# Situation: After a typhoon flooded a low-lying barangay, the nurse at the Rural Health Unit (RHU), which also serves as an animal bite treatment center (ABTC), sees clients with animal bites and flood-related illness. A 25-year-old man was bitten on the leg by a stray dog today; the bite broke the skin and bled. His vaccination card shows that he completed a full course of rabies post-exposure prophylaxis 2 years ago. After wound washing, what should he receive according to DOH guidelines?

> source: MyMerci (mymerci.kr)  
> url: https://mymerci.kr/pages/nclex_q.php?qn_id=627126  
> language: ko  
> subject: Nursing Practice I — Community Health Nursing

## 문제

Situation: After a typhoon flooded a low-lying barangay, the nurse at the Rural Health Unit (RHU), which also serves as an animal bite treatment center (ABTC), sees clients with animal bites and flood-related illness.

A 25-year-old man was bitten on the leg by a stray dog today; the bite broke the skin and bled. His vaccination card shows that he completed a full course of rabies post-exposure prophylaxis 2 years ago. After wound washing, what should he receive according to DOH guidelines?

## 보기

1. Vaccine on days 0, 3, and 7, plus rabies immune globulin
2. Rabies immune globulin only, since he is already immune
3. Vaccine on days 0 and 3, with no rabies immune globulin **✔ 정답**
4. No vaccine, since his previous course still protects him

**정답: 3**

## 해설

A transdermal, bleeding bite is a category III exposure, which in an unvaccinated person needs vaccine plus rabies immune globulin (RIG). A person who previously completed a full vaccine series, however, needs only booster doses on days 0 and 3 and no RIG, because the immune memory responds quickly.

## 심화 해설

Why the answer is booster doses only

The bite is on the leg, broke the skin, and bled. That makes it a category III exposure. In a person with no prior rabies immunization, category III exposure requires both rabies vaccine and rabies immune globulin (RIG). However, this client completed a full post-exposure prophylaxis series 2 years ago, so his immune system already has memory cells against rabies virus.

A previously immunized person who is re-exposed needs only two booster doses on days 0 and 3, and does not need RIG. The reason is immunologic: memory B cells and T cells from the prior series mount a rapid anamnestic response. The booster doses quickly push neutralizing antibody titers back to protective levels, so passively administered RIG is unnecessary and would add cost and injection-site burden without benefit.

Watch out! The day 0 and day 3 booster schedule applies only when the previous vaccination status is documented and the prior series was complete. If the card were missing or the series incomplete, the client would be managed as unvaccinated.

Key point! RIG is indicated for category III exposure in unvaccinated persons because active immunization takes time to generate antibody. In previously vaccinated persons, the anamnestic response is fast enough that RIG is not needed.

| Exposure category | Unvaccinated client | Previously fully vaccinated client |
| --- | --- | --- |
| Category III (transdermal bite, bleeding wound, mucous membrane exposure) | Vaccine on days 0, 3, 7, and 28 plus RIG infiltrated around the wound | Vaccine booster on days 0 and 3 only; no RIG |
| Category II (minor scratch or abrasion without bleeding) | Vaccine on days 0, 3, 7, and 28; no RIG | Vaccine booster on days 0 and 3 only; no RIG |

The systematic review by Langedijk et al. supports this approach by showing that previously immunized individuals reliably produce a rapid antibody recall response after booster inoculation [1]. Even when the primary series was given years earlier, booster doses restore protective antibody levels quickly. This is the basis for the shortened two-dose schedule in re-exposed persons.

The Thai Red Cross intradermal regimen study also illustrates the principle that the immune memory from a completed series provides durable protection . Although that study focused on the primary post-exposure schedule, it reinforces that a completed vaccine series establishes reliable immunologic memory, which is the same foundation for using only two boosters without RIG in re-exposed clients.

Therefore, the correct intervention after thorough wound washing is rabies vaccine on days 0 and 3, with no rabies immune globulin.References (research sources)

- [1]Rabies Antibody Response After Booster Immunization: A Systematic Review and Meta-analysis.Meta-analysis/systematic reviewLangedijk AC, De Pijper CA, Spijker R, Holman R, Grobusch MP, Stijnis C (2018) · DOI: 10.1093/cid/ciy420

## 임상 시나리오

Rabies PEP for Previously Vaccinated ClientsCategory III re-exposure management
A bleeding transdermal bite is a category III exposure. In a client with documented complete prior rabies vaccination, give only 2 booster doses on days 0 and 3, with no RIG.

The anamnestic response from memory B and T cells rapidly restores protective antibody levels, making passive RIG unnecessary and cost-ineffective.

CautionThis booster-only schedule applies only when the previous series was complete and documented. If the vaccination card is missing or the series was incomplete, manage the client as unvaccinated with full vaccine course plus RIG for category III exposure.

## 핵심 개념

- **Category III exposure** — Transdermal bite or scratch with bleeding, or mucous membrane contamination with saliva. Highest-risk rabies exposure category.
- **Rabies immune globulin (RIG)** — Passive immunization given only to unvaccinated individuals with category III exposure to provide immediate antibodies while active vaccine response develops.
- **Anamnestic response** — Rapid immune memory response in previously vaccinated individuals, allowing booster doses alone to quickly restore protective antibody titers.
- **Post-exposure prophylaxis (PEP)** — Preventive treatment after rabies exposure, consisting of wound washing, vaccination, and possibly RIG depending on exposure category and vaccination history.
- **Booster doses** — Additional vaccine doses given to previously immunized individuals on days 0 and 3 after re-exposure to rapidly elevate antibody levels.

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