rabies

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Definition

Rabies is an acute viral disease of the central nervous system that affects humans and other mammals. It is almost exclusively transmitted through saliva from the bite of an infected animal. Another name for the disease is hydrophobia, which literally means "fear of water," a symptom shared by half of all people infected with rabies. Other symptoms include fever, depression, confusion, painful muscle spasms, sensitivity to touch, loud noise, and light, extreme thirst, painful swallowing, excessive salivation, and loss of muscle tone. If rabies is not prevented by immunization, it is essentially always fatal.

Description

Worldwide, approximately 15,000 cases of human rabies continue to occur annually. Remarkably, although more than one million persons in the United States are bitten each year by animals, on average, only one or two persons die from the disease each year. Nevertheless, with the continued encroachment of humans on animal habitats, both for housing and recreational purposes, rabies remains a public health concern.

Both domestic and wild animals may transmit rabies. With the widespread vaccination of domesticated animals in the United States, dogs in particular, the number of cases of rabies has significantly declined. In 1955 domesticated animals, especially dogs, constituted 47% of the reported rabies cases. By 1994, fewer than 2% of positive tests occurred in dogs. In fact, in the 1990s, cats outnumbered dogs as transmitters of the disease. As of 1997, most cases of rabies are in wild animals, particularly bats, raccoons, skunks, foxes, wolves, and coyotes.

Anyone who has been bitten by an animal, regardless of age or sex, can contract rabies. However, people whose occupations involve routine exposure to a domestic animal that has not been immunized or to wildlife are at a greater risk for getting the disease. As a result, cave explorers, farm and ranch workers, animal trainers and caretakers, forest rangers, animal exterminators, some laboratory workers, and veterinarians are at a higher risk.

— Janet Byron Anderson

An acute, infectious, often fatal viral disease of most warm-blooded animals, especially wolves, cats, and dogs, that attacks the central nervous system and is transmitted by the bite of infected animals.

[Latin rabiēs, rage, from rabere, to rave.]

An acute, encephalitic viral infection. Human beings are infected from the bite of a rabid animal, usually a dog. Canine rabies can infect all warm-blooded animals, and death usually results. See also Animal virus.

The virus is believed to move from the saliva-infected wound through sensory nerves to the central nervous system, multiply there with destruction of brain cells, and thus produce encephalitis, with severe excitement, throat spasm upon swallowing (hence hydrophobia, or fear of water), convulsions, and death—with paralysis sometimes intervening before death.

All bites should immediately be cleaned thoroughly with soap and water, and a tetanus shot should be considered. The decision to administer rabies antibody, rabies vaccine, or both depends on four factors: the nature of the biting animal; the existence of rabies in the area; the manner of attack (provoked or unprovoked) and the severity of the bite and contamination by saliva of the animal; and recommendations by local public health officials. See also Public health.

Diagnosis in the human is made by observation of Negri bodies (cytoplasmic inclusion bodies) in brains of animals inoculated with the person's saliva, or in the person's brain after death. A dog which has bitten a person is isolated and watched for 10 days for signs of rabies; if none occur, rabies was absent. If signs do appear, the animal is killed and the brain examined for Negri bodies, or for rabies antigen by testing with fluorescent antibodies. See also Fluorescence microscope; Viral inclusion bodies.

Individuals at high risk, such as veterinarians, must receive preventive immunization. If exposure is believed to have been dangerous, postexposure prophylaxis should be undertaken. If antibody or immunogenic vaccine is administered promptly, the virus can be prevented from invading the central nervous system. An inactivated rabies virus vaccine is available in the United States. It is made from virus grown in human or monkey cell cultures and is free from brain proteins that were present in earlier Pasteur-type vaccines. This material is sufficiently antigenic that only four to six doses of virus need be given to obtain a substantial antibody response. See also Vaccination.

An acute, usually fatal viral disease of the central nervous system of animals. It is transmitted from animals to humans by infected blood, tissue, or most commonly, saliva.

Definition

Rabies is a viral illness that can affect any mammal but is most common in carnivores (flesh-eaters). It is sometimes referred to as a zoonosis, or disease of animals that can be communicated to humans. Rabies is usually transmitted in the saliva through a bite wound. The virus attacks the central nervous system, and is fatal once symptoms begin, with very rare exceptions.

Description

Rabies, also known as hydrophobia, belongs to the rhabdovirus family. Fewer than 10% of animal cases reported in the United States in 1998 were in domestic animals. Raccoons accounted for the largest number of cases in wild animals. Cases of rabies in humans are very infrequent in the United States, averaging one or two a year (down from over 100 cases annually in 1900), but the worldwide incidence is estimated to be between 30,000 and 50,000 cases each year. These figures are based on data collected by the World Health Organization (WHO) in 1997 and updated in 2002. Rabies is most common in developing countries in Africa, Latin America, and Asia, particularly India. Dog bites are the major origin of infection for humans in developing countries, but other important host animals may include the wolf, mongoose, and bat. Most deaths from rabies in the United States result from bat bites; the most recent victim was a man in Iowa who died in September 2002.

People whose work frequently brings them in contact with animals are considered to be at higher risk than the general population. This would include those in the fields of veterinary medicine, animal control, wildlife work, and laboratory work involving live rabies virus. People in these occupations and residents of or travelers to areas where rabies is a widespread problem should consider being immunized.

In late 2002, rabies re-emerged as an important public health issue. Dr. Charles E. Rupprecht, director of the World Health Organization (WHO) Collaborating Center for Rabies Reference and Research, has listed several factors responsible for the increase in the number of rabies cases worldwide:

• Rapid evolution of the rabies virus. Bats in the United States have developed a particularly infectious form of the virus.
• Increased diversity of animal hosts for the disease.
• Changes in the environment that are bringing people and domestic pets into closer contact with infected wildlife.
• Increased movement of people and animals across international borders. In one recent case, a man who had contracted rabies in the Philippines was not diagnosed until he began to feel ill in the United Kingdom.
• Lack of advocacy about rabies.

Causes & Symptoms

The most common way to contract rabies is from the bite of an infected animal. Although bats are the most frequent source of human infection in the United States, dogs are the primary vector of rabies in most parts of the world. The disease may also be transmitted by tissues and body fluids other than saliva. Rare cases have occurred as a result of infection through corneal transplantation.

