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What system of thebody does Rabies

virus mainly affect?

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What kind ofnucleic acid does a

Rabies viruscontains in its core?

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Click to edit Master subtitle style

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RabiesDr. May Grace N. RolleDFCM Resident

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RABIES A fatal zoonoticviral disease of the

central nervoussystem (CNS) that

is transmitted tohumans by infectedanimals.

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Etiology

Rabies virus is a memberof the genus Lyssavirus inthe family Rhabdoviridae.

Rhabdos, meaning"rodlike," refers to the

distinctive elongated shapeof these viruses.

enveloped virions - single-

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RABIES

A neglected disease that is 99.9% fatalbut 100% preventable

Globally it is the 10th leading cause ofdeath due to infection in humans

China- Leading cause of infectiousdisease mortality in 2006

Predominant affects poor people indeveloping countries

60,000 deaths annually, mostly in Asiaand Africa

- 99% in developing countries

- 50% are children

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Rabies and Animal bites inthe Philippines

Rabies continues to be a public health problemin the Philippines

Philippines- 6th in rabies incidence in the

world 200- 300 deaths per year (269 in 2007)

Majority of bite victim are children under

the age of 15 years old

Dogs remain the principal cause ofanimal bites and rabies cases in 2006 in

2007 (90%)

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10,000

120,000

70,000

20,000

90,000

150,000

BITEVICTIMS

BITE VICTIMS VS RABIES CASES

20021992 1993 1994 1995 1996 1997 1998 1999 2000 2001

350

450

300

400

500

RABIES CASES

2003 2004 2005

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0

1

2

3

4

5

6

7

8

9

10

Animal Bite Consults for 2008 and 2010

No. Of Patients

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Transmission

Transmitted to humansfollowing a bite from aninfected animal.

Rabies virus is the formcarried by dogs andaccounts for most human

rabies globally. Non-bite exposures are

also possible and include

being scratched, being

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6/24/12 Pathophysiology

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Negri Body

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Rabid Animal

Refers to biting animal withclinical manifestation of

rabies and/or confirmedlaboratory finding of rabies.

A i l h i

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Animals that can transmitrabies

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DEFINITIONOF TERMS

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DEFINITION

OF TERMS

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Active Immunization:Refers to the administration of a vaccine to

induce protective immune response

Passive Immunization:

Refers to administration of pre- formedantibodies (immune globulins or passiveimmnunization products) to provideimmediate protection. These antibodies

come from either human or animal source

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Immunocompromised Host refers to patientsreceiviing

immunosuppressive drugssuch as systemic steroid(not topical or inhaled) and

chemotherapeutic drugsfor cancer, patients takingchloquine, AIDS and HIVinfected patients. Thesepatients are expected to

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CATEGORIZATION OFRABIES EXPOSURE

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CATEGORY I

Feeding / touching ananimal

Licking of intact skin (with

reliable history andthorough PE)

Exposure to patient with

signs and symptoms ofrabies by sharing of eatingor drinking utensils

Casual contact (talking to,

PRE-EXPOSUREPROPHYLAXIS

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Pre-exposure Prophylaxis

Vaccination of School

Children

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PRE-EXPOSUREPROPHYLAXIS

?

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Approved TCV

Generic Name Preparation Dose

Purified verocell rabies

vaccine (PVRV)0.5 ml/vial

ID 0.1 mlIM 0.5 ml

Purified chickembryo cell

vaccine

(PCECV)

1 ml/vialID 0.1 mlIM 1.0 ml

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CATEGORY I

MANAGEMENT

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PrEP

Schedule

PVRV PCECV

Day 0 Day 7Day

21/28Day 0 Day 7

Day21/28

ID 0.1ml

0.1ml

0.1ml

0.1ml

0.1ml

0.1ml

IM 0.5ml

0.5ml

0.5ml

1 ml 1 ml 1 ml

TAKE NOTE:Give only at ONE SITE for allvaccine types.

re xposure

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re- xposureProphylaxis

Consist of three doses of 0.1 ml ofPCEC or PVRV given intradermally(ID) or 1 vial of 1 ml of PCEC or 0.5ml of PVRV given intramuscularly

