Rabies & Animal Bites Information for Health Professionals

Wound Care

According to the Canadian Immunization Guide, wound care is probably the most effective procedure in the prevention of rabies. Wound care is also important to prevent other infections transmitted by animals. Accordingly:

• Care should be taken to clean the wound to its full depth. Flushing for approximately 15 minutes is suggested.
• Some guidelines also suggest the application of a viricidal agent, such as iodine-containing or alcohol solutions.
• Suturing the wound should be avoided if possible.
• Tetanus prophylaxis and antibiotics should be given as appropriate.

Risk Assessment for Terrestrial Animal Bites/Exposures

A four-Ws approach can be used to assess whether or not post-exposure prophylaxis is indicated for your patient.

Where did the exposure occur?

• Knowing where the exposure occurred is a key piece of information as the incidence of rabies varies a lot within Ontario and around the world.
• In Toronto, the risk of being exposed to a terrestrial animal with rabies is very low.
  • Bats are not a terrestrial mammal and are high risk for rabies transmission regardless of location.
• Cases of rabies have been confirmed in terrestrial animals in South West and Central West Ontario since 2015. Active surveillance of wildlife rabies in Ontario and annual confirmed animal cases can support risk assessment.
• In countries or areas at risk, the risk of being exposed to an animal with rabies can be much higher. There are also many countries recognized as rabies-free for domestic cats and dogs.
• Some more information about rabies in Toronto:
  • The most recent terrestrial wildlife with rabies in Toronto was in 1997.
  • In 2008, a puppy with rabies was imported from rural Ontario to Toronto.
  • In 2021, a dog with rabies was imported into Ontario from a country considered to be high risk for rabies in animal populations. The animal was in Toronto for two days.
  • In 2022, a dog with rabies was found in Toronto. It was imported about half a year earlier (in 2021) from a country considered to be high risk for rabies in animal populations.

What type of animal was involved?

• Only mammals can be infected with rabies. Non-mammal exposures are not a risk for rabies exposure and do not require rabies post-exposure prophylaxis.
• Bats should be assumed to be infected with rabies unless the animal tests negative. An estimated one to four per cent of bats in Canada may be infected with rabies.
• Small rodents (e.g., rats, mice and squirrels), are rarely found to be carrying the rabies virus. Exposures to these animals require post-exposure prophylaxis in exceptional circumstances only, such as if the animal demonstrates highly unusual behaviour.
• In Canada, outside of Toronto, wild animals (e.g., raccoons, skunks, foxes, bats) have a higher risk of carrying the rabies virus than domestic animals (e.g., dogs, cats, ferrets). In the last 20 years in Toronto, aside from bats, rabid animals have come from outside the City of Toronto.

Why did the exposure occur?

• Provoked exposures are generally considered normal behaviour for terrestrial mammals, and occur when an animal responds to a perceived threat to its: (1) body (fear-induced); or (2) food (possessive); or (3) territory or off-spring (protective).
  • Example(s) include:
    • Walking, running, or riding a bike (relatively close) past an animal (e.g., dog tied to a post/pole, common areas of a building, etc.).
    • Taking food from or attempting to feed an animal.
    • Petting or playing with an unfamiliar (e.g., someone else’s pet) animal.
  • Unprovoked attacks are more likely to indicate that the animal may have rabies.
    • Example(s) include:
      • Attack by an animal for an unknown reason and from a neutral site or site that is not the animal’s territory.
• Provocation is not a consideration for bat exposures.

Who is the animal’s owner?

• For exposures involving domestic and livestock animals, Toronto Public Health can contact the animal owner to observe its health and determine its immunization status. This information could potentially allow your patient to avoid unnecessary treatment and visits to the healthcare provider.
  • Domestic animals (i.e., dog, cat, or ferret) and livestock (i.e., horse, cow, bull, steer, calf, sheep, pig or goat) can be observed for a period of 10 days and 14 days, respectively.
• Testing an animal for rabies may be done in rare circumstances, such as illness or death of the animal during the observation period.
• If an animal cannot be observed (i.e., domestic animal unable to be located, or wild animals), then the rest of the risk assessment should guide post-exposure prophylaxis decision-making.

Contact Toronto Public Health for assistance with the risk assessment.

Risk Assessment For Bat Bites/Exposures

Rabies is transmitted from bats the same way as other animals – from rabies infected saliva that enters the body through a break in the skin or contact with a mucus membrane.

Bats are a concern because they are the most likely mammal to carry rabies in Ontario and a bite from a bat may not leave a visible mark. Most rabies cases in North America in the last few decades have been from bats.

If the bat did not touch the patient, there is no risk of rabies except in unusual cases such as going into a cave with many bats or working with live rabies virus in a laboratory.

