Case Presentation:

A 10 year old boy presents with a dog bite sustained 3 days ago, during a family trip to India.  He has no prior history of vaccination and, at the time, he was taken to a local clinic where the wound was irrigated and he received a rabies vaccine.

Clinical Question:

Now that his has come to your ED 3 days later, is there anything further to be done?

Answer:

This patient should also receive rabies immunoglobulin (RIG) and complete his post-exposure prophylaxis. Post-exposure prophylaxis is a combination of rabies vaccine and rabies immunoglobulin (RIG).

RIG:

• Infiltrate the wound and surrounding tissue RIG 20 IU/kg (if human RIG) or 40 IU/kg (if equine RIG). 
• Can be administered up to 7 days after the first vaccine. 

Vaccine:

• Several vaccine regimens are approved by the WHO. Based on the CDC guidelines, vaccination should be administered at day 0, 3, 7 and 14. 
• Had the patient received rabies immunization prior to travel, he would only need 2 vaccines should be given on days 0 and 3. 
• Thus our patient needs RIG today and 3 more vaccinations (one today and then  one at days 7 and 14)

Bottom Line:

• Travelers at highest risk are individuals visiting families in endemic areas.
• Often times, rabies IG is not available but can be administered up to 7 days after initial vaccination. 

University of Maryland Section of Global Emergency Health

Author: Jenny Reifel Saltzberg

 

References

http://www.cdc.gov/rabies/index.html

http://www.who.int/rabies/en/

Gautret P, Shaw M, Gazin P, et al. Rabies postexposure prophylaxis in returned injured travelers from France, Australia, and New Zealand: a retrospective study. J Travel Med. 2008 Jan-Feb;15(1):25-30.

Hatz CF, Kuenzli E, Funk M. Rabies: relevance, prevention, and management in travel medicine. Infect Dis Clin North Am. 2012 Sep;26(3):739-53.