What is the post-exposure prophylaxis (PEP) regimen for a monkey scratch that may expose an individual to rabies?

Post-Exposure Prophylaxis for Monkey Scratch Rabies Exposure

For a monkey scratch that may expose an individual to rabies, immediate wound cleansing followed by administration of both rabies immune globulin (HRIG) and a 5-dose rabies vaccine series is recommended as post-exposure prophylaxis. 1

Initial Assessment and Wound Management

• Immediately and thoroughly clean the wound with soap and water or a povidone-iodine solution to reduce the likelihood of rabies virus transmission 1
• Avoid suturing the wound when possible to prevent deeper inoculation of the virus 1
• Consider tetanus prophylaxis and antibiotic treatment based on the wound characteristics 1

Post-Exposure Prophylaxis (PEP) Protocol

For previously unvaccinated individuals:

1. Human Rabies Immune Globulin (HRIG):

   • Administer 20 IU/kg body weight as soon as possible after exposure 1
   • Infiltrate the full dose around and into the wound area if anatomically feasible 1
   • Inject any remaining volume intramuscularly at a site distant from vaccine administration 1
   • HRIG can be administered up to day 7 after the first vaccine dose if not given initially 1

2. Rabies Vaccine:

   • Administer a 5-dose regimen of either human diploid cell vaccine (HDCV) or purified chick embryo cell vaccine (PCECV) 1
   • Give 1 mL doses intramuscularly in the deltoid area (or anterolateral thigh in children) 1
   • Follow the schedule: days 0,3,7,14, and 28 1

For previously vaccinated individuals:

• Administer only the vaccine (2 doses on days 0 and 3) without HRIG 1

Special Considerations for Monkey Exposures

• Monkey scratches should be treated with the same level of concern as bites due to potential rabies transmission 1
• In addition to rabies, consider the risk of herpes B virus infection, which is endemic in macaque monkeys and potentially fatal to humans 2
• Consult with local or state health departments for guidance on management of exposures to non-domestic animals 1

Timing and Urgency

• PEP should be initiated as soon as possible after exposure 1
• While PEP is a medical urgency rather than an emergency, do not delay treatment 1
• PEP is effective even when started days or weeks after exposure, provided the patient is not showing signs of rabies 1

Monitoring and Follow-up

• Monitor the wound site for signs of infection 1
• Complete the full course of vaccination unless laboratory testing confirms the animal is not rabid 1
• If the exposing animal can be captured, it should be euthanized and tested for rabies when appropriate 1

Pitfalls to Avoid

• Never administer HRIG and the first vaccine dose at the same anatomical site 1
• Do not exceed the recommended HRIG dose as it may suppress active antibody production 1
• Do not delay PEP while waiting for animal testing results if the risk of rabies is considered significant 1
• Do not withhold PEP due to a delay between exposure and medical evaluation, as rabies can have long incubation periods 1