ByJohn E. Greenlee, MD, University of Utah Health
Reviewed/Revised Mar 2022 | Modified Sept 2022

Rabies is a viral infection of the brain that is transmitted by animals and that causes inflammation of the brain and spinal cord. Once the virus reaches the spinal cord and brain, rabies is almost always fatal.

  • The virus is usually transmitted when people are bitten by an infected animal, usually a bat in the United States or a dog in countries where dogs are not routinely vaccinated against rabies.

  • Rabies can cause restlessness and confusion or paralysis.

  • A skin biopsy can detect the virus.

  • Infection can be prevented by immediately cleaning the wound and by injecting rabies vaccine and immune globulin.

(See also Overview of Brain Infections.)

The virus is transmitted in the saliva of an infected animal. From the point of entry (usually a bite), the rabies virus travels along nerves to the spinal cord and then to the brain, where it multiplies. From there, it travels along other nerves to the salivary glands and into the saliva. Once the rabies virus reaches the spinal cord and brain, rabies is almost always fatal. However, the virus typically takes at least 10 days—usually 30 to 50 days—to reach the brain (how long depends on the bite’s location). During that interval, measures can be taken to stop the virus and help prevent death. Rarely, rabies develops months or years after an animal bite.

Rabies causes more than 55,000 deaths worldwide each year. Most deaths occur in rural areas of Latin America, Asia, and Africa. In the United States, only a few people die each year.

Causes of Rabies

The rabies virus is present in many species of wild and domestic animals throughout most of the world. Animals with rabies may be sick for several weeks before they die. During that time, they often spread the disease.

The rabies virus, which is present in the saliva of a rabid animal, is transmitted when the animal bites or, very rarely, licks another animal or a person. The virus cannot pass through intact skin. It can enter the body only through a puncture or another break in the skin or through the nose or mouth when many airborne droplets containing the virus are inhaled (as can occur in a cave that contains infected bats).

Many different mammals—such as dogs, cats, bats, raccoons, skunks, and foxes—can transmit rabies to people.

In the United States, vaccination has largely eliminated rabies in dogs, and the source of rabies is almost always wild animals, usually bats but also foxes, skunks, or racoons. In many cases, the bat bites are unnoticed. Most deaths due to rabies result from being bitten by an infected bat.

In countries where dogs are not routinely vaccinated against rabies (including most countries in Latin America, Africa, Asia, and the Middle East), most deaths due to rabies result from being bitten by an infected dog. A few cases result from being bitten by other animals including monkeys, which are sometimes kept as pets.

Rabies rarely affects rodents (such as hamsters, guinea pigs, gerbils, squirrels, chipmunks, rats, and mice), rabbits, or hares. In the United States, these animals have not been known to cause rabies among people. Rabies does not affect birds and reptiles.

Did You Know...

  • In the United States, people who are bitten by rabbits and most small rodents—such as hamsters, gerbils, squirrels, rats, and mice—almost never need a rabies vaccination.

  • Bats are responsible for most of the few deaths due to rabies in the United States.

Symptoms of Rabies

The wound from the bite may be painful or numb. Bat bites typically cause no symptoms.

Rabies symptoms appear when the rabies virus reaches the brain or spinal cord, usually 30 to 50 days after a person is bitten. However, this interval can vary from 10 days to more than a year. The closer the bite to the brain (for example, on the face), the more quickly symptoms appear.

Rabies may begin with a fever, headache, and a general feeling of illness (malaise). Most people become restless, confused, and uncontrollably excited. Their behavior may be bizarre. They may hallucinate and have insomnia. Saliva production greatly increases. Spasms of the muscles in the throat and larynx occur because rabies affects the area in the brain that controls swallowing, speaking, and breathing. The spasms can be excruciatingly painful. A slight breeze or an attempt to drink water can trigger the spasms. Thus, people with rabies cannot drink. For this reason, the disease is sometimes called hydrophobia (fear of water).

As the disease spreads through the brain, people become more confused and agitated. Eventually, coma and death result. The cause of death can be blockage of airways, seizures, exhaustion, or widespread paralysis.

In 20% of people, rabies begins with tingling or paralysis of the limb that was bitten. The paralysis then moves through the body. In these people, thinking is typically unaffected, and most of the other symptoms of rabies do not develop.

Diagnosis of Rabies

  • Examination and testing of samples of skin, saliva, and cerebrospinal fluid (obtained by spinal tap)

Doctors suspect rabies when people have a headache, confusion, and other symptoms of the disease, especially if people have been bitten by an animal or exposed to bats (for example, if they were exploring a cave). However, many people with rabies are unaware of having been bitten by an animal or exposed to bats.

