Rabies - post exposure prophylaxis
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- Rabies virus is a lyssavirus that primarily causes disease in mammalian animals.
- The virus is shed in the animals saliva so can be transmitted to humans via animal bites or scratches.
- Animals may shed virus for at least a week before the onset of clinical symptoms. There has been no proven human-to-human transmission.
- The bites of all mammals should be evaluated but carnivores and bats are the major reservoirs.
At Risk Locations
New Zealand is rabies free. However it is still endemic in Asia, Africa, North America, South America and parts of Europe.
Other similar lyssaviruses cause rabies-like illnesses including the Australian bat lyssavirus.
World Health organization information regarding rabies endemic countries can be accessed via: http://www.who.int/topics/rabies/en/
Variable: from 9 days up to many years later.
Clinical case definition
An acute encephalomyelitis that progresses to coma and death within 10 days of onset
First aid for rabies prone wounds
Wounds should be thoroughly cleansed +/- debrided as soon as possible
- Immediate flushing with water for 15 minutes
- Disinfection with iodine
Vaccination +/- immunoglobulin therapy should be administered as soon as possible
Consider need for:
- Tetanus toxoid
- Antibiotics (see guideline on lacerations and wound closure)
- Discussion with infectious diseases specialist regarding risk
of other animal bite associated infection (e.g. monkey herpes B
Herpes B virus is common in macaque monkeys found in tourist areas. Although risk of transmission to humans from bites is unclear herpes B virus can cause human infection including vesicular rash, fever and a rapidly progressive encephalitis
Bite history is important to help assess risk:
- timing of bite
- location and severity of wound
- first aid received
- type of animal
If it is a 'domestic' dog bite sustained whilst staying with family in endemic area it may be possible to verify with family if the dog involved remains alive and well 10-14 days after the bite. If the dog is well at this time it is unlikely the implicated dog has rabies and rabies post-exposure prophylaxis can be stopped
- risk of associated infection
In New Zealand the only rabies vaccine available is Verorab©.
This is an inactivated vaccine. It comes as a freeze dried powder and is made up to a 0.5ml dose. It is used as pre-exposure prophylaxis (PrEP) prior to travel and post-exposure prophylaxis after an animal bite in an endemic area.
Previously, post-exposure prophylaxis for rabies always required a 5 dose regime. In 2010 the CDC and WHO both approved a 4 dose post-exposure prophylaxis regime using a cell derived vaccine. HOWEVER, Verorab© is not a cell derived vaccine and due to concerns about reduced immunogenicity is not approved for the reduced dose regime - Verorab© requires a 5 dose PEP regime.
The dose of rabies vaccine is the same regardless of age or
Pregnancy, lactation and infancy are NOT contraindications to the rabies vaccine.
Vaccine adverse effects
- Local reaction: pain, erythema, itching and induration
- Systemic reactions (uncommon): fever, chills, malaise, fatigue, headaches, arthralgia and myalgia, nausea and abdominal pain
- Anaphylaxis is very uncommon
Post-Exposure Prophylaxis Schedule
If no pre-exposure prophylaxis used
Human rabies immunoglobulin (HRIG)
- infiltrate as much as possible into the wound and around wound and then administer the remainder , if any , as an IM injection
- 0.5 ml IM
Into deltoid or thigh. Do not inject into gluteal region.
If some RIG has been placed IM then inject vaccine into other deltoid
Day 3, 7, 14, 28
- 0.5 ml IM
Into deltoid or thigh. Do not inject into gluteal region.
While HRIG and the vaccination series should be started as soon as possible after a bite they can still be started even if there is considerable delay between the bite and the person seeking care.
HRIG can be given up to 7 days after starting PEP vaccinations
if it was not given at the time vaccinations were started.
HRIG is accessed through the Blood Bank at ADHB.
HRIG is free for all patients accessing it through the public hospital system in New Zealand.
If pre-exposure prophylaxis used (PrEP)
Some travelers will have had pre-exposure prophylaxis prior to travel. This involves 3 primary immunizations at day 0, 3 and 28.
Most NZ travellers who have only occasional at risk travel will not require boosters after their primary immunization.
If a patient has completed pre-exposure prophylaxis and then sustains a rabies-prone wound then they still require the following post-exposure prophylaxis:
- Through cleansing +/- debriding of the wound as first aid
- 2 additional doses of the rabies vaccine at day 0 and day 3
If a patient has received the intradermal PrEP schedule rather than the standard IM PrEP then they will need rabies booster vaccinations if there is ongoing exposure risk.
