Basic rabies-for-dep ed

RABIES

JOMELL V. MOJICA, RNRabies Prevention and Control Program CoordinatorDOH Regional Office IV-A

WHAT IS RABIES

Rabies is a zoonotic disease caused by a virus.

Rabies is the deadliest disease on earth and you will have a 99.9% chance of dying if you

do not receive vaccine immediately after getting infected.

RABIES

Human rabies caused by the classical rabies virus continues to be 99.9% fatal

No specific treatment available anywhere in the world

Responsible for the death of 188 Filipinos for the year 2015

RABIES

Dogs remain the principal cause of animal bites and rabies cases in 2015- 72%, Cats 27%.

CAUSATIVE AGENT Rabies Virus Bullet-shaped, single

stranded RNA- virus belonging to the genus Lyssavirus, family of Rhabdoviridae.

Cannot cross intact skin

Sensitive to heating/ boiling, drying, UV and X-ray, sunlight, ether, and detergents

TRANSMISSIONIs due to a bite, scratch or even lick on

mucous membrane from animals (dogs) whose saliva contains the virus

By inhaling virulent aerosol (laboratory experiment, exploration of enclosed caves inhabited by infected bats)

By transmission: from man to man Indirectly: transplantation of infected

cornea Directly: from bite or through saliva of

an infected person

IN ALMOST ALL CASES

IN VERY EXCEPTIONAL CASES

TRANSMISSIONHuman to Human Transmission

Directly- bite or contact with saliva and other body fluids of infected person

Indirectly- transplant 15 documented cases of fatal rabies following

transplantation Corneal transplantation (8) Transplantation of solid organs and vascular conduit

(7)

TRANSMISSIONHuman to Human Transmission

There are no human cases due to consumption of cooked meat

Although rabies patients are extremely unlikely to bite other people, caregiver should be watchful and alert when looking after them, and avoid contact with patient’s saliva.

TRANSMISSION Risk of developing clinical rabies

Approximately 15-20 % Influenced by:

1. Virus content of saliva- intermittent viral shedding in saliva

2. Severity of the bite3. Location of the wound4. Virus variant

Head 50-80%

Legs 3-10%

Finger/ Hand 15 – 40%

WHAT MATERIALS CAN SPREAD RABIES

Rabies virus is transmitted through saliva and brain/ nervous system tissue. Only these specific bodily excretions and tissues transmit rabies virus.

Contact such as petting or handling an animal, or contact with blood, urine or feces does not constitute an exposure. No PEP is needed in these situations.

EXPOSURE

The rabies virus enter the human body via exposure to an infected animal

Scratches from an infected animal can give rabies because if an animal has rabies, it often drools excessively, and the saliva drips on to its claws.

INCUBATION PERIODThe rabies virus replicates in

the muscle at the bite site.

IP: 2 weeks to 6 yearsAverage IP: 1-3 months

3 months 87%

1 month 71%

6 months 95%

INCUBATION PERIOD

The Rabies virus travels by retrograde transport along the peripheral nervous system

Speed of virus migration: 12-24 mm/day

Length of Incubation Period affected by: Infecting strain Size of inoculum Degree of innervation Proximinity to CNS

INCUBATION PERIOD

SIGNS AND SYMPTOMS

PRODROMAL PHASEThe rabies virus replicates in the dorsal root ganglion and travels along the CNS

Manifestations:o Fatigue/ Malaiseo Headacheo Anorexiao Fevero Pain, Itching, numbness at

the bite site

Duration: 2-10 days

ACUTE NEUROLOGIC PHASE

Hydrophobia Fear of water (shows

panic when presented with liquids to drink)

Difficulty swallowing Painful spasm of the

muscles in the throat and larynx

Hypersalivation Aerophobia Restlessness, aggression,

hallucinations. seizure

Lack of aggression Weakness Can be mistaken for

GBS

The Rabies Virus Infect the brain

Duration: 2-7 days

Encephalytic/ Furious/ Frantic Type Paralytic/ Dumb Type

COMA Onset of complications

Respiratory Cardiovascular Neurologic Pituitary Others

Ends in Death in almost 100% of cases

WHAT SHOULD WE DO WHEN A PERSON SHOWS ANY OF THESE SYMPTOMS?

Take them immediately to the nearest health facility.

Rabies cannot be cured once the symptoms appear in a person, but the person ca be made comfortable and given medicines to help relieve the suffering.

