Dr. Charles "Pat" Davis, MD, PhD, is a board certified Emergency Medicine doctor who currently practices as a consultant and staff member for hospitals. He has a PhD in Microbiology (UT at Austin), and the MD (Univ. Texas Medical Branch, Galveston). He is a Clinical Professor (retired) in the Division of Emergency Medicine, UT Health Science Center at San Antonio, and has been the Chief of Emergency Medicine at UT Medical Branch and at UTHSCSA with over 250 publications.
Mary D. Nettleman, MD, MS, MACP is the Chair of the Department of Medicine at Michigan State University. She is a graduate of Vanderbilt Medical School, and completed her residency in Internal Medicine and a fellowship in Infectious Diseases at Indiana University.
Treatment for rabies (or more accurately, prevention of rabies before the
latent symptoms can develop) consists of giving a person an injection of rabies
immune globulin and another injection of rabies vaccine as soon as possible
after the bite or exposure to saliva from an infected animal. As of 2010, the CDC recommends
additional doses (injections) of rabies vaccine on the third, seventh, and 14th
day after exposure. This schedule is for people who have had no previous
treatment (vaccination) against rabies. For people previously vaccinated against
rabies, only two doses of the vaccine are recommended; one as soon as possible
after the exposure (no rabies immune globulin is recommended) and one more three
days later. Most researchers and clinicians suggest that the treatment begin as
soon as possible after exposure. No one who has begun this treatment within 48
hours of exposure and has followed it appropriately has ever developed a fatal
case of rabies in the U.S. The following table is from the CDC that provides a
recent (2010) update of a treatment schedule:
All PEP should begin with immediate, thorough cleansing of all wounds
with soap and water. If available, a virucidal agent (for example,
povidone-iodine solution) should be used to irrigate the wounds.
Human rabies immune globulin (HRIG)
Administer 20 IU/kg body weight. If anatomically feasible, the full
dose should be infiltrated around and into the wound(s), and
any remaining volume should be administered at an anatomical site (intramuscular
[IM]) distant from vaccine administration. Also, HRIG should not be administered
in the same syringe as vaccine. Because RIG might partially suppress active
production of rabies virus antibody, no more than the recommended dose should be
administered.
Vaccine
Human diploid cell vaccine (HDCV) or purified chick embryo cell
vaccine (PCECV) 1.0 mL, IM (deltoid area¥), one each on days 0§ three,
seven, and
14.¶
Previously vaccinated**
Wound cleansing
All PEP should begin with immediate thorough cleansing of all wounds
with soap and water. If available, a virucidal agent such as povidone-iodine solution should be used to irrigate the wounds.
HRIG
HRIG should not be administered.
Vaccine
HDCV or PCECV 1.0 mL, IM (deltoid
area†), one each on days 0§ and three.
* These regimens are applicable for people in
all age groups, including children.
¥ The deltoid area is the only acceptable
site of vaccination for adults and older children. For younger children, the
outer aspect of the thigh may be used. Vaccine should never be administered in
the gluteal area.
§ Day 0 is the day dose one of vaccine is administered.
¶ For
persons with immunosuppression, rabies PEP should be administered using all five
doses of vaccine on days 0, three, seven, 14, and 28.
** Any person with a history of
pre-exposure vaccination with HDCV, PCECV, or rabies vaccine adsorbed (RVA);
prior PEP with HDCV, PCECV or RVA; or previous vaccination with any other type
of rabies vaccine and a documented history of antibody response to the prior
vaccination.
The reason human rabies immune globulin is used (and sometimes even injected
into the bite area) is that it immediately attacks the virus and slows or stops
viral progression through the nerves. Vaccine is used to stimulate the body's
immune response enough to make the body develop enough of an immune response to
eventually kill all of the virus population in the body. Timing and the ability
of the patient to respond by making a good immune response is a key to patient
survival. If human rabies immune globulin and vaccine are started more
than about 48 hours after the exposure, the viral proliferation in the nerves may outpace the immune response and the person has a greater chance of developing
fatal rabies. However, even late attempts at treatment can be successful and
always should be tried.
Untreated or inappropriately treated rabies is almost always fatal; treatment
is supportive only to limit the patient's pain, suffering, harm to the
caregivers and self, and exposure of saliva to other humans. Barrier precautions
(for example, gloves, gowns, and mask) are usually recommended for caregivers.
Mild local reactions to the rabies vaccine (for example, mild pain,
erythema, swelling, or itching at the injection site) may occur. Rarely, other
symptoms such as headache, nausea, abdominal pain, muscle aches, and dizziness
may happen. Rabies immune globulin may cause local pain and low-grade fever
following its injection in some patients. Treatment protocols should always be
started in all people (children, pregnant females, immunodepressed) especially
when they are known to be exposed to the virus; otherwise if they develop
rabies, the patient will likely die. Infectious-disease consultants can help
develop specific treatment plans for patients who have other health
complications. Researchers may develop a more effective vaccine that may require
only one dose with less side effects, but such vaccines are not available
currently.
Can rabies be prevented?
Yes. There are several ways to prevent rabies. The best way to prevent
animals from getting rabies and completing the rabies life cycle is by
large-scale vaccination programs. Most developed countries have programs to
vaccinate pets and many have additional programs to reduce or eliminate rabies
in many wild animals. The few incidences per year in most developed countries
are good indications of how successful these programs have been at preventing rabies.
