eMedicine Specialties > Pediatrics: General Medicine > Infectious Disease

Rabies: Follow-up

Author: Donna J Fisher, MD, Assistant Professor, Department of Pediatrics, Division of Pediatric Infectious Diseases, Tufts University School of Medicine and Baystate Children's Hospital, Baystate Medical Center
Contributor Information and Disclosures

Updated: Oct 9, 2008

Follow-up

Further Inpatient Care

  • Inpatient care of patients with rabies may be needed if wounds are extensive or are on the face and hands, if surgical repair or replacement of blood loss is required, or if infection occurs.

Further Outpatient Care

  • Watch for local wound complications and ensure follow-up for the repeated injections of vaccine. Analgesics may be needed for any patient with animal bites.

Transfer

  • For a patient with an illness consistent with rabies, transfer to a tertiary care center with intensive care support and capability of providing timely diagnostic workup is essential.

Deterrence/Prevention

  • Domestic animal vaccination programs have effectively limited canine rabies in the United States. Encourage families to keep their pet vaccinations up to date and to limit the reproduction of domestic animals to prevent stray populations.9
  • Massachusetts, Texas, and various countries in Europe have active oral recombinant rabies vaccine drop programs to immunize wildlife to limit geographic spread of terrestrial rabies. Oral vaccines are loaded into feed pellets, which wildlife ingest, and periodic sera checks on animals show effective antibody responses.11

Complications

  • Muscle fasciculations, priapism, and focal or generalized convulsions are observed.
  • Patients may die immediately or may progress to paralysis, which may be present only in the bitten limb at first but usually becomes diffuse.
  • Paralysis may ascend (similar to Guillain-Barré syndrome).
  • Coma may last for hours to months with active intensive care support.
  • Cardiac arrhythmias, myocarditis, and further autonomic dysfunction lead to cardiopulmonary arrest.

Prognosis

  • Rabies is almost always a fatal illness once symptoms begin.
  • For cases in which prompt and correct postexposure treatment is administered, no documented failures are reported, and patients do not develop rabies.

Patient Education

  • Promote educational efforts at home and at schools teaching children about safety procedures and precautions regarding pets and wild animals. Many communities have programs through camps, schools, and public libraries as well as information through local health department Web sites.23
  • Teach children at an early age not to handle stray animals or wildlife.
  • Report any animals that are sick or acting strange to local authorities.
  • Keep pets indoors at night and fenced in or on a leash when outdoors.
  • Keep pet food and water dishes indoors.
  • Remove bat colonies from homes and barns.
  • Handle sick or dead animals with heavy gloves and shovels.
  • Keep trash container lids tight and maintain compost piles away from dwellings.
  • Veterinarians and public health officials are excellent resources for concerns regarding animal rabies prevention.9,24
  • For excellent patient education resources, visit eMedicine's Bacterial and Viral Infections Center. Also, see eMedicine's patient education article Rabies.

Miscellaneous

Medicolegal Pitfalls

  • The most common management errors in reported failures of postexposure prophylaxis are insufficient cleansing of the wounds and improper administration of immunoglobulin.25

Special Concerns

  • Children are prone to extensive wounds on the face, upper body, and hands because of their short stature.26 These wounds may require extensive debridement and inpatient management. The dose of human rabies immunoglobulin (HRIG), calculated by body weight, may be of insufficient volume to infiltrate all the wounds. The HRIG may be diluted with sterile saline so that more volume can be used without exceeding the total recommended dose.27
  • Pregnancy is not a contraindication to vaccination, although the products used for postexposure prophylaxis are pregnancy category C. Studies have indicated no substantial risk in pregnancy, and, if the risk of exposure to rabies is high, pre-exposure prophylaxis should be considered.20,28,29,30
  • Vaccine production problems and higher rates of vaccine use can sometimes lead to shortages of rabies vaccine. Appropriate use of vaccine may be guided by local and state health departments as these issues are resolved.31,20,22
 


More on Rabies

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

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  2. Srinivasan A, Burton EC, Kuehnert MJ, et al. Transmission of rabies virus from an organ donor to four transplant recipients. N Engl J Med. Mar 17 2005;352(11):1103-11. [Medline]. [Full Text].

  3. Centers for Disease Control and Prevention. Investigation of rabies infections in organ donor and transplant recipients--Alabama, Arkansas, Oklahoma, and Texas, 2004. MMWR Morb Mortal Wkly Rep. Jul 9 2004;53(26):586-9. [Medline].

