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Case Presentation:
A 10 year old boy presents with a dog bite sustained 3 days ago, during a family trip to India. He has no prior history of vaccination and, at the time, he was taken to a local clinic where the wound was irrigated and he received a rabies vaccine.
Clinical Question:
Now that his has come to your ED 3 days later, is there anything further to be done?
Answer:
This patient should also receive rabies immunoglobulin (RIG) and complete his post-exposure prophylaxis. Post-exposure prophylaxis is a combination of rabies vaccine and rabies immunoglobulin (RIG).
RIG:
- Infiltrate the wound and surrounding tissue RIG 20 IU/kg (if human RIG) or 40 IU/kg (if equine RIG).
- Can be administered up to 7 days after the first vaccine.
Vaccine:
- Several vaccine regimens are approved by the WHO. Based on the CDC guidelines, vaccination should be administered at day 0, 3, 7 and 14.
- Had the patient received rabies immunization prior to travel, he would only need 2 vaccines should be given on days 0 and 3.
- Thus our patient needs RIG today and 3 more vaccinations (one today and then one at days 7 and 14)
Bottom Line:
- Travelers at highest risk are individuals visiting families in endemic areas.
- Often times, rabies IG is not available but can be administered up to 7 days after initial vaccination.
University of Maryland Section of Global Emergency Health
Author: Jenny Reifel Saltzberg
References
http://www.cdc.gov/rabies/index.html
Gautret P, Shaw M, Gazin P, et al. Rabies postexposure prophylaxis in returned injured travelers from France, Australia, and New Zealand: a retrospective study. J Travel Med. 2008 Jan-Feb;15(1):25-30.
Hatz CF, Kuenzli E, Funk M. Rabies: relevance, prevention, and management in travel medicine. Infect Dis Clin North Am. 2012 Sep;26(3):739-53.