Assessment pathway

Post-exposure prophylaxis rabies pathway

1. Where there is concern that an animal has rabies, this will be alerted by a vet to the Animal and Plant Health Authority (APHA). They will then inform the NHS Ayrshire and Arran Health Protection Team (HPT).
2. The HPT will assess if there have been any possible human exposures to the animal.
3. If exposed individuals are identified, they will be referred to the Infection Specialist for assessment for the need for Rabies PEP. If the individual has a wound, they will be referred to the Emergency department (ED) for wound treatment and further assessment (see below).
4. If Rabies post-exposure prophylaxis (PEP) is recommended, the patient will be referred by the HPT to the Immunisation Coordination Team in hours, or the Combined Assessment Unit (CAU) out of hours (OOH), for any necessary vaccine or treatment.

Post-exposure prophylaxis rabies pathway

1. A patient may attend General Practice or the Emergency Department (ED) following a potential exposure to rabies. Immediate wound care should be given by irrigating the wound with copious amounts of soapy water for 15 minutes. If a patient presents at community pharmacy, they should be redirected to the ED. If patients are being redirected from Pharmacy to the ED, the Pharmacy should telephone the ED via NHSAA switchboard to advise them to expect the patient.
2. A history should be taken by the clinician assessing the patient that includes:
   1. Animal characteristics:
      1. the species
      2. whether the bite/injury was provoked
      3. a description of the health of the animal
      4. the animal’s vaccination status
      5. the origin of the animal (UK or elsewhere)
   2. Exposure characteristics:
      1. date and time of exposure
      2. the country where the exposure occurred
      3. the nature of the exposure:
         1. any breach in skin
         2. single/multiple wounds
         3. contamination of animal saliva to human mucous membranes
         4. bites to head, neck, face, hands or genitals.
   3. Patient characteristics:
      1. is the patient fully vaccinated against rabies? How many doses have they received and when was this given?
      2. is the patient immunosuppressed?

Consideration should also be given to other relevant risks from bites, including the need for antibiotics and tetanus cover.

3. After obtaining these details, the clinician should contact the On-call Infection Specialist via NHS AA switchboard.
   1. In practice, this will be: Dr Sam Allen as the first point of contact; if Dr Allen is not available then the clinician should contact ID on call for NHS Lanarkshire (Monklands Hospital).
   2. In circumstances where the individual is a child (<16 years old), this should be discussed with both Paediatrics on-call and the On-Call Infection Specialist.
4. The On-call Infectious Specialist will conduct a risk assessment using the information provided. They should give advice to the treating clinician on any post-exposure prophylaxis required.
5. The first dose of post-exposure vaccine and Human Rabies Immunoglobulin (HRIG) should be given to the patient as soon as possible.
   1. For individuals who present to the ED, treatment will usually be given in the ED.
   2. In circumstances where the risk assessment is undertaken in Primary Care and post-exposure treatment is recommended:
      1. If there are no wounds requiring management, the patient should be referred by the GP to the Combined Assessment Unit (CAU) for rabies vaccination +/- HRIG.
      2. If there are wounds requiring management, the patient should be referred to the ED for assessment and treatment, vaccination +/- HRIG.
   3. In circumstances where HRIG is not available for administration, the patient should have a first vaccination and return to ED to have HRIG if this can be obtained within 24 hours. This should be coordinated by ED staff.
   4. If HRIG takes longer than 24h to be obtained, patients should be referred to Rapid Assessment and Care (RAC) (Mon-Fri, 9am-5pm) or the CAU (OOH) to receive HRIG when this is available. The patient should be provided with an appointment by ED when to attend.
      1. Where a patient is <16 years old, they should be referred to Ward 1A/C at University Hospital Crosshouse (UHC) to have HRIG if this is not available within 24 hours. Ward 1A/C staff should contact the patient and guardian to arrange an appropriate time to attend when HRIG is available.
6. The On-Call Infection Specialist has responsibility for referring the patient for subsequent vaccinations. They should contact the Immunisation Coordination Team and Health Protection Team to advise of the potential rabies exposure, detail the required vaccination course and advise of any additional relevant information.