  4. Centers for Disease Control and Prevention. Human death associated with bat rabies--California, 2003. MMWR Morb Mortal Wkly Rep. Jan 23 2004;53(2):33-5. [Medline].

  5. Pape WJ, Fitzsimmons TD, Hoffman RE. Risk for rabies transmission from encounters with bats, Colorado, 1977- 1996. Emerg Infect Dis. May-Jun 1999;5(3):433-7. [Medline].

  6. Blanton J D, Hanlon CA, Rupprecht CE. Rabies surveillance in the United States during 2006. J Am Vet Med Assoc. Aug 15 2007;231(4):540-56. [Medline].

  7. Wyatt JD, Barker WH, Bennett NM, Hanlon CA. Human rabies postexposure prophylaxis during a raccoon rabies epizootic in New York, 1993 and 1994. Emerg Infect Dis. May-Jun 1999;5(3):415-23. [Medline].

  8. Centers for Disease Control and Prevention (CDC). First human death associated with raccoon rabies--Virginia, 2003. MMWR Morb Mortal Wkly Rep. Nov 14 2003;52(45):1102-3. [Medline].

  9. Compendium of animal rabies prevention and control, 2008: National Association of State Public Health Veterinarians, Inc. (NASPHV). MMWR Recomm Rep. Apr 18 2008;57:1-9. [Medline]. [Full Text].

  10. Moore DA, Sischo WM, Hunter A, Miles T. Animal bite epidemiology and surveillance for rabies postexposure prophylaxis. J Am Vet Med Assoc. Jul 15/ 2000;217(2):190-4. [Medline].

  11. Nel LH, Markotter W. Lyssaviruses. Crit Rev Microbiol. 2007;33(4):301-24. [Medline].

  12. Baer GM. The Natural History of Rabies. Boston, MA: CRC Press; 1991.

  13. Mrak RE, Young L. Rabies encephalitis in humans: pathology, pathogenesis and pathophysiology. J Neuropath Exp Neurol. 1994;53(1):1-10. [Medline].

  14. Tsiang H. Pathophysiology of rabies virus infection of the nervous system. Adv Virus Res. 1993;42:375-412. [Medline].

  15. Fisher DJ. Epidemiology and prevention of rabies. Curr Probl Pediatr. Nov-Dec 1995;25(10):304-13. [Medline].

  16. Fishbein DB, Robinson LE. Rabies. N Engl J Med. Nov 25 1993;329(22):1632-8. [Medline].

  17. Rupprecht CE, Gibbons RV. Clinical practice. Prophylaxis against rabies. N Engl J Med. Dec 16 2004;351(25):2626-35. [Medline].

  18. Willoughby RE, Tieves KS, Hoffman GM, et al. Survival after treatment of rabies with induction of coma. N Engl J Med. Jun 16 2005;352(24):2508-14. [Medline]. [Full Text].

  19. McDermid RC, Saxinger L, Lee B, et al. Human rabies encephalitis following bat exposure: failure of therapeutic coma. CMAJ. Feb 26 2008;178(5):557-61. [Medline].

  20. Manning SE, Rupprecht CE, Fishbein D, et al. Human rabies prevention--United States, 2008: recommendations of the Advisory Committee on Immunization Practices. MMWR Recomm Rep. May 23 2008;57:1-28. [Medline]. [Full Text].

  21. Goldstein EJ. Current concepts on animal bites: bacteriology and therapy. Curr Clin Top Infect Dis. 1999;19:99-111. [Medline].

  22. Moran GJ, Talan DA, Mower W, et al. Appropriateness of rabies postexposure prophylaxis treatment for animal exposures. Emergency ID Net Study Group. JAMA. Aug 23-30 2000;284(8):1001-7. [Medline].

  23. Dandoy S, Scanlon F. Teaching kids about rabies. Am J Public Health. Mar 1999;89(3):413-4. [Medline].

  24. Murray KO, Arguin PM. Decision-based evaluation of recommendations for preexposure rabies vaccination. J Am Vet Med Assoc. Jan 15 2000;216(2):188-91. [Medline].

  25. Fescharek R, Schwarz S, Quast U, et al. Postexposure rabies prophylaxis: when the guidelines are not respected. Vaccine. Dec 1991;9(12):868-72. [Medline].

  26. Fisher DJ. Resurgence of rabies. A historical perspective on rabies in children. Arch Pediatr Adolesc Med. Mar 1995;149(3):306-12. [Medline].

