Rabies
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þ Preexposure
 - Check titre in 3 or 12 months
 - CDC suspects that people with negative titres really get good protection
   and to keep on giving the vaccine.
 - From 1996 CDC data, only 22% gave history of rabies exposure
 - hydrophobia is rare

þ Types of Vaccine
 - HDCV (human diploid cell vaccine), three over four weeks.
 - PCEC:  Purified Chick Embryo Culture:  advertised to avoid serum sickness,
   but serum sickness only in those who've had previous vaccines.
 - RVA:
 - Can't use in gluteus or SQ, must be in deltoid.

 Post-Exposure Treatment in the ED.  J Emerg Med 1996; 14:28:287-282[

þ Post exposure:
 - If had previous vaccine and exposed:  check titer, no RIG,  booster on day
   zero and day three.
 - Five IM diploid injections over one month - 0,3,7,14,28 days
 - RIG 20 IU/kg:  one half in site and one half IM at different site.

þ Rabies Vaccine Adsorbed (RVA)
 - Killed viruses from Monkey lung fibroblasts.
 - Makes Murray Hamlet nervous, me too.  Avoid.

þ Horse Serum:
 - lots of serum sickness, avoid
 - if in foreign country, go to US Embassy and demand human diploid vaccine
   (supposed to stockpile in embassies)

þ Betadine is useless and may potentiate infection
 (get reference from Murray Hamlet)

þ Cat with bat:
 - Cats don't fly.
 - Assume bat is rabid.
 - Submit head of bat for examination.

þ Exposure in house:
 - Child with bat found in room, considered exposed until bat's head is
   examined, according to CDC (recent 1998).  Can be a minute bite.

þ Rules
 - vary from community to community
   CDC:
 - Dog or Cat bite to human:  observe for 10 days.  If dies, pathological exam of brain.
 - Wild animal:  kill, but preserve head.
 - Dog or Cat bitten by suspect animal:
  + Vaccine good for 3 years
  + Boost and strict observation for 90 days, if dies, examine.
  + Unvaccinated dog or cat bitten by suspect animal:
   - destroy
   - if refused, isolate for three months in vet clinic ($$$), then confine
     in house for three months, and vaccinate in fifth month.

þ Provoked vs. Unprovoked Attack:
 - bite in yard by dog:  provoked attack, recognized in law
 - bite out of yard by dog: unprovoked attack.

þ Questions to Ask when deciding about prophylaxis
 - What species?
 - Provoked or not?
 - Type of exposure - bite (worse) or scratch?
 - Where did bit occur (anatomic)?
 - Vaccination history?
 - The below is from the MMWR, Jan 16, 1998
   (full text available at the CDC website, www.cdc.gov).
   Unfortunately, it's just *slightly* ambiguous, but it seems to be saying --
   in the light of the two cases mentioned in which rabies developed after
   bats were touched but there was no scratch or bite or mucous membrane
   contact -- that everyone who touches a bat, or even *might* have touched a
   bat, gets PEP.
   [MMWR text begins: ]
   In all potential human exposures involving bats, the bat in question should
   be safely collected, if possible, and submitted through local or state
   health departments for rabies diagnosis. PEP is recommended for all persons
   who have sustained bite, scratch, or mucous membrane exposures to a bat
   unless the bat is available for test-ing and is negative for evidence of
   rabies. Although both cases described in this report had histories of
   contact with a bat, neither reported being bitten. Of the 21 cases of human
   rabies reported since 1980 that were caused by bat-associated rabies virus
   variants, only one had a definite history of a bat bite. Therefore, PEP
   also is appropri-ate even in the absence of a demonstrable bite, scratch,
   or mucous membrane expo-sure in situations in which there is reasonable
   probability that such contact occurred (e.g., a sleeping person awakens to
   find a bat in the room or an adult witnesses a bat in the room with a
   previously unattended child or mentally disabled or intoxicated person).
   This recommendation used in conjunction with current Advisory Committee for
   Immunization Practices (ACIP) guidelines ( 3 ) should maximize the ability
   of health-care providers to respond to situations in which accurate
   exposure histories may not be obtainable and should minimize inappropriate
   PEP.

þ Cats vs. Dogs
 - Cats 10x more often infected in dogs

þ No rabies in Great Britain and Ireland

þ Asymptomatic Carriers:
 - Skunks, Bats, Grey Foxes (sometimes months).