# Tetanus & Rabies Post-Exposure Prophylaxis

## Overview

This module describes how to give post-exposure prophylaxis for tetanus and rabies. Both tetanus and rabies are notifiable diseases. Contact the Department of Environmental Health of your local municipality to report suspected cases.

Tetanus prophylaxis is given as primary immunisation for children, booster vaccines every 10 years, and post-exposure as a vaccine (passive) and an immunoglobulin (active). Rabies vaccines are only given to people at high risk of exposure such as veterinarians and animal handlers, or post-exposure with or without immunoglobulin.

## Indications

### Tetanus

Tetanus exposure

Tetanus-prone wounds tend to be:

1. Older than 6 hours

2. More than 1 cm deep

3. Star-shaped or avulsed (torn skin) wounds

4. Containing dead tissue

5. Contaminated with dirt, manure or rust

6. Gunshot wounds

7. Puncture or crush wounds

8. Wounds from burns or frostbite

All other wounds are considered non-tetanus-prone.

Tetanus prophylaxis schedule

Patient who was fully vaccinated as a child:

Tetanus-prone wound: administer an intramuscular tetanus vaccine in the deltoid if their last tetanus vaccine or booster was given more than

5 years ago

5 years ago

Many patients will not know when their last tetanus vaccine was. Try to prompt them by asking them if they had received sutures. If unsure, administer the vaccine.

. If giving the vaccine, also administer tetanus immunoglobulin into the opposite deltoid, only if immunodeficient/IV drug user. Other wound: give a tetanus vaccine if their last tetanus vaccine or booster was given more than 10 years ago.

Patient who was not fully vaccinated as a child:

Tetanus-prone wound: give a tetanus vaccine, and a dose of tetanus immunoglobulin. Other wound: give a tetanus vaccine, but no tetanus immunoglobulin. Refer these patients to their local clinic to complete their immunisation.

### Rabies

Rabies exposure

Rabies is spread by

animal saliva

animal saliva

Rabies can be spread by any mammal, including domestic animals such as cows and sheep.

, and is rare in South Africa, but 100% fatal.

- Risk category I: Touching or feeding an animal suspected of rabies
- Risk category II: Animal nibbling skin or causing minor scratches without bleeding
- Risk category III: Animal bites, scratches drawing blood, contamination of mucus membranes, or licking broken skin

Rabies prophylaxis

schedule

schedule

If access to rabies vaccine and immunoglobulin is not immediately available, refer urgently.

- Risk category I: None required.
- Risk category II: Give one dose of the rabies vaccine into the deltoid on days 0, 3, 7, 14, and 28.
- Risk category III: Give one dose of the rabies vaccine into the deltoid on days 0, 3, 7, 14, and 28.

Give 20 IU/kg rabies immunoglobulin into and around the wound, with first dose as soon as possible. Inject the rest intramuscularly into the deltoid,

never the buttock

never the buttock

Increased risk of vaccination failure due to depositing vaccine in subcutaneous space.

, unless the wound is in the buttock.

## Procedure

Refer to Intramuscular Injection for technique, troubleshooting, and risks.

Additionally, in suspected rabies cases:

1. Wash the wound thoroughly with soap under running water for 5-10 minutes.

2. Apply disinfectant if available.

3. Do not suture bite wounds unless on the head/face.

4. Clean thoroughly, dress (avoid compressive dressings) and review after 48 hours for secondary closure at that time.

5. If possible, the suspect animal should be observed, and if still well after 10 days, rabies prophylaxis may be stopped.

6. Antibiotics are only indicated for category III exposure for hand wounds.

## References

1. Newell KA. Wound Closure.In: Essential Clinical Procedures, Third Edition. Philadelphia: Elsevier; 2013. p. 250-272.

2. Centers for Disease Control and Prevention. Tetanus: For Clinicians. Available at: https://www.cdc.gov/tetanus/clinicians.html

3. WHO. WHO Guide for Rabies Pre and Post Exposure Prophylaxis in Humans. 2014.