Rabies... Vaccines & Post-Exposure Treatment

[TN_Farmer]

Not to interfere with a fellow doc’s excellent and informative thread, but I can share with you the protocol we use.

Category 1 exposure is contact with an infected animal, saliva exposure to in tact skin. This carries minimum risk for transmission and is regarded by some as not an exposure.

Category 2 exposure is minor skin trauma from bites or scratches, involving saliva from the animal, but with no visible bleeding. This exposure carries a risk for transmission, although still low. Obviously these things are impossible to quantify in terms of percentage or absolute values.

Category 3 exposure is when skin is breached, with associated bleeding and subsequent saliva contact or contact of saliva on mucosal surfaces. This is regarded as a high risk exposure and will receive immunoglobulin in the wound sites as well as the four vaccines.

Contact with all other bodily fluids, except saliva and cerebrospinal fluid, from an infected animal is believed to not carry any exposure risk and seen as a Category 1 exposure.

This is absolutely correct. This is the WHO Guidelines and is used by most countries outside of the U.S. Do you practice medicine or just well-informed?

My recommendations are an amalgamation from CDC, US Military, and UpToDate.

The only difference I see with the WHO guidelines is that it assumes that you know the animal is infected with rabies or suspected to have rabies. The US Military unofficial recommendations, when I was practicing overseas in rabies endemic areas, was more cautious and assumed any wild animal exposure was from a suspected animal (because what wild animal, in their right mind, would approach a human?).

Hunting, or other activity where humans initiate the contact, puts all of this in the gray zone. If you have the ability to really observe an animal, you may be able to tell if it is acting normally or not. If you don't have the ability to observe the animal, or you are doing cull hunts for sickly animals, you don't know for sure. But the chances are still low that you will happen to shoot a rabies-infected animal AND have exposure.

Again, you need to weigh your own risk vs benefit.

 

[Field28]

I looked into getting the Pre exposure vaccine last year. It was extremely difficult to find. My family medicine practice did not have it, I had to go to a travel clinic. It wasn't cheap, if I remember correctly it was around $1300.00 and not covered by insurance. I opted to not get it.

The price surprised me, during the summer here there are multiple rabies clinics for dogs at no charge. There are multiple rabies scares here in the Southeast during the summer months.
There are a good number of coyotes here that fall to rabies and parvo, not enough unfortunately.

I'm sure i probably already know the answer for the human vaccine being so expensive but it would end up in the politics thread.

That being said, I would think the vaccine use would be more common amongst outdoorsman here in the South. I know quite a few people that have had run ins with bobcats, raccoons, etc that have had to endure the post exposure treatment.

 

[TOBY458]

I was bitten by a rabid fox several years ago, and had to take the vaccine. If I remember correctly, it was a shot in each arm and two in each side of the hips. I was extremely sore the next day, and walking was painful for a day or two.
As a side note, I had the urge to chase cars for several years after that.

 

[TN_Farmer]

When is it considered exposure for rabies? My understanding is that blood contact doesn't expose you to rabies, it's all in the saliva.

This is correct. Blood does not transfer rabies. It's only in the saliva. This is the basis of the recommendations.

The only thing to consider is... are you sure there's no saliva?

The recommendations for rabies treatment includes bites... this is an obvious exposure to saliva.

The recommendations for rabies treatment also includes scratches... this is less obvious, but there is a large enough chance of saliva being on the animals' claws (like with dogs, cats, raccoons, bats, etc.)

But... just to make you paranoid... here are a couple of other things to consider.

First, people who are allergic to cats or dogs are actually allergic to their saliva or and their dander (dead skin cells). Most people think it's cat or dog hair. That's not correct. When a dog or cat clean themselves, their saliva dries on the hairs and then flakes off along with dead skin cells These dried flakes of saliva are very light and then float around in the air. This is what we have allergic reactions to when we breath it in. Now... the good news is that you really shouldn't be able to get rabies from dried saliva.

Second... over the past few decades, in the U.S., about 1 person dies every other year from bat rabies. Yes, we can test a person who has rabies and identify the vector (bat, fox, skunk, etc.) that gave them rabies. Half of these people had no known exposure to a bat! So they were just living their life as normal with no known bat interactions, then started getting sick and having odd symptoms, and they finally get tested for rabies, and they are positive... and it's too late then. Yikes!
Now... the good news is that we are talking about less than 1 in 335 million chance of this happening! It's like the winning a really bad lottery. And the risk of a really bad reaction from the rabies vaccine (which is really, really rare) is still higher than getting rabies without a known exposure, so we don't just vaccinate everyone.

With all that said, despite the sensational and unnecessary scary information I shared , I still follow the CDC recommendations.

 

[Field28]

We're seeing a ton of foxes here in coastal SC recently, probably due to all the development. The ones I've seen have been pretty brave if not aggressive. I've seen them in multiple neighborhoods and even at the beach during peak season when the area is packed with people.

 

[TN_Farmer]

I looked into getting the Pre exposure vaccine last year. It was extremely difficult to find. My family medicine practice did not have it, I had to go to a travel clinic. It wasn't cheap, if I remember correctly it was around $1300.00 and not covered by insurance. I opted to not get it.

The price surprised me, during the summer here there are multiple rabies clinics for dogs at no charge. There are multiple rabies scares here in the Southeast during the summer months.
There are a good number of coyotes here that fall to rabies and parvo, not enough unfortunately.

I'm sure i probably already know the answer for the human vaccine being so expensive but it would end up in the politics thread.

That being said, I would think the vaccine use would be more common amongst outdoorsman here in the South. I know quite a few people that have had run ins with bobcats, raccoons, etc that have had to endure the post exposure treatment.

