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Department of HealthandDepartment of AgricultureFebruary 2,2411

DEPARTMENT OF I{EALTHADMINISTRATIVE ORDER NO. 2 O II - OOO2DEPARTMENT OF AGRICULTURF-ADMINISTRATIVE ORDER NO. ? ISERIES 2011

SUBJECT:

BACKGROI JIID/RATIONALERabies, present in all continents and endemic in most African and Asian countries, isa fatal zoonotic viral disease, transmitted to humans through contact with infectedanimals, both domestic and wild. Rabies is estimated to cause at least 55,000 deaths peryear worldwide, about 56% of which occur in Asia and 43.6Yo in Africa" particularly inrural areas on both continents. In the Philippines, although rabies is not among theleading causes of morbidity and mortality, it is considered a significant public^health

probleir for several reasons: l) it is one- of the most acutely fatal infections; 2) it isresponsible for the death of 200-fOO Filipinos annually and 3) post-exposure prophylaxis(PEP) for victims of animal bites entails considerable expense'The Departrnent of Health and Department of Agriculture continues to be committedto the fighi against rabies and has set the goal of rabies elimination in 2020. An essentialpart of tttir tttut"gy is the provision of Fnp to bite victims as mandated by the Anti-itabies Act of 2007. pursuant thereto, guidelines for the appropriate as well as cost-effective management of animal bite patients have been issued.Historically the management of animal bite cases had to be updated every five (5)

years and the guidelinesleed to be revised accordingly to incorporate new and betterireatnent modalities based on research results and recommendations of inte-rnationalbodies. The first revision was made rnlggT,the second in2002 and the 3'd in 2007which was amended in 2009.Since the release of the latest guidelines in 2009, the issue on the management ofrabies exposure secondary to bites from vaccinated dogs and cats has not beenadequately addressed. Thii has been consistently raised by veterinarians in many for4particulariy the issue on g1ing PEP to all bite cases even those involving vaccinatediogs and cats. Given the above situatiorU a joint DA- DOH Administrative Order ishereby issued. I

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U. DECLARATION OF POLICIESThese operational guidelines shall be guided by- fhe follou{ng legal mandates mdpolicies:

A. Republic ^ct 9482 or the Anti-Rabies Ae of 2O$7 * An Act Providing for the Cantroland Elimination of Humam and Animal Rabies, Prccribing Penalties for ViolationThereof and Appropriating Funds Therefor.B. Memorandum of Agrement entered into by the Secretaries of the Department ofAgriculture, Health, Education, Culture and Sport and &e Interior and Local

Gor,-ernment on May 8, l9gl.C. Batas Pambansa Blg. 9? - An Act Pro*.iding for the Compulsory Immunization ofLivestock, Poultry and OtherAnimals Against Dangerous Communicable Diseases.D. DOH Administratile Order iqol eoOZ- 0o29: Guidelines on Management of AnimalBite PatientsE. DOH Administrdiv-e Order No. 2009- 0027: Amendment to AO 2W7- OO29regarding the Revised Guidelines on Management of Animal Bite PatientsA. WHO Expert Consultation on Rabies. WHO Technical Report Series 931 First Report2AA5

GOALS AI{D OBJECTIVESTo provide updated guidelines and procedures to ensure the effective and efficientrnanagemefi of rabies xposures toward eventual reductioq ifnot eliminatiorq of humanrabies

SCOPE AND COVERAGEAll govemment heatth workers at atl levels shall adopt these Post ExposureProphylaxis (PEP) guidelines to eRsure standardized and rational management of animalbite patients. Private practitioners in the country are strongly encouraged to adopt theseguidelines.

DEFINITION OF TERMSA. Post Exposure Proplryla:ris (PEP) - formerly post enposrre ireafinent (PETi;refers to mti-rabies treafrnent administered afier anexposure {such as bitgscratctr, lick, etc-) to poteirtially rabid animals- It includes local wound carg

administration of rabies vaccine with or without Rabies Immune Globulin(RIG) deffdir on the calegory of exposure.B. Updated rabis vaccindion- Dog/cat mustbe at least 1 yr6 nnnths old andhas updatd vaccination certificate from aduly licensed veterinarian for thelast 2 years with the last vaccination within the past 12 months.C. Rabid Animal - refers to biting animal with clinical manifestation of rabiesand/or confirmed laboratory findinss of rabies.

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vr. GENERAL GUIDELII\{ESA. The Department of Health in collaboration with the LGUs shall be resporxiblefor the managernnt of animal bite victims including provision of humanrabis vaccine to alrgmenl stryplies of the LGUs.B. The Rabies Control Prograrn shall be integrated with the regular health

services provided by local health facilities.C. PEP shall be carried out both by the Departrrnent of Health and LocalGovemment Units.D. The funding requirements to operationalize this issuance shall be secured priorto its implementation.E. Advocacy througfu informafion dissernindion and training of health workersshall be conducted at all levels.F. Collaboration among govemment agencies, non-govemment and privateorganizations to ensure successful implementation shall be sre,ngthend.VII. SPECIFIC GUII}ELINES AND PROCEDURES :

A. Categorizatioa of Babies Exposurrc:Table l. Categories of Rabies Expsure

Category ofexposune Type of ExFlsuneCATEGORY I a) Feeding/touching an animal

b) Licking of intaa skin (with reliable history and thorough physicalexaminaion)c) Expozure to patient with signs and rymptoms of rabies by sharingof eating or drinking utensilsd) Casual contact (talking to, visiting and feeding suspected rabiescass) and routine delivwy of health care to pdient with signs andsymptoms of rabie

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CATEGORY II a) Nibbling of uncovered skin with orwithout bruising/hematomab) Minor scratcheslabrasions without bledingc) Minor scratches/abrasions which are induced to bleedd) All Category II exposrnes on the head and nwk area are consideredCategory III and should be managed as such

