RABIESRABIES

CONTENTSCONTENTS::

What is rabies?What is rabies? ((DEFINITION & ETIOLOGY)DEFINITION & ETIOLOGY)

•Is an acute infectious disease of warm-blooded animals Is an acute infectious disease of warm-blooded animals and humans characterized by an involvement of the and humans characterized by an involvement of the

nervous system resulting in deathnervous system resulting in death . .•It is caused by the RABIES VIRUS, a rhabdovirus of the It is caused by the RABIES VIRUS, a rhabdovirus of the

genus lyssavirusgenus lyssavirus..Rabies is a serious disease. Each year, it kills more than 50,000 people and millions of animals around the world. Rabies is a big problem in Asia, Africa, and Central and South America. In the United States, rabies has been reported in every state except Hawaii. Any mammal can get rabies. Raccoons, skunks, foxes, bats, dogs, and cats can get rabies. Cattle and humans can also get rabies. Only mammals can get rabies. Animals that are not mammals -- such as birds, snakes, and fish -- do not get rabies. Rabies is caused by a virus. An animal gets rabies from saliva, usually from a bite of an animal that has the disease.

The Rabies VirusThe Rabies VirusRV – a neurotropic filterable virus present in the saliva of rabid animals. It has a preferrence for nerve tissues.

Virus – minute organism not visible with ordinary light microscopy. It is parasitic in that it is entirely dependent on nutrients inside cells for its metabolic and reproductive needs. Can only be seen by use of eclectron microscopy. Consists of DNA or RNA covered with a protein covering called capsid.Neurotropic – viruses that reproduce in nerve tissueFilterable virus – virus causing infectious disease, the essential elements of which are so tiny that they retain infectivity after passing through a filter of the Berkefeld type.Berkefeld filter – a filter of diatomaceous earth designed to allow virus-size particles to pass throughDiatomaceous earth – substance composed of diatoms, a group of unicellular microscopic algae that possess a siiceous or calcium-containing cell wall.

RHABDOVIRUS: any group of rod-shaped RNA viruses with 1 important member, rabies virus, pathogenic to man. The virus has a predilection for tissue of mucus-secreting glands and the Central Nervous System. All warm-blooded animals are susceptible to infection with these viruses.

RHABDO: from Greek rhabdos, "rod"LYSSA: Greek – frenzy, rage, fury, canine madness

A rhabdovirus of the genus lyssavirus.

This is a photograph of the virus under electron

microscope

Parts of the rabies virus

Rod-shaped rabies viruses colored for

effect

MononegaviralesMononegavirales

RhabdoviridaeRhabdoviridae

lyssavirus

novirhabdovirus

cytorhabdovirus nucleorhabdovirus

Australian Bat lyssavirus

European Bat lyssavirus 1

Lagos Bat virus

Rabies virus

Duvenhage virusEuropean Bat lyssavirus 2

Mokola Bat virus

ephemerovirusvesiculovirus

order

family

genus

species

How do you get rabies? (MODE & MEDIA OF TRANSMISSION, IMMUNITY)

•All warm-blooded mammals are susceptible. Natural immunity in man is unknown.•You get rabies through the saliva of an infected animal by an exposure to an open break in the skin such as bites, open wound or scratch and inhalation of infectious aerosols such as from bats.•In some cases, it is transmitted through organ transplants (corneal transplant), from an infected person.•The virus gets transmitted through saliva, tears, semen, some liquor (amniotic fluid, CST) but not blood, urine or stool.

You get rabies from the saliva of a rabid animal, usually from a bite. The rabies virus is spread through saliva. You cannot get rabies by petting an animal. You may get rabies from a scratch if the animal, such as a cat, was licking its paw before it scratched you. (Remember that the rabies virus is found in the saliva of an animal).

How do you know if an animal has How do you know if an animal has rabiesrabies??

•Animals with rabies may act differently Animals with rabies may act differently from healthy animalsfrom healthy animals . .

•Some signs of rabies in animals areSome signs of rabies in animals are : :changes in an animal’s behaviorchanges in an animal’s behavior general sickness general sickness (fever, restlessness)(fever, restlessness) problems swallowingproblems swallowing increased droolingincreased drooling aggression aggression (biting at inanimate objects, aimless running)(biting at inanimate objects, aimless running)

•Wild animals may move slowly or may act as if they are tame. Some wild Wild animals may move slowly or may act as if they are tame. Some wild animals (foxes, raccoons, skunks) that normally avoid porcupines, may animals (foxes, raccoons, skunks) that normally avoid porcupines, may

even try to bite these prickly rodentseven try to bite these prickly rodents . .•A pet that is usually friendly may snap at you or may try to biteA pet that is usually friendly may snap at you or may try to bite..

How do you know if one has How do you know if one has rabiesrabies??

•There is yet no way of immediately knowing who had acquired rabies virus. No tests are available to diagnose rabies in humans before the onset of clinical disease.

•The most reliable test for rabies in patients who have clinical signs of the disease is a DIRECT IMMUNOFLUORESCENT STUDY of a full thickness biopsy of the skin taken from the back of the neck above the hair line.

•The RAPID FLUORESCENT FOCUS INHIBITION TEST is used to measure rabies-neutralizing antibodies in serum. This test has the advantage of providing results within 24 hours. Other tests of antibodies may take as long as 14 •days.

