Most people have heard of the rabies virus. It’s one of the few vaccinations required by law here in the U.S. for dogs and cats, with some areas requiring you to purchase licenses as well to document your pet’s up to date status.

Some people know that rabies is only transmitted by mammals, which are fur-bearing creatures that also produce milk for their young. ANY mammal can develop and spread rabies, but in reality, there are four main species here in the U.S. we consider at high risk for spreading rabies: foxes, skunks, raccoons, and bats. Worldwide, dogs are the most common source of rabies (which is something you need to consider when traveling to countries where rabies is present), but dogs typically only make up 5% of the rabies cases in the U.S. In the Americas, bats are the most common source of the infection. This is due in part to vaccination protocols for pets.

I’ll never forget the time I saw a documentary about the number of urban foxes living in London, and how some people fed them like squirrels. Much as I love foxes, I was aghast at this notion until I remembered rabies isn’t present in the United Kingdom. That’s one of the reasons it is so difficult to get a dog or cat into certain countries (or Hawaii, for that matter). They don’t have rabies in these places (often islands or continents isolated by water) and they don’t want it there.

“What does rabies do to you anyway?”

That was the question a client asked when I plead with her at the VERY LEAST, please vaccinate the feral tom cat she allowed to sleep on her toddler’s bed every night.

Mentally, I shouted, “GO RENT Ol’ YELLER!”

Sometimes I think that vaccinations are the victims of their own success. Because we’ve eradicated or limited the damage of so many serious diseases due to vaccination, there are many people out there who believe the vaccination is more harmful than the disease itself, or who don’t realize just how important vaccination is to public safety.

Instead of yelling at my clueless client, I explained that rabies is a virus that causes inflammation of the brain. There is no way to diagnose it in the living person before symptoms appear, and it is almost always fatal once symptoms do appear. While most people assume the only way to get rabies is by being bitten by a rabid animal, saliva from an infected animal can transmit the virus if the spit comes into contact with broken skin, or in the eyes, nose, and mouth. The virus is also present in the spinal fluid of affected animals, which is another reason why you must be very careful how you handle an animal you suspect might have rabies.

Once the virus gets into the nervous system, it travels very slowly to the brain. It typically takes anywhere from one to three months for someone who has contracted the disease to begin showing symptoms, though the closer the area of exposure is to the brain (say the eye versus being bitten on the foot), the shorter the time course of the disease. The symptoms vary so much, it can be hard to identify them at first. Humans may experience nausea, uncontrollable movements, an inability to swallow, confusion, and coma. Photophobia (an avoidance of bright light) can also be a symptom. Dogs and cats often show behavioral changes, including aggression and uncontrollable seizures. They frequently salivate heavily and avoid water, not because they are afraid of water (hydrophobia) but because it hurts so much to swallow, there is an avoidance factor at work. In the “dumb” form (the non-aggressive kind) of rabies, wild animals will often act tame, or appear drunk and disoriented. They can circle aimlessly or appear partially paralyzed. Self-mutilation is not uncommon.

As of 2016, only fourteen people have survived rabies once they developed clinical signs.

This is why it is critical to start post-exposure vaccination and immunotherapy as soon as any potential exposure occurs, as this is very effective in preventing the development of the disease.

Wait a minute, I can hear you say. You said it can take months for the symptoms to appear, but we only quarantine a suspected rabid dog or cat for 14 days. More on the reason behind that when we discuss what to do in the face of a possible exposure.

Vaccination is the hero in the rabies prevention story. Worldwide vaccination of humans has decreased the risk of mortality in those regions where rabies is rampant. Here in the U.S., people in high-risk professions (such as veterinarians, support staff, and people who work with wildlife) get vaccinated to help protect them in the face of exposure. Because it is not unusual for people who get vaccinated for rabies to develop reactions to this particular vaccine, instead of getting booster shots, people who have been protectively vaccinated against rabies undergo titer testing every couple of years to make sure they have a protective level of antibodies in case of exposure.

Having a protective titer doesn’t mean you don’t get boosted if you do get exposed, however! Let’s walk through the different scenarios.

I mentioned above that when a dog, cat, or ferret bites someone, it is only quarantined for 14 days in most parts of the U.S. That is because we know if an animal bites you because it has rabies (and not because it was scared or aggressive), it will die from the disease within that time frame. So, if a dog or cat bites someone, regardless of its rabies vaccination status, the health department will insist on a quarantine period. Because rabies vaccination is so effective, however, the restrictiveness of the quarantine for a pet is likely to be less severe than if the rabies status of the animal is unknown (as in a feral animal).

