Rabies (hydrophobia) - Prevention

Immunization against rabies can be prophylactic and therapeutic-prophylactic. For prophylactic purposes, individuals whose work is associated with the risk of infection (veterinarians, foresters, hunters, dog catchers, slaughterhouse workers, taxidermists, employees of laboratories working with the street rabies virus) are immunized. Primary immunization includes three injections (0, 7 and 30 days) of 1 ml. The first revaccination is carried out after 1 year - one injection at a dose of 1 ml. The next revaccination is every 3 years - one injection at a dose of 1 ml. Vaccination is carried out taking into account contraindications.

Therapeutic and prophylactic immunization is carried out in case of contact and bites of people with rabid, suspected of rabies or unknown animals, there are no contraindications in this case. Pregnancy and infancy are not a reason to refuse therapeutic and prophylactic immunization.

Post-exposure prophylaxis of rabies includes wound treatment and administration of anti-rabies vaccine in combination with anti-rabies immunoglobulin. Tetanus prophylaxis is administered simultaneously according to existing schemes.

First aid to victims of animal bites should be provided immediately or as soon as possible after the bite. Wounds, scratches, abrasions, and areas of salivation should be washed abundantly with running water and soap or another detergent, the edges of the wounds should be treated with 70° alcohol or 5% iodine solution, and a sterile bandage should be applied. The edges of the wound should not be excised or sutured during the first 3 days. Suturing is indicated only in the following cases: in case of extensive wounds, when several skin sutures should be applied after preliminary treatment of the wound; to stop external bleeding (it is necessary to stitch up bleeding vessels); for cosmetic reasons (applying skin sutures to facial wounds). After local treatment of the wound, therapeutic and prophylactic immunization should be started immediately, for which the victim should be sent to a trauma center. Emergency tetanus prophylaxis is carried out in accordance with existing schemes.

Currently, the rabies vaccine and anti-rabies immunoglobulin are used for the vaccine-serum prophylaxis of rabies. Instead of the previously used brain vaccine, which had high reactogenicity, culture vaccines are used. Currently, the most widely used anti-rabies culgural concentrated purified inactivated dry vaccine (KOKAV) is used. Culture vaccines only in isolated cases cause reactions of a local and general nature. In case of severe multiple bites of dangerous localization, along with the vaccine, anti-rabies immunoglobulin is administered - heterologous (equine) or homologous (human), neutralizing the rabies virus. Anti-rabies immunoglobulin must be administered in the first hours after the bite (no later than 3 days) in order to create passive immunity. To prepare the anti-rabies immunoglobulin commonly used in practice, the serum of immunized animals (horses, mules, sheep, etc.) is used, therefore, when administering it to prevent anaphylactic reactions, certain rules must be followed (administration according to Bezredka). The dose of anti-rabies immunoglobulin is determined based on 40 IU/kg when administering heterologous and 20 IU/kg when administering homologous immunoglobulin. To determine the dose of immunoglobulin required for administration, the victim's weight must be multiplied by 40 (20) IU and the resulting number must be divided by the immunoglobulin activity, also measured in IU (indicated on the label). The calculated dose of immunoglobulin is infiltrated around the wounds and into the wound depth. If the anatomical location of the wound does not allow the entire dose to be administered around the wound, the remainder of the immunoglobulin is administered intramuscularly at other sites. Anti-rabies immunoglobulin is not used after the administration of the rabies vaccine. COCAV is administered 6 times in a dose of 1 ml into the deltoid muscle (for children - into the thigh muscles) on days 0, 3, 7, 14, 30 and 90.

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Determination of indications for therapeutic and prophylactic immunization against rabies

When examining a person who has been bitten, the issue of post-exposure prophylaxis for rabies must be addressed in each case. Every effort must be made to capture the animal that attacked the person. All wild animals that have bitten a person must be destroyed, and among domestic animals - sick, unvaccinated, stray, those that have made an unprovoked attack on a person, those that are behaving unusually or that have other signs of rabies. The animal's head must be immediately sent for examination to a specialized laboratory for immunofluorescent staining of the brain to determine rabies virus antigens. If the result is negative, the animal's saliva cannot contain the pathogen and there is no need for prophylaxis. If a person has been bitten by a wild animal that could not be caught, active and passive immunization must be administered simultaneously. In areas where rabies is not common among domestic animals, outwardly healthy dogs and cats must be isolated and observed for 10 days. If symptoms of the disease appear or if there is a change in behavior, the animal is destroyed and its head is sent to a specialized laboratory for immunofluorescent staining of the brain for rabies virus antigens. If the animal does not become ill within 10 days, its saliva could not contain the rabies virus at the time of the bite. In this case, the immunization that has begun is stopped (the patient has time to receive three injections of the vaccine - on the 0, 3, and 7th day after the bite). In areas where rabies is common among dogs, an immediate examination of the animal's brain is justified, especially in cases of severe bites. The schedule of therapeutic and prophylactic vaccinations with COCAV and anti-rabies immunoglobulin is given in the instructions for these drugs. Persons who have previously received a full course of therapeutic and prophylactic or prophylactic vaccinations, from the end of which no more than 1 year has passed, are prescribed three injections of the vaccine, 1 ml each, on the 0, 3, and 7th day; If 1 year or more has passed or an incomplete course of immunization was completed, the vaccine is administered in a dose of 1 ml on the 0th, 3rd, 7th, 14th, 30th and 90th day. According to indications, antirabies immunoglobulin and the vaccine are used in combination.

Glucocorticoids and immunosuppressants can lead to failures of vaccine therapy, therefore, in cases of vaccination against the background of taking these drugs, it is necessary to determine the level of virus-neutralizing antibodies. In the absence of virus-neutralizing antibodies, an additional course of treatment is necessary.

The person being vaccinated should know: he/she is prohibited from drinking any alcoholic beverages during the entire course of vaccinations and for 6 months after its completion. Overwork, hypothermia, and overheating should also be avoided.

Scheme of therapeutic and prophylactic vaccinations COCAV and anti-rabies immunoglobulin (anti-rabies immunoglobulin)

Damage categories	Nature of contact	Animal details	Treatment
1	No damage or saliva contamination of the skin, no direct contact	Sick with rabies	Not assigned
2	Salivation of intact skin, abrasions, single superficial bites or scratches of the body, upper and lower extremities (except the head, face, neck, hands, fingers and toes, genitals) inflicted by domestic and farm animals	If the animal remains healthy during 10 days of observation, then the treatment is stopped (i.e. after the 3rd injection). In all other cases, when it is impossible to observe the animal (killed, died, ran away, disappeared, etc.), the treatment is continued according to the specified scheme.	Start treatment immediately: COCAV 1 ml on days 0, 3, 7, 14, 30 and 90
3	Any drooling of mucous membranes, any bites of the head, face, neck, hand, fingers, arms and legs, genitals, multiple bites and deep single bites of any localization, inflicted by domestic and farm animals. Any drooling and damage inflicted by wild carnivores, bats and rodents	In cases where it is possible to observe the animal and it remains healthy for 10 days, the treatment is stopped (i.e. after the 3rd injection). In all other cases, when it is impossible to observe the animal, the treatment is continued according to the specified scheme.	Start combination treatment immediately: antirabies immunoglobulin on day 0 + COCAV 1 ml on days 0, 3, 7, 14, 30 and 90

Doses and immunization schedules are the same for children and adults. Treatment for rabies is prescribed regardless of the time of the victim's request for help, even several months after contact with a sick, suspected rabies or unknown animal.

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