(DIAGNOSIS)

RABIES INCIDENCE:

WORLDWIDE:35, 000- 50, 000 cases/

year(WHO)

EPIDEMIOLOGY

•parts of Africa and Asian continents and many parts of Africa and Asian continents and many parts of South America are endemic for rabiesparts of South America are endemic for rabies

•UK and most of Western Europe are rabies free UK and most of Western Europe are rabies free due to success of coordinated wildlife oral due to success of coordinated wildlife oral

vaccination programsvaccination programs

• annual # of deaths caused by rabies worldwide: annual # of deaths caused by rabies worldwide: 50,000-60,00050,000-60,000

EPIDEMIOLOGYEPIDEMIOLOGY PHILIPPINES: 350-450 cases/ year

5-7 per million population

DOG BITE INCIDENCE: 140, 000- 560, 000/ year200-800 per 100, 000 population/ year

 AGE MOST AFFECTED: 5-14 year age group

(53% of cases)

BITING ANIMALS: (SLH STUDY 1982- 2002) 

DOGS: 98% PET: 88%

  STRAY: 10%CATS: 2%

•Based on the report from NCDPC (2004), the six Based on the report from NCDPC (2004), the six regions with the most number of rabies cases regions with the most number of rabies cases

are Western Visayas, Central Luzon, Bicol, are Western Visayas, Central Luzon, Bicol, Central Visayas, Ilocos and Cagayan ValleyCentral Visayas, Ilocos and Cagayan Valley

•Data shows that 53.7 percent of animal bite Data shows that 53.7 percent of animal bite patients are childrenpatients are children

•Dogs remain the principal animal source of Dogs remain the principal animal source of rabiesrabies

The trend for animal bite cases has increased from 1992 to 2001 but decreased in the year 2002-2004. The increasing number of patients who are consulting the health centers for animal bite cases is due to the increasing level of awareness on rabies. On the other hand, the human rabies cases have been decreasing from 1995 to 2004. This is due to early provision of post exposure vaccination to dog bite victims.

In 2004, there were 95,568 animal bite victims reported with 88 percent of them bittenby dogs. Of this animal bite victims, 55,582 or 58 percent had post-exposurevaccination and the other 40,000 or so had no vaccine protection at all. During the sameyear, 228 (0.2 percent of the total animal bite cases) were confirmed cases based on theappearance of the unequivocal signs and symptoms of rabies which include death formost.

Distribution of Animal Bite

Cases of Cebu Province

(Jan-June 2006)

How does rabies affect usHow does rabies affect us ? ?((PATHOPHYSIOLOGY & SIGNS N SYMPTOMSPATHOPHYSIOLOGY & SIGNS N SYMPTOMS))

What does the virus do?The targets of the rabies virus are nerve cells. Nerve cells are one part of the body’s nervous system. Once inside the body, the rabies virus infects the nerve cells and travels along the peripheral nerves (the nerves that run throughout the body). Its main target is the central nervous system, which is made up of the brain and spinal cord. How does the virus travel?When the virus travels from the peripheral nerves (infected periphery) to the brain, it is called CENTRIPETAL SPREAD.The viral travel and spread from the center (brain) to the periphery is called CENTRIFUGAL SPREAD.

PATHOLOGY CHART 1: Rabies infection

PATHOLOGY CHART 2: Rabies InfectionPATHOLOGY CHART 2: Rabies Infection

STAGES OF RABIES STAGES OF RABIES INFECTIONINFECTION

Rabies virus Entry into the bodyINCUBATI0N PERIOD

(20 – 90 days)

INVASION(0 – 10 days)

PARALYTIC

EXCITEMENT(2 – 7 days)

COMA(5 – 14 days) DEATH

RABIES CLASSIFICATIONRABIES CLASSIFICATIONANIMAL RABIESANIMAL RABIES

•There are two common types of rabies. One type is There are two common types of rabies. One type is "furious""furious" rabies. Animals with this type are rabies. Animals with this type are hostile, may bite at objects, and have an increase in saliva. In the movies and in books, rabid hostile, may bite at objects, and have an increase in saliva. In the movies and in books, rabid animals foam at the mouth. In real life, rabid animals look like they have foam in their mouth animals foam at the mouth. In real life, rabid animals look like they have foam in their mouth

because they have more salivabecause they have more saliva . .

The second and more common form is known as paralytic or The second and more common form is known as paralytic or "dumb""dumb" rabies. The dog pictured below rabies. The dog pictured below has this type. An animal with "dumb" rabies is timid and shy. It often rejects food and has paralysis has this type. An animal with "dumb" rabies is timid and shy. It often rejects food and has paralysis

of the lower jaw and musclesof the lower jaw and muscles..

•Another two types of rabies. One type is Another two types of rabies. One type is “urban”“urban” rabies. The type of rabies in domestic dogs and rabies. The type of rabies in domestic dogs and catscats..

The other type is called The other type is called “ sylvatic”“ sylvatic” rabies. These type came from wild animals such as bats, weasels, rabies. These type came from wild animals such as bats, weasels, skunks and moles & volesskunks and moles & voles..

HUMAN RABIESHUMAN RABIES

•Humans also have a “furious” type, the classic foaming of the mouth, aggression, apprehension & Humans also have a “furious” type, the classic foaming of the mouth, aggression, apprehension & hydrophobia, and the “dumb” type, progressive paralysis of the body until they couldn’t breathe hydrophobia, and the “dumb” type, progressive paralysis of the body until they couldn’t breathe

anymoreanymore..

DIFFERENT STAGES OF RABIES DIFFERENT STAGES OF RABIES INFECTIONINFECTION

INVASION PHASE

VIRUS IN SALIVA

EXCITEMENT

INHALED AEROSOLS

INVASION PHASE

VIRUS IN SALIVA

DEATH DEATH

PARALYSIS

PARALYSIS

DOGS

CATS

B A T S

MANAGEMENTMANAGEMENTPREVENTIONPREVENTION

•Responsible pet ownershipResponsible pet ownershipa) pet immunization, esp. cats, usually starting at 3 months of age and every year a) pet immunization, esp. cats, usually starting at 3 months of age and every year

thereafterthereafterb) don’t allow pets to roam around the streetsb) don’t allow pets to roam around the streets

c) take care of your pets, keep them in good health – bathe, feed with clean adequate food c) take care of your pets, keep them in good health – bathe, feed with clean adequate food and provide clean sleeping quartersand provide clean sleeping quarters

•Thoroughly clean ALL BITES AND SCRATCHES made by any animal with Thoroughly clean ALL BITES AND SCRATCHES made by any animal with strong medicinal soap or solutionstrong medicinal soap or solution..

