Rabies (cont.)

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What is the treatment for rabies in humans?

Treatment for rabies (or more accurately, prevention of rabies before the 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 and is the new four-dose schedule:

Rabies post-exposure prophylaxis (PEP) schedule -- United States, 2010 -- CDC recommendations
Vaccination status   Intervention   Regimen*
Not previously vaccinated   Wound cleansing   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 preexposure 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.

Side effects may occur with any vaccine. Mild local reactions to the rabies vaccine (for example, mild pain, redness, swelling, or itching at the injection site) may occur in 5%-40% of patients, according to the CDC. Rarely, other symptoms such as headache, nausea, abdominal pain, muscle aches, dizziness, allergic reactions, and Guillain Barré disease 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, immunosuppressed people) 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.

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