the genus Lyssavirus of the family Rhabdoviridae. Found in saliva
and also in tears and urine.

Virus
unstable in the external environment – dies when heated to 56.C in 15 minutes, when
boiling for 2 minutes. Sensitive to ultraviolet and direct sunlight
rays, ethanol and many disinfectants. However, it is resistant to low
temperatures, phenol, antibiotics.

After
penetration into the body, the rabies virus spreads through the nervous
endings, affecting almost the entire nervous system.Edema is observed
hemorrhages, degenerative and necrotic changes in nerve cells
brain and spinal cord.

Source
rabies virus are both wild and domestic animals. To the wild
include wolves, foxes, jackals, raccoons, badgers, skunks, bats,
rodents, and pets – dogs, cats, horses, pigs, small and large
cattle. However, the greatest danger to humans is represented by foxes and
stray dogs outside the city in the spring and summer.Animals are considered contagious
3-10 days before signs of illness appear and then throughout the entire period
diseases. Often animals with rabies can be distinguished by abundant
salivation and lacrimation, as well as when observing signs of hydrophobia.

Infection
a person occurs when bitten by a “rabid” animal. And also at
contact with the saliva of a sick animal on damaged skin or mucous membranes
shell. In recent years, airborne, alimentary (through
food and water) and transplacental (through the placenta during pregnancy) pathways
transmission of the virus.Several cases of human infection give rise to much debate.
rabies as a result of organ transplant operations.

Incubation
the period (the period from the bite to the onset of the disease) averages 30-50
days, although it can last 10-90 days, in rare cases – more than 1 year. Moreover
the farther the bite is from the head, the longer the incubation period. A particular
the danger is bites to the head and hands, as well as child bites.
The incubation period lasts the longest with a bite in the legs.

Allocate 3
stages of the disease: I – initial, II – excitement, III – paralytic. The first
stage begins with general malaise, headache, slight increase
body temperature, muscle pain, dry mouth, loss of appetite, pain in
throat, dry cough, there may be nausea and vomiting. At the site of the bite appear
discomfort – burning, redness, pulling pains, itching, increased
sensitivity. The patient is depressed, withdrawn, refuses to eat, he has
there is unexplained fear, melancholy, anxiety, depression, less often – increased
irritability.Insomnia, nightmares, olfactory and visual hallucinations are also characteristic.

Through 1-3
day, the patient with rabies begins the second stage – excitement. Appears
restlessness, anxiety, and, most characteristic of this stage, attacks
hydrophobia. When trying to drink, and soon even at the sight and sound of pouring water,
there is a feeling of horror and spasms of the muscles of the pharynx and larynx. Breathing becomes
noisy, accompanied by pain and convulsions. At this stage of the disease, a person
becomes irritable, excitable, very aggressive,
“mad”.During seizures, patients scream and rush about, they can
breaking furniture, showing superhuman strength, throwing themselves at people. It is noted
increased sweating and salivation, it is difficult for the patient to swallow saliva and
spits it out all the time. This period usually lasts 2-3 days.

Next
the third stage of the disease begins, for the onset of which sedation is characteristic
– fear disappears, attacks of hydrophobia, there is hope for recovery.
After that, the body temperature rises above 40 – 42 degrees, paralysis of the limbs and cranial nerves of various
localization, impaired consciousness, convulsions.Death comes from paralysis
breathing or cardiac arrest. Thus, the duration of the disease
rarely exceeds a week.

Rabies treatment

Methods
there is no cure for rabies as such. If the disease is already in the first stage, otherwise
an outcome than lethal, most likely, will not be. Although the world knows only a few
cases of cure for rabies. But for now it is exotic.

However
there is a way to prevent disease by killing it in the bud.This is the method
specific prophylaxis – the introduction of a special vaccine against rabies,
no later than the 14th day from the moment of the bite. The best specific prophylaxis is
this is the introduction of a specific immunoglobulin and / or active immunization
(vaccination).

The vaccine is administered
intramuscularly 1 ml 5 times: on the day of infection, then on the 3rd, 7th, 14th and 28th
day. With this scheme, good immunity is created, but WHO also recommends
and the 6th injection 90 days after the first.

The best
the site of inoculation is the deltoid muscle of the shoulder or thigh. In that case,
if a person is bitten, but was vaccinated according to the full scheme before the bite, and he has
a sufficient level of antibodies, it is vaccinated according to a special scheme without
the use of immunoglobulin.

Therapy
can be discontinued if it is found that the animal remains healthy in
during the 10-day observation period or if the animal did not have
rabies virus detected.

Some
persons who are at risk (veterinarians, dog handlers, hunters) need
be vaccinated in advance. Vaccinations are also carried out specifically
the established scheme with the first revaccination after 12 months. and then every
5 years.

What
do if you get bitten?

First,
what needs to be done is to immediately wash the bite with soap. It is necessary to wash
quite intensely, for 10 minutes.Deep wounds are recommended
flush with soapy water, for example with a syringe or catheter. Not
you need to cauterize wounds or apply stitches.

After
this you need to immediately contact the nearest emergency room, because success
rabies vaccination is highly dependent on how quickly you
turned to a doctor for help. It is advisable to inform the doctor at the emergency room
the following information – a description of the animal, its appearance and behavior,
the presence of a collar, circumstances of the bite.

Next
a course of vaccinations prescribed by a doctor should be carried out. Forty injections in the stomach
no one has done it for a long time, you will be given a vaccine and sent home. And so five or
six times. A bitten person can be left in the hospital if his condition
especially severe, re-vaccinated, as well as persons with diseases
nervous system or allergic diseases, pregnant women, as well as persons
other vaccinations in the past two months.

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