title: Using serology to assist with complicated post-exposure prophylaxis for rabies and Australian bat lyssavirus.
abstract: BACKGROUND
  Australia uses a protocol combining human rabies immunoglobulin (HRIG) and rabies vaccine for post-exposure prophylaxis (PEP) of rabies and Australian bat lyssavirus (ABLV), with the aim of achieving an antibody titre of ≥0.5 IU/ml, as per World Health Organization (WHO) guidelines, as soon as possible.
  
  
  RESULTS
  We present the course of PEP administration and serological testing for four men with complex requirements. Following dog bites in Thailand, two men (62 years old, 25 years old) received no HRIG and had delayed vaccine courses: 23 days between dose two and three, and 18 days between dose one and two, respectively. Both seroconverted following dose four. Another 62-year-old male, who was HIV-positive (normal CD4 count), also suffered a dog bite and had delayed care receiving i.m. rabies vaccine on days six and nine in Thailand. Back in Australia, he received three single and one double dose i.m. vaccines followed by another double dose of vaccine, delivered intradermally and subcutaneously, before seroconverting. A 23-year-old male with a history of allergies received simultaneous HRIG and vaccine following potential ABLV exposure, and developed rash, facial oedema and throat tingling, which was treated with a parenteral antihistamine and tapering dose of steroids. Serology showed he seroconverted following dose four.
  
  
  CONCLUSIONS
  These cases show that PEP can be complicated by exposures in tourist settings where reliable prophylaxis may not be available, where treatment is delayed or deviates from World Health Organization recommendations. Due to the potentially short incubation time of rabies/ABLV, timely prophylaxis after a potential exposure is needed to ensure a prompt and adequate immune response, particularly in patients who are immune-suppressed or who have not received HRIG. Serology should be used to confirm an adequate response to PEP when treatment is delayed or where a concurrent immunosuppressing medical condition or therapy exists.
authors.affiliation: Public Health Registrar, Queensland Health, Brisbane, Queensland, Australia.
authors.forename: Niall
authors.initials: N
authors.lastname: Conroy
authors.forename: Susan
authors.initials: S
authors.lastname: Vlack
authors.forename: Julian M
authors.initials: JM
authors.lastname: Williams
authors.forename: John J
authors.initials: JJ
authors.lastname: Patten
authors.forename: Robert L
authors.initials: RL
authors.lastname: Horvath
authors.forename: Stephen B
authors.initials: SB
authors.lastname: Lambert
mesh_terms: D000328:Adult; D000818:Animals; D000914:Antibodies, Viral / Q000008:administration & dosage*; D001315:Australia; D001733:Bites and Stings / Q000150:complications; D004285:Dogs; D006801:Humans; D018114:Lyssavirus / Q000276:immunology*; D008297:Male; D008875:Middle Aged; D056990:Post-Exposure Prophylaxis / Q000379:methods*; D011818:Rabies / Q000276:immunology* / Q000517:prevention & control*; D011819:Rabies Vaccines / Q000008:administration & dosage*; D013785:Thailand; D055815:Young Adult
chemical_list: D000914:Antibodies, Viral; D011819:Rabies Vaccines