Rabies and Vaccination: Insights from Nepal and Around the Globe

Epidemiology

Rabies is a preventable yet deadly zoonotic disease affecting over 150 countries, with an estimated 59,000 to 70,000 human deaths annually, predominantly in Asia and Africa. Tragically, about 40% of these deaths are in children under 15 years of age. Dogs are responsible for 99% of human rabies transmissions through bites or scratches. Despite global efforts, underreporting remains an issue, and the disease disproportionately impacts rural and low-income communities where access to vaccines is limited.

In Nepal, rabies is endemic, with dogs as the primary reservoir. Human deaths have declined significantly due to vaccination campaigns, from around 97 in 2008/09 to about 32 in 2017/18, and fewer than 35 annually in recent years. However, outbreaks persist, such as a 2025 incident in Dhading where three people died, and hundreds were at risk. Nepal reports over 56,000 people seeking anti-rabies vaccinations yearly in government facilities, reflecting ongoing exposure risks. The country is advancing toward the “Zero by 30” goal—eliminating dog-mediated human rabies deaths by 2030—through mass dog vaccinations and public awareness. Travelers to Nepal should note higher risks in rural areas and during festivals when animal interactions increase.

Definition

Rabies is a viral infectious disease that primarily affects the central nervous system of mammals, including humans. It is characterized by acute encephalitis (inflammation of the brain) and is nearly 100% fatal once clinical symptoms develop, making prevention crucial.

Etiology

Rabies is caused by the rabies virus, a bullet-shaped RNA virus belonging to the genus Lyssavirus in the family Rhabdoviridae. Variants exist, such as bat rabies in the Americas, but the classic form is associated with terrestrial mammals like dogs, cats, and wildlife.This virus is neurotropic, meaning it has a strong affinity for the nervous system, traveling along nerves from the site of the bite to the brain, where it replicates and causes the devastating symptoms.

Transmission

The virus is typically transmitted through the saliva of an infected animal via bites, scratches, or licks on broken skin or mucous membranes. Rarely, it can spread through aerosols in bat caves or organ transplants. Incubation periods range from 1 week to over a year, averaging 1-3 months, depending on the wound’s proximity to the brain.

You cannot get rabies from petting a rabid animal or from contact with its blood, urine, or feces.

Signs & Symptoms

The incubation period (time from exposure to symptoms) is usually 2-3 months but can vary from one week to over a year.

1. Prodromal Stage (First 2-10 days): Symptoms are non-specific and flu-like: fever, headache, malaise, and discomfort or an unusual tingling, itching, or burning sensation (paresthesia) at the site of the wound.
2. Acute Neurologic Phase: The disease progresses to one of two forms:
   • Furious Rabies – Classical (80% of cases): Hyperactivity, hallucinations, agitation, Excessive sweating and salivation, dehydration, hydrophobia (fear of water due to spasms when trying to drink), and aerophobia (fear of drafts or fresh air). Death occurs within 2-5 days from cardiorespiratory arrest.
   • Paralytic Rabies (20% of cases): A slower, more gradual ascending paralysis starting at the bite site, myoedema and piloerection, stupor, coma and death. This form is often misdiagnosed, resemble Guillain–Barré syndrome. However, Hydrophobia is not seen. Death within 1-2 weeks.

Diagnosis

Diagnosis is primarily clinical, based on history of exposure and symptoms. Confirmatory tests include direct fluorescent antibody (DFA) testing on brain tissue (post-mortem), or antemortem methods like skin biopsies from the nape of the neck, corneal impressions, or saliva PCR. Rapid diagnosis is vital for contacts of suspected cases.

Differential Diagnosis

Rabies can be confused clinically with

• Cerebral malaria
• Organophosphate poisoning
• Herpes simplex encephalitis
• Post-vaccinal encephalitis
• Scorpion and snake envenomation
• Illicit drug use
• Psychiatric disorders
  Note : Guillain–Barré syndrome is often clinically indistinguishable from the paralytic form
  of rabies.

Treatment

There is no effective treatment for rabies once symptoms begin. Care is supportive and palliative.

The only life-saving intervention is immediate action after exposure:

1. Immediate and Thorough Wound Cleansing: Wash and flush the wound with soap and running water for a minimum of 15 minutes. This is the single most effective first-aid measure to reduce the viral load.
2. Application of a virucidal agent (e.g., povidone-iodine solution) after washing.
3. Immediate Medical Attention: This is non-negotiable. A doctor will assess the exposure and administer:
   • Post-Exposure Prophylaxis (PEP): A series of rabies vaccines.
   • Rabies Immunoglobulin (RIG): In cases of severe exposure (bites to the head, neck, face, hands, or multiple bites), RIG is injected around the wound(s) to provide immediate antibodies before the body can respond to the vaccine.

Source: National Guideline Rabies Prophylaxis in Nepal (2019)

Local Wound Treatment

• Attend to all bite wounds and scratches immediately after exposure to remove saliva and virus through efficient wound toilet, avoiding additional trauma.
• Thoroughly wash and flush wounds for 15 minutes with soap/detergent and water; use running water for 15 minutes if soap is unavailable.
• Avoid applying local remedies (e.g., herbs, oil, chili, turmeric); remove such irritants with thorough washing.
• Apply viricidal antiseptics like Povidone Iodine after washing.
• Avoid suturing wounds; if unavoidable (e.g., lacerations), infiltrate RIG first, delay suturing for hours, and use minimal sutures, with secondary sutures possible after two weeks.
• Administer tetanus prophylaxis (0.5ml IM) can be given