•Responsible awareness. Report immediately rabid or suggestive of rabies Responsible awareness. Report immediately rabid or suggestive of rabies domestic or wild animals to proper authorities (local government clinic, domestic or wild animals to proper authorities (local government clinic,

veterinarians or community officials)veterinarians or community officials)..•Pre-exposure to high risk individuals. Veterinarians, hunters, people in Pre-exposure to high risk individuals. Veterinarians, hunters, people in

contact with animals (zoo), butchers, lab-staff in contact with rabies, forest contact with animals (zoo), butchers, lab-staff in contact with rabies, forest rangers/caretakersrangers/caretakers..

•DOH Standard ProtocolDOH Standard Protocol•If dog is apparently healthy, observe the dog for 14 days. If it dies or show signs suggestive or If dog is apparently healthy, observe the dog for 14 days. If it dies or show signs suggestive or

rabies, consult a physicianrabies, consult a physician..•If the dog shows signs suggestive of rabies, kill the dog immediately and bring head for lab If the dog shows signs suggestive of rabies, kill the dog immediately and bring head for lab

examination. Submit for immunization while waiting for resultsexamination. Submit for immunization while waiting for results..•If the dog is not available for observation (killed, died or stray), submit forIf the dog is not available for observation (killed, died or stray), submit for

immunizationimmunization..

*see DOH- Revised Guidelines on Management of Animal Bite Patients- 2007 for more complete guide

A cat’s brain for examination

MANAGEMENTMANAGEMENTMEDICAL INTERVENTIONSMEDICAL INTERVENTIONS

Local wound treatment. Immediately wash wound with soap and water. Treat Local wound treatment. Immediately wash wound with soap and water. Treat with antiseptic solutions such as iodine, alcohol and other disinfectantswith antiseptic solutions such as iodine, alcohol and other disinfectants..

Antibiotics and anti-tetanus as prescribed by physicianAntibiotics and anti-tetanus as prescribed by physician..Rabies – Specific Treatment. Post-exposure treatment is given to persons who Rabies – Specific Treatment. Post-exposure treatment is given to persons who

are exposed to the rabies virus. It consists of active immunization are exposed to the rabies virus. It consists of active immunization (vaccination) and passive immunization (immune globulin administration)(vaccination) and passive immunization (immune globulin administration)..

ACTIVE IMMUNIZATION – aims to induce the body to develop antibodies and T-cells ACTIVE IMMUNIZATION – aims to induce the body to develop antibodies and T-cells against rabies up to 3 years. It induces an active immune response in 7-10 days against rabies up to 3 years. It induces an active immune response in 7-10 days

after vaccination, which may persist for one year or more provided primary after vaccination, which may persist for one year or more provided primary immunization is completedimmunization is completed

MEDICAL AGENT: Human Diploid Cell rabies Vaccine (HDCV)MEDICAL AGENT: Human Diploid Cell rabies Vaccine (HDCV)

PASSIVE IMMUNIZATION – aims to provide IMMEDIATE PROTECTION against rabies which PASSIVE IMMUNIZATION – aims to provide IMMEDIATE PROTECTION against rabies which should be administered within the first 7 days of active immunization. The effect of should be administered within the first 7 days of active immunization. The effect of

thethe immune globulin is only short term. Rabies antibodies are introduced before it isimmune globulin is only short term. Rabies antibodies are introduced before it is

physiologically possible for the patient to begin producing his own antibodies afterphysiologically possible for the patient to begin producing his own antibodies after vaccination. Some of the RIG is infiltrated around the site and the rest is givenvaccination. Some of the RIG is infiltrated around the site and the rest is given

intramuscularlyintramuscularly.. MEDICAL AGENT: Rabies Immune Globulin (RIG)MEDICAL AGENT: Rabies Immune Globulin (RIG)

MANAGEMENTMANAGEMENT

NURSING INTERVENTIONSNURSING INTERVENTIONS •HIGH RISK FOR INFECTION TRANSMISSIONHIGH RISK FOR INFECTION TRANSMISSION

provide patient isolationprovide patient isolationhandwashing. Wash hands before and after each patient contact and following procedures that offer contamination handwashing. Wash hands before and after each patient contact and following procedures that offer contamination

risk while caring for an individual patient. Handwashing technique is important in reducing transient flora on outer risk while caring for an individual patient. Handwashing technique is important in reducing transient flora on outer epidermal layers of skinepidermal layers of skin..

Wear gloves when handling fluids and other potential contaminated articles. Dispose of every after patient care. Wear gloves when handling fluids and other potential contaminated articles. Dispose of every after patient care. Gloves provide effective barrier protection. Contaminated gloves becomes a potential vehicle for the transfer of Gloves provide effective barrier protection. Contaminated gloves becomes a potential vehicle for the transfer of

organismsorganisms . .Practice isolation techniques. To prevent self-contamination and spread of diseasePractice isolation techniques. To prevent self-contamination and spread of disease . .

•KNOWLEDGE DEFICIT (about the disease, cause of infection and preventive measures)KNOWLEDGE DEFICIT (about the disease, cause of infection and preventive measures)assess patient’s and family’s level of knowledge on the disease including concepts, beliefs and known treatmentassess patient’s and family’s level of knowledge on the disease including concepts, beliefs and known treatment..Provide pertinent data about the diseaseProvide pertinent data about the disease::organism and route of transmissionorganism and route of transmissiontreatment goals and processtreatment goals and process community resources if necessarycommunity resources if necessaryallow opportunities for questions and discussionsallow opportunities for questions and discussions

•ALTERED BODY TEMPERATURE: FEVER RELATED TO THE PRESENCE OF INFECTION. Since fever is ALTERED BODY TEMPERATURE: FEVER RELATED TO THE PRESENCE OF INFECTION. Since fever is continuous, provide other modes to reduce discomfortcontinuous, provide other modes to reduce discomfort..

