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Will POST-EXPOSURE RABIES IMMUNOGLOBULIN interfere with natural ANTIBODIES?

Resolved Question:

I have a question about post-exposure rabies treatment.

I'm in Indonesia right now and 2 days ago (June 19) I was in contact with a sick dog for a few hours. I was holding it, it vomited on me a couple of times. It also had symptoms of rabies including difficulty walking properly, and a foaming mouth after it drank water or milk.

I had some wounds on my legs (mostly scabbed over) and the vomit may easily have touched those areas. The vomit also touched my hands and I may have touched my eyes / nose / mouth before washing my hands.

So I'm concerned about being infected with rabies.

Yesterday (June 20) I got 2 shots of Verorab (one in each shoulder), and will get another shot of Verorab on day 7 and another shot on day 21. I did NOT receive any rabies immunoglobulin, because it's not part of the standard treatment here in Indonesia (probably because it is expensive, I think)

In Canada and the US, rabies immunoglobulin is always given whenever there's a rabies risk, and it is given at the same time as the first shot of Verorab.

My questions are:
1 - If I receive an injection of the immunoglobulin tomorrow or the next day (i.e. NOT the same day as the first Verorab shots), will that be a problem? Might it interfere with the antibodies that my body will produce naturally, or cause my body to produce less?
2 - Instead of getting an injection of immunoglobulin asap, would it be best if I waited until my next shot of Verorab?
3 - Based on the information I've provided, how important is it for me to try to get a shot of the rabies immunoglobulin?
4 - In which jurisdiction are you (the doctor answering these questions) certified?

Category: Allergy and Immunologist

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Category: HIV- AIDS Specialist
 20 Doctors Online

Hello,
Thanks for your query at DoctorSpring.com
I understand your concern
I have gone through the information you provided carefully. As you have mentioned you are being treated with the 2-1-1 regime of intramuscular vaccine (two doses on the first day and second and third dose on 7 th and 21 th day respectively)
In different parts of world different regime are used for prophylaxis against rabies. I am a board certified physician in India and we here follow WHO recommended guidelines for the same.
There are three categories of rabies exposures depending on the severity of the exposure. You fall in second category (because you mentioned that there is an exposure of the dog vomits on your scabbed-over wound). According to the WHO guidelines immunoglobulin is not required for category 2 patients and which is only required for Category 3 patients.
Coming to your questions,
1. Though not required you can take RIG upto 7th day from the first vaccine dose. It will not interfere with the natural antibody production.
2. No. you should take it before 7 days as your second shot is scheduled on the seventh day.
3. RIG is not required
4. Board certified physician in India.
Hope it answers your questions.
Feel free to discuss further
Regards


Patient replied :




Hi, thanks for your response. For question 2 from my previous email, can you explain why I shouldn't take RIG on or after day 7? You said I shouldn't take it on day 7 because that's when my second vaccine shot is happening... but why is it a problem to take both on the same day? If I were to take RIG on day 1 with my first vaccine shots that would apparently he fine... so why not on the 7th day also?
Also, the WHO website says that with the 2-1-1 schedule that I'm on, the 2 shots on day 1 stimulate my body to create antibodies faster than 7 days, but it doesn't say how long it would take... do you know how many days it will take?
Also, someone told me that production of antibodies increases gradually and won't be produced in my body in full quantities until after the full vaccine schedule is finished on day 21. If that's true. and if the rabies in me finishes incubating before the 21 days, could I still get sick? After what day can I be confident that my body will be producing enough antibodies to protect against incubated rabies?
Thanks.


Hello,
I am sorry I indeed sounded confusing in last post. I meant you should not take it before 7 days, and on the sceduled day you should take both the vaccine as well as the RIG.
It normally takes a week or two for the body to produce antibodies, but it completely varies from one individual to the other.
Now, the moment the vaccine is given, body starts producing antibodies, and even if the rabies virus is incubating, it can fight that off. The optimum level is reached within 2-3 weeks, but the effect starts right away.
I hope that answers your question,
Regards.


Patient replied :

Now I'm really confused! :(
In your first response you wote: "you should take it before 7 days as your second shot is scheduled on the seventh day."
I your second response you wrote: "I meant you should not take it before 7 days, and on the sceduled day you should take both the vaccine as well as the RIG"
Those are EXACTLY OPPOSITE statements! In one you said that I SHOULD take it before 7 days, and in the other you said that I SHOULD NOT take it before 7 days.
Which is true?
Also, I would like to know WHY the correct statement is correct. So if I should take it BEFORE the 7th day, why should I take it then? If I should take it ON the 7th day, why should I take it then? I would like to understand exactly why.
I just booked a flight to Singapore for later today so I can get a shot of the immunoglobulin there. I also booked a flight back to Indonesia (where they have no immunoglobulin) for June 24 (before the 7 days are up). These were expensive flights and I booked them because of what you told me in your first message.
I NEED TO KNOW WHAT I SHOULD DO, AND I NEED TO KNOW FAST. AND I ALSO NEED TO KNOW **WHY** THE IMMUNOGLOBULIN SHOULD BE TAKEN AT THE TIME THAT YOU'RE TELLING ME TO TAKE IT.
It would be much better if you can call me to discuss this instead of sending another confusing email. My number in Indonesia is 0812 3721 4545 (country code is 62)
Thanks,
Justin


Hello,
Kindly relax. It is not a big problem. I can understand all your apprehensions but I will clear all your doubts.
You had already taken one vaccine and the second one as you know is scheduled for the 7th day.
Now, according to the category of the exposure, you do not need RIG, however if you still want it, you can get it on the 7th day along with the second dose of active vaccine, or you can take it any time before the 7 days. It is not going too cause any harm or cause any failure of the prophylaxis.
Please read this email carefully as we don't have any provisions of calling. I am ready to answer your queries. Please go ahead and get your RIG for Singapore, it will not cause any failure or harm.
Hope this was helpful,
Regards.


Patient replied :

Great, thanks very much. I understand and appreciate your help :) That's all the information I need, so I'll close this consultation now. Thanks again :)
Justin


Thank You Justin!
I appreciate you writing back to me.
Best Regards.


Dr. Jaydeep Tripathy
Category: HIV- AIDS Specialist
Experience: 
MBBS from Sri Ramachandra University in December 2011
M.Med (Family Medicine) - TNMGR University, Chennai
MBA-MPH in Public Health in March 2016, SRM University
Finished AFIH in March 2016, SRM University
MRCP ( UK ), Internal Medicine, Royal College of Physicians, June 2016
Fellowship in Diabetology from Martin Luther University in January 2017

Currently Resident Physician, in MD Radiodiagnosis - Kamakshi Memorial Hospital, Chennai
Dr. Jaydeep Tripathy and 4 other Medical Specialists are ready to help you

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