eMedicine Specialties > Infectious Diseases > Viral Infections

Rabies: Follow-up

Author: Sandra G Gompf, MD, FACP, FIDSA, Associate Professor of Infectious Diseases and International Medicine, University of South Florida College of Medicine; Chief, Infectious Diseases Section, Director, Occupational Health and Infection Control Programs, James A Haley Veterans Hospital
Coauthor(s): Charurut Somboonwit, MD, Assistant Professor of Medicine, Division of Infectious Disease and International Medicine, University of South Florida College of Medicine; Senior Physician, Polk County Health Department; Tri M Pham, MD, Fellow, Division of Infectious Diseases and International Medicine, University of South Florida College of Medicine; Albert L Vincent, PhD, Associate Professor, Division of Infectious Diseases and International Health, Department of Internal Medicine, University of South Florida College of Medicine; Scientific and Research Advisor to the Division of Epidemiology, Hillsborough County Health Department
Contributor Information and Disclosures

Updated: Oct 3, 2008

Follow-up

Further Outpatient Care

Coordinate follow-up evaluations of patients to rabies with the primary caregiver, the local health department, and, if applicable, the veterinarian who quarantined the animal.

Deterrence/Prevention

Universal precautions and respiratory precautions during respiratory therapy are indicated for health care providers. Rabies postexposure prophylaxis of health care workers is indicated only for high-risk exposures. Pretransplantation screening for potential rabies infection or exposure should be performed on organ donors.

Control of rabies in the animal population

Because rabies is a zoonosis, primary prevention requires control of rabies in the animal population. In 1997, approximately 100,000 animal brains were tested for rabies virus antigen using a direct fluorescent assay. Of these brains, 8509 (8.5%) had positive results.

Mass control and mandatory vaccination of domesticated dogs and cats is effective in controlling rabies in the United States; however, developing nations have found that cost is a barrier to such campaigns.

Live viral vaccines containing modified live rabies or recombinant vaccinia-rabies glycoprotein virus, placed in a bait, are used for disease control in Europe and North America. In the United States, more than 22 million doses of vaccinia-rabies glycoprotein vaccine were distributed between 1990 and 2000. The baits were mainly used to control rabies in raccoons in the eastern United States and foxes and coyotes in Texas. People will inevitably find vaccine-laden baits. Dogs are frequently attracted to the baits and bring them to their owners. Luckily, adverse events are rare.

Postexposure prophylaxis is sometimes modified to reduce cost relative to risk. Postexposure therapy is described in detail in Medical Care.

Immunization

Active immunization is recommended for veterinarians, veterinary students, persons who regularly explore or hike in caves, laboratory workers who are exposed to rabies virus or who handle specimens considered high risk for rabies, and persons who visit countries where rabies is a significant problem (ie, visits >30 d).

The WHO recommends 2 doses of cell-culture vaccine administered intramuscularly or intradermally on days 0 and 3 for booster dosing. A study published in 2001 found that a 4-site intradermal booster regimen had a more rapid NAb response than the series traditionally recommended by the WHO.16 The NAb was also shown to be consistently high 1 year after the booster vaccination.

Nervous-tissue vaccine is commonly used in developing countries and is associated with many neurologic complications, including acute demyelinating encephalomyelitis.17  

Risk Categories for Active Preexposure Immunization and Rabies Titer Monitoring

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Table
CategoryRisk FactorsImmunization RegimenSerologic Testing
ContinuousRabies research laboratory or biologics production workersPrimary course; booster when serum antibody <1:5 dilution based on RFFIT resultsEvery 6 mo
FrequentRabies diagnostic laboratory workers, spelunkers, veterinarians and staff, animal control and wildlife workers in rabies-enzootic areas, travelers to areas of enzootic rabies for >30 dPrimary course; booster every 2 y or when serum antibody <1:5 dilution based on RFFIT resultsEvery 2 y if not regularly boosted
InfrequentVeterinarians and staff/students, animal control and wildlife workers in areas of low rabies riskPrimary course; no boosterNone
RareUS population at largeNoneNone
CategoryRisk FactorsImmunization RegimenSerologic Testing
ContinuousRabies research laboratory or biologics production workersPrimary course; booster when serum antibody <1:5 dilution based on RFFIT resultsEvery 6 mo
FrequentRabies diagnostic laboratory workers, spelunkers, veterinarians and staff, animal control and wildlife workers in rabies-enzootic areas, travelers to areas of enzootic rabies for >30 dPrimary course; booster every 2 y or when serum antibody <1:5 dilution based on RFFIT resultsEvery 2 y if not regularly boosted
InfrequentVeterinarians and staff/students, animal control and wildlife workers in areas of low rabies riskPrimary course; no boosterNone
RareUS population at largeNoneNone

Passive immunization consists of the administration of HRIG pooled from the sera of immunized human donors.

Complications

  • Regardless of treatment, symptomatic rabies is invariably fatal because autonomic dysfunction leads to cardiac arrhythmia and hypotension.

Prognosis

  • The prognosis of rabies is fair if postexposure prophylaxis is administered exactly as recommended and in a timely fashion.
  • Coordination with local health authorities is crucial.
  • Death is almost certain if rabies treatment is not started before the onset of prodromal symptoms.

Patient Education

  • The need for adherence to local public health recommendations regarding the control and vaccination of domestic animals and the vaccination of individuals who may be exposed to rabies in their occupation cannot be stressed enough.
  • Counsel patients regarding the subjective nature of provocative behavior toward animals. Especially stress avoiding contact with unfamiliar or wild animals.
  • Prompt vigorous cleansing of any injury or bite from any animal is critical and may reduce the risk of rabies transmission.
  • Provide extensive reassurance after any injury that may be related to rabies transmission. Fear of rabies is primal and is known to induce hysterical reactions that mimic the disease manifestations.
  • For excellent patient education resources, visit eMedicine's Bacterial and Viral Infections Center. Also, see eMedicine's patient education article Rabies.