WHO Classification and PEP by Category of Exposure

Category of Exposure	Type of Contact	Post-Exposure Prophylaxis (PEP) for Immunologically Naive Individuals
Category I	– Touching or feeding of animals – Animal licks on intact skin (NO EXPOSURE)	No PEP required
Category II	– Nibbling of uncovered skin – Minor scratches or abrasions without bleeding (EXPOSURE)	Wound washing and immediate vaccination
Category III	– Single or multiple transdermal bites or scratches – Contamination of mucous membrane or broken skin with saliva from animal licks – (Exposures due to direct contact with bats*) (SEVERE EXPOSURE)	Wound washing, immediate vaccination, and RIG administration

Note : HIV-infected and other potentially immunocompromised individuals : RIG in both Cat. II and III exposures, even if previously immunized

Source : National Guideline for Rabies Prophylaxis in Nepal

Vaccinations Available : Post-Exposure Prophylaxis (PEP)

Vaccination is the cornerstone of rabies prevention.

1. Post-Exposure Prophylaxis (PEP) (First Exposure)

PEP is critical after a potential rabies exposure (e.g., bite, scratch, or mucosal contact with saliva from a suspected rabid animal). It includes wound care, rabies immunoglobulin (RIG), and a vaccine series.

Note: In rabies-endemic countries like Nepal with limited resources, the intradermal route (e.g., IPC 2-2-2-0-0 regimen) is cost-effective and WHO-approved.

Dose	Route	Duration	No of Injection Sites Per Clinic Visit	Sites
0.1 ml Each site	Intradermal	1 week	2-2-2-0-0	– Deltoid OR
		– Day 0		– Lateral thigh
		– Day 3		– Supra scapular region
		– Day 7

Source: National Guideline Rabies Prophylaxis in Nepal (2019)

2. PEP for Re-exposure Cases on Previous Vaccinated Patient

Previously Immunized Individuals of All Age Groups	Category I Exposure	Category II Exposure	Category III Exposure
	No PEP required	Wound washing and immediate vaccination	Wound washing and immediate vaccination
		RIG is not indicated	RIG is not indicated

Note: If re-exposure occurs less than 3 months after a previous exposure with complete PEP, only wound treatment is required; neither vaccine nor RIG is needed. Persons without documented prior pre- or post-exposure prophylaxis should be treated as a fresh case with complete PEP.

Vaccine Regimen for Re-exposure

Dose	Route	Duration	No of Injection Sites Per Clinic Visit	Sites
0.1 ml	Intradermal	Days	1-1-0-0-0	– Deltoid OR
		– Day 0		– Lateral thigh
		– Day 3

Note: This regimen applies to re-exposure cases for previously immunized individuals, using 0.1 ml intradermally at one site per visit on days 0 and 3.

Rabies Immunoglobulins (RIG)

• RIG provides neutralizing antibodies at the exposure site, administered once with the first vaccine dose, ideally on day 0 or by day 3 , not beyond day 7 to avoid suppressing vaccine immunity.
• Suturing Warning: If a wound is to be sutured, RIG must be infiltrated first.
• Types Available:
  • Human RIG (hRIG): Dose is 20 IU/kg body weight.
  • Equine RIG (eRIG): Dose is 40 IU/kg body weight. Modern eRIG is highly purified and safe.
• Rabies Monoclonal Antibodies (RmAb) are an alternative (3.33 IU/kg, one 2.5ml vial for up to 30kg), used as a cocktail with at least two antibodies.
• Shortage Protocol: If RIG is completely unavailable, the emphasis must be on scrupulous and immediate wound cleansing and the timely administration of the first vaccine dose.

Prophylactic Vaccination

Vaccine Regimen for Pre-Exposure Prophylaxis (PrEP)

WHO recommends PrEP for individuals at high risk of RABV exposure

• Sub-populations in highly endemic settings with limited access to timely and
  adequate PEP
• Individuals at occupational risk
• Travelers who may be at risk of exposure

Benefits of PrEP:

• Eliminates the need for Rabies Immunoglobulin (RIG), which is expensive, scarce, and often unavailable in remote parts of Nepal.
• Simplifies post-exposure treatment (you would only need 2 booster vaccine doses, without RIG).
• Provides crucial protection if there is any delay in accessing PEP.

Dose	Route	Duration	No of Injection Sites Per Clinic Visit	Sites
0.1 ml Each site	Intradermal	2 visits	2 sites	– Deltoid OR
		(1 week)	2-0-2-0-0	– Lateral thigh
		– Day 0
		– Day 7

Note: Recommended for pre-exposure prophylaxis (PrEP), administering 0.1 ml per site at two sites on days 0 and 7, using deltoid or lateral thigh areas.

Facts

1. WHAT ARE THE CLINICAL FEATURES OF RABIES IN DOGS?

Conclusion

Rabies remains a global health threat, but with effective vaccinations and control measures, it’s entirely preventable. For travelers, the key is vigilance: avoid stray animals, get pre-exposure vaccination if visiting high-risk areas, and seek PEP without delay after any potential exposure. Stay informed, stay safe—your adventure depends on it.

References:

1. National Guideline for Rabies Prophylaxis in Nepal, Government of Nepal, Ministry of Health and Population, Department of Health Services, Epidemiology and Disease Control Division.
2. World Health Organization (WHO). (2023). Rabies: Epidemiology and Burden. Retrieved from https://www.who.int/health-topics/rabies.
3. The Himalayan Times. (2025, August). Rabies Outbreak in Dhading Claims Three Lives. Retrieved from https://thehimalayantimes.com.
4. Hampson, K., et al. (2015). Estimating the global burden of endemic canine rabies. PLoS Neglected Tropical Diseases, 9(4), e0003709.