Rabies travels from the site of the bite along the peripheral nerves to the brain. The average incubation period in humans is 30–50 days, although it varies from 10 days to over a year. The initial symptoms are flu-like and nonspecific. They may include fever, headache, muscle pain, sore throat, fatigue, nausea, and vomiting. Altered sensation and muscle twitching in the area of the bite are signs that are more suspicious of rabies. When the virus reaches the brain, signs related to encephalitis (local or general inflammation of brain tissue) appear. This typically involves agitation, progressing to confusion, combativeness, seizures, and localized areas of paralysis. There may also be hypersensitivity to light, sound, and touch. The patient may be coherent at times, but less so as the disease progresses. Many viruses causing encephalitis may produce similar signs. The next stage is dysfunction of the brainstem. The well-known phenomenon of foaming at the mouth is caused by excessive saliva production combined with difficulty swallowing. Many patients will refuse liquids at this point due to the painful muscle contractions caused by swallowing. This is how rabies came to be known as hydrophobia, which means "fear of water." Coma ensues soon after brainstem involvement, and death occurs when the respiratory center is affected. The course of the disease is four to 20 days after symptoms appear, unless life support is used.

Diagnosis

Early in its course, and without a known history of an animal bite, rabies can be difficult to diagnose. Symptoms of the early encephalitic (brain tissue inflammation) phase are similar to those of most viral types of encephalitis. When signs of brainstem dysfunction appear shortly after this time, rabies becomes a more likely possibility. Several tests are available for rabies diagnosis, but none are extremely reliable in the living patient. Part of the challenge is that rabies is so limited to nerve tissue until the late phases of the disease. The examination of brain tissue reveals a characteristic known as a Negri body, which is diagnostic. Direct fluorescent antibody (dFA) staining of saliva, skin biopsy, and corneal impressions may also yield a diagnosis.

Treatment

Local wound cleansing is important. Anyone who has experienced an animal bite should wash it thoroughly with soap and water. Rabies is a fatal illness, so a bite that breaks the skin warrants a call to a health care provider for evaluation of whether post-exposure prophylaxis (PEP) is necessary. Alternative treatments are recommended as a complementary therapy to conventional treatment in the case of rabies. Observation of the animal for signs of rabies is recommended whenever possible.

Allopathic Treatment

If a person is bitten by a domestic animal and the owner is known, vaccination status should be checked. People bitten by healthy, immunized animals are unlikely to need post-exposure prophylaxis (PEP). The animal can be confined for 10 days. If it is healthy at the end of that time, it is presumed not to have been capable of transmitting rabies at the time of the bite, so PEP for the person bitten is not necessary.

Wild animals that have bitten can be captured, destroyed, and tested for rabies. Postexposure vaccine and specific immune globulin can be given if deemed necessary. In the United States, if the person who was bitten has not had prophylactic immunization and has a high-risk bite, generally five rabies vaccinations and one injection of human rabies immune globulin are given. There have been no cases in this country of people contracting rabies after receiving correctly administered PEP.

Bites from mice, rats, or squirrels rarely require rabies prevention because these rodents are typically killed by any encounter with a larger, rabid animal, and would therefore be less likely to be carriers. Bites from raccoons, bats, or unvaccinated dogs or cats are more suspect. Anyone bitten by a bat in the United States should receive PEP unless the bat is captured and proven not to be rabid.

If a pet is bitten by an animal suspected to have rabies, its owner should contact a veterinarian immediately and notify the local animal control authorities. Domestic pets with current vaccinations should be revaccinated immediately; unvaccinated dogs, cats, or ferrets are usually euthanized (put to sleep). Further information about domestic pets and rabies is available on the American Veterinary Medical Association (AVMA) web site.

Expected Results

Survival of rabies after the appearance of symptoms is exceedingly rare.

Prevention

The following precautions should be observed in environments where humans and animals may likely come into contact. Domesticated animals, including household pets, should be vaccinated against rabies. Booster shots, given according to the manufacturer's recommendations, are required to maintain immunity. Wild animals should not be touched or petted, no matter how friendly an animal may appear. It is also important not to touch an animal that appears ill or passive, or whose behavior seems odd, such as failing to show the normal fear of humans. These are all possible signs of rabies. Many animals, such as raccoons and skunks, are nocturnal and their activity during the day should be regarded as suspicious. People should not interfere with fights between animals. Because rabies is transmitted through saliva, a person should wear rubber gloves when handling a pet that has had an encounter with a wild animal. Windows and doors should be screened. Some victims of rabies have been attacked by infected animals, particularly bats, that entered through unprotected openings. Finally, garbage or pet food should not be left outside because it may attract wild or stray animals.

Members of the high-risk occupations mentioned above should consider prophylactic immunization. Those who receive this pre-exposure vaccine still require PEP in the event of a potentially infective episode, but they have several advantages. One is that they require fewer post-exposure vaccines. A second advantage is that the timing of the PEP may be less critical for people who are in remote areas, or don't have ready access to vaccine for other reasons. Last, some people may be exposed without being aware of it, and the prophylactic vaccine might protect them.

Resources

Books

"Central Nervous System Viral Diseases: Rabies (Hydrophobia)." Section 13, Chapter 162 in The Merck Manual of Diagnosis and Therapy, edited by Mark H. Beers, MD, and Robert Berkow, MD. Whitehouse Station, NJ: Merck Research Laboratories, 1999.

Corey, Lawrence. "Rabies Virus and Other Rhabdoviruses." Harrison's Principles of Internal Medicine, edited by Anthony S. Fauci et al., 14th ed.; New York: McGraw-Hill, 1998.

Periodicals

Fooks, A. R., N. Johnson, S. M. Brookes, et al. "Risk Factors Associated with Travel to Rabies Endemic Countries." Journal of Applied Microbiology 94 (2003) (Supplement): 31S–36S.

"Human Rabies—Iowa, 2002." Morbidity and Mortality Weekly Report 52 (January 24, 2003): 47–48.

Messenger, S. L., J. S. Smith, L. A. Orciari, et al. "Emerging Pattern of Rabies Deaths and Increased Viral Infectivity." Emerging Infectious Diseases 9 (February 2003): 151–154.

Smith, J., L. McElhinney, G. Parsons, et al. "Case Report: Rapid Ante-Mortem Diagnosis of a Human Case of Rabies Imported Into the UK from the Philippines." Journal of Medical Virology 69 (January 2003): 150–155.

Stringer, C. "Post-Exposure Rabies Vaccination." Nursing Standard 17 (February 5-11, 2003): 41–42.

Weiss, R. A. "Cross-Species Infections." Current Topics in Microbiology and Immunology 278 (2003): 47–71.

