Fighting Potential Rabies Infections with PEP Therapy

Dogs were previously the leading cause of rabies deaths in the United States, but now bats are considered the major threat. Rabies causes approximately 59,000 deaths worldwide annually, including about 2 deaths in the United States.¹

The best way to avoid rabies is to stay away from wildlife, but pharmacists can educate patients about rabies risks, especially with bats, and discuss the importance of postexposure prophylaxis (PEP) to fight infection.

The CDC report analyzed rabies trends in the United States during 1938-2018, using national rabies surveillance data.¹ Additionally, data from the Healthcare Cost and Utilization Project were used to estimate the number of PEP visits per 100,000 persons during 2017-2018. The data showed that from 1960-2018, 125 human rabies cases were reported in the United States, with 28% attributed to dog bites during international travel. Among the 89 infections acquired in the United States, 70% were attributed to bats. In 2018, about 55,000 individuals received PEP after contact with a potentially rabid animal.¹

Rabies virus is transmitted through saliva, usually from the bite or scratch of an infected animal. It is considered 1 of the most deadly diseases since it is fatal in over 99% of cases.¹ Fortunately, it is 100% preventable with PEP that includes a dose of human rabies immune globulin (HRIG) and rabies vaccine given on the day of the rabies exposure, and then a dose of vaccine given on days 3, 7, and 14.^1,2 The combination of HRIG and vaccine is recommended for both bite and non-bite exposures, and they are considered safe and effective.²

Possible adverse effects from HRIG and the vaccine may include mild local reactions such as pain, redness, swelling, or itching at the injection site. Additional adverse effects may include headache, nausea, abdominal pain, muscle aches, dizziness, and low-grade fever.²

Pharmacists should educate patients that there is no treatment for rabies once signs and symptoms begin. Rabies is fatal in humans within 1-2 weeks after symptoms begin, so it is extremely important to receive PEP quickly.¹

Wound treatment is also important with animal scratches and bites to prevent infection.² Immediate gentle irrigation with water or a dilute water povidone-iodine solution can decrease the risk of bacterial infection. Individuals should receive a tetanus vaccine if it has been more than 10 years since their last immunization.² Antibiotics may be needed depending on the severity of the wound.

The CDC report indicated that bats with rabies have been found in every state except Hawaii.¹ Patients may consult with pharmacists in the community setting after coming in contact with a bat, even possibly in their home. Pharmacists should educate patients that contact with a bat includes bites and scratches, which are usually difficult to identify since they can be smaller than the top of a pencil eraser.

Bats that are present in a room with a child or while someone is sleeping should be considered as an exposure and PEP is recommended.¹ The bat or wildlife involved in the exposure may not be available for testing, so it is always better to err on the side of caution and receive PEP. The CDC Travelers’ Health also provides guidance on rabies risk for specific travel destinations.

References

• Pieracci EG, Pearson CM, Wallace RM, et al. Vital Signs: Trends in Human Rabies Deaths and Exposures-United States, 1938-2018. MMWR Morb Mortal Wkly Rep 2019;68:524-528. DOI: http://dx.doi.org/10.15585/mmwr.mm6823e1.
• Rabies postexposure prophylaxis (PEP). CDC website. https://www.cdc.gov/rabies/medical_care/index.html. Last reviewed June 11, 2019. Accessed June 13, 2019.