  27. Committee on Infectious Diseases, American Academy of Pediatrics. 2006 Red Book - Report of the Committee on Infectious Diseases. 27. Elk Grove, IL: American Academy of Pediatrics; 2006:552-9.

  28. Chutivongse S, Wilde H, Benjavongkulchai M, et al. Postexposure rabies vaccination during pregnancy: effect on 202 women and their infants. Clin Infect Dis. Apr 1995;20(4):818-20. [Medline].

  29. Arya SC, Agarwal N. Assessing the safety of post-exposure rabies immunization in pregnancy. Hum Vaccin. Sep-Oct 2007;3(5):155; author reply 155. [Medline].

  30. Abazeed ME, Cinti, S. Rabies prophylaxis for pregnant women. Emerg Infect Dis. Dec 2007;13(12):1966-7. [Medline].

  31. Wilde H, Tipkong P, Khawplod P. Economic issues in postexposure rabies treatment. J Travel Med. Dec 1999;6(4):238-42. [Medline].

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Further Reading

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Keywords

rabies, terrestrial rabies, hydrophobia, mad dog disease, bat rabies, avian rabies, paralytic rabies, dumb rabies, furious rabies, rabies virus, rhabdovirus, Lyssavirus, Rhabdoviridae, encephalitis, raccoon bite, bat bite, paralysis, altered mental status, anxiety, hyperactivity, hypertension, hypersalivation, hyperthermia, hyperventilation

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Contributor Information and Disclosures

Author

Donna J Fisher, MD, Assistant Professor, Department of Pediatrics, Division of Pediatric Infectious Diseases, Tufts University School of Medicine and Baystate Children's Hospital, Baystate Medical Center
Donna J Fisher, MD is a member of the following medical societies: American Academy of Pediatrics, American Society for Microbiology, Infectious Diseases Society of America, and Pediatric Infectious Diseases Society
Disclosure: Nothing to disclose.

Medical Editor

Rosemary Johann-Liang, MD, Medical Officer, Infectious Diseases and Pediatrics, Division of Special Pathogens and Immunological Drug Products, Center for Drug Evaluation and Research, Food and Drug Administration
Rosemary Johann-Liang, MD is a member of the following medical societies: American Academy of Pediatrics, American Medical Association, and Infectious Diseases Society of America
Disclosure: Nothing to disclose.

Pharmacy Editor

Mary L Windle, PharmD, Adjunct Assistant Professor, University of Nebraska Medical Center College of Pharmacy, Pharmacy Editor, eMedicine
Disclosure: Pfizer Inc Stock Investment from broker recommendation; Avanir Pharma Stock Investment from broker recommendation

Managing Editor

Leslie L Barton, MD, Professor, Program Director, Department of Pediatrics, University of Arizona School of Medicine
Leslie L Barton, MD is a member of the following medical societies: American Academy of Pediatrics, Association of Pediatric Program Directors, Infectious Diseases Society of America, and Pediatric Infectious Diseases Society
Disclosure: Nothing to disclose.

CME Editor

Robert W Tolan Jr, MD, Chief, Division of Allergy, Immunology and Infectious Diseases, The Children's Hospital at Saint Peter's University Hospital; Clinical Associate Professor of Pediatrics, Drexel University College of Medicine
Robert W Tolan Jr, MD is a member of the following medical societies: American Academy of Pediatrics, American Medical Association, American Society for Microbiology, American Society of Tropical Medicine and Hygiene, Infectious Diseases Society of America, Pediatric Infectious Diseases Society, Phi Beta Kappa, and Physicians for Social Responsibility
Disclosure: GlaxoSmithKline Honoraria Speaking and teaching; MedImmune Honoraria Consulting; MedImmune Honoraria Speaking and teaching; Merck Honoraria Speaking and teaching; Novartis Honoraria Speaking and teaching; sanofi pasteur Grant/research funds Unrestricted research grant; sanofi pasteur  Consulting; sanofi pasteur Honoraria Speaking and teaching; Tap Honoraria Speaking and teaching

Chief Editor

Russell W Steele, MD, Head, Division of Pediatric Infectious Diseases, Ochsner Children's Health Center; Clinical Professor, Department of Pediatrics, Tulane University School of Medicine
Russell W Steele, MD is a member of the following medical societies: American Academy of Pediatrics, American Association of Immunologists, American Pediatric Society, American Society for Microbiology, Infectious Diseases Society of America, Louisiana State Medical Society, Pediatric Infectious Diseases Society, Society for Pediatric Research, and Southern Medical Association
Disclosure: None None None

 
 
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