Rabies post-exposure

[Gulfsailor]

Hi. I was lightly bitten by a street dog last week while traveling. The area it happened is a rabies zone, so today I decided to better be safe than sorry and get some shots. 

From what I read the first time you should get a shot of the vaccine and a separate immunoglobulin injection. At the government hospital I now only received a single shot, but with 4 more to go on later days. The vaccine is called TRCS Speeda. Was this first injection the immunoglobulin or did the doctor not prescribe it?

Thanks to anyone who may know!

Edited January 29, 2019 by Gulfsailor

[VocalNeal]

What they gave you is the new norm in Thailand. They should also have given you a card with the timetable of the follow up 3.

[Sheryl]

You were not given the immune globulin.  Had you been there would have been 2 injections plus they should also have injected soem of the immunoglobulin around the site of the bite.

 

If you were ever previously immunized (pre-exposure or post exposure) then omitting the immunoglobulin is correct.

 

Otherwise they did not follow correct protocol. Seems to be a common failing here.

 

Ideally both the immune globulin and the 1st dose of vaccine should be given immediately or at least within 24 hours. It is still helpful to get the immunoglobulin up to 7 days from when the first vaccine was given,  beyond that time it is pointless.

[Gulfsailor]

2 minutes ago, Sheryl said:

You were not given the immune globulin.  Had you been there would have been 2 injections plus they should also have injected soem of the immunoglobulin around the site of the bite.

 

If you were ever previously immunized (pre-exposure or post exposure) then omitting the immunoglobulin is correct.

 

Otherwise they did not follow correct protocol. Seems to be a common failing here.

 

Ideally both the immune globulin and the 1st dose of vaccine should be given immediately or at least within 24 hours. It is still helpful to get the immunoglobulin up to 7 days from when the first vaccine was given,  beyond that time it is pointless.

Thank you Sheryl. I was never vaccinated for rabies before. The hospital is rather far, but free (social security). Can I normally get the immunoglobulin injection at a nearby clinic? What would be the expected cost? Contemplating to drive back to the hospital tomorrow, but the wait time is rather long. 

[Sheryl]

Unlikely at a nearby clinic especially given the Thai tendency to give only the vaccine.

 

Also no guarantee the hosp[ital will agree to give it to you, but you can try. Mention that it is the WHO  recommended protocol.

 

Unfortunately the Thai  "mai pen rai"  attitude which many find so charming in general makes its way into spheres where it is not so charming. Medical care being one of them.  Electrical work, plumbing, house construction and repair, auto repair  being some of the others..... ????

[from the home of CC]

So if not a Thai standard for rabies treatment (to paraphrase, commonly failing to follow correct protocol) do they have a higher incidence of failed treatment? If I ever get bit, should I be insisting that I receive the immunoglobulin with the vaccine? I mean I don't give a damn how they react -  hell it's the potential of rabies we're talking about here - but I know in the west when you start to tell a doc his job it usually doesn't end well. And since I don't have any experience with the medical system here, how should this be played? These damn dogs, I hope I never have the need for any of this.

[Gulfsailor]

6 minutes ago, Sheryl said:

Unlikely at a nearby clinic especially given the Thai tendency to give only the vaccine.

 

Also no guarantee the hosp[ital will agree to give it to you, but you can try. Mention that it is the WHO  recommended protocol.

 

Unfortunately the Thai  "mai pen rai"  attitude which many find so charming in general makes its way into spheres where it is not so charming. Medical care being one of them.  Electrical work, plumbing, house construction and repair, auto repair  being some of the others..... ????

Okay. I'll see if I can get someone on the phone first at the hospital. It was only a single bite (two small holes) just above the knee, so assuming in the unlikely event the dog was rabid, any incubation time would exceed the 2 weeks between exposure a week ago and the vaccine to start working next week. 

Thanks again!

[KNJ]

Rabies needs treatment immediately within 6 days PEP is required.

Wait for 2 weeks and if the dog was carrying rabies it is very simple......You're DEAD

[Sheryl]

18 hours ago, from the home of CC said:

So if not a Thai standard for rabies treatment (to paraphrase, commonly failing to follow correct protocol) do they have a higher incidence of failed treatment? If I ever get bit, should I be insisting that I receive the immunoglobulin with the vaccine? I mean I don't give a damn how they react -  hell it's the potential of rabies we're talking about here - but I know in the west when you start to tell a doc his job it usually doesn't end well. And since I don't have any experience with the medical system here, how should this be played? These damn dogs, I hope I never have the need for any of this.

Occasional prophylactic  treatment failures in Thailand have been reported in the literature.

 

Incidentally the Thai Red Cross rabies prophylaxis protocol is based on WHO recommendations and calls for administration of immunoglobulin if the bite clearly broke through  the skin.

 

As to what you can do - you can print out  the Thai Red cross guidelines (see below) and indicate the initial flow chart and also item 7 (politely of course). BUT they may tell you they do not have any immune globulin, and this may well be true, or they may say that they have very little of it and must save it for the most severe , actively bleeding bites only. It is extremely expensive and I suspect this is why hospitals try to avoid giving it.

 

Better yet you can avoid the whole dilemma by getting pre-exposure vaccination.  This is by far the best approach. It completely removes the need for the use of immune globulin and also reduces the number of vaccinations needed to just 2 shots in the event you are bitten which, in Thailand, is hardly an unlikely prospect.

 

Rabies protool TRC.pdf

 

 

[mindovermatter]

They should have given you the immunoglobulin (ERIG or HRIG) with the 1st shot.

[Gulfsailor]

Quick update. Had a Thai person call the public hospital to check why no ERIG or HRIG was prescribed. Pharmacist told that the doctor makes that assessment and is the only one who can order it. You can't even buy it if you wanted to. 

Anyway i called around to some private hospitals and found one nearby who stocked ERIG and was the cheapest. Had the injections done this morning. The doctor fully agreed that based on WHO protocols I should have been given it at the public hospital. Anyway 10,000 Baht lighter but a piece of mind. 

 

Anyone know when I know for 100% that I'll be okay, and can stop worrying? E.g. Symptom free for another 5 or 6 days?

Edited January 30, 2019 by Gulfsailor

[Sheryl]

Symptoms of rabies can take a very long time to develop. But please do nto work yourself up about this, just follow through with the rest of the vaccine schedule. The odds of getting it are extremely small.

[Gulfsailor]

1 hour ago, Sheryl said:

Symptoms of rabies can take a very long time to develop. But please do nto work yourself up about this, just follow through with the rest of the vaccine schedule. The odds of getting it are extremely small.

Thank you very much for all the advice Sheryl.