Risk Assessment and Management of Exposures

  • Sudhi Ranjan Garg


The assessment of risk of rabies transmission in individual cases is important in arriving at appropriate decision regarding the course of postexposure prophylaxis (PEP) requirements. The World Health Organization has laid down guidelines for differentiating the categories of potential rabies exposure and taking appropriate prophylactic measures. Development of a decision tree assists in risk evaluation. A three-pronged strategy is adopted to manage the exposures. It involves bite wound management, postexposure passive immunisation through rabies immunoglobulin (RIG), and vaccination for active immunity. Wound treatment includes mechanical and chemical action against rabies virus. RIG neutralises and destroys the virus while postexposure antirabies vaccination helps in developing active immunity against rabies. Pre-exposure prophylactic vaccination is also recommended in high-risk individuals. Intradermal rabies vaccination has emerged as a less expensive alternative to intramuscular route of vaccine administration. PEP treatment is a proven method of rabies prevention; however, prophylaxis failures and rabies-related deaths are encountered largely due to deviations from the recommended guidelines. There is no specific treatment after the onset of symptoms of rabies.


Rabies Virus Rabies Vaccine Human Rabies Postexposure Prophylaxis Rabies Vaccination 
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  1. Abazeed ME, Cinti S (2007) Rabies prophylaxis for pregnant women. Emerg Infect Dis 13:1966–1967PubMedCrossRefGoogle Scholar
  2. APCRI (2009) Manual on rabies immunoglobulin (RIG) administration, 1st edn. Association for Prevention and Control of Rabies in India, BangaloreGoogle Scholar
  3. Bernard KW, Fishbein DB, Miller KD, Parker RA, Waterman S, Sumner JW, Reid FL, Johnson BK, Rollins AJ, Oster CN, Schonberger LB, Baer GM, Winkler WG (1985) Pre-exposure rabies immunization with human diploid cell vaccine: decreased antibody responses in persons immunized in developing countries. Am J Trop Med Hyg 34:633–647PubMedGoogle Scholar
  4. Briggs DJ, Banzhoff A, Nicolay U, Sirikwin S, Dumavibhat B, Tongswas S, Wasi C (2000) Antibody response of patients after postexposure rabies vaccination with small intradermal doses of purified chick embryo cell vaccine or purified Vero cell rabies vaccine. Bull WHO 78:693–698PubMedGoogle Scholar
  5. CDC (2005) Recovery of a patient from clinical rabies – Wisconsin, 2004. Morb Mortal Wkly Rep 53(50):1171–1173Google Scholar
  6. CDC (2008) Human rabies prevention – United States, 2008: recommendations of the advisory committee on immunization practices. Morb Mortal Wkly Rep 57(RR03):1–26, 28Google Scholar
  7. CDC (2010a) Presumptive abortive human rabies-Texas, 2009. Morb Mortal Wkly Rep 59(7):185–190Google Scholar
  8. CDC (2010b) Use of a reduced (4-dose) vaccine schedule for postexposure prophylaxis to prevent human rabies. Recommendations of the advisory committee on immunization practices. Morb Mortal Wkly Rep 59(RR02):1–9Google Scholar
  9. CDC (2012) Recovery of a patient from clinical rabies – California, 2011. Morb Mortal Wkly Rep 61(4):64–65Google Scholar
  10. CDCB (2012) Rabies: protocol for management of human rabies and management of animal exposures to prevent human rabies 2012. Communicable Disease Control Branch, Manitoba Government, Manitoba. http://www.gov.mb.ca/health/publichealth/cdc/protocol/rabies_protocol.pdf. Accessed 30 Aug 2012
  11. Dobardzic A, Izurieta H, Woo EJ, Iskander J, Shadomy S, Rupprecht C, Ball R, Braun MM (2007) Safety review of the purified chick embryo cell rabies vaccine: Data from the Vaccine Adverse Event Reporting System (VAERS), 1997–2005. Vaccine 25:4244–4251PubMedCrossRefGoogle Scholar
  12. Dreesen DW, Bernard KW, Parker RA, Deutsch AJ, Brown J (1986) Immune complex-like disease in 23 persons following a booster dose of rabies human diploid cell vaccine. Vaccine 4:45–49PubMedCrossRefGoogle Scholar
  13. Fishbein DB, Dreesen DW, Holmes DF, Pacer RE, Ley AB, Yager PA, Sumner JW, Reid-Sanden FL, Sanderlin DW, Tong TC, Kemp DT (1989) Human diploid cell rabies vaccine purified by zonal centrifugation: A controlled study of antibody response and side-effects following primary and booster pre-exposure immunizations. Vaccine 7:437–442PubMedCrossRefGoogle Scholar
  14. Florida Department of Health (2012) Rabies prevention and control in Florida, 2012. Florida Department of Health, USA. http://www.doh.state.fl.us/environment/newsroom/brochures/rabiesguide2012.pdf. Accessed 30 Aug 2012
  15. Georgia Department of Community Health (2011) Georgia rabies control manual, 6th edn. Georgia Department of Community Health, USA. http://health.state.ga.us/pdfs/epi/zvbd/Rabies%20Manual%202010_FINAL.pdf. Accessed 5 July 2012
  16. Jackson AC, Warrell MJ, Rupprecht CE, Ertl HCJ, Dietzschold B, O’Reilly M, Leach RP, Fu ZF, Wunner WH, Bleck TP, Wilde H (2003) Management of rabies in humans. Clin Infect Dis 36:60–63PubMedCrossRefGoogle Scholar
