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Answers to your questions about rabies, prevention, and treatment

What is rabies?

Rabies is an ancient infectious disease that has been around for thousands of years.1 It is usually caused by exposure to animals with the rabies virus, Rabies lyssavirus. It can be transmitted to humans through saliva via bites, scratches, or direct contact with mucosal membranes.1,2

What are symptoms of rabies?

Because untreated rabies is almost always fatal, it’s important to seek treatment for rabies immediately after exposure, before symptoms appear.

Once symptoms are present, the rabies infection has taken hold and it’s too late. Symptoms often start with a tingling or burning sensation at the wound. As the virus spreads into the central nervous system, people can develop flu-like symptoms such as fever, chills, and headache. Depending on the rabies virus strain, the next symptoms can include muscle weakness or hyper-excitability and agitation that turns into hypersalivation (frothing) and hydrophobia (fear of water) as the virus attacks tissues and organs. Finally, as the central nervous system fails, the end result is coma and death.2,3

How long is the incubation period for rabies?
Graphic of a calendar page representing the rabies incubation period

The incubation period after exposure to rabies is variable, typically 20 to 90 days, but ranges from a few days to a year or more. The incubation period depends on the strain of virus, how much of the virus has been transmitted, involvement of nerves at the wound site, and how close the wound is to the central nervous system.2,3

How common is rabies in humans?

Rabies in humans in the U.S. is actually quite rare. Only 25 cases were reported from 2009 to 2018,4 though an average of 55,000 people are treated for potential rabies exposure each year.5 Because untreated rabies is almost always fatal, it is advisable to seek immediate medical attention if you suspect you may have been exposed.

Graphic of U.S. flag to representing the United States

The U.S.

averages 1 to 3 rabies deaths reported each year.4

Graphic of globe to represent

Worldwide,

rabies is estimated to cause 59,000 deaths annually in over 150 countries, with 95% of cases in Africa and Asia.6

Which animals can get rabies?

Any mammal can get rabies, but worldwide, dogs are the source of 99% of human rabies infections.7 In the U.S., dog transmission of rabies has been virtually eliminated, in part due to widespread domestic canine rabies vaccine programs.7 Pets have typically received rabies vaccines annually, but the practice is shifting to a 3-year rabies vaccine.8

Wildlife such as foxes, raccoons, skunks, or bats are common transmitters of the rabies virus and, while U.S. rabies deaths are rare, rabid bats are the most common cause. Be cautious of animals who show signs of fearfulness, aggression, staggering, paralysis, seizures, or drooling more than normal. Others may act shy or timid, even uncharacteristically tame. All are possible symptoms of rabies.9 Be careful as well around domestic animals. Do not approach or touch any animal you do not know.

How is rabies prevented in humans?

Pre-exposure rabies vaccination adds a layer of protection before you are exposed to the rabies virus. It can be considered for those at higher risk, such as individuals who are often exposed through their work or travelers visiting high-risk areas. Receiving rabies vaccination before you are exposed does not eliminate the need for additional treatment if you are bitten. But it can offer a level of protection, particularly against unrecognized exposures. Pre-exposure vaccination primes your immune response so treatment after exposure can be effective more quickly. It also reduces the number of vaccinations you would need after exposure and simplifies treatment because human rabies immune globulin (HRIG) would no longer be needed.10

Preventing the onset of rabies after someone is exposed to the virus requires thorough cleansing of any wound as well as administration of rabies vaccine and HRIG for those who have not received pre-exposure vaccination.11

How long is the rabies vaccine good for when you receive pre-exposure vaccination?