If patient is still well oriented, Inform the relation of fever to the disease process. The presence of virus in the bodyIf patient is still well oriented, Inform the relation of fever to the disease process. The presence of virus in the body ……

Monitor temperature at regular intervalsMonitor temperature at regular intervalsProvide a well ventilated environment free from drafts and windProvide a well ventilated environment free from drafts and wind..

•DEHYDRATION related to refusal to take in fluids secondary to throat spasms and fear of spasmodic DEHYDRATION related to refusal to take in fluids secondary to throat spasms and fear of spasmodic attacksattacks . .

Assess level of dehydration of patientAssess level of dehydration of patient..Maintain other routes of fluid introduction as prescribed by the physician e.g. parenteral routesMaintain other routes of fluid introduction as prescribed by the physician e.g. parenteral routesMoisten parched mouth with cotton or gauze dipped in water but not drippingMoisten parched mouth with cotton or gauze dipped in water but not dripping..

OBJECTIVESOBJECTIVES::

•To provide new policy guidelines and To provide new policy guidelines and procedure to ensure an effective and procedure to ensure an effective and

efficient management for eventual efficient management for eventual reduction if not elimination of human rabiesreduction if not elimination of human rabies

•To increase voluntary pre-exposure To increase voluntary pre-exposure coverage among high risk group (animal coverage among high risk group (animal

handlers, field workers, health staff working handlers, field workers, health staff working in rabies unit, rabies diagnostic lab staff, in rabies unit, rabies diagnostic lab staff, children ↓ 15 yo living in endemic areaschildren ↓ 15 yo living in endemic areas..

SPECIFIC GUIDELINES AND SPECIFIC GUIDELINES AND PROCEDURESPROCEDURES::

Management of Management of Potential Rabies Potential Rabies

ExposureExposure

33 CATEGORIES OF CATEGORIES OF EXPOSUREEXPOSURE

CATEGORY ICATEGORY I•Feeding/ touching an animalFeeding/ touching an animal•Licking of intact skin (w/ reliable history Licking of intact skin (w/ reliable history

and thorough physical examination)and thorough physical examination)•Exposure to patient with signs and Exposure to patient with signs and

symptoms of rabies by sharing of eating symptoms of rabies by sharing of eating or drinking utensilsor drinking utensils* *

•Casual contact to patient with signs and Casual contact to patient with signs and symptoms of rabiessymptoms of rabies**

MANAGEMENTMANAGEMENT::

1.Wash exposed skin immediately w/ soap and water

2. No vaccine or RIG needed

*Pre-exposure vaccination may be considered

CATEGORY IICATEGORY II

  

•Nibbling/ nipping of uncovered skin Nibbling/ nipping of uncovered skin with bruisingwith bruising

•Minor scratches/ abrasions without Minor scratches/ abrasions without bleedingbleeding****

•Licks on broken skinLicks on broken skin

****includes wounds that are induced to includes wounds that are induced to bleedbleed

MANAGEMENTMANAGEMENT::Complete vaccination regimen until day 28/30 Complete vaccination regimen until day 28/30

ifif::

•Animal is rabid, killed, died OR unavailable for 14- Animal is rabid, killed, died OR unavailable for 14- day observation or examination ORday observation or examination OR

•Animal under observation died within 14 days and Animal under observation died within 14 days and was IMMUNOFLOURESCENT ANTIBODY TEST (IFAT)- was IMMUNOFLOURESCENT ANTIBODY TEST (IFAT)- positive OR no IFAT testing was done OR had signs positive OR no IFAT testing was done OR had signs

of rabiesof rabies  

Complete vaccination regimen until day 7 ifComplete vaccination regimen until day 7 if::

•Animal is alive AND remains healthy after 14- day Animal is alive AND remains healthy after 14- day observation periodobservation period

•Animal under observation died within 14 days but Animal under observation died within 14 days but had no signs of rabies and as IFAT- negativehad no signs of rabies and as IFAT- negative..

CATEGORY IIICATEGORY III

•Transdermal bites or scratches ( to include Transdermal bites or scratches ( to include puncture wounds, lacerations, avulsions)puncture wounds, lacerations, avulsions)

•Contamination of mucous membrane with saliva Contamination of mucous membrane with saliva (i.e. licks)(i.e. licks)

•Exposure to a rabies patient through bites, Exposure to a rabies patient through bites, contamination of mucous membranes or open contamination of mucous membranes or open

skin lesions with body fluids (except blood/feces) skin lesions with body fluids (except blood/feces) through splattering, mouth-to-mouth through splattering, mouth-to-mouth

resuscitation, licks of the eyes, lips, vulva, sexual resuscitation, licks of the eyes, lips, vulva, sexual activity, exchanging kisses on the mouth or other activity, exchanging kisses on the mouth or other

direct mucous membrane contact with salivadirect mucous membrane contact with saliva..•Handling of infected carcass or ingestion of raw Handling of infected carcass or ingestion of raw

infected meatinfected meat•All Category II exposures on head and neck areaAll Category II exposures on head and neck area

**Does not include sharing of food/ drink/ utensils Does not include sharing of food/ drink/ utensils and casual contact with rabid patientand casual contact with rabid patient

MANAGEMENTMANAGEMENTComplete vaccination regimen until day 28/ 30 Complete vaccination regimen until day 28/ 30

ifif::  

•Animal is rabid, killed, died OR unavailable for 14 Animal is rabid, killed, died OR unavailable for 14 day observation or examination ORday observation or examination OR

•Animal under observation died within 14 days and Animal under observation died within 14 days and was IMMUNOFLOURESCENT ANTIBODY TEST was IMMUNOFLOURESCENT ANTIBODY TEST

(IFAT)- positive OR no IFAT testing was done OR (IFAT)- positive OR no IFAT testing was done OR had signs of rabieshad signs of rabies

  Complete vaccination regimen until day 7 ifComplete vaccination regimen until day 7 if::

•Animal is alive AND remains healthy after 14-day Animal is alive AND remains healthy after 14-day observation periodobservation period..

