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Rabies and Australian Bat Lyssavirus post exposure prophylaxis


  • Statewide logo

    This guideline has been adapted for statewide use with the support of the Victorian Paediatric Clinical Network

  • See also

    Management of tetanus prone wounds
    Cellulitis and other bacterial skin infections

    Key Points

    1. Rabies is a vaccine-preventable disease
    2. Post-exposure prophylaxis treatment with thorough washing of wounds with soap, as well as the appropriate vaccine ± immunoglobulin regimen, prevents virus entry into the central nervous system
    3. Locally, exposure is from bats and travellers who have returned from rabies endemic areas

    Background

    • Rabies virus primarily causes disease in wild or domestic mammals, eg monkeys and dogs. Australian Bat Lyssavirus (ABLV) is closely related to rabies and is found in bats
    • These viruses are shed in the saliva of animals
    • The clinical disease caused by rabies virus and the other lyssaviruses are indistinguishable and is termed “rabies”
    • Rabies is not endemic in Australia. The global distribution of rabies can be found here
    • Transmission from animals to humans can occur as a result of bites or scratches from animals, or from direct viral contact with a mucosal surface. Transmission between humans has not been proven
    • Incubation period varies from 5 days to many years
    • The virus infects the nervous system resulting in encephalitis and brain stem dysfunction causing death
    • Advising families on prevention by avoiding contact with wildlife and undertaking vaccination prior to travelling to rabies endemic areas is extremely important
    • Symptoms, investigations and management of suspected rabies cases are not discussed in this guideline

    Assessment

    Red flag features in Red

    History and examination

    • History of exposure
      • Nature of exposure: bite, scratch, mucous membrane exposure
      • Location of bite head and neck
      • Animal source of exposure (note: within Australia if a bat is the source, and it is possible without placing others at risk, keep the bat to be sent for ABLV testing)
      • Country of exposure
      • First aid administered
    • Immunisation history of the child (pre-exposure rabies prophylaxis, tetanus)
    • Information on any rabies treatment given overseas; date, volume, type, route

    Management

    Investigations

    • No investigations are required for asymptomatic children

    Treatment

    • First aid: wash wound with soap or detergent then flush wound for 15 minutes. Apply an iodine-containing solution on top of the wound after flushing. Appropriate first aid substantially reduces the infection risk
    • If the wound is open: clean ± debride, do not suture

    Post-exposure prophylaxis flowchart from mammals overseas and bats in Australia

    Rabies and Australian Bat Lyssavirus post exposure -prophylaxis
    Note:

    • If unsure whether treatment is required, discuss with state department of health or infectious diseases team
    • The first dose of vaccine should be given as soon as possible after exposure
    • Rabies immunoglobulin (HRIG) dose 20 IU/kg, infiltrate as much of the dose as possible in and around all wounds if feasible. Give the remainder of the dose IM in a different limb from the rabies vaccine injection site
    • Management of category 2 bat exposure is different to mammals because superficial wounds from bats are a higher risk for infection
    • Consult the immunisation handbook and infectious diseases team for treatment and serological follow-up of immunocompromised children
    • Post-exposure prophylaxis commenced overseas:
      • If there is clear documentation of an appropriate vaccine course, complete treatment with the standard post-exposure prophylaxis regimen
      • If there is unclear documentation or in other scenarios, consult the immunisation handbook as to whether the schedule should be restarted at Day 0

    Provision of treatment varies by state, check local information

    Consider consultation with local paediatric team when

    Consider consultation with local infectious diseases team or state department of health if unsure how to proceed

    For emergency advice and paediatric or neonatal ICU transfers, see Retrieval Services .

    Consider discharge when

    Plan is in place for completion of vaccination schedule and review of wounds 

    Parent information

    NSW Rabies and Australian Bat Lyssavirus infection fact sheet

    Last updated November 2020

  • Reference List

    1. Australian Technical Advisory Group on Immunisation (ATAGI). Australian Immunisation Handbook. Australian Government Department of Health. <https://immunisationhandbook.health.gov.au/vaccine-preventable-diseases/rabies-and-other-lyssaviruses> (viewed October 2020)
    2. NSW Health. Rabies and other lyssavirus infections (including Australian Bat Lyssavirus) control guidelines. <https://www.health.nsw.gov.au/infectious/controlguideline/pages/rabies.aspx>  (viewed October 2020)
    3. World Health Organisation. Frequently asked questions about rabies for clinicians. <https://www.who.int/docs/default-source/ntds/rabies/rabies-clinicians-faqs-20sep2018.pdf?sfvrsn=97d94712_4> (viewed October 2020)