The protective effect of pre-exposure rabies vaccination lasts for a limited time, which is why people at highest risk for exposure to rabies may have routine tests that check their immunity level, or titer. These tests can help determine whether vaccine booster doses are needed to enhance the immune response. It’s important to know that pre-exposure vaccination does not eliminate the need for additional treatment after a suspected exposure to rabies.11

How many shots do you get for rabies treatment and where are they injected?
Graphic of a syringe

The number of doses given after an exposure depends on whether you received pre- exposure vaccination. If you have previously received rabies immunization, you should receive 2 doses of a rabies vaccine. If you have not previously received rabies immunization, you will receive special antibodies known as HRIG. According to the FDA- approved prescribing information, the HRIG injection is followed by a series of 5 individual injections of RabAvert® (1.0 mL each) given intramuscularly on days 0, 3, 7, 14, and 28.17

Please note that current CDC/ACIP dosing recommendations differ, calling for a fifth dose on Day 28 only for patients who are immunocompromised.16

Adults receive rabies immunization injections in the upper arm; small children and infants receive them in the thigh. Rabies injections are no longer given in the stomach.12

Where do I go for rabies vaccination and will my insurance cover it?

You can consult with your healthcare provider about rabies and considerations for pre-exposure vaccination. If you will be traveling to areas at high risk of rabies exposure, you may want to seek the advice of a travel healthcare professional to help assess your specific level of risk. Also, to help find vaccination near you, visit www.hhs.gov/immunization/get-vaccinated/where/index.html.

If you suspect you have been exposed to rabies, seek the help of a medical professional and share all relevant information about your potential exposure. When evaluating the need for anti-rabies treatment, your provider will likely consider a number of things. You may be asked for information about the species and behavior of the animal you had contact with along with the circumstances and type of potential exposure you had (bite or non-bite).

If you are traveling and experience a potential rabies exposure, seek help at the nearest medical facility and explain the circumstances around your possible rabies exposure. Don’t wait until symptoms appear, because it will be too late.

Many health insurance plans cover much of the rabies vaccine cost for humans and an injection of HRIG antibodies if treatment after suspected exposure is required. Pre-exposure rabies vaccine may not be covered by your health plan. Consult with your doctor, pharmacist, insurance provider, or nearby travel clinic for more information on what coverage may be available to you.

When should I seek medical attention after potential exposure to rabies?

Immediately seek medical attention if you suspect you may have been exposed to the rabies virus. Even a scratch is potentially dangerous. Regarding bats, if one landed on you while you were sleeping or if you waken to a bat nearby, you may have been exposed even if you do not see bites or scratches. Bat bites or scratches sometimes do not leave obvious marks on the skin.13

Not every animal exposure will result in a need for anti-rabies treatment. To help avoid unnecessary vaccination, your healthcare provider will carefully assess your situation and consider factors such as the animal species involved, the circumstances of the bite or other exposure, the immunization status of the animal, and the presence of rabies in the region.

What are the steps to take if I’ve potentially been exposed to rabies?
  1. Immediately wash any wound for at least 15 minutes using soap and water. This can help reduce rabies virus infection by eliminating or inactivating rabies virus particles that may have infiltrated the wound.14
  2. Seek the help of a medical professional and share all relevant information about your potential exposure. In evaluating the need for anti-rabies treatment, your provider will likely consider, among other things, the species and behavior of the animal with which you had contact; the circumstances of your potential exposure; and the type of potential exposure (bite or non-bite).
  3. The number of doses given after an exposure depends on whether you received pre- exposure vaccination. If you have previously received rabies immunization, you should receive 2 doses of a rabies vaccine. If you have not previously received rabies immunization, you will receive special antibodies known as HRIG. According to the FDA- approved prescribing information, the HRIG injection is followed by a series of 5 individual injections of RabAvert® (1.0 mL each) given intramuscularly on days 0, 3, 7, 14, and 28.17

Please note that current CDC/ACIP dosing recommendations differ, calling for a fifth dose on Day 28 only for patients who are immunocompromised.16

If you have been previously vaccinated, you will receive 2 doses of RabAvert, 3 days apart. HRIG is not needed.11

How high is my risk of rabies exposure if I’m traveling to remote areas? Overseas?
Graphic of a suitcase

Camping, outdoor exploration, and overseas travel to high-risk destinations such as Southeast Asia, India, and North Africa all increase the risk of rabies exposure.15 The Centers for Disease Control and Prevention (CDC) recommends considering pre-exposure rabies vaccination for international travelers who are likely to come into contact with animals in parts of the world where rabies is common and immediate access to appropriate care is limited. Also at higher risk are people whose activities bring them into frequent contact with the rabies virus or with possibly rabid animals.11

Where can I get rabies vaccination?

