Although the most recent case of rabies in an active-duty soldier was in 2011, this fatal disease remains a threat that the U.S. Army continues to address.

According to the Centers for Disease Control and Prevention, almost 60,000 people around the world die from rabies each year. People get rabies from the bite of a rabid animal or if the animal’s saliva comes into contact with a person’s eyes, mouth, or broken skin.

Despite the common belief that rabid animals are easily identified by foaming at the mouth and aggressive behavior, infected animals may not look sick or act strangely.

“All bites or contact with saliva from animals should be evaluated by a qualified medical provider in consultation with a veterinarian,” says Lt. Col. Michael Superior, a medical doctor and advisor to the U.S. Army Public Health Center’s Division of Preventive Medicine.

“It’s critical to decide if prophylactic rabies vaccination is needed,” says Superior, “since rabies is nearly always fatal once symptoms appear.”

Symptoms can take weeks to months to develop and initially may be non-specific. Early symptoms include irritability, headache, fever, and itching or pain at the exposure site. Along with increasing neurological effects and possible hallucinations, the disease eventually progresses to spasms of the throat and the muscles used for breathing - which can appear to be a fear of water due to difficulty swallowing - and seizures, paralysis, and then death.

Though a fatal viral disease, rabies is 100 percent preventable if a person receives the post-exposure prophylaxis, known as rabies PEP, after a potential rabies exposure. The rabies PEP is a series of shots that consists of a dose of human rabies immune globulin (ideally administered on the day of the rabies exposure) and three rabies vaccine doses given on days three, seven, and fourteen after the initial dose.

Due to the cost and special storage needs of the rabies PEP, the need for multiple doses, and the low exposure risk to most persons, mass vaccinations for civilians and soldiers are not considered an appropriate public health measure. This is why getting the PEP as soon as possible after a potential exposure is so important.

The APHC provides guidance to prevent the occurrence of rabies in the Army family. The Center also uses the military’s Disease Reporting System internet, known as DRSi, to monitor rabies cases and rabies PEP recipients among the Army community. The DRSi captures visits of soldiers, as well as others, such as dependents and retirees, who seek care at Army medical treatment facilities.

“Luckily we have not identified a case of human rabies in the Army community since 2011,” says Kiara Scatliffe-Carrion, senior APHC epidemiologist. “This is likely due in part to the Army’s education program and effective use of rabies PEP.”

While PEP is effective, the best prevention is avoidance of exposure. Due to U.S. laws that require pet rabies vaccination programs, the CDC reports that rabies in the U.S. is mostly found in wild mammals like bats, raccoons, skunks, and foxes. Though woodchucks (groundhogs), have also been reported with the disease, small rodents and rabbits are almost never found to be infected.

Bats are the leading cause of human rabies deaths in the U.S. Because a bat scratch or bite can be very small, people may not realize they have been exposed.

The CDC reports that hundreds of cats and dogs, as well as livestock - cattle and horses - also get rabies in the U.S. each year, although much less frequently than wildlife. The cats, dogs, and livestock that develop rabies are typically not vaccinated for rabies and are infected by wildlife.

Scatliffe-Carrion says dogs and cats were by far the most commonly cited animals associated with PEP vaccines reported in DRSi. Dog bites alone accounted for about one-half of the reported exposures, while almost a third were cat bites or scratches.

In many other countries - especially those that do not mandate pet vaccinations – dogs remain a primary threat. According to the CDC, over 90 percent of human rabies deaths around the world are caused by dog bites. The rabies death of an Army soldier in August 2011 was due to an unreported dog bite in Afghanistan.

As a key prevention step, the Army mandates that deployed soldiers stay away from animals and not take in local pets or “mascots” since such animals are likely not vaccinated.

But regardless of soldiers’ location, their accidental contact with a wild or unvaccinated mammal still occurs. The PEP is therefore a critical public health tool against the threat of rabies.

The reported cases in the DRSi indicate slight annual increases in the number of rabies PEP administrations from 2017 to 2021 among active-duty service members and other beneficiaries. “In the last five years, over 2,600 rabies PEP reports were documented in the DRSi, says Scatliffe-Carrion. “There may be undocumented rabies PEP administrations, but the data show the Army is treating an average of 1.5 possible rabies exposures daily.”

“The highest number of PEP administrations have been recorded at Army medical treatment facilities in Texas, specifically Fort Bliss, Fort Hood, and Fort Sam Houston; and then Fort Bragg in North Carolina,” says Scatliffe-Carrion. “This doesn’t mean that the animals were definitely rabid, but the risk of rabies infection informs health care providers’ decisions to proceed with the PEP.”

Superior emphasizes the seriousness of rabies and steps to protect yourself:

• Vaccinate your pets. Even a bat that gets inside your house can be a potential source of exposure to them.
• Do not approach, feed, or handle wild or stray animals. Not all animals infected with rabies appear sick or display abnormal behavior, so you cannot always tell if an animal has rabies.
• Do not keep pets or mascots while deployed. Animals, especially dogs, have high risk for rabies in several foreign countries.
• Immediately wash any wound if you are bitten or if an animal’s saliva contacts your broken skin. Wash vigorously for 15 minutes with soap and water or diluted iodine to reduce the likelihood of rabies and possible bacterial infections.
• Seek immediate medical care if bitten or your eyes, mouth, or broken skin has been possibly exposed to animal saliva. If your provider is not available, seek care at an emergency room. You may need to receive the rabies PEP, as well as a tetanus shot and/or antibiotics.

The U.S. Army Public Health Center focuses on promoting healthy people, communities, animals, and workplaces through the prevention of disease, injury, and disability of Soldiers, retirees, family members, veterans, Army civilian employees, and animals through population-based monitoring, investigations, and technical consultations.

NOTE: The mention of any non-federal entity and/or its products is for informational purposes only, and not to be construed or interpreted, in any manner, as federal endorsement of that non-federal entity or its products.