Conference08 Rabies

8/18/2019 Conference08 Rabies

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Rabies and IntradermalRabies Vaccination

Alan C. Jackson, MDProfessor of Medicine (Neurolog!

and of Medical Microbiolog

"ead, #ection of Neurolog

$ni%ersit of Manitoba

&inni'eg, Manitoba, Canada


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Rabies virus structure

EnvelopeMatrix protein

Source: http://www.cdc.gov

Glycoprotein

Nucleocapsid protein


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Human rabies

Poto courtes of Da%id &arrell, $)


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Clinical forms of rabies

ence'alitic * furious + -

'araltic * dumb + /-


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0nce'alitic rabies

'rodromal sm'toms

'arestesias1'ain1'ruritus at site of bite

e'isodes of generali2ed arousal or'ere3citabilit se'arated b lucid

'eriods

autonomic dsfunction

dro'obia


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Paraltic rabies

'arestesias1'ain1'ruritus at site of bite

earl flaccid muscle 4eakness often begins in bitten e3tremit

'rogresses to 'roduce 5uadri'aresis bilateral facial 4eakness

sensor e3amination is usuall normal

s'incter in%ol%ement fatal outcome

often misdiagnosed as 6uillain 7 8arr9 sndrome


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6eogra'ic distribution of rabies 7 /---

No information: DRC, Benin ,Burkina, Sierra Leone, Liberia, Gambia,

Mauritania, Somalia, Yemen, Malaysia, Laos, Myanmar, ietnam

Cambo!ia, Nort" #orea


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Disease Total DA!s lost "# $%%%&

Malaria '()(*%

Tu+erculosis ,-)%'%

yphatic ilariasis 0)-''

eishaniosis (.,01

Schistosoiasis $)1-%

Trypanosoiasis $)02*

3a+ies $)$-%

4nchocerciasis 2*1

Dengue -0,

5hagas -'2

eprosy $11

Eerg 6n Dis $%) (%%'

DA:; (disabilit7ad


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"uman rabies 're%ention $nited #tates

Recommendations of te CDC>s

Ad%isor Committee on Immuni2ation PracticesMM&R Recommendations and Re'orts

Januar , ?@@@

http://www.cdc.gov/wr


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Evaluation o Anial 3ecoendation

7ealthy and availa+le or$% days o+servation No treatent unlessanial develops clinical

signs o ra+ies

3a+id or suspected ra+id 6ediate treatent8

9nnown "e.g.) escaped& 5onsult local

pu+lic health

departent8Discontinue treatent i tests on anial prove negative.

Rabies 'oste3'osure guidee3'osure to dogs, cats, and ferrets


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Recommended 'ro'la3is in e3'osed indi%idualsnot 're%iousl %accinated against rabies

6ediate thorough cleansing o

all wounds with soap and water.

Tetanus prophylaxis; anti+iotics


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Rabies accines $vailable in Cana!a

MMWR RR7?, Januar , ?@@@

Product 'ackage inserts, /--E

No%artis

(Merck Frosst!

'rimar cickembro

fibroblasts

PC0CV

#anofi Pasteur

MRC7G uman

lung cell line

"DCV

RabA%ertH Imo%a3 H

Manufacturer

Cell culture

Commondesignation


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$!verse Reactions to Rabies accines

Most common side7effects of rabies %accines

#stemic reactions suc as eadace,

malgia, malaise (G7-!

Mild to moderate local reactions at in


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Po'ulations at increased risk of

e3'osure to rabies Rabies researc laborator 4orkers

Veterinarians, staff, %eterinar students

Animal control and 4ildlife 4orkers

8at andlers

#'elunkers

Kra%ellers to certain rabies7endemic areas

MMWR '*: "33=$&) $222


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Assessing te Rabies Risk for Kra%ellers

Destination

Duration of tra%el

Antici'ated acti%ities

Access to medical care and

a''ro'riate P0P biologics


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Pree3'osure rabies 'ro'la3is

doses of rabies %accine (das -, , and /? or

/!

Ma ceck rabies antibod titre 'eriodicall L4ant -.G I$1m:

after a rabies e3'osure

/ doses of IM rabies %accine (das - and !

no "RI6


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Day % 1 ($ (*

Pre7e3'osure rabies 'ro'la3is

Kissue culture %accine ? dose 6M or -.? ml 6D

B If C":RO$IN0 malaria 'ro'la3is, gi%e IM onlB If immunosu''ressed ceck neut. Antibod titre ? -.G I$1ml

"IV 'ositi%e 'atients 7 CD counts -- ma be unres'onsi%e

Modified from MJ &arrell, $ni%ersit of 3ford


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Poto courtes of Claudius Malerc2k (No%artis!


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Can Comm Dis Re' ??, /--G


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Intradermal use of rabies %accine 6old standard is IM administration of rabies

%accine

ID regimen is an acce'table alternati%e

$ses one7tent te dose

Com'arable degree of 'rotection 0conomical and 4idel acce'ted



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Intradermal use of rabies %accine

Pre7e3'osure * tree -.? m: doses on das -,, and /? or / intradermall on u''er arm

After reconstitution of ?.- m: dose, ma store

at L degrees C for u' to ours 4it'ro'er ase'tic 'recautions

PC0CV so4n to be immunogenic das

after reconstitution 4it storage in a clinicrefrigerator ()a4'lod et al. CID /--/!



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Neutrali2ation titres after ID %accination are

lo4er tan after IM, but ade5uate 'rotecti%e

le%els

8riggs found tat after /7/.G ears

@ of IM %s. G? of ID ad satisfactor titres

ACIP, at / ears

@7@ for IM %s. 7@G for ID



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Manitoba n* in /--G

E7?/ mo after rd dose

@G -.G I$1m:

Median /. I$1m:

ntario and Alberta fa%ourable, but smaller e3'erience



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Manitoba n*?--- as of /--

? ear after rd dose @/ -.G I$1m:

/ ears after rd dose -.G I$1m:

ears after rd dose - -.G I$1m:

G ears after rd dose G -.G I$1m:

Preliminar data from Drs. . :arios and F. Aoki


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%m&ortance of maintainin' t"eantibo!y level is unkno(n

Ke res'onse to booster doses is

'redictable and ra'id.

In Qlo4 res'onders> te antibod res'onsema not be so ig (significance unkno4n!.

Detectable antibodies ma not benecessar for 'rotection if booster dosesare gi%en 'rom'tl after e3'osure.



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$&&roac" to immuni)ation of travellers

, dose pre=exposure course

If risk of e3'osure continues, ten booster dose at

? L / ears

Kra%ellers 4it access to %accine If e3'osed to

rabies need no furter boosters

Kra%ellers to remote areas 4it no access to

%accine #ould re'eat booster dose before

de'arture if last dose 4as 7 G ears're%iousl (if antibod -.G I$1ml!

0nsure booster doses if rabies e3'osure A#AP



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*fficacy of &ro&"yla+is

Pre7e3'osure %accine follo4ed b 'ost7

e3'osure boosters L no deats re'orted

If no 're%ious %accine o'timal 'ost7

e3'osure treatment igl effecti%e, but

deats occur 4it dela or incom'letetreatment



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Rabies &revention Summary Rabies is a 're%entable disease. Failure to recogni2e a risk of infection results in

uman deats. Increased a4areness of sources and routes of

%irus transmission could sa%e li%es. Pre7e3'osure %accination sould be used 4idel. Post7e3'osure treatment is urgent. For 're%iousl %accinated 'eo'le 'ost 7e3'osure

treatment is sim'ler, cea'er and more effecti%e.



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Conference08 Rabies