Page 118 - Journal of Special Operations Medicine - Fall 2015

the vaccines in use in the United States. The two vaccine
brands used in the United States are interchangeable.

HRIG should never be administered in the same syringe
or at the same anatomic site as the first vaccine dose.
However, subsequent doses of the vaccine can be admin-
istered in the same anatomic location where the HRIG
dose was given. If treatment is started long after the
initial wound was incurred, HRIG should be infiltrated
into the area of the scar or previous exposure. The vac-
cine should be given in the deltoid in adults or in the
thigh in children. The gluteal area should never be used
for administration of the rabies vaccine.
Source: From the World Health Organization.
http://www.who-rabies-bulletin.org/travel/recommendations.aspx. To eliminate the need for HRIG, which is costly and
often scarce in the developing world, a preexposure se-
prophylaxis series of immunizations (see below). For ries of rabies vaccinations can be given. The three-shot
severe facial wounds, widely spaced single sutures are preexposure prophylaxis series is given on days 0, 7,
advised several hours after administration of HRIG if it and 21 or 28. Antibodies have been shown to persist for
is indicated, followed by plastic surgery later if possible. 2 years after a properly completed preexposure series.
The full dose should be infiltrated around the wound Exposures after proper completion of this series should
site, if feasible. If the wounds are large, the World be handled in exactly the same manner, except HRIG
Health Organization recommends diluting the HRIG is not administered and only two doses of the vaccine
with normal saline up to threefold to infiltrate the entire are given on days 0 and 3. Again, the need for tetanus
area of the wound. Any remaining dose should be given prophylaxis must be assessed.
intramuscularly at a nongluteal site that is distal from
where the rabies vaccine is to be administrated. The rec- Once those exposed have shown symptoms of rabies
ommended dose of HRIG should not be exceeded, as infection, the disease is almost universally fatal. The
excess can partially suppress active production of an- Milwaukee Protocol, an experimental treatment regi-
tibody that is created in response to the rabies vaccine. men involving intensive care and a drug-induced coma
HRIG is a temporary protection against the rabies virus while the native immune response matures and without
while the body creates antibodies following vaccination. using the rabies vaccine has had limited success and is
beyond the scope of this brief review. For more informa-
Two important points from the CDC about the use of tion on The Milwaukee Protocol please see the follow-
HRIG include the following: ing webpage: http://www.mcw.edu/FileLibrary/Groups/
PedsInfectiousDiseases/Rabies/Milwaukee_protocol_
• If there is a delay in obtaining HRIG, it can be ad- v4_20913.pdf.
ministered through the and including the seventh day
after the first of the postexposure prophylaxis vac- Importance in a Deployed Setting
cination series has been given. Beyond the seventh
day, HRIG is not recommended, since an antibody It is estimated that, annually, between 50,000 and
response to the vaccine is presumed to have occurred. 60,000 people worldwide die of rabies, although this is
• The combination of HRIG and vaccine is recommended likely an underestimate due to the lack of diagnostics in
for both bite and nonbite exposures, regardless of the the developing world. Virtually all deaths globally are
interval between exposure and initiation of treatment caused by rabid dogs, and most deaths occur in Africa
and Asia. Sadly, on 31 August 2011, the US military
Following administration of HRIG, four doses of the had its first fatality from rabies acquired in a deployed
rabies vaccine should be given on days 0, 3, 7, and 14 setting in over 30 years in a soldier who cared for stray
following exposure. A fifth dose should be given on day dog “mascots” on his deployment to Afghanistan. The
28 for patients who are immunocompromised or who potential fatal risk of nonvaccinated or improperly vac-
are on malaria prophylaxis (Department of Defense rec- cinated mascots or pets kept on deployments overseas
ommendation). This fifth dose has been found no longer cannot and should not be underestimated. Servicemem-
necessary in those patients who have a normal immune bers admitting to exposures, even years after the event
system and are not on malaria prophylaxis, although occurred, should be thoroughly evaluated for treatment
the previously recommended five doses for all treatment because of the often lengthy time (years) from exposure
plans remain on the package inserts of the two brands of to symptoms.

106 Journal of Special Operations Medicine Volume 15, Edition 3/Fall 2015