Rabies Postexposure Prophylaxis

1. See Also
   1. Rabies
   2. Rabies Vaccine
   3. Dog Bite
2. Epidemiology
   1. Postexposure Rabies Prophylaxis is given to as many as 39,000 patients per year in United States
3. Approach
   1. Dog, cat, or ferret bite
      1. Worldwide, dogs are responsible for many of the 59,000 human deaths due to Rabies each year
         1. Rabies Prophylaxis is needed if Dog Bite occurs outside developed regions
      2. Healthy appearing animals
         1. Observe for 10 days and start Rabies Vaccine if Rabies clinical signs develop
         2. Do not euthanize any animal involved in a bite injury prior to completion of 10 day observation
      3. Start Vaccination immediately if
         1. Rabies suspected or
         2. Unknown status such as an escaped dog that cannot be observed (consult with public health first)
   2. Bat, raccoon, skunk, fox or other carnivorous mammal bite
      1. Assume rabid status unless Rabies test negative
      2. Vaccination may be delayed if Rabies testing of the animal is pending (consult with public health)
   3. Livestock and horse bite
      1. Livestock are typically fully vaccinated in the U.S.
      2. Consult public health
   4. Rabbit, hare, small rodent (squirrel, chipmunk, rat, mouse, hamster, gerbil, guinea pig) or other mammal bite
      1. Rarely requires Rabies Prophylaxis
      2. No known cases of these small rodents transmitting Rabies to humans
      3. Consult public health
   5. References
      1. Manning (2008) MMWR Recomm Rep 57(RR-3): 1-28 [PubMed]
4. Indications: Post-exposure Prophylaxis
   1. High risk exposures
      1. Lab workers
      2. Veterinarians
      3. Spelunkers
      4. International travelers to high risk areas, and unable to be medically evaluated within 24 hours
   2. High risk animal exposure
      1. See Approach above
      2. Dog or cat with unknown Vaccination status
         1. Animal cannot be quarantined for 10 days
         2. Rabies suspected or unprovoked attack
      3. Bite from bat, raccoon, skunk, fox or other carnivorous mammal bite
      4. Possible bat exposure (e.g. awakening in same room as bat)
         1. Many U.S. confirmed human Rabies cases did not recall a specific bite (and bat bite marks are small)
         2. Bats aerosolize their Saliva and may transmit to mucous membranes when in close contact
         3. Prophylaxis if bat in same room as child, mentally disabled person, sleeping or intoxicated adult
5. Protocol: Post-exposure Prophylaxis
   1. Wash wound with soap and water
   2. Also update Tetanus Vaccine
   3. Unvaccinated against Rabies: Administer both Immune globulin and Vaccine
      1. Human Rabies immune globulin 20 IU/kg
         1. Inject into and around all wound sites
         2. Intended to neutralize Rabies virus before it enters nerve
         3. Remote site injections are less likely to be of benefit (minimal distribution via systemic circulation)
         4. May be administered up to 7 days following bite
            1. However, administer immune globulin as soon as possible
      2. Rabies Vaccine (HDCV, RVA, PCEC)
         1. Consider Vaccination even if delayed presentation weeks after exposure
            1. Rabies incubation may be 1-3 months or even delayed for years (and is uniformly fatal)
         2. Administer 1 ml Vaccine IM in Deltoid
         3. Days 0, 3, 7, 14
            1. Prior 5th dose on day 28 was eliminated in U.S. as of 2007-2009
   4. Vaccinated against Rabies
      1. Complete unvaccinated protocol unless can demonstrate immunity
      2. Indications
         1. Prior cell-culture Vaccine OR
         2. Protective rabies Antibody response (>0.5 IU/ml)
      3. Protocol
         1. No immune globulin needed
         2. Give 2 Rabies Vaccine doses on Days 0 and 3
6. Resources
   1. CDC Rabies Contact Information
      1. http://www.cdc.gov/rabies/resources/contacts.html
7. References
   1. Swaminathan and Hope in Herbert (2018) EM:Rap 18(12): 11-2
   2. Ellis (2014) Am Fam Physician 90(4):239-43 [PubMed]
   3. Wilde (2003) Clin Infect Dis 37:96-100 [PubMed]