Best practice: Rabies vaccination and post-exposure prophylaxis
Joyce Skeet outlines the risks associated with rabies, the advice patients should receive in vaccination clinics when travelling to at-risk areas and post-exposure prophylaxis
Author Joyce Skeet RGN, MSc, MFTM, is practice nurse, Holbrook Surgery, Horsham, West Sussex
Skeet, J. (2007) Rabies vaccination and post-exposure prophylaxis. Nursing Times; 103: 10, 45–47.
The rabies virus is a member of the rhabdovirus family and infects the central nervous system causing encephalitis and, usually, death. The World Health Organization estimates that there are around 55,000 deaths worldwide from rabies, mostly in rural areas of Africa and Asia (WHO, 2006).
Transmission to other animals and humans is usually through saliva via a bite, scratch or lick from an infected animal. Some types of bat can spread a rabies-like virus. Accidental transmission of rabies to humans has been reported through corneal transplant surgery in France, the US, Thailand and Iran but there are no reported cases in the UK (Health Protection Agency, 2006). There is no evidence that rabies can be spread from an infected patient to health professionals or family members, but a vaccine should be offered to those who come into contact with an infected person (HPA, 2006).
The incubation period is usually 30–90 days but may be a number of years. If bites are to the face or neck rather than the legs this appears to be shorter.
A history of a bite from an animal, particularly an unprovoked bite, is important. The disease can progress to a harmful stage before being recognised and paraesthesia around the bitten area is one of the early symptoms. Headache, malaise, fever and nausea may then develop with spasms of those muscles associated with swallowing. Patients become agitated, increasingly anxious or confused and experience hallucinations and delirium; they also develop hydrophobia. When attempting to drink the muscles of the diaphragm contract violently; thereafter even the sight or sound of water may provoke distressing spasms and panic attacks.
Once symptoms of rabies develop, treatment is palliative and death occurs from respiratory failure (Department of Health, 2000).
Rabies can be diagnosed by isolating the virus in saliva, brain tissue, cerebral spinal fluid and urine. Rabies should be considered if a patient has three or more typical signs of the disease even if there is no history of an animal bite or bat exposure. If a patient has the paralytic form of rabies it may be difficult to distinguish from Guillain-Barre syndrome or forms of myelitis. A definitive diagnosis is only possible late in the disease trajectory or at autopsy, after death.
Risk for travellers
All travellers to rabies-endemic countries should be advised of the risk of acquiring rabies and should avoid close contact with dogs, cats, monkeys and bats while abroad. Travellers who plan outdoor activities (camping, walking, trekking and cycling) and who may be staying in remote areas of the world where immediate access to medical care is limited, should be encouraged to consider a pre-exposure rabies vaccine (Table 1). If bites occur they should be taken seriously and medical help sought.
A pre-exposure vaccine should be given to:
Any person who could be exposed to the live rabies virus, including laboratory staff, veterinarians, animal and bat handlers, and wildlife officials (Wyand Walker, 2003);
Children travelling to or living in a rabies-endemic area;
Travellers who may be more than 24 hours from a medical centre with a post-exposure vaccine.
The vaccine should be given by intramuscular or deep subcutaneous injection into the deltoid region and not into the gluteal muscle in adults and large children. In toddlers and small children it is advisable to use the anterolateral aspect of the thigh. Children can be given the same dose as adults. The intradermal method of giving rabies vaccine is not licensed in the UK.
Side-effects to the vaccine include local redness around the injection site, malaise and occasional fever. Contraindications include:
An acute febrile or infectious illness;
A confirmed anaphylactic reaction to a previous dose of rabies vaccine;
A confirmed anaphylactic reaction to any of the components in the vaccine.
Rabies vaccine can be given to pregnant women if it is considered that the benefits outweigh the risks (DH, 2006). The vaccine should be considered for any infant or child travelling to endemic areas of the world. Children are more likely to be bitten on the face and head because of their height and these sites are associated with increased risk of infection (Centers for Disease Control and Prevention, 2005).
Post-exposure care and vaccine
Wash the wound with soap and water as this removes the virus from the bite site. Suturing of wounds should be postponed for 24–48 hours as it may introduce the rabies virus to nerve endings. Disinfect the wound with alcohol or iodine. Follow the guide for post-exposure prophylaxis (PEP) (Table 2); antitetanus prophylaxis and antibiotics should be considered to avoid further infection (Kassianos, 2001). In the UK the HPA issued a duty doctors rabies protocol in 2006 (revised January 2007).
Human rabies immunoglobulin (HRIG) or rabies immunoglobulin (RIG).
For immediate protection HRIG should be used with rabies vaccines for PEP following exposure to an animal thought to have rabies. HRIG 20iu/kg of body weight is infiltrated in and around the site of the bite and prevents the virus from entering the nervous system. It takes the immune system approximately seven days to produce rabies virus neutralizing antibodies (RVNAs). Any remaining HRIG should be injected intramuscularly in a site distant from the initial administration site (DH, 2006).
Rabies in humans is a preventable disease and anyone going to high-risk areas should be offered a vaccination. Practice nurses are in the ideal position to educate and advise those travellers who may be at risk to consider this.
Centers for Disease Control and Prevention (2005) Prevention of specific diseases. in: Travelers’ Health: Yellow Book. Health Information for International Travel, 2005–2006. www2.ncid.cdc.gov/travel/yb/utils/ybGet.asp?section=dis&obj=rabies.htm&cssNav=browseoyb
Department of Health (2006) Rabies. In: Department of Health Immunisation Against Infectious Disease. London: DH.
Department of Health (2000) Memorandum on Rabies: Prevention and Control. www.dh.gov.uk/PublicationsAndStatistics/Publications/PublicationsPolicyAndGuidance/PublicationsPolicyAndGuidanceArticle/fs/en?CONTENT_ID=4010434&chk=uGsQTL
Health Protection Agency (2007) Duty Doctor Joint Protocol for Rabies Queries. London: HPA.
Health Protection Agency (2006) Rabies www.hpa.org.uk/infections/topics_az/rabies/menu.htm
Kassianos, G.C. (2001) Immunization Childhood and Travel Health. Oxford: Blackwell Science.
Wyand Walker, B. (2003) Reducing the risk of rabies. Nursing; 33: 10, 20.
World Health Organization (2006) Rabies. Fact Sheet No. 99. www.who.int/mediacentre/factsheets/fs099/en/index.html
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