The US is tracking 14 potential rabies outbreaks in 20 states. Here’s what to know

By Katia Hetter, CNN

(CNN) — While human cases of rabies in the United States are rare, it’s still a deadly disease: six people have died from rabies nationwide since September 2024, a US Centers for Disease Control and Prevention spokesperson confirmed to CNN. In addition, the CDC is tracking 14 potential outbreaks in 20 states,

What is rabies? How is it transmitted and by which animals? What are the symptoms of infection in humans, and is there a vaccine? How should rabies exposure be treated? And what can people do to reduce their risk of exposure?

To guide us through these questions, I spoke with CNN wellness expert Dr. Leana Wen, an emergency physician and clinical associate professor at the George Washington University. Wen previously served as Baltimore’s health commissioner.

CNN: What is rabies, and how is it transmitted?

Dr. Leana Wen: Rabies is caused by a deadly virus that is spread mainly through the saliva of infected animals. The rabies virus is part of the Rhabdoviridae family and genus Lyssavirus, which comprises 16 virus species. All 16 can cause rabies disease in humans, though the rabies virus is by far the most common cause.

This virus is typically transmitted through an animal bite, though scratches or direct contact with mucosa can also spread the virus. For instance, if the saliva of the infected animal comes in contact with a human’s eyes, mouth or open wounds, the virus could be spread.

The virus primarily affects the central nervous system, with inflammation of the brain and spinal cord. The incubation period, the time between exposure to the virus and symptom onset, may last weeks to months. Once a person starts showing symptoms of rabies, the disease is nearly always fatal.

CNN: What kinds of animals spread rabies to humans?

Wen: Dogs are responsible for the majority of human rabies deaths worldwide, and young children are frequent victims, according to the World Health Organization. In the United States, where rabid dogs are far less common due to effective rabies prevention programs, contact with infected bats is the leading cause of human rabies deaths. Rabies can be found in many other wildlife species, including raccoons, skunks, coyotes and foxes. According to the CDC, around 4,000 animal rabies cases are reported every year, with 90% occurring in wildlife.

CNN: What symptoms does an infected person exhibit?

Wen: During the incubation period, there are typically no symptoms. Weeks to months after exposure, an infected person may experience flu-like symptoms that can include fever, headache and overall body aches. Discomfort, such as a prickling sensation, at the site of the bite is also possible.

Symptoms quickly progress. Within two weeks, the infected person starts having increasingly severe symptoms such as confusion, agitation, hallucinations and aggressive behavior. A classic symptom is hydrophobia, or fear of water: Despite feeling very thirsty, the individual may seem to panic at the sight of fluids. The person may also produce a lot of saliva and appear agitated, thrashing arms and legs. Death occurs not long after.

CNN: Who is at higher risk for rabies?

Wen: According to the CDC, someone traveling to areas where rabid dogs are a problem is at a higher risk of contracting the rabies virus, as are people who may encounter animals through work or leisure activities.

The CDC has a helpful website that lists rabies status by country. Information includes the prevalence of rabies, whether a robust surveillance and prevention program is in place, and whether treatment is readily available if exposure occurs. WHO also has a useful website documenting areas with recent cases of human rabies. Annually, an estimated 60,000 people die from rabies worldwide; 95% of these fatalities occur in Africa and Asia.

If you are visiting a country with a higher rabies risk, consider taking extra precautions, especially if it will be difficult to access rabies treatment if you are exposed to the virus. Veterinarians, veterinary technicians, animal control officers, wildlife workers, laboratory workers who handle live rabies virus and people in similar professions should also consider prophylaxis. The same goes for people planning to hike in remote areas with dog-transmitted rabies or to explore caves in regions where rabid bats have been.

CNN: Can you explain what this prophylaxis is? Can people get vaccinated against rabies?

Wen: Yes. Someone at high risk of being exposed to rabies can get the rabies vaccine as part of what’s called pre-exposure prophylaxis — that is, vaccination before any exposure occurs — to provide protection in case contact with the virus happens later. In these cases, the CDC recommends two doses of the vaccine spaced seven days apart.

Depending on an individual’s risk exposure, the CDC recommends taking additional precautions. People in Risk Category 1, the highest risk, should have their blood checked for antibody titers six months after the second dose of the vaccine to make sure they are optimally protected. This category includes lab workers in contact with live or concentrated virus.

People in Risk Category 2, which includes those who frequently handle bats or dead animals, should have their antibody titers checked every two years. Most veterinarians, technicians, wildlife workers and animal control officers are considered Risk Category 3: They can either opt for a one-time antibody titer check between one to three years after the two-dose vaccination or receive a one-time booster.

For the general US population, however, the rabies vaccine is not recommended as pre-exposure prophylaxis. The vaccine is essential, though, as part of post-exposure prophylaxis, the therapies given to someone after a possible rabies exposure to prevent the disease from developing.

CNN: What is considered a possible rabies exposure?

Wen: The clearest example is someone who has been bitten by a wild dog, bat, fox, raccoon or other animal known to carry rabies. If someone had direct contact with a bat — for instance, waking up to find a bat in the room — this is also considered a possible exposure unless a bite or scratch can be definitively ruled out. If possible, contain the animal so it can be observed and tested, but do not attempt to capture it if that may result in additional exposure. If you find a dead bat, do not throw it away. Do not touch it or allow other people or pets to touch it. Instead, call animal control so that the bat can be tested.

If you are not sure whether a possible exposure warrants treatment, it is always best to contact a health care provider. Your local or state health department can also help evaluate whether you need rabies-related care.

CNN: If someone had a bite or other exposure, what kind of treatment should they receive?

Wen: If you suspect rabies exposure, seek medical care right away. First, contact your primary care physician, who will generally refer you to the hospital emergency department for the first part of the treatment. Some urgent care centers may also administer the treatment. If you do not have a primary care physician, go directly to the emergency department.

If you have a wound, it will be washed thoroughly with soap and water immediately. According to CDC recommendations, what will happen next depends on whether you have ever been vaccinated against rabies. If you have never been vaccinated against rabies, you will be given both the human rabies immunoglobulin and a rabies vaccine. You will then need three more doses of the vaccine, on Days 3, 7 and 14 (Day 0 being the day you received the first dose). People with immune disorders would receive a fifth dose on Day 28.

If you have been vaccinated against rabies, you would not receive the immunoglobulin. However, you would still need two doses of the vaccine, one given on the initial day and one three days later.

CNN: What can you do to prevent rabies exposure?

Wen: Keep your pets up-to-date on their rabies vaccines. Stay away from wildlife and stray animals, and make sure your pets do as well. Also teach children not to handle or approach unfamiliar animals. If you see a wild animal such as a fox or raccoon behaving unusually, do not get close, and contact animal control instead. In addition, try to prevent bats from getting inside your home through windows, chimneys or other holes. Most importantly, if you, a family member or a pet is potentially exposed to rabies, seek medical care immediately.

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