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 CAHS clinical disclaimer
|
Aim
To guide ED staff with the assessment and management of rabies and other lyssaviruses.
Risk
Rabies is an almost invariably fatal disease. Failure to follow this guideline may increase morbidity and mortality for patients infected with these viruses.
Key points
- All bats in Australia may be able to transmit virus
- Refer to Australian Immunisation Handbook for risk stratification and Post Exposure Management
Public Health Cache Stock of Human Rabies Vaccine and Immunoglobulins stock are accessible via Pod C ADM but should only be administered after discussion with Public Health.
Definition
Rabies virus, Australian bat lyssavirus (ABLV) and other lyssaviruses are members of the Rhabdoviridae family. These viruses cause the rabies disease.
Rabies and other lyssavirus infections are notifiable diseases and considered to be an urgent public health priority.
Background1,2
- Rabies virus affects some terrestrial mammals in some parts of the world including Asia, Africa, North and South America, some parts of Europe but NOT Australia. Most cases are due to transmission by dogs and monkeys.
- Bat associated rabies occurs globally, including all bat species in Australia which can transmit Australian Bat Lyssavirus (ABLV).
- Rabies and ABLV Infection share the same clinical features, and both follow the same Rabies post-exposure prophylaxis pathway.
Transmission
Rabies is caused by exposure to saliva or neural tissue in infected animals. This can occur by bite, scratch and direct mucosal contact. Patient should be considered exposed during:
- Any bite, scratch, mucous membrane or broken skin contact with saliva or neural tissues from any bat anywhere in the world. This includes any direct contact where the bite or scratch may not be apparent as some bats have small teeth and claws.
- Any bite, scratch, mucous membrane or broken skin contact with saliva or neural tissue of a wild or domestic terrestrial mammal in rabies-enzootic countries (e.g., Asia, Africa, North, Central and South America and parts of Europe).
- Any potential exposure from deceased animals fitting the above criteria. Please seek advice from Public Health or Infectious Diseases Consultant.
- Any potential exposure where the affected person is unaware or unable to communicate about the exposure. Please seek advice from public health or Infectious Diseases Consultant.
Clinical features of Rabies3,4
- Incubation period: 5 days to several years (usually 2-3 months)
- Risk highest in bites to head and neck (due to proximity to the central nervous system (CNS)) and fingers (richly innervated).
- Prodromal Phase (10 days) - non-specific: 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 deterioration to coma or cardiorespiratory arrest. Invariably fatal.
Pre-exposure Vaccination – Human Rabies Virus (HRV)
- See Australian Immunisation Handbook – Rabies and other Lyssaviruses for recommendations and administration.
- Recommendations for pre-exposure vaccination may differ in other countries based on the 2018 WHO position statement.6,7
Assessment
Management
Rabies and ABLV exposures should be managed as per the Rabies and other Lyssavirus chapter in the Australian Immunisation Handbook and the CDNA National Guidelines for Public Health Units.
Wound Care
All exposures require wound care as soon as possible following the exposure.
- Wash wound with soap and water thoroughly for 15 minutes then apply a virucidal antiseptic e.g., Povidone-Iodine 10%
- Primary suture of wounds should be avoided where possible. If required, it should occur after Human Rabies Immunoglobulin (HRIG) administration in the wound.
- Check Tetanus status – Tetanus prone wounds - ED Guideline.
- Consider antibiotics.
Public Health Notification
Suspected or confirmed cases of rabies and other lyssaviruses must be notified urgently to the local Public Health unit via telephone and using the communicable disease notification form5. In addition, use the online public health Rabies virus and other lyssaviruses exposure assessment form to document the details of the exposure and to access rabies post-exposure prophylaxis.
- Phone MCDC on 9222 8588 (8am to 5pm Mon-Fri)
- Phone On-Call Duty Officer at Department of Health on 9328 0553 (Out of Hours) and ask to speak to the On-Call Public Health Physician
Public Health, through the above contacts, provides post exposure prophylaxis (PEP) advice, recommendations and formal approval for use of stock.
Post Exposure Prophylaxis
- Advice and approval to access post exposure prophylaxis must be obtained from Public Health before using cache stock. Refer to WA protocol for accessing immunoglobulin blood products for public health use in Western Australia.
- At PCH ED, stock is available in Pod C ADM. No stock is held by the PCH Pharmacy. If urgent out-of-hours resupply is required, the on-call Public Health Physician should be contacted and advised to organise delivery directly to PCH ED.
- Completion of communicable disease notification form is vital for ensuring restock to PCH ED (See above).
Human Rabies Immunoglobulin (HRIG)
- Refer to Australian Immunisation Handbook for eligibility and administration information.
- To access rabies post-exposure prophylaxis stock complete the Rabies virus and other lyssaviruses exposure assessment form.
- Available from ED Pod C ADM.
- Dosage 20 units/kg (same dose for infants, children and adults).
