RabiesMonica Cardenas, MD, PGY14/18/14

AB is a 10 year old boy presents to the ED after being bit by his neighbors dog in the left lower extremity. His brother states that the dog was playing and sniffing them when AB got scared and ran away. The dog was jumping and sniffing at him when he bit his leg. His mother brought him immediately to the emergency room. On exam vitals are stable and the bite is about 4cm in diameter localized to posterior calf muscle. Exam is otherwise WNL. His mom reports that the owner stated the dog was healthy and fully immunized but could not produce papers to support it. She wants to know if he needs to get any shots today. What do you tell her?

a. He will require a combination of rabies immunoglobulin and rabies vaccine.

b. He will only require rabies immunoglobulinc. He will only require rabies vaccined. He will not require rabies vaccine or immunoglobulin as long

as the dog can be observed for 10 days for signs of rabies

AB is a 10 year old boy presents to the ED after being bit by his neighbors dog in the left lower extremity. His brother states that the dog was playing and sniffing them when AB got scared and ran away. The dog was jumping and sniffing at him when he bit his leg. His mother brought him immediately to the emergency room. On exam vitals are stable and the bite is about 4cm in diameter localized to posterior calf muscle. Exam is otherwise WNL. His mom reports that the owner stated the dog was healthy and fully immunized but could not produce papers to support it. She wants to know if he needs to get any shots today. What do you tell her?

a. He will require a combination of rabies immunoglobulin and rabies vaccine.

b. He will only require rabies immunoglobulinc. He will only require rabies vaccined. He will not require rabies vaccine or immunoglobulin

as long as the dog can be observed for 10 days for signs of rabies

What type of exposure occurred? Rabies is transmitted only when the virus is introduced into a bite wound,

open cuts in skin, or onto mucous membranes such as the mouth or eyes. Bite

Any penetration of the skin by teeth constitutes a bite exposure. All bites, regardless of body site, represent a potential risk of rabies transmission

Bites by some animals, such as bats, can inflict minor injury and thus be difficult to detect.

Was the bite from a provoked or an unprovoked attack? Bites inflicted on a person attempting to feed or handle an apparently healthy animal should generally be regarded as provoked.

If it was an unprovoked attack, that's more likely to indicate that the animal is rabid.

What type of exposure occurred?

Nonbite The contamination of open wounds, abrasions, mucous

membranes, or theoretically, scratches (potentially contaminated with infectious material from a rabid animal) constitutes a nonbite exposure.

Nonbite exposures from terrestrial animals rarely cause rabies. However, occasional reports of rabies transmission by nonbite exposures suggest that such exposures should be evaluated for possible postexposure prophylaxis administration.

Other contact by itself, such as petting a rabid animal and contact with blood, urine, or feces of a rabid animal, does not constitute an exposure and is not an indication for postexposure vaccination.

According to the CDC…

According to CDC and AAP…Vaccination Status

Intervention Regimen*

Not previously vaccinated

Wound cleansing

All PEP should begin with immediate thorough cleansing of all wounds with soap and water. If available, a virucidal agent (eg, povidine-iodine solution) should be used to irrigate the wounds.

Human rabies immune globulin (HRIG)

Administer 20 IU/kg body weight.

Vaccine Human diploid cell vaccine (HDCV) or purified chick embryo cell vaccine (PCECV) 1.0 mL, IM (deltoid area†), 1 each on days 0, 3, 7 and 14.

According to CDC and AAP…

Vaccination Status

Intervention

Regimen*

Previously vaccinated

Wound cleansing

All PEP should begin with immediate thorough cleansing of all wounds with soap and water. If available, a virucidal agent such as povidine-iodine solution should be used to irrigate the wounds.

HRIG HRIG should not be administered.

Vaccine HDCV or PCECV 1.0 mL, IM (deltoid area†), 1 each on days 0and 3.

HRIG Human rabies immune globulin (HRIG) is administered only

once, at the beginning of anti-rabies prophylaxis, to previously unvaccinated persons.

The full dose should be thoroughly infiltrated in the area around and into the wounds. Any remaining volume should be injected intramuscularly at a site distant from vaccine administration.

HRIG should never be administered in the same syringe or in the same anatomical site as the first vaccine dose.

If HRIG was not administered when vaccination was begun, it can be administered up to seven days after the administration of the first dose of vaccine

Because HRIG can partially suppress active production of antibody, no more than the recommended dose should be administered. The recommended dose of HRIG is 20 IU/kg body weight.

You are seeing a 12 year old girl with perinatally acquired HIV as a follow-up for racoon bite at your clinic. Her HIV is well controlled on HAART therapy, viral load is suppressed to undetectable levels. She received appropriate post-exposure prophylaxis (PEP) and is here for her last dose of rabies vaccine on day 28. She has been asymptomatic without fever, weakness, or headache. What is the next step in management of this patient?

a. No routine testing to document seroconversion is necessary after PEP

b. She received a 5 dose regimen instead of the usual 4 dose regimen and therefore will not require routine testing for seroconversion

c. She should be tested for for rabies-virus neutralizing antibody with rapid fluorescent focus inhibition test in 1-2 weeks

d. She should be tested for rabies-virus neutralizing antibody with rapid fluorescent focus inhibition test in 4-6 weeks.

You are seeing a 12 year old girl with perinatally acquired HIV as a follow-up for racoon bite at your clinic. Her HIV is well controlled on HAART therapy, viral load is suppressed to undetectable levels. She received appropriate post-exposure prophylaxis (PEP) and is here for her last dose of rabies vaccine on day 28. She has been asymptomatic without fever, weakness, or headache. What is the next step in management of this patient?

a. No routine testing to document seroconversion is necessary after PEP

b. She received a 5 dose regimen instead of the usual 4 dose regimen and therefore will not require routine testing for seroconversion

c. She should be tested for for rabies-virus neutralizing antibody with rapid fluorescent focus inhibition test in 1-2 weeks

d. She should be tested for rabies-virus neutralizing antibody with rapid fluorescent focus inhibition test in 4-6 weeks.

Seroconversion

No routine testing to document seroconverion in healthy patients who have completed PEP is necessary

For persons with immunosuppression, rabies PEP should be administered by using 5 dose regimen (days 0,3,7,14 and 28). Patient should be tested for rabies virus-neutralizing antibody with the rapid fluorescent focus inhibition test 1-2 weeks after the 5th dose of vaccine.

If an acceptable antibody response is not detected the patient should be managed in consultation with an expert in rabies.

References

CDC center for disease control and prevention. http://www.cdc.gov/rabies/index.html

http://www.cdc.gov/rabiesandkids/ Rabies-Prevention Policy Update: New Reduced-Dose Schedule.

Pediatrics 2011; 127:785. March 28, 2011