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					         PROTOCOL FOR RABIES PREEXPOSURE PROPHYLAXIS OF
         VETERINARIANS, VETERINARY STUDENTS, VETERINARY
             EMPLOYEES, AND ANIMAL CONTROL OFFICERS

Individuals who are at high risk for exposure to rabies in animals should receive preexposure
vaccination. These individuals include veterinarians, their employees, veterinary students, and
animal control officers. Immunization can be done with the 1.0 ml intramuscular (IM) products.
Recipients of preexposure prophylaxis are expected to reimburse the health department for
expenses associated with this immunization procedure.

       Rabies Preexposure Prophylaxis Schedule, Kentucky Health Departments

          Type of Vaccine                               Route                                Regimen
                                                                                     HDCV¹, RVA², or PCEC³,
                Primary                                    IM                         1.0 ml (deltoid area), one
                                                                                     each on 0, 7, and 21 or 28.
                                                                                     HDCV, RVA, or PCEC, 1.0
                Booster4                                   IM                          ml (deltoid area), day 0
                                                                                                only.

¹Human Diploid Cell Vaccine
²Rabies Vaccine Absorbed
³Purified Chick Embryo Cell
4
  A booster dose of vaccine should be given when the serum titer falls below 1:5; a serum titer should be tested every
two years.



                                                                          _______________________________
                                                                          M.D. Signature          Date




                                                       Page 1 of 5
                                         Kentucky Public Health Practice Reference
                                                    Section: Rabies
                                                       July 1, 2001
        GUIDELINES FOR RABIES POSTEXPOSURE PROPHYLAXIS

The decision to administer rabies postexposure prophylaxis (PEP) is based on several factors
related to the potential exposure to rabies virus. These factors include the type of exposure (bite
or nonbite), the species of animal involved, if the bite was provoked, and the epidemiology of
rabies in a specific geographic area. The environmentalist in your health department is usually
quite familiar with these factors and the circumstances involving a potential exposure; they
should be regarded as a local resource for determining if PEP is indicated. (See recommended
Rabies Exposure Assessment Algorithm) Ultimately the decision to administer PEP is between
the patient and their physician. The local health department must have a physician’s
order (phone order is acceptable) to administer PEP. Administering PEP is not difficult,
however, most nurses are unfamiliar with the procedure and may feel uncomfortable about first
time administration.

Rabies is an incurable disease; it is important to remember that even though we may refer to this
procedure as “rabies treatment” it is strictly a prevention (prophylaxis) strategy. This prevention
strategy consists of 3 steps:
    1. Immediate and thorough washing of the exposed site/wound
    2. Administration of human rabies immune globulin for immediate passive immunity
    3. Administration of rabies vaccine for the development of active immunity.

Local Wound Treatment

The immediate and thorough washing, with soap and water, of bite wounds, scratches, and
mucous membranes exposed to the rabies virus have been shown to markedly decrease the
likelihood of rabies. Tetanus prophylaxis should be administered by protocol if indicated.
Measures to control bacterial infection and indications for surgical intervention (suturing) are
decisions for the physician.

Human Rabies Immune Globulin Usage

Human Rabies Immune Globulin (HRIG) is administered only once (at the beginning of
antirabies prophylaxis) to provide immediate antibodies until the patient responds to the rabies
vaccine by actively producing antibodies. Previously vaccinated individuals do not receive
HRIG. If HRIG is not given at the same time vaccination is begun, it can be given through the
seventh day after the administration of the first dose of vaccine. HRIG is not given beyond the
seventh day since an antibody response to the vaccine is presumed to have occurred. The dose of
HRIG is 20 IU/kg (approximately .06ml/lb of HRIG containing 150 IU/ml.) The current
recommendation of the Advisory Committee on Immunization Practices (ACIP) is for the entire
dose to be infiltrated in the area around the wound if anatomically feasible. If none or only part
of the HRIG is used for infiltration, the remainder should be administered in the gluteal area.
HRIG should never be administered in the same syringe or into the same anatomic site as a
vaccine.




