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Information

Editors

KatariinaKainulainen
EevaRuotsalainen

Suspicion of Rabies Exposure

Essentials

  • Rabies is a fatal disease, but it is always preventable through a series of vaccinations and immunoglobulin treatment started immediately after exposure.

General remarks

  • Rabies is a viral infection affecting the central nervous system of mammals. It is transmitted to a human by infectious saliva of an animal (a bite or mucous membrane contact).
    • The average incubation period is from 20 to 90 days after which the patient develops encephalomyelitis which in humans leads to death within a few days from the onset of symptoms.
    • However, the incubation period may vary from 5 days even up to several years.
    • It has been estimated that rabies kills 100 000 people each year worldwide.
  • Rabies is widely distributed across the globe.
    • In industrialized countries, the most important source of human infection are wild animals, whereas in high risk regions in Asia, Africa as well as South and Central America unvaccinated dogs.
    • In Europe rabies is most prevalent in Russia, Ukraine and Belarus. Estonia, Latvia and Lithuania are free of rabies.
    • Rabies occurs in bats also in countries that are free of other forms of rabies.
    • For information about rabies situation in different countries, see:

The likelihood of rabies exposure in different situations

  • Rabies exposure is suspected if
    • a mammal showing signs of rabies (exhibiting abnormal behaviour), or in an area where rabies occurs even an asymptomatic mammal
      • bites or nibbles a human
      • licks the mucous membranes or broken skin of a human
    • a bat bites, snaps or scratches a person
    • mucous membrane or broken skin comes to contact with rabies bait vaccine
    • an accidental needle stick injury or cut injury occurs while examining an animal or human with suspected rabies infection.
  • Rabies exposure is very unlikely if the animal involved was a small rodent (e.g. rat, mouse, squirrel, guinea pig, hamster, gerbil) or a rabbit.
    • Treatment should be considered if the possible exposure occurred in an endemic region, and there is any uncertainty about the type of animal.
  • Rabies exposure is not suspected if
    • in a country free of rabies and with appropriate animal control mechanisms:
      • a random pet or domestic animal (the origin of which cannot be found out) bites a human
      • a veterinarian does not suspect rabies in an imported animal
      • an animal imported from an area where rabies occurs has been in the new country, verifiably, longer than 6 months
      • a wild animal other than a bat bites a human in an area that is not close to the border of a neighbouring country where rabies occurs.
    • a human has stayed in the same space with a bat, without certain contact (touching) with the bat
    • an animal has only licked intact skin
    • contact occurred only with an animal's fur, droppings or blood
    • the animal involved was not a mammal

Post-exposure management

  • When a human is exposed to a suspect animal, attempts should be made to identify and capture the animal involved. Depending on the case, the suspected rabid animal may need to be humanely killed and tested. Consult local guidance.
  • The wound must be immediately cleaned (cleaning significantly reduces the risk of infection)
    • initially with soap and water for 15 minutes
    • and then with 70% alcohol, e.g. hand disinfectant.
  • In mucous membrane exposure, the contaminated areas are irrigated with ample amount of water for 15 minutes.
  • Post-exposure prophylaxis (vaccine and immunoglobulin) should be started as soon as possible, preferably within 24 hours after the exposure. See table T1.
    • The treatment should be started even if months or years have elapsed from the exposure.
    • Also the state of tetanus immunization and the need for antimicrobial treatment should be checked; see article on Bite wounds Bite Wounds.
  • In the case of a monkey bite, treatment with valacyclovir 1 g 3 times daily or acyclovir 800 mg 5 times daily (treatment duration 14 days) should be started within 5 days from the bite to cover potential infection by Herpesvirus simiae.

Administration of post-exposure vaccine and immunoglobulin

Mode of exposureTreatment
  • Contact consists of nibbling of uncovered skin leading to scratches or abrasions without bleeding.
A dose of the vaccine is administered four times, on days 0, 3, 7 and 14 after the exposure1, 2 .
A fifth dose is administered on day 28 after exposure if the wound has initially not been cleaned in an appropriate manner or the exposed person has a severe immunodeficiency,
  • Transdermal bite, contamination of broken skin or mucous membranes with saliva or rabies bait vaccine
  • Bat bites, snaps or scratches
  • Accidental needle stick injury or cut injury3 .
Vaccination as above + a dose of immunoglobulin administered together with the first dose of the vaccine2 .
A fifth dose is administered on day 28 after exposure if the wound has initially not been cleaned in an appropriate manner or the exposed person has a severe immunodeficiency or the person has not been given recommended immunoglobulin in the initial phase.
1 Also immunoglobulin should be given to persons with severe immunodeficiency, such as transplant patients or persons in AIDS stage.
2 A less intense vaccination regime (injections on days 0 and 3 after the exposure) without immunoglobulin is sufficient for individuals who have earlier received full pre-exposure prophylaxis (≥ 2 doses) or full post-exposure profylaxis (4 or 5 doses) against rabies. For persons with severe immunodeficiency, however, a full post-exposure treatment (immunoglobulin + vaccination series of 5 doses) is given.
3 When examining or treating an animal or human with suspected or established rabies infection.
Administering post-exposure prophylaxis

Vaccination

  • An intramuscular injection to the deltoid region, never in the gluteal region
  • The dose is the same for children. In infants, the injection is given to the anterolateral area of the outer thigh muscle.
  • The first dose of the vaccine should be injected to a limb opposite to that used for the injection of the immunoglobulin (if administered); the subsequent doses may be injected to either side.
  • If the person has been given vaccinations at times that differ from the ones described above or if the vaccination series is interrupted and the time between doses is prolonged:
    • Continue the vaccinations in such a way that the period between the next and previous doses is in accordance with the schedule described here (e.g. the period between the 3rd and 4th doses is 7 days and between the 4th and potential 5th dose the period is 14 days).
    • If the vaccination series has been initiated using the WHO schedule 2+1+1 (2 doses on day 0 and single doses on days 7 and 21), the series may be continued according to the WHO schedule.

Rabies immunoglobulin

  • Administered only once, preferably in a hospital setting.
  • The dose is 20 IU/kg at the time of the first vaccination dose and it must not be exceeded because too high a dose may weaken the vaccination response.
  • As much of the dose as possible is infiltrated directly to the wound(s) and the surrounding tissues. If necessary, the rest of the dose is injected i.m. proximally in the bitten extremity (e.g. in the quadriceps or brachial muscle).
  • If the need for immunoglobulin is decided after the vaccination programme has already been started, the immunoglobulin must be administered no later than on the 7th day after the first dose.

Note

  • Do not hesitate to consult
    • an on-call specialist in infectious diseases, in case of an adult patient
    • an on-call specialist in pediatric infectious diseases, in case of a child patient
    • as required, a physician locally responsible for communicable diseases, a national rabies expert or rabies advisory centre.
  • When starting post-exposure therapy at a hospital emergency clinic, inform, as appropriate, the physician responsible for infectious diseases or the relevant health services at the patient's home municipality, so that the remaining vaccination series will be taken care of.
  • Rabies is a notifiable disease. Take care of the necessary reporting regarding the suspected rabies exposure.
  • The vaccination series may be discontinued or the discontinuation may be considered, if
    • the animal causing the exposure is a dog, cat or ferret, and the animal is asymptomatic 10 days after the exposure, or
    • a laboratory investigation of the animal's brain confirms that the animal did not have rabies.