Find rabies vaccination near you. Visit www.hhs.gov/immunization/get-vaccinated/where/index.html.

References
  1. Rupprecht CE, et al. Lancet Infect Dis. 2002;2(6):327-343. doi:10.1016/s1473-3099(02)00287-6 https://www.thelancet.com/journals/laninf/article/PIIS1473-3099(02)00287-6/fulltext
  2. World Health Organization. Rabies. Accessed April 15, 2021. https://www.who.int/en/news-room/fact-sheets/detail/rabies
  3. Centers for Disease Control and Prevention. What are the signs and symptoms of rabies? Accessed April 15, 2021. https://www.cdc.gov/rabies/symptoms/index.html
  4. Centers for Disease Control and Prevention. Is rabies in your state? Accessed April 21, 2021. https://www.cdc.gov/rabies/location/usa/surveillance/index.html
  5. Pieracci EG, et al. MMWR Morb Mortal Wkly Rep. 2019;68(23):524-528. doi:10.15585/mmwr.mm6823e1 https://www.cdc.gov/mmwr/volumes/68/wr/mm6823e1.htm
  6. World Health Organization. Epidemiology and burden of disease. Accessed April 15, 2021. https://www.who.int/teams/control-of-neglected-tropical-diseases/rabies/epidemiology-and-burden
  7. Ma X, et al. J Am Vet Med Assoc. 2020;256(2):195-208. doi:10.2460/javma.256.2.195 https://avmajournals.avma.org/view/journals/javma/256/2/javma.256.2.195.xml
  8. Thornton KC. AVME 2017: rabies vaccination – what you need to know. Accessed April 20, 2021. https://www.dvm360.com/view/avma-2017-rabies-vaccination–what-you-need-to-know
  9. American Veterinary Medical Association. Rabies and your pet. Accessed April 14, 2021. https://www.avma.org/resources/public-health/rabies-and-your-pet
  10. Centers for Disease Control and Prevention. Preexposure vaccinations. Accessed April 19, 2021. https://www.cdc.gov/rabies/specific_groups/travelers/pre-exposure_vaccinations.html
  11. Centers for Disease Control and Prevention. Human Rabies Prevention—United States, 2008. Morbidity and Mortality Weekly Report; 2008. Accessed April 14, 2021. https://www.cdc.gov/mmwr/PDF/rr/rr5703.pdf
  12. Centers for Disease Control and Prevention. When to seek care. Accessed April 14, 2021. https://www.cdc.gov/rabies/exposure/index.html
  13. Centers for Disease Control and Prevention. Coming in contact with bats. Accessed April 19, 2021. https://www.cdc.gov/rabies/bats/contact/
  14. Briggs DJ. The Immunological Basis for Immunization Series. Module 17: Rabies. World Health Organization; 2011. Accessed April 14, 2021. https://apps.who.int/iris/bitstream/handle/10665/44517/9789241501088_eng.pdf
  15. Centers for Disease Control and Prevention. Rabies. Accessed April 14, 2021. https://wwwnc.cdc.gov/travel/diseases/rabies
  16. Rupprecht CE, et al. MMWR Morb Mortal Wkly Rep. 2010;59(RR02);1-9. Available at: https://www.cdc.gov/mmwr/preview/mmwrhtml/rr5902a1.htm. Accessed October 2023.
  17. RabAvert® Prescribing Information. Available at: https://dailymed.nlm.nih.gov/dailymed/fda/fdaDrugXsl.cfm?setid=84b7a672-eeb1- 4527-84ac-68196b156be2. Accessed October 2023.

Important Safety Information

  • People with a history of severe allergic reaction (e.g., anaphylaxis) to RabAvert or any of its ingredients should not receive RabAvert…

Indication

RabAvert is a vaccine approved for all age groups to help prevent rabies infection both before and after a suspected exposure.

