UK schedule is for 3 tetanus containing vaccines in first year of life, followed by extra dose of 6 in 1 at 18 months (new from July 2025). First real booster is pre-school (3 years 4 months). Second booster is at 10 years after 1st course, routine is for Td/IPV at 14.

Incubation period is 4-21 days.

Tetanus prone wounds

• Puncture in soil contaminated environment
• Wounds containing foreign bodies
• Compound fractures
• Wounds/burns with systemic sepsis
• Some animal bites/scratches

Not exclusive. Animal bites/scratches depends on whether there would have been soil in the mouth/claw…

High risk wounds on the other hand include heavy contamination with soil/manure, wounds/burns with extensive devitalised tissue, delayed surgical intervention beyond 6 hours even if not high risk initially.

Management of Wounds

If within 5 years of last vaccine (and complete primary course) – so up to 8 years old, likely good antibody levels so no booster required. If more than 5 years since immunisation, then giving booster vaccine is as effective as giving Tetanus immunoglobulin (TIG) so save it for high risk wounds only.

Incubation period can be more than 1yr!

Nasty viral infection that travels slowly through the nervous system until it reaches the brain. Around 30 people have survived but often with severe disability.

A 15yr old girl from Milwaukee survived with only mild neurological sequelae (reported in 2005) after treatment with induced coma (midazolam, barbiturates, ketamine) and antivirals (amantadine and ribavirin). The aim was to maintain burst suppression until rabies antibodies in the CSF started to increase (day 8). Extubated on day 27. Since then this approach has been tried multiple times, with poorly reported outcomes – has been criticised for lack of evidence of benefit but also for poor evidence for underlying therapeutic principles [Alan Jackson, neurologist at University of Calgary].

Any warm blooded animal is a potential risk, including bats, monkeys and rodents as well as cats, dogs and foxes. Animals behaving abnormally represent a higher risk of infection (but normal appearance and behaviour do not exclude rabies) – unprovoked bites obviously suggest abnormal behaviour, and carry greater risk than provoked bites.

Domestic dogs or cats behaving normally at 15 days after an exposure would not have been infectious at the time of the exposure.

The risk of infection depends on:

• country of exposure – see below
• category of exposure – see below – higher risk with broken skin, including single or multiple transdermal bites, severe lacerations, or where mucous membranes or an existing skin lesion have been contaminated by the animal’s saliva or other body fluid (intact skin is a barrier against infection).
• site (on body) of exposure
• whether the patient is immunosuppressed or has any allergies
• any previous rabies vaccinations or immunoglobulin treatment

For more on bites, see PHS bat bites page and PHS other animal bites page.

Country and category of exposure

Determine “combined country or animal risk” – Rabies risks by country – GOV.UK

Determine category of exposure – grade 1-3, with 1 being no physical contact with saliva, 3 being direct contact. Slightly different rules for bats!

Combine the 2 according to the risk matrix –

Green get nothing, obviously, amber get rapid vaccine schedule (days 0, 3, 7, 21) – modified if fully immunised already or immunosuppressed. Red get rapid vaccine schedule plus Human Rabies Immunoglobulin.

Classically a cold abscess, usually in the neck. Ingested soil?

Overlying skin can become discoloured, and ultimately fistulation may occur. Child is usually systemically well.

Blood tests are normal. Mantoux testing can be positive due to cross reaction with BCG. Fine needle aspiration may be most appropriate.

Drug treatment needs to be prolonged and recurrence is common.

Surgery can be tricky.

=mpox (considered less stigmatising?).

Emerging infection particularly in men who have sex with men. Reached the UK in 2022.

New variant (Clade I) has high mortality, started in Central Africa (Congo, Central African Republic, Burundi, Uganda), now in Kenya, first case now reported in Europe (Sweden, 2024). Grade 3 human pathogen (along with Yersinia pestis, O157, TB, anthrax…).

Viral haemorrhagic fever found in these areas too, of course…

Incubation period is 5-21 days. High risk would be household contact, mucosal (with bodily fluids) or broken skin, inhalation without PPE if cleaning room or changing bedding. Medium risk would be intact skin with bodily fluids or face to face within 1m considered medium risk – do not need to isolate but should be offered post-exposure prophylaxis. See PHS matrix.

Besides blistering rash, can cause fever, sore throat, lymphadenopathy, myalgia.

Swab blistering lesion, or if none then throat. MSS (molecular sampling solution, as used for flu etc) ideally otherwise extra transport precautions required. Mark sample “suspected HCID”, notify lab in advance – needs to arrive for 9am!!!

Cases are asked to self isolate at home.

PPE – as for viral haemorrhagic fever. https://learn.nes.nhs.scot/58193/high-consequence-infectious-diseases-hcid

Post-exposure prophylaxis with MVA-BN vaccine (Imvanex®) offered within 14 days. Pregnant and children under 5 considered at risk.

Smallpox vaccine was considered effective.