Dave Jay S. Manriquez RN. R A B I E SFAST FACTSDEFINITION: An acute infectious disease of warm-blooded animals characterized by involvement of the nervous system resulting in death. It is caused by the RABIES VIRUS, a rhabdovirus of the genus lyssavirus. 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. LYSSAVIRUS: Greek – frenzy. A genus of the family Rhabdoviridae. There are 2 kinds of rabies. URBAN or CANINE RABIES are transmitted by dogs. SYLVATIC RABIES are transmitted from wild animals and bats which sometimes spread to dogs, cats and livestock.MODE OF TRANSMISSION: It is commonly communicated to man through the saliva of an infected mammal by an exposure to an open break in the skin such as bites 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.MEDIA OF TRANSMISSION: Through saliva, tears, urine, serum, liquor and other body fluids.INCUBATION PERIOD: The period between the exposure to the virus to the occurrence of the first symptom, is usually 2-8 weeks. It may be as short as 4 days or as long as 2 years depending on depth of laceration and site of wound. The virus moves along nerve axons passively about 3 millimeters per hour. It is not known how the virus remains viable or where it is located during prolonged incubation period.SUSCEPTIBILITY AND RESISTANCE: All warm-blooded mammals are susceptible. Natural immunity in man is unknown.DIAGNOSIS: There is yet no way of immediately segregating thosewho had acquired rabies infection from those who had beenbitten by non-rabid sources. No tests are available to diagnoserabies in humans before the onset of clinical disease. Themost reliable test for rabies in patients who have clinical signsof the disease is DIRECT IMMUNOFLUORESCENT STUDY of afull thickness biopsy of the skin taken from the back of theneck 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.
True rabies must be distinguished from RABIES HYSTERIA, a psychological condition in persons who think they have been bitten by a rabid animal. In such cases, a patient ordinarily attempts to emulate convulsive seizures. Patient receiving rabies vaccine treatment may develop paralysis attributable to a sensitization caused by the rabbit brain material in the vaccine. This paralysis may simulate paralytic rabies and may produce symptoms referable to cranial nerves, such as difficulty swallowing, paralysis of the masseter muscles and unilateral or bilateral facial paralysis. Encephalitis without paralysis may be caused by the vaccine treatment and in such cases the disease begins with high fever and headache with may be followed by convulsions and coma.I.EPIDEMIOLOGYRABIES IN THE PHILIPPINES Although rabies is not among the leading causes ofdisease and death in the country it has become a public healthproblem of significance for two reasons: it is one of the mostacutely fatal infections which causes the death of between200-500 Filipinos annually, and the Philippines ranked numbersix among the countries with the highest reported incidence ofrabies in the world. Based on the report from NCDPC (2004), the six regionswith the most number of rabies cases are Western Visayas,Central Luzon, Bicol, Central Visayas, Ilocos and CagayanValley. Since the Philippines is highly endemic of rabies,voluntary pre-exposure prophylaxis among people who are atrisk, like pet owners, animal handlers, health personnelworking in anti-rabies units and children below 15 years old, isa must. Data shows that 53.7 percent of animal bites patientsare children. The trend for animal bite cases has increased from 1992to 2001 but decreased in the year 2002-2004. The increasingnumber of patients who are consulting the health centers foranimal bite cases is due to the increasing level of awarenesson rabies. On the other hand, the human rabies cases havebeen decreasing from 1995 to 2004. This is due to earlyprovision of post exposure vaccination to dog bite victims. Dogs remain the principal animal source of rabies.Although a great majority of animal bites are non-infected withthe rabies virus, animal control and other public health
measures are undertaken because of the high case fatalityrate for rabies. It is hard to make a definite early diagnosis of rabies, andthe disease almost always leads to death even whenvaccination and medical management are given as soon as thesymptoms have set in. Further, the cost of post-exposurevaccination against rabies can be prohibitive.II. PATHOPHYSIOLOGY Rabies virus Incubation period Entry into break in skin (4 days – 2 years) (bites, abrasions, mucosa) § Pain § Fever I NV A SI ON § Headache PHA SE § MalaiseØ Imminent thoraco- § Sore throat lumbar involvement § Anorexia (PNS): Pupillary § Increased sensitivity dilation, lacrimation,Ø increased thick saliva production / foaming of mouth, excessive perspiration EX CI TEM ENTØ Anxiety & fear PHA SE Ø Gradual weakness of muscle groups: muscleØ Hydrophobia spasms cease , ocular palsy, vertigo, facial &Ø Pronounced muscular masseter palsy, weakness of muscles of stimulation & general phonation, loss of tendon reflexes, neck