…for protection before a potential exposure (PrEP) to the rabies virus. They should receive a different rabies vaccine if a suitable product is available. However, because rabies is almost always fatal if left untreated, the protection provided with RabAvert after a potential exposure (PEP) to the rabies virus outweighs the risks associated with a severe allergic reaction.

  • The ingredients of RabAvert, which could in rare cases, cause allergic reactions in some people, include egg and chicken proteins, processed bovine (cow) gelatin and trace amounts of neomycin, chlortetracycline, and amphotericin B. Let your healthcare professional know if you have had any issues, including allergic reactions, with any of these ingredients or with vaccines in general.
  • Severe, potentially life-threatening allergic reaction, swelling of the brain and spinal cord; loss of movement or sensation due to nerve damage, such as inflammation of the brain or temporary loss of movement; Guillain-Barré Syndrome; inflammation of spinal cord; inflamed nerves of the eye; and multiple sclerosis have in very rare cases been reported.
  • RabAvert should be injected into muscle only. RabAvert injected into a vein may cause a reaction throughout the body, including shock.
  • Fainting can occur when injectable vaccines are used, including RabAvert. Your healthcare provider should put procedures in place to avoid falling injury and to restore blood flow to the brain after fainting.
  • Patients with a weakened immune system due to illness or the use of certain medications or treatments (such as radiation therapy, antimalarials, and corticosteroids) may have issues developing immunity. If such a patient is receiving RabAvert, then the healthcare professional may measure immune response through blood testing. Vaccination with RabAvert for protection before a potential exposure (PrEP) to the rabies virus should be delayed in anyone who is sick or recovering from an illness.
  • RabAvert contains albumin which is a protein found in human blood that carries an extremely remote risk for transmission of viral diseases, including Creutzfeldt-Jakob disease (CJD), a rare brain disorder. No cases of transmission of viral diseases or CJD have ever been identified for albumin.
  • Persons who have not been previously vaccinated against rabies will receive Human Rabies Immune Globulin (HRIG). HRIG should not be administered to persons who have been previously vaccinated as it may counteract the effect of the rabies vaccine. Let your healthcare provider know if you were previously vaccinated for rabies as you may not need HRIG.
  • Only use RabAvert while pregnant or breastfeeding if clearly needed. RabAvert was not studied in pregnant or lactating women so it is not known if RabAvert can cause any harm to the fetus, have any effect on ability to get pregnant, or whether it is passed through breast milk to infants (but many drugs are excreted in human milk).
  • There is no information on how RabAvert works when given at the same time as other vaccines.  
  • The most common side effects in clinical trials were reactions at the injection site, such as reddening, hardening, and pain; flu-like symptoms, such as lack of energy, tiredness, fever, headache, muscle pain, and feeling of discomfort; joint pain; dizziness; swelling of lymph nodes; upset stomach; and rash.
  • Vaccination before a potential exposure (PrEP) to the rabies virus does not remove the need for additional therapy after a suspected or known rabies exposure.
  • Seek the advice of a healthcare professional to help assess your specific level of risk if you are traveling to areas of high risk of rabies exposure; in frequent contact with the rabies virus or rabid animals, such as on the job; and/or are active outdoors and could encounter animals with rabies in the wild.
  • If you are exposed to a potentially rabid animal, seek medical attention right away before you have symptoms. Once symptoms are present, the rabies infection has spread through the body and survival is unlikely.

Uses for RabAvert

RabAvert is a vaccine approved for all age groups to help prevent rabies infection both before and after a suspected exposure. 

Patients should always ask their healthcare professionals for medical advice about the appropriate use of vaccines and adverse events. To report SUSPECTED ADVERSE REACTIONS, contact Bavarian Nordic at 1-844-4BAVARIAN or the US Department of Health and Human Services by either
visiting www.vaers.hhs.gov/reportevent.html or calling 1-800-822-7967.

Please see full Prescribing Information