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.
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Aim
To guide ED staff with the assessment and management of rabies and lyssavirus.
Definition
Rabies virus and Australian bat lyssavirus (ABLV) are members of the
Rhabdoviridae family. These viruses cause the rabies disease. Lyssavirus infection is a
notifiable disease and considered to be an
urgent public health priority.
Background1,2
- 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 3 human deaths, one in 1996, one in 1998 and one in 2013.2
- 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 Rabies3,4
- Incubation period: 1 week to several years (usually 3-8 weeks)
- 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) – 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 – Human Rabies Virus (HRV)
- Three doses on days 0, 7 and 21–28
- See Australian Immunisation Handbook for recommendations and administration
- Recommendations for pre-exposure vaccination may differ in other countries based on the 2018 WHO position statement, however the current recommendation in Australia remains for three doses7,8
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 a bat in anywhere in the world including Australia
- Management is dependent on the category of exposure, as defined in the Australian Immunisation Handbook.
- Clinical advice can be sought from an Infectious Diseases consultant, however the public health unit must be contacted for advice and approval of post-exposure prophylaxis. Refer to Post Exposure Prophylaxis (PEP) below.
Management of Exposure
- Post exposure management is recommended for any potential exposure and should start as soon as possible following the exposure
- All exposures require wound care
- Wash all wounds with soap and water thoroughly for approximately 15 minutes as soon as possible after the exposure
- Apply a virucidal antiseptic solution (e.g. povidone-iodine 10%)
- Primary suture of wound is to be avoided where possible. If required, it should only occur after Human Rabies Immunoglobulin (HRIG) administration (if indicated)
- Consideration should be given to the possibility of tetanus and other wound infections. Refer to Tetanus Prone Wounds – ED Guideline and Skin and Soft Tissue (Paediatric Empiric Guidelines) – ChAMP.
- Post exposure prophylaxis (PEP); dependent on previous vaccination history.
- Unvaccinated: HRIG and HRV
- Vaccinated: HRV
- The number of PEP vaccine doses is dependent on previous vaccination history and immune status. If vaccination history is uncertain, treat as unvaccinated.
- Do not give rabies vaccine in the buttock, because post-exposure prophylaxis can fail when vaccine is given in this area.6
- Discuss all patients who are immunocompromised, or any patient you are uncertain about, with an Infectious Diseases consultant.
Post-exposure prophylaxis (PEP): Human Rabies Immunoglobulin (HRIG) and / or Human Rabies Vaccine (HRV)
Advice and approval to access PEP must be obtained via the public health unit (available 24/7)
- During office hours, contact the local public health unit
- After hours, contact the public health on-call duty officer. Phone: 9328 0553.
- Rabies PEP is funded by the WA Department of Health (regardless of Medicare eligibility).
- Please ensure the public health unit is aware of the clinical area (i.e. PCH Emergency Department) that the HRIG needs to be delivered to.
- Further guidance on accessing PEP is available here:
Administration of Human Rabies Immunoglobulin (HRIG)3
- HRIG is to be given to unvaccinated patients, and those with uncertain vaccination history
- Dosage of HRIG is 20 units/kg (the same dose for infants, children and adults)
- HRIG should be given at the same time as the first rabies vaccine dose, as soon after exposure as possible. If the first rabies vaccine is given prior to HRIG, HRIG administration should occur within 7 days
- Infiltrate as much of the calculated dose as possible in and around all wounds, the remainder is to be given intramuscularly (IM) into the proximal deltoid / lateral thigh (away from the rabies vaccine injection site)
- Do not inject HRIG into the buttocks
- See Australian Immunisation Handbook for further administration information
Administration of Human Rabies Vaccine (HRV)
- Please see the Australian Immunisation Handbook for recommendations and administration based on the patient’s exposure, vaccination history and immune status; there are slight differences between management of bat and terrestrial animal 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)
Government funded rabies PEP supplies
Some Perth travel clinics have government funded rabies PEP on premises and often can see patients that day. Contact details are below; clinic should be contacted to ensure they can provide treatment to children.
200 St Georges Tce, Perth
Phone: 9321 7888
Contact details – Notifiable Diseases
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, following the submission details on that form.
- Phone: 9222 0255 (office hours) or 9328 0553 (after hours)
- For cases residing in regional areas refer to the appropriate regional population/public health unit - WA Country Health Service (WACHS)
Metropolitan Communicable Disease Control (MCDC)
References
- Rabies Virus and other Lyssavirus (including Australian Bat Lyssavirus) Exposures and Infections. CDNA National Guidelines for Public Health Units (SoNGs). Last updated: 24 Jun 2022. Cited: 31 Aug 2022. Available from: rabies-and-other-lyssavirus-cdna-national-guidelines-for-public-health-units.pdf
- Francis, J.R., McCall, B.J., Hutchinson, P., Powell, J., Vaska, V.L., & Nourse, C. (2014, December 11). Australian bat lyssavirus: Implications for public health. The Medical journal of Australia, 201(11), 647-649. https://doi.org/10.5694/mja13.00261
- Rabies and other lyssaviruses. Australian Immunisation Handbook Last updated: 6 Jun 2018. Cited 31 Aug 2022. Available from: Clinical features | Rabies and other lyssaviruses | The Australian Immunisation Handbook (health.gov.au)
- Lyssavirus (ABLV) Healthdirect Last updated April 2021. Cited 31 Aug 2022. Available from: Lyssavirus (ABLV) - vaccine, treatment and symptoms | healthdirect
- Rabies and other Lyssavirus (including Australian Bat Lyssavirus) Statutory notification alert. Department of Health (WA) Last reviewed 18 July 2022. Cited: 31 Aug 2022. Available from: Rabies and other Lyssavirus (including Australian Bat Lyssavirus) (health.wa.gov.au)
- Centers for Disease Control and Prevention (CDC), Manning SE, Rupprecht CE, et al. Human rabies prevention – United States, 2008: recommendations of the Advisory Committee on Immunization Practices. MMWR. Recommendations and Reports 2008;57(RR-3):1-28
- Rabies Vaccines: WHO position paper – April 2018. Weekly epidemiological record, No 16, 2018, 93, 201–220 Available from: Rabies vaccines: WHO position paper – April 2018
- 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 -
| Endorsed by: |
CAHS Drug and Therapeutics Committee |
Date: |
March 2023 |
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