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Rabies

KEY POINTS

  1. Rabies is virtually uniformly fatal and animal bites or scratches or contact with their saliva can transmit the virus.
  2. Outside the U.S., dogs and cats are the main source of rabid illness. In the U.S., domesticated animals are almost universally vaccinated against rabies, but often not at all in other countries.Bats are the most frequent source of U.S. rabies.
  3. Pre-Exposure vaccination is recommended for,
    1. Individuals spending substantial time in Third World countries.
    2. Substantial exposure to local animals.
    3. Expatriates.
  4. Post-Exposure vaccination is indicated for bites, scratches, or saliva exposure to rabies animal vectors.
  5. Rabies vaccine shots are no more uncomfortable than flu shots (minimally), contrary to those 40 – 50 yrs. ago.

 


DISEASE: A central nervous system infection with rabies virus manifested by symptoms of encephalitis (brain inflammation)

Symptoms/Signs:

  1. Pain
  2. Behavioral Changes
  3. Seizures
  4. Paralysis
  5. Coma
  6. Choking

Prognosis: Almost invariably fatal, usually within 7 days of illness onset

Incubation: several weeks – months (avg = 2 months), but range is 5 days – over a year (1 documented case more than 7 yrs)

 

Prevalence:

  • Worldwide, except for New Zealand, most south Pacific Islands, and Antarctica. Southeast Asia, Africa, and India lead in cases.
  • In the U.S., most cases are from wild animals, by far bats; also skunks, raccoons, coyotes, foxes, and livestock. In other countries, most rabies is from unvaccinated domestic animals (dogs and cats).

 

Transmission:

  1. Animal bites – especially to the face and hands
  2. Non-bites
  • Scratches
  • Saliva (licks)
  • Airborne (caves with bats)

Notes:

  • Touching rabid animals or contacting their blood, urine, or feces is not a valid exposure and does not require prophylaxis.
  • Animals may not appear sick or ferocious when infected with rabies; in fact, they may be docile.

 

Treatment: None for the virus, other than as described below, under “Prevention”

 

Prevention:

  1. Avoid contact with wild animals or unvaccinated pets.
  2. Thorough washing with soap and water for several minutes of any animal-related wound or saliva contaminated tissue.
  3. Rabies Prevention Protocol
    1. Pre-Exposure
      1. Human Diploid Cell Vaccine (HDCV/Imovax) – killed
        1. 3 doses – day 0, 7, and 21 or 28
        2. Boosters – to be given per waning of immunity as determined by rabies antibody blood tests every 6 months (continuous exposure) or every 2 yrs (frequent exposure)
        3. Rabies shots are no more uncomfortable than flu shots (minimally), contrary to those 40 – 50 yrs ago.
    2. Post-Exposure
      1. Previously Unimmunized
        1. Human Rabies Immunoglobulin (HRIG) x 1 intramuscular
        2. HDCV: day 0, 3, 7, 14 (and 28 in the immune compromised)
      2. Previously Rabies Immunized
        1. HDCV: days 0 and 3
          1. HRIG should also be given if immune compromised
      3. Note: This protocol should be started ASAP after exposure, unless uncertain if animal was rabid – if so, can quarantine animal 10 days (cats, dogs, ferrets only) and obviate the immunization protocol altogether if the animal remains well.
  4. The Vaccine (HDCV/killed)
    1. Targets
      1. Pre-Exposure
        1. Increased risk of rabies virus exposure by occupation or residence
        2. Travelers with extensive outdoor activities and exposed to animals, where immediate access to appropriate medical care is questionable
        3. Children in rabies virus endemic areas
      2. Post-exposure
        1. Depends on type of contact (consult Infectious Diseases specialist)
    2. Side-Effects
      1. Mild, local (30 – 75%): Injection site pain, inflammation
      2. Mild, systemic (5-40%): Headache, nausea, abdominal pain, muscle aches, local gland swelling, fever, dizziness
      3. Hives, itching, malaise, 2-21 days post booster doses (6%)
      4. Rare, self-resolving neurological reactions (such as Guillain-Barré syndrome)
    3. Precautions/Contraindications
      1. With moderate illness, consider postponing vaccination.
      2. Hypersensitivity to neomycin sulfate
      3. Immunocompromised persons should be vaccinated by IM (intramuscular) route and have a blood test to confirm adequate rabies antibody production post-vaccine series.
      4. Pregnancy is not a contraindication to post exposure preventive protocol.
      5. Note: The rabies vaccine is killed, and so cannot cause rabies.

Access the VIS Sheet here

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