Rabies - Emergency treatment 

Treating rabies 

The treatment given for rabies will depend on whether you have started to show signs or symptoms.

If you show no signs or symptoms and it is suspected you may be infected, a course of treatment called post-exposure prophylaxis (PEP) is used. This can usually prevent a rabies infection from becoming established and producing symptoms.

If you have symptoms of rabies, treatment will usually focus on making you as comfortable as possible. This is because rabies is almost always fatal when it reaches this stage.

These two types of treatment are described in more detail below.

Post-exposure prophylaxis

Post-exposure prophylaxis consists of three elements:

  • cleaning the wound
  • administering rabies immunoglobulin – a special preparation of antibodies
  • administering a course of the rabies vaccine

Cleaning the wound

Immediately after being bitten, you should:

  • wash the wound thoroughly under a running tap
  • use antiseptic or alcohol to clean the wound and apply ethanol, tincture or aqueous solution of iodine, if available
  • leave the wound open – use a simple dressing but do not try to stitch it, because this could expose your nerve endings to the rabies virus
  • go to the nearest hospital or medical centre and explain you have been bitten

If you think your eye may have been infected with the saliva of an animal, you should wash it thoroughly with clean water and seek medical help.

Rabies immunoglobulin

If there is a high risk you are infected with rabies, you should be given an injection of rabies immunoglobulin. This should help protect you against the virus and prevent it travelling to your nervous system.

The immunoglobulin works by providing ready-made antibodies designed to neutralise the rabies virus and prevent it from spreading.

Aside from some temporary soreness at the site of the injection, rabies immunoglobulin does not usually cause any side effects.

Vaccination

The rabies vaccine should be given in every case of suspected exposure to rabies. The length of your course of vaccinations will depend on whether you have previously been vaccinated.

If you have never been vaccinated, you should receive five doses of the vaccine. The first dose is given at the beginning of the treatment, followed by four further doses, which are given three, seven, 14 and 30 days after the start of treatment.

If you have previously been vaccinated, you should receive two doses of the vaccine. The first dose is given at the start of your treatment, followed by a second dose three to seven days later. The doses are given by injection into the shoulder muscle.

A common side effect of the rabies vaccine is redness, swelling and pain at the site of the injection that occurs 24 to 48 hours after the injection has been given.

Choice of vaccine

There are three types of rabies vaccine:

  • human diploid cell vaccine (HDCV), which is created by using samples of human cells
  • purified chick embryo cell rabies vaccine (PCEC), which is created by using samples of chicken embryos 
  • nerve tissue vaccine, which is created using samples of nerves taken from animal brains

The World Health Organization (WHO) recommends that only HDCV or PCEC should be used. This is because there are safety concerns over the nerve tissue vaccine. Researchers have found this type of vaccine has a one in a 650 chance of causing serious complications that can result in permanent disability, such as muscle paralysis.

A small number of countries have not followed the WHO recommendation and still use the nerve tissue vaccine. They include Mongolia, Myanmar (Burma) and Pakistan.

In many developing countries, the HDCV or PCEC vaccine may only be available if you are willing to pay for private treatment.

If you are offered the nerve tissue vaccine, it is recommended you refuse and ask for one of the alternative vaccines.

Supportive treatment

If a person who is infected with rabies is not treated and they have developed symptoms, rabies is said to be established.

In this situation, there is almost nothing that can be done apart from keeping them comfortable. This is usually done by using powerful tranquilisers and sedatives to keep them free from physical pain and emotional upset.

To date, there have been no reported cases of human-to-human transmission of rabies. However, it is theoretically possible, so anyone who has been in close contact with someone who has a rabies infection may be advised to have post-exposure prophylaxis as a precaution.

In very rare cases, established rabies infections have been treated using a technique called the Milwaukee Protocol.

The Milwaukee Protocol

Until recently, all cases of established rabies infection were thought fatal.

However, a technique called the Milwaukee Protocol was attempted in 2004 on a patient with established rabies, and it saved their life. It involves inducing a coma so the person's brain is protected while their immune system tackles the infection.

Since then, the lives of five more people with rabies, none of whom had post-exposure prophylaxis treatment, have been saved using this technique.

However, this technique has only been used about 35 times overall and currently has a low success rate.

It is therefore still considered to be highly experimental and is not widely used.

Page last reviewed: 06/12/2012

Next review due: 06/12/2014

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Comments

The 2 comments posted are personal views. Any information they give has not been checked and may not be accurate.

missblueeyes said on 03 December 2011

I was going to say the same thing as Philip. In addition, the girl who he's talking about was already displaying symptoms when she presented to doctors. I also read on another website that the survival rate for this protocol is only 8%, but what that website doesn't tell you is that not everyone who uses this protocol follows the protocol exactly & that it's not been used often enough to give a reliable rate of survival, it's simply too soon to come up with a survival rate for this, especially when there's no guarantee how closely the protocol was followed. Then there are other factors like the person's age & previous state of health. etc. But as it's already saved several lives, it's always worth trying it.

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philipcfromnyc said on 17 July 2009

I have to comment about the claim that nothing can be done for an established infection. The Milwaukee protocol has saved several lives. This protocol calls for the induction of a coma using phenobarbital, midazolam, and ketamine. Treatment is then initiated with a combination of ribavirin and amantadine. In the case documented in the June or July 2005 edition of the New England Journal of Medicine, immunoglobulin was NOT administered, and antiviral therapy was maintained for five days, until the patient's immune system mounted its own attack. The patient survived with MINIMAL residual deficit, and was discharged more than 72 days after being admitted to the hospital.

This protocol has saved several other lives, and is now the standard of care in the US.

PHILIP

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