5 Things to Know About the Rabies Vaccine After CDC Issues Alert

The Centers for Disease Control and Prevention (CDC) has issued a health alert after an increase in reports of exposure to rabid or possibly rabid animals in the U.S. The alert is a reminder to healthcare providers about the importance of giving people rabies assessments and post-exposure prophylaxis (PEP) with the rabies vaccine as needed.

It’s an important point of awareness, since rabies is virtually 100% fatal once clinical signs appear, according to the World Health Organization (WHO). Initial symptoms are flu-like and include headache, fever, and discomfort at the site of the bite, and progress to severe brain effects—like anxiety, delirium, insomnia, hallucinations, and fear of water—a few weeks later, per the CDC.

Since July, public health officials in several areas of the country have reported increases in human rabies exposures from animals that are commonly known to carry rabies, along with ones that aren’t typically linked with the virus. That includes nearly 300 people in North Carolina who were recently exposed to rabies after interacting with infected goats at a mobile petting zoo.

From July through August, the CDC received 17% more rabies-related inquiries than during the same period last year, the agency reports. The CDC also received reports from at least eight state health departments regarding an increase in post-exposure prophylaxis for rabies, post-exposure prophylaxis administration errors, or both.

If post-exposure prophylaxis is started quickly after rabies exposure, it’s considered 100% effective at preventing a fatal infection. Nearly 100,000 people are treated with post-exposure prophylaxis for rabies each year in the U.S., according to CDC data.

Most Americans aren’t familiar with the rabies vaccine, or how post-exposure prophylaxis works if you’ve been exposed. The CDC notes that there have been “administration errors” with post-exposure prophylaxis for rabies, suggesting that there’s confusion in the medical community around proper use of this vaccine, too.

Actual rabies cases in humans are still considered rare in the U.S., although the virus circulates in wild animals. Bats, raccoons, foxes, skunks, and mongooses are considered “reservoirs” for the virus, meaning they tend to carry it.

But with the increase in cases and CDC alert, more people are likely concerned about rabies—and it’s clear there’s a lot folks don’t know about the rabies vaccine. Below, infectious disease doctors break it down.

Meet the experts: William Schaffner, M.D., an infectious disease specialist and professor at the Vanderbilt University School of Medicine; infectious disease expert Amesh A. Adalja, M.D., senior scholar at the Johns Hopkins Center for Health Security; Thomas Russo, M.D., professor and chief of infectious disease at the University at Buffalo in New York

1. The rabies vaccine can work after exposure and is given in several doses.

Rabies is usually spread through the bite of an infected animal, per the CDC. “Then, the rabies virus works its way into the local nerves and then the spinal cord,” says William Schaffner, M.D., an infectious disease specialist and professor at the Vanderbilt University School of Medicine. “You have a little time before the virus can actually get into the nerve to have antibodies attach itself to the virus and render it harmless.”

That’s where the rabies vaccine comes in. “Rabies is nearly unique in that vaccination works after exposure,” says infectious disease expert Amesh A. Adalja, M.D., senior scholar at the Johns Hopkins Center for Health Security. “Almost every other vaccine has to be given beforehand, because building antibodies takes one to two weeks and most pathogens outrun that. Rabies doesn’t.”

It can take days to months to develop rabies, depending on where on your body you were bitten, Dr. Adalja says. “A facial bite is a short distance, a foot bite is a long one,” he says. “That delay is the therapeutic window.”

The vaccine “stimulates your immune system” to neutralize the virus, Dr. Schaffner explains.

If you’ve already received a rabies vaccine in the past—say, if you work around potentially infected animals and got one as a preventive measure—you’ll receive two doses over a four-day period, starting as soon as possible after the exposure, per the CDC. If you’ve never gotten the vaccine before, you’ll get four doses over a two-week period, again, starting as soon as possible after your exposure.

2. The vaccine isn’t usually given alone.

The first dose of the rabies vaccine is usually given alongside another medication called human rabies immune globulin (HRIG), which provides some immediate protection against the virus.

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“Rabies immune globulin is a pre-made antibody infiltrated directly into and around the wound, neutralizing the virus right there,” Dr. Adalja explains. The vaccine then encourages your body to make its own antibodies over the following days and weeks, he says.

3. It can be really expensive.

Rabies is nearly always deadly if you don’t get the vaccine, making post-exposure prophylaxis crucial, points out Thomas Russo, M.D., professor and chief of infectious disease at the University at Buffalo in New York. But this vaccine can be expensive, depending on where you live and your health insurance coverage.

The CDC notes in its latest health alert that a “typical” course of post-exposure prophylaxis for rabies can cost between $11,000 and $14,000 per person. If you don’t have health insurance or if your policy doesn’t cover the rabies vaccine, it’s possible that your local health department will cover some or all of the cost, Dr. Russo says.

“Insurance generally does cover PEP—it’s medically necessary and CDC-recommended—but it’s billed as an emergency visit,” Dr. Adalja says. If your policy doesn’t cover emergency room visits, they’re incredibly high for you, or you don’t have health insurance, he says your local health department should be able to help with the cost.

“Local health departments in a number of jurisdictions stock vaccine and HRIG, and will administer the series in an outpatient clinic at a fraction of emergency department pricing,” Dr. Adalja says. “Some cover it entirely for uninsured patients.”

4. The vaccine is given differently than it was in the past.

The rabies vaccine used to be given in 20 or more shots to the stomach. However, that’s no longer the case. “That’s very old timey stuff,” Dr. Schaffner says.

“It’s now an intramuscular injection,” Dr. Russo says. Meaning, it’s given just like the COVID-19 or flu shot in the arm.

5. Doctors have a certain way of determining if you’ll need it.

Typically this involves your local health department. “What frequently happens is that a patient shows up in the emergency room and decisions have to be made,” Dr. Schaffner says. “Doctors can call their state health departments or call the CDC directly.”

Public health officials will typically use an algorithm that looks at the type of animal involved, how you were exposed—say, a bite, scratch, nibble, touch, or a lick—and the history of rabies in the area, Dr. Schaffner says.

“The biggest variable is species and local epidemiology,” Dr. Adalja says. “Bats, raccoons, skunks, and foxes are the U.S. reservoirs and carry real risk. Rodents and rabbits essentially never transmit—there is no documented U.S. human case from a rodent bite.” If the animal can be tested, brain tissue testing will usually give you an answer, Dr. Adalja says. But if it takes off or it’s a wild animal that’s considered a reservoir species, people are usually treated.

“Bats are in their own category, because their teeth are small enough that a bite may not be felt—someone waking up with a bat in the room is an indication for PEP even without a visible wound,” Dr. Adalja says.

Dr. Russo stresses the importance of getting checked out if you think you’ve been exposed to rabies. “People shouldn’t minimize exposure,” Dr. Russo says. “Post-exposure prophylaxis is the only option you have. If you develop rabies, it’s pretty much 100% lethal.”