Rabies

Fact Sheet
Updated March 2016

Key facts

Rabies is a vaccine-preventable viral disease which occurs in more than 150 countries and territories.
Dogs are the source of the vast majority of human rabies deaths, contributing up to 99% of all rabies transmissions to humans.
Rabies elimination is feasible by vaccinating dogs.
Infection causes tens of thousands of deaths every year, mostly in Asia and Africa.
40% of people who are bitten by suspect rabid animals are children under 15 years of age.
Immediate wound cleansing with soap and water after contact with a suspect rabid animal can be life-saving.
Every year, more than 15 million people worldwide receive a post-bite vaccination. This is estimated to prevent hundreds of thousands of rabies deaths annually.

Rabies is an infectious viral disease that is almost always fatal following the onset of clinical signs. In up to 99% of human cases, the rabies virus is transmitted by domestic dogs. Rabies affects domestic and wild animals, and is spread to people through bites or scratches, usually via saliva.

Rabies is present on all continents with the exception of Antarctica, but more than 95% of human deaths occur in Asia and Africa.

Rabies is a neglected disease of poor and vulnerable populations whose deaths are rarely reported and where human vaccines and immunoglobulin are not readily available or accessible. It occurs mainly in remote rural communities where children between the age of 5–14 years are frequent victims.

The average cost of rabies post-exposure prophylaxis (PEP) can be the cost of catastrophic expenses for poor populations, since a course of PEP can cost US$ 40 in Africa and US$ 49 in Asia, where the average daily income is about US$ 1–2 per person.

Prevention

Eliminating rabies in dogs

Rabies is a vaccine-preventable disease. Vaccinating dogs is the most cost-effective strategy for preventing rabies in people. Dog vaccination will drive down not only the deaths attributable to rabies but also the need for PEP as a part of dog bite patient care.

Preventive immunization in people

The same safe and effective vaccines can be used for pre-exposure immunization. This is recommended for travellers spending a lot of time outdoors, especially in rural areas, involved in activities such as bicycling, camping, or hiking as well as for long-term travellers and expatriates living in areas with a significant risk of exposure to dog bites.

Pre-exposure immunization is also recommended for people in certain high-risk occupations such as laboratory workers dealing with live rabies virus and other rabies-related viruses (lyssaviruses), and people involved in any activities that might bring them professionally or otherwise into direct contact with bats, carnivores, and other mammals in rabies-affected areas. As children are considered at higher risk because they tend to play with animals, may receive more severe bites, or may not report bites, their immunization could be considered if living in or visiting high-risk areas.

Symptoms

The incubation period for rabies is typically 1–3 months, but may vary from < 1 week to > 1 year, dependent upon factors such as location of rabies entry and rabies viral load. The initial symptoms of rabies are fever and often pain or an unusual or unexplained tingling, pricking or burning sensation (paraesthesia) at the wound site. As the virus spreads through the central nervous system, progressive, fatal inflammation of the brain and spinal cord develops.

Two forms of the disease can follow. People with furious rabies exhibit signs of hyperactivity, excited behaviour, hydrophobia (fear of water) and sometimes aerophobia (fear of flying). After a few days, death occurs by cardiorespiratory arrest.

Paralytic rabies accounts for about 30% of the total number of human cases. This form of rabies runs a less dramatic and usually longer course than the furious form. The muscles gradually become paralyzed, starting at the site of the bite or scratch. A coma slowly develops, and eventually death occurs. The paralytic form of rabies is often misdiagnosed, contributing to the under-reporting of the disease.

Diagnosis

No tests are available to diagnose rabies infection in humans before the onset of clinical disease, and unless the rabies-specific signs of hydrophobia or aerophobia are present, the clinical diagnosis may be difficult. Human rabies can be confirmed intra-vitam and post mortem by various diagnostic techniques aimed at detecting whole virus, viral antigens or nucleic acids in infected tissues (brain, skin, urine or saliva).

Transmission

People are usually infected following a deep bite or scratch by an infected animal. Dogs are the main host and transmitter of rabies. They are the cause of human rabies deaths in Asia and Africa in more than 95% of all cases.

Bats are the source of most human rabies deaths in the Americas. Bat rabies has also recently emerged as a public health threat in Australia and western Europe. Human deaths following exposure to foxes, raccoons, skunks, jackals, mongooses and other wild carnivore host species are very rare.

