1. Systematic review of the health impacts of mass earth movements PREVENTION OF RABIES IN HUMANS HUMAN DISEASE IS FATAL BUT IS PREVENTABLE BY POST EXPOSURE PROPHYLAXIS (PEP) ALL ANIMAL EXPOSURES MUST BE ASSESED FOR POTENTIAL RABIES EXPOSURE RISK MANAGEMENT OF PATIENTS EXPOSED TO POTENTIALLY RABID ANIMAL RABIES EXPOSURE RISK ASSESSMENT Risk assessment is necessary to determine if the animal exposure carries a risk of rabies. This assessment is based on species, behavior of the animal, and health of the animal. Indicators of high risk attacks include: Unprovoked animal attack, Animal with abnormal behavior – e.g. domestic animals being aggressive; wild animals may appear ‘tame’, Animal appears sick – drooling, wobbling/unsteady, snapping at imaginary objects, Animal has died. After considering these factors, then consider the category of exposure- see below. GENERAL WOUND MANAGEMENT IS CRITICAL IN ALL PATIENTS: Flush very well with soap and water or water alone if soap is not available, for at least 10 minutes, then clean with 70% alcohol solution After cleaning apply iodine solution or ointment if available. Give antibiotics e.g. amoxycillin clavulanate when indicated. Give tetanus vaccination or booster. Avoid suturing and use of local anaesthetic agents. FURTHER SPECIFIC MANAGEMENT DEPENDS ON CATEGORY OF RABIES EXPOSURE AND PREVIOUS VACCIANTION HISTORY: Vaccine course in category 2 and 3 exposures.* Addition of rabies immunoglobulin in category 3 exposures is critical.** Give rabies immunoglobulin in addition to vaccine for category 2 exposures, if patient is immunocompromised NOTES All animal bites are reportable as per district requirements. There is NO test to confirm or exclude rabies virus transmission from animal to human at the time of exposure Vaccination history of animal may be unreliable, and as such should be treated with caution given least weight in the risk assessment. Do not delay PEP pending test results for the animal. If state vet later confirms animal is rabies free, then PEP can be discontinued. PEP is most effective if given immediately after the exposure. Do not withhold PEP when there is a delay PRESENTATION. If PEP is given, then count the date first vaccine dose is given as Day 0.. CATEGORIES OF EXPOSURE CategoryDescriptionAction 1 Touching or feeding animal Licking intact skin No action if history of exposure is reliable If history of exposure is not reliable treat as category 2 2 Nibbling of uncovered skin Superficial scratch without any bleeding General wound management as above, plus Give full course of rabies vaccine* Give rabies immunoglobulin in addition to vaccine if patient is immunocompromised 3 Bites or scratches penetrating skin or drawing blood Licking of mucous membranes (eg eyes, mouth) Licking of broken skin or abrasions General wound management as above, plus Give full course of vaccine* Give rabies immunoglobulin** Administration of rabies immunoglobulin is critical in category 3 bites *RABIES VACCINE Indication: CATEGORY 2 AND 3 EXPOSURES Vaccination schedule requires FOUR doses. Course: day 0, 3, 7, 14. Day 0 = day of first vaccination. IMI deltoid muscle in adults, anterolateral thigh in children. DO NOT GIVE INTO GLUTEUS MAXIMUS Dose: 1 amp per dose for adults and children. Vaccine induces immune response in 7-10 days Evidence suggests that immunity from pre-exposure prophylaxis lasts up to 15 years. If patient has had two or more rabies vaccines in past, then only give two booster doses on days 0 and 3. **RABIES IMMUNOGLOBULIN (RIG) Indication: CATEGORY 3 EXPOSURES and category 2 exposure if patient is immunocompromised. Dose: 20 IU/kg. Infiltrate RIG around wounds, giving as much as anatomically appropriate without compromising blood supply (especially for extremities). Inject any remaining RIG into deltoid in opposite arm to vaccine, DO NOT GIVE INTO GLUTEUS MAXIMUS. Each 2ml ampoule contains 300 IU of RIG. If multiple wounds, dilute RIG in equal volumes of saline and infiltrate all wounds. Give RIG at same time as vaccine administration. Give RIG and vaccine as soon as possible after exposure for best effect. If RIG is not immediately available, it should be sourced and administered as soon as possible, but should not be given more than 7 days after the first vaccination. Omit RIG if past rabies vaccination in the patient can be confirmed. RIG is immediately protective. Protection lasts 7-10 days, giving time for vaccine to induce immune response. IMMUNOCOMPROMISED PATIENTS Give RIG and vaccines in category 2 and 3 exposure. Give 5 th dose of vaccine on day 28. NICD Hotline for Clinical Advice: 082 883 9920 Updated June 2013 Adapted from Rabies: Guide for medical, veterinary and allied professions, Second edition Department of Agriculture