That is not to say that animals vaccinated for rabies are always completely protected in the face of exposure. There can be issues with a vaccine lot number, or improper handling of the vaccine itself (such as vaccines that should be refrigerated arriving with the ice packs melted, or a power outage resulting in the storage unit getting too hot). The rabies vaccination may also fail to take effect if the animal is ill at the time of vaccination. I have to vaccinate a puppy by 16 weeks of age because it’s required by law in my area, but if that puppy has severe demodectic mange (which could indicate a compromised immune system), I’m going to recommend an additional rabies booster once the medical condition is resolved. These are just some of the reasons that a companion animal might need to be quarantined despite proof of vaccination.

If a wild animal bites someone, and can be caught, it will be humanely destroyed and have its head removed because examination of brain matter is the only way to test for rabies at this time. Because it is imperative that rabies prophylaxis treatment begins right away when humans are bitten, there are no exceptions if this occurs. And because wolf-hybrids are considered wild species (and rabies vaccines were not tested or approved for use in those species), there is no quarantine period if a wolf-hybrid bites someone. It is automatically euthanized. Many of the people who boast of having a wolf-hybrid have no such thing. In reality they have a mix of one of the Arctic Circle breeds, such as a Siberian Husky or Alaskan Malamute. Please, please, please do DNA testing on your dog before you go around telling people it is a wolf-hybrid.

In order to be tested for rabies (and in order for you to avoid undergoing the expensive and uncomfortable post-exposure treatment), the brain of the affected animal must be examined. This means it is critical that if you must shoot a wild animal attacking you or your pets, you avoid shooting it in the head if at all possible. Not only will it make it nearly impossible to test for rabies if the head is destroyed, but you could well have explosively scattered bits of rabies-infected material all over everyone nearby. It is also critical that testing be done as soon as possible. Animals that have begun to decay in a hot environment may not have viable brain matter to test. DO NOT FREEZE ANY CARCASSES. Freezing will also destroy the rabies virus and prevent identification. Ideally, the remains should be refrigerated and taken either directly to the nearest state laboratory or to a professional equipped to safely remove the head for shipment. Remember, the virus is in the central spinal fluid as well as in the saliva.

The real issue is when you are dealing with the potential exposure to you or your pet by a rabid animal such as a racoon or bat. Remember the long incubation period? So, while we know that if an animal bites you because is it rabid, it will die in a specific period of time due to the disease. It will take you or your pet weeks to months to show signs of illness if you are exposed.

There are a couple of different scenarios to look at here. Let’s take the animal contact ones first before examining the human contact situations.

First: Your vaccinated pet comes into contact with a wild animal, but you are unable to present it for rabies testing because it ran off. Your pet’s rabies vaccine is up to date. The health department will probably recommend boosting the rabies vaccination right away and no quarantine period, depending on the degree of contact and if there was any human involvement as well. Your pet should be examined for wounds by your veterinarian.

Second: Your up to date, vaccinated pet fights with a wild animal which is then killed or trapped by either your pet or you. If the animal is deceased, you should (wearing gloves and a mask) bag the dead animal and contact the health department. If the animal is still alive, leave it completely alone and contact the health department. If it is after hours and you cannot get someone out to you, contain the wild animal as best as possible if doing so will not risk further exposure to you or your pet. Try to get animal control out as soon as possible so the wild animal can be safely euthanized and tested.

If the wild animal doesn’t have rabies, all is well. If the animal DOES have rabies, then the health department will institute some kind of quarantine period for at least 45 days. This is because no vaccine is 100% effective (as we discussed earlier) and because on average, an animal infected by rabies will develop clinical signs by this time. However, because rabies vaccination is considered very effective, usually the quarantine procedure will not be as restrictive (must remain confined on the property, such as in a pen or a horse stall, only one person designated to care for the animal, etc.) as it would be if the pet were not up to date on vaccination. The rabies vaccine may be boosted at the beginning of the quarantine period or the end, depending on the locality and regulations.

Third: The exposed pet in question is NOT up to date, or worse, has never been vaccinated at all. Now the health department will institute very strict quarantine protocols. Most departments will require the pet to be confined in a pen inside another pen, with no possibility of human contact whatsoever for six months. This is very upsetting to a well-socialized pet accustomed to being part of the family, but it is devastating to a young animal that hasn’t had much human contact in the first place.

I will never forget the tragedy of having to euthanize an entire litter of seven-week-old Labrador Retriever puppies. We’d just seen them the week before for their first distemper/parvo vaccines. A confirmed rabid skunk got in the pen with them, and their breeder made the heartbreaking decision to euthanize them rather than attempt to quarantine them under the strict guidelines. They realized at the end of the six-month period that the puppies would be impossible to rehome, as they would have been more like wild animals than dogs raised in a loving environment.