I doubt preventive rabies vaccination would be covered by most insurances unless your job required it, and then your job would probably cover it.

Upon further review, I am going to have to change my opening post information... it is not $50-$100 per shot like it used to be. You are correct, it is way more expensive now... like up to $500 per shot, and you need 2 shots. So, with administration costs, $1,300 sounds pretty close.

This is really frustrating. Rabies vaccine for dogs is like $20 per shot.

Don't you just love big Pharma?!

 

[pilar]

Rabies kinda freaks me out, I got bitten by a feral street dog in Mexico and I refused treatment while there ( luckily it wasn’t rabid)
And we trap lots of skunks and raccoons In the chicken coop
Was my hands in bleach and soap then some 90% alcohol after I handle them

 

[Dewald]

This is absolutely correct. This is the WHO Guidelines and is used by most countries outside of the U.S. Do you practice medicine or just well-informed?

My recommendations are an amalgamation from CDC, US Military, and UpToDate.

The only difference I see with the WHO guidelines is that it assumes that you know the animal is infected with rabies or suspected to have rabies. The US Military unofficial recommendations, when I was practicing overseas in rabies endemic areas, was more cautious and assumed any wild animal exposure was from a suspected animal (because what wild animal, in their right mind, would approach a human?).

Hunting, or other activity where humans initiate the contact, puts all of this in the gray zone. If you have the ability to really observe an animal, you may be able to tell if it is acting normally or not. If you don't have the ability to observe the animal, or you are doing cull hunts for sickly animals, you don't know for sure. But the chances are still low that you will happen to shoot a rabies-infected animal AND have exposure.

Again, you need to weigh your own risk vs benefit.

Hi @TN_Farmer,

Not unlike you, I also started my career as an emergency medicine physician, then started dabbling with a few other things. Currently I still do calls in our local EMU in Northern KZN, but practice as a family physician with a travel medicine practice.

That is when I’m not relapsing into my addictions of buying and selling firearms and taking people hunting.

I agree that there is always room for erring on the side of caution when it comes to WHO guidelines.

Just out of interest, Verorab or similar Rabies vaccines are now R602.00 or $34 a shot in RSA and Rabies Immunoglobulin is R1056.00 or $60 per vial of 300 IU. I see a business opportunity here if I offer a vaccination service on OR Tambo or forreign hunters.

 

[pilar]

Hi @TN_Farmer,

Not unlike you, I also started my career as an emergency medicine physician, then started dabbling with a few other things. Currently I still do calls in our local EMU in Northern KZN, but practice as a family physician with a travel medicine practice.

That is when I’m not relapsing into my addictions of buying and selling firearms and taking people hunting.

I agree that there is always room for erring on the side of caution when it comes to WHO guidelines.

Just out of interest, Verorab or similar Rabies vaccines are now R602.00 or $34 a shot in RSA and Rabies Immunoglobulin is R1056.00 or $60 per vial of 300 IU. I see a business opportunity here if I offer a vaccination service on OR Tambo or forreign hunters.

With the crazy health system in the USA, a rabies vaccination is probably $10,000
By the time it’s said and done

 

[V.Veritas]

Hi @TN_Farmer,

Just out of interest, Verorab or similar Rabies vaccines are now R602.00 or $34 a shot in RSA and Rabies Immunoglobulin is R1056.00 or $60 per vial of 300 IU. I see a business opportunity here if I offer a vaccination service on OR Tambo or forreign hunters.

I know this would fit better into the Political thread, but:

I remember reading in a book (Tailspin by Steven Brill) that mentioned that the USA parlament at big Pharma's lobby pressure passed a law in the '80 that made it illegal for anyone to negocaite any prices set by the Big Pharma. (This law explains why the same meds in Mexico are sometimes 100 times cheaper than in US).

And recently I saw this:

View this content on Instagram

View this content on Instagram

It might also go in the Jokes thread if I think about it.

 

[cwpayton]

I doubt preventive rabies vaccination would be covered by most insurances unless your job required it, and then your job would probably cover it.

Upon further review, I am going to have to change my opening post information... it is not $50-$100 per shot like it used to be. You are correct, it is way more expensive now... like up to $500 per shot, and you need 2 shots. So, with administration costs, $1,300 sounds pretty close.

This is really frustrating. Rabies vaccine for dogs is like $20 per shot.

Don't you just love big Pharma?!

hmmm, probably the same vaccine ,what do you think doc. I know I took alot of horse dewormer in covid season.

 

[TN_Farmer]

hmmm, probably the same vaccine ,what do you think doc. I know I took alot of horse dewormer in covid season.

I know people who have used fish antibiotics (which are often identical to human antibiotics), because they could get them without a prescription and for cheaper. This assumes they knew when to use an antibiotic and knew which one was the correct one... unfortunately, the decision of when to use them and which one to use is often not simple... and they have a potential for side effects... no medicine is completely benign.

With that said, many medications used for animals ARE identical to human medications, but they don't necessarily go through the same safety protocols or verifications before being sold. But it is really frustrating to see meds that I know are the same being sold for 10 to 100 times when it is for human use.

I personally wouldn't take ivermectin (dewormer) for COVID, human or animal, but I also don't recommend vaccines for COVID now anyway. Generally speaking, medications like antibiotics or dewormers are basically just the medicine... there is nothing else in the pills other than the medicine and some binders to hold the pill together.

Vaccines are often different though. They frequently have an adjuvant, and that can be different depending on the species it is being used in (human, canine, equine, etc.). Unfortunately, this is not something I can verify, so I can't recommend it without getting some more information, which is difficult to find.