Organizations

American Veterinary Medical Association (AVMA). 1931 North Meacham Road, Suite 100, Schaumburg, IL 60173-4360. .

Centers for Disease Control and Prevention. 1600 Clifton Rd., NE, Atlanta, GA 30333. (800) 311-3435, (404) 639-3311. .

Institut Pasteur. 25-28, rue du Dr. Roux, 75015 Paris, France. +33 (0) 1 45 68 80 00. .

Other

CDC. "Epidemiology of Rabies." http://www.cdc.gov/ncidod/dvrd/rabies/Epidemiology/Epidemiology.htm.

National Association of State Public Health Veterinarians, Inc. "Compendium of Animal Rabies Prevention and Control, 2003." Morbidity and Mortality Weekly Report Recommendations and Reports 52 (March 21, 2003) (RR-5): 1–6.

[Article by: Judith Turner; Rebecca J. Frey, PhD]

Definition

Rabies is an acute viral disease of the central nervous system that is transmitted through saliva from the bite of an infected animal.

Description

Rabies affects humans and other mammals but is most common in carnivores (flesh eaters). It is sometimes referred to as a zoonosis, or disease of animals that can be communicated to humans. Rabies is almost exclusively transmitted through saliva from the bite of an infected animal. Another name for the disease is hydrophobia, which literally means fear of water, a symptom shared by half of all people infected with rabies. Other symptoms include fever, depression, confusion, painful muscle spasms, sensitivity to touch, loud noise, and light, extreme thirst, painful swallowing, excessive salivation, and loss of muscle tone. If rabies is not prevented by immunization, it is almost always fatal.

In late 2002, rabies re-emerged as an important public health issue. Charles E. Rupprecht, director of the World Health Organization (WHO) Collaborating Center for Rabies Reference and Research, listed several factors responsible for the increase in the number of rabies cases worldwide:

• Rapid evolution of the rabies virus. Bats in the United States have developed a particularly infectious form of the virus.
• Increased diversity of animal hosts for the disease.
• Changes in the environment that are bringing people and domestic pets into closer contact with infected wildlife.
• Increased movement of people and animals across international borders. In one case, a man who had contracted rabies in the Philippines was not diagnosed until he began to feel ill in the United Kingdom.
• Lack of advocacy about rabies.

Demographics

Cases of rabies in humans are very infrequent in the United States, averaging one or two a year (down from over 100 cases annually in 1900), but the worldwide incidence is estimated to be between 30,000 and 50,000 cases each year. These figures are based on data collected by the World Health Organization (WHO) in 1997 and updated in 2002. Rabies is most common in developing countries in Africa, Latin America, and Asia, particularly India. Dog bites are the major origin of infection for humans in developing countries, but other important host animals are the wolf, mongoose, and bat. Worldwide, the highest risk groups for contracting rabies are boys under the age of fifteen. Most deaths from rabies in the United States result from bat bites.

People whose work frequently brings them in contact with animals are also considered to be at higher risk than the general population. This group includes those in the fields of veterinary medicine, animal control, wildlife work, and laboratory work involving live rabies virus. People in these occupations and residents of or travelers to areas where rabies is a widespread problem should consider being immunized.

Causes and Symptoms

Rabies is caused by a rod- or bullet-shaped virus that belongs to the family Rhabdoviridae. The virus is usually transmitted via an animal bite; however, cases have also been reported in which the virus penetrated the body through infected saliva, moist tissues such as the eyes or lips, a scratch on the skin, or the transplantation of infected tissues. Inhalation of the virus from the air, as might occur in a highly populated bat cave, is also thought to occur.

From the bite or other area of penetration, the virus multiplies as it spreads along nerves that travel away from the spinal cord and brain (efferent nerves) and into the salivary glands. The rabies virus may lie dormant in the body for several weeks or months, but rarely much longer, before symptoms appear. Initially, the area around the bite may burn and be painful. Early symptoms may also include a sore throat, low-grade fever, headaches, loss of appetite, nausea and vomiting, and diarrhea. Painful spasms develop in the muscles that control breathing and swallowing. The individual may begin to drool thick saliva and may have dilated or irregular pupils, increased tears and perspiration, and low blood pressure.

As the disease progresses, the patient becomes agitated and combative and may exhibit increased mental confusion. The affected person usually becomes sensitive to touch, loud noises, and bright lights. The victim also becomes extremely thirsty but is unable to drink because swallowing is painful. Some patients begin to dread water because of the painful spasms that occur. Other severe symptoms during the later stage of the disease are excessive salivation, dehydration, and loss of muscle tone. Death usually occurs three to 20 days after symptoms have developed. Recovery is very rare.

Diagnosis

After the onset of symptoms, blood tests and cerebrospinal fluid (CSF) analysis tests will be conducted. CSF will be collected during a procedure called a lumbar puncture in which a needle is used to withdraw a sample of CSF from the area around the spinal cord. The CSF tests do not confirm diagnosis but are useful in ruling out other potential causes for the patient's altered mental state.

The two most common diagnostic tests are the fluorescent antibody test and isolation of the rabies virus from an individual's saliva or throat culture. The fluorescent antibody test involves taking a small sample of skin (biopsy) from the back of the neck of the patient. If specific proteins, called antibodies, that are produced only in response to the rabies virus are present, they will bind with the fluorescent dye and become visible. Another diagnostic procedure involves taking a corneal impression in which a swab or slide is pressed lightly against the cornea of the eye to determine whether viral material is present.

Treatment

Because of the extremely serious nature of a rabies infection, the need for rabies immunizations should be carefully considered for anyone who has been bitten by an animal, based on a personal history and results of diagnostic tests.

If necessary, treatment includes the following:

• The wound is washed thoroughly with medicinal soap and water. Deep puncture wounds should be flushed with a catheter and soapy water. Unless absolutely necessary, a wound should not be sutured.
• Tetanus toxoid and antibiotics will usually be administered.
• Rabies vaccination may or not be given, based on the available information. If the individual was bitten by a domestic animal and the animal was captured, the animal will be placed under observation in quarantine for ten days. If the animal does not develop rabies within four to seven days, then no immunizations are required. If the animal is suspected of being rabid, it is killed, and the brain is examined for evidence of rabies infection. In cases involving bites from domestic animals in which the animal is not available for examination, the decision for vaccination is made based on the prevalence of rabies within the region where the bite occurred. If the bite was from a wild animal and the animal was captured, it is generally killed because the incubation period of rabies is unknown in most wild animals.
• If necessary, the patient is vaccinated immediately, generally through the administration of human rabies immune globulin (HRIG) for passive immunization, followed by human diploid cell vaccine (HDCV) or rabies vaccine adsorbed (RVA) for active immunization. Passive immunization is designed to provide the individual with antibodies from an already immunized individual, while active immunization involves stimulating the individual's own immune system to produce antibodies against the rabies virus. These rabies vaccines are equally effective and carry a lower risk of side effects than some earlier treatments. Unfortunately, however, in underdeveloped countries, these vaccines are usually not available. Antibodies are administered to the patient in a process called passive immunization. To do so, the HRIG vaccine is administered once, at the beginning of treatment. Half of the dose is given around the bite area, and the rest is given in the muscle. Inactivated viral material (antigenic) is then given to stimulate the patient's own immune system to produce antibodies against rabies. For active immunization, either the HDCV or RVA vaccine is given in a series of five injections. Immunizations are typically given on days 1, 3, 7, 14, and 28.

