RABIES THE FACTS
Vijay kr. Singh
DNB PGT (Pediatrics)
Under guidance ofUnder guidance of
Dr T K MONDAL
Consultant pediatrician M R Bangur Hospital
Date 20 july 2013
DNB Seminar hall M R Bangur hospital Kolkata-33
Intoduction-Rabies is an acute viral diease
which cause fatal encephalitis in virtually all
warm blooded animals including man.
This virus is found in wild and some
domestic animal like Dog, Cat, Cattle, anddomestic animal like Dog, Cat, Cattle, and
Pigs, Mangoose and jackals and, Bats.
Human death from rabies is estimated from
26000 to 61000.
85% death occurs in rural area.
According to APCRI(Association for
preventive control of Rabies in India) thepreventive control of Rabies in India) the
annual incidence of human rabies death in
India was 17137.
In India 50-60% of rabies death occur in
children, particularly age under 15 yrs.
Shorter stature of children lead to more bite
in the upper part of the body which lead to
shorter time for virus to reach brain.shorter time for virus to reach brain.
Bites by domestic and per idomestic
mammals does not cause rabies like
Rabies virus is a single structure RNA virus
belonging to the genus Lyssavirus of the
family Rhhabdo viridae.
It is neurotropic virus and rapidly inactivated
Quaternary ammonium compound, soap and
Rabies virus enters the body through wound
or by direct contact with mucosal surface.
It can not cross intact skin.
Rabies virus replicates in the bitten muscle
and gain access to motor ends plates andand gain access to motor ends plates and
reach central nervous system not by sensory
and parasympathetic ending.
Viruses can also enter motor axon in
peripheral nerve directly during a
In Bat variant – viral propagation may also
occur via sensory nerve due skin tropism.occur via sensory nerve due skin tropism.
It is highly variable.
It varies from 5day to several yrs.
Usually 2-3 months
It is rarely more than 1 yr.It is rarely more than 1 yr.
Incubation period depends upon.
The amount of virus in the incolution
The density of motor end plates
The proximity of virus entry to CNSThe proximity of virus entry to CNS
There are two distinct clinical forms
1. Furious Rabies or encephalitis type. It is
2. Dumb Rabies or Paralytic type. It is about
Accoding to WHO
Suject presenting with an acute neurological
syndrome(encephalitis) dominated by forms
of hyperactivity(furious) or paralytic
syndrome(dumb rabies) progresssing towardssyndrome(dumb rabies) progresssing towards
coma and death, usually by cardiac or
respiratory failure, typicaly within 7-10 days
after sign, if no intensive care s instituted.
It may be used in diagnosis
Presence of viral antigen
Isolation of virus in cell culture
Presence of virus specific antibodies in CSFPresence of virus specific antibodies in CSF
or in serum in unimmunized
Suspected- It is compantable with clinical
Probable –reliable history with exposure to
Confirmed-suspected or probable case that isConfirmed-suspected or probable case that is
And tingling sensation at site of bite.
Thease symptoms are common in both type
Symptoms are mainlly related with spasm
due to stimulation of olfactory system
Myoedema (in chest, deltoid muscle , thigh)
Tingling at site of bite
Diagnosis of rabies mainly clinical
Laboratory test may be required in atypical
Ante mortem diagnosis
It is by detection of virus or viral antigen in
saliva or CSF.
Viral nucleic acid may be detected in
infected tissue by reverse transcriptase or
To detect antibodies to rabies virus
Post mortem diagnosis
Demonstration of negries body in brain tissue
CATEGORY I Licks on intact skin,
fall down on animal,
touching, feeding of
No prophylaxis if
history is reliable.
CATEGORY II Minor scratches or
bleeding or licks on
ant anti rabies
vaccine.bleeding or licks on
broken skin and
nibbling of uncovered
CATEGORY III Single or multiple
transdermal bites or
Hostory of bite
Animal vaccine failure does occur and
considering the fatal nature of the disease, it
is mandatory to start prophylaxis
After starting the vaccination, the scheduleAfter starting the vaccination, the schedule
may be modified in cases where the animal is
suspected not being rabid.
If it is healthy throughout an observation
period of 10 days by converting post
exposure to pre- exposure prophylaxis.
This observation is valid for dogs and cats
only because natural history of rabies is not
known in other animals.
Bat rabies is not conclusively proved in
Exposure to Bat bite does not warrant
Tretment must be started as soon as possible
Person who exposure is months before, must
be treated like recent exposure.
Management of wound
Passive immunization – rabies
Active immunization- anti-rabiesActive immunization- anti-rabies
Immediate washing and flushing the wound
with soap and water.
Followed by disinfection with ethanol or
Suturing of wound should be avoided.Suturing of wound should be avoided.
But if suturing is necessary, it will be loosely
sutured with infiltration of immuniglobin.
Administration of tetanus toxoid or tetanus
immunoglobin as per requirement.
Two types of RIG(Rabies immunoglobin)
ERIG Require sensitivity testing as perERIG Require sensitivity testing as per
HRIG does not require sensitivity testing.
ERIG Available in 300 IU /ml.Doses 40 IU/kg
with maximum 3000 IU.
HRIG Available in 150 IU/ml. Doses 20 IU/kg
with maximum 1500 IU.
Total calculated dose should be infiltrede
locally around the wound.
Remaining amount, if any, must be
administered deep intramuscular injection
distant site from vaccine site.distant site from vaccine site.
In case of multiple wound, ammunoglobin
mixed with normal saline and infitreted
locally and remaining will be given deep IM
RIG can be given up to 7th day of first dose of
RIG should never be given at same site or
same syringe as vaccine.
Transient tendrenes and mild fever mayTransient tendrenes and mild fever may
occurs, required no any treatment.
RIG never be used intra venouslly.
Anti rabies vaccine
There are different types of ARV available in
Human diploid cell vaccine(HDCV)
Purified chick embryo cell vaccine(PCEC)
Purified vero cell vaccine(PVRV)
All cell culture vaccine are in dried –freezed
form and should be stored at 2-8 degre
Reconstited vaccine must be used within 6-8
Inter switching between different cell
culture vaccine is not recommended.
All vaccines should must have potency
above2.5IU per dose.
ESSEN Schedule – Five dose of ARV
intramuscularly(1-1-1-1-1) given single
intramuscular on day0,3,7,14,28.
Zagreb Schedule-four dose intramucular (2-0-Zagreb Schedule-four dose intramucular (2-0-
1-0-1) given as two dose on day 0, on day
0,7, and on day 21.
Updated Thai red cross schedule(2-2-2-0-2) –
two doses of 0.1 ml of vaccine at different
sites on each deltoid area on day 0, 3, 7, 28.
Thai red cross schedule- it is same as
previous except a single dose dose on day 28previous except a single dose dose on day 28
Vaccine are approved by DCGI should be
Two booster doses either by intradermal or
IM will be given on day 0 and 3.
No Rabies immunoglobin is required.
Immunocompromised with category II
exposure should receive rabies immunoglobin
in addition to full post exposure vaccination.
Children constitute special risk group of
High risk children will be vaccinated after 3
IM schedule- On day 0, 3, 28.IM schedule- On day 0, 3, 28.
ID schedule – On day 0, 7, 28.