Health Care Provider Information on Rabies

• Human rabies is extremely rare in Ottawa and Canada. A human case of rabies in Ontario was reported in in September 2024 with exposure to a bat in northern Ontario. This is the first human case of rabies acquired locally in Ontario since 1967.
• In all parts of Ontario, bats testing positive for rabies are found intermittently, thereby necessitating a careful assessment of all potential bat exposures.

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:

• Severity/depth of bites
• Bites on hands, neck, or face
• Animal saliva exposure to a pre-existing wound, mucous membrane, or respiratory tract
• Abnormal or aggressive behaviour in animal
• Unprovoked attack
• Prevalence of animal rabies in the area

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.).

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:

1. Online: Ottawa Public Health has recently launched a web form to receive reports of potential rabies exposures: Animal Exposure Reporting Form HCP - Ottawa Public Health
2. Phone: 
   • Regular Business Hours (Monday to Friday, 8:30 a.m. to 4:30 p.m.) - 613-580-6744 (after selecting language press 2 to enter the Healthcare stream, 1 to report to OPH, then 1 again to report an animal bite) or: 
   • After Hours/Weekends/Holidays: Please call 3-1-1 and request to speak to a Public Health Inspector  

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.).

Rabies Post-Exposure Prophylaxis (RPEP) for Previously Unimmunized Individuals

Download Rabies Immune Globulin (RabIg) and Rabies Vaccine Quick Reference Guide to Administration (PDF - 438 KB)

Rabies Post-Exposure Prophylaxis for Previously Vaccinated Persons

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:  

• OPH will attempt to contact the owner and issue a 10-day confinement/observation notice. The animal will most often be confined in the owner’s home. The animal will be released from confinement after 10 days when it is observed alive and healthy by a Public Health Inspector, and, at that time, the patient who was exposed will be informed that there is no risk for rabies and RPEP is not needed.  

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. 

Rabies, Ottawa Public Health

General Information on Rabies

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

Lab Testing

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 

Reporting

Communicable Diseases Reporting Page, Ottawa Public Health  

International Resources on Rabies

Rabies, U.S. Centers for Disease Control and Prevention (CDC)

• Rabies Status by Country 

Rabies, World Health Organization (WHO)

• Global Burden of Dog-Transmitted Human Rabies 

Rabies Risks in Terrestrial Animals by Country, UK Health Security Agency (UKHSA) 

Global Alliance for Rabies Control