England was successful in eliminating rabies from the country until it was
recently found again in a bat population. Pre-exposure
vaccination is
recommended by the CDC in certain circumstances (outlined as follows):
Rabies pre-exposure prophylaxis guide (by CDC)
Risk category
Nature of risk
Typical population
Pre-exposure recommendations
Continuous
Virus present
continuously, often in high concentrations. Specific exposures likely to go
unrecognized. Bite, non-bite, or aerosol exposure.
Rabies research laboratory
workers; rabies biologics production workers.
Primary course. Serologic testing
every six months; booster vaccination if antibody titer is below acceptable level.
Frequent
Exposure usually episodic, with source recognized, but exposure also
might be unrecognized. Bite, non-bite, or aerosol exposure.
Rabies diagnostic
lab workers, spelunkers, veterinarians and staff, and animal-control and
wildlife workers in rabies-enzootic areas. All people who frequently handle
bats.
Primary course. Serologic testing every two years; booster vaccination if
antibody titer is below acceptable level.
Infrequent
Exposure nearly always
episodic with source recognized. Bite or non-bite exposure.
Veterinarians and
terrestrial animal-control workers in areas where rabies is uncommon to rare.
Veterinary students. Travelers visiting areas where rabies is enzootic and
immediate access to appropriate medical care including biologics is limited.
Primary course. No serologic testing or booster vaccination.
Rare (population at
large)
Exposure always episodic with source recognized. Bite or non-bite
exposure.
U.S. population at large, including people in rabies-epizootic areas.
No vaccination necessary.
This article is not designed to cover every aspect of rabies in animals, but
in this section, a short presentation of how dogs can be vaccinated is an
example of how prevention can be easy and effective seems appropriate:
Puppies get vaccinated at age 9-16 weeks (some suggest to wait until age 12
weeks).
Adult dogs can get a yearly vaccination; some states only require a
vaccination every three years.
Consult a veterinarian for local laws on rabies
vaccination; get a vaccine certificate and keep it.
A dog without a vaccine
certificate that bites a human (in the U.S.) is at risk for being impounded or euthanized; its owner may be subjected to fines and lawsuits.
Costs are
relatively low; about $20-$30 per year for dog vaccine and tag (vaccine
certificate included).
Another way to reduce or eliminate rabies is to vaccinate wild animals.
Although it may be difficult to eliminate the disease, ongoing attempts reduce
the chance a wild animal will develop the disease. For example, in 2011 in
Texas, health officials announced that the oral vaccine for wild animals,
Raboral V-RG vaccine, would be placed in bait for coyotes and foxes. The
vaccine-treated bait is safe, even if ingested by domestic animals, but is not
approved for use in domestic animals.
Finally, people should avoid any animal that is behaving oddly (see rabies
transmission section above) and call authorities to handle the animal. Exposure
to bat guano carries a small risk of rabies; filter masks that can stop two
micron-sized particles may offer some protection against aerosolized guano.
These actions should reduce the chances an individual will be exposed to rabies
virus.
Anxiety is a feeling of apprehension and fear characterized by physical symptoms. Anxiety disorders are serious medical illnesses that affect approximately 19 million American adults.
Headaches can be divided into two categories: primary headaches and secondary headaches. Migraine headaches, tension headaches, and cluster headaches are considered primary headaches. Secondary headaches are caused by disease. Headache symptoms vary with the headache type. Over-the-counter pain relievers provide short-term relief for most headaches.
Muscle spasms are involuntary muscle contractions that come on suddenly and are usually quite painful. Dehydration, doing strenuous exercise in a hot environment, prolonged muscle use, and certain diseases of the nervous system may cause muscle spasms. Symptoms and signs of a muscle spasm include an acute onset of pain and a possible bulge seen or felt beneath the skin where the muscle is located. Gently stretching the muscle usually resolves a muscle spasm.
Itching can be a common problem. Itches can be localized or generalized. There are many causes of itching to include: infection (jock itch, vaginal itch), disease (hyperthyroidism, liver or kidney), reactions to drugs, and skin infestations (pubic or body lice). Treatment for itching varies depending on the cause of the itch.
Stress occurs when forces from the outside world impinge on the individual. Stress is a normal part of life. However, over-stress, can be harmful. There is now speculation, as well as some evidence, that points to the abnormal stress responses as being involved in causing various diseases or conditions.
Although a fever technically is any body temperature above the normal of 98.6 degrees F. (37 degrees C.), in practice a person is usually not considered to have a significant fever until the temperature is above 100.4 degrees F (38 degrees C.). Fever is part of the body's own disease-fighting arsenal: rising body temperatures apparently are capable of killing off many disease- producing organisms.
Dysphagia or difficulty in swallowing, swallowing problems. Dysphagia is due to problems in nerve or muscle control. It is common, for example, after a stroke. Dysphagia compromises nutrition and hydration and may lead to aspiration pneumonia and dehydration.
There are millions of dogs living in the United States, and thus many cases of dog bites. Annually, hundreds of people seek emergency medical care for dog bites. Treatment for a dog bite depends on how deep the injury is and the amount of tissue damage. Dog bites can be prevented by employing preventative measures.
Tetanus is an often-fatal disease caused by nerve toxins produced by the common bacteria Clostridium tetani. In a seven-day period after infection, a person experiences muscle spasms, restlessness, headache, irritability, then lockjaw, and the lungs stop functioning. Tetanus is treatable with antibiotics and drainage. Sedation is often give to stop muscle spasms.
Insomnia is the perception or complaint of inadequate or poor-quality sleep because of difficulty falling asleep; waking up frequently during the night with difficulty returning to sleep; waking up too early in the morning; or unrefreshing sleep. Secondary insomnia is the most common type of insomnia. Treatment for insomnia include lifestyle changes, cognitive behavioral therapy, and medication.
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