   Team	Email address
   Immunisation Coordination Team	immunisationcoordinationteam@aapct.scot.nhs.uk
   Health Protection Team	HPTeam@aapct.scot.nhs.uk

7. Following assessment, the patient should be provided with an information leaflet; this also indicates their post-exposure prophylaxis vaccination schedule (Appendix 3). The information leaflet also contains the HPT contact details, who will act as a point of contact for any concerns or questions.
8. Following referral from the On-Call Infection Specialist, the Immunisation Coordination Team will contact the patient to provide them with an appointment. They will vaccinate the patient based on the recommendations from the Infection Specialist. They must inform the HPT if the patient does not attend any appointments, who will then contact the patient.
   1. Patient Specific Directions (PSD) for post-exposure treatment vaccinations will be provided by the HPT.
9. Information detailing the vaccinations a patient receives via the Immunisation Coordination Team will be sent to the GP by admin support for the Immunisation Coordination Team using standard correspondence.

In circumstances where subsequent PEP vaccinations are required out of hours (weekends and bank holidays), this can be administered by the Immunisation Coordination team if the referral is received and acknowledged during normal working hours (Mon-Fri, 9-5, excluding bank holidays). Referrals should be via email (immunisationcoordinationteam@aapct.scot.nhs.uk) or by telephoning 01292 513351 (option 2).

In circumstances where any subsequent PEP vaccinations are required out of hours (weekends and bank holidays) and arrangements have not yet been made with the Immunisation Coordination team, the treating clinician should refer the patient to the CAU to make arrangements for them to receive the vaccine during the out of hours period. If the patient is <16 years old, they should be referred to Ward 1A/C. The Infection Specialist should contact the Immunisation Coordination Team and Health Protection Team to inform them of the outcome of the risk assessment, to advise about the recommended vaccination course and advise that a vaccine is scheduled to be administered in the CAU or Ward 1A/C during the out of hours period.

Please follow immediate first aid and follow Health and Safety Guidance.

Pathway for individuals already commenced on post-exposure prophylaxis at the time of first assessment in NHSAA

1. An individual who has commenced PEP whilst overseas may present to GP, NHS111 or Emergency Department to continue and complete the course.
2. Within hours, details should be gathered by the clinician and the individual referred to the Immunisation Coordination Team by email [immunisationcoordinationteam@aapct.scot.nhs.uk] and telephone 01292 513351 (option 2).
3. The Immunisation Coordination Team will discuss the PEP vaccine course and risk assessment with the On Call Infection Specialist and then proceed with the post-exposure prophylaxis vaccination course based on the advice provided.
4. The Immunisation Coordination Team will inform the HPT where vaccination is being provided.
   1. Patient specific directions (PSDs) for PEP vaccination will be provided by the Health Protection Team.
5. Information detailing the vaccinations administered will be sent to the GP using standard templates from the Immunisation Coordination Team.

If an individual presents out of hours to either the Emergency Department or AUCS, this should be discussed with the On Call Infection Specialist. If the patient is seen in ED, any vaccines recommended immediately should be administered. If the patient is seen via AUCS and following assessment, immediate vaccination is required, the patient should be referred to CAU to have this, unless they are <16 years old when they should be referred to Paediatrics (Ward 1A/C at UHC). The Infection Specialist should contact the Immunisation Coordination Team and Health Protection Team to inform them of the outcome of the risk assessment and to advise about the recommended vaccination course.

In circumstances where subsequent PEP vaccinations are required out of hours (weekends and bank holidays), this can be administered by the Immunisation Coordination team if the referral is received and acknowledged during normal working hours (Mon-Fri, 9-5, excluding bank holidays). Referrals should be via email (immunisationcoordinationteam@aapct.scot.nhs.uk) or by telephoning 01292 513351 (option 2).

In circumstances where any subsequent PEP vaccinations are required out of hours (weekends and bank holidays) and arrangements have not yet been made with the Immunisation Coordination team, the treating clinician should refer the patient to the CAU to make arrangements for them to receive the vaccine during the out of hours period. If the patient is <16 years old, they should be referred to Ward 1A/C. The Infection Specialist should contact the Immunisation Coordination Team and Health Protection Team to inform them of the outcome of the risk assessment, to advise about the recommended vaccination course and advise that a vaccine is scheduled to be administered in the CAU or Ward 1A/C during the out of hours period.

Where an individual is a child <16 years old, Paediatrics should also be informed. Further vaccination out of hours should be arranged via Ward 1A/C.