                                                 Page 2 of 5
                                   Kentucky Public Health Practice Reference
                                              Section: Rabies
                                                 July 1, 2001
Vaccine Usage

Three brands of rabies vaccines are currently available in the United States. A regimen of five
1.0 ml doses of rabies vaccine is given intramuscularly. The first dose is given as soon as it is
determined that PEP is indicated. This initial dose is given on designated day zero. HRIG is
usually administered at the same time as described above. Additional doses of rabies vaccine are
given on days 3, 7, 14, and 28. The vaccine should always be given IM in the deltoid. The
anteriolateral thigh is an acceptable alternate site for small children. Rabies vaccine should
never be administered in the gluteal area since administration in this area results in lower
neutralizing antibody titers.

For individuals who have received rabies preexposure prophylaxis, received PEP since 1980, or
received PEP before 1980, but developed a demonstrated titer, treatment is abbreviated. No
HRIG is given and 1.0 ml of rabies vaccine is administered IM in the deltoid on days 0 and 3
only.

Because the antibody response after the recommended postexposure vaccination regimen with
modern rabies vaccines has been satisfactory, routine postvaccination serologic testing is not
recommended. Serologic testing is only indicated in unusual circumstances, as when the patient
is known to be immunosuppressed.




                                                Page 3 of 5
                                  Kentucky Public Health Practice Reference
                                             Section: Rabies
                                                July 1, 2001
                RABIES POSTEXPOSURE PROPHYLAXIS SCHEDULE
                      KENTUCKY HEALTH DEPARTMENTS

  Vaccination Status                         Treatment                                      Regimen¹
                                                                             All postexposure treatment should begin
                                      Local wound cleansing                  with immediate thorough cleansing of
                                                                             all wounds with soap and water.
                                                                             20 IU/kg body weight. If anatomically
                                                                             feasible, the entire dose should be
                                                                             infiltrated around the wound(s) and any
                                                                             remaining immune globulin should be
                                                                             administered IM in the gluteal area.
Not Previously Vaccinated                        HRIG                        HRIG should not be administered in the
                                                                             same syringe or into the same
                                                                             anatomical site as vaccine. Because
                                                                             HRIG may partially suppress active
                                                                             production of antibody, no more than
                                                                             the recommended dose should be given.
                                                                             PCEC, HDCV, or RVA2 1.0 ml, IM
                                                Vaccine                      (deltoid area3), one each on days 0, 3, 7,
                                                                             14, and 28.
                                                                             All postexposure treatment should begin
                                      Local Wound Cleansing                  with immediate thorough cleansing of
                                                                             all wounds with soap and water.
 Previously Vaccinated4                          HRIG                        HRIG should not be administered.
                                                                             PCEC, HDCV, or RVA2 1.0 ml, IM
                                                Vaccine                      (deltoid area3), one each on days 0 and
                                                                             3.

 ¹The regimens are applicable for all age groups, including children and pregnant women.
 2
   PCEC- Purified Chick Egg Cell (RabAvert by Chiron Corp.), HDCV- Human Diploid Cell Vaccine (Imovax
 Rabies by Aventis Pasteur), and RVA- Rabies Vaccine Adsorbed (Rabies Vaccine Adsorbed by BioPort Corp.)
 3
   The deltoid area is the only acceptable site of vaccination for adults and older children. For younger children, the
 outer aspect of the thigh may be used. Vaccine should never be administered in the gluteal area.
 4
   Any person with a history of preexposure vaccination with human diploid cell vaccine (HDCV), rabies vaccine
 absorbed (RVA), or purified chick embryo cell (PCEC); prior postexposure prophylaxis with HDCV, RVA, or
 PCEC; or previous vaccination with any other type of rabies vaccine and a documented history of antibody response
 to prior vaccination.