•Animal under observation died within 14 days but Animal under observation died within 14 days but had no signs of rabies and was IFAT- negativehad no signs of rabies and was IFAT- negative

IMMUNIZATIONIMMUNIZATION  ACTIVE IMMUNIZATIONACTIVE IMMUNIZATION

-induce antibody and T-cell production in induce antibody and T-cell production in order to neutralize the rabies virus in the order to neutralize the rabies virus in the

body. It induces an active immune body. It induces an active immune response in 7-10 days after vaccination, response in 7-10 days after vaccination, which may persist for one year or more which may persist for one year or more

provided primary immunization is provided primary immunization is completedcompleted..

TYPESTYPES::

.a.aPVRV (Purified Vero Cell Rabies Vaccine)PVRV (Purified Vero Cell Rabies Vaccine)

.b.bPCEVC (Purified Chick Embryo Cell PCEVC (Purified Chick Embryo Cell Vaccine)Vaccine)

PASSIVE IMMUNIZATIONPASSIVE IMMUNIZATION

- -RIG (Rabies Immune Globulins)RIG (Rabies Immune Globulins)

-provide the immediate availability of provide the immediate availability of antibodies at the site of exposure before it is antibodies at the site of exposure before it is

physiologically possible for the pt.to begin physiologically possible for the pt.to begin producing his own antibodies after producing his own antibodies after

vaccinationvaccination..

-Important for pts. w/ Cat III exposuresImportant for pts. w/ Cat III exposures

TypesTypes::

.a.aHRIG (Human Rabies Immune Globulins)HRIG (Human Rabies Immune Globulins)

.b.bHighly Purified Antibody Antigen Binding Highly Purified Antibody Antigen Binding fragmentsfragments

.c.cERIG (Equine Rabies Immune Globulins)ERIG (Equine Rabies Immune Globulins)

TREATMENTTREATMENT

•POST-EXPOSURE TREATMENT (PET)POST-EXPOSURE TREATMENT (PET)

.A.ALOCAL WOUND TREATMENTLOCAL WOUND TREATMENT

-Wash with soap/detergent and water Wash with soap/detergent and water preferably for 10 minspreferably for 10 mins..

-Apply alcohol, povidone iodine/ any antisepticApply alcohol, povidone iodine/ any antiseptic

-Anti-TetanusAnti-Tetanus

**Avoid suturing woundsAvoid suturing wounds

**Don’t apply ointment, cream/ wound dressingDon’t apply ointment, cream/ wound dressing

•ANTIMICROBIALANTIMICROBIAL

-AmoxicillinAmoxicillin

-CloxacillinCloxacillin

-CefuroximeCefuroxime

**For those instances where there’s no For those instances where there’s no obvious signs of infection( Amoxicillin as obvious signs of infection( Amoxicillin as

prophylaxis )prophylaxis )

******Educate the public simple local wound Educate the public simple local wound treatment & warn not to use procedures treatment & warn not to use procedures

that may further contaminate the that may further contaminate the woundswounds

VACCINATIONVACCINATION(Intradermal Schedule)(Intradermal Schedule)

Day of Day of ImmunizationImmunization

PVRV/PCECVPVRV/PCECV SiteSite

DAY 0DAY 0 0.10.1 mlml L & R deltoids/ L & R deltoids/ anterolateral thighs anterolateral thighs

of infantsof infants

DAY 3DAY 3 0.10.1 mlml L & R deltoids/ L & R deltoids/ anterolateral thighs anterolateral thighs

of infantsof infants

DAY 7DAY 7 0.10.1 mlml L & R deltoids / L & R deltoids / anterolateral thighs anterolateral thighs

of infantsof infants

DAY 28/30DAY 28/30 0.10.1 mlml L & R deltoids/ L & R deltoids/ anterolateral thighs anterolateral thighs

of infantsof infants

Intramuscular ScheduleIntramuscular Schedule

Day of Day of ImmunizationImmunization

PVRVPVRV PCECVPCECV SiteSite

Day 0Day 0 0.50.5 mlml 1.01.0 mlml One deltoid/ One deltoid/ anterolateral anterolateral

thigh of infantsthigh of infants

Day 3Day 3 0.50.5 mlml 1.01.0 mlml SameSame

Day 7Day 7 0.50.5 mlml 1.01.0 mlml SameSame

Day 14Day 14 0.50.5 mlml 1.01.0 mlml SameSame

Day 28Day 28 0.50.5 mlml 1.01.0 mlml samesame

Special ConditionsSpecial Conditions::•Pregnancy & infancy are not C/I to Pregnancy & infancy are not C/I to

treatmenttreatment

•Babies born of rabid mothers should be Babies born of rabid mothers should be given ARV as early as birth as possiblegiven ARV as early as birth as possible

•Alcoholics should be given standard IM Alcoholics should be given standard IM regimenregimen

•Immunocomrpomised individuals- IMImmunocomrpomised individuals- IM

•Interchangeability of vaccine brands & Interchangeability of vaccine brands & shifting from one regimen to another is not shifting from one regimen to another is not

recommendedrecommended

•Bites of rodents, rabbits, guinea pig- no PETBites of rodents, rabbits, guinea pig- no PET

•Dogs, cats, livestock, wild animals- give PETDogs, cats, livestock, wild animals- give PET

PET Schedule for previously PET Schedule for previously immunized patientsimmunized patients::

Interval from the last doseInterval from the last dose GiveGive

< <11 monthmonth No boosterNo booster

11 month- 6 monthsmonth- 6 months 11 booster dosebooster dose

> >66 months- 3 yearsmonths- 3 years 22 booster doses (D0, D3)booster doses (D0, D3)

> >Than 3 yearsThan 3 years Full course of active immunFull course of active immun..