Provide comfort to the patient’s family

THE OUTCOME IS DEATH…

…PREVENTION is the answer

RABIES PREVENTION

• Animal Rabies Control• Human Rabies Control• Post-exposure prophylaxis (PEP) – for exposed individuals• Pre-exposure prophylaxis (PrEP) – before exposure, to high risk individuals

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Rabies prevention

ANIMAL RABIES CONTROL

MASS DOG VACCINATION

Mass dog vaccination campaigns have been

most effective measures for

controlling rabies

DOG POPULATION MANAGEMENT Stray dog management

through enforced confinement of owned strays

Humane capture, euthanasia and disposal

DOG POPULATION MANAGEMENT

Surgical Sterilization Non- Surgical sterilization Habitat control

HUMAN RABIES CONTROL

Given to exposed patients

Objectives:To minimize the amount of virus at the site of inoculation

To develop a high titer of neutralizing antibody early and maintain it for as long as possible

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Post-exposure Prophylaxis

Components:

Local wound careCategorization of exposureImmunization

Active immunization Passive immunization

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Post-exposure Prophylaxis

Local wound care

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Wounds should be immediately and vigorously washed and flushed with soap and water

preferably for 10-15 minutes

Local Wound Care

Apply antiseptic (alcohol, tincture of iodine

etc)

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Local Wound Care

Local Wound Care

oGive antibiotics for: • All frankly infected wounds• All category III cat bites• All other category III bites that are

either deep, penetrating, multiple or extensive or located on the hand/face/genital area

• Drugs of choice: Amoxicillin/clavulanic OR Cloxacillin OR Cefuroxime axetil

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COIN

SUCKING THE BITE WOUND

TANDOK

BAWANG BATO

Local Wound Care: Don’ts

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Rubbing garlic on wound


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Suturing of wounds should be avoided (as it may inoculate virus deeper into the wound) Wounds may be coaptated using sterile

adhesives strips


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However, if suturing is unavoidable: RIG should be infiltrated around and into

the wound before suturing Suturing should be delayed for at least 2

hours after administration of RIG to allow diffusion of the RIG to occur through the tissues


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Categorization of exposure

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Feeding/touching an animal Licking of intact skin (with reliable history and

thorough physical examination) Exposure to patient with S/Sx of rabies by sharing

of eating or drinking utensils Casual contact to patient with S/Sx of rabies

(talking, visiting, feeding, routine health care delivery)

Category I

Wash exposed skin immediately with soap and water

No vaccine or RIG neededConsider pre-exposure prophylaxis for high risk persons

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Category I

Nibbling of uncovered skin w/ or w/o bruising/hematoma

Minor/superficial scratches/abrasions without bleeding, including those induced to bleed

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All Category II exposures on the head and neck area are considered Category III and should be managed as such

Category II

Wash wound with soap and water Start vaccine immediately RIG is not indicated Complete vaccination regimen until

day 28 if: Animal is rabid Animal is killed/died w/o testing Animal has signs and symptoms of

rabies Animal is unavailable for 14 -day

observation (e.g. stray) 43

Category II

May omit day 28 dose if: Animal is alive AND remains healthy after 14-day observation period

Biting animal died within the 14 days observation period, confirmed by veterinarian to have no signs of rabies AND was FAT-negative

Patients who have completed 3 doses (day 0, 3 and 7 doses) are considered to have completed pre-exposure prophylaxis

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Category II

Transdermal bites (puncture wounds, lacerations, avulsions, deep abrasions) or scratches with spontaneous bleeding

Licks on broken skin or mucous membranes (eyes, oral/nasal, genital/anal mucous membranes)

Exposure to a rabies patient through bites, contamination of mucous membranes or open skin lesions with body fluids through splattering, through mouth-to-mouth resuscitation

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Category III

CATEGORY III

Unprotected Handling of infected carcass Ingestion of raw infected meat All Category II exposures on head and neck area

Exposure to bats

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Category III

Wash wound with soap and water Start vaccine and RIG immediately Complete vaccination regimen until day 28 if:

Animal is rabid Animal is killed/died w/o testing Animal has S/Sx of rabies Animal is unavailable for 14 -day observation (e.g. stray)

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Category III

May omit day 28 dose if: Animal is alive AND remains healthy after 14-day observation period

Biting animal died within the 14 days observation period, confirmed by veterinarian to have no signs of rabies AND was FAT-negative

Patients who have completed 3 doses (day 0, 3 and 7 doses) are considered to have completed pre-exposure prophylaxis

Category III

IMMUNIZATION

ACTIVE IMMUNIZATION

o Vaccine is administered to induce antibody and T-Cell production in order to neutralize the rabies virus in the body.

o It induce an active immune response in 7-10 days after vaccination.

