225.3 🩺 內科專科考前版

225.3.0.1 1⃣ Rabies PEP After Travel Returning

  • Bite history in endemic country (esp Asia/Africa)
  • Even if delayed — give PEP (no time limit; PEP effective even if started weeks after exposure as long as not yet symptomatic)
  • HRIG + 4-dose vaccine schedule
  • Public Health notification + investigation

225.3.0.2 2⃣ Imported Rabies USA

  • 1-3 deaths/yr typically
  • Often imported from Asia/Africa (delayed presentation)
  • 2024 cases reported in returning travelers
  • 提醒 medicine: thorough exposure history

225.3.0.3 3⃣ PEP Time Sensitivity

  • Sooner the better — but no absolute time limit before symptoms
  • Best if started within days of exposure
  • Effective even if started weeks-months later (as long as no symptoms)
  • Don’t deny PEP based on delay alone

225.3.0.4 4⃣ Milwaukee Protocol Controversy

  • Originally hopeful (Jeanna Giese 2004 survivor)
  • ~ 30 attempts, ~ 5 documented survivors
  • 2024: meta-analysis suggests no clear benefit over standard supportive care
  • Some experts now disfavor specific protocol
  • Cases evaluated individually with ID/critical care consultation

225.3.0.5 5⃣ Organ Transplant Rabies

  • 2004 USA: 4 recipients of organs from donor with undiagnosed rabies — all died
  • Donor screening (history) but no universal lab test
  • Rare but well-documented
  • Highlights importance of clinical screening + atypical fever workup in donors

225.3.0.7 7⃣ Pediatric Bites

  • Children more likely:
    • Closer to ground (animal head proximity)
    • Bites on face/scalp (rapid PEP critical)
    • Less likely to report exposure
  • High suspicion + lower threshold for PEP

225.3.0.8 8⃣ 健保 / Taiwan

  • 通報 mandatory
  • Taiwan: 2013 outbreak in ferret-badgers (Melogale moschata) — first wild rabies in 50+ yr
  • Vaccination of farm animals + pets
  • 公費 PEP for exposed
  • 公費 PrEP limited (high-risk groups)
  • 盧醫垫 hint: 動物咬傷 + 䞍明 vaccination → 立即 PEP + ID consult

225.3.0.9 9⃣ WHO 2030 Goal

  • End dog-mediated rabies deaths by 2030
  • Mass dog vaccination
  • Improved PEP access
  • Surveillance + community engagement
  • One Health approach (human + animal + environment)

225.3.0.10 10. Future + Newer Vaccines

  • mRNA rabies vaccine (Moderna mRNA-1944) — in development
  • Simplified schedules
  • Single-dose post-exposure vaccines researched
  • Improved access for LMICs
  • Cost-effectiveness analyses for global rollout