Patient selection: exposure to rabies
Protocols involve the use of both rabies immunoglobulin (RIG) and vaccine.
Reasons why a patient may develop rabies despite prophylaxis:
(1) delay in therapy while observing animal
(2) not all wounds injected with RIG (overlooked, insufficient RIG, multiple wounds)
(3) not all wounds irrigated and disinfected
(4) wound(s) sutured prior to RIG injection
(5) reliance on intradermal regimen without using RIG
(6) delay in therapy while transporting the patient to a hospital where RIG would be free
(7) inexperienced clinician
(8) bite in a location with a high density of nerve fibers (hands, face)
(9) injection of immunoglobulin into the gluteal muscle and not into wounds
(10) injection of vaccine into muscle and vaccine not absorbed adequately
(11) vaccine or RIG of low potency
(12) deterioration of RIG or vaccine due to error in transport or storage
(13) atypical rabies virus not neutralized by RIG or vaccine antibodies
(14) exceptionally large viral load
(15) patient immunosuppressed or immunodeficient
One factors not mentioned was counterfeit rabies vaccine or immunoglobulin.
