Rabies Prevention and Treatment

RABIES PREVENTION AND TREATMENT
LATEST GUIDELINE 2019

RABIES PREVENTION AND TREATMENT
PRE EXPOSURE POST EXPOSURE DOG VACCINATION

PROPHYLAXIS TREATMENT.
PRE EXPOSURE PROPHYLAXIS
❑ Indicated for personnel with high risk for exposure. (Health care workers, Veterinary surgeons and
assistants, wild life officers, animal quarantine officers, Sanitary workers, Farmers etc.)
❑ 2 options:-
Intradermal ARV 0.1ml single dose
Intramuscular ARV 1 dose on day-0, day-7 and day-28
Followed by a booster dose in 1 year and additional booster doses every 5 years.
In the event of an exposure, RIG is not required.

Only additional doses if ID 2 sites or IM ARV one dose on day-0 and day-3 will be sufficient even for a
confirmed rabid animal attack.
POST EXPOSURE PROPHYLAXIS
Screening the patient- Categorization of the exposure

1 Major exposures:
❖ Single or multiple bites with bleeding on head, neck, face, chest, upper arms, palms, tips of
fingers & toes and genitalia
❖ Single or multiple deep bites with free flowing of blood on any part of the body
❖ Single or multiple deep scratches with free flowing of blood on the head, neck and face
❖ Contamination of mucous membranes with saliva
❖ Bites of wild animals with bleeding

2. Minor exposures:
❖ Single, superficial bite with oozing of blood or scratches with bleeding on any part of the body
❖ Multiple scratches with oozing of blood on any part of the body
❖ Nibbling of uncovered skin
❖ Contamination of open wounds with saliva
❖ Superficial bites and scratches of wild animals without bleeding
3. The following are not considered as exposures:

❖ Contamination of intact skin with saliva of a proven rabid/suspicious/stray animal
❖ Petting, bathing or coming in contact with utensils of a proven rabid/suspicious/stray animal
❖ Eating of leftovers which were previously eaten by a proven rabid/suspicious/stray animal
❖ Drinking water from a well where an animal has fallen and died
❖ Drinking raw milk of a rabid cow or goat
❖ Bites from cold blooded animals (reptiles, amphibians) and pecks by birds
❖ House rat bites

Management of a patient with a minor exposure
❖ If the animal is apparently healthy, observable and has had a minimum of one rabies vaccination
with documented evidence.
- within 1 year of the incident
- at an age above 3 months
- incident occurring at least 1 month after the last vaccination
PET can be delayed while observing the animal for healthiness / behavioral changes for 14 days from
the day of the exposure.
❖ PET for superficial scratches with bleeding, caused by healthy observable domestic animals
(irrespective of vaccination status of the animal) also could be delayed while observing the animal
for 14 days.
❖ If the animal becomes sick, develops any suspicious behavior, goes missing or dies, the patient
should be advised to report to the hospital immediately to commence PET.
 If the animal is having suspicious behavior or sick but observable (irrespective of the vaccination
status) initiate PET while observing the animal. Discontinue PET if the animal is healthy after 14
days.
 If the animal is having rabies (confirmed by laboratory diagnosis) or unobservable (stray animal,
animal dead, killed, missing; irrespective of the vaccination status) initiate PET and continue the
full course .
 PET for minor exposures: only anti rabies vaccine is indicated even if the animal is proven to be
rabid.
Management of a patient with a major exposure
❑ If the animal is apparently healthy, observable with a reliable history and has documented proof of: -
-a minimum of 2 rabies vaccinations given not more than 2 years apart

- with the last vaccination given within 1 year of the incident
PET could be delayed while observing the animal for 14 days.
❑ If the animal is apparently healthy, domestic and observable with a reliable history: -
In situations where the animal is improperly vaccinated or not vaccinated

If the wounds are not in the head and neck
If the wound/s does not need surgical manipulations or suturing
If the bite was due to a provoked situation
If the patient/ parent of a child is responsible and reliable
If the patient is immune-competent
Patient could be managed with modified ID 4 site schedule (4-2-2-0-2) in place of RIG, while observing the animal for 14 days
for healthiness.
Exposure to sick/Rabid animal
❖ If the animal is sick (irrespective of the vaccination status),
❖ having rabies (confirmed by laboratory diagnosis)
❖ unobservable (animal dead, killed, missing or stray animal)
Initiate PET immediately with rabies immunoglobulin (RIG) and follow with a full course of anti rabies
vaccine (ARV).
RABIES TREATMENT
Two Major injection treatments are used in Rabies treatment.
1. Immunoglobulins or Anti Rabies Serum (ARS)

-Equine Rabies Immunoglobulin (ERIG)
-Human Rabies Immunoglobulin (HRIG)
2. Anti Rabies Vaccine (ARV)

Dosage of RIG
Maximum dose of Equine rabies immunoglobulin (ERIG) 40 IU/ Kg body weight

Maximum dose of Human rabies immunoglobulin (HRIG) 20 IU/Kg body weight
❖ There is no minimum dose
Anti Rabies Vaccines (ARV)

Intradermal (ID) schedules of ARV
❖ WHO recommends the use of ID schedules as there is a global shortage of ARV and for developing countries,
where cost of vaccines is a major limiting factor.
❖ The recommended ID dose is 0.1ml per site for both PCEC and PVRV.
❖ For all age groups, ID injection sites are the deltoid region, anterolateral thigh or suprascapular regions.
❖ It is recommended to use fixed needle 1ml disposable syringes for intradermal administration of ARV to
minimize vaccine wastage.
Intradermal (ID) schedules of ARV
The 2 site ID schedule (2-2-2-0-2 schedule)

