Urgent Care Management of Possible Rabies Exposure

Table of Contents

 

About This Course

Rabies in humans is a rare but almost always fatal disease; it is responsible for over 59,000 deaths worldwide annually. Appropriate use of pre- and post-exposure prophylaxis can eliminate the risk of developing rabies if administered according to the guidelines of the CDC Advisory Committee on Immunization Practices guidelines. Though rabies is very rare, rapid recognition of potential exposures is vital to patient care and protection of public health. This review focuses on the challenges of managing patients who are at risk for or have had a potential rabies exposure, indications and guidelines for administering pre- or postexposure prophylaxis, and requirements for reporting and monitoring.

What are the risks of exposure to rabies?

When should patients be referred for pre-exposure prophylaxis (PrEP) and postexposure prophylaxis (PEP)?

What factors should clinicians consider when determining if a patient is at risk for rabies exposure?

1. About This Course
2. Case Presentations
3. Introduction
4. Etiology and Pathophysiology
5. Differential Diagnosis
6. Urgent Care Evaluation
   1. Evaluation for Pre-exposure Prophylaxis
   2. Evaluation for Postexposure Prophylaxis
      1. Exposure to Wild Animals
      2. Bites From Domestic Animals
      3. Exposure to Bats
      4. Other Exposures
7. Treatment
   1. Pre-exposure Prophylaxis for Rabies
   2. Wound Care
   3. Postexposure Prophylaxis for Rabies
      1. Failure of Postexposure Prophylaxis
8. Special Populations
   1. Immunosuppressed Patients
   2. Pregnant Patients
   3. Returning Travelers
9. KidBits: Rabies Vaccine in Pediatric Patients
10. Disposition
11. Time- and Cost-Effective Strategies
12. Summary
13. Critical Appraisal of the Literature
14. Risk Management Pitfalls For Management of Patients With Possible Rabies Exposure
15. Case Conclusions
16. Clinical Pathway for Postexposure Prophylaxis in Patients With Possible Rabies Exposure
17. References

Case Presentations

CASE 1: A 35-year-old woman presents to UC requesting malaria prophylaxis for an upcoming 3-month adventure trip to Southeast Asia…

• She plans on staying in remote areas and spelunking in jungle caves.
• She asks you whether rabies vaccination is also warranted...

CASE 2: A 2-year-old girl is brought in after her mother found a bat in the girl’s bedroom that morning…

• On your full body exam, the child appears well, and no bite marks are evident.
• You ask yourself whether this patient requires rabies post-exposure prophylaxis…

CASE 3: A 58-year-old man returned to the United States from India yesterday. He sustained a dog bite to his lower leg the day prior to his return trip. He states that the dog was “medium sized” and wearing a collar, but that there was no obvious owner nearby…

• He requests antibiotics and a tetanus booster.
• In addition to administering proper wound care, you wonder if there are other steps you should take in the management of this patient…

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Introduction

Rabies is a rare diagnosis, but with a fatality rate of over 99%, it is one of the world’s most deadly infectious diseases.¹ Once symptoms begin, no treatment is available, and death is almost inevitable within weeks of symptom onset.¹ As above, rabies is responsible for approximately 59,000 annual deaths worldwide; this figure is likely a gross underestimate due to poor surveillance and underreporting.² Rabies is a scourge of the developing world, with more than 95% of cases arising in resource-limited countries in Africa and Asia; 35% of cases are found in India alone.² Children account for nearly half of human rabies cases.³ The estimated annual economic burden of rabies worldwide is $8.6 billion.²

Worldwide, 99% of human rabies deaths are attributed to bites from infected dogs.^1,3 In North America, Europe, and some countries in Latin America, rabies has been eliminated in domestic dogs due to widespread vaccination programs beginning in the early 1950s.³ (See Figure 1.) This successful public health effort has reduced the number of human rabies cases in the United States from more than 100 per year in the early 20th century to no more than 6 per year since 1960.^4,5 The canine rabies virus strain was eradicated from the United States in 2004, but dogs can occasionally acquire other strains from encounters with wildlife.¹

Clinical Pathway for Postexposure Prophylaxis in Patients With Possible Rabies Exposure

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Key References

Following are the most informative references cited in this paper, as determined by the authors.

1. Pieracci EG, Pearson CM, Wallace RM, et al. Vital signs: trends in human rabies deaths and exposures - United States, 1938-2018. MMWR Morb Mortal Wkly Rep. 2019;68(23):524-528. (Surveillance)

5. *Nigg AJ, Walker PL. Overview, prevention, and treatment of rabies. Pharmacotherapy. 2009;29(10):1182-1195. (Review)

8. US Centers for Disease Control and Prevention. "Domestic Animals." 2018. Accessed January 15, 2022. (CDC website)

16. Johnson N, Phillpotts R, Fooks AR. Airborne transmission of lyssaviruses. J Med Microbiol. 2006;55(Pt 6):785-790. (Basic science)

29. *Rupprecht CE, Briggs D, Brown CM, et al. Use of a reduced (4-dose) vaccine schedule for postexposure prophylaxis to prevent human rabies: recommendations of the advisory committee on immunization practices. MMWR Recomm Rep. 2010;59(Rr-2):1-9. (CDC ACIP clinical practice guidelines)

34. Nasser R, Rakedzon S, Dickstein Y, et al. Are all vaccines safe for the pregnant traveller? A systematic review and meta-analysis. J Travel Med. 2020;27(2). (Systematic review, meta-analysis)

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Keywords: rabies, bite, wild, animal, canine, bat, travel, pre-exposure prophylaxis, PrEP, post-exposure prophylaxis, PEP, vaccination, saliva, prodrome, encephalitis, furious, paralytic, dumb, hydrophobia, aerophobia, HRIG, rabies immune globulin