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Rabies is an acute progressive encephalitis caused by a virus in the genus Lyssavirus, family Rhabdoviridae. It is nearly always fatal. It is most often transmitted to humans through the bite of an infected mammal. The virus in the saliva of an infected animal can be transmitted to humans through a bite or scratch, or contact with broken skin, mucous membranes, or the respiratory tract. In Canada, foxes, skunks, raccoons, and bats may be reservoirs capable of transmitting infection to domestic pets, livestock, and people. In Ontario, animals most at risk for having rabies are raccoons, foxes, skunks, and bats. World-wide, however, rabies in domestic and stray dogs poses the greatest risk. Aerosolized rabies virus in bat caves or laboratories and organ transplants are uncommon routes of transmission.
High-risk exposures include bites to the hands, face and neck. Bat bites are not always visible, and direct contact with a bat, when a bite, scratch or saliva exposure into a wound or mucous membrane cannot be ruled out, is sufficient exposure to warrant rabies post-exposure prophylaxis (RPEP).
Rabies is nearly always fatal but can easily be prevented by encouraging people to vaccinate their pets, avoid touching or interacting with any unknown animals, and seeking proper care for any animal bites or scratches.
As a healthcare provider, you may be asked to administer RPEP, and appropriate administration is vitally important to ensure patients have the necessary immune protection to avoid contracting rabies. This can be accomplished by:
Rabid animals most frequent in Ontario are bats, raccoons, foxes, and skunks.
Symptoms usually appear approximately 3 to 8 weeks after an exposure, but they can appear as soon as nine days or as long as seven years after a bite. Rabies is usually fatal unless post-exposure prophylaxis is given before the rabies virus enters the nervous system.
Early symptoms of rabies may include discomfort, paraesthesia, or pain at the exposure site, as well as headache, malaise, fever, and fatigue, and possibly psychological symptoms such personality changes or apprehension. More specific symptoms develop after an average of 4 days (up to 10 days) of prodrome. The fully developed illness typically presents in one of two ways. The more common furious form presents with symptoms of hydrophobia (fear of drinking, difficulty swallowing, foaming at the mouth caused by severe laryngeal or diaphragmatic spasms that cause a sensation of choking when attempting to drink or swallow), aggression and other behavioural changes. The paralytic (or dumb) form of the disease manifests as progressive flaccid paralysis. Both forms of the disease rapidly progress, typically within days, to encephalitis and death.
Factors taken into account during the exposure risk assessment:
More severe bites may be more likely to suggest the animal is rabid, and these bites may also provide more opportunity for exposure to and transmission of the virus because of increased exposure to saliva.
Bites on the hands and face are considered high risk exposures because of the high density of nerve endings. Bites to the face and neck are also considered higher-risk exposures because of the proximity to cranial nerves leading directly into the brain.
Ottawa Public Health (OPH) will conduct a risk assessment concerning suspected rabies exposures. However, the ultimate decision regarding administration of rabies post-exposure prophylaxis (RPEP) is based on the informed-consent discussion between the attending health care provider and the patient or parent/guardian.
The very small, sharp teeth of bats make it difficult to rule out a bite and therefore RPEP and testing of the bat, if it is available, are recommended after direct contact between a person and a bat. Minor or transient direct contact with a bat are considered an exposure because a bite may not be felt and may leave no visible mark. In situations where patients find a bat in a room in which they have been sleeping, assessment of direct contact may be difficult, particularly if the bat was found in the room with a child or adult who is unable to give a reliable history. Please see the Canadian Immunization Guide discussion of “Type of exposure” in the “Recommendations for use” section.
Please see the Management of Potential Rabies Exposures Guideline, 2020 as well as the Canadian Immunization Guide for further details.
In animals, the gold-standard diagnostic technique is post-mortem testing of brain tissue by fluorescent antibody test (FAT), which is very sensitive and specific.
There are currently no tests available to diagnose human rabies infection before the onset of clinical disease. Ante-mortem testing (before death) in humans can be performed via RT-PCR on samples of saliva. Serum, saliva, cerebrospinal fluid, and nuchal skin biopsy can be tested for antibodies to rabies virus. Note that no single test is sufficient to rule out rabies, and several tests in combination may be necessary to diagnose ante-mortem rabies in humans. Post-mortem diagnosis is done via FAT.
Please see Guidance for Submission of Human Specimens for Rabies Testing in Canada for further details (This link is found on Health Canada’s webpage: Rabies: For health professionals - Canada.ca.).
To confirm the effectiveness of pre- or post-exposure vaccination (i.e., a human case of rabies is not suspected), serology can be ordered to determine titres of antibodies to rabies virus.
All mammal bites as well as any contact with a mammal that has the potential to transmit rabies to a person must be reported as soon as possible to Ottawa Public Health or your local public health unit (O. Reg. 501/17, s. 1.).
A patient who is suspected to have human rabies must be reported as soon as possible to Ottawa Public Health or your local public health unit (R.S.O. 1990, c. H.7, s. 25; 1998, c. 18, Sched. G, s. 55 (2); O. Reg. 559/91, s. 1).
