Nursing Spectrum
July 26, 2004
PEP for Bat Bites
by Donna Naturale, RN, MSN, APN-C

This timely article in the magazine called "Nursing Spectrum" impressed me when I read it a week or two ago over a bowl of oatmeal. Then, one of our own suddenly had cause for needing PEP. After reading JohnnyGoodyear's harrowing tales I checked some primary sources online. I still credit the above author, Donna Naturale, as my primary source for this node. Everything I read confirmed or merely added to the foundation laid by her well organized summary article. (available online) 1

Rabies shots are not what they used to be. Today, if one is exposed to rabies (either by bite or by saliva and/or neural tissue exposure to mucus membranes and/or an open lesion) the treatment recommended is a scheduled series of 6 doses (and for reasons that will be explained below, often in more than 6 injections) of medication, which together are called post exposure prophylactic (PEP) treatment.

The first medication is the RABIES immune globulin (RIG). This jumps starts the body with immune factors until vacination forces the body to produce its own. RIG is given intramuscularly around the actual injury site. If the recommended dose is too large to be absorbed near the actual area of the injury the dose may be given in divided doses in other deep muscles. This can turn one dose into at least 2 sticks and they must all be given in the same time frame. The literature I’ve read also describes infiltrating the wound area with RIG, which implies a series of multiple sticks, similar to when an area is infiltrated with Novocain. RIG should be given “AS SOON AS POSSIBLE AFTER EXPOSURE AND AT THE SAME TIME AS THE FIRST DOSE OF HDCV”. RIG is derived from the blood of human volunteers who have been superimmunized.

The second medication is the actual vaccine, most commonly Human Diploid Cell Vaccine (HDCV) in the US, and ”is to be administered immediately (day 0) after contact”,….”then on day three, seven, 14, and 28.”

“Since vaccine-induced antibody begins to appear within one week, there is no value in administering RIG more than 8 days after initiating a course of vaccine.” 2

Despite the wonderful modern medicine available for PEP the first step is a good washing of the wound with soap and water.

There will be at least 2 shots on the first day of PEP treatment.

In some cases where exposure is likely and/or treatment may be delayed rabies vaccines is also given pre-exposure. 3

“If a human has contact with a bat or another nocturnal animal, even if a bite has not occurred, that individual should be treated prophylactically. The treatments are continued until the animal has been determined rabies-free” 1

Common misconceptions about rabies shots are that there are “20 shots in the belly” and “I’m OK if I was not bitten.” 1

Another online source nicely summarized just how rare human rabies is in the US, and why. They say “While up to 50,000 people worldwide die of rabies every year, only 36 cases of human rabies have been diagnosed in the United States between 1980 and 2000. (Note, A US 4 year old died in 2001 as well.) This low rate of human cases in the United States reflects the success of domestic animal control and vaccination programs, which require an expenditure of several hundred million dollars annually.” 2 The ongoing problem with rabid wild animals is explained elsewhere. “There is an ongoing epidemic of rabies in wild animals in the U.S. Efforts to control the spread by dropping meat laced with vaccine into wooded areas are on-going, but they have not been totally successful. Further, most experts believe it is impossible to completely eradicate the disease in non-island countries.” 4 “Rabies is a disease that naturally affects only mammals (like raccoons, skunks, foxes and bats).”….”In the United States today, about 93 of every 100 reported cases of rabies are in wild animals. Most of the cases are found in raccoons, skunks, bats, and foxes. Raccoons are the most common wild animal with rabies today. Cats had the largest number of reported rabies cases in pets.” 5 Vaccines exist for dogs, cats, sheep, cattle, horses and ferrets. 6

Prophylaxis can prevent unnecessary deaths in patients exposed to rabies domestically or while traveling abroad, the treatment regimen is expensive at a cost for the biologics alone of $1500 per person and is not always administered under the appropriate circumstances. It is estimated that approximately 40,000 people in the United States receive rabies post exposure prophylaxis (PEP) annually. One prospective study of university-affiliated, urban emergency departments suggested that post exposure prophylaxis was given inappropriately in approximately 40 percent of cases.” 2

1 (easy to read but directed at health care professionals)
2 (technical reading)
3 (technical reading)
(easy but worthwhile reading on more myths about rabies)
5 (great section here for children to read and written on their reading level)(The CDC also has a good section on bat proofing your home.)
6 (article published by the FDA for consumers called "Mad Dogs and Friendly Skunks -- Controlling Rabies" by Ken Flieger)
7 (interesting article on bats and rabies and why most rabies in the US is now traced to bats but used to be traced to raccoons)

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