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Clinical Practice Guidelines

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

  • Background 

    • Rabies:
      • Rabies is a virus that primarily causes disease in animals (wild or domestic animals especially dog-species). It is not endemic in Australia.
      • Rabies is still endemic in Asia (in particular Philippines, Thailand, Indonesia and India), Africa, North and South America and parts of Europe.

    Note: Information regarding global distribution of rabies can be found here

    • Australian bat lyssavirus is closely related to rabies and is found in bats.
    • These viruses are shed in the saliva of animals.
    • Transmission from animals to humans can occur as a result of bites or scratches from animals. Transmission between humans has not been proven.
    • Clinical features:
      • The incubation period varies from 5 days to many years.
      • The virus infects the nervous system and infection eventually results in encephalitis and brain stem dysfunction. This is invariably fatal. 

    Assessment 

    History:

    • History of exposure:
      • Nature of exposure (exposure to animal saliva through bite, scratch or mucous membrane exposure)
      • Animal
      • Country of exposure
      • First aid administered
    • Immunisation history of the patient (rabies pre-exposure prophylaxis, tetanus)
    • Information on any rabies treatment given overseas - document as much detail as possible about the treatment received including:
      • Date of rabies immunoglobulin and vaccine
      • Volume of rabies immunoglobulin
      • Type of vaccine used
      • Route of administration

    Management

    Management of rabies-prone wound

    • First aid: Initial thorough washing
    • If the wound is open: Clean +/- debride 

    Rabies post-exposure prophylaxis 

    The management of children with rabies-prone wounds varies depending on whether or not they have received pre-exposure prophylaxis (or rabies immunisations after a previous exposure): 

    Did not receive pre-exposure prophylaxis

    Received pre-exposure prophylaxis

    Rabies vaccine

    • 4 dose schedule - intramuscular injection on days 0, 3, 7 and 14 (give whole vial - dose depends on vaccine)
    • A 5th dose should be given on day 28 to immunocompromised people
    • The first dose of the vaccine should be given as soon as possible after exposure

    and

    Rabies immunoglobulin (HRIG)

    • 1 dose - 20 IU/kg IM given at the same time as the 1st dose of rabies vaccine (day 0)
    • Infiltrate as much of the dose in and around all wounds if feasible. The remainder of the dose should be given IM in a different limb from the rabies vaccine injection site
    • Do NOT give HRIG if it is ≥ 8 days since the 1st dose of vaccine as it may affect the immune response to the vaccine.
    • Each vial of HRIG contains 300 IU of HRIG (150 IU per mL x 2mL volume) 

    Rabies vaccine

    • 2 additional doses on days 0 and 3

       

    Post-exposure prophylaxis commenced overseas

    • If a child has received a rabies vaccine overseas, it is important to find out the type administered. If they have received a cell culture-derived vaccine (e.g. Zagreb, Essen, Modified Essen, Rabipur, Merieux) overseas, it is recommended that the standard post-exposure prophylaxis regimen is continued.
    • For other scenarios - refer to the Australian Immunisation Handbook

    How to order rabies immunoglobulin and vaccines 

    • Contact DHS Immunisation Service:
      • 1300 882 008 if you require the rabies vaccine or immunoglobulin between the hours of 9-12 pm and 2-3 pm from Monday to Friday.
      • 1300 651 160 (DHS after hours) if you require rabies vaccine or immunoglobulin outside of these hours.
      • Link to Rabies treatment order form 

    Other things to consider 

    Information specific to RCH

    • If the child is first seen in the Emergency Department, rabies immunoglobulin and the initial dose of the vaccine can be given. This is stored in the Emergency Department vaccine fridge. 'Rabies post-exposure vaccine and immunoglobulin supply procedure from Pharmacy'
    • Subsequent doses should be given by the general practitioner. Please ensure that you get the name of the patient's general practitioner and arrange for the subsequent doses to be sent to their practice.  
    • Management of immunocompromised patients should be discussed with the Infectious Diseases Fellow (pager 5787).