China News Network, September 9 According to the WeChat public account of the National Disease Control and Prevention Administration, in order to further do a good job in the prevention and treatment of rabies exposure, the National Disease Control Administration and the National Health Commission formulated the "Rabies Exposure Prevention and Disposal Work Specification (16 Edition)". The details are as follows:
Code for the Prevention and Management of Rabies Exposure (2023 Edition)
In order to strengthen and standardize the prevention and treatment of rabies exposure, reduce the incidence of rabies, and protect the health of the people, this specification is formulated in accordance with the Law of the People's Republic of China on the Prevention and Control of Infectious Diseases, the Vaccine Management Law of the People's Republic of China and other relevant provisions, combined with the development progress of rabies vaccine and passive immunization preparations in China.
Chapter I: Principles for Determining and Disposing of Exposure Levels
Article 1 Rabies exposure refers to the bite, scratch, licking mucosa or broken skin of rabies, suspected rabies, or host animals that are unsure whether they have rabies, or open wounds or mucous membranes in direct contact with saliva or tissues that may contain rabies virus.
Article 2 Rabies exposure is classified into three levels according to the mode of exposure and the degree of exposure.
Contact or feeding of animals, or licking intact skin is Class I exposure.
Minor scratches or abrasions on bare skin that are lightly bitten or without significant bleeding are classified as grade II 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 are grade III exposure.
Article 3 After determining the level of exposure, the medical staff of the rabies prevention and treatment clinic shall promptly inform the exposed person of the harm of rabies and the disposal measures to be taken. After obtaining informed consent (see annex for the template of the informed consent form, each province can also formulate it according to local conditions), medical staff take corresponding measures to deal with the wound.
Article 4 Those who are judged to be Class I exposed shall wash the exposed parts without medical treatment.
Article 5 Those who are judged to be Class II exposed shall dispose of their wounds and receive rabies vaccine. If a person with grade II exposure and severe immunocompromise, or a grade II exposure, whose wound is located on the head and face and the health status of the injured animal cannot be determined, it shall be treated as a grade III exposure.
Article 6 Those judged to be grade III exposed shall dispose of their wounds and inject rabies passive immunization preparations and rabies vaccine.
Chapter II: Wound Disposal
Article 7 Wound disposal includes thorough irrigation and standardized debridement disposal. The sooner the wound is treated, the better, and wound management is not advocated at presentation if the wound has scabbed over or healed. If the pain is severe during irrigation or debridement, local anesthesia may be given.
Wound irrigation: Rinse all bites and scratches with soapy water (or other weak alkaline detergents, professional rinsing solutions) and running water at a certain pressure for about 15 minutes, then wash the wound with normal saline, and finally suck up the residual liquid at the wound with sterile skim cotton to avoid leaving soapy water or detergent on 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 treatment: After wound rinsing, rub the wound with diluted iodophor or other skin and mucous membrane disinfectants with virus inactivation effect (such as quaternary ammonium salt disinfectants, etc.). If there is a large number of broken wound tissue, it should be debridement first.
Article 8: Factors such as the type of exposed animal, the size and location of the wound, and the time interval after exposure are to be treated differently.
If the wound is mild, cover the wound with a breathable dressing.
When the wound is large or the facial injury is severe and affects the appearance or function, the wound should be closed as much as possible. Debridement and passive immunotherapy infiltration injections should be completed before wound closure. Wound drainage as needed.
Article 9: According to the contamination or infection of wounds, rational use of antibiotics to reduce infections other than rabies virus.
The prevention and management of tetanus should follow the relevant provisions of the non-neonatal tetanus diagnosis and treatment norms. 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.
Article 10 When disposing of wounds in special parts, it is recommended that qualified rabies prevention and treatment clinics be completed with the assistance of relevant professional physicians.
Eye: When disposing of intraocular wounds, it should be rinsed with sterile normal saline, generally without any disinfectant.
Oral: When rinsing oral wounds, care should be taken to keep the patient's head low to avoid suffocation caused by the irrigation fluid flowing into the throat.
External genital or mucosa: wound disposal and irrigation methods are the same as ordinary wounds, and attention should be paid to the direction of irrigation should be outward to avoid contamination of the deep mucosa.
Chapter III: Vaccination and the Use of Passive Immunization Agents
Article 11 The sooner rabies vaccination after the first exposure, the better. The recommended immunization schedule is limited to rabies vaccine products for which the appropriate procedure has been approved. If the state approves a new rabies vaccine product immunization program, it will be implemented in accordance with the latest requirements.
5-dose immunization schedule: 0 dose of rabies vaccine on 3 (day of injection, the same below), 7, 14, 28 and 1 days, for a total of 5 doses.
"2-1-1" immunization schedule: 0 doses of rabies vaccine (2 dose each in the deltoid muscle of the left and right upper arm) on day 1, 7 dose on the 21th and 1st days, for a total of 4 doses.
Article 12 The lyophilized rabies vaccine diluent shall be used in strict accordance with the requirements of the instructions.
Article 1 Rabies vaccination is given one dose per dose, regardless of weight or age.
Article 2 For the rabies vaccine injection site, recipients aged 2 years and above should be injected intramuscularly into the deltoid muscle of the upper arm, and infants under <> years old should be injected intramuscularly in the anterolateral thigh to avoid buttock injection.
Article 15: When the health status of the injured animal cannot be determined, those who have not been vaccinated against rabies for several months may receive the rabies vaccine in accordance with the immunization procedure.
Article 16 Children who are undergoing vaccination under the national immunization programme may receive rabies vaccine in accordance with normal immunization procedures. Other vaccines may also be given as part of the normal immunization schedule during rabies vaccination, but rabies vaccination is preferred. Those who have been injected with rabies immunoglobulin should postpone vaccination with other live attenuated vaccines as required.