- Infiltrate as much as possible in and around all wounds, the remainder can be given IM at a site away from HRV injection site. Suitable locations could be the alternative deltoid, lateral thigh or gluteal muscle.
- Consider regional anaesthesia (e.g. ring block) and procedural sedation (nitrous oxide) for infiltration into painful areas.
- Potential risk of compartment syndrome if injected into hand.
- May be administered for late presentation up to 12 months after exposure.
- HRIG should be given at the same time as the first rabies vaccine dose but can be given within 7 days of receiving the 1st dose of HRV. Late administration may interfere with the immune response to the vaccine.
It is not uncommon for patients who have been exposed overseas to have commenced PEP in that country. Refer to the Australian Immunisation Handbook for detailed guidance on how to align and complete the schedule, and to determine whether HRIG is required now. Note that ‘day 0’ of an overseas schedule refers to the day of the first vaccine, not the day of the exposure.
Human Rabies Vaccine (HRV)
- Refer to Australian Immunisation Handbook for eligibility and administration information. Note different protocols exist for terrestrial animal exposures and bat exposures.
Refer to Rabies post-exposure prophylaxis: bat exposures | The Australian Immunisation Handbook (health.gov.au)
Refer to Rabies post-exposure prophylaxis: terrestrial animal exposures | The Australian Immunisation Handbook (health.gov.au)
- Available from Pod C ADM
- Note some vaccine products contain eggs, including Rabipur®. PCH currently only stocks Verorab® which is cell-cultured and suitable in egg allergy. An appropriate product should be used if patient has egg allergy.
- Do not administer into the buttock, as post exposure prophylaxis may fail when given in this area.8
- Immunocompetent patients with no previous vaccination course should receive 4 doses of HRV (Day 0, 3, 7 and 14, plus HRIG if indicated).
- Immunocompetent patients with previous vaccinations should receive 2 doses of HRV (Day 0 and 3).
- Immunosuppressed patients should be discussed with an Infectious Diseases Consultant. Severely immunosuppressed children should receive 5 doses of HRV (Day 0, 3, 7, 14 and 28, plus HRIG if indicated)
Completing the PEP Course
References
1. Rabies Virus and other Lyssavirus (including Australian Bat Lyssavirus) Exposures and Infections. CDNA National Guidelines for Public Health Units. Last updated: 28 March 2024. Cited: 21 May 2026. Available from: https://www.cdc.gov.au/sites/default/files/2025-11/rabies-and-other-lyssavirus-cdna-national-guidelines-for-public-health-units.pdf
2. Francis, JR, McCall, BJ, Hutchinson, P, Powell, J, Vaska, V.L, & Nourse, C. Medical Journal of Australia. [Internet]. 2014 [Cited 21 May 2026]. 201(11), 647-649. Australian bat lyssavirus: Implications for public health. Available from: https://doi.org/10.5694/mja13.00261
3. Rabies and other lyssaviruses. Australian Immunisation Handbook [Internet].2025. [Updated 18 Dec 2025; cited 21 May 2026]. Available from: Rabies and other lyssaviruses | The Australian Immunisation Handbook
4. Healthdirect. Lyssavirus (ABLV) [Internet]. Healthdirect; 2025 [updated May 2025; cited 21 May 2026]. Available from: Lyssavirus (ABLV) - vaccine, treatment and symptoms | Healthdirect
5. Department of Health Western Australia. Rabies and other Lyssavirus (including Australian Bat lyssavirus) Statutory notification alert. Department of Health Western Australia. 2025. [Updated10 Nov 2025; cited: 21 May 2026]. Available from: Rabies and other Lyssavirus (including Australian Bat Lyssavirus) (health.wa.gov.au)
6. World Health Organisation. Rabies Vaccines: WHO position paper – April 2018. Weekly epidemiological record, No 16, 2018, 93, 201–220. World Health Organisation 2018. [Updated April 2018; Cited 21 May 2026]. Available from: Rabies vaccines: WHO position paper – April 2018
7. Pre-exposure prophylaxis (PrEP) Centres for Disease Control and Prevention – Rabies Homepage. [Last reviewed May 4, 2022. Cited: Jan 10, 2023.] Available from: Pre-exposure Prophylaxis (PrEP) | Prevention | CDC -
8. Centers for Disease Control and Prevention. Human rabies prevention – United States, 2008: Recommendations of the Advisory Committee on Immunization Practices. MMWR. Recommendations and Reports 2008;57(RR-3):1-28. Centers for Disease Control and Prevention. [Updated 5 Juny 2008; Cited 21 May 2026]. Available from: Human Rabies Prevention --- United States, 2008 Recommendations of the Advisory Committee on Immunization Practices
| Endorsed by: |
CAHS Drug and Therapeutics Committee |
Date: |
May 2026 |
This document can be made available in alternative formats on request for a person with a disability.