RABIES POST EXPOSURE PROPHYLAXIS

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.

General management

Dealing with the animal

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

If animal cannot be identified

  • Presume animal infected and patient at risk

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
  • LOCAL WOUND TREATMENT: Prompt and thorough local treatment is an effective method to reduce risk of infection
  • For mucous mebranes contact, rinse throroughly with water or normal saline
  • 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

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
patients

In 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 different site

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