Rabies causes >59,000 deaths worldwide, mostly in Africa and Asia, according to WHO. Incidence in countries with domestic animal vaccination programs is far lower- for instance, 3 human deaths per year in the US. Ukraine remains the only country in Europe where rabies is widespread amongst animals, with natural foci present in Kharkiv, Lukhansk, Poltava, Sumy, Chernikhiv, Kirovohrad, and Khmelnitskiy. The main rabies reservoir amongst wild animals in Ukraine is foxes and other wild canids, such as racoon dogs. Dogs are, by far, the most common cause of bites to humans. Significant historical rabies outbreaks occurred in Ukraine in 1951, 1979, and 2007. Anecdotally, at the height of an outbreak, one might see neighbors with their morning coffee, chatting together at the mailbox, leaning on a precautionary shotgun. Like other other endemic diseases (e.g. hantavirus/”trench fever”, TB, HIV, etc), the spread of rabies is promoted by wartime disruptions. The full-scale invasion has led to an increase in the number of stray animals, and has disrupted programs that vaccinated wild and domestic animals. Fields left fallow due to UXO contamination and economic disruptions allow proliferation of rodents and associated predator species. The epidemiological picture in post-2014 Ukraine has been clouded by lack of reporting from occupied parts of the Donbas. The Ministry of Health of Ukraine has reported a substantial increase in rabies cases since 2022. In 2024, 369 communities reported having animals infected with confirmed rabies, compared with 190 communities in 2023. An average of 22,000 patients receive anti-rabies treatment annually in Ukraine.
Rabies can be transmitted by dogs, cats, bats, raccoons, skunks, and foxes, usually via saliva transfer during biting. Exposure is considered to be a bite that breaks the skin, or any contact between mucous membrane or broken skin and infected animal saliva. Racoons, skunks, and foxes that have bitten a human are presumed to be infected. Bat bites may go unnoticed by the patient. Rabid animals often act strangely. They may be agitated, vicious, weak, or paralyzed, make strange noises or flight patterns, and be unafraid of people. Nocturnal animals may be out during the day. Suspected rabid animals should be humanely euthanized in a way that preserves the brain, if possible, and removed by local health authorities.
After initial infection, the virus travels via the peripheral nervous system to the spinal cord and brain. The speed of progression depends on the amount of viral inoculum and proximity of the wound to the brain. The average incubation period is 1-2 months, but may last >1 year.
Pain or paresthesia may occur at the wound site. Initial global symptoms are flulike (fever, malaise, headache). This progresses within days to encephalitis (furious rabies, in 80%) or paralysis (dumb rabies, in 20%). Confusion, agitation, hallucinations, insomnia occur, along with excessive salivation. Attempts to drink cause painful spasms of the laryngeal and pharyngeal muscles (hydrophobia). In the paralytic form, ascending paralysis develops, without delirium and hydrophobia. Diagnosis is confirmed via skin biopsy or sometimes PCR. Treatment, once symptomatic rabies has developed, consists only of supportive and expectant care, including heavy sedation. Death usually occurs 3-10 days after onset of symptoms. Vaccination does not remove the need for post-exposure prophylaxis treatment, but it greatly simplifies it. Post-vaccination, titer checks every two years are recommended for those at risk of exposure.
If exposure occurs, prompt prophylaxis almost always prevents development of human rabies. The wound should be washed extremely thoroughly with soap and water, and deep punctures well-flushed with moderate pressure, using a syringe of soapy water. The patient should be evacuated immediately to a hospital that can do post-exposure prophylaxis. Prophylaxis consists of rabies vaccine and rabies immune globulin. 20 IU/kg of rabies IG is injected around the wound. In previously vaccinated patients, two booster doses of rabies vaccine is the only treatment needed.
* Clinical info was paraphrased from the Merck Manual