MANAGEMENT OF RABIES MANAGEMENT OF RABIES PATIENTPATIENT

•Once symptoms start, treatment should Once symptoms start, treatment should center on comfort care, using sedation & center on comfort care, using sedation &

avoidance of intubation & life support avoidance of intubation & life support measures once diagnosis is certainmeasures once diagnosis is certain

.1.1MEDICATIONSMEDICATIONS

.a.aDiazepamDiazepam

.b.bMidazolamMidazolam

.c.cHaloperidol + DipenhydramineHaloperidol + Dipenhydramine

22 . .SUPPORTIVE CARESUPPORTIVE CARE-Pts w/ confirmed rabies should receive Pts w/ confirmed rabies should receive

adequate sedation & comfort care in an adequate sedation & comfort care in an appropriate medical facilityappropriate medical facility..

.a.aOnce rabies diagnosis has been Once rabies diagnosis has been confirmed, invasive procedures must be confirmed, invasive procedures must be

avoidedavoided.b.bProvide suitable emotional and physical Provide suitable emotional and physical

supportsupport.c.cDiscuss & provide important info. to Discuss & provide important info. to

relatives concerning transmission of dse. relatives concerning transmission of dse. & indication for PET of contacts& indication for PET of contacts

.d.dHonest gentle communication Honest gentle communication concerning prognosis should be provided concerning prognosis should be provided

to relatives of ptto relatives of pt

33 . .INFECTION CONTROLINFECTION CONTROL

.a.aPatient should be admitted in a Patient should be admitted in a quiet, draft-free, isolation roomquiet, draft-free, isolation room

.b.bHLCR workers & relatives in contact HLCR workers & relatives in contact w/ pt should wear proper personal w/ pt should wear proper personal

protective equipment (gown, gloves, protective equipment (gown, gloves, mask, goggles)mask, goggles)

44 . .DISPOSAL OF DEAD BODIESDISPOSAL OF DEAD BODIES

How can I prevent rabiesHow can I prevent rabies ? ?

Vaccinate your dogs, cats, and ferrets against Vaccinate your dogs, cats, and ferrets against rabiesrabies . .

Keep your pets under supervisionKeep your pets under supervision . .Do not handle wild animals. If you see a wild Do not handle wild animals. If you see a wild

animal or a stray, especially if the animal is animal or a stray, especially if the animal is acting strangely, call an animal control officeracting strangely, call an animal control officer . .

If you do get bitten by an animal, wash the If you do get bitten by an animal, wash the wound with soap and water for at least 5 wound with soap and water for at least 5

minutes. Make sure you tell an adult and call minutes. Make sure you tell an adult and call your doctor to see if you need shotsyour doctor to see if you need shots . .

Get your pets spayed or neutered. Pets that Get your pets spayed or neutered. Pets that are fixed are less likely to leave home, are fixed are less likely to leave home,

become strays, and make more stray animalsbecome strays, and make more stray animals..

This racoon is eating a special bait which contains a vaccine against rabies.

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How do I keep my pet from getting How do I keep my pet from getting rabies?rabies?

The best way to prevent rabies is to make sure your The best way to prevent rabies is to make sure your pets get and stay vaccinated against rabiespets get and stay vaccinated against rabies !! !!

•Other ways to prevent rabies in your Other ways to prevent rabies in your petspets::

Walk your dog on a leash. Never let them roam Walk your dog on a leash. Never let them roam freely where wildlife may be presentfreely where wildlife may be present . .

Consider keeping your pets indoorsConsider keeping your pets indoors . .Call animal control to take wild or stray animals Call animal control to take wild or stray animals

away, especially if you see an animal acting away, especially if you see an animal acting strangelystrangely . .

If an animal bites your pet, handle your pet If an animal bites your pet, handle your pet carefully so you do not get bitten. Get a rabies carefully so you do not get bitten. Get a rabies

booster vaccination for them. Even if they have booster vaccination for them. Even if they have had the rabies vaccination, a booster shot will had the rabies vaccination, a booster shot will

help them fight off the disease betterhelp them fight off the disease better . .Get your pets spayed or neutered. Pets that are Get your pets spayed or neutered. Pets that are

fixed are less likely to leave home, become fixed are less likely to leave home, become strays, and make more stray animalsstrays, and make more stray animals . .

Make sure your pet gets and wears their rabies Make sure your pet gets and wears their rabies vaccination tags. They should also wear a tag with vaccination tags. They should also wear a tag with

their name and your address and phone number. their name and your address and phone number. Keep them in a fenced yard or on a leashKeep them in a fenced yard or on a leash..

This dog wears a special tag which says “I’m rabies vaccinated!”

How do I keep from getting rabiesHow do I keep from getting rabies?? Never touch unfamiliar or wild Never touch unfamiliar or wild

animals. Enjoy wild animals from afaranimals. Enjoy wild animals from afar . .Avoid direct contact with stray Avoid direct contact with stray

animals. Stray cats and dogs may not animals. Stray cats and dogs may not have been vaccinated against rabieshave been vaccinated against rabies . .

Never adopt wild animals or bring Never adopt wild animals or bring them into your homethem into your home . .

Do not try to nurse sick animals to Do not try to nurse sick animals to health. It is common to want to health. It is common to want to

rescue and nurse a hurt wild animal, rescue and nurse a hurt wild animal, but that animal may have rabies. Call but that animal may have rabies. Call

an animal control person or animal an animal control person or animal rescue group if you find a sick animalrescue group if you find a sick animal . .

Make sure that your trash cans and Make sure that your trash cans and pet foods are secured so that they do pet foods are secured so that they do

not attract wild animalsnot attract wild animals . .

QUESTION:QUESTION:Is an increase in the incidence Is an increase in the incidence

of rabies r/t El Niño?of rabies r/t El Niño?

