Management of possible rabies exposure in children and young people (1192)

A focussed history is required, covering:

• date of exposure
• country of exposure
• species and current health status of animal involved
• details of injuries sustained
• any treatments to date
• if the child has had previous rabies immunisations (if yes, see Section 6: Note 1)
• if the child is immunosuppressed (if possibility, see Section 6: Note 2)
• if the child has any allergies (if yes, see Section 6: Note 3)
• if the child has any history of bleeding disorder (if yes, see Section 6: Note 4)

Use this information to complete a risk assessment using the Flow-chart and Tables below.

Rabies risks in terrestrial animals by country - GOV.UK

Table 1 - Category of Exposure

Source: 2023-09-04-rabies-guidance-prep-and-pet-scotland-v2-1pdf.pdf (publichealthscotland.scot)]

Table 2: Composite Risk

Table 3: Treatments required

Treatment notes:

• Most children will be considered non-immunised - see Section 6: Note 1
• Day 0 is the day of first vaccine, not necessarily the day of exposure
• Rabies vaccinations are given in the deltoid for children and adolescents, or anterolateral thigh in infants
• If HRIG indicated, see Section 7: HRIG,

Note 1: immunisation status

Most children will not have had previous rabies immunisations. To be considered fully immunised they would need EITHER:

• a well documented pre-exposure or post-exposure course of rabies immunisations
• a recent documented rabies antibody titre of at least 0.5 IU/ml

If in doubt, manage as the child as if they are unimmunised.

Note 2: Immunosuppression

For the purposes of rabies risk assessment, a child should be considered immunosuppressed if they fulfil the criteria for immunosuppression in Annexe 1 of the document linked below:

Guidelines on managing rabies postexposure (UK Health Security Agency, January 2023)

Note 3: Allergies

There are no contraindications to post-exposure treatment with rabies vaccine (including Rabipur for those with severe egg allergies). In the event of a hypersensitivity reaction to a dose of a pre-exposure course, such individuals should still receive post-exposure immunisation if indicated, because the risks of rabies outweigh the risks of hypersensitivity. When there is a history of a hypersensitivity reaction to rabies immunisation, seek advice.

Note 4: Bleeding disorders

If vaccinations are required and the child has a bleeding disorder, if may be more appropriate for these to be given subcutaneously. Seek advice if unsure.

Note 5: Immunisation schedules already started

The risk assessment above should be completed. Where a regime has been started that is different from what would have been used in the UK, advice should be sought from the paediatric ID team in daytime hours (between 9 am and 5 pm), e.g. the following day if out of hours (Section 9: Sources of Advice).

Arranging follow-up immunisations

• If the patient is in ED, follow-up immunisations should be requested for 1C as per Section 8: Follow-up
• If the patient is in Primary Care, please contact the ID team in-hours (as per Section 9: Sources of Advice). who will assist in arranging follow-up. Please have the details required for the Risk Assessment to hand.

Note 6: Exposure to recently imported animals

Animals recently imported into the UK may pose a rabies risk. If the animal is in a facility (e.g, zoo), discuss with the responsible veterinary surgeon to determine the risk.

Patients requiring HRIG should be discussed with the paediatric infectious diseases team.

Note that HRIG is not indicated:

• More than 7 days after first dose of post-exposure course
• More than one day after second dose of post-exposure course
• If exposure over 12 months previous (although vaccine may be indicated)

If required, HRIG should be given in ED:

• Wound washing is the most important preventative measure:
  • Potentially rabies-exposed wounds should be cleaned immediately and thoroughly with soap or detergent and flushed with running water for 10–15 minutes
  • A virucidal agent such as povidone-iodine solution or 40–70% alcohol should be applied and the wound covered with a simple dressing (not closed)
  • Remember that tetanus prophylaxis may also be required.
• 20 IU/kg body weight should be infiltrated in and around the cleansed wound

Refer to full guidance on giving HRIG in the Green Book chapter 27: Rabies: the green book, chapter 27 - GOV.UK (www.gov.uk)

Strengths of HRIG vary, but generally come as 150iu/ml or 300iu/ml. The product vial and manufacturer’s leaflet should be checked to confirm the strength when calculating the volume required.

Local infiltration of HRIG around the wound site is essential to efficacy. However, this can be painful and distressing to children, particularly for facial wounds. Consideration should be given to topical anaesthetic cream/gel and other measures such as entonox or sedation dependent on the age of the child.

Overview

If the patient is resident in the GGC catchment area, subsequent doses of rabies immunisation should be requested to be given on Ward 1C (paediatric day unit).

Please note: GP surgeries are unable to do request or provide these immunisations, so follow-up needs to be requested before discharge from ED.

If the patient is outside the GGC catchment area then subsequent doses should be given by local services as per local arrangements.

Procedure for completing referral to 1C

Please find out the name of the consultant on-call for paediatric infectious diseases – this can be found on Rotawatch or by asking the switchboard operator.

On Trakcare, go to “New Request” → Select “Other” tab → Click the magnifying glass next to “Other” → Use right arrow to find “Paediatric investigation unit ref”):

• Under “Please arrange…”: State date of exposure, and dates that follow-up rabies vaccination are required
• Under “Medical review required”: No
• Under “Name and designation of reviewing doctor”: “If input required, please contact ID service phone: 84939”
• Consultant: name of the on-call paediatric ID consultant
• Requestors contact details: ID service phone 84939

Once complete, please email the consultant on call for paediatric infectious diseases with name, CHI, and dates of requested vaccinations.

Notes:

• Please ensure the ED discharge letter contains enough details of the Risk Assessment for the ID team to verify that the child is on the correct immunisation course
• 1C will contact the family with appointments for subsequent immunisations
• While in 1C for follow-up vaccinations, patient will be formally under care of ID team
• A prescription for the immunisations will do done on a paper Kardex by the ID team
• After the final immunisation, the ID team will dictate a letter to the GP to document the completed course.

More detailed advice on the pathways outlined here is included in national guidance documents, linked in Section 10: Key references.

For patients in ED, for initial advice please discuss with the senior clinician in ED. Further support is also available from the paediatric infectious disease team (Mon-Fri 5pm 84939, out-of-hours consultant on call via switchboard).

For patients presenting to primary care, if in doubt please discuss with the paediatric infectious diseases team as above.

In either case, if a child has already commenced their rabies post-exposure prophylaxis (whether in UK or abroad) and are clinically well, any queries regarding follow-up doses or arrangements should be discussed in-hours the following day rather than out of hours.

Rabies: guidance on pre-exposure and post-exposure measures for humans in Scotland (Public Health Scotland, September 2023)

Guidelines on managing rabies postexposure (UK Health Security Agency, January 2023)