Recently, the National Health Commission and the National Disease Control Administration issued the "Specifications for the Prevention and Treatment of Rabies Exposure (2023 Edition)" (hereinafter referred to as the "Specification"), which provides the latest basis for further improving the prevention and treatment of rabies exposure.
This is the latest and most effective document on rabies exposure management in mainland China to date. The last version of the Specification, published in 2009. During this period, the Chinese Center for Disease Control and Prevention issued the Technical Guidelines for the Prevention and Control of Rabies (2016 Edition) (hereinafter referred to as the "Guidelines") in 2016. At present, most dog injury treatment clinics in the country follow this practice.
Today we will take a look, rabies vaccine, how to fight? Where is the latest "specification", "new"?
1
In what cases, should I be vaccinated against rabies?
Rabies exposure is classified into three levels according to the mode of exposure and the degree of exposure:
Class I exposure Contact with or feeding animals, or intact skin licked as;
Grade II exposure Minor bites on exposed skin, or minor scratches or abrasions without obvious bleeding;
Grade III exposure Single or multiple penetrating skin bites or scratches, or licking of broken skin, or open wounds, mucous membranes contaminated with saliva or tissue, or direct contact with bats.
Compared to the 2009 version of the specification, the following has been updated:
(1) The definition of level III exposure adds "direct contact with bats"
(2) Class I exposure disposal increases "cleaning exposed parts"
2
How to deal with the wound after exposure?
Significant!
The new version of the specification further refines the wound closure requirements, and medical personnel should distinguish wounds based on factors such as the type of exposed animal, the size and location of the wound, and the time interval after exposure.
Compared with the 2009 version: the wound debridement and disinfection treatment steps remove soap, water, iodophor concentration, standardize the terms "professional rinse" and "professional rinse equipment", replace "75% alcohol" with "other skin and mucous membrane disinfectants with virus inactivation effect (such as seasonal salt disinfectants, etc.)", and "anti-rabies serum or rabies immunoglobulin" is collectively referred to as "passive immune preparations".
It is very, very important to treat wounds after exposure! Let's get the key points together:
Simply put: rinse first, then disinfect (the sooner the better!). ）：
❀ Rinse:
1. Use soapy water (or other weak alkaline detergent, professional rinse solution) and a certain pressure of running water, alternately and thoroughly rinse all bites and scratches for about 15 minutes;
2. Then wash the wound with normal saline;
3. Finally, use sterile skim cotton to suck up the residual liquid at the wound to avoid leaving soapy water or detergent at the wound;
When deep wounds are flushed, the inside of the wound can be perfused and rinsed with a syringe or special irrigation equipment to achieve comprehensive and thorough.
❀ Disinfection: After rinsing, rub the wound with diluted iodophor or other skin and mucous membrane disinfectants with virus inactivation effect (such as quaternary ammonium salt disinfectant, etc.); (If there is a large number of broken wound tissue, it should be debridement first)
❀ Prevention of other infections: Appropriate use of antibiotics to reduce infections other than rabies virus, depending on wound contamination or infection.
Particular attention should be paid to the comprehensive judgment of whether to use tetanus vaccine and its passive immune agents based on the nature of the wound and previous immunization history.
3
After the first exposure
What are the immunization schedules for the rabies vaccine?
Optimize vaccination schedules after first exposure. On the basis of the original 5-dose post-exposure immunization program, the "2-1-1" immunization program that has been approved for use and has corresponding vaccine products is added:
The parts that have not changed compared to before are:
If a needle is postponed, each subsequent dose should be postponed accordingly to ensure the time interval. There is no need to restart vaccination.
Rabies vaccines do not conflict with other vaccines. Before, during, and after vaccination, other vaccines can be given normally (except for the new crown vaccine).
The first mention or change is:
Those who have been injected with rabies immunoglobulin need to postpone vaccination with other live attenuated vaccines.
The injection site is clarified - for those aged 2 years and older, intramuscular injection is made in the deltoid muscle of the upper arm; Infants under 2 years of age, intramuscular injection on the anterolateral thigh, avoiding buttock injection.
Note: During the vaccination process, the same brand of rabies vaccine should be used to complete the full course of vaccination. If this is not possible, a different brand of rabies vaccine can be substituted.
After rabies vaccination, a small number of people may experience minor adverse reactions that generally do not require special treatment. If the vaccinated person is found to have serious adverse reactions to the rabies vaccine being used, after re-assessing the exposure risk and signing the informed consent form, the different types of rabies vaccine can be changed, and the remaining doses can be completed according to the immunization schedule of the replacement vaccine.