A travel medicine specialist or ID physician should guide this schedule
Providing Post-Exposure Prophylaxis in Starship Children's Emergency Department
Access to Vaccine and Immunoglobulin
Verorab© is stored in the after-hours pharmacy cupboard.
It can be accessed by the Clinical Nurse Advisors and does NOT require pharmacy approval.
HRIG is accessed through the Blood Bank.
If the child's first consultation is in the emergency department then the first dose of vaccine +/- immunoglobulin (as per schedule above) can be given.
HOWEVER ideally subsequent doses should be accessed in the community if possible as these can be pre-arranged appointments. See section below on accessing subsequent vaccines in the community.
If a patient is presenting for follow-up vaccines after a PEP course has been started overseas then they should be encouraged to access this in the community.
The day 3/7/14/28 timing schedule is not 'absolute' therefore slight variation is possible to allow vaccinations during the 'working week' in the community.
The health provider providing the first assessment in New Zealand must complete an ACC form. See the ACC Eligibility section below.
Accessing Rabies PEP and PrEP in the community
Rabies vaccine is not offered by GP practices routinely.
The easiest way to access post-exposure prophylaxis in the community is through a specialized travel medicine centre.
They routinely provide rabies PEP to clients in the non-urgent setting and many are happy to have children referred to them for completion of their PEP regime. In addition they are important providers of PrEP and other travel advice prior to travel.
There are several specialized travel clinics in Auckland.
The wholesale cost for the rabies vaccine is $95 per vial(+GST).
At private travel medicine clinics there is an additional surcharge for the vaccine plus a consultation fee (overall cost estimated at $200 per vaccine).
The health provider providing the first assessment in New Zealand must complete an ACC form.
Families can then apply to ACC to have the vaccine costs reimbursed AFTER completion of the PEP. See the ACC Eligibility section below.
Travel insurance Funding
Many travel insurance policies do cover the cost of post exposure prophylaxis (PEP) vaccinations BUT it is policy dependent so needs to be checked on an individual basis.
ACC Eligibility for rabies vaccine entitlement
All of the following criteria must be met:
- The overseas injury is covered by ACC
- The client has not been immunised for rabies previously
- Rabies is a high risk occurrence in the country where the client says they received the bite or scratch
- The animal was a wild animal, not a pet
- It is reasonable to give a rabies PEP as treatment, i.e. there is a high risk of rabies virus exposure due to the nature and circumstances of the injury
- The PEP protocol has started almost immediately after the bite. Overseas vaccines are not paid for by ACC
- World Health Organisation (WHO) rabies post-exposure prophylaxis (PEP) protocol has been followed. See Determining entitlement for rabies claims
- WHO rabies PEP course has been completed
- The vaccine used is the standard vaccine available in New Zealand.
Costs ACC may contribute to:
The consultation costs on the Cost of Treatment Regulations rates for GPs and/or nurse consults - not surcharges.
If the Pharmaceutical Advisor recommends payment, ACC will contribute to wholesale vaccine costs only. ACC does not fund pre-exposure vaccination costs or extra charges the provider may charge for the vaccine.
- Communicable Disease Control Manual: Rabies and other lyssaviruses, Ministry of Health NZ, May 2012
- Use of a reduced (4 dose) Vaccine Schedule for Post exposure Prophylaxis to Prevent Human Rabies. CDC Morbidity and Mortality Weekly Report March 19, 2010; Vol59; RR2
- Policy Statement - Rabies Prevention Policy Update: New reduced Dose Schedule. Committee of Infectious Diseases Paediatrics Vol 127, number 4, April 2011
- WHO Guide for Rabies Pre and Post Exposure Prophylaxis in Humans. www.who.int/rabies/en/
- Ritz, N et al. Monkey Bites in Travelers: Should we Think of Herpes B Virus? Paediatric Emergency Care 2009; 25 : 529-531
Did you find this information helpful?
- Date first published: 27 November 2014
- Date last published: 27 November 2014
- Document type: Clinical Guideline
- Services responsible: Children’s Emergency Department
- Author(s): Emma Best, Joanne Cole, Joan Ingram
- Editor: Greg Williams
- Review frequency: 2 years
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