 The standard schedule used in government hospitals
 One dose each (0.1ml) is given at 2 sites, on both arms (over deltoids) on DO, D3, D7 and D30.
The modified 4 site ID schedule (4-2-2-0-2 schedule)

▪ One dose each (0.1ml) is given at 4 sites on day DO (deltoids and lateral thighs) one dose each (0.1ml) given
at 2 sites on D3, D7 and D30.
 This schedule could be recommended for patients with minor exposures with late presentation, borderline
exposures and major exposures from healthy observable domestic animals (If the animal is apparently
healthy, domestic and observable with a reliable history)
 Patient could be managed with modified ID 4 site schedule (4-2-2-0-2) in place of RIG, while observing the
animal for 14 days for healthiness.
Intramuscular (IM) schedules of ARV
❑ For major exposures:- 5 dose regimen with RIG
IM-ARV one dose* each on DO, D3, D7, D14, & D30
This schedule is recommended for patients who are immunocompromised and for international travelers.
❑ For minor exposures:- 4 dose (2-1-1) regimen
2 doses * of IM-ARV one in each deltoid on DO, followed by 1 dose* each on D7 & D21.
*1 dose - PCEC 1ml (1 vial) / PVRV 0.5ml (1vial)
❖ IM injections should be given into the deltoid muscle or into the anterolateral aspect of the thigh in small
children.
❖ Administration of ARV on the buttocks is not recommended as absorption is poor
Management of patients following previous rabies PET
1. Patients presenting with exposures from healthy, observable domestic animals (irrespective of the vaccination status)
▪ Following a full or a partial course of ARV (3 doses of ID /IM ARV) irrespective of the time duration for both major and
minor exposures, PET could be delayed while observing the animal for 14 days.
▪ If the animal becomes sick, develops any suspicious behavior, goes missing or dies during the observation period, the
patient should be advised to report to the hospital immediately to commence PET
2. Patients presenting with exposures from proven rabid, suspicious, sick, dead or unobservable animals
With a documented evidence of a full course of ARV-
a) with an exposure occurring within 3 months, neither RIG nor ARV is needed. Only wound treatment is required.
b) with an exposure occurring after 3 months of the previous course of PET, irrespective of the time duration,
-RIG is not indicated
-ID ARV 2 doses each or IM ARV one dose each, should be given on DO and D3 as boosters. As an alternative to this, the
patient may be offered a single visit 4 site intradermal doses (0.1ml ID) over deltoids and suprascapular/anterolateral thigh
areas.
3. With a documented evidence of a partial course of ARV (3 doses)
a) RIG is not indicated irrespective of the time duration from the previous course of ARV.
b) If the patient presents with an exposure occurring within one month from the initiation of the course, it could
be completed with the D30 ARV dose.
c) If the patient presents within 10years - ID ARV 2 doses each or IM ARV one dose each should be given on DO
and D3 as boosters
d.) If the patient presents after 10years -ID/ IM ARV full course is recommended.
Important points to be noted
❖ Ideally RIG should be administered before starting on ARV.
❖ Pregnancy/breast feeding is not a contraindication for RIG (ERIG/HRIG) and ARV therapy when indicated.
❖ All patients who receive rabies PET should be given a document/card, clearly stating the date, month & the year of
vaccination, the type of vaccine used and RIG given or not.
❖ In situations where the animal is not vaccinated, encourage the owner to vaccinate the animal concerned after the
observation period.
❖ Laboratory confirmation of rabies should always be encouraged.
❖ Human to human transmission of rabies has not been reported (except through corneal or organ grafts)
❖ There’s no association of Rabies disease with consuming pork or alcohol. (Myth).

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RABIES PREVENTION AND TREATMENT

LATEST GUIDELINE 2019

PRE EXPOSURE POST EXPOSURE DOG VACCINATION

In the event of an exposure, RIG is not required.

Screening the patient- Categorization of the exposure

❖ Contamination of mucous membranes with saliva

❖ Bites of wild animals with bleeding

❖ Multiple scratches with oozing of blood on any part of the body

❖ Nibbling of uncovered skin

❖ Contamination of open wounds with saliva

❖ Superficial bites and scratches of wild animals without bleeding

3. The following are not considered as exposures:

❖ Petting, bathing or coming in contact with utensils of a proven rabid/suspicious/stray animal

❖ Eating of leftovers which were previously eaten by a proven rabid/suspicious/stray animal

❖ Drinking raw milk of a rabid cow or goat

❖ House rat bites

-a minimum of 2 rabies vaccinations given not more than 2 years apart

In situations where the animal is improperly vaccinated or not vaccinated

❖ If the animal is sick (irrespective of the vaccination status),

❖ having rabies (confirmed by laboratory diagnosis)

❖ unobservable (animal dead, killed, missing or stray animal)

Two Major injection treatments are used in Rabies treatment.

1. Immunoglobulins or Anti Rabies Serum (ARS)

2. Anti Rabies Vaccine (ARV)

Maximum dose of Equine rabies immunoglobulin (ERIG) 40 IU/ Kg body weight

Anti Rabies Vaccines (ARV)

The 2 site ID schedule (2-2-2-0-2 schedule)

The modified 4 site ID schedule (4-2-2-0-2 schedule)

❑ For major exposures:- 5 dose regimen with RIG

❑ For minor exposures:- 4 dose (2-1-1) regimen

❖ Ideally RIG should be administered before starting on ARV.

❖ Laboratory confirmation of rabies should always be encouraged.

❖ There’s no association of Rabies disease with consuming pork or alcohol. (Myth).

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