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8. Viral diseases
Treatment of the wound
– In all cases
P ro lo nged cleansing o f the wo und o r co ntact site to elim inate th e virus, as so o n as
p o ssible after exp o sure, is o f critical im p o rtance. F o r sk in: use so ap , rinse
co p io usly
with running w ater, rem o ve all fo reign m aterial; ap p licatio n o f polyvidone iodine
1 0 % o r ethanol 7 0 % is an ad d itio nal p recautio n wh ich d o es no t tak e th e p lace o f
wo und wash ing. F o r m uco us m em branes ( ey e, m o uth, etc.): rinse tho ro ugh ly with
w ater o r 0 .9 % so d ium ch lo rid e. L o cal cleansing is ind icated even if th e p atient
p resents late.
– According to condition/type of wound
I n o rd er to avo id ino culating virus d eep er into the tissues, wo und s are either no t
sutured at all (e.g. sup erficial, no n-m utilating o r p uncture wo und s), o r are left o p en
and re- evaluated in 4 8 - 7 2 h o urs, w ith a view to p o ssib le clo sure. H ig h ly
co ntam inated wo und s, o r wo und s that m ay co m p ro m ise functio n, require surgical
m anagem ent (exp lo ratio n, rem o val o f fo reign m aterial, excisio n o f necro tic tissue,
co p io us irrigatio n with 0 .9 % so d ium chlo rid e o r R inger lactate, with lo cal o r general
anaesth esia) . W h en suturing is unavo id able, rabies im m une glo bulin sh o uld be
ad m inistered several h o urs o r d ay s befo re wo und clo sure ( see belo w ) . I nfected
wo und s are no t sutured and reassessed d aily .
Passive and active immunisation
G iven the variable d uratio n o f incubatio n, ad m inistratio n o f vaccine/ im m une glo bulin
is an urgent p rio rity , even fo r p atients exp o sed several m o nths p revio usly .
– RAdambiiensisitmratmionunoef rgalboiebsuliimnm(RunIeGgl)oibsuinlind icated fo r C atego ry I II exp o sures , and C atego r
2
I I and I II exp o sures in im m une-co m p ro m ised p atients. 8
R I G is intend ed to neutraliz e virus in the exp o sure site. I t is given as a single d o se
iomnmuDne0g,lowbuitlhin,th2e0firIsUt d/oksge, oo frrahbigiehslyvpaucrcifinieed. eCquhiniled irmenmuanned galodbuulltisn: derivhautimveanF(raabb’)ie2s,
I4n0filtIraUte/aks gm. uch o f th e d o se as p o ssible in and aro und th e wo und s(s) . I nject any
3
resid ual p ro d uct, using th e I M ro ute, in a site rem o te fro m th at used fo r
vaccinatio n. I n th e event o f m ultip le w o und s, d ilute th e d o se 2 - to 3 - fo ld with
sterile 0 .9 % so d ium chlo rid e to o btain a sufficient quantity to infiltrate all the sites
exp o sed .
I f R I G is no t available o n D 0 , th e first d o se o f rabies vaccine is ad m inistered
alo ne. R I G can still be given as so o n as p o ssible w ith in th e next few d ay s.
H o w ever, R I G is no lo nger reco m m end ed w h en 7 o r m o re d ay s h ave elap sed
since th e first d o se o f vaccine w as given, as vaccine- ind uced im m unity w ill h ave
d evelo p ed by th is tim e.
Unless it can be established that the patient has been correctly vaccinated against rabies before exposure
2
I(ncfoilmtraptleteRpIGre, -exvpeonsuifrethveacwcoinuantdionhawsithhe3adleods.esForf afinCgCeVr )w. ounds, infiltrate very cautiously to avoid causing a
3
compartment syndrome. When it is not possible to infiltrate the wound (mucous membranes), the entire dose is
administered IM.
195
Treatment of the wound
– In all cases
P ro lo nged cleansing o f the wo und o r co ntact site to elim inate th e virus, as so o n as
p o ssible after exp o sure, is o f critical im p o rtance. F o r sk in: use so ap , rinse
co p io usly
with running w ater, rem o ve all fo reign m aterial; ap p licatio n o f polyvidone iodine
1 0 % o r ethanol 7 0 % is an ad d itio nal p recautio n wh ich d o es no t tak e th e p lace o f
wo und wash ing. F o r m uco us m em branes ( ey e, m o uth, etc.): rinse tho ro ugh ly with
w ater o r 0 .9 % so d ium ch lo rid e. L o cal cleansing is ind icated even if th e p atient
p resents late.
– According to condition/type of wound
I n o rd er to avo id ino culating virus d eep er into the tissues, wo und s are either no t
sutured at all (e.g. sup erficial, no n-m utilating o r p uncture wo und s), o r are left o p en
and re- evaluated in 4 8 - 7 2 h o urs, w ith a view to p o ssib le clo sure. H ig h ly
co ntam inated wo und s, o r wo und s that m ay co m p ro m ise functio n, require surgical
m anagem ent (exp lo ratio n, rem o val o f fo reign m aterial, excisio n o f necro tic tissue,
co p io us irrigatio n with 0 .9 % so d ium chlo rid e o r R inger lactate, with lo cal o r general
anaesth esia) . W h en suturing is unavo id able, rabies im m une glo bulin sh o uld be
ad m inistered several h o urs o r d ay s befo re wo und clo sure ( see belo w ) . I nfected
wo und s are no t sutured and reassessed d aily .
Passive and active immunisation
G iven the variable d uratio n o f incubatio n, ad m inistratio n o f vaccine/ im m une glo bulin
is an urgent p rio rity , even fo r p atients exp o sed several m o nths p revio usly .
– RAdambiiensisitmratmionunoef rgalboiebsuliimnm(RunIeGgl)oibsuinlind icated fo r C atego ry I II exp o sures , and C atego r
2
I I and I II exp o sures in im m une-co m p ro m ised p atients. 8
R I G is intend ed to neutraliz e virus in the exp o sure site. I t is given as a single d o se
iomnmuDne0g,lowbuitlhin,th2e0firIsUt d/oksge, oo frrahbigiehslyvpaucrcifinieed. eCquhiniled irmenmuanned galodbuulltisn: derivhautimveanF(raabb’)ie2s,
I4n0filtIraUte/aks gm. uch o f th e d o se as p o ssible in and aro und th e wo und s(s) . I nject any
3
resid ual p ro d uct, using th e I M ro ute, in a site rem o te fro m th at used fo r
vaccinatio n. I n th e event o f m ultip le w o und s, d ilute th e d o se 2 - to 3 - fo ld with
sterile 0 .9 % so d ium chlo rid e to o btain a sufficient quantity to infiltrate all the sites
exp o sed .
I f R I G is no t available o n D 0 , th e first d o se o f rabies vaccine is ad m inistered
alo ne. R I G can still be given as so o n as p o ssible w ith in th e next few d ay s.
H o w ever, R I G is no lo nger reco m m end ed w h en 7 o r m o re d ay s h ave elap sed
since th e first d o se o f vaccine w as given, as vaccine- ind uced im m unity w ill h ave
d evelo p ed by th is tim e.
Unless it can be established that the patient has been correctly vaccinated against rabies before exposure
2
I(ncfoilmtraptleteRpIGre, -exvpeonsuifrethveacwcoinuantdionhawsithhe3adleods.esForf afinCgCeVr )w. ounds, infiltrate very cautiously to avoid causing a
3
compartment syndrome. When it is not possible to infiltrate the wound (mucous membranes), the entire dose is
administered IM.
195