Ottawa Public Health is available to receive animal exposure reports 24 hours a day, 7 days a week:
3. Fax: A pdf version of our reporting form can be printed off and faxed to 613-580-9648.
Wash with a mild soap and flush the wound to its depth with copious amounts of water under moderate pressure for approximately 15 minutes. The wound must be carefully cleaned of debris, broken teeth, etc. Some guidelines also suggest the application of a viricidal agent, such as iodine-containing or alcohol solutions.
The wound should not be sutured unless indicated for cosmetic or tissue support reasons. Sutures, if required, should be placed after local infiltration of rabies immune globulin (RabIg). They should be loose and not interfere with free bleeding and drainage (Heymann 2022).
As appropriate, follow-up wound care should be undertaken by a physician. Although the risk of rabies may be small, there is a risk of other infections at the wound site. Tetanus-diphtheria vaccination should be updated as required and administration of antibiotics should depend on the clinical picture.
All mammal bites as well as any contact with a mammal that has the potential to transmit rabies to a person must be reported as soon as possible to Ottawa Public Health (OPH) or your local public health unit (O. Reg. 501/17, s. 1.).
Most humans are given rabies post-exposure prophylaxis (RPEP) as a result of exposure to domestic animals, therefore it is important to emphasize keeping rabies vaccinations up-to-date for all domestic cats, ferrets, and dogs. Also, maintaining control of pets by keeping cats and ferrets indoors and keeping dogs under direct supervision outdoors is important to prevent their exposure to wild animals with rabies.
Finally, it is important to call animal control if you encounter a stray animal or sick or injured wild animal. Do not approach, touch, or feed wild or stray animals. Teach children not to touch animals, including dogs and cats, even if they appear friendly.
Advise your patients who are at higher-risk of exposure to consider pre-exposure vaccine for rabies, particularly if they have occupational exposures (such as lab workers, veterinarians, animal control or wildlife workers) or are travellers who will spend more than one month in a country where rabies is endemic.
Pre-exposure prophylaxis of high-risk individuals consists of rabies vaccine administered at Day 0, 7 and 21–28. Exposure to a potentially rabid animal still requires two doses of rabies vaccine post-exposure. For persons at high risk of exposure (e.g., a lab technician working with rabies virus) constant protection is necessary to cover unrecognized exposures and, as protection wanes over time, serologic testing is required every six months to two years depending on the ongoing exposure risk scenario. A booster shot is necessary if antibody titres fall below 0.5 IU/mL. For details see the Canadian Immunization Guide rabies vaccine “Serologic and cerebrospinal fluid testing”: “People with ongoing high risk of exposure.”
When Ottawa Public Health (OPH) is contacted by a health care provider who has assessed a patient with a potential exposure to the rabies virus after a bite or contact with an animal's saliva, OPH will conduct a risk assessment. However, the ultimate decision regarding administration of rabies post-exposure prophylaxis (RPEP) is based on the informed-consent discussion between the attending health care provider and the patient or parent/guardian. OPH will deliver RPEP to the health care provider. Following the rabies vaccine schedule from the Canadian Immunization Guide is very important. OPH will call you to make sure that you receive the right doses on the right days.
For domestic animals, patients are often concerned about what happens to the animal and may find the following information reassuring:
In the rare event that the animal becomes ill during confinement, a veterinarian assessment is recommended. If the veterinarian suspects rabies, the animal must be humanely euthanized, and Ottawa Public Health (OPH) arranges for testing of the animal for rabies – results are typically available within 72 hours from delivery to the lab. OPH will speak with the vet, the patient, and the health care provider to determine risk and support decision-making for RPEP.
Vaccine Administration - Rabies vaccine: Canadian Immunization Guide, Public Health Agency of Canada
Rabies Prevention and Control Protocol, 2023, Ministry of Health
Rabies Immune Globulin (RabIg) and Rabies Vaccine Quick Reference Guide to Administration (PDF - 438 KB), Ottawa Public Health
Short Report: Is injecting a finger with rabies immunoglobulin dangerous?, American Journal of Tropical Medicine and Hygiene
How to Administer Rabies Post-Exposure Prophylaxis, Public Health Ontario (In English only)
Management of Potential Exposure to Rabies Guideline, 2020, Ministry of Health
Rabies Serology, Public Health Ontario
Rabies Testing at the CFIA: General Information and Submission Guidelines, Canadian Food Inspection Agency [PDF]
Vector-borne and Zoonotic Diseases, Public Health Agency of Canada
Communicable Diseases Reporting Page, Ottawa Public Health
Rabies, U.S. Centers for Disease Control and Prevention (CDC)
Rabies, World Health Organization (WHO)
Rabies Risks in Terrestrial Animals by Country, UK Health Security Agency (UKHSA)
If you have questions regarding rabies or want to notify Ottawa Public Health about an animal bite or potential exposure to rabies, please call 613-580-6744 (after selecting language press 2 to identify yourself as a health care professional and then press 1 and press 1 again to report an animal bite). After hours/weekends/holidays: Please call 3-1-1 and request to speak to a Public Health Inspector.
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