(IM) on the following days:Day 0 Day 7 Day 21/28

One booster dose every one to threeyears

depending

on risk exposure

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CATEGORY II

Nibbling of uncovered skinwith or withoutbruising/hematoma

Minor scratches/abrasionswithout bleeding

Minor scratches/abrasions

which are induced to bleed All Category II exposures

on the hand and neck are

considered CATEGORY III

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CATEGORY III

Transdermal bites (punctured wounds,lacerations, avulsions) orscratches/abrasions with spontaneous

bleeding Licks on broken skin Exposure to a rabies patient through

bites, contamination of mucous

membranes or open skin lesions withbody fluids through splattering andmouth-to-mouth resuscitation

Handling of infected carcass oringestion of raw infected meat

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MANAGEMENT

Of Category II and III

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CATEGORY IIMANAGEMENT

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Approved TCV

Generic Name Preparation Dose

Purified verocell rabies

vaccine (PVRV)0.5 ml/vial

ID 0.1 mlIM 0.5 ml

Purified chickembryo cell

vaccine (PCECV) 1 ml/vialID 0.1 mlIM 1.0 ml

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SCHEDULE OF ACTIVEIMMUNIZATION

RegimenDose

No. of doses on specifieddays

PVRV PCECV Day 0 Day 3 Day 7Day

28/30Modified2-site IDregimen

0.1ml

0.1 ml 2 2 2 2

StandardIMregimen

0.5ml

1.0 ml 1 1 1 1

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A2.2-site IntradermalRegimen

(Modified TRC ID regimen: 2-2-2-0-2)Day0

Day 3 Day 7

Day30

ID dose = 0.1 ml

PCECV/PVRV

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CATEGORY IIIMANAGEMENT

Passive Immunization

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Passive ImmunizationWHO and DOH approved

RIGGeneric Name Preparation Dose

HRIG150 U/ml(2ml/vial)

20 U/kg

ERIG 200 U/ml(5ml/vial)

40 U/kg

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Post Exposure Prophylaxis(PEP)

RIG Infiltration Anti Rabies Vaccination

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Delay in dosing scheduleDelay in Day 3 dose If delay is 1-2 days from day 3

schedule, give day 3 dose upon visitand follow the original schedule of day7and day28/30If delay is 3-4 days, give day3 upon

visit and adjust succeeding dosesIf delay is >4days, restart

Delay in Day 7 dose If delay is < 7 days from day7, giveday7 dose upon visit, give day28/30 as

scheduledIf >7-14 days, repeat day3 dose andrevise accdglyIf delay is >14days, restart

Delay in Day 28/30dose

Give anytime on visit

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Updates on AO 2011-0002

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Can PEP be delayed forCategory II exposures?

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Provided ALL of thefollowing are satisfied:

Animal available forobservation for 14 days.

Vaccinated against rabies forthe past 2 years: Must be at least 1 year and 6

months old and has updatedvaccination certificate from a

duly licensed vet for the last2 years Last vaccination must be

within the past 12 months

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* If biting dog/catbecomes sick ordies within theobservationperiod, PEPshould be startedimmediately

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PEP should be given immediately forANY of the following conditions:

1. rabies exposure is category III;

PEP h ld b i i di t l

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2. The dog/cat is provenrabid/sick/ dead with nolaboratory exam forrabies/not available before orduring the consultation;

PEP should be given immediatelyfor ANY of the following conditions:

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3. The dog/cat is involved in at least 3 biting

incidents within 24 hours or

PEP should be given immediatelyfor ANY of the following

conditions:

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4. Dog/cat manifests the following behaviour

changes suggestive of rabies before, during orafter the biting incident:

PEP should be given immediatelyfor ANY of the following conditions:

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What do we do for

previously immunizedanimal bite patients?

