# 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. Four residents come to the animal bite treatment center (ABTC) on the same morning after contact with stray dogs today. None of them has ever received rabies vaccine, and none of the dogs can be found for observation. According to DOH guidelines, which resident needs rabies immune globulin (RIG) in addition to the vaccine?

> source: MyMerci (mymerci.kr)  
> url: https://mymerci.kr/pages/nclex_q.php?qn_id=627129  
> 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.

Four residents come to the animal bite treatment center (ABTC) on the same morning after contact with stray dogs today. None of them has ever received rabies vaccine, and none of the dogs can be found for observation. According to DOH guidelines, which resident needs rabies immune globulin (RIG) in addition to the vaccine?

## 보기

1. A 9-year-old whose intact forearm was licked by a stray dog
2. A 12-year-old with a non-bleeding scratch on the back of the hand from a stray dog
3. A 40-year-old whose fresh abrasion was licked by a stray dog **✔ 정답**
4. A 30-year-old whose bare calf was nibbled, with no break in skin

**정답: 3**

## 해설

A lick on broken skin or mucous membranes is a category III exposure, because saliva reaches tissue through the break; it needs vaccine plus RIG. Nibbling of uncovered skin and minor scratches without bleeding are category II (vaccine only). The DOH rule that manages category II as category III applies to the head and neck, not the hands. A lick on intact skin is category I and needs no post-exposure prophylaxis.

## 심화 해설

Category of exposure determines whether RIG is added
Rabies post-exposure prophylaxis (PEP) is decided by the WHO exposure category, which classifies contact based on whether saliva reaches broken skin, mucous membranes, or intact skin. Category III exposures require both rabies vaccine and rabies immune globulin (RIG), because the virus may already be present in tissue before vaccine-induced antibodies appear. RIG provides immediate passive immunity at the wound site while the vaccine series builds active immunity over 7–14 days [2][3].

Why a lick on a fresh abrasion is category III
A fresh abrasion means the epidermis is disrupted. When a rabid dog licks that area, saliva carrying rabies virus can directly enter through the break in the skin, which is functionally equivalent to a bite that breaks the skin. The virus travels along peripheral nerves toward the central nervous system, and once clinical signs appear, the infection is nearly 100% fatal [2]. Because the incubation period can be shorter than the time needed for vaccine-induced antibody production, RIG must be infiltrated into and around the wound to neutralize virus immediately [2][3].

Comparing the four residents

| Resident | Exposure description | WHO category | PEP needed |
| --- | --- | --- | --- |
| 9-year-old | Lick on intact forearm skin | Category I | No PEP; wash skin only |
| 12-year-old | Non-bleeding scratch on back of hand | Category II | Vaccine only |
| 40-year-old | Lick on fresh abrasion | Category III | Vaccine plus RIG |
| 30-year-old | Nibbling of bare calf, no skin break | Category II | Vaccine only |

Why the hand scratch and calf nibble do not require RIG
A non-bleeding scratch and nibbling of uncovered skin without a break are both category II exposures. In these cases, the virus has not been introduced through a full-thickness skin defect, so vaccine alone is sufficient to generate protective antibodies before the virus reaches the CNS . Key point! The DOH provision that upgrades category II to category III applies only to head and neck exposures, not to the hand or calf. The hand is not a special site under this rule.

Why intact skin licking needs no PEP
Intact skin is an effective barrier against rabies virus. A lick on unbroken skin is category I and requires only washing of the exposed area; no vaccine or RIG is indicated . Watch out! If the same lick occurred on mucous membranes such as the mouth, eyes, or genital area, it would be category III even without visible bleeding, because mucous membranes are not keratinized and permit viral entry [3].

Clinical reasoning for the correct answer
The 40-year-old with a fresh abrasion licked by a stray dog is the only resident whose exposure crosses into category III, because the broken skin provides a portal for saliva-borne virus. The 9-year-old has intact skin (category I), while the 12-year-old and 30-year-old have category II exposures that require vaccine only. Since none of the dogs can be observed and none of the residents has prior vaccination, the category III resident must receive RIG infiltrated around the abrasion in addition to the first vaccine dose [2][3].References (research sources)

- [2]Administration of rabies immunoglobulin: Improving evidence-based guidance for wound infiltration.Research articleBookstaver PB, Akpunonu P, Nguyen HB, Swan JT, Howington GT (2021) · DOI: 10.1002/phar.2604

- [3]Expert consensus on the clinical application of ormutivimab injection for use against the rabies virus.GuidelineChen R, Li H, Zhu W, Cheng H, Li Y, Li X (2024) · DOI: 10.1080/14740338.2023.2233411

## 임상 시나리오

Rabies PEP Category DecisionDOH ABTC guide for vaccine vs vaccine plus RIG
A lick on broken skin or mucous membrane is Category III and requires vaccine plus RIG because saliva reaches tissue through the break.

Minor scratches without bleeding and nibbling of uncovered skin are Category II and need vaccine only. The DOH rule managing Category II as Category III applies only to head and neck exposures, not the hands.

A lick on intact skin is Category I and requires no post-exposure prophylaxis; wash the area only.

CautionRIG must be infiltrated into and around the wound as much as anatomically possible to provide immediate passive immunity before vaccine-induced antibodies appear in 7 to 14 days.

## 핵심 개념

- **Rabies immune globulin (RIG)** — Passive antibody preparation infiltrated into and around the wound for Category III exposures to neutralize rabies virus immediately.
- **Category III exposure** — Bites or scratches with skin break, mucous membrane exposure, or licks on broken skin; requires vaccine plus RIG.
- **Category II exposure** — Minor scratches or nibbling of uncovered skin without bleeding; requires vaccine only.
- **Category I exposure** — Touching or feeding animals, licks on intact skin; no post-exposure prophylaxis needed.
- **Post-exposure prophylaxis (PEP)** — Rabies prevention after exposure, combining wound washing, vaccine, and RIG depending on exposure category.

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