Home >News > ProMED翻訳情報(439回) ~カリフォルニア州で発生したコウモリからの人の狂犬病曝露~

ProMED翻訳情報(439回) ~カリフォルニア州で発生したコウモリからの人の狂犬病曝露~



Date: Sat 26 Sep 2015   Source: Banning-Beaumont Patch [edited]

A San Jacinto High School student who handled a rabid bat is receiving medical treatment and appears to be out of danger, health officials said [on Fri 25 Sep 2015]. “The student is not sick,” Riverside County Department of Public Health infectious diseases specialist Barbara Cole told City News Service. “We started the rabies post-exposure treatment very quickly. It’s designed to protect the person and keep them from becoming ill.”

保健当局は、[2015年9月25日の金曜日に] 狂犬病のコウモリに触れたサン・ジャッキント高校の生徒が治療を受け、窮地は脱したようだと述べた。“その生徒は病気になってはいない。”と、リバーサイド郡公衆衛生局の感染症の専門家であるBarbara Coleは、City News Serviceに語った。“我々は、迅速に狂犬病の暴露後治療に取りかかりました。その治療は、その人を発症から守り、健康のままにしておくためのものです。”

The youth found the bat [Wed 23 Sep 2015] afternoon in the high school gymnasium and suffered a ‘puncture wound’ while handling the creature, while other students watched close by, according to the San Jacinto Unified School District. The student reported the incident and sought treatment soon after, according to Cole. “We received the bat on [Wed
23 Sep 2015] and had it tested for rabies yesterday [25 Sep 2015],”
she said. “The results were positive.” 


According to Cole, rabies can be transferred without a bite or scratch, emphasizing that “transmission can occur through secretions. “The rabies exposure protocol requires the victim to receive 4 vaccinations over a 2-week span.[byline: Alexander Nguyen]


[Guidelines from WHO for post exposure prophylaxis


Guide for post-exposure prophylaxis

The recommendations given here are intended as a general guide. It is recognized that, in certain situations, modifications of the procedures laid down may be warranted. Such situations include exposure of infants or mentally disabled persons and other circumstances where a reliable history cannot be obtained, particularly in areas where rabies is enzootic, even though the animal is considered to be healthy at the time of exposure. Such cases may be treated as category II or III.


Post-exposure treatment, which consists of local treatment of the wound, followed by vaccine therapy (with or without rabies immunoglobulin) should be initiated immediately with contacts of categories II and III. Treatment may be discontinued if the animal involved (dog or cat) remains healthy throughout an observation period of 10 days; or if the animal is killed humanely and found to be negative for rabies by laboratory examination. Any biting animal suspected of being rabid should be immediately killed humanely and tissues examined using appropriate laboratory technique(s). Modification of the recommended procedures would be indicated in a rabies-free area where animal bites are encountered. In areas where canine or wildlife rabies is epizootic, adequate laboratory and field experience, indicating that there is no infection in the species involved, may justify local health authorities in not recommending specific anti-rabies treatment.


The indication for post-exposure vaccination with or without rabies immune globulin depends on the type of contact with the rabid animal.


Types of contact are:
– category I: touching or feeding animals, licks on the skin
– category II: nibbling of uncovered skin, minor scratches or abrasions without bleeding, licks on broken skin
– category III: single or multiple transdermal bites or scratches, contamination of mucous membrane with saliva from licks; exposure to bat bites or scratches



For category I no treatment is required, whereas for category II immediate vaccination and for category III immediate vaccination and administration of rabies immune globulin are recommended in addition to immediate washing and flushing of all bite wounds and scratches.
Depending on vaccine type, the post-exposure schedule prescribes intramuscular doses of 1 ml or 0.5 ml given as 4 to 5 doses over 4 weeks. For rabies-exposed patients who have previously undergone complete pre-exposure vaccination or post-exposure treatment with cell-derived rabies vaccines, 2 intramuscular doses of a cell-derived vaccine separated by 3 days are sufficient. Rabies immune globulin treatment is not necessary in such cases. The same rules apply to persons vaccinated against rabies who have demonstrated neutralizing antibody titres of at least 0.5 IU/ml.

カテゴリーIに対しての治療は必要ないが、カテゴリーIIに対しては早急なワクチン接種が、またカテゴリーIIIに対しては、全ての噛み傷や引っかき傷の洗浄と流水洗浄に加えて、早急なワクチン接種および狂犬病免疫グロブリンの投与が必要である。ワクチンのタイプにもよるが、暴露後治療のスケジュールは4週間以上にわたり、0.5mlから1ml量を4ないし5回筋内接種で処方されることとなる。狂犬病に暴露された患者が、以前に暴露前または暴露後の予防接種を、培養細胞由来ワクチンを用いて完全なスケジュールで受けている場合は、3日の間隔をあけ、培養細胞由来ワクチンの筋内接種を2回受ければ十分である。この場合は狂犬病免疫グロブリンの投与は必要ない。抗狂犬病ワクチンを受け、中和抗体価が少なくとも0.5 IU/ml を示す人にも同じ原則が適用できる。

In order to reduce the cost of post-exposure treatment, intradermal multi-site regimens using a fraction of the intramuscular volume per intradermal inoculation site have been developed. Purified Vero cell vaccine has been given intradermally to more than 70,000 recipients in Thailand, where it has been in routine use for several years. Intradermal rabies vaccination is also recommended by the ministries of health of Sri Lanka (since 1995) and the Philippines (since 1997). In each of these countries the introduction of this route for post-exposure treatment has permitted the discontinuation of the local production of vaccines prepared on brain tissue. Only the cell-derived vaccines that meet the WHO requirements regarding safety, potency, and efficacy for this application may be considered for intradermal use. Although rabies vaccines are usually administered under qualified medical supervision, field experience from routine infant immunization programmes with other intradermally injected vaccines highlights the potential difficulties in assuring proper delivery. This emphasizes the need for appropriate staff training to ensure correct storage, reconstitution, and injection. Provided that a correct sterile technique is used, the remaining doses may be kept in the vial at 2-8 deg C [35.6-46.4 deg F] and used for another patient within 6 hours after reconstitution.