CATEGORY III a) Transdermal bites (puncture wounds, lacerations, avulsions) orscratches/ abrasions with spontaneous bleeding

b) Licks on broken skinc) Expozure to a rabis patient through bites, contarrirdion ofmucous membranes (eyes, oral/nasal mucos4 gelritayanal mucousmembrane) oropen skin lesions with body fluids throughsplattering and mouth'to-mouth resuscitation.d) Handling of infected carcass or ingestion of raw infected meate) All Category il expos.nes onhead and neck area

B. ManagernentI. PEP is not rccomnended for all Categorlr I exmsurcs.II. PEP can be delayed for @ providd that ALL of thefollowing conditions are satisfied:

i. Dog/cat is healthy and available for observation for 14 daysii. Doglcat was vaccinated against rabies for the past 2 years.a- Dog/cat must be at least 1 yr 6 monttu old and has updatedvaccination certificate from a duly licersed veterinarian for thelast 2 yearsb. The last vaccination must be within the past 12 months, theimmunization status af the do$cat will not be consideredupdated if the animal is not vaccinatsd on the due date of thenext vaccinalion* If biting dog/cat becomes sick or dies within the observation period, PEP should

be started immediatelv

III. PEP should bc given immediatety for ANY of the following conditions:i. Ths rabies s(posure is caregory III;ii. The dog/cd is proven rabidlsicld dead with no laboratory exam forrabies/not available before or during ihe consultation;iii. The dog/cal is involved in at least 3 biting incidr$s within 24 hows oriv. Doglcat manifests the following behavior change zuggestive of rabiesbefore, during or after the biting incideirt:

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Table 2. Clinical Si of Animal RabiesProdromal Stace (uzuallv lasts 2-3 davs: sometime onlv a few hous)A. Changes in attitude/behavior/temperanrent sudr as unusual shyness oraggressivenessL Friendly animal becomes aggressiveb. Solitude

c. Rstlessnessd. Snapping at imaginary objectse. Apprehensionf Nervousnessg. Anxiefyh. Brkiag/vocalization at the slightest provocationB. Dilated pupils; become myotic in advance stateC. Mydriasis and/or sluggish palpebral or comeal reflexesD. Slisht rise in body temperature (slisht fever)Clinical RabiesFurious Stage (usually lasts 1-7 days) ParalSrtic (dumb) shge (develops 2-10days after clinical signs; usually last2-4davs)L Increased response to auditoryand visual stimulation such aso Restlssnesso PhotophobiaI Hyperaesthesi4r Eating unusual objectst Aggressiono Attacking any live orinanimate objectsII. Erratic behaviorr Bitingor snappingr Licking or chewing ofwound/bite siteo If caged, biting of theircageo Wandering and roamingo Excitabili8:rtrritability;o VicioumessIII. SellmutilationIV. Muscular in-coordination and

seizuresV. Disorientationr Roams and bitesinanimate object and alsoother animals includingilun

Paralysisa Paralysis may begin at the bite

areaAnd progress until entire CNSinvolvementFollowing paralysis of the headand neclg the entire bodybecomes paralyzsChange in tone ofvocalization/barking (indicativeof laryngeal/phryngealparalysis)Hypersalivation or frothing ;drooling/slobbering of saliva(indicative oftaryngeaVpharyngeal paralysis)Dysphagia/diffi culty/inability toswallow (indicative oflaryngeaVpharyngeal paralysis)"Jaw drop"/Dropped jaw due tomasseter muscle paralysis

(suspects foreign body in mouthor esophagus)Pupil dilation or pupilconstrictionProtrusion of third eyelidAtaxia, progressive paralysis andcannibalism (terminal stage)Coma andlor respiratoryparalysis resulting in deathwithin 24 davs

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IV. PEP is not required for bite/s of the following biting animals: rds, mousgrabbits, makes and other reptiles, birds and other avian, insects and frsh.VIIL IMPLEMENTINGMECHANISM:

a Roles and Responsibilitiesi. Departrnent ofHealth1. The National Center for Disease Prevention and Control{NCDPC) shall be rmponsible for disseminating &is Joint AOto all Centers for Health Development.2. All Centers for Health Developmort (CHD) through theDirectors and the Rabie Control Program Coordinators shallensure that this Joint AO is disseminated to allProvinciaUCity/Ivlunicipal Health Offices, Animal BiteTreatrnent Centers and private practitioners, hospitals andanimal bite clinics in their respective regions.

Department o f Agriculturel. The Bureau of Animal Industry (BAI) shall be responsiblq fordisseminating this Joint AO to all DA- Regional Field Units2. The Department of Agriculture - Regional Field Units (DA-RFUs) ttnoughthe Regional Executive Directors and theRabies Control Program Coordinators shall ensure that thisJoint AO is disseminated to all ProvinciaVCity/MunicipalVeterinary Offices or their equivalents in their respectiveregions.

Local Govemment Units:The Provincial Health Offices shall be responsible fordisseminating this Joint AO to all Cityllvlunicipal Health Offices,Animal Bite Treatment Centers and private practitioners, hospilals andaniml bite clinics in their rspective provinces. Likewise, TheProvincial Veterinary Offices shall be responsible for disseminatingthis Joint AO to all City/efmicipal Veterinary Offices or theirequivalents in their respective provinces.Ix. REPEALING CLAUSE

The provisions of the National Rabies Prevention and Control Program Manual ofOperations, National Rabies Cornmittee CY 20Sl and any other issuances inconsistenthere$.ith are hereby rescinded"

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X. EFFECTTYITYThis order shall take effect immediatel-v.

ENRTQUE T. ONA, MD, FPCS, FACSSecretarv of Health

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