Article 17: The full course of rabies vaccination shall be completed on time, and full and standardized vaccination of rabies vaccine can stimulate the body's immunity against rabies virus. When a dose is delayed, the subsequent dose delivery time will be postponed accordingly according to the original immunization schedule, and there is no need to restart the vaccine immunization schedule.
Article 18: The same brand of rabies vaccine shall be used as far as possible to complete the full course of vaccination. If this is not possible, a different brand of rabies vaccine can be substituted, and the remaining doses will continue according to the immunization schedule of the replacement vaccine. The rabies vaccine should not be kept by the recipient or brought to other outpatient clinics for administration.
Article 100 The case fatality rate of rabies is almost <>%, and there are no contraindications to rabies vaccination after exposure. A small number of people may experience mild adverse reactions after vaccination, which generally do not require special treatment. Very few people may have serious adverse reactions and should be seen in time. When it is found that the recipient has a serious adverse reaction to the rabies vaccine, 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 continued according to the immunization schedule of the replacement vaccine.
Article 20 The dose of passive immunization preparations shall be calculated according to the weight of the recipient, and all of them shall be used at one time. Immunoglobulin for rabies patients is calculated at 20 international units (40 IU/kg) per kilogram of body weight; Anti-rabies serum is calculated at 40 international units (<> IU/kg) per kilogram of body weight; Monoclonal antibodies are used at approved doses. If the calculated dose is not enough to infiltrate the entire wound, the passive immune agent can be appropriately diluted to a sufficient volume with normal saline before injection.
Article 21 Before injecting anti-rabies serum, allergy tests must be carried out in strict accordance with the product instructions.
Article 22: The use of passive immunological preparations.
If the exposed site allows anatomical structure, passive immune agents should be injected into the wound as completely as possible according to the calculated dose, and all wounds regardless of size should be infiltrated and injected.
Special exposed areas such as fingers, toes, tip of nose, auricle and male external genitalia are infiltrated at the maximum locally acceptable dose to avoid compartment syndrome.
For patients with mucosal exposure, if the anatomy allows, passive immunologic agents should be injected locally as much as possible, and a small amount of passive immunological agents should be instilled or applied to the mucosal surface.
If there is a residual passive immune agent after the infiltration injection of all wounds, the remaining passive immune agent is injected into the muscle away from the vaccine injection site.
Article 7 If passive immunization preparations cannot be used on the day of rabies vaccination, passive immunization preparations can still be injected within 7 days (including <> days) of the first dose of rabies vaccine. Passive immunization agents and rabies vaccines must not be injected at the same site; It is forbidden to inject rabies vaccine and passive immunization agents with the same syringe.
Article 24: After full and standardized vaccination of rabies vaccine, antibody testing is generally not required. If antibody levels need to be detected, nationally recognized detection methods such as rapid fluorescence foci inhibition test (RFFIT) and mouse brain neutralization test should be used.
Article 25: Handle suspected abnormal reactions to vaccination in accordance with the norms for immunization work and the relevant requirements of the national monitoring plan for suspected abnormal reactions to vaccination.
Chapter IV: Pre-exposure Prevention and Post-Re-exposure Disposal
Article 26: Pre-exposure prophylaxis.
Scope of personnel: People at high risk of rabies exposure should be immunized before exposure, including laboratory staff engaged in rabies research, staff exposed to rabies patients, veterinarians, staff of animal shelters, researchers exposed to wild animals, hunters, etc. Pre-exposure immunization is also available to persons planning to travel to countries and regions at high risk of rabies epidemic.
Vaccination: The pre-exposure primary immunization schedule is 0 dose of rabies vaccine on days 7, 21, and 28 (or 1). For patients with continuous exposure to rabies risk, after completing the full course of pre-exposure primary immunization, in the absence of animal injury, 1 dose after 1 year, and then 3 dose every 5-1 years.
Deferred immunization: Pre-exposure immunization may be deferred as appropriate for pregnant women and those with acute febrile illness, acute allergic phase, steroids and immunosuppressants.
Article 27: Dispose of after re-exposure.
Wound management: Wound management should be carried out first, promptly, and thoroughly after any exposure.
Vaccination: re-exposure occurs during immunization, and the remaining doses should be completed according to the original immunization schedule; Those who are re-exposed within 3 months after full vaccination generally do not need booster vaccination; Those who are re-exposed 3 months or more after full vaccination should receive 0 dose of rabies vaccine on 3 and 1 days.
Passive immunization preparations: Patients who are fully vaccinated against rabies according to the pre-exposure or post-exposure procedure, except for severely immunocompromised patients, do not need to use passive immune agents after exposure or re-exposure.
Chapter V: Outpatient Management
Article 28: Local health departments and disease control departments at the county level or above shall make reasonable arrangements for rabies prevention and treatment clinics within their jurisdiction. 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.
Article 29: Rabies prevention and disposal clinics shall reasonably set up functional zones such as trauma disposal and vaccination, and shall be equipped with necessary equipment such as wound irrigation and cold chain, as well as rabies vaccines and their passive immunization preparations, emergency rescue drugs, etc., and in principle, shall be equipped with at least two different types of rabies vaccines. Rabies prevention and management clinics requiring tetanus prevention and management should be equipped with tetanus vaccine and its passive immunization agents.
Article 30: Rabies prevention and disposal clinics shall establish and complete corresponding management systems, mainly including systems such as personnel management, vaccine and cold chain management, informed notification, vaccination information collection reports, and monitoring reports on suspected abnormal reactions to vaccination. After vaccination is completed, fill in the vaccination information in the immunization program information system in a timely manner.