  17. Lang J, Cetre JC, Picot N, Lanta M, Briantais P, Vital S, Le Mener V, Lutsch C, Rotivel Y (1998) Immunogenicity and safety in adults of a new chromatographically purified Vero-cell rabies vaccine (CPRV): a randomized, double-blind trial with purified Vero-cell rabies vaccine (PVRV). Biologicals 26:299–308PubMedCrossRefGoogle Scholar
  18. NASPHV (2011) Compendium of animal rabies prevention and control, 2011. National Association of State Public Health Veterinarians, recommendations and reports. Morb Mortal Wkly Rep 60(RR06):1–14Google Scholar
  19. NICD (2007) National guidelines for rabies prophylaxis and intra-dermal administration of cell culture rabies vaccines. National Institute of Communicable Diseases, New DelhiGoogle Scholar
  20. Pappaioanou M, Fishbein DB, Dreesen DW, Schwartz IK, Campbell GH, Sumner JW, Patchen LC, Brown WJ (1986) Antibody response to preexposure human diploid-cell rabies vaccine given concurrently with chloroquine. N Engl J Med 314:280–284PubMedCrossRefGoogle Scholar
  21. Partners for Rabies Prevention (2010) Blueprint for rabies prevention and control. http://www.rabiesblueprint.com/. Accessed 12 Apr 2012
  22. Quiambao BP, Dimaano EM, Ambas C, Davis R, Banzhoff A, Malerczyk C (2005) Reducing the cost of post-exposure rabies prophylaxis: efficacy of 0.1 ml PCEC rabies vaccine administered intradermally using the Thai Red Cross post-exposure regimen in patients severely exposed to laboratory-confirmed rabid animals. Vaccine 23:1709–1714PubMedCrossRefGoogle Scholar
  23. Radostits OM, Gay CC, Hinchcliff KW, Constable PD (2007) Veterinary medicine – a textbook of the diseases of cattle, horses, sheep, pigs and goats, 10th edn. Saunders-Elsevier, EdinburghGoogle Scholar
  24. Rupprecht CE, Briggs D, Brown CM, Franka R, Katz SL, Kerr HD, Lett S, Levis R, Meltzer MI, Schaffner W, Cieslak PR (2009) Evidence for a 4-dose vaccine schedule for human rabies postexposure prophylaxis in previously non-vaccinated individuals. Vaccine 27:7141–7148PubMedCrossRefGoogle Scholar
  25. Shantavasinkul P, Tantawichien T, Wacharapluesadee S, Jeamanukoolkit A, Udomchaisakul P, Chattranukulchai P, Wongsaroj P, Khawplod P, Wilde H, Hemachudha T (2010) Failure of rabies postexposure prophylaxis in patients presenting with unusual manifestations. Clin Infect Dis 50:77–79PubMedCrossRefGoogle Scholar
  26. Sudarshan MK, Giri MS, Mahendra BJ, Venkatesh GM, Sanjay TV, Narayana DH, Ravish HS (2007) Assessing the safety of post-exposure rabies immunization in pregnancy. Hum Vaccine 3:87–89CrossRefGoogle Scholar
  27. Thisyakorn U, Pancharoen C, Ruxrungtham K, Ubolyam S, Khawplod P, Tantawichien T, Phanuphak P, Wilde H (2000) Safety and immunogenicity of pre-exposure rabies vaccination in children infected with human immunodeficiency virus type 1. Clin Infect Dis 30:218PubMedCrossRefGoogle Scholar
  28. van Thiel PP, de Bie RMA, Eftimov F, Tepaske R, Zaaijer HL, van Doornum GJJ, Schutten M, Osterhaus ADME, Majoie CBLM, Aronica E, Fehlner-Gardiner C, Wandeler AI, Kager PA (2009) Fatal human rabies due to Duvenhage virus from a bat in Kenya: failure of treatment with coma-induction, ketamine, and antiviral drugs. PLoS Negl Trop Dis 3(7):e428. doi: 10.1371/journal.pntd.0000428 PubMedCrossRefGoogle Scholar
  29. WHO (2005) WHO expert consultation on rabies. First report, WHO technical report series, no. 931. World Health Organization, GenevaGoogle Scholar
  30. WHO (2010a) Rabies vaccines: WHO position paper. Wkly Epidemiol Rec No 32 85:309–320Google Scholar
  31. WHO (2010b) WHO guide for rabies pre and post-exposure prophylaxis in humans (revised 15 June 2010). Department of Neglected Tropical Diseases, World Health Organization, GenevaGoogle Scholar
  32. WHO (2011) The immunological basis for immunization series. Module 17: rabies. Immunization, vaccines and biologicals. World Health Organization, GenevaGoogle Scholar
  33. WHO (2012) Current strategies for human rabies pre and post-exposure prophylaxis. Guide for post-exposure prophylaxis (PEP). http://www.who.int/rabies/human/WHO_strategy_prepost_exposure/en/index1.html. Accessed 15 Aug 2012
  34. WHO SEARO (2012) Rabies: Country profile: India. World Health Organization, Regional Office for South-East Asia, New Delhi. http://www.searo.who.int/LinkFiles/Zoonoses_IND-rabies-cp.pdf. Accessed 15 Aug 2012
  35. Wilde H (2007) Failures of rabies post-exposure prophylaxis. Vaccine 25:7605–7609PubMedCrossRefGoogle Scholar
  36. Willoughby RE Jr, Tieves KS, Hoffman GM, Ghanayem NS, Amelie-Lefond CM, Schwabe MJ, Chusid MJ, Rupprecht CE (2005) Survival after treatment of rabies with induction of coma. N Engl J Med 352:2508–2514PubMedCrossRefGoogle Scholar

Copyright information

© Springer India 2014

Authors and Affiliations

  • Sudhi Ranjan Garg
    • 1
  1. 1.Veterinary Public Health & EpidemiologyLala Lajpat Rai University of Veterinary and Animal SciencesHisarIndia

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