ANSWER: No. Rabies both in ANSWER: No. Rabies both in humans & animals doesn’t in humans & animals doesn’t in

any way follow a seasonal any way follow a seasonal patternpattern . .

QUESTIONS MOST FREQUENTLY ASKED ABOUT RABIESQUESTIONS MOST FREQUENTLY ASKED ABOUT RABIES

•QUESTION:QUESTION:Is it true that a dog which is rabid Is it true that a dog which is rabid

dies only after it has bitten a person?dies only after it has bitten a person?

ANSWER: No. Whether the dog has ANSWER: No. Whether the dog has bitten a person or not, a rabid dog bitten a person or not, a rabid dog

dies within 14 daysdies within 14 days..

•QUESTION:QUESTION:Is rabies curable?Is rabies curable?

ANSWER: No. Once signs and ANSWER: No. Once signs and symptoms of brain involvement are symptoms of brain involvement are

manifested, the rabies victim dies manifested, the rabies victim dies within 1-3 dayswithin 1-3 days..

•QUESTION:QUESTION:Is rabies preventable?Is rabies preventable?

ANSWER: Yes. By administering ANSWER: Yes. By administering vaccine & immunoglobulin at the vaccine & immunoglobulin at the

right time to an animal bite victim, right time to an animal bite victim, rabies can be preventedrabies can be prevented . .

•QUESTION:QUESTION:If bitten by a stray animal, what If bitten by a stray animal, what

should be properly done?should be properly done?

ANSWERANSWER : :

•A. Immediately wash the bite woundA. Immediately wash the bite wound

•B. Consult physician/ ABTCB. Consult physician/ ABTC

•C. Consult a vet for mgt of biting dogC. Consult a vet for mgt of biting dog

•QUESTION:QUESTION:Do we need to kill the dog Do we need to kill the dog

immediately?immediately?

ANSWER: No. If the dog is apparently ANSWER: No. If the dog is apparently healthy, it should not be killed healthy, it should not be killed

immediately & should be kept on leash immediately & should be kept on leash / caged for observation for 14 days/ caged for observation for 14 days..

•QUESTION:QUESTION:Does a person bitten by a rabid person Does a person bitten by a rabid person

need to be given AR immunization?need to be given AR immunization?

ANSWER: Yes, a rabid person can ANSWER: Yes, a rabid person can transmit the rabies virus to another transmit the rabies virus to another

person & need to be given AR person & need to be given AR immunizationimmunization..

Incubation periodIncubation periodthe interval between exposure to infection and the appearance of the first symptomthe interval between exposure to infection and the appearance of the first symptom

.1.1One week to seven and a half momths in dogsOne week to seven and a half momths in dogs

.2.2Ten days to fifteen years in humanTen days to fifteen years in human

.3.3Incubation period depends upon the following Incubation period depends upon the following factorsfactors::

–Distance of the bite to the brainDistance of the bite to the brain–Extensiveness of the biteExtensiveness of the bite–Specie of the animalSpecie of the animal–Richness of the nerve supply in the area of the biteRichness of the nerve supply in the area of the bite–Resistance of the hostResistance of the host

How does the rabies How does the rabies virus interact with virus interact with

the nerve cellsthe nerve cells?? There are four main stages the virus goes throughThere are four main stages the virus goes through::

• Attachment: The rabies virus attaches itself to a healthy Attachment: The rabies virus attaches itself to a healthy nerve cellnerve cell . .

•Penetration: The virus is taken in by the cellPenetration: The virus is taken in by the cell . .

•Replication: Inside the cell, the virus multiplies rapidlyReplication: Inside the cell, the virus multiplies rapidly . .

•Budding: The new rabies virus leaves the host cell. It Budding: The new rabies virus leaves the host cell. It attaches to other nerve cells. The virus then spreads from attaches to other nerve cells. The virus then spreads from

the brain to the rest of the body by the nervesthe brain to the rest of the body by the nerves.. These different stages are happens during the INCUBATION These different stages are happens during the INCUBATION

PERIODPERIOD..The rabies virus in this picture has been made large The rabies virus in this picture has been made large

so that you can understand it betterso that you can understand it better . .Tick me!

INVASION STAGEINVASION STAGE

•Also called PRODOME PERIOD; Prodrome – symptom indicative of an approaching Also called PRODOME PERIOD; Prodrome – symptom indicative of an approaching diseasedisease

• 2-102-10 DAYSDAYS

•Sensory changes on the site of entrySensory changes on the site of entry..

Pain: dull, constant pain referable to the nervous pathways proximal to the location of Pain: dull, constant pain referable to the nervous pathways proximal to the location of the wound or itching, intermittent, stabbing pains radiating distally to the region of the wound or itching, intermittent, stabbing pains radiating distally to the region of

inoculation. In general, sensitivity is the early symptom which may be ascribed to the inoculation. In general, sensitivity is the early symptom which may be ascribed to the stimulative action of the virus affecting groups of neurons, esp. sensory system. stimulative action of the virus affecting groups of neurons, esp. sensory system.

Though there is apt to be decreased sensitivity to local pain e.g. needle introduction, Though there is apt to be decreased sensitivity to local pain e.g. needle introduction, patient may complain bitterly of drafts & bed clothes which produce a general patient may complain bitterly of drafts & bed clothes which produce a general

stimulationstimulation

•Fever,headache malaise sore throat anorexia increased sensitivity (bright lights, loud Fever,headache malaise sore throat anorexia increased sensitivity (bright lights, loud noises) increased muscle reflex irritability, tics and muscle tonenoises) increased muscle reflex irritability, tics and muscle tone

•Overactive facial expressionOveractive facial expressionTick me!