ACTIVE IMMUNIZATION

Type of Rabies Vaccines and DosageThe NRPCP shall provide the following anti-rabies tissue culture vaccines(TCV):a) Purified Vero Cell Rabies Vaccine (PVRV)-

0.5ml/vialb) Purified Chick Embryo Cell Vaccine (PCECV)-

1.0ml/vialGeneric Name Preparation DosePurified Vero Cell Rabies Vaccine (PVRV)

0.5ml/vial ID- 0.1 mlIM- 0.5 ml

Purified Chick Embryo Cell Vaccine (PCECV)

1ml/vial ID- 0.1 mlIM- 1.0 ml

Requirements for Vaccines• Registered with and approved by FDA• WHO prequalified• Proven safe and efficacious for PEP when administered by the IM/ID route using WHO recommended schedules• Vaccine potency

• IM use - at least 2.5 IU/dose • ID use - at least 0.5 IU/dose

• Product insert must contain the vaccine’s approved ID dose consistent with its CPR

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Day 0 Day 3 Day 7

ID dose = 0.1 mlDay 28

Updated 2-site ID regimen

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Day 0 Day 3 Day 7 Day 14 Day 28

IM dose = 0.5 ml for PVRV; 1.0 ml for PCECV

Into the deltoid muscle or anterolateral thigh in infants

5-dose Intramuscular regimen

o To neutralize rapidly the virus locally in the wound before it reaches the local nerve endings

(usually 7 to 14 days later)

Passive Immunization

PASSIVE IMMUNIZATION

To provide the immediate availability of neutralizing Ab at the site of the exposure before it is physiologically possible for the

patient to begin producing his or her own Ab after vaccination

RABIES IMMUNE GLOBULINComputation and Dosage of RIG

a. HRIG at 20 IU/kg. body weight (!%) IU/ml)50kg. Patient X 20 IU/kg- 1,000 IU1,000 IU ÷150 IU/ml= 6.7 ml

b. ERIG/ F(ab’)2 at 40 IU/kg. body weight (200IU/ml)

50kg. Patient X 40 IU/kg- 2,000 IU2,000 IU ÷200 IU/ml= 10 ml

Guidelines for Passive Immunization

A skin test is performed prior to ERIG administration and read after 15 min Induration of > 6 mm = positive skin test Hypersensitivity to ERIG may not be predicted by skin test. Always be ready with epinephrine and antihistamines for treatment of hypersensitivity Patients should be observed for at least 1 hr after injection of ERIG

Passive Immunization:Skin testing for ERIG

There are no scientific grounds for performing a skin test prior to administering equine immunoglobulin because testing does not predict reactions, and it should be given whatever the result of the test.

The treating physician should be prepared to manage anaphylaxis which, although rare, could occur during any stage of administration.

WHO position paper, 2010

Use of HRIG

HRIG is preferred in the following circumstances: history of hypersensitivity to equine sera multiple severe exposures (especially where

dog is sick or suspected of being rabid) symptomatic HIV infected patients


RIG should be given as a single dose for all Category III exposures, in combination with anti-rabies vaccine Dose: HRIG - 20 iu/kg ERIG - 40 iu/kRIG should be infiltrated around and into the wound as much as anatomatically feasible, even if the lesion has begun to healAny remaining RIG should be administered IM at a site distant from the site of vaccine injection


o Avoid multiple needle injectionso If a finger/toe needs to be infiltrated, care must

be taken not to impair blood circulationo Injection of excessive amount may lead to

cyanosis, swelling, pain

GUIDELINES FOR PASSIVE IMMUNIZATION

o RIG should not exceed the calculated dose as it may reduce the efficacy of the vaccine

o If the calculated dose of RIG is insufficient to infiltrate bite wounds, it may be diluted with sterile saline 2 or 3 fold for thorough infiltration

o Can infiltrate RIG even if wound is infected

Guidelines for Passive ImmunizationRIG should be administered at the same time as the first dose of vaccine

If RIG is unavailable when the first dose of vaccine is injected, it may be given until 7 days after the first dose of the vaccine. Beyond day 7, RIG is no longer indicated, regardless of whether day 3 and 7 doses were given

In the event that RIG and vaccine cannot be given on the same day, the vaccine should be given before the RIG since the latter inhibits the development of Ab from immunization

RIG is given only once during the course of PEP

PEP under Special Conditions• There are no contraindications to

rabies PEP

pregnant newborns

Immune-compromised

elderly

Sick

Local wound treatment

Previously Immunized Animal BitePatients

Guidelines1. Patients with chronic liver disease and those taking

chloroquine and systemic steroids should be given standard IM regimen as the response to ID regimen is not optimum for these conditions

2. Immunocompromised individuals should be given vaccine using standard IM regimen and RIG for both Category II and III exposures

Patients with hematologic conditions where IM injections are contraindicated, should receive rabies vaccine by ID route.

