Overview
How is the rabies virus characterized and how is it transmitted?
What is the annual incidence of rabies in the US?
Which animals serve as reservoirs for rabies?
How has climate change affected the prevalence of rabies?
What is the role of bats in the transmission of rabies in the US?
What is the role of raccoons in the transmission of rabies in the US?
What is the role of skunks in the transmission of rabies in the US?
What is the role of cats and dogs in the transmission of rabies in the US?
Which animal species are at lower risk for rabies in the US?
What are the adverse effects of exposure to oral animal vaccines for rabies?
What is the mortality rate for rabies in transplant recipients?
What is the global prevalence of rabies?
How do the reservoirs of rabies virus vary by geographic location?
How does the incidence of rabies vary by sex?
What is the pathophysiology of rabies?
What is the prognosis of rabies?
What patient education details should be provided to patients about rabies?
Presentation
What is the focus of history in the evaluation of rabies?
What are the features of rabies during the incubation period?
What are the signs and symptoms of rabies during the prodromal period?
What are the signs and symptoms of rabies in the acute neurologic period?
What is the progression of rabies following coma?
What are the physical signs of rabies during neurologic period?
What are the symptoms of autonomic instability in rabies?
What are the indications of coma in rabies?
How is death determined in patients with rabies?
DDX
What are conditions to consider in the differential diagnoses of rabies?
What are the differential diagnoses for Rabies?
Workup
What is the initial approach to evaluation for rabies after an acute or recent bite?
What is included in the evaluation of encephalitis when rabies is suspected?
What is the role of blood gas analysis in the workup of rabies?
Which findings of hematology studies suggest rabies?
What is the role of imaging studies in the workup of rabies?
What is the role of EEG in the workup of rabies?
Which results of cardiac monitoring are characteristic of rabies?
What is the role of nucleic acid sequence-based amplification (NASBA) in the diagnosis of rabies?
What is the role of serology in the diagnosis of rabies?
What is the role of skin biopsy in the workup of rabies?
Which histologic findings are characteristic of rabies?
Treatment
How are bite wounds managed when rabies is suspected?
When is inpatient care indicated for patients with rabies?
When is transfer to a tertiary center indicated for patients with rabies?
Who should conduct follow-up evaluations in patients with rabies?
When is preexposure, prophylaxis or immunization against rabies indicated?
What are the CDC and WHO recommendations for rabies vaccination?
What is the initial care of animal bites with possible exposure to rabies?
Which rabies vaccines are used in the US, and what are their adverse effects?
What is included in the treatment of rabies prior to onset of symptoms?
How is the rabies vaccine administered?
What are the indications for empiric treatment and prophylaxis for rabies?
How is rabies treated in pregnant women?
What is the role of intradermal (ID) vaccinization regimens in the treatment of rabies?
What is included in inpatient care of rabies?
When is transfer indicated in patients with rabies?
What is included in patient education about rabies prevention?
How is rabies prevented among healthcare workers?
How should organ donors be screened to prevent rabies transmission?
What are preventive measures to control rabies in the animal population?
Which medical personnel provide consultation to patients with rabies?
Medications
What is the role of passive and active immunizations against rabies?
Which medications in the drug class Passive Immunizing Agents are used in the treatment of Rabies?
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Hematoxylin and eosin stain of Negri body in a rabies-infected neuron. Courtesy of the US Centers for Disease Control and Prevention.
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Distribution of the 5 strains of rabies virus and the associated wildlife in the United States.
Tables
Category |
Nature of exposure | Target Population |
Relevant biogeography | Immunization Regimen |
Serologic Testing |
1. Elevated risk for unrecognized and recognized exposures including unusual or high-risk exposures |
High concentration exposure is possible, might be recognized or unrecognized, or might be unusual (eg, aerosolized virus) | Rabies research laboratory workers, vaccine production workers, or diagnostic laboratory workers who may work with live rabies virus |
Laboratories | Primary series: IM rabies vaccine on days 0 and 7 |
Rapid Fluorescent Foci Inhibition Test (RFFIT) titer every 6 months; booster if titer < 0.5 IU/mL |
2. Elevated risk for unrecognized and recognized exposures |
Exposure typically recognized but could be unrecognized; unusual exposures are unlikely | Persons who frequently 1) handle bats, 2) have contact with bats, 3) enter high-density bat environments, or 4) perform animal necropsies (eg, biologists who frequently enter bat roosts or who collect suspected rabies samples). |
All geographic regions where any rabies reservoir is present, US domestic and international | Primary series: IM rabies vaccine on days 0 and 7 |
RFFIT titer every 2 years; booster if titer < 0.5 IU/mL |
3. Elevated risk for recognized exposures, sustained risk |
Exposure nearly always recognized; risk for recognized exposures higher than that for the general population and duration exceeds 3 years after the primary vaccination | Persons who interact with animals that could be rabid; occupational or recreational activities that typically involve contact with animals include 1) veterinarians, technicians, animal control officers, and their students or trainees; 2) persons who handle wildlife reservoir species (eg, wildlife biologists, rehabilitators, and trappers); and 3) spelunkers |
All US domestic and international geographic regions where any rabies reservoir is present | Primary series: IM rabies vaccine on days 0 and 7 |
1) One-time RRFIT titer at years 1–3 after primary series; booster if titer < 0.5 IU/mL, OR 2) Booster at at point between day 21 and year 3 after primary series |
4. Elevated risk for recognized exposures, but not sustained or continuous |
Exposure nearly always recognized; risk for exposure higher than for general population but expected to be time-limited (≤3 years from the 2-dose primary vaccination series) | Same as for risk category 3, but risk duration ≤3 years (eg, short-term volunteer providing hands-on animal care or infrequent traveler with no expected high-risk travel >3 years after PrEP administration) |
Same as for risk category 3 | IM rabies vaccine on days 0 and 7 |
None |
| 5. Low risk for exposure | Uncommon exposure. | Typical person living in the United States. General population. | None | None | None |
