Day: April 25, 2016

What Do You Do When the Rabies Vaccination Schedule is Off Schedule?

Patient Presentation
A 3-year-old male with his mother walked into clinic requesting rabies vaccination. Five days previously, the child had been playing in his bedroom alone and had a bat fly directly at him from a closet. He said the bat had hit or bit him on the arm. He cried. His father came, caught the bat and released the bat. The boy was evaluated at a local emergency room later that day and was given rabies vaccine but no rabies immunoglobulin because it was not available. The boy was supposed to followup at his local doctors on day 3 after the incident but the mother said that she had transportation issues and couldn’t go. She was now visiting relatives and they helped bring the child to general pediatric clinic. The past medical history revealed a healthy male with intermittent medical care but who was fully vaccinated. He had been seen in this clinic 2 years previously for his 9 and 12 month health supervision visits. The social history showed a family who was working but having financial struggles. There had been other bats seen in the home before.

The pertinent physical exam showed a healthy male with normal vital signs. His weight and height were at the 75-90% for age. He had a 10-15 mm red spot on his right dorsal forearm that he said was where the bat hit/bit him. There were no obvious bite marks and the area did not look infected. The rest of his examination was normal.

The diagnosis of a probable rabies exposure through a bat bite was made. The resident and attending physician had many questions about how best to treat the patient and consulted online resources as well as contacting the Centers for Disease Control and the state Department of Public Health to come up with a plan. The questions were how to appropriate schedule the rest of the rabies vaccines for the patient who was now off schedule, can rabies immune globulin still be given at day 5, what should be done for bat control in the house, and how can they help the family come back for the additional vaccines on schedule? The patient was given rabies vaccine (second dose, “Day 3 vaccine”) while in clinic, along with rabies immunoglobulin. The 3rd dose of rabies vaccine was scheduled in 4 days time. The clinic social worker worked with the health care providers and family to identify potential resources for transportation back to the clinic, bat-proofing the house and also resources to have the father treated for potential rabies as it was later determined that he had not been treated yet and had captured the bat with his hands and wasn’t sure if he had been bitten also.

At followup 4 days later the child received his 3rd rabies vaccine, the family was working on batproofing the house, but the father had not been treated because of lack of medical insurance. He was scheduled to receive his 4th vaccine in another 7 days (“Day 14 dose”) and then was to followup again to have rabies serology testing 7-14 days after the last vaccine dose. The CDC and health department both indicated this should be done because the schedule had to be modified.

Discussion
Rabies virus causes progressive encephalopathy and has a high fatality rate if not treated. Fortunately, post-exposure prophylaxis (PEP) regimens are highly effective. Any mammal is susceptible to rabies vaccine with domesticated dogs being important sources in some international locations and in the U.S. coyotes, fox, raccoon, and skunk and bats are important reservoirs.

Rabies transmission from bats “…can occur from minor, seemingly unimportant, or unrecognized bites from bats.” Therefore contact should be minimized. PEP is considered for people who had significant contact, were known to be bitten or were in a room and might be unaware that the bat touched them or bit them. Examples would be a sleeping person or a child who was unattended and is now found to have a bat in the room.

Current rabies vaccine schedule is a 4 dose series – Day 0, 3, 7 and 14. A fifth dose is given on day 28 for immunocompromised individuals. Vaccination is considered safe for pregnant women and should be given if PEP is indicated. Rabies immunoglobulin is also recommended to be given on Day 0. Once the PEP series is started it generally is continued. One reason to stop is if the bat tests negative for rabies, then the PEP can be stopped. It is recommended to consult current resources such as the Centers for Disease Control or local health department regarding current PEP treatment and individual circumstances.

Learning Point
It is important for the PEP to be given on the appropriate schedule. However, if a patient becomes off schedule for the PEP, the series is not restarted. “Every effort should be made to adhere to the recommended PEP regimen schedule, especially the first two days of treatment, days 0 and 3. After day 3 of the regimen, deviations of a few days are acceptable. For most minor delays or interruptions, the vaccination schedule can be shifted and resumed as though the patient were on schedule. For example, if a patient misses the dose scheduled for day 7 and presents for vaccination on day 10, the day 7 dose should be administered that day, and the final dose given one week later on day 17.”

Rabies virus can persist in tissue for a long time before moving into a peripheral nerve. Rabies immunoglobulin can be used up to and including 7 days after the exposure.

Identification of where the bats are living in the house is sometimes easy but often can be difficult or impossible. At dusk the bats can sometimes be seen moving in and out of the house and then steps to close up the openings can be made. If control measures cannot be successfully implemented then pre-exposure vaccination can be considered.

Questions for Further Discussion
1. How do PEP regimens change if a person has been previously vaccinated?
2. What are indications for pre-exposure rabies vaccination?

Related Cases

To Learn More
To view pediatric review articles on this topic from the past year check PubMed.

Evidence-based medicine information on this topic can be found at SearchingPediatrics.com, the National Guideline Clearinghouse and the Cochrane Database of Systematic Reviews.

Information prescriptions for patients can be found at MedlinePlus for these topics: Rabies and Animal Bites.

To view current news articles on this topic check Google News.

To view images related to this topic check Google Images.

To view videos related to this topic check YouTube Videos.

Iowa Department of Public Health. Available from the Internet at http://www.idph.state.ia.us/IDPHChannelsService/file.ashx?file=7D53ED18-4B3C-4087-AA8C-735B90EC8C25 (rev. 5/21/2010, cited 2/9/16).

New York State Department of Public Health. Guidance Regarding Human Exposure to Rabies and Postexposure Prophylaxis Decisions. Available from the Internet at https://www.health.ny.gov/diseases/communicable/zoonoses/rabies/docs/genguide.pdf (rev. 9/21/10, cited 2/9/15).

Centers for Disease Control. Precautions or Contraindications for Rabies Vaccination. Available from the Internet at http://www.cdc.gov/rabies/specific_groups/doctors/vaccination_precautions.html (rev. 6/30/11, cited 2/9/16).

Centers for Disease Control. Rabies Vaccine. Available from the Internet at http://www.cdc.gov/rabies/medical_care/vaccine.html (rev. 9/24/14, cited 2/9/15).

Hanlon CA, Schlim DR. Infectious Disease Related to Travel – Rabies. Centers for Disease Control. Available from the Internet at http://wwwnc.cdc.gov/travel/yellowbook/2016/infectious-diseases-related-to-travel/rabies (rev. 6/30/15, cited 2/9/15).

Minnesota Department of Health. Rabies Post-Exposure Prophylaxis Regimen Animal Bites and Rabies Risk: A Guide for Health Professionals. Available from the Internet at http://www.health.state.mn.us/divs/idepc/diseases/rabies/risk/postexposure.htm (cited 2/9/16).



Author
Donna M. D’Alessandro, MD
Professor of Pediatrics, University of Iowa Children’s Hospital