Waking up in a room with a bat is not considered an indication for rabies post-exposure prophylaxis unless the bat touches the patient. If the person in the room cannot reliably communicate if the bat has touched them, for example, if they are an infant, or a person with dementia then a more detailed assessment is required.

Refer to the Public Health Ontario guidance on how to assess rabies exposures including helpful algorithms for bats which start on page 7 of the document.

Post-Exposure Prophylaxis (PEP)

Rabies Vaccine

• Brand names: Imovax® Rabies, RabAvert®

Rabies Immune Globulin (RabIg)

• Brand names: Imogam® Rabies or HyperRAB® or KamRAB®

Administration Schedule for Rabies Vaccine and Rabies Immune Globulin (RabIg)

Administration Schedule

Patient is	Day 0	Day 3	Day 7	Day 14	Day 28
Not previously immunized against rabies and immunocompetent	Rabies vaccine and Rabies Immune Globulin	Rabies Vaccine	Rabies Vaccine	Rabies Vaccine	No further action
Not previously immunized against rabies and immunocompromised or on antimalarial drugs	Rabies vaccine and Rabies Immune Globulin	Rabies vaccine	Rabies vaccine	Rabies vaccine	Rabies vaccine
Previously immunized with a documented complete course of rabies vaccine (HDCV/PCECV).^	Rabies vaccine	Rabies vaccine	No further action	No further action	No further action
Previously immunized with a complete course of rabies vaccine without documentation	Serology prior to administering: Rabies vaccine and Rabies Immune Globulin	Rabies vaccine	If an acceptable antibody concentration (0.5 IU/mL or greater) is demonstrated, the vaccine course may be discontinued, provided that at least two doses of vaccine have been given. Otherwise, administer the complete series based on patient immune status (as set out above).

^Documentation of complete immunization with other types of rabies vaccine, or with unapproved schedules of HDCV/PCECV rabies vaccine, with demonstration of acceptable serology requires consultation with a Toronto Public Health Associate Medical Officers of Health.

How to Administer Rabies Immune Globulin (RabIg)

RabIg Delivery

• Healthcare providers will be delivered one of the following products:
  • ImoGAM® 150 IU/mL (2 mL)
  • HyperRAB® 150 IU/mL (2 mL)
  • HyperRAB® 300 IU/mL (1 mL)
  • KamRAB® 150 IU/mL (2 mL)
• An appropriate number of vials will be delivered based on the weight of the patient; weight must be based on a current scale reading.

RabIg Dosing

• The volume to be administered will depend on the patient’s weight.
• Administer 20 IU per kg (9.09 IU per lb) body weight for all age groups.

How to Administer RabIg

• RabIg should be administered as soon as possible (on Day 0).
• You will need to administer multiple vials of RabIg on Day 0. The calculated dose should not be exceeded.
• There is no value in administering RabIg after Day 7 (i.e., 8 days or more) after the first dose of rabies vaccine was administered as it could interfere with immune response to the vaccine.
• RabIg comes as a liquid and should not be reconstituted.
• Infiltrate as much immune globulin as anatomically possible into and around the wound(s), similar to freezing a wound. Ensure to use a different syringe and needle than for the vaccine.
• Any remaining volume of RabIg should be injected intramuscularly (IM), using a new needle, at one or more site(s) distant from the site of vaccine administration (e.g., gluteal area, anterolateral thigh).
• If there are multiple or extensive wounds present, RabIg can be diluted in a diluent permitted by the specific product labelling in order to provide the full amount of RabIg required for thorough infiltration of all wounds.
• DO NOT administer RabIg at the same anatomical site as the vaccine.
• Other considerations:
  • Where there is no obvious wound (as may be the case for bat exposures), infiltrate as much RabIg as possible into the location(s) of the direct contact/exposure and the remainder intramuscularly, as described above.
  • Where there is no obvious wound, nor site of direct contact and rabies PEP is felt to be indicated (consult TPH for the risk assessment), the entire calculated dose of RabIg should be administered intramuscularly. As noted above, DO NOT administer RabIg at the same anatomical site as the vaccine.

How to Administer Rabies Vaccine

Rabies Vaccine Delivery

• Healthcare providers will be delivered one of the following products:
  • ImoVAX® Rabies (HDCV) or
  • RabAvert® (PCECV)
• An appropriate number of vials will be delivered based the applicable vaccine series per the chart above.

Rabies Vaccine Dosing

• Administer one dose of 1.0 mL rabies vaccine on each scheduled day of the rabies PEP series schedule.