In those rare instances in which rabies has progressed beyond the point where immunization would be effective, the patient is given medication to prevent seizures, relieve some of the anxiety, and relieve painful muscle spasms. Pain relievers are also given. In the later stages, aggressive supportive care will be provided to maintain breathing and heart function. Survival is rare but can occur.

Prognosis

If preventative treatment is sought promptly, rabies need not be fatal. Immunization is almost always effective if started within two days of the bite. Chance of effectiveness declines, however, the longer vaccination is put off. It is, however, important to start immunizations, even if it has been weeks or months following a suspected rabid animal bite, because the vaccine can be effective even in these cases. If immunizations do not prove effective or are not received, rabies is nearly always fatal within a few days of the onset of symptoms.

Prevention

The following precautions should be observed in environments where humans and animals are likely to come into contact:

• Domesticated animals, including household pets, should be vaccinated against rabies. If a pet is bitten by an animal suspected to have rabies, its owner should contact a veterinarian immediately and notify the local animal control authorities. Domestic pets with current vaccinations should be revaccinated immediately; unvaccinated dogs, cats, or ferrets are usually euthanized (killed).
• Wild animals should not be touched or petted, no matter how friendly they may appear. It is also important not to touch an animal that appears ill or passive or whose behavior seems odd, such as failing to show the normal fear of humans. These are all possible signs of rabies. Many animals, such as raccoons and skunks, are nocturnal and their activity during the day should be regarded as suspicious.
• People should not interfere in fights between animals.
• Because rabies is transmitted through saliva, a person should wear rubber gloves when handling a pet that has had an encounter with a wild animal.
• Garbage or pet food should not be left outside the house or camp site because it may attract wild or stray animals.
• Windows and doors should be screened. Some victims of rabies have been attacked by infected animals, particularly bats, that entered through unprotected openings.
• State or county health departments should be consulted for information about the prevalence of rabies in an area. Some areas, such as New York City, have been rabies-free, only to have the disease reintroduced at a later time.
• Preventative vaccination against rabies should be considered if one's occupation involves frequent contact with wild animals or non-immunized domestic animals.
• Bites from mice, rats, or squirrels rarely require rabies prevention because these rodents are typically killed by any encounter with a larger, rabid animal, and would, therefore, not be carriers.
• Travelers should ask about the prevalence of the disease in countries they plan to visit.

Parental Concerns

Parents should speak with their children about the importance of avoiding contact with wild animals and reporting strange behavior in any animal, even a pet.

Resources

Books

Adams, William G. "Rabies." In Nelson Textbook of Pediatrics. Edited by Richard E. Behrman et al. Philadelphia: Saunders, 2004.

Plotkin, Stanley A. "Rabies Virus." In Principles and Practice of Pediatric Infectious Diseases, 2nd ed. Edited by Sarah S. Long et al. St. Louis, MO: Elsevier, 2003.

Periodicals

Fooks, A. R., et al. "Risk Factors Associated with Travel to Rabies Endemic Countries." Journal of Applied Microbiology 94 Suppl. (2003): 31S–6S.

"Human Rabies—Iowa, 2002." Morbidity and Mortality Weekly Report 52 (January 24, 2003): 47–8.

Messenger, S. L., et al. "Emerging Pattern of Rabies Deaths and Increased Viral Infectivity." Emerging Infectious Diseases 9 (February 2003): 151–4.

National Association of State Public Health Veterinarians Inc. "Compendium of Animal Rabies Prevention and Control, 2003." Morbidity and Mortality Weekly Report Recommendations and Reports 52 (March 21, 2003): 1–6.

Smith, J., et al. "Case Report: Rapid Ante-Mortem Diagnosis of a Human Case of Rabies Imported into the UK from the Philippines." Journal of Medical Virology 69 (January 2003): 150–5.

Stringer, C. "Post-Exposure Rabies Vaccination." Nursing Standard 17 (February 5–11, 2003): 41–2.

Weiss, R. A. "Cross-Species Infections." Current Topics in Microbiology and Immunology 278 (2003): 47–71.

Organizations

American Veterinary Medical Association (AVMA). 1931 North Meacham Road, Suite 100, Schaumburg, IL 60173–4360. Web site: www.avma.org.

Centers for Disease Control and Prevention. 1600 Clifton Rd., NE, Atlanta, GA 30333. Web site: www.cdc.gov.

Web Sites

"Epidemiology [of rabies]." National Center for Infectious Diseases. Available online at www.cdc.gov/ncidod/dvrd/rabies/Epidemiology/Epidemiology.htm (accessed January 9, 2005).

[Article by: Janet Byron Anderson Rebecca J. Frey, PhD Rosalyn Carson-DeWitt, MD]

Rabies is a viral disease of wild and domestic animals. It is particularly prevalent in feral dogs, while humans are occasional victims. The virus is transmitted in saliva and enters the body through puncture wounds caused by bites, or via abrasions, open cuts, or sores. The virus attacks the central nervous system by migrating up peripheral nerves from the site of entry. It can take several months to reach the central nervous system, so there can be a very long incubation period. In humans and most animals it is almost invariably fatal, but bats may be symptomless carriers. Rabies occurs almost worldwide, but it has been eliminated from Britain, Iceland, and Scandinavia through rigorously enforced animal quarantine, which has also prevented it from ever gaining entry to Australia. Because of the long incubation period, exposed animals must be quarantined for many months. In much of the world, including the United States and Canada, rabies is endemic in foxes, raccoons, skunks, bats, and other wild animals, and these occasionally infect domestic animals and humans.

