Rabies
Description Diagnostic criteria General and supportive measures Medicine treatment to prevent infection Referral ICD-10 code: A82.9 *Notifiable condition. (Inform state veterinarian or local veterinary official.) DESCRIPTION A viral infection of the central nervous system following transmission of the rabies virus from the saliva of affected animals through bites or contamination of mucosa
Description
Diagnostic criteria
General and supportive measures
Medicine treatment to prevent infection
Referral
ICD-10 code: A82.9
*Notifiable condition. (Inform state veterinarian or local veterinary official.)
DESCRIPTION
A viral infection of the central nervous system following transmission of the rabies virus from the saliva of affected animals through bites or contamination of mucosa or skin lesions.
Incubation period 2–8 weeks.
DIAGNOSTIC CRITERIA
Clinical
- Signs and symptoms may begin with:
- fever,
- headache,
- nausea,
- diarrhoea,
- irritability.
- Early signs include paraesthesia or itching at the site of the bite in ⅓ of cases.
- The acute neurologic phase interspersed with lucid periods manifests with:
- agitation,
- mania,
- hyperactivity,
- hallucinations.
- Seizures may be precipitated by auditory or tactile stimuli.
- Hypersalivation, hydrophobia or aerophobia may occur.
- Death is usually due to cardio-respiratory failure.
Investigations
- Testing of animals with suspected rabies: Virus specific fluorescent antigen in brain tissue confirms the diagnosis in animals.
- Preserve brain tissue of the dead animal.
- Testing of humans with suspected rabies: Clinical diagnosis with Rabies RT-PCR of saliva, CSF and/or nuchal skin biopsy.
GENERAL AND SUPPORTIVE MEASURES
- Symptomatic and supportive treatment.
- Prompt cleansing of the bite wound.
- Do not suture puncture wounds.
- Seek advice.
| Telephone Hotline | |
| National Institute of Communicable Diseases | 011 386 6337 or 011 386 6000 |
| After hours | 082 883 9920 |
Post exposure prophylaxis
Caution
Start post exposure prophylaxis immediately. Do not wait for confirmatory laboratory tests in the animal.
Post exposure prophylaxis may be lifesaving and should always be given if there is a reasonable suspicion that the animal may have been rabid.
The decision to give post exposure prophylaxis is based on the risk of rabies transmission, the species and behaviour of the animal and the nature of the bite. Diagnosis is largely clinical.
MEDICINE TREATMENT TO PREVENT INFECTION
Treatment depends on the risk category.
| Risk Category | Type of exposure | Action |
| 1. | - Touching or feeding animal. - Licking intact skin. |
- None if reliable history. |
| 2. |
- Nibbling uncovered skin.
|
- Wound treatment. Stop vaccination if laboratory tests of animal are |
| 3. |
- Bites or scratches penetrating skin and drawing blood.
|
- Wound treatment. Stop vaccination if laboratory tests of animal are |
Wound treatment
Local wound care:
Flush wound thoroughly and clean with soap and water or sodium chloride 0.9% or chlorhexidine 0.05%.
- Povidone iodine 10%, topical.
For penetrating wounds:
- Tetanus toxoid (TT), IM, 0.5 mL.
Pre-emptive antibiotic only if hand is bitten or for extensive wounds or human bites. Data does not support the use of antibiotics in minor animal bites.
- Amoxicillin/clavulanic acid, oral, 45 mg/kg/dose of amoxicillin component, 12 hourly (amoxicillin/clavulanic acid in a ratio of 14:1).
- Maximum dose of amoxicillin component: 1.5 g 12 hourly. (See annexure 1: Amoxicillin/Clavulanic weight band dosing table)
Rabies Vaccine
- Only indicated for direct animal contact.
- Patients who have previously been fully immunised or who received PEP more than 3 months ago need only two doses: on Day 0 and Day 3.
- Patients who have received previous PEP or PrEP within the previous 3 months do not require vaccination against rabies. Only wound treatment is required.
- Rabies vaccine, 1 amp, IM anterolateral thigh.
- Day 0 – single dose
- Day 3 – single dose
- Day 7 – single dose
- Between day 14-28 – single dose
CAUTION
Do not administer rabies vaccine into buttock (gluteus maximus).
Rabies Immunoglobulin (RIG)
- Only indicated for:
- Direct animal contact with breach of skin/ bleeding/ mucosal contact, immunocompetent patients
- Any direct animal contact, immunocompromised patients
- All bat exposures
- Patients who have received PEP or PrEP do not require RIG. Only wound treatment is required.
- Available from the nearest district hospital.
- If not immediately available, source and give as soon as possible.
- When 7 days have lapsed since the initial rabies vaccination, RIG is no longer indicated as the vaccine induced immune response will be effective at that time.
- Infiltrate as much as possible in and around the wound.
- It is no longer recommended to inject the remainder of the calculated RIG dose at a site distant to the wound.
- In the case of smaller wounds/areas where it is not possible to infiltrate the entire calculated dose, infiltrate as much as is anatomically feasible in and around the wound site/s without causing compartment syndrome.
- In case of large and multiple wounds, RIG can be diluted with sodium chloride 0.9% solution if necessary to ensure infiltration of all wounds.
- Follow with a complete course of vaccine.
- Human-derived rabies immunoglobulin (HRIG), IM 20 IU/kg. Infiltrate as much as possible in and around the wound.
OR
- Equine-derived rabies Immunoglobulin (ERIG), IM 40 IU/kg. Infiltrate as much as possible in and around the wound.
- Administer ERIG only in facilities where anaphylaxis or adverse reactions can be managed.
| (HRIG) Rabigam® | (HRIG) KamRAB® | (ERIG) Equirab® | |
| Max. dose | 20 IU/kg | 20 IU/kg | 40 IU/kg |
| Description | 150 IU/mL (Supplied in 2 mL vial) | 150 IU/mL (Supplied in 2,5 and 10 mL vials). | 200 IU/mL (Supplied in 5 mL vial). |
| Site of administration | Infiltrate up to the maximum calculated dose in and around the wound site/s. For smaller wounds where it is not possible to infiltrate all of the calculated dose, infiltrate as much as is anatomically feasible in and around the wound site/s. |
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| Schedule | On day 0 (when patient presents for first time)/as soon as possible after exposure to be effective to neutralise virus. When RIG is not available it should be sourced as a matter of urgency. When 7 days have lapsed since initial rabies vaccination, RIG is no longer indicated. |
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Source: NICD updated human rabies prophylaxis guideline. www.nicd.ac.za
REFERRAL
- Where prophylactic treatment is not immediately available.
- All cases of human clinical rabies for appropriate palliative care.
Standard Treatment Guidelines and Essential Medicines List for South Africa Paediatric Hospital _2023, 5th edition_Updated October 2024
Chapter 8: Infective/Infectious Diseases, 8.19 Rabies