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PEP Schedule for previouslyimmunized animal bite patients

PrEP / PEP History Give RIG MANAGEMENT

Completed PrEP onDays 0, 7, and 21/28ORCompleted PEP onDays

0, 3, 7 of ID/IM dose

NO

Give 0.1 ml ID dose at 1 siteeach on D0, D3OR1 vial IM dose at 1 site eachon D0, D3

DID NOT COMPLETE 3doses of PrEPOR

Received ONLY 1 or 2ID IM dose of PEP

Ifindicate

d

Give full course of PEP

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Tetanus Prophylaxis

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Indication forTT

immunization

Vaccination History

Unknown or

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Routine Booster Doses for

previously immunizedindividuals

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Involved

Personnel

PrEP

immunization

Serologi

c test

Booster dose

With

exposure

Without

definiteexposure

All workersin rabieslabs

Recommended

Every 6months

1boostereach onD0 and

D3

No boosterif Ab titers> 0.5 IU/ml

1 booster ifAb titers fallbelow 0.5IU/ml

If no serotest, 1boosterdose every5 years

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InvolvedPersonnel

PrEPimmunization

Serologictest

Booster dose

Withexposure

Without definiteexposure

All vets, vet

students,animalhandlers (dogtrainers,workers in pet

shops, zoos,etc.)

Recommended Every 2

years

1 booster

each onD0 and D3

No booster if

Ab titers > 0.5IU/ml

1 booster if Abtiters fall below0.5 IU/ml

If no sero test,1 booster doseevery 5 years

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InvolvedPersonnel

PrEPimmunization

Serologictest

Booster dose

Withexposure

Without definiteexposure

HCW involved

in care ofrabiespatients;involved inrabies control

program; fieldworkers;morticians

Recommended None 1 booster

each onD0 and D3

1 booster dose

every 5 years

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InvolvedPersonnel

PrEPimmunization

Serologictest

Booster dose

Withexposure

Withoutdefinite

exposureGeneralpopulation

Notrecommendedbut may beconsidered as

an option inyoungchildren andother

individuals

None 1boostereach onD0 and

D3

None

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Special Conditions

1.Pregnancy and infancy arenot contraindications totreatment with TCV;

2. Avoid chloroquine, systemic

steroids and heavy alcoholconsumption during rabiesimmunization as they mayinterfere with the immuneresponse. If this cannot beavoided, the standard IMregimen should be used

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Special Conditions3. Immunocompromised

individuals (HIV infection,

cancer/transplantpatients onimmunosuppressivetherapy etc) should be

given vaccine usingstandard IM regimen andRIG for both Category IIand III exposures

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Management of

rabid patients No cureonce symptoms of

rabies set in Recommended care

Adequate sedation Comfort care - appropriate

medical facility with suitableemotional and physical support

Once rabies diagnosis hasbeen confirmed, invasiveprocedures (intubation andlife-support measures) shouldbe avoided

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Management of rabid

patients Infection control Patients should be admitted in

a quiet, draft-free, isolationroom.

Healthcare workers andrelatives coming in contact

with patients should wearproper personal protectiveequipment (PPE) includinggown, gloves, mask, goggles

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RABIS:

Tuod ukon Indi

Tuod

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Butangan ahos,

kapayas, kagmga dahon-dahon ang pilaspara dasig mag-ayo.

INDI

TUOD

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MagpaTANDOK

para maayo angkinagtan ka idokag para indimagka-RABIS.

INDI

TUOD

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Indi pwede

maligo kungnakagat ka idokay dasigmalapta angRABIS.

INDI

TUOD

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Obserbaran ang

ido bag-omagpakonsultasa duktor. INDI

TUOD

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Kung na-

immunize naang ido, indi nakelanganmagpaAntiRABIS.

INDI

TUOD

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Dapat

magpakonsultagilayon konmakagat kasapat (ido,kuring, baboy,ukon amo).

TUOD

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Hugasan gilayon

sang tubig kaghabon angkinagat ka sapat. TUOD

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Ang gabusong

kag mga lapsagpwedemaImmunizepangontraRABIS.

TUOD

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Kon malatnan

kaRABIS, maykaayuhan pa ini.

INDI

TUOD

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Mapatay ang isa

ka tawo konmalatnan kaRABIS. TUOD

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In what category ofRabies exposure does

a minor scratch /abrasion which areinduced to bleed

belong?

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In what category ofRabies exposure does

handling of infectedcarcas or ingestion ofraw infected meat

belong?

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In what category ofRabies exposure does

abrasion on the facewith no spontaneousbleeding belong?

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In what category ofRabies exposure does

licking of intact skinbelong?

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ThankYou