stiffness tremor Ø (+)Babinski [lesions at pyramidal tract], (-)Ø Mania & Kernig’s, (-) Brudzinski’s hallucinations with Ø HR shifting from tachycardia (100-120) to lucid intervals bradycardia (40-60)Ø Convulsions Ø Cheyne-Stokes respiration PA RA LYTI C Ø Ø Local sensation diminshed (pain, heat, cold) Incoordination PHA SE Ø General arousal ( DE E PR SSION PH ) ASE Ø Bladder & intestinal retention (damage to the innervation of the musculature of intestine & bladder) Ø Hydrophobia disappear but with slight difficulty swallowing in some cases , patient shows period of recovery , this apparent remission is followed by rapid progressive paralysis Ø Ascending paralysis ,flaccid paralysis of coma extremities until it reaches the respiratory muscle Ø Apathy, stupor Death
III. SIGNS & SYMPTOMS (most common) • Sensory change on or • Insomnia near the site of entry • Convulsions • Fever • Salivation or foaming • Laryngeal spasm of the mouth • Sense of apprehension, • Acute attack: fever, anxiety, irritabilty muscle twitching, • Headache hyperventilation and • Delirium excess salivationThe usual duration is 2-6 days without medical intervention.Death is often due to convulsion or respiratory paralysis.IV. MANAGEMENT A. PREVENTION 1.Responsible pet ownership a) pet immunization, esp. cats, usually starting at 3 months of age and every year thereafter b) 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 and provide clean sleeping quarters 2.Thoroughly clean ALL BITES AND SCRATCHES made by any animal with strong medicinal soap or solution. 3.Responsible awareness. Report immediately rabid or suggestive of rabies domestic or wild animals to proper authorities (local government clinic, veterinarians or community officials). 4.Pre-exposure to high risk individuals. Veterinarians, hunters, people in contact with
animals (zoo), butchers, lab-staff in contact with rabies, forest rangers/caretakers. 5.DOH Standard Protocol a) If dog is apparently healthy, observe the dog for 14 days. If it dies or show signs suggestive or rabies, consult a physician. b) If the dog shows signs suggestive of rabies, kill the dog immediately and bring head for lab examination. Submit for immunization while waiting for results. c) If the dog is not available for observation (killed, died or stray), submit for immunization.*see DOH- Revised Guidelines on Management of Animal Bite Patients-2007 for more complete guide B. MEDICAL INTERVENTIONS a. Local wound treatment. Immediately wash wound with soap and water. Treat with antiseptic solutions such as iodine, alcohol and other disinfectants. b. Antibiotics and anti-tetanus as prescribed by physician. c. Rabies – Specific Treatment. Post-exposure treatment is given to persons who are exposed to the rabies virus. It consists of active immunization (vaccination) and passive immunization (immune globulin administration).ACTIVE IMMUNIZATION – aims to induce the body to develop antibodiesand T-cells against rabies up to 3 years. It induces an active immuneresponse in 7-10 days after vaccination, which may persist for one year ormore provided primary immunization is completed MEDICAL AGENT: Human Diploid Cell rabies Vaccine (HDCV)
PASSIVE IMMUNIZATION – aims to provide IMMEDIATE PROTECTIONagainst rabies which should be administered within the first 7 days ofactive immunization. The effect of the immune globulin is only short term.Rabies antibodies are introduced before it is physiologically possible forthe patient to begin producing his own antibodies after vaccination.Some of the RIG is infiltrated around the site and the rest is givenintramuscularly.MEDICAL AGENT: Rabies Immune Globulin (RIG) C. NURSING INTERVENTIONS 1. HIGH RISK FOR INFECTION TRANSMISSION § provide patient isolation § 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 epidermal layers of skin. § 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 organisms. § Practice isolation techniques. To prevent self- contamination and spread of disease. 2. 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 treatment. § Provide pertinent data about the disease: a. organism and route of transmission b. treatment goals and process c. community resources if necessary § allow opportunities for questions and discussions
3. ALTERED BODY TEMPERATURE: FEVER RELATED TO THE PRESENCE OF INFECTION. Since fever is continuous, 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 body … § Monitor temperature at regular intervals § Provide a well ventilated environment free from drafts and wind. 4. DEHYDRATION related to refusal to take in fluids secondary to throat spasms and fear of spasmodic attacks. § Assess level of dehydration of patient. § Maintain other routes of fluid introduction as prescribed by the physician e.g. parenteral routes § Moisten parched mouth with cotton or gauze dipped in water but not dripping.SOURCE: Taber’s Cyclopedic Medical Dictionary 17th Edition. 1994. Singapore:Davis Company. Department of Health.2000. Community Health Nursing Services inthe Philippine Department of Health, 9th Edition.Philippines.DOH Smeltzer, Suzanne and Bare, Brenda. 2000. Brunner & Suddarth’sTextbook of Medical-Surgical Nursing, 9th Edition. Philadelphia: Lippincott Williams and Wilkins
