Questions on post-exposure disposal of rabies

1. What are the vaccination sites for rabies vaccine?
The main vaccination site is intramuscular injection in the deltoid muscle of the upper arm. Infants less than 2 years old can be injected intramuscularly in the anterolateral muscle of the thigh. Buttock injection is prohibited, buttock fat is more, antigen presenting cells are less, and immune response after vaccination is difficult to predict; the ipsilateral deltoid should not be injected in those who have undergone axillary lymph node dissection; intravascular injection is prohibited.

2. If the wound is located in the deltoid muscle of the upper arm and the passive immunization preparation of rabies is injected around the wound, how to choose the vaccination site of rabies vaccine.

In the "Regulations for the Prevention and Disposal of Rabies Exposure (2009 Edition)" (referred to as the "Regulations") and the "Technical Guidelines for Rabies Prevention and Control (2016 Edition)" (referred to as the "Guidelines"), it is indeed stipulated that rabies passive immunization preparations and rabies The vaccine is injected in the same part. (1) When the wound is located in the deltoid muscle of the upper arm, we suggest to standardize the treatment of the wound first, inject sufficient rabies passive immune preparation in and around the wound, and inject rabies vaccine into the deltoid muscle of the upper arm on the other side, using the five-needle method;(2) If the "2-1-1" procedure is used, it is recommended to inject one dose of rabies vaccine into the healthy deltoid muscle and one anterolateral muscle;(3) If there is a wound on both sides of the upper arm deltoid and the rabies passive immune preparation is injected, then one dose of rabies vaccine is inoculated on both sides of the anterolateral thigh.

3. In the process of rabies vaccination, a certain injection was delayed. What should I do?

In general, post-exposure vaccination must be carried out in strict accordance with the immunization program. The first 7 days of the needle on the body to produce antibodies is very critical, so the vaccination time must be strictly guaranteed. The 2009 edition of the "Code" is like this: when a certain injection is delayed for one or several days, the time of subsequent injections will be postponed according to the interval of the original immunization program after the delay. WHO's treatment of delayed vaccination: whether it is pre-exposure immunization or post-exposure immunization, if any injection is delayed, the vaccination can be resumed, and it is not necessary to restart a program.

4. Can rabies vaccines of different manufacturers, different brands and different matrices be replaced and connected with each other?

The active ingredient of the vaccine is inactivated rabies virus outer membrane protein. In theory, qualified modern cell-cultured vaccines can be exchanged, but it is not recommended to replace them without special clinical circumstances. Once adverse reactions occur, they cannot be traced back to the source, which also brings difficulties to the subsequent vaccination. If there are special circumstances, different brands of vaccines need to be vaccinated within one program, which can be used without affecting the final effect. Serious adverse reactions occur in the procedure of rabies vaccination. After evaluation, rabies vaccines with different substrates can be replaced to complete the whole procedure. Or in case of special circumstances, the same brand of vaccine cannot be used, and the whole procedure needs to be completed by replacing and connecting other brands of vaccines. In principle, after the replacement of the vaccine, it is necessary to comply with the procedures for the replacement of the vaccine. In particular, the original "2-1-1" vaccination procedure, the replaced vaccine only registered five-shot procedure, then must be vaccinated according to the five-shot procedure, and the first 2-shot vaccination is regarded as the first dose doubled.

Day 7 replacement vaccine: 0(2 shots)-7-11-18-32

Day 21 replacement vaccine: 0(2 shots)-7-21-28-42

It can also be executed by referring to the following figure:

If you need to renew the needle after returning from abroad, if you are vaccinated according to the five-needle method or the "2-1-1" procedure, you can complete the original procedure or convert according to the above contents. If it is a simple four-needle method, you can complete the procedure according to the five-needle method. If it is intradermal multipoint method, since there is no approved intradermal multipoint immunization procedure in China, it is recommended to restart.

