Rabies Post Exposure Prophylaxis

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Management

Post exposure prophylaxis effectively prevents the development of rabies after the contact with saliva of infected animals, through bites, scratches, licks on broken skin or mucous membranes.

For further details refer to Rabies Post-Exposure Treatment Guidelines, Veterinary Public Health Unit, Community Health Dept, Ministry of Health, September 2001.

General Management

Dealing with the animal:
Treatment LOC

If the animal can be identified and caught:

  • If domestic, confirm rabies vaccination
  • If no information on rabies vaccination or wild: quarantine for 10 days (only dogs, cats or endangered species) or kill humanely and send the head to the veterinary department for analysis
  • If no signs of rabies infection shown within 10 days: release the animal, stop immunisation
  • If it shows signs of rabies infection: kill the animal, remove its head, and send to the veterinary department for verification of the infection
HC2

If animal cannot be identified

  • Presume animal infected and patient at risk
HC2

 

Notes:

  • Consumption of properly cooked rabid meat is not harmful
  • Animals at risk: dogs, cats, bats, other wild carnivores
  • Non-mammals cannot harbour rabies

Dealing with the patient:

  • The combination of local wound treatment plus passive immunisation with rabies immunoglobulin (RIG) plus vaccination with rabies vaccine (RV) is recommended for all suspected exposures to rabies
  • Since prolonged rabies incubation periods are possible, persons who present for evaluation and treatment even months after having been bitten should be treated in the same way as if the contact occurred recently
  • Administration of Rabies IG and vaccine depends on the type of exposure and the animal’s condition

Treatment

Treatment LOC
  • LOCAL WOUND TREATMENT: Prompt and thorough local treatment is an effective method to reduce risk of infection
  • For mucous membranes contact, rinse thoroughly with water or normal saline
HC2
  • Local cleansing is indicated even if the patient presents late
  • DO NOT SUTURE THE WOUND

If Veterinary Department confirms rabies infection or if animal cannot be identified/tested:

  • Give rabies vaccine+/- rabies immunoglobulin human as per the recommendations in the next table
H

Recommendations for Rabies Vaccination/Serum

 

NATURE OF EXPOSURE

CONDITION OF ANIMAL

 

RECOMMENDED ACTION

AT TIME OF EXPOSURE

10 DAYS LATER

Saliva in contact with skin but no skin lesion

Healthy

Healthy

Do not vaccinate

Rabid

Vaccinate

Suspect/ Unknown

Healthy

Do not vaccinate

Rabid

Vaccinate

Unknown

Vaccinate

Saliva in contact with skin that has lesions, minor bites on trunk or proximal limbs

Healthy

Healthy

Do not vaccinate

Rabid

Vaccinate

Suspect/ unknown

Healthy

Vaccinate; but stop course if animal healthy after 10 days

Rabid

Vaccinate

Unknown

Vaccinate

Saliva in contact with mucosae, serious bites (face, head, fingers or multiple bites)

 

Domestic or wild rabid animal or suspect

 

Vaccinate and give antirabies immunoglobulin

Healthy domestic animal  

Vaccinate but stop course if animal healthy after 10 days

Prevention

Vaccinate all domestic animals against rabies e.g. dogs, cats and others

Administration of Rabies Vaccine (RV)

The following schedules use Purified VERO Cell Culture Rabies Vaccine (PVRV), which contains one intramuscular immunising dose (at least 2.5 IU) in 0.5 ml of reconstituted vaccine.

RV and RIG are both very expensive and should only be used when there is an absolute indication

Post-Exposure Vaccination in Non-Previously Vaccinated Patients

Give RV to all patients unvaccinated against rabies together with local wound treatment. In severe cases, also give rabies immunoglobulin.

The 2-1-1 intramuscular regimen

This induces an early antibody response and may be particularly effective when post-exposure treatment does not include administration of rabies immunoglobulins.

  • Day 0: One dose (0.5 ml) in right arm + one dose in left arm
  • Day 7: One dose
  • Day 21: One dose

Notes on IM doses:

Doses are given into the deltoid muscle of the arm. In young children, the anterolateral thigh may also be used.