How to Administer Rabies Vaccine

• Use a different syringe and needle than for the RabIg
• For patients 2 years of age and older: administer one dose (1 mL) IM in the deltoid.
• For patients between 1 year and 2 years of age: one dose (1mL) of rabies vaccine should be given IM in the anterolateral thigh, or in the deltoid if there is sufficient muscle mass.
• For patients less than 12 months of age: one dose (1mL) of rabies vaccine should be given IM in the anterolateral thigh.
• DO NOT administer rabies vaccine in the gluteal muscle.
• DO NOT administer rabies vaccine at the same anatomical site as RabIg on Day 0. The limb with the IM RabIg injection(s) can be used for subsequent doses of rabies vaccine in the vaccination series after Day 0.

Rabies Serology

When to Perform Serology

• Serology should be performed as follows:
  • Prior to initiating Day 0: for persons who may have previously completed a full course of rabies immunization (undocumented).
  • Seven (7) to fourteen (14) days after last dose:
    • For persons vaccinated using vaccines other than HDCV / PCECV or by the intra-dermal route.
    • For persons who are immunocompromised or are taking immunosuppressive agents (e.g., anti-malarial chloroquine)
    • For persons who had substantial deviation in their vaccine course (e.g., by several days or more).

Process to Submit Serology to PHO Laboratory

To ensure timely receipt of serology results from the Public Health Ontario Laboratory to determine further treatment decisions for patients of animal exposures, health care providers must:

1. Notify PHO’s laboratory Customer Service Centre of the incoming priority request at 416-235-6556/1-877-604-4567, prior to submitting a serum specimen for testing.
2. Ship priority specimens immediately, and separately from routine specimens in accordance with the Transportation of Dangerous Goods Regulations.
3. Clearly mark packaging with “Priority for WRA-Immuno Laboratory” for easy identification and retrieval upon arrival at PHO’s laboratory.
4. Ship priority specimens directly to PHO’s laboratory Toronto site at 661 University Ave., Toronto, Ontario. For delivery instructions please see Directions to 661 University Shipping Dock for Clinical Samples.

Notes:

• Failure to follow the submission instructions above may result in testing delays.
• Find additional information regarding Rabies serology testing at PHO’s Rabies Serology – Test Information.
• You can also call PHO’s Customer Service Centre at 1-877-604-4567 (toll free) or 416-235-6556, or email CustomerServiceCentre@oahpp.ca.

Vaccine schedule deviations

Vaccination schedules for post-exposure prophylaxis should be adhered to as closely as possible. It is essential that all doses be received. Doses should not be given early to allow for sufficient immune response between doses.

If a dose of vaccine is delayed, it should be given as soon as possible and the schedule resumed, preserving the spacing between intervals for subsequent doses. If there has been a significant deviation from the recommended vaccination schedule, immunity can be assessed with serology testing 7 to 14 days after the last vaccine dose.

Contraindications and precautions

There are no contraindications for rabies vaccine or RabIg after significant exposure to a proven rabid animal; however, care should be taken if PEP is to be administered to persons who are hypersensitive to the products or to any ingredient in the formulation or component of the container, including the following potential allergens:

• Imovax® Rabies vaccine: neomycin, phenol red
• RabAvert® vaccine: amphotericin B, chick protein, chlortetracycline, neomycin, polygeline (gelatin)
• Imogam® Rabies immune globulin: latex in vial stopper

Imovax® Rabies vaccine is preferred for patients with a history of hypersensitivity reactions to eggs or egg products. RabAvert® vaccine should only be administered to these persons if Imovax® rabies is not available and with strict medical monitoring.

Pregnancy and breastfeeding

Pregnancy and breastfeeding are not contraindications to post-exposure rabies prophylaxis.

Common adverse reactions

Common adverse reactions include injection site reactions, such as pain, erythema, swelling, and itching. Serious side effects are rare.

PEP initiated outside of Canada

• Rabies PEP given outside of Canada may include products not approved in Canada.
• Review available documentation from the patient, including product name, dosage, and route of administration.
• The following vaccines meet World Health Organization’s (WHO) safety, potency and efficacy requirements :
  • Verorab™ (a purified Vero cell rabies vaccine)
  • Rabipur® (a PCECV vaccine)
  • Rabivax-S™ (a purified Vero cell rabies vaccine)
  • VaxiRab N™ (a PCECV vaccine)
• If a WHO-approved vaccine series was started while overseas, the series can be completed with a rabies vaccine approved in Canada. Serological testing is recommended 7 to 14 days after completing the series.
• If the vaccine or schedule is not WHO-approved or if it was given intradermally and not completed, it is recommended to consult with Toronto Public Health about whether to reinitiate the series using rabies vaccine approved in Canada and if serology is needed. Health care providers should be aware that based on risk assessment, timing, and vaccine, re-initiating a series could potentially be avoided by consulting with Toronto Public Health.
• If no rabies immune globulin has been administered while overseas, as noted above, it can be provided in Canada up to seven days after the first dose of WHO or Health Canada-approved vaccine.