                         For questions about PEP, call the Division of
                       Epidemiology and Health Planning (502) 564-3418




                                                        Page 4 of 5
                                          Kentucky Public Health Practice Reference
                                                     Section: Rabies
                                                        July 1, 2001
                                                RABIES EXPOSURE ASSESSMENT ALGORITHM
       Small rodents including squirrels,                        Was there an exposure?            NO              Rabies post-exposure prophylaxis
       mice, gerbils, chipmunks, rats and                        See footnote 1.                                   is not recommended. Exception
       lagomorph (rabbit or hare)                                                                                  for bats. See footnote 2.
                                                                                    YES                                                                              Domestic animal such as
                                                                                                                                                                     cow, horse, sheep, pig,
                                                                                                                                                                     elk or bison
                                                                            Type of animal
     Rabies post-exposure prophylaxis is not                                                                                 Free ranging wild animal
     usually recommended. If unusual                                                                                         such as skunk, fox, coyote,
     circumstances exits, contact the                                                                                        raccoon, bat                            Does animal exhibit
     Division of Epidemiology and Health                                                                                                                             signs of rabies (footnote
     Planning for guidance. See Footnote 5.                                                                                                                  NO      4) or die suddenly?
                                                                            Domestic dog, cat,
                                                                            or ferret
                                                                                                                                                                                  YES
                    FOOTNOTES
1.   Exposure: Defined as a bite that broke the skin, or
                                                                                                                             Has the animal been      YES
                                                                                                                             apprehended?
     saliva contact to an open cut, sore or wound or to                                                                                                              Is animal available for
     mucous membrane (mouth, nose, eye).                                    Has the animal been                                                       NO             testing or extended         NO
2.   Bats pose particular risks and rabies transmission has                 apprehended? May delay                                                                   quarantine?
     occurred in the absence of a recognized bite. Every                    initiating post-exposure
     effort should be made to capture and test the bat                      prophylaxis up to 10 days                        Other wild animal kept in a
     involved in any exposure incident. If the patient can                  from exposure in order to                        zoo, pet store, exhibit or
                                                                                                                             under the control of a                               YES
     provide adequate history that no direct exposure                       capture animal unless
     occurred, then no treatment is necessary. If the patient               unusual circumstances
                                                                                                             NO              private individual
                                                                                                                                                                     Test animal for rabies.
     is an unobserved child, a person who was asleep,                       exist. See footnote 3.                                                                   See footnote 6. Is test
     intoxicated or mentally challenged, then post-exposure                                                                                                          positive?
     prophylaxis may be indicated, especially if the status of
     the bat cannot be ascertained through lab testing.                             YES
                                                                                                                         Contact Division of Epi
3.   If the animal exhibited any signs or symptoms of rabies
                                                                                                                         and HP for guidance.
                                                                                                                                                                  YES
     or illness (see footnote 4), if the attack was vicious or                 Options
     unprovoked or the bite(s) occurred in the head and                                                                  See footnote 5.
     neck region, consideration should be given to starting
     post-exposure prophylaxis immediately.
4.   Symptoms of rabies may include any one or more of                                                                                                      Administer vaccine and
     the following: excitability, vicious attacks, biting,           Post-exposure prophylaxis not                                                          RIG according to ACIP
                                                                     recommended at this time.                   Euthanize and submit for                   recommendations.
     agitation, restlessness, aggressiveness, lack of fear,
                                                                     Quarantine animal, whether                  testing. Post-exposure
     excess salivation, aversion to water, inability to
                                                                     vaccinated or not, for 10 days after        prophylaxis treatment may be
     swallow or drink, muscular dysfunction, coordination
                                                                     exposure. Exam to be conducted at           delayed pending test results
     or gait irregularities, paralysis, convulsions, avoidance
     of contact with humans or other animals, lethargy, and          day one and day 10 to assess health         unless unusual circumstances                                     YES
     loss of appetite.                                               status of animal. During                    exist. See footnote 3.
5.   The Division of Epidemiology and Health Planning                quarantine, did animal show signs
     may be contacted at 1-888-973-7678 (9REPORT) or                 of rabies (footnote 4) or die within
     502-564-3418. After 4:30 p.m., weekends, and                    the 10 days?                            NO                                             Post-exposure prophylaxis
     holidays, the answering service can assist you.                                                                                                        not indicated.
6.   The Division of Laboratory Services may be contacted
     at 502-564-4446 for assistance.                                                                                                                                                             NO
                                                                                           Page 5 of 5
                                                                             Kentucky Public Health Practice Reference
                                                                                        Section: Rabies
                                                                                           July 1, 2001

				
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