2. PREVENTION OF RABIES IN HUMANS ADDITIONAL INFORMATION FOR HEALTH CARE WORKERS WOUND MANGEMENT AND ADMINISTRATION TECHNIQUE FACTORS TO CONSIDER FOR DETAILED RISK ASSESSMENT OTHER CONSIDERATIONS Animal species At risk of carrying rabies DogsCats LivestockBats Bat-eared fox Mongoose Cane rats Not a risk for rabies Birds Reptiles Mice and rats (other than cane rats) Animal Behaviour Factors which indicate higher risk of exposure: The attack was unprovoked - teasing an animal, trying to take an animals food or guard, dog attacking an unfamiliar person entering their territory are provoked attacks, The animal has bitten multiple people, Domestic animal being aggressive, wild animal appearing tame. Veterinary services If you give PEP then the state vet/animal health practitioner should be contacted to inform them of potentially rabid animal. This contact should be made urgently if there is a risk of other citizens being exposed, for example the animal has attacked multiple people and it is still alive. Wounds do not have to be large or bleed profusely to be considered category 3. A single drop of blood drawn from the wound indicates a category 3 exposure. All three pictures show category 3 wounds Category two exposures only occur when there has been no break in the skin or bleeding at all. There are no category 2 bat exposures should always be considered category 3, as A human rabies case constitutes a public health system failure so it is important to confirm all suspected rabies cases and to investigate as to the reason for the failure. GEOGRAPHY Consider where the exposure occurred and where the animal is from. Higher risk areas include KwaZulu-Natal, and parts of Eastern Cape, Free State, Mpumalanga and Limpopo, However outbreaks have occurred in all provinces and there are no areas of zero risk. CATEGORIES OF EXPOSURES Animal Health If the animal has died or is sick this increases the risk of rabies exposure Typical rabies symptoms include: Dogs: aggression, drooling, wobbling, snapping at imaginary insects, muscle paralysis. Cats: aggression, uncoordinated, frothing, abnormal vocalisation and response to owners. Cattle and goats: choking – “bone in the throat”, knuckling of fetlocks and hind-quarters. Wild animals: lose fear of humans. Jackals and badgers more aggressive. Kudu and yellow mongoose tend to be more tame. If the patient presents more than 10 days since exposure, and the animal is still alive and healthy, then risk of rabies exposure is very low. Non-compliance: Most cases of rabies in those receiving PEP occur when the protocol has not been followed correctly: It is therefore critical to follow the protocol. Patients should be actively followed up to ensure completion of vaccination schedule. If the patient does not comply fully, they should be informed that they are placing themselves at higher risk, and staff should make every effort to ensure PEP is completed. Pregnancy: No contraindication to vaccine or RIG. Supply of biologicals Procedures should be in place to ensure access to adequate supplies of vaccine and immunoglobulin (either local stocks or robust referral systems). Each facility should have a process in place to resolve stock outs quickly. Provincial Department of Health should be contacted if there are any difficulties in sourcing rabies immunoglobulin. Examples of vaccine (left and centre) and RIG (right) packaging PICTURE OF VACCINE ADMINSITRATION DO NOT USE LOCAL ANAESTHETIC AND AVOID SUTURING IF AT ALL POSSIBLE. If suturing of wound which is a high risk of rabies exposure suturing is unavoidable, RIG must be infiltrated around the wound first, and suturing delayed for as long as possible. Step 3: Administer vaccine by IM injection into deltoid muscle in adults, anterolateral thigh in children. Give further doses as per PEP schedule Step 2: If indicated, infiltrate rabies immunoglobulin around wound at a dose of 20IU/kg Step 1: Thoroughly clear the wound for 10 minutes with soap and water, then clean with 70% alcohol solution. Finally apply iodine solution. These lists are for example only – if you are unsure of risk for a particular species seek expert advice Figure 1. A map illustrating the distribution of the main rabies vectors in South Africa Picture of large/deep bite wound Picture of bleeding scratch Picture of bat bite. diagram of wound cleaning. diagram of RIG infiltration. diagram of vaccine administration. rabies vaccine packaging 1 rabies vaccine packaging 2 rabies vaccine packaging 3