The French bacteriologist Louis Pasteur developed a postexposure vaccine against rabies in 1885, using desiccated nerve tissue containing the virus. For many years, Pasteur's prolonged and painful course of injections was used to treat all persons who had been bitten by suspected rabid animals. Prophylactic immunizations for animal and human use have been much improved by the human diploid cell vaccine (HDCV), developed in the 1970s. Rabies immune globulin is used for postexposure prophylaxis. When humans are bitten by a suspected rabid animal, the animal should be killed and its brain examined for evidence of infection. Vaccination of wild animals utilizes an oral vaccine delivered in baits.

(SEE ALSO: Communicable Disease Control; Immunizations; Pasteur, Louis; Veterinary Public Health)

Bibliography

National Center for Infectious Diseases. Rabies. Available at http://www.cdc.gov/ncidod/dvrd/rabies.

— JOHN M. LAST

For more information on rabies, visit Britannica.com.

An acute disease, caused by a virus, which attacks the central nervous system and results in paralysis and death if not treated promptly. Rabies is transmitted to humans by the bite of an animal infected with the disease.

A highly fatal viral infection of the nervous system which affects all warm-blooded animal species. The causative rhabdovirus is transmitted in the saliva and the principal method of infection in animals is by a bite. Separate furious and dumb (paralytic) forms are described but both commonly occur in the one animal. The syndrome includes an ascending paralysis which may be preceded by a period of mania and aggression. Rabies is one of the most important of the zoonoses because of the inevitably fatal outcome for the infected human.

• bat r. — an infection which is endemic in bats and may be caused by the rabies virus or by other similar rhabdoviruses such as Lagos, Mokola and Australian flying fox bat viruses.
• fixed r. virus — see fixed virus.
• r. inhibiting substance — present in the salivary glands and brain tissue of infected animals and may make the tissue nonlethal for mice by the intracerebral route. It does not interfere with detection of rabies antigen by immunofluorescent staining.
• non-terrestrial r. — bat rabies.

This article is about the disease. For the virus, see Rabies virus. For other uses, see Rabies (disambiguation).

Rabies
Classification and external resources
Rabies virus
ICD-10	A82.
ICD-9	071
DiseasesDB	11148
MedlinePlus	001334
eMedicine	med/1374  emerg/493 ped/1974
MeSH	D011818

Rabies (pronounced /ˈreɪbiːz/. From Latin: rabies) is a viral neuroinvasive disease that causes acute encephalitis (inflammation of the brain) in warm-blooded animals. It is zoonotic (i.e. transmitted by animals), most commonly by a bite from an infected animal but occasionally by other forms of contact. Generally fatal if left untreated, it is a significant killer of livestock in some countries.

The rabies virus travels to the brain by following the peripheral nerves. The incubation period of the disease depends on how far the virus must travel to reach the central nervous system, usually taking a few months.^[1] Once the infection reaches the central nervous system and symptoms begin to show, the untreated infection is usually fatal within days.

Early-stage symptoms of rabies are malaise, headache and fever, later progressing to more serious ones, including acute pain, violent movements, uncontrolled excitement, depression and inability to swallow water. Finally, the patient may experience periods of mania and lethargy, followed by coma. The primary cause of death is usually respiratory insufficiency.^[1]

Contents 1 Etymology 2 Virology 3 Epidemiology 3.1 Transmission 3.2 Prevalence 3.3 Rabies in animals 4 Medical aspects 4.1 Prevention 4.2 Symptoms 4.3 Diagnosis 4.4 Prognosis 4.5 Treatments 4.5.1 Post-exposure prophylaxis 4.5.2 Blood-brain barrier 4.5.3 Induced coma 4.5.4 Ketamine 5 History 5.1 Cultural impact 5.2 Cultural references 6 See also 7 References 8 External links

Etymology

The term is derived from the Latin rabies, "madness".^[2] This, in turn, may have come from the Sanskrit rabhas, "to do violence". The Greeks derived the word "lyssa", which is derived from "lud" or "violent", this terminology is used in the name of the genus of rabies lyssavirus.^[3]

Virology

Main article: Rabies virus

The rabies virus is the type species of the Lyssavirus genus, which encompasses other similar viruses. Lyssaviruses have helical symmetry, with a length of about 180 nm and a cross-sectional diameter of about 75 nm. These viruses are enveloped and have a single stranded RNA genome with negative-sense. The genetic information is packaged as a ribonucleoprotein complex in which RNA is tightly bound by the viral nucleoprotein. The RNA genome of the virus encodes five genes whose order is highly conserved. These genes are nucleoprotein (N), phosphoprotein (P), matrix protein (M), glycoprotein (G) and the viral RNA polymerase (L).^[4]

From the point of entry, the virus travels quickly along the neural pathways into the central nervous system (CNS), and then further into other organs. The salivary glands receive high concentrations of the virus thus allowing further transmission.

Epidemiology

Transmission

This article may require cleanup to meet Wikipedia's quality standards. Please improve this article if you can. (January 2009)

Main article: Rabies transmission

TEM micrograph with numerous rabies virions (small dark-grey rod-like particles) and Negri bodies (the larger pathognomonic cellular inclusions of rabies infection).

Any warm-blooded animal, including humans, may become infected with the rabies virus and develop symptoms. Indeed the virus has even been adapted to grow in cells of poikilothermic vertebrates^[5][6] though natural transmission has only been documented among mammals.^{[citation needed]} Most animals can be infected by the virus and can transmit the disease to humans. Infected bats, monkeys, raccoons, foxes, skunks, cattle, wolves, coyotes, dogs, mongoose (normally yellow mongoose)^{[citation needed]} or cats provide the greatest risk to humans. Rabies may also spread through exposure to infected domestic farm animals, groundhogs, weasels, bears and other wild carnivores. Rodents (mice, squirrels etc) are seldom infected.^[7]

The virus is usually present in the nerves and saliva of a symptomatic rabid animal.^[8][9] The route of infection is usually, but not necessarily, by a bite. In many cases the infected animal is exceptionally aggressive, may attack without provocation, and exhibits otherwise uncharacteristic behavior.^[10]

Transmission between humans is extremely rare. A few cases have been recorded through transplant surgery.^[11]

After a typical human infection by bite, the virus enters the peripheral nervous system. It then travels along the nerves towards the central nervous system.^[12] During this phase, the virus cannot be easily detected within the host, and vaccination may still confer cell-mediated immunity to prevent symptomatic rabies. Once the virus reaches the brain, it rapidly causes encephalitis. This is called the prodromal phase, and is the beginning of the symptoms. Once it reaches this point and symptoms show, there is no treatment, and death is certain. Rabies may also inflame the spinal cord producing transverse myelitis.^[13][14]

Prevalence

Main article: Prevalence of rabies

Rabies-free jurisdictions, as of January 2006: Australia, New Zealand, Singapore, Fiji, Papua New Guinea, Indonesian provinces of Irian Jaya and West Papua on the island of New Guinea, Germany, Guam, Hawaii, the United Kingdom, Republic of Ireland, Norway, Sweden, Finland, Iceland, Japan and Taiwan.