3. Delay in consult Treat as if the exposure occurred recently If the biting animal has remained healthy and alive w/o

signs of rabies until 14 days after the bite, no treatment is needed

Guidelines

4. Shifting from one vaccine brand to another is not recommended but may be warranted for the ff situations provided that it is one of the WHO recommended cell culture vaccines:

Severe hypersensitivity reaction unavailability of initial vaccine used

5. Shifting from one regimen to another is not recommended. As much as possible the initial regimen should be completed.

Guidelines6. Missed doses delay in day 3 (2nd) dose

If delay is 1-2 days from day 3 schedule – give day 3 dose upon visit and follow the original schedule of day 7 and 28/30.

If delay is 3-4 days from day 3 schedule- give day 3 dose upon visit, adjust succeeding doses (day 7 and 28) according to the prescribed interval.

If delay is > 4 days from day 3 schedule – restart a new course

Guidelines6. Missed dosesdelay in day 7 (3rd) dose

If delay is <7 days from day 7 schedule - give day 7 dose upon visit, give day 28 dose as originally scheduled

If delay is >7 - 14 days from day 7 schedule – repeat day 3 dose and revise according to the prescribed interval

If delay is > 14 days from day 7 schedule - restart a new course

delay in day 28 (4th) dose

give day 28 upon visit; this may be considered as a booster.

If RIG has already been administered, it should not be given again

Guidelines8. Bites by vaccinated dogs/catsPEP is not recommended for Category I exposuresPEP can be delayed* for CATEGORY II bites provided that ALL of the following conditions are satisfied:Dog/cat is healthy and available for observation for 14 daysDog/cat was vaccinated against rabies for the past 2 years: Dog/cat must be at least 1 yr 6 months old and has updated

vaccination certificate from a duly licensed veterinarian for the last 2 years

The last vaccination must be within the past 12 months; the immunization status of the dog/cat will not be considered updated if the animal is not vaccinated on the due date of the next vaccination

* If biting dog/cat becomes sick or dies within the observation period, PEP should be started immediatelv

Joint DA-DOH AO 2011-002

Guidelines8. Bites by vaccinated dogs/catsPEP should be given immediately for ANY of the following conditions:Category III exposureThe dog/cat is proven rabid/sick /dead with no

laboratory exam for rabies/not available before or during the consultation;

The dog/cat is involved in at least 3 biting incidents within 24 hours or

Dog/cat manifests behavioral changes suggestive of rabies before, during or after the biting incident

Pre-exposure prophylaxis

o Given prior to exposureo Benefits

o The need for RIG is eliminatedo PEP vaccine regimen is reduced

from five to two doseso Protection against rabies is possible

if PEP is delayedo Protection against inadvertent

exposure to rabies is possibleo The cost of PEP is reduced


Target population Personnel in rabies diagnostic or research

laboratories Veterinarians and veterinary students Animal handlers Health care workers directly involved in care of

rabies patients Individuals directly involved in rabies control Field workers Rabies Act of 2007 provides for pre-exposure

immunization of children 5-14 yrs old living in areas with high incidence of rabies


Day 0

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Day 7 Day 21/28

IM dose = 0.5 ml PVRV or 1.0 ml PCECVID dose = 0.1 ml PVRV/ PCECV

There is no need to restart series if doses are not given on the exact schedule Into the deltoid muscle or

anterolateral thigh in infants

Booster doses

Routine boosters in the absence of exposure Recommended only for those with continuous

and frequent risk Not necessary for general population

In the event of an exposure, previously immunized persons require 2 booster doses regardless of time interval from last dose to repeat exposure

Day 0, Day 3; 1 dose each

THINGS TO REMEMBER The best way to control rabies is to vaccinate

dogs regularly Rabies vaccination is only effective during

the incubation period After clinical symptoms appear the patient

usually dies within few days There is no test to diagnose rabies before the

symptoms appear Traditional or folk practices cannot cure or

prevent rabies

THANK YOU…

THANK YOU

THANK YOU

Environment

Basic rabies-for-dep ed