Rage | Clinique Omicron Québec
Epidemiology in Quebec — Animals at Risk
- Bats (main risk in Quebec): Reservoir of several lyssavirus variants in Canada + bite often unfelt (very small teeth + painless bite during sleep) + any direct exposure to a bat (found in a bedroom + contact with skin or mucous membranes + bite or scratch) requires urgent evaluation for PEP + even without a visible wound if the bat was present in the same room as a sleeping person + or a child unable to report a bite
- Fox + skunk + raccoon potential reservoirs, but terrestrial rabies is rare in Quebec thanks to oral baiting campaigns (oral vaccine in wild foxes) + any wild animal acting abnormally (diurnal for a nocturnal animal + not fearful of humans + ataxic + aggressive for no reason) must be considered suspicious
- Vaccinated dogs + cats (Quebec): Practically no risk if vaccinations are up to date + mandatory rabies vaccination for dogs in Quebec (Animal Health Protection Act) + unvaccinated dog or cat bites → 10-day veterinary quarantine
- Rodents (squirrels + rats + mice + rabbits): Rarely infected with rabies + no documented cases of human rabies transmitted by rodents in North America → PEP generally not indicated after rodent bite if no abnormal behavior
- Animals traveling abroad: Dogs + cats + monkeys + mongooses in rabies-endemic countries (South Asia + Africa + Latin America + Eastern Europe) → major risk → requires urgent PPE + pre-exposure prophylaxis recommended before at-risk stays
Clinical presentation of declared rabies
- Incubation (silent): 1 to 3 months on average (extremes: 4 days to 19 years) + duration related to the distance between the bite site and the brain (head bites = shorter incubation) + severity of inoculation + amount of virus inoculated + PEP is effective throughout this silent phase
- Prodromal phase (2–10 days): fever, headache, malaise, pruritus or paresthesias at the bite site (early, almost pathognomonic sign—pain or paresthesia at an old, healed wound), anxiety, irritability, photophobia
- Furious neurological phase (classic form - 80 %): hydrophobia (painful spasms of the swallowing muscles at the sight or touch of water – pathognomonic) + aerophobia (spasms triggered by drafts) + hypersalivation + agitation + hallucinations + aggressive behavior + autonomic hyperactivity (tachycardia + hypertension + hypersalivation + hyperthermia)
- Paralytic phase (paralytic form — 20 %): progressive ascending paralysis (Guillain-Barré-like syndrome) + less recognized than the furious form → often diagnosed late + predominant in bat transmissions
- Evolution coma + multiple organ failure + death within 7-14 days of symptom onset + fatality rate close to 100 % + a few rare survivors documented after intensive treatment with the Milwaukee protocol (midazolam + ketamine + amantadine + ribavirin) → highly variable results + not validated as standard treatment
Post-exposure prophylaxis (PEP) — medical emergency
| Step | Measure | Details and importance |
|---|---|---|
| 1 — Immediate wound cleaning | Thorough and prolonged washing (minimum 15 minutes) with running water and soap + disinfection with povidone-iodine 10% % or 70% alcohol % + DO NOT suture the wound immediately (promotes deep inoculation of the virus) | Most important and most often overlooked step → immediate and prolonged washing reduces transmission risk by 90 % + to be performed even before going to the emergency room + do not wait |
| 2 — Risk Assessment (Emergencies or Public Health) | Animal's vaccination status + animal's behavior + circumstances of exposure + identification of animal species + geographical area + availability of the animal for observation or analysis | Public Health of Quebec (DRSP) is available 24/7 to advise physicians on the indication for PEP + a vaccinated and healthy dog or cat can be placed under veterinary observation for 10 days → PEP can be deferred |
| 3 - Human rabies immunoglobulin (HRIG) | HRIG (Human Rabies Immune Globulin) 20 IU/kg + infiltration of the entire dose around and into the wound + remainder injected IM if volume is insufficient for wound infiltration + administered simultaneously or within 7 days of the first vaccine dose + DO NOT administer after day 7 (interferes with vaccine response) | Indicated only for people who have never received pre-exposure rabies vaccination + provides immediate passive immunity until the vaccine induces active immunity (takes 7–10 days) |
| 4 — Post-exposure rabies vaccination | Inactivated rabies vaccine (PCEC or HDCV) × 4 doses: D0 + D3 + D7 + D14 (deltoid IM) + if previously vaccinated person (PvP) → 2 doses only (D0 + D3) + no RIG | Effectiveness close to 100% % if initiated before symptoms + it's never too late to initiate if the patient is asymptomatic + full PPE must be ensured even if the exposure was several weeks ago |
Pre-Exposure Prophylaxis (PrEP) — Travelers and High-Risk Professions
- Indications: Travelers staying in countries with endemic rabies (South Asia, Africa, Latin America) for > 1 month, or at risk of intense exposure (hiking, remote regions without rapid access to healthcare), veterinarians, wildlife technicians, lab workers handling the virus, animal control officers, speleologists
- PrEP Protocol 2 doses of rabies vaccine (D0 + D7) → basic immunity + booster according to rabies virus neutralizing antibody (RVNA) titer (goal: neutralizing titer ≥ 0.5 IU/mL) + advantages: if subsequent exposure → only 2 doses + no RIG (product difficult to find in many countries) + allows for extending the emergency timeframe
- Protection period: No systematic follow-up recommended if titer ≥ 0.5 IU/mL + antibody testing recommended every 2 years for individuals with ongoing occupational exposure
Consult the emergency room or call the Regional Public Health Department (DRSP) immediately — within hours of exposure, not days — if you have been bitten or scratched by a wild animal (bat ++, fox +, skunk +, raccoon) + an unvaccinated domestic animal + or an animal with abnormal behavior. Wash the wound thoroughly with soap and water for 15 minutes immediately and before going to the emergency room. Post-exposure prophylaxis is almost 100% effective % if initiated in time — but becomes impossible once neurological symptoms appear. Declared rabies is fatal. Do not wait.
For post-exposure consultations to a potentially rabid animal, risk assessment, and PEP (RIG + rabies vaccine) prescription, Clinique Omicron offers medical consultations at its service points in Quebec. For evening or weekend exposures, go to the emergency room or call 811 (Info-Santé). To make an appointment for travel medicine for PEP, visit cliniqueomicron.ca.
Consult at Clinique Omicron
Clinique Omicron's nurse practitioners (NPs) assess potential rabies exposures (bites + scratches + bat contacts), coordinate with Public Health for PEP decisions, initiate PEP (RIG + rabies vaccine) according to MSSS/INSPQ protocols, and offer pre-exposure prophylaxis for travelers to endemic areas and for at-risk professions. Travel medicine consultations are available at several service points in Quebec and via telemedicine for PrEP planning. To book an appointment, visit cliniqueomicron.ca.
The content of this page is provided for informational purposes only and does not substitute for medical advice or public health guidance. Any decision to initiate or not initiate post-exposure rabies prophylaxis should be made in consultation with the Regional Public Health Department (DRSP) or a qualified physician. Rabies is a notifiable disease (MADO) in Quebec - any suspected or confirmed case must be reported immediately.
Omicron Clinic
Need to consult a doctor?
Treatment within 24-48 hours. In-clinic or telemedicine, anywhere in Quebec.
Insurance receipts. 7j/7. No family doctor required.