The rabies virus survives in widespread, varied, rural fauna reservoirs. However, in Asia, parts of America and large parts of Africa, dogs remain the principal host. Mandatory vaccination of animals is less effective in rural areas. Especially in developing countries, pets may not be privately kept and their destruction may be unacceptable. Oral vaccines can be safely distributed in baits, and this has successfully reduced rabies in rural areas of France, Ontario, Texas, Florida and elsewhere, like in the City of Montréal (Québec) where baits are successfully used among raccoons in the Mont-Royal park area. Vaccination campaigns may be expensive, and a cost-benefit analysis can lead those responsible to opt for policies of containment rather than elimination of the disease.

There are an estimated 55,000 human deaths annually from rabies worldwide, with about 31,000 in Asia, and 24,000 in Africa.^[15] One of the sources of recent flourishing of rabies in East Asia is the pet boom. China introduced in the city of Beijing the “one-dog policy” in November 2006 to control the problem.^[16] India has been reported as having the highest rate of human rabies in the world, primarily because of stray dogs.^[17]

Rabies was once rare in the United States outside the Southern states^{[citation needed]}, but as of 2006, raccoons in the mid-Atlantic and northeast United States were suffering from a rabies epidemic since the 1970s, which was moving westwards into Ohio.^[18] In the midwestern United States, skunks are the primary carriers of rabies, comprising 134 of the 237 documented non-human cases in 1996^[update].

Rabies in animals

This section requires expansion with: information from the main article.

Main article: Rabies in animals

Rabies is infectious to mammals. Three stages of rabies are recognized in dogs and other animals. The first stage is a one- to three-day period characterized by behavioral changes and is known as the prodromal stage. The second stage is the excitative stage, which lasts three to four days. It is this stage that is often known as furious rabies due to the tendency of the affected dog to be hyperreactive to external stimuli and bite at anything near. The third stage is the paralytic stage and is caused by damage to motor neurons. Incoordination is seen due to rear limb paralysis and drooling and difficulty swallowing is caused by paralysis of facial and throat muscles. Death is usually caused by respiratory arrest.^[19]

As recently as 2004, a new symptom of rabies has been observed in foxes. Probably at the beginning of the prodromal stage, foxes, who are extremely cautious by nature, seem to lose this instinct. Foxes will come into settlements, approach people, and generally behave as if tame. How long such "euphoria" lasts is not known. But even in this state such animals are extremely dangerous, as their saliva and excretions still contain the virus and they remain very unpredictable. ^[20].

Medical aspects

Prevention

Main article: Rabies vaccine

Almost every infected case with rabies resulted in death until a vaccine was developed by Louis Pasteur and Emile Roux in 1885. Their original vaccine was harvested from infected rabbits, from which the nerve-tissue was weakened by allowing to dry for five to ten days.^[21] Similar nerve tissue-derived vaccines are still used in some countries, as they are much cheaper than modern cell culture vaccines.^[22] The human diploid cell rabies vaccine (H.D.C.V.) was started in 1967, however a new and less expensive purified chicken embryo cell vaccine and purified vero cell rabies vaccine are now available.^{[citation needed]} A recombinant vaccine called V-RG has been successfully used in the field of Belgium, France, Germany and the United States to prevent outbreaks of rabies in wildlife.^[23] Currently pre-exposure immunization has been used in both human and non-human populations, whereas in many jurisdictions domesticated animals are required to be vaccinated.^{[citation needed]}

In the U.S., since the widespread vaccination of domestic dogs and cats and the development of effective human vaccines and immunoglobulin treatments, the number of recorded deaths from rabies has dropped from one hundred or more annually in the early twentieth century, to 1–2 per year, mostly caused by bat bites, which may go unnoticed by the victim and hence untreated.^[24]

Symptoms

A patient with rabies, 1959.

The period between infection and the first flu-like symptoms is normally two to twelve weeks, but can be as long as two years. Soon after, the symptoms expand to slight or partial paralysis, cerebral dysfunction, anxiety, insomnia, confusion, agitation, abnormal behavior, paranoia, terror, hallucinations, progressing to delirium.^[25] The production of large quantities of saliva and tears coupled with an inability to speak or swallow are typical during the later stages of the disease; this can result in “hydrophobia”, where the patient has difficulty swallowing because the throat and jaw become slowly paralyzed, shows panic when presented with liquids to drink, and cannot quench his or her thirst. The disease itself was also once commonly known as hydrophobia, from this characteristic symptom.

Death almost invariably results two to ten days after the first symptoms; the few humans who are known to have survived the disease^{[citation needed]} were all left with severe brain damage, with the exception of Jeanna Giese (see below). It is neurotropic in nature.

Diagnosis

The reference method for diagnosing rabies is by performing PCR or viral culture on brain samples taken after death. The diagnosis can also be reliably made from skin samples taken before death.^[26] It is also possible to make the diagnosis from saliva, urine and cerebrospinal fluid samples, but this is not as sensitive. Inclusion bodies called Negri bodies are 100% diagnostic for rabies infection, but found only in 20% of cases.

The differential diagnosis in a case of suspected human rabies may initially include any cause of encephalitis, particularly infection with viruses such as herpesviruses, enteroviruses, and arboviruses (e.g., West Nile virus). The most important viruses to rule out are herpes simplex virus type 1, varicella-zoster virus, and (less commonly) enteroviruses, including coxsackieviruses, echoviruses, polioviruses, and human enteroviruses 68 to 71. In addition, consideration should be given to the local epidemiology of encephalitis caused by arboviruses belonging to several taxonomic groups, including eastern and western equine encephalitis viruses, St. Louis encephalitis virus, Powassan virus, the California encephalitis virus serogroup, and La Crosse virus.

New causes of viral encephalitis are also possible, as was evidenced by the recent outbreak in Malaysia of some 300 cases of encephalitis (mortality rate, 40%) caused by Nipah virus, a newly recognized paramyxovirus.^[27] Similarly, well-known viruses may be introduced into new locations, as is illustrated by the recent outbreak of encephalitis due to West Nile virus in the eastern United States.^[28] Epidemiologic factors (e.g., season, geographic location, and the patient’s age, travel history, and possible exposure to animal bites, rodents, and ticks) may help direct the diagnostic workup.