Remember what I said about bats being the most common source of rabies exposure in the U.S.? Do not assume that that your 100% indoor pet doesn’t need rabies vaccination. It does because it’s the law. It does because if your pet bites a visitor (or in one case I know, the person rescuing it during a house fire), the health department will get involved. And lastly, I know of three clients who have had rabid bats get into their homes. Keep your pets legal and safe!

The health department must be merciless when it comes to protecting the public from a possible rabies exposure. It has to be. I recall many years ago when someone exposed over forty people at a church social to rabies by bringing a baby raccoon to the event. The rabies vector species can be carrying the virus at birth, and raccoons can have rabies without showing any clinical signs. Every person exposed at that event had to undergo the expensive and uncomfortable post-exposure series of shots.

The fact remains that over 70% of rabies cases in the U.S. are as the result of bat bites or scratches. Many times, the victim has no recollection of when the exposure occurred. The other cases are usually due to contact with wildlife, and after that, contact with a rabid companion species, such as a dog or cat. Because many communities don’t require licenses for them, cats are more likely to not be current on their rabies vaccinations. Because outdoor cats hunt, hang around barns, and their feeding stations can attract wildlife, cats often come into contact with the vector species. As a professional, I can tell you it is frustrating to be presented with a sick pet and not be able to immediately take rabies off the list of possible problems.

Livestock are also at risk of exposure to rabies-vector species, and you should talk to your veterinarian about vaccination.

What happens when there is human exposure, such as the example of the church picnic?

The protocols vary on an individual basis, depending on how much contact you had with the affected animal, and whether or not it can be proven the animal was indeed rabid. You must work closely with the health department and your doctor to determine what is best for you.

If you have never had the pre-exposure rabies vaccination series, recommended for anyone working in a high-risk profession (veterinary medicine, wildlife management, etc.), then if it is determined you need post-exposure treatment, you will be given a large dose of immunoglobulins first. This is to give you an immediate passive transfer of antibodies against the virus. It’s called passive transfer because these are not antibodies you created yourself. Think of passive transfer like a large patch on a deep, bleeding wound. It will stop the bleeding long enough for you to get to the hospital, but you’re still going to need stitches to close the wound.

The immunoglobulin therapy (large volume given by injection in a large muscle, probably the one you sit on) is then followed by a series of rabies vaccinations. Currently, the protocol requires a series of five boosters given over a period of many weeks. This stimulates your own immune system to create an active antibody response to the threat. This is necessary because passively transferred antibodies won’t hang around for the months and months needed to completely protect you if the virus gets into your nervous system.

What happens if a previously vaccinated person gets exposed to a rabid animal? That happened to me. A dog came in on emergency having seizures. It was a stray dog the family had been feeding for about a month. The differential list of possible problems included organophosphate poisoning, mushroom toxicity, epilepsy, canine distemper, and rabies. The patient’s lab work was unremarkable, and he appeared to respond to strong anticonvulsants as the seizures stopped and his behavior was completely normal.

Twenty-four hours later, he died.

We insisted on rabies testing, much to the resistance of everyone involved. Rabies wasn’t considered very high on the rule-out list, and the dog hadn’t bitten anyone. But we persisted, and the dog came back positive for rabies.

When a pre-vaccinated person is exposed to rabies, the first thing they do is they check your rabies titer. If your titer is below the recommended levels for protection, you are treated like an unvaccinated person and must get the immunoglobulin therapy as well as the five booster shots. If your titer is good, they skip the immunoglobulin therapy and give you only two boosters.

It doesn’t matter if the titer is considered “good.” Rabies is almost always fatal, so booster shots are ALWAYS given to the pre-vaccinated person. The titer determines how many and if the immunoglobulin is needed or not.

I was fortunate enough to have a strong titer, and only needed two boosters, which is good because I developed hives from head to foot after the second booster and was told I could not take anything systematically to treat them—no Benadryl, no steroids. Anything I took to minimize the symptoms might limit the effectiveness my immune response to the vaccination. The only thing I was allowed to use was a little over the counter topical cortisone cream.

As I mentioned before, because reaction to rabies vaccination in humans is common, instead of getting regular rabies vaccinations like your dog or cat, people get their titers checked every couple of years and only get boosted if the titer is low. I’m lucky in that my titer has been high ever since, so I have not needed additional boosters, but that could change if I am exposed to another rabid animal. At the same time, I consider myself lucky I live in a time when vaccinations can protect both myself and our pets against such a devastating disease.

Don’t take the risk of having an unvaccinated pet. While there may be medical exceptions at times, vaccinating your pet for rabies is the safest, smartest thing you can do.