5. How to deal with it after re-exposure?

Effective duration of protection after rabies vaccination:

The preventive effect of rabies is mainly based on the level of middle antibody. The titer of serum neutralizing antibody ≥ 0.5IU/ml is considered as positive conversion. Many years of clinical experience have also confirmed that there is almost no incidence of rabies in patients who have completed the whole immunization. In general, the level of neutralizing antibody can be maintained for at least one year. Theoretically, as long as the neutralizing antibody ≥ 0.5IU/ml after re-exposure is completely effective, no need to inject the vaccine again. However, at present, our testing methods are not perfect and must be strengthened in accordance with the requirements of the 09 edition of the Code. After completing the whole immunization in the past, it will be exposed again, and there is no need to strengthen it within half a year to one year. Strengthen two injections for half a year to one year: one for each of the 0, 3 and 7 days; Three years later, full immunization is required. Half a year, one year, three years, this time node is calculated from the last shot of the last vaccine program (full or enhanced). April 2018 World Health Organization position paper: previously completed full vaccine immunization, re-exposure (1) within 3 months: no need to strengthen;(2)3 months and above: strengthen two injections 0.3 one injection each;(3) Currently not implemented. If within 7 days of the first dose of vaccine, and the wound reaches grade III or meets the special case of grade III treatment, rabies human immunoglobulin should be used, and the vaccine should continue to be vaccinated. For exposure that occurs during pre-exposure immunization, change the pre-exposure procedure to the post-exposure procedure, and make up five shots. If the wound reaches grade III or meets the special case of grade III treatment within 7 days of the first dose of vaccine, rabies immunoglobulin should be used. Of course, we still want to emphasize that for every rabies exposure, standardized wound treatment is especially important.

6. Is there any taboo for rabies vaccination?

With a 100 per cent mortality rate from rabies, there is no contraindication to use after exposure.

(1) Current studies have shown that qualified rabies vaccines will not have adverse effects on pregnant women, nor will they affect the fetus, because:(a) rabies vaccines are inactivated virus vaccines, and inactivated viruses generally cannot pass through the placental barrier. There are no reports of fetal abnormalities caused by inactivated vaccines; (B) The current clinical observations at home and abroad have not found that rabies vaccines cause abortion, premature delivery or teratogenicity.

(2) After the lactating women are vaccinated with rabies vaccine, they can continue to breastfeed without affecting the growth and development of the baby.

(3) The central nervous system and immune function of newborns and infants are not perfect. After being bitten by a mad dog, the risk of rabies is greater than that of an adult. Once exposed to suspicious animals, be sure to treat the wound in a timely and standardized manner, and immediately inoculate rabies vaccine, and use passive immunization agents if necessary.

(4) Children who are undergoing planned immunization can receive rabies vaccine according to the normal immunization procedure. The current study did not find that the use of rabies vaccine and other vaccines (including children's planned immunization vaccine) at the same time will have a mutual impact on the immune effect. Other vaccines can also be given during rabies vaccination according to normal immunization procedures. Try to avoid injecting the same side of the limb. Given the lethal nature of rabies, rabies vaccination should be given priority.

(5) The dose of rabies vaccine is the same for children and adults.

(6) At present, there is no evidence that normal diet will affect the effectiveness of rabies vaccine.

7. Can rabies vaccine and new crown vaccine be vaccinated at the same time?

On the last day of 2020, China's new crown vaccine was approved for marketing and announced free vaccination for all. Recently, many people have been wondering whether the new crown vaccine can be vaccinated with other vaccines. The main question is: if the simultaneous vaccination will affect the immune effect of the vaccine? Will it produce or aggravate adverse reactions? At present, there is no data on the safety and immunogenicity of the new crown vaccine and other vaccines at the same time. Therefore, it is recommended that the new crown vaccine and other vaccines be vaccinated separately and at an interval of not less than 2 weeks before the national guidelines and programs are published.

So can the new crown vaccine and rabies vaccine be vaccinated at the same time? There are two situations:

(1) Just after the new crown vaccine, accidentally bitten by a dog, we recommend as soon as possible to vaccinate rabies vaccine and standardize the treatment of wounds. Because once the incidence of rabies, the mortality rate is close to 100. According to Article 14 of the Code, "there is no contraindication for rabies vaccination after rabies exposure".

The vaccination process can be used in the opposite side of the new crown vaccine to distinguish possible local adverse reactions.

After rabies vaccination, if there is still a second dose of new crown vaccine that has not been vaccinated, it is recommended to vaccinate the second dose of new crown vaccine 14 days after the rabies vaccine has been vaccinated.

(2) Is being vaccinated against rabies, can you still get the new crown vaccine?

When the rabies vaccine is being vaccinated after being bitten by a dog and has not yet been completed, we recommend delaying the vaccination of the new crown vaccine until 14 days after the completion of the rabies vaccine, in order to reduce the possible adverse reactions of the interaction between the new crown vaccine and the rabies vaccine.