Management of Rabies

Rabies is an acute viral infection resulting in encephalomyelitis and almost invariably in death. The incubation period is usually between 2 to 8 weeks (range 9 days to 2 years). Infection is usually through the bite of a rabid animal. Rarely, transmission of the virus can also occur through mucous membranes. Person to person spread of the disease is extremely rare but there had been instances of transmission through corneal grafts.

Pre-exposure prophylaxis

Pre-exposure prophylaxis should be offered to all those whose work may lead to potential contact with rabid animals. It should be given to all health workers caring for a patient with confirmed or suspected rabies. Three 1 ml doses (0, 7, 28) by deep subcutaneous or i.m, is normally used. The vaccine may also be given in smaller doses by the intradermal route (0.1 ml) with the same intervals. The intradermal route may also be used for the rapid immunization of staff caring for a patient with rabies by giving 0.1 ml into each limb (0.4 ml in all) on the first day of exposure to the patient. Intradermal immunization is only reliable if the whole of the 0.1 ml dose is given into the dermis and should only be given by a person experienced in the technique. The use of the intradermal route is not covered by the manufacturer’s license. Booster doses of the vaccine should be given every 2 to 3 years. The three-dose course gives virtually 100% protection and thus routine post-immunization testing is unnecessary. However, serological testing is advised for those who work with live virus and this should be carried out every 6 months.

Post-exposure prophylaxis

In the event of a possible exposure, the following protocol should be observed in the UK;-

1. The wound should be thoroughly cleaned
2. The animal involved should be observed for 10 days, if no signs develop, then no further action is necessary. It is not necessary to commence postexposure prophylaxis since UK is a rabies free area. However, if the wound is very severe and near the CNS eg. the face, then post-exposure prophylaxis may be started and stopped if the animal remains normal after the observation period.
3. If the animal is a stray or a wild animal and observation is impossible, advice should be taken from a local doctor or CCDC who will know whether rabies occur in the locality and thus whether post-exposure prophylaxis is advised. It may be advisable to give a course of vaccine without immunoglobulin in such cases.
4. If the exposure occurred abroad, postexposure prophylaxis should be started as soon as possible while enquiries are made about the prevalence of rabies in the country concerned, and where possible, the condition and ownership of the biting animal.
5. Unimmunized individuals should be given 1.0 ml of HDCV by deep subcutaneous or i.m. infection on days 0, 3, 7, 14, 30, and 90. The vaccine should be given into the deltoid region. Rabies-specific immunoglobulin should be given; up to half the dose is infiltrated in and around the wound and the rest given by im injection.
6. Previously immunized individuals should be given two 1.0 ml doses of HDCV into the deltoid. Immunoglobulin treatment is not needed.

Management of patient diagnosed or suspected of having rabies

1. The patient should be put under strict isolation, particular attention should be paid to nasopharyngeal secretions and saliva. Blood is most unlikely to be infectious.
2. Staff caring for the patient should be immunized against rabies.