Rabies and lyssavirus

Disclaimer

These guidelines have been produced to guide clinical decision making for the medical, nursing and allied health staff of Perth Children’s Hospital. They are not strict protocols, and they do not replace the judgement of a senior clinician. Clinical common-sense should be applied at all times. These clinical guidelines should never be relied on as a substitute for proper assessment with respect to the particular circumstances of each case and the needs of each patient. Clinicians should also consider the local skill level available and their local area policies before following any guideline. 

Read the full PCH Emergency Department disclaimer.

Aim 

To guide staff with the assessment and management of rabies and lyssavirus.

Definition

Rabies virus and Australian bat lyssavirus (ABLV) are members of the Rhabdoviridae family, genus. These viruses cause the rabies disease. Lyssavirus infection is a notifiable disease and considered to be an urgent public health priority

Background

  • Australian bat lyssavirus ABLV - (first identified in 1996) has been found in several species of flying foxes and bats in Australia, and has been associated with 2 human deaths, one in 1996 and one in 1998
  • It is assumed that ABLV infection has the same clinical features as rabies. Hence, rabies post-exposure prophylaxis recommended for patients with a possible exposure to ABLV or rabies.

Clinical features of Rabies

  • Incubation period: 1 week to several years (usually 3-8 weeks)
  • Risk highest in bites to head and neck (close to CNS) and fingers (richly innervated)
  • Prodromal Phase (10 days): nonspecific-anorexia, cough, fever, headache, myalgia, sore throat, nausea
  • Paraesthesia/fasciculation near site of wound
  • Acute encephalitis: aerophobia, hydrophobia, hyperactivity
  • Autonomic instability: hypersalivation, hyperthermia, hyperventilation
  • Neurological status deteriorates to coma or cardiorespiratory arrest. Invariably fatal.

Pre-exposure vaccination (HRV)

Assessment

Potential exposure to Rabies

  • Bites, scratches, mucous membrane or broken skin exposure to saliva or neural tissues from a wild or terrestrial mammal (e.g. dogs, cats, bats and monkeys) in rabies-endemic regions (Asia, Africa, Central and South America). Includes Bali from August 2008. WHO: Rabies enzootic areas
  • Bites, scratches, mucous membrane or broken skin exposure to saliva or neural tissues from an Australian flying fox or microbat.

Management

  • Post exposure management is recommended for any potential exposure
  • Post exposure management should start as soon as possible following the potential exposure
  • All exposures require wound care
  • If the risk is determined the post exposure prophylaxis is dependent on previous vaccination
    • Unvaccinated: Human Rabies Immunoglobulin (HRIG) and Human Rabies Vaccine (HRV)
    • Vaccinated: Human Rabies Vaccine (HRV)
  • Discuss patients who are immunocompromised with an infectious diseases consultant.

Management of exposure

  • Wash all wounds with soap and water thoroughly for approximately 5 minutes as soon as possible after the exposure
  • Apply a virucidal antiseptic solution (povidone-iodine)
  • Primary suture of wound is to be avoided where possible. If required it should only occur after HRIG administration
  • Consideration should be given to the possibility of tetanus and other wound infections 
  • Human Rabies Immunoglobulin (HRIG) and/or Human Rabies Vaccine (HRV)

Contact telephone numbers

Office hours Northern Metropolitan Public Health Unit  9222 8588
After hours/weekends Communicable Diseases on call physician 9328 0553

Some Perth travel clinics have government funded rabies PEP on premises and often can see patients that day. Their numbers are:

  • The Travel Doctor Perth: Shop 9 St Martin's Arcade, 50 St Georges Tce, Perth Ph: 6467 0900
  • Perth Vaccination and Travel Centre: 168 Adelaide Tce, Perth Ph: 9221 4242
  • Travel Health Fremantle: 85 South St, Fremantle Ph: 9336 6630

Please fax the Rabies and Australian Bat Lyssavirus Exposure Form to the North Metropolitan Public Health Unit during office hours.

Administration of Human Rabies Immunoglobulin (HRIG)

  • Immunoglobulin is to be given to unvaccinated patients
  • Dosage of HRIG is 20 IU/kg
  • HRIG should be given within 7 days of first rabies vaccine (ideally at the same time)
  • Infiltrate as much of the dose in and around the wound, the remainder is to be given intramuscularly (IM) into proximal deltoid/lateral thigh (away from the rabies vaccine injection site)
  • Do not inject immunoglobulin into the buttocks
  • See Australian Immunisation Handbook for further administration information

Administration of Human Rabies Vaccine (HRV)

  • Unvaccinated schedule: 4 - 5 doses over 21 - 28 days
  • Usually Day 0,3,7 and 14.If immunocomprimised another dose is given at Day 28
  • Vaccinated schedule: 2 doses over 3 days at Day 0 and 3
  • See Australian Immunisation Handbook for recommendations and administration.

Bibliography

  1. WA Department of Health. Operational Directive OD: 0543/14. Guidelines for the Public Health Management of Rabies and Other Lyssavirus (including Australian Bat Lyssavirus) Exposures and Infection
  2. National Health and Medical Research Council. Australian Immunisation Handbook, 10th Edition 2013. Australian Government Department of Health and Ageing

Endorsed by:  Director, Emergency Department  Date:  Jul 2018


 Review date:   Jul 2021


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