Rabies

Disease Description (Causes and Symptoms)

• Cause: Infection of the central nervous system caused by the Rabies virus, which is mainly transmitted to humans through the saliva of infected animals (bites or scratches) or contaminated mucous membranes. Rarely, it may be transmitted through corneal transplantation, laboratory exposure, or organ transplantation.
• Pathophysiology: The virus penetrates the terminal nerves at the wound site and ascends through the peripheral nerves to the central nervous system → causes encephalitis and leads to neurological dysfunction (autonomic nervous system abnormalities, behavioral changes, respiratory failure, etc.). The incubation period is usually 20–90 days (shorter for wounds near the face or neck), but it can rarely vary from several days to several years.
• Main symptoms: Early nonspecific prodromal symptoms such as fever, headache, malaise, localized pain, and sensory abnormalities. As the disease progresses, the furious form may cause anxiety, aggression, sleep disturbance, hydrophobia (phobia), dysphagia, high fever, and seizures, while the paralytic form may cause localized or progressive paralysis of the limbs. The prognosis after symptom onset is extremely poor (almost always fatal).

Treatment Methods

• Wound care (immediately): Wash the wound with soap and running water for at least 15 minutes and, if possible, disinfect it with an iodine-based solution (povidone-iodine) or 70% alcohol. Surgical treatment may be performed if necessary, but sterilization and suturing should be determined by a physician.
• Post-exposure prophylaxis (PEP; most important):
  • Human rabies immunoglobulin (HRIG): The recommended dose is 20 IU/kg body weight. Inject it into the tissue at the wound site as much as possible (if injection is feasible), and administer the remainder intramuscularly (half around the wound and half into a distant muscle).
  • Active immunization (inactivated vaccine): For people with no history of immunization, use the standard schedule (e.g., HDCV or an equivalent vaccine) — days 0, 3, 7, 14, and 28 (some guidelines use a 4-dose schedule).
  • People who previously received complete vaccination (e.g., occupational or pre-travel vaccination): Do not administer HRIG (consult a specialist in cases of severe exposure). Additionally, administer the vaccine on days 0 and 3 (2 doses total).
  • Pregnancy and children: PEP is safe and is recommended.
  • Immunocompromised people: Consider additional vaccination and serological follow-up (neutralizing antibody testing) — specialist advice is required.
• Treatment after symptom onset: There is no specific treatment once symptoms appear, so intensive supportive care (respiratory and circulatory support, anticonvulsants, etc.) is mainly provided. Some experimental treatments have been reported, but there is no consistent evidence of efficacy (e.g., the Milwaukee protocol has not been reproducible).
• Preventive measures: Vaccinate pets, avoid contact with wild animals, and follow laboratory safety procedures.

Outpatient Visit Checkpoints (Including Example Questions)

• Items/materials to prepare:
  • Time of exposure (exact date/time), circumstances of exposure (bite, scratch, saliva contact with mucous membranes), and photographs of the wound
  • Type of animal involved, location of the wound (face, hand, limb, etc.), whether the animal can be observed, and its vaccination history
  • Previous rabies vaccination history (e.g., whether pre-exposure vaccination was received and when)
  • Current medications (especially immunosuppressants, cancer treatment, etc.) and allergies (related to vaccines or immunoglobulin)
  • Pregnancy status and chronic diseases (including whether immunocompromised)
• Information to submit/explain to medical staff during the outpatient visit:
  • Whether and when the wound was washed, and the depth of the wound and whether it was bleeding
  • The animal’s condition (dead, escaped, available for observation, etc.)
  • Recent travel history (whether you visited an area where rabies is endemic)
• Example questions (items for patients to note before an outpatient visit):
  • “When and how did you treat the wound?”
  • “What type of animal was involved, and what was its condition?”

Examples of General Questions to Ask a Doctor

• What are the side effects and expected reactions to this treatment (vaccine and HRIG)?
• I am undergoing immunosuppressive treatment. What are the recommendations for PEP and follow-up testing?
• I was exposed during pregnancy. What are the safety considerations and recommendations for PEP?
• How should the process proceed when the animal cannot be observed?
• After vaccination, when can I be considered safe (when is the exposure risk considered resolved)?

Examples of Disease-Specific Questions

• Do I definitely need PEP (HRIG + vaccine) for the wound I received (e.g., on the face, neck, or hand)?
• I have previously received rabies vaccination. How can I determine whether additional vaccination and HRIG are needed?

Additional Information

• Rapid wound washing and consultation with a specialist after exposure are the most important steps. Because treatment options are limited after symptom onset, prevention (PEP) is essential.