Miscellaneous

Medicolegal Pitfalls

  • Failure to administer prophylaxis appropriately to patients at risk for rabies
  • Failure to involve local public health authorities, which is critical in determining whether an injury requires prophylaxis

Special Concerns

  • The following are from the American Veterinary Medical Association Compendium of Animal Rabies Prevention and Control, 2004 recommendations for owners of unvaccinated livestock exposed to rabid animals:18
    • If the animal is slaughtered within 7 days of being bitten, its tissues may be eaten without risk of infection, provided that liberal portions of the exposed area are discarded. US federal meat inspectors must reject for slaughter any animal known to have been exposed to rabies within 8 months.
    • Neither tissues nor milk from a rabid animal should be used for human or animal consumption. Pasteurization temperatures inactivate the rabies virus; therefore, drinking pasteurized milk or eating cooked meat does not constitute a rabies exposure.
    • The presence of more than one rabid animal in a herd or herbivore-to-herbivore transmission is uncommon; therefore, isolating the rest of the herd if a single animal has been exposed to or infected by rabies might not be necessary.
 
Acknowledgments

The authors and editors of eMedicine gratefully acknowledge the contributions of previous coauthors Wendy Carter, DO, Lucinda Elko, MD, and Anibal Jose Maldonado, MD, to the development and writing of this article.



More on Rabies

Overview: Rabies
Differential Diagnoses & Workup: Rabies
Treatment & Medication: Rabies
Follow-up: Rabies
Multimedia: Rabies
References
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Further Reading

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Keywords

rabies, rabies virus, Lyssavirus, lyssaviruses, classic rabies, bat rabies virus, human rabies, zoonosis, rabies encephalitis, furious rabies, paralytic rabies, rabieslike illness, rabid canines, hydrophobia, rabid animal bite, wild animal bite, cat bite, dog bite, bat bite, mad dog, dumb rabies, apathetic rabies, RABV, Rhabdoviridae, rhabdoviruses, Mokola virus, Duvenhage virus, Obodhiang virus, Kotonkan virus, Rochambeau virus, European bat Lyssavirus type 1, European bat Lyssavirus type 2, Australian bat Lyssavirus

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Contributor Information and Disclosures

Author

Sandra G Gompf, MD, FACP, FIDSA, Associate Professor of Infectious Diseases and International Medicine, University of South Florida College of Medicine; Chief, Infectious Diseases Section, Director, Occupational Health and Infection Control Programs, James A Haley Veterans Hospital
Sandra G Gompf, MD, FACP, FIDSA is a member of the following medical societies: American College of Physicians and Infectious Diseases Society of America
Disclosure: Nothing to disclose.

Coauthor(s)

Charurut Somboonwit, MD, Assistant Professor of Medicine, Division of Infectious Disease and International Medicine, University of South Florida College of Medicine; Senior Physician, Polk County Health Department
Charurut Somboonwit, MD is a member of the following medical societies: American College of Physicians, American Medical Association, and Infectious Diseases Society of America
Disclosure: Nothing to disclose.

Tri M Pham, MD, Fellow, Division of Infectious Diseases and International Medicine, University of South Florida College of Medicine
Tri M Pham, MD is a member of the following medical societies: American College of Physicians, Florida Medical Association, and Infectious Diseases Society of America
Disclosure: Nothing to disclose.

Albert L Vincent, PhD, Associate Professor, Division of Infectious Diseases and International Health, Department of Internal Medicine, University of South Florida College of Medicine; Scientific and Research Advisor to the Division of Epidemiology, Hillsborough County Health Department
Disclosure: none None None

Medical Editor

Daniel R Lucey, MD, MPH, Chief, Fellowship Program Director, Department of Internal Medicine, Division of Infectious Diseases, Washington Hospital Center; Professor, Department of Internal Medicine, Uniformed Services University of the Health Sciences
Daniel R Lucey, MD, MPH is a member of the following medical societies: Alpha Omega Alpha and American College of Physicians
Disclosure: Nothing to disclose.

Pharmacy Editor

Francisco Talavera, PharmD, PhD, Senior Pharmacy Editor, eMedicine
Disclosure: eMedicine Salary Employment

Managing Editor

Richard B Brown, MD, FACP, Chief, Division of Infectious Diseases, Baystate Medical Center; Professor, Department of Internal Medicine, Tufts University School of Medicine
Richard B Brown, MD, FACP is a member of the following medical societies: Alpha Omega Alpha, American College of Chest Physicians, American College of Physicians, American Medical Association, American Society for Microbiology, Infectious Diseases Society of America, and Massachusetts Medical Society
Disclosure: Nothing to disclose.

CME Editor

Eleftherios Mylonakis, MD, Clinical and Research Fellow, Department of Internal Medicine, Division of Infectious Diseases, Massachusetts General Hospital
Eleftherios Mylonakis, MD is a member of the following medical societies: American Association for the Advancement of Science, American College of Physicians, American Society for Microbiology, and Infectious Diseases Society of America
Disclosure: Nothing to disclose.

Chief Editor

Burke A Cunha, MD, Professor of Medicine, State University of New York School of Medicine at Stony Brook; Chief, Infectious Disease Division, Winthrop-University Hospital
Burke A Cunha, MD is a member of the following medical societies: American College of Chest Physicians, American College of Physicians, and Infectious Diseases Society of America
Disclosure: Nothing to disclose.

 
 
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