Immunization records

Health care providers should record all vaccine doses and immune globulin administered to an individual in two places:

• the personal immunization record held by the vaccine recipient, or his or her parent or guardian AND
• the record maintained by the health care provider who administered the vaccine.

For more information

• Toronto Public Health – Physician Instructions for Administering Rabies Post-Exposure Prophylaxis (PEP) (Updated September 2021) 
• Toronto Public Health – Rabies Vaccine and Rabies Immune Globulin Fact Sheet for Patients

Rabies Disease Information

Transmission

Rabies is spread to humans when the virus in the saliva of an infected animal enters through broken skin, the mucous membranes or the respiratory tract. Bites from an infected animal are the main route of exposure. Transmission also occurs through transplantation of organs from infected persons.

Incubation period

The virus gains access to the central nervous system through peripheral nerves. The usual incubation period is proportional to the distance from the portal of entry to the brain and may vary from several days to years (most commonly three to eight weeks).

Signs and symptoms

Once clinical signs of rabies appear, the disease is nearly always fatal. Preliminary symptoms of rabies in human may be similar to the flu, such as weakness or discomfort, fever, or headache. In addition, there may also be discomfort, prickling, or an itching sensation at the site of the bite. Preliminary symptoms may last for days.

Following preliminary symptoms, progression of rabies includes cerebral dysfunction, anxiety, confusion, and agitation. In addition, as the disease further progresses, patients may experience delirium, abnormal behavior, hallucinations, hydrophobia (fear of water), and insomnia.

Prevention

Pre-exposure prophylaxis

Pre-exposure prophylaxis is recommended for people at high risk of close contact with rabid animals or the rabies virus, including:

• people with occupational exposure to animals, such as veterinarians and veterinary staff, animal control and wildlife workers
• laboratory workers handling the rabies virus
• certain travellers to countries or areas at risk.
• hunters and trappers in areas with confirmed rabies
• people who explore caves (spelunkers)

Pre-exposure immunization consists of three 1 mL IM doses in the deltoid of rabies vaccine (brand names: Imovax® Rabies, RabAvert®) given on day-0, day-7 and any time between days 21 to 28.

Rabies Vaccine and Rabies Immune Globulin Fact Sheet for Patients

Toronto Public Health does not provide rabies pre-exposure prophylaxis. If your patient is a person at high risk of close contact with rabid animals or the rabies virus, they can be provided a prescription to obtain the vaccine from a local pharmacy, or referred to a travel medical clinic.

Immunization records

Health care providers should record all vaccine doses administered to an individual in two places:

• the personal immunization record held by the vaccine recipient, or his or her parent or guardian AND
• the record maintained by the health care provider who administered the vaccine.

Protection measures

The following measures can be taken to protect people and their pets from rabies:

• Pet dogs, cats and ferrets must be vaccinated against rabies. Certain livestock that come into contact with the public are also required to be vaccinated against rabies. This is required under Ontario legislation, Health Protection and Promotion Act, Regulation 567
• Make sure that pet dogs are supervised. They should not run loose in public spaces, unless in off-leash parks
• Stay away from all wild animals, especially if they appear tame, injured or sick
• Wild animals that show abnormal or sick behaviour should be reported to 3-1-1
• Wildlife-proof the home and yard. Store garbage bins inside a garage/basement until the morning of pick-up.

References

• Public Health Ontario – Rabies Guidance for Health Care Providers
• Public Health Agency of Canada – Canadian Immunization Guide Chapter on Rabies Vaccine 
• Toronto Public Health – Rabies Prevention & Control Website
• Ministry of Natural Resources- Rabies in Ontario
• World Health Organization – Rabies vaccines: WHO position paper- April 2018

Contact Toronto Public Health

Physicians have a duty to report animal-to-human exposures that in their opinion may result in the transmission of rabies under Regulation 557, Section 2(1), of the Health Promotion and Protection Act. Toronto Public Health can assist physicians with risk assessments, manage potentially rabid animals, and provide post-exposure prophylaxis (PEP) to requesting physicians.

To report an animal exposure to Toronto Public Health

• Report online using the Animal Exposure Report.
• Call Toronto Health Connection at 416-338-7600 on weekdays between 8:30 a.m. and 4:30 p.m.
• Call 3-1-1 at any other time.

Order post-exposure prophylaxis

• Speak with a TPH staff member by telephone to discuss the risk assessment and to order post-exposure prophylaxis:
  • Call Toronto Health Connection at 416-338-7600 on weekdays between 8:30 a.m. and 4:30 p.m.
  • Call 3-1-1 at any other time.
• The online Animal Exposure Report does not need to be completed when PEP is ordered or the exposure is reported by telephone.

Report a suspected or confirmed case of rabies in a human

Physicians have a duty to report suspected or confirmed human cases of rabies immediately to the Medical Officer of Health, under the Health Promotion and Protection Act.

•  How to report a communicable disease