Rabies Postexposure Prophylaxis
(excerpt from "Rabies Prevention in Texas")
The essential components of rabies postexposure prophylaxis are local treatment of wounds and immunization, including administration, in most instances, of both rabies immune globulin and vaccine. Local Treatment of Wounds
This section cannot be overemphasized. Immediate and thorough washing of all bite wounds and scratches with soap and water is perhaps the most effective measure for preventing rabies. In experimental animals, simple local wound cleansing has been shown to reduce markedly the likelihood of rabies.
Tetanus immunization and measures to control bacterial infection should be given as indicated.
Decision to Provide Immunoprophylaxis
The decision to treat or not to treat must be based on all available information about the circumstances surrounding the exposure incident. The Postexposure Prophylaxis Decision Chart is helpful in guiding the evaluation of a possible rabies exposure and determining the need or lack of need for antirabies treatment. Local or state public health departments may be consulted to clarify the guidance provided in this decision chart and to provide information concerning the prevalence of animal rabies in the geographic locale where the exposure occurred.
Immunization
Postexposure antirabies immunization should include administration of both rabies antibody (HRIG) and vaccine (HDCV, RVA or PCEC). An exception to this guideline is made for exposed persons who have been previously immunized with the recommended preexposure or postexposure regimens of HDCV, RVA or PCEC (or who have been immunized with other types of vaccines and have documented an adequate rabies antibody titer). In these cases, HRIG would not be given and only two doses of vaccine would be given on day 0 and day 3 (Table)
The combination of immune globulin and vaccine is recommended for both bite exposures and nonbite exposures, regardless of the interval between exposure and treatment. The sooner treatment is begun after exposure, the better the chance of effectiveness. However, if there was a delay in recognizing a rabies exposure, treatment may be begun even months after that exposure occurred.
Five 1.0 ml doses of HDCV, RVA or PCEC should be given intramuscularly (in the deltoid region) in adults, or the anterolateral thigh in infants. The ID route should not be used. The first dose should be given as soon as possible after exposure; additional doses should be given on days 3, 7, 14, and 28 after the first dose. Because the antibody response following the recommended vaccination regimen has been uniformly satisfactory, routine postvaccination serologic testing is not recommended by or available from the Texas Department of Health. In unusual instances, such as when the patient is immunodeficient or immunosuppressed, serologic testing (Rapid Fluorescent Focus Inhibition Test - RFFIT) is indicated. RFFIT testing is available through the Department of Veterinary Diagnosis, Veterinary Medical Center, Kansas State University, Manhattan, Kansas 66506, telephone: (785) 532-5650.
The selection of sites for intramuscular injections appears to be critical for vaccine efficacy. In adults and larger children, HDCV, RVA or PCEC should be given in the deltoid area. In infants and small children, the anterolateral thigh should be used. In the two laboratory confirmed human cases of rabies following postexposure treatment with HDCV and HRIG within 24 hours, the HDCV was administered in the gluteal area. Presumably, subcutaneous fat in the gluteal area may interfere with the immunogenicity of HDCV.
HRIG is administered only once, at the beginning of antirabies prophylaxis, to provide immediate antibodies until the patient responds to HDCV by active production of antibodies. If HRIG was not given when vaccination was begun, it can be given up to the eighth day after the first dose of vaccine was given. From the eighth day on, HRIG is not indicated, since an antibody response to the vaccine is presumed to have occurred.
The recommended dose of HRIG is 20 IU/kg or 0.06ml/lb of body weight. As much as possible of the full dose of HRIG should be thoroughly infiltrated into and around the wound(s). Any remaining volume should be administered intramuscularly at a site distant from vaccine inoculation. Because HRIG may partially suppress active production of antibody, no more than the recommended dose of HRIG should be given.
Rabies postexposure prophylaxis schedule, United States
| Vaccination status |
Treatment |
Regimen* |
Not previously vaccinated |
Local wound cleansing |
All postexposure treatment should begin with immediate thorough cleansing of all wounds with soap and water.
|
| HRIG |
20 lU/kg or 0.06 ml/lb body weight. As much as possible of the full dose should be infiltrated into and around the wound(s), and the remainder should be administered IM at an anatomical site distant from vaccine administration. HRIG should not be administered in the same syringe as vaccine. Because HRIG may partially suppress active production of
antibody, no more than the recommended dose should
be given.
|
| Vaccine |
HDCV, RVA or PCEC, 1.0 ml, IM (deltoid areas**), on days 0, 3, 7, 14 and 28 (day 0 indicates the first day of treatment). |
Previously vaccinated*** |
Local wound cleansing |
All postexposure treatment should begin with immediate thorough cleansing of all wounds with soap and water.
|
| HRIG |
HRIG should not be administered. |
| Vaccine |
HDCV, RVA, or PCEC 1.0 ml, IM (deltoid areas**), on days 0 and 3. |
*These regimens are applicable for all age groups, including children.
**The deltoid area is the only acceptable site of vaccination for adults and older children. For younger children, the outer aspect of the thigh may be used. Vaccine should never be administered in the gluteal area.
***Any person with a history of preexposure vaccination with HDCV, RVA or PCEC; prior postexposure prophylaxis with HDCV, RVA or PCEC; or previous vaccination with any other type of rabies vaccine and a documented history of antibody response to the prior vaccination.
Last Updated: Monday, February 13, 2006
Texas Department of State Health Services - Infectious Disease Control Unit
1100 West 49th Street, Suite T801, Mail Code: 1960 PO BOX 149347 - Austin, TX 78714-9347
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