Cheaper rabies diagnosis will be possible for low-income settings according to research reported on the Science and Development Network website in 2008. Accurate rabies diagnosis can be done ten times more cheaply, according to researchers from the Farcha Veterinary and Livestock Research Laboratory and the Support International Health Centre in N'Djamena, Chad. The scientists evaluated a method using light microscopy, cheaper than the standard tests, and say this could provide better rabies control across Africa.^[29]

Prognosis

In non-vaccinated humans, rabies is almost always fatal after neurological symptoms have developed, but prompt post-exposure vaccination may prevent the virus from progressing. Rabies kills around 55,000 people a year, mostly in Asia and Africa.^[15] There are only six known cases of a person surviving symptomatic rabies, and only two known cases of survival in which the patient received no rabies-specific treatment either before or after illness onset.^[30][31]

Treatments

Post-exposure prophylaxis

Treatment after exposure, known as post-exposure prophylaxis or “P.E.P.”, is highly successful in preventing the disease if administered promptly, generally within ten days of infection. Thoroughly washing the wound as soon as possible with soap and water for approximately five minutes is very effective at reducing the number of viral particles. “If available, a virucidal antiseptic such as povidone-iodine, iodine tincture, aqueous iodine solution or alcohol (ethanol) should be applied after washing...Exposed mucous membranes such as eyes, nose or mouth should be flushed well with water.”^[32] In the United States, patients receive one dose of human rabies immunoglobulin (HRIG) and five doses of rabies vaccine over a twenty-eight day period. One-half the dose of the immunoglobulin is injected in the region of the bite, if possible, with the remainder injected intramuscularly away from the bite. This is much less painful compared with administering the immunoglobulin through the abdominal wall with a large needle, as was done in the past. The first dose of rabies vaccine is given as soon as possible after exposure, with additional doses on days three, seven, fourteen, and twenty-eight after the first. Patients that have previously received pre-exposure vaccination do not receive the immunoglobulin, only the post-exposure vaccinations on day 0 and 3.

In instances when post-exposure prophylaxis is administered as a precaution (e.g. a person wakes up and finds a bat in the room they were sleeping in), it is now mainly given in the gluteal region and deltoid (upper arm). The number of shots delivered to the gluteal area on the first day is determined by weight, and it is not uncommon to require three of these shots. Subsequent shots of the immunoglobulin (to build longer term immunity to rabies) are given to the arm. Recipients of the vaccine have reported that these shots are no more painful than normal shots (such as tetanus boosters).^{[citation needed]} The recommendation for the precautionary use of post-exposure prophylaxis in occult bat encounters where there is no recognized contact has been questioned in the medical literature based on a cost-benefit analysis.^[33]

Most official documentation on rabies on the internet and otherwise warn that treatment becomes futile with the onset of prodrome (when symptoms begin to appear). These texts are written to convince the layman not to delay seeking treatment (and rightly so).^{[citation needed]} However, this may also lead them to falsely conclude that their situation is not an urgency and that treatment is possible up until the very end of the incubation period, as it may last 1 to 3 months on average; or it may at least convince them that it is safe to delay treatment by a few days. While the virus is treatable only during the incubation period, it is important to note that it is not treatable during its entirety. Rabies is fully treatable while the virus is present in tissues composed of cells other than neurons, such as skin and muscle. However, once the infection spreads to a neuron, the virus is sequestered from the immune system and will eventually make its way to the spinal cord and then to the brain. Treatment at this point may not be effective, even though symptoms may begin to appear weeks or even months later. Therefore, it is highly recommended that P.E.P. be administered as soon as possible. Begun without delay, or very little delay, P.E.P. is 100% effective against rabies.^[34] In the case where there has been a significant delay in administering P.E.P., the treatment should be administered regardless of that delay, as it may still be effective if it is not too late.^{[citation needed]} If there has been a delay between exposure and attempts at treatment, such that the possibility exists that the virus has already penetrated the nervous system, the possibility exists that amputation of the affected limb might thwart rabies, if the bite or exposure was on an arm or leg. This treatment should be combined with an intensive PEP regimen.^{[citation needed]}

Blood-brain barrier

Some recent works have shown that during lethal rabies infection, the blood-brain barrier (BBB) does not allow anti-viral immune cells to enter the brain, the primary site of rabies virus replication.^[35] This aspect contributes to the pathogenicity of the virus and artificially increasing BBB permeability promotes viral clearance.^[36] Opening the BBB during rabies infection has been suggested as a possible novel approach to treat the disease, even though no attempts have yet been made to determine whether or not this treatment could be successful.^{[citation needed]}

Induced coma

See also: Milwaukee protocol

In 2005, American teenager Jeanna Giese survived an infection of rabies unvaccinated. She was placed into an induced coma upon onset of symptoms. Her doctors administered treatment based on the hypothesis that detrimental effects of rabies were caused by temporary dysfunctions in the brain and could be avoided by inducing a temporary partial halt in brain function that would protect the brain from damage while giving the immune system time to defeat the virus. After thirty-one days of isolation and seventy-six days of hospitalization, Giese was released from the hospital.^[37]

Giese's treatment regimen became known as the "Milwaukee protocol". To date only one other patient has survived under the protocol, despite numerous attempts at the treatment. Rodney Willoughby Jr., Giese's primary care physician, has asserted that subsequent failures occurred because patients were not given the same combination of drugs used in the initial incident.^{[citation needed]}

Ketamine

The anesthetic drug ketamine has shown the potential for rabies virus inhibition in rats.^[38]

History

Cultural impact

This section requires expansion with: currently the following web page [1].

