Exposure to rabies virus

• Products for post-exposure treatment: rabies vaccine +/- rabies specific immunoglobulin (RIG).
• Rabies risk assessment: must be performed by a PHE doctor (see flowchart below). The clinician with responsibility for the patient should let the PHE doctor know if the patient has any kind of bleeding disorders, if the patient is on anticoagulant treatment, is immunocompromised or has history of allergies.

Rabies risk assessment

• UHS Prescription form for rabies vaccine +/- RIG is necessary when post-exposure treatment is issued by UHS Pharmacy. It can be signed by the clinician with responsibility for the patient or by the PHE doctor who has performed the risk assessment (see flowchart above).

UHS rabies prescription form

• Please note that when a patient receives the first dose of the post-exposure treatment in A&E late at night or during weekends, and cannot therefore immediately bring the remaining of the post-exposure treatment preparations to his GP surgery, a split prescription (one prescription for the first dose of post-exposure treatment and a second prescription for the remaining doses) may be indicated. Alternatively, only one prescription is issued and the remaining of the post-exposure treatment is stored in a fridge in A&E until the GP surgery is open.
• Please note that when the post-exposure treatment is sent by taxi or courier from UHS Pharmacy to a GP surgery or to the A&E department of another hospital, the products are shipped in styrofoam boxes with cold packs to maintain the cold chain.
• Rabies vaccine and immunoglobulin (RIG) stock and Issuing Centre: pharmacy at Southampton General Hospital (UHSFT) and centre for infection, Colindale.

Please note: rabies vaccine and RIG are issued only when the UHS Pharmacy receives both prescription and risk assessment forms.

Deliver or Fax (023 8120 6792) prescription and risk assessment forms to the main dispensary at Southampton General Hospital. If faxed, the original prescription will need to be received by pharmacy within 72 hours.

Out-of-hours, contact on-call pharmacist through switchboard (023 8077 7222).

Information on rabies vaccine and RIG can be found in The Green Book: immunisation against infectious disease.

General information about rabies

Rabies is a zoonotic (transmitted to humans from animals) disease caused by members of the lyssavirus genus. Rabies affects domestic and wild animals, and is spread to people through close contact with infectious material, usually saliva, via bites or scratches from infected animals. Transmission can also occur when infectious material - usually saliva - comes into direct contact with human mucosa or fresh skin wounds. Human-to-human transmission by bite is theoretically possible but has never been confirmed. Rarely, rabies may be contracted by inhalation of virus-containing aerosol or via transplantation of an infected organ. Ingestion of raw meat or other tissues from animals infected with rabies is not a source of human infection.

Dogs are the main host and transmitter of rabies in Asia and Africa. Bats are the source of most human rabies deaths in the Americas. Bat rabies has also recently emerged as a public health threat in Australia and Western Europe. Human deaths following exposure to foxes, raccoons, skunks, jackals, mongooses and other wild carnivore host species are very rare.

Rabies is present on all continents with the exception of Antarctica, but more than 95% of human deaths occur in Asia and Africa. Once symptoms of the disease develop, rabies is nearly always fatal. Rabies is a neglected disease of poor and vulnerable populations whose deaths are rarely reported and occurs mainly in remote rural communities where measures to prevent dog to human transmission have not been implemented.

The incubation period for rabies is typically one to three months, but may vary from less than one week to more than one year. The initial symptoms of rabies are fever and often pain or an unusual or unexplained tingling, pricking or burning sensation (paraesthesia) at the wound site. As the virus spreads through the central nervous system, progressive, fatal inflammation of the brain and spinal cord develops.

Two forms of the disease can follow:

1. People with furious rabies exhibit signs of hyperactivity, excited behaviour, hydrophobia and sometimes aerophobia. After a few days, death occurs by cardio-respiratory arrest.
2. Paralytic rabies accounts for about 30% of the total number of human cases. This form of rabies runs a less dramatic and usually longer course than the furious form. The muscles gradually become paralyzed, starting at the site of the bite or scratch. A coma slowly develops, and eventually death occurs. The paralytic form of rabies is often misdiagnosed, contributing to the under-reporting of the disease.

Post-exposure treatment: every year, more than 15 million people worldwide receive post-exposure vaccination to prevent the disease - this is estimated to prevent hundreds of thousands of rabies deaths annually. Post-exposure treatment consists of:

1. Local treatment of the wound: immediate and thorough flushing and washing of the wound for a minimum of 15 minutes with soap and water, detergent, povidone iodine or other substances, removes the rabies virus at the site of the infection.
2. Course of rabies vaccine plus/minus the administration of rabies immunoglobulin (immunoglobulin is given only in case of category III exposures, see table below).

Effective treatment soon after exposure to rabies can prevent the onset of symptoms and death.

PEP depends on the type of contact with the suspected rabid animal (see table below).

This risk is increased if the biting mammal is a known rabies reservoir or vector species, the animal looks sick or has an abnormal behaviour, a wound or mucous membrane was contaminated by the animal’s saliva; the bite was unprovoked and the animal has not been vaccinated. In developing countries, the vaccination status of the suspected animal alone should not be considered when deciding whether to initiate prophylaxis or not.