Never use the gluteal area (buttock) as fat deposits may interfere with vaccine uptake making it less effective.

Alternative: 2-site intradermal (ID) regimen This uses PVRV intradermal (ID) doses of 0.1 ml (i.e. one fifth of the 0.5 ml IM dose of PVRV).

  • Day 0: one dose of 0.1 ml in each arm (deltoid)
  • Day 3: one dose of 0.1 ml in each arm
  • Day 7: one dose of 0.1 ml in each arm
  • Day 28: one dose of 0.1 ml in each arm

Notes on ID regime:

Much cheaper as it requires less vaccine.

Requires special staff training in ID technique using 1 ml syringes and short needles.

Compliance with the Day 28 is vital but may be difficult to achieve.

Patients must be followed up for at least 6-18 months to confirm the outcome of treatment.

If on malaria chemoprophylaxis, do NOT use.

Post-exposure immunisation in previously vaccinated patientsIn persons known to have previously received full pre- or post-exposure rabies vaccination within the last 3 years.

Intramuscular regimen

  • Day 0: One booster dose IM
  • Day 3: One booster dose IM

Intradermal regimen

  • Day 0: One booster dose ID
  • Day 3: One booster dose ID

Note: If incompletely vaccinated or immunosuppressed: give full post exposure regimen.

Passive immunisation with rabies immunoglobulin (RIG)

Give in all high risk rabies cases irrespective of the time between exposure and start of treatment  BUT  within  7 days of first vaccine. DO NOT USE in patient previously immunised.

Human rabies immunoglobulin (HRIG)

HRIG 20 IU/kg (do not exceed)

  • Infiltrate as much as possible of this dose around the wound/s (if multiple wounds and insufficient quantity, dilute it 2 to 3 fold with normal saline)
  • Give the remainder IM into gluteal muscle
  • Follow this with a complete course of rabies vaccine
  • The first dose of vaccine should be given at the same time as the immunoglobulin, but at a site as far away as possible from the site where the vaccine was injected. If the bite is at or near the upper arm, do not infiltrate the wound with the immunoglobulin unless the vaccine won’t be injected in the deltoid muscle of that arm. If the wound near the deltoid is infiltrated with the immunoglobulin, use the deltoid muscle of the opposite arm for the vaccine”

Notes: If RIG not available at first visit, its administration can be delayed up to 7 days after the first dose of vaccine.

Pre-exposure immunisation

Offer rabies vaccine to persons at high risk of exposure such as:

  • Laboratory staff working with rabies virus
  • Veterinarians
  • Animal handlers
  • Zoologists/wildlife officers
  • Any other persons considered to be at high risk
    • Day 0: One dose IM or ID
    • Day 7: One dose IM or ID
    • Day 28: One dose IM or ID

 

Rabies Vaccine Schedules

DAY Vaccine Dose No of Doses Comments
Intramuscular region

0

0.5ml

2 (one in each deltoid)

  • Into the deltoid muscle

NEVER IN THE GLUTEAL MUSCLE (buttocks)

  • Children with less muscle mass: Anterolateral aspect of the thigh

Note: Day 14 is skipped

  • The 2:1:1 regimen uses 4 doses in 3weeks
  • It has fewer patient appointments and it is easy to comply with

If the patient is on anti-malarial prophylaxis with Chloroquine, it should be withheld and an alternative malaria prophylaxis should be started if needed.

7

0.5ml

1

21

0.5ml

1

2-site Intradermal (ID) Regimen

0

0.1ml

2 (one in each deltoid)

  • It is cheaper since it uses less drug
  • It requires special staff training in ID technique using 1ml syringes with shorter needles
Note: Days 14 and 21 are skipped

3

0.1ml

2 (one in each deltoid)

7

0.1ml

2 (one in each deltoid)

28

0.1ml

2 (one in each deltoid)

Rabies Immunoglobulin

0

20IU/

kg

Infiltrate in the area around and in the wound at the same depth as the wound

The Immunoglobulin should be administered as far as possible from the vaccine to avoid antibody-antigen reaction