Because of its potentially violent nature, rabies has been known since 3500 B.C.^{[citation needed]} The first written record of rabies is in the Codex of Eshnunna (ca. 1930 BC), which dictates that the owner of a dog showing symptoms of rabies should take preventive measure against bites. If a person was bitten by a rabid dog and later died, the owner was fined heavily.^[39]

Rabies was considered a scourge for its prevalence in the 19th century. Fear of rabies related to methods of transmissions was almost irrational;^[3] however, this gave Louis Pasteur ample opportunity to test post-exposure treatments in 1895.^{[citation needed]}

Cultural references

• Cujo, a Stephen King novel and film about a mother and son being terrorized by a rabid dog.
• Fun Run, an episode from the television sitcom The Office in which Meredith discovers that she may have been exposed to rabies via several animal bites.
• "Histories" (House), an episode of the television medical drama House where a homeless woman suffers from rabies.
• I Drink Your Blood, a 1970s cult horror film about a gang of Satanic hippies who get infected with rabies.
• My Lunch, an episode of the comedy-drama Scrubs which refers to a case involving rabies transmitted by organ transplants.
• Old Yeller, a novel and film that involves a frontier dog becoming infected by a rabid wild wolf.
• REC a 2007 Spanish horror film, along with the American remake Quarantine, both involve a new strain of rabies which causes its subjects to succumb to uncontrollable violence, rage, and cannibalism.
• Their Eyes Were Watching God, Tea Cake, a character in the novel, is mentally affected by a bite from a rabid dog.
• The Mad Death, a 1983 BBC TV series in which Britain is gripped by an outbreak of rabies after an afflicted pet cat is illegally smuggled into the country.
• To Kill a Mockingbird, a novel and film in which a main character, Atticus Finch, is called upon to shoot a 'mad,' presumably rabid, dog.
• Vampire's Kiss, a 1989 film in which the main character (portrayed by Nicolas Cage) slowly goes insane after discovering a bat in his apartment, implying a rabies infection.
• Rant, a novel by Chuck Palahniuk in which the main character inflicts those around him with rabies.
• Mad Dogs and Servicemen, an episode of M*A*S*H in which Radar must receive a painful vaccine injection after being bitten by a stray dog.
• To Kill a Ladybird, an episode of King of the Hill in which Ladybird is bitten by a raccoon, then bites Dale Gribble, who becomes convinced he has rabies.
• 28 Days Later, A horror film where humans infect one another with a virus called rage, which happens to be the French word for rabies. In the movie, almost all the infected come down with the manic/violent form of the disease and transmit it to one another through biting or aerosolized saliva.
• Sunset Babies (All Got Rabies), a song by Alice Cooper, in which Cooper's twisted lyrical humor can be seen into a parallel being made between having rabies and some women's wicked sexual behavior.
• Quarantine, A horror film where a T.V. journalist reports on the events of disease outbreak from inside a quarantined building. A veteraniarian trapped inside the quarantine claims that the spreading disease is a mutated form of rabies.
• Rabid, A Canadian made horror film in which a character played by Marilyn Chambers undergoes experimental surgery that appears successful, but actually gave her a needlelike appendage in her armpit that feeds on human blood. Anyone that she feeds off of becomes infected with a particularly virulent and vaccine resistant strain of rabies, causing them to crave blood, and this passes the infection to their victim.
• Little House on the Prairie, In the Season 1 episode, The Raccoon, Laura adopts a stray raccoon whom she names Jasper. The raccoon bites her and the Ingalls family fear that she may have contracted rabies.

See also

• Alliance for Rabies Control
• Neurotropic virus
• World Rabies Day

References

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22. ^ Srivastava AK, Sardana V, Prasad K, Behari M (March 2004). "Diagnostic dilemma in flaccid paralysis following anti-rabies vaccine". Neurol India 52 (1): 132–3. PMID 15069272. http://www.neurologyindia.com/article.asp?issn=0028-3886;year=2004;volume=52;issue=1;spage=132;epage=133;aulast=Srivastava. 
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25. ^ MD. Arthur Schoenstadt, (July 21, 2008) Rabies Symptoms eMedTV
26. ^ Dacheux L, Reynes J-M, Buchy P, et al. (2008). "A reliable diagnosis of human rabies based on analysis of skin biopsy specimens". Clin Infect Dis 47 (11): 1410–1417. doi:10.1086/592969. 
27. ^ Taylor DH, Straw BE, Zimmerman JL, D'Allaire S (2006). Diseases of swine. Oxford: Blackwell publishing. ISBN 0-8138-1703-X. http://books.google.com/books?id=3o9l77HdZkgC&dq=diseases+of+swine. Retrieved on 2008-10-05. 
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31. ^ Jordan Lite (2008-10-08). "Medical Mystery: Only One Person Has Survived Rabies without Vaccine—But How?". Scientific American. pp. 4. http://www.sciam.com/article.cfm?id=jeanna-giese-rabies-survivor&sc=WR_20081014. Retrieved on 2008-10-16. 
32. ^ Rabies & Australian bat lyssavirus information sheet http://www.health.vic.gov.au/ideas/bluebook/rabies_info
33. ^ de Serres G, Skowronski DM, Mimault P, et al. (2009). "Bats in the bedroom, bats in the belfry: Reanalysis of the rationale for rabies postexposure prophylaxis". Clin Infect Dis 48 (11): 1493–1499. doi:10.1086/598998. 
34. ^ http://www.scientificamerican.com/article.cfm?id=jeanna-giese-rabies-survivor&page=4
35. ^ Roy A, Phares TW, Koprowski H, Hooper DC (2007). "Failure to open the blood-brain barrier and deliver immune effectors to central nervous system tissues leads to the lethal outcome of silver-haired bat rabies virus infection". J. Virol. 81 (3): 1110–8. doi:10.1128/JVI.01964-06. PMID 17108029. 
36. ^ Roy A, Hooper DC (2007). "Lethal silver-haired bat rabies virus infection can be prevented by opening the blood-brain barrier". J. Virol. 81 (15): 7993–8. doi:10.1128/JVI.00710-07. PMID 17507463. 
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External links

Wikimedia Commons has media related to: Rabies

Look up rabies in Wiktionary, the free dictionary.

• Aerophobia and Hydrophobia in Rabies Videos
• Rabies at the Open Directory Project

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Dansk (Danish)
n. - hundegalskab, rabies

Nederlands (Dutch)
hondsdolheid

Français (French)
n. - rage

Deutsch (German)
n. - Tollwut

Ελληνική (Greek)
n. - λύσσα, υδροφοβία

Italiano (Italian)
idrofobia

Português (Portuguese)
n. - hidrofobia (Med.)

Русский (Russian)
бешенство

Español (Spanish)
n. - rabia

Svenska (Swedish)
n. - rabies, vattuskräck

中文（简体）(Chinese (Simplified))
狂犬病, 恐水病

中文（繁體）(Chinese (Traditional))
n. - 狂犬病, 恐水病

한국어 (Korean)
n. - 광견병

日本語 (Japanese)
n. - 狂犬病

العربيه (Arabic)
‏(الاسم) داء الكلب‏

עברית (Hebrew)
n. - ‮כלבת‬

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