A sample of skin is taken (usually from the neck) and examined under a microscope (skin biopsy) to determine whether the virus is present. Samples of saliva are also examined to check for the virus. A spinal tap (lumbar puncture) is done to obtain a sample of cerebrospinal fluid (the fluid that flows through the tissues that cover the brain and spinal cord). This sample is also examined.

The polymerase chain reaction (PCR) technique, which produces many copies of a gene, is often used to identify the virus's unique DNA sequence in a sample of skin, cerebrospinal fluid, or saliva. Several samples of the fluids, taken at different times, are tested to increase the chances of detecting the virus.

Prevention of Rabies

Before an animal bite

Avoiding being bitten by animals, especially wild animals, is best. Pets that are not known and wild animals should not be approached. Signs of rabies in wild animals may be subtle, but their behavior is typically abnormal, as in the following:

  • Wild animals may not appear shy or afraid when people approach them.

  • Nocturnal animals (such as bats, skunks, raccoons, and foxes) are out during the day.

  • Bats make unusual noises or have difficulty flying.

  • Animals bite without being provoked.

  • Animals are weak or agitated and vicious.

An animal that may be rabid should not be picked up to try to help it. A sick animal often bites. If an animal appears sick, people should call local health authorities, who can help remove it.

The rabies vaccine should be given to people who are likely to be exposed to the rabies virus before exposure. Such people include the following:

  • Veterinarians

  • Laboratory workers who handle animals that may be rabid

  • People who live or stay more than 30 days in developing countries where rabies in dogs is widespread

  • People who explore bat caves

Three doses of the vaccine are injected into a muscle. The first dose is given right away (called day 0). The other injections are given on day 7 and between days 21 and 28. The injection site may be painful and swollen but usually only slightly. Serious allergic reactions are rare.

Vaccination protects most people to some degree for the rest of their life. However, protection decreases with time, and if exposure is likely to continue, people are tested periodically, and if the levels of protective antibodies are low, they are given a booster dose of vaccine.

After an animal bite

Doctors also try to determine the likelihood that rabies was transmitted. Early determination is essential because rabies can usually be prevented if appropriate measures are taken promptly.

Whether vaccine and immune globulin are needed depends on whether people have been previously immunized with rabies vaccine and what the type and status of animal are. For example, doctors determine the following:

  • Whether the animal was a bat, a dog, a raccoon, or something else

  • Whether it appeared sick

  • Whether the attack was provoked

  • Whether the animal is available for observation

Who Should Receive the Rabies Vaccine?

In the United States, the decision to give the rabies vaccine to a person who has been bitten by an animal depends on the type and status of the animal.

For people bitten by a pet dog, cat, or ferret:

If the status of an animal cannot be determined—for example, because it escaped—public health officials are consulted to determine how likely rabies is to be in that particular area and whether the vaccine should be given. If there are no local public health officials and rabies is possible, the vaccine is given immediately. Very rarely in the United States, if an animal has or appears to have rabies, the vaccine and the immune globulin are given immediately.

For people bitten by skunks, raccoons, foxes, most other carnivores, or bats: Such an animal is considered rabid unless it can be tested and the results are negative. Usually, the vaccine and the immune globulin are given immediately. Waiting to observe wild animals for 10 days is not recommended. When possible, these animals are put to sleep (euthanized), and their brain is examined for the rabies virus as soon as possible. The vaccine is stopped if the animal tests negative for the rabies virus.

Because people may not notice a bat bite, they are given the vaccine if a bite seems possible. For example, if someone awakens and a bat is in the room, the vaccine is given.

For people bitten by livestock, small rodents, large rodents (such as woodchucks and beavers), rabbits, or hares: Each biting incident is considered individually, and public health officials are consulted. People who are bitten by hamsters, guinea pigs, gerbils, squirrels, chipmunks, rats, mice, other small rodents, rabbits, or hares almost never require rabies vaccination.

If people have already been vaccinated, the risk of developing rabies is reduced. However, the wound must be cleaned promptly, and an injection of rabies vaccine is given immediately and on day 3.

Treatment of Rabies

  • Comfort measures

After symptoms develop, no treatment can help. At this point, the infection is virtually always fatal. Treatment involves relieving symptoms and making people as comfortable as possible. Rarely, people who are given support in an intensive care unit for a long time survive.

More Information

The following is an English-language resource that may be useful. Please note that THE MANUAL is not responsible for the content of this resource.

  1. Centers for Disease Control and Prevention: Rabies. This web site provides links to how rabies is transmitted, what its symptoms are, how to prevent rabies, and when to seek medical care, as well as information for specific groups of people and other resources. Accessed 2/18/22.

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