EXCITATION STAGEEXCITATION STAGE•Also called ACUTE NEUROLOGICAL PHASE; Also called ACUTE NEUROLOGICAL PHASE;

hyperactivityhyperactivity•22 – – 1010 DAYSDAYS•Imminent thoraco-lumbar involvement (SNS): Imminent thoraco-lumbar involvement (SNS):

pupillary dilation, lacrimation increased thick pupillary dilation, lacrimation increased thick saliva production / foaming of mouth, saliva production / foaming of mouth, excessive perspiration, increased HRexcessive perspiration, increased HR

•Anxiety: increased nervousness, insomnia, Anxiety: increased nervousness, insomnia, apprehension; a strong desire to be up, apprehension; a strong desire to be up,

wandering aimlessly about, and Fear: a sense wandering aimlessly about, and Fear: a sense of impending doomof impending doom

•Hydrophobia (perhaps, SNS stimulation: Hydrophobia (perhaps, SNS stimulation: depresses GI activity > inhibits esophageal, depresses GI activity > inhibits esophageal,

gastric & intestinal function) > violent gastric & intestinal function) > violent expulsion of fluids, drooling (in attempt not to expulsion of fluids, drooling (in attempt not to swallow) > dehydration and parched mouth & swallow) > dehydration and parched mouth &

tonguetongue•Pronounced muscular stimulation & general Pronounced muscular stimulation & general

tremortremor•Mania (tearing of clothes & bedding, cases of Mania (tearing of clothes & bedding, cases of

biting & fighting rare but may occur) and biting & fighting rare but may occur) and Hallucinations with lucid intervals (normal Hallucinations with lucid intervals (normal

mental function in which patient is well-mental function in which patient is well-oriented & answers questions intelligently)oriented & answers questions intelligently)

•Convulsions( besides r/t pronounced muscular Convulsions( besides r/t pronounced muscular stimulation, further precipitated by sensory stimulation, further precipitated by sensory

stimuli – sight, sound, name of water > throat stimuli – sight, sound, name of water > throat spasms > choking > apnea, cyanois, gaspingspasms > choking > apnea, cyanois, gasping

• > >death, but if patient survive excitement death, but if patient survive excitement phasephase…… Tick me

next!

Sympathetic nervous system

Parasympathetic nervous systemTick me 1st!

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PARALYTIC STAGEPARALYTIC STAGE--also called DEPRESSION PHASEalso called DEPRESSION PHASE

•Gradual weakness of muscle groupsGradual weakness of muscle groups–muscle spasms ceasemuscle spasms cease–OCULAR PALSYOCULAR PALSY – strabismus, ocular incoordination, nystagmus, diplopia, central – strabismus, ocular incoordination, nystagmus, diplopia, central

type partial blindness > responds poorly to light, @ times pupil is constricted or type partial blindness > responds poorly to light, @ times pupil is constricted or unequal (parasympathetic involvement)unequal (parasympathetic involvement)

–Oro-facial: Oro-facial: FACIAL & MASSETER PALSYFACIAL & MASSETER PALSY > difficulty closing eyes & mouth, face > difficulty closing eyes & mouth, face expressionlessexpressionless

–Oral: Weakness of muscles of phonation > Oral: Weakness of muscles of phonation > hoarsness & loss of voicehoarsness & loss of voice•Loss of tendon reflexesLoss of tendon reflexes, always precedes weakness of extremity, always precedes weakness of extremity•Corneal reflex decreased or absent, dryCorneal reflex decreased or absent, dry •Ears: Ears: VERTIGOVERTIGO . Middle ear disease . Early symptom, but may develop @ any period . Middle ear disease . Early symptom, but may develop @ any period•Neck stiffnessNeck stiffness• )+( )+(BabinskiBabinski [lesions of pyramidal tract], ( - ) Kernig’s ( - ) Brudzinski’s [lesions of pyramidal tract], ( - ) Kernig’s ( - ) Brudzinski’s•Cardiac: shifts from tachycardia (100 – 120bpm) @ bed rest to Cardiac: shifts from tachycardia (100 – 120bpm) @ bed rest to bradycardiabradycardia (40 -60 bpm) (40 -60 bpm)•Respi: Respi: Cheyne-StokesCheyne-Stokes > breathing pattern characterized by a periodic 10 – 6- sec of > breathing pattern characterized by a periodic 10 – 6- sec of

apnea followed by gradual increasing depth and frequency of respirationapnea followed by gradual increasing depth and frequency of respiration•Local sensationLocal sensation (pin prick, heat, cold) (pin prick, heat, cold) diminisheddiminished•IncoordinationIncoordination•Hydrophobia and aerophobia goneHydrophobia and aerophobia gone, but still has some difficulty swallowing, but still has some difficulty swallowing•General arousal (PNS stimulation)General arousal (PNS stimulation)•Bladder & intestinal retention and obstipationBladder & intestinal retention and obstipation (damage to to innervation of the (damage to to innervation of the

musculature of intestine & bladder)(SNS damage)musculature of intestine & bladder)(SNS damage)

in some cases, patient shows period of recovery, this apparent remission is followed by in some cases, patient shows period of recovery, this apparent remission is followed by progressiveprogressive

•Ascending, flaccid paralysisAscending, flaccid paralysis of extremities until it reaches the respiratory muscle of extremities until it reaches the respiratory muscle•Apathy, stuporApathy, stupor•Complications: Complications: Pneumothorax, thrombosis, secondary infectionsPneumothorax, thrombosis, secondary infectionsTick me!

A painting of the US’ campaign against rabies in wildlife.A painting of the US’ campaign against rabies in wildlife.Wildlife advocates believe that a vaccinated racoon is the best tool for combating rabies in the wildlife. Wildlife advocates believe that a vaccinated racoon is the best tool for combating rabies in the wildlife. Racoons are one of the most common vectors of Rabies. It may eat an infected bat yet may also spread Racoons are one of the most common vectors of Rabies. It may eat an infected bat yet may also spread

the virus itself to the bats as it rummages through the bat colonythe virus itself to the bats as it rummages through the bat colony . . Tick me!

Submitted by:Submitted by:

Precious Leanellie U. GuerreroPrecious Leanellie U. Guerrero

Hilda G. GuintoHilda G. Guinto