MANAGEMENT OF POTENTIAL RABIES EXPOSURE (DOH- Revised Guidelines on Management of Animal Bite Patients- 2007)I. CATEGORIES OF EXPOSURE TO A RABID ANIMAL OR TOANIMALCATEGORY I a. Feeding/ touching an animal b. Licking of intact skin (w/ reliable history and thorough physical examination) c. Exposure to patient with signs and symptoms of rabies by sharing of eating or drinking utensils * d. Casual contact to patient with signs and symptoms of rabies*Management: 1. Wash exposed skin immediately w/ soap and water 2. No vaccine or RIG needed*Pre-exposure vaccination may be consideredCATEGORY II a. Nibbling/ nipping of uncovered skin with bruising b. Minor scratches/ abrasions without bleeding** c. Licks on broken skin**includes wounds that are induced to bleedManagement: a. Complete vaccination regimen until day 28/30 if: 1. Animal is rabid, killed, died OR unavailable for 14- day observation or examination OR 2. Animal under observation died within 14 days and IMMUNOFLOURESCENT ANTIBODY TEST positive (IFAT +) OR no IFAT testing was done OR had signs of rabies
b. Complete vaccination regimen until day 7 if: 1. Animal is alive AND remains healthy after 14- day observation period 2. Animal under observation died within 14 days but had no signs of rabies and as IFAT- negative.CATEGORY III a. Transdermal bites or scratches ( to include puncture wounds, lacerations, avulsions) b. Contamination of mucous membrane with saliva (i.e. licks) c. Exposure to a rabies patient through bites, contamination of mucous membranes or open skin lesions with body fluids (except blood/feces) through splattering, mouth-to-mouth resuscitation, licks of the eyes, lips, vulva, sexual activity, exchanging kisses on the mouth or other direct mucous membrane contact with saliva. d. Handling of infected carcass or ingestion of raw infected meat e. All Category II exposures on head and neck area *Does not include sharing of food/ drink/ utensils and casual contact with rabid patientManagement: a. Complete vaccination regimen until day 28/ 30 if: 1. Animal is rabid, killed, died OR unavailable for 14 day observation or examination OR 2. Animal under observation died within 14 days and was IMMUNOFLOURESCENT ANTIBODY TEST (IFAT)- positive OR no IFAT testing was done OR had signs of rabies b. Complete vaccination regimen until day 7 if: 1. Animal is alive AND remains healthy after 14-day observation period. 2. Animal under observation died within 14 days but had no signs of rabies and was IFAT- negative
II. POST- EXPOSURE TREATMENT CONCEPT OF THERAPY/ REMEDY: removal or neutralization ofinfectious virus before it enters the Nervous System 1. Local Wound Treatment - Soap and water - Alcohol, povidone iodine or any antiseptic - Suturing of wounds should be avoided - Don’t apply any ointment, cream/ dressing - Anti-tetanus immunization 2. Antimicrobial - Amoxicillin/ clavulanic - Cloxacillin - Cefuroxime axetil 3. Vaccination - Updated 2- Site Intradermal Schedule - Standard IM Schedule
MANAGEMENT OF RABIES PATIENTS (DOH- Revised Guidelines on Management of Animal Bite Patients- 2007)Considering the fatal outcome and lack of cure for humanrabies once symptoms start, treatment should center oncomfort care, using sedation and avoidance of intubation andlife- support measures once the diagnosis is certain. 1. Medications – any of the ff. Regimens may be used: a. Diazepam b. Midazolam c. Haloperidol plus Dipenhydramine – this regimen has been used at San Lazaro Hospitald 2. Supportive Care Patients with confirmed rabies should receive adequate sedation and comfort care in an appropriate medical facility. a. Once rabies diagnosis has been confirmed, invasive procedures must be avoided. b. Provide suitable emotional and physical support. c. Discuss and provide important information to relatives concerning transmission of disease and indication for post- exposure treatment of contacts d. Honest gentle communication concerning prognosis should be provided to the relatives 3. Infection Control a. Patients should be admitted in a quiet, draft- free, isolation room. b. Healthcare workers and relatives coming in contact with patients should wear proper personal protective equipment (PPE) including gown, gloves, mask, goggles
4. Disposal of dead bodiesa. Humans who have died of rabies generally presents a small risk of transmission to others. There is evidence that blood does not contain virus but that the virus is present in many tissues such as the CNS, salivary glands and muscle. It is also present in saliva and urine.b. Embalming should be discouragedc. Performing necropsies carelessly can lead to mucous membrane and inhalation exposuresd. Wearing protective clothing, goggles, face mask and thick gloves should provide sufficient protection.e. Instruments must be autoclaved or boiled after use.f. Early disposal of the body by cremation or burial is recommended.