Rabies Exposure Risk Assessment and Management

Primary Exposure Categories

The Centers for Disease Control and Prevention recommends that any penetration of the skin by teeth constitutes a bite exposure, regardless of body location or severity of visible trauma, and all bites represent potential rabies transmission risk 2, 3
The risk of rabies transmission varies based on the biting animal species, anatomic site, and wound severity, but these factors should not delay the decision to initiate treatment, according to the Centers for Disease Control and Prevention 2, 4
Nonbite exposures, such as scratches, abrasions, open wounds, or mucous membranes contaminated with saliva or other potentially infectious material from a rabid animal, can also transmit rabies, as stated by the Centers for Disease Control and Prevention 2, 3, 4
The highest-risk nonbite exposures include aerosolized rabies virus exposure in laboratories or bat caves, organ/corneal transplants from rabies-infected donors, and scratches by rabid animals, according to the Centers for Disease Control and Prevention 3, 4
If the material containing virus is dry, it can be considered noninfectious, as rabies virus is inactivated by desiccation and ultraviolet irradiation, as stated by the Centers for Disease Control and Prevention 2, 3

The World Health Organization categorizes exposures into three categories: Category I (no prophylaxis required), Category II (vaccine only, no immunoglobulin), and Category III (vaccine + immunoglobulin required) 1
Category II exposures, such as nibbling of uncovered skin without bleeding, minor scratches or abrasions without bleeding, and licks on broken skin, require rabies vaccine series only, according to the World Health Organization 1
Category III exposures, such as any penetration of skin by teeth, contamination of mucous membranes with saliva, and contamination of open wounds with saliva or potentially infectious material, require immediate thorough wound washing, Human Rabies Immune Globulin (HRIG), and complete vaccine series, as stated by the World Health Organization 1

The Centers for Disease Control and Prevention considers wild terrestrial carnivores, such as raccoons, skunks, foxes, coyotes, and bobcats, to be high-risk animals that must be considered rabid unless proven otherwise 4, 5
Bats are also considered high-risk animals, and any bat contact requires post-exposure prophylaxis (PEP) when bite/scratch cannot be excluded, according to the Centers for Disease Control and Prevention 4, 5
Healthy domestic dogs, cats, and ferrets can be confined and observed for 10 days rather than immediately starting PEP, as stated by the Centers for Disease Control and Prevention 5

The World Health Organization recommends that immediate thorough wound washing with soap and water for 15 minutes is the most important first step in managing potential rabies exposures, and should not be delayed while arranging for PEP 1
The Centers for Disease Control and Prevention advises against delaying post-exposure prophylaxis for severe wounds to the face and head, given the shorter incubation period with proximity to the central nervous system 1
The World Health Organization recommends that vaccine should never be administered in the gluteal area, and the deltoid is the only acceptable site in adults and older children 1