Rabies Guide 2010.pdf - the South African Veterinary Council

packaging in secure rigid secondary, and where possible
tertiary, containers filled with absorbent material
(paper or sawdust) and direct communication with
the National Institute for Communicable Diseases is
essential before the specimen is dispatched by courier.
All rabies diagnostics for suspected human cases are
carried out by the Special Pathogens Unit of the
National Institute for Communicable Diseases of the
National Health Laboratory Service.
Managing clinical rabies
The almost universally futile nature of clinical rabies
management makes it imperative that relatives of the
victim be honestly counselled as to the extremely
poor prognosis. Every effort must be made to ensure
a patient’s comfort with adequate sedation, while
high-quality supportive care is provided. It should
be emphasised that although lifesupport measures
may prolong the clinical course of disease, they are
unlikely to result in survival, except in extremely rare
occasions. 22,147, 183 The so-called Milwaukee protocol
which was followed in the treatment of a rabies
survivor patient is regarded as experimental.
Concerted efforts must be made to ensure that the
patient is as comfortable as possible and symptoms
alleviated. This includes adequate sedation and
pain relief with opioids and anxiolytic treatment,
maintenance of nutrition and correction of fluidelectrolyte
and acid-base balances, and mechanical
respiration. 99 As multiple systems bear the
brunt of terminal disease, careful monitoring is
necessary. Antiviral drugs, particularly interferon
and interferoninducers, have been employed with
little success. 148 Corticosteroid use has not proven
effective and antirabies vaccine has no proven benefit
in treatment. Intensive nursing care may limit
complications, such as bedsores and pneumonia.
Infection control precautions are important for health
workers responsible for managing these patients and
should include both standard precautions (hand
washing, gloves, mask, eye protection or a face
shield, gown and plastic apron) and respiratory
precautions (isolation in a private room preferably
with an extraction fan, wearing respiratory protection
and limiting the movement of the patient). 145,149 If a
staff member is exposed to potentially contaminated
secretions, e.g. patient saliva contamination of a
mucous membrane, then they should immediately
receive post-exposure prophylaxis, by flushing with
copious clean water and vaccination according to
their vaccination status.
The rabies virus is not particularly resistant and is
inactivated by heat, sunlight and desiccation. Objects
soiled by infective secretions must be disinfected by
boiling or autoclaving. 74
Disposable items used in treating patients should be
incinerated. Surgical instruments should be autoclaved,
while other items in the patient’s environment
should be cleaned with an appropriate disinfectant,
containing chlorine (10 000 ppm available chlorine)
or glutaraldehyde. The corpse of a rabies victim is
thought to pose little risk but it is prudent to avoid
embalming the body. 74
In a well documented case report of survival, that of
a six-year old boy bitten by a rabid bat in the United
States of America, it appears that careful monitoring
and rapid supportive therapy to prevent hypoxia,
intracranial hypertension, cardiac arrythmias, seizures
and nosocomial infection, may have contributed to his
recovery. 142 The only human case of surviving rabies
without any history of receiving rabies prophylaxis
was reported in a teenage girl from the United
States who was exposed to a rabid bat. The patient
developed rabies and a decision was made to institute
experimental treatment which included an induced
coma and administration of several drugs. 183 The
patient recovered with some neurological sequelae
but continual improvement of her condition has
been noted.
Serum antibody can only
be detected after onset of
clinical disease, or seven
to 10 days after vaccine
administration
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