Tissue culture or purified duck-embryo vaccines of potency at least 2.5 IU per single intramuscular immunizing dose should be applied according to the following schedules.


Intramuscular schedules
One dose of the vaccine should be administered on days 0, 3, 7, 14, and 30. All intramuscular injections must be given into the deltoid region or, in small children, into the anterolateral area of the thigh muscle. Vaccine should never be administered in the gluteal region.


Abbreviated multisite schedule
In the abbreviated multisite schedule, the 2-1-1 regimen, one dose is given in the right arm and one dose in the left arm at day 0, and one dose applied in the deltoid muscle on days 7 and 21. The 2-1-1 schedule induces an early antibody response and may be particularly effective when post-exposure treatment does not include administration of rabies immunoglobulin.


Intradermal schedule
WHO recommended the following intradermal regimen and vaccines for use by the intradermal route: 2-site intradermal method (2-2-2-0-1-1) for use with PVRV [purified Vero cell rabies vaccine] (Verorab TM, Imovax TM, Rabies vero TM, TRC Verorab TM) and PCECV [purified chick embryo cell vaccine] (Rabipur TM)

 WHOは皮内接種に用いるワクチンとその処方を次のように推奨している。すなわち、2箇所に皮内接種する手法として、PVRV(精製Vero培養細胞由来ワクチン[purified Vero cell rabies vaccine:VerorabTM, ImovaxTM, Rabies veroTM, TRC VerorabTM]およびPCECV (精製鶏胚培養細胞由来ワクチン[purified chick embryo cell vaccine:RabipurTM])を2-2-2-0-1-1の順で接種する。【訳者注:TM(トレードマーク)がついている単語は、いずれもワクチンの商標名と思われる】

For 2-site intradermal method (2-2-2-0-1-1), the volume per intradermal site is: 0.1 ml for PVRV (Verorab TM, Imovax TM, Rabies vero TM, TRC Verorab TM) 0.1 ml for PCECV (Rabipur TM)

 2箇所の皮内接種法(2-2-2-0-1-1)では、上記のいずれのワクチンの場合でも、1箇所当たりの投与量は0.1 mlである。

Brain-tissue vaccines
The use of brain-tissue vaccines should be discontinued. WHO does not recommend any schedule using brain-tissue vaccine. National authorities should recommend a schedule of immunization that has been shown to induce an adequate level of protection when brain tissue vaccines are available in that country.


Combined immunoglobulin-vaccine
Combined immunoglobulin-vaccine treatment was considered in the 8th report of the WHO Expert Committee as the best specific systemic treatment available at that time for the post-exposure prophylaxis of rabies in humans, although experience indicated that vaccine alone was sufficient for minor exposures (category II). Immunoglobulin should be given in a single dose of 20 IU per kg of body weight for human anti-rabies immunoglobulin, and 40 IU per kg of body weight for heterologous (equine) immunoglobulin; the 1st dose of vaccine should be inoculated at the same time as the immunoglobulin, but in a different part of the body. Sensitivity to heterologous immunoglobulin must be determined before it is administered. The physician should be prepared to deal with anaphylactic shock reactions. Administration of rabies immunoglobulin (RIG) should be infiltrated into the depth of the wound and around the wound as much as anatomically feasible. Any remainder should be injected at an intramuscular site distant from that of vaccine inoculation, such as into the anterior thigh.

 免疫グロブリンとワクチンを併用した治療は、WHOの専門家会議が出した8番目のレポートにおいて、人が狂犬病暴露後に予防処置を受ける際に採りえる最良の、本質的な効果を発揮する治療法であるとされているが、経験則からはわずかな暴露(カテゴリーII)ではワクチン単独の投与でも十分であると示されている。抗狂犬病免疫グロブリンがヒト由来のものである場合は、1回投与量は体重1 kgあたり20 IU、異種(ウマ)由来の場合は40 IUであるべきである。最初のワクチン投与の際、同時に免疫グロブリンも投与されるべきだが、これらは体の別々の場所に接種されなければならない。異種動物由来の免疫グロブリンに対する感受性は、それを投与する前に決定しておかなければならない。医師は、アナフィラキシーショックの対処にも備えておかなければならない。狂犬病免疫グロブリン(rabies immunoglobulin:RIG)は、できる限り傷口の奥深く、および周囲に浸透するように投与されるべきである。(ワクチンの)残部は、大腿筋前部のような、ワクチン接種された箇所とは離れた筋内に接種されるべきである。

Treatment should be started as early as possible after exposure, but in no case should it be denied to exposed persons whatever time interval has elapsed.


Local treatment of wounds involving possible exposure to rabies are recommended in all exposures. – Mod.TG]