4
After being exposed again, how to get the vaccine?
【Major Update】
Wound disposal: Any exposure must be carried out first, timely and thoroughly.
Vaccinations:
1. If the re-injury occurs during immunization, the remaining doses should continue to be completed in accordance with the original immunization procedure;
2. If you are injured again within 3 months after full vaccination, you generally do not need to be vaccinated;
3. If you are injured again 3 months or more after full vaccination, you should receive 1 dose of rabies vaccine on the 0th and 3rd days, a total of 2 doses.
Patients who are fully vaccinated against rabies according to the pre-exposure or post-exposure procedure, except for those who are severely immunocompromised, do not need to use passive immunoassays after exposure or reexposure.
5
Rabies passive immunization agents
【There is an update】
Optimize the use of passive immunologics.
When severely injured (grade III, or severely immunocompromised to grade II), in addition to the rabies vaccine, "rabies passive immunization preparations" are also given.
Passive immunologic use increases "monoclonal antibody use at approved doses"
The use of anti-rabies monoclonal antibodies is added to the application of passive immune preparations, and the requirements for the use of passive immune agents are refined for different parts such as general exposure sites, special exposure sites, and mucosal exposure sites.
Passive immunoassays that increase "special exposed areas such as fingers, toes, tip of the nose, pinna, and male external genitalia are injected at the maximum locally acceptable dose to avoid compartment syndrome." ”
Delete "When the exposed part is located on the head and face, upper limbs, and torso above the chest, the remaining passive immunological agents can be injected into the ipsilateral back muscle group (such as trapezius muscle) at the exposed site, and rabies vaccination can be given on the opposite side." When the exposed site is located in the lower extremities and the trunk below the chest, the remaining passive immunological agent can be injected into the ipsilateral thigh muscle group at the exposed site. ”
6
On the prevention of tetanus
【Addition】
Severe bites and scratches from high-risk animals also consider the risk of tetanus infection.
The latest Code clearly states:
Operate in accordance with the relevant provisions of the "non-newborn" tetanus diagnosis and treatment standard. You can see this article for details.
If rabies vaccine and tetanus vaccine are required at the same time, they should be injected into the deltoid muscle of the left upper arm and right upper arm, respectively; If injected in the ipsilateral deltoid muscle, at least 2.5 cm apart.
7
How to set it up and manage it properly
Rabies Prevention and Management Clinic?
The new version of the Code optimizes the outpatient management of rabies prevention and treatment.
In principle, rabies prevention and management clinics should be equipped with at least two different types of rabies vaccines, so that in special circumstances, vaccine replacement can be carried out in time. Rabies prevention and management clinics that require tetanus prophylaxis should be equipped with tetanus vaccine and its passive immunization agents.
The first is to reasonably set up functional zones such as trauma disposal and vaccination. It has necessary wound rinsing, cold chain and other equipment, as well as rabies vaccine and its passive immunization preparations, emergency rescue drugs, etc.
The second is to establish and improve the corresponding management system. It mainly includes personnel management, vaccine and cold chain management, informed notification, vaccination information collection report, suspected vaccination abnormal reaction monitoring report and other systems.
The third is to strengthen personnel training. Medical personnel engaged in rabies exposure prevention and treatment must undergo professional training organized by local health departments and disease control departments at or above the county level and pass the assessment before they can take up their posts.
8
Other updates
Optimize the range of people at high risk of rabies exposure. Increase animal shelter staff, researchers who come into contact with wildlife, hunters, etc. as those at high risk of exposure.
Antibody testing: After the full and standardized rabies vaccine, antibody testing is generally not required;
Other changes are normative terminology changes, such as "planned immunization" changed to "immunization programme", "health administrative department" changed to "health department", etc. In addition, some of the content description language has been adjusted to make the whole smoother.
Resources:
1. Specification for the prevention and disposal of rabies exposure (2023 edition). National Health Commission, National Disease Control Administration
2. Specification for the prevention and disposal of rabies exposure (2009 edition). National Health and Family Planning Commission
3. Technical Guidelines for Rabies Prevention and Control (2016 Edition).Chinese Center for Disease Control and Prevention
4. Expert consensus on rabies exposure prevention and management[J]. Chinese Journal of Preventive Medicine,2019,07:668-679.
5.WHO Position Paper-Rabies Vaccines. April 2018
Reference source: vaccine circle, National Disease Control Administration's "Rabies Exposure Prevention and Disposal Work Specification (2023 Edition)" interpretation Q&A, Jiangsu CDC