Transmission can also occur when infectious material – usually saliva – comes into direct contact with human mucosa or fresh skin wounds. Human-to-human transmission by bite is theoretically possible but has never been confirmed.

Rarely, rabies may be contracted by inhalation of virus-containing aerosol or via transplantation of an infected organ. Ingestion of raw meat or other tissues from animals infected with rabies is not a confirmed source of human infection.

Post-exposure prophylaxis (PEP)

Post-exposure prophylaxis (PEP) means the treatment of a bite victim that is started immediately after exposure to rabies in order to prevent rabies from entering the central nervous system which would result in imminent death. This consists of:

local treatment of the wound, initiated as soon as possible after exposure;
a course of potent and effective rabies vaccine that meets WHO standards; and
the administration of rabies immunoglobulin (RIG), if indicated.

Effective treatment soon after exposure to rabies can prevent the onset of symptoms and death.

Local treatment of the wound

This involves first-aid of the wound that includes immediate and thorough flushing and washing of the wound for a minimum of 15 minutes with soap and water, detergent, povidone iodine or other substances that kill the rabies virus.

Recommended PEP

Depending on the severity of the contact administering with the suspected rabid animal, administration of PEP is recommended as follows (see table):

Table: Categories of contact and recommended post-exposure prophylaxis (PEP)

Categories of contact with suspect rabid animal	Post-exposure prophylaxis measures
Category I – touching or feeding animals, licks on intact skin	None
Category II – nibbling of uncovered skin, minor scratches or abrasions without bleeding	Immediate vaccination and local treatment of the wound
Category III – single or multiple transdermal bites or scratches, licks on broken skin; contamination of mucous membrane with saliva from licks, contacts with bats.	Immediate vaccination and administration of rabies immunoglobulin; local treatment of the wound

All category II and III exposures assessed as carrying a risk of developing rabies require PEP. This risk is increased if:

the biting mammal is a known rabies reservoir or vector species;
the animal looks sick or displays an abnormal behaviour;
a wound or mucous membrane was contaminated by the animal’s saliva;
the bite was unprovoked; and
the animal has not been vaccinated.

In developing countries, the vaccination status of the suspected animal alone should not be considered when deciding whether to initiate prophylaxis or not.

WHO continues to promote human rabies prevention through the elimination of rabies in dogs as well as a wider use of the intradermal route for PEP which reduces volume and thereby the cost of cell-cultured vaccine by 60% to 80%.

WHO response

Rabies, a zoonotic disease, requires close co-ordination between animal and human health sectors at the national, regional and continental levels.

In December 2015, a global framework to reach zero human rabies deaths by 2030 was launched by WHO and the World Organisation for Animal Health (OIE), in collaboration with the Food and Agriculture Organization of United Nations (FAO) and the Global Alliance for Rabies Control. This initiative marks the first time that the human and animal health sectors have come together to adopt a common strategy against this devastating but massively neglected disease.

Great strides have been made in the Philippines, South Africa and Tanzania where proof of concept projects as part of a Bill & Melinda Gates Foundation project led by WHO recently showed that a decrease in human rabies is possible through a combination of interventions involving dog vaccination, improved access to PEP, and increased surveillance and public awareness raising. The key towards sustaining and expanding the rabies programmes to new territories and countries has been to start small, demonstrate success and cost-effectiveness, and ensure community engagement.

Stockpiles of dog and human rabies vaccine have had a catalytic effect on rabies elimination efforts. WHO is working to assemble forecasts on the supply of human and dog vaccines and the need for rabies immunoglobulin, to understand the global manufacturing capacity and to explore bulk purchasing options for countries through WHO/UNICEF (human vaccine and RIG) and OIE/WHO (animal vaccine) mechanisms.

The use of stimulus packages consisting of technical and material support to kick-start rabies prevention programs for endemic countries and regions has proven successful. By enabling the implementation of proven control strategies, these create sustainable rabies elimination programs and could ideally be expanded to neighbouring regions and countries.

Rabies transmitted by dogs has been eliminated in many Latin American countries, including Chile, Costa Rica, Panama, Uruguay, most of Argentina, the states of São Paulo and Rio de Janeiro in Brazil, and large parts of Mexico and Peru.

Many countries in the WHO South-East Asia Region have embarked on elimination campaigns in line with the target of regional elimination by 2020. Bangladesh launched an elimination programme in 2010 and, through the management of dog bites, mass dog vaccination and increased availability of vaccines free of charge, human rabies deaths decreased by 50% during 2010–2013.