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Post exposure prophylaxis in Rabies


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Facts about Rabies

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Post exposure prophylaxis in Rabies

  1. 1. Seminar On RABIES THE FACTS Presented by Vijay kr. Singh DNB PGT (Pediatrics) Under guidance ofUnder guidance of Dr T K MONDAL MD(PEDIATRICS) Consultant pediatrician M R Bangur Hospital Date 20 july 2013 Venue DNB Seminar hall M R Bangur hospital Kolkata-33
  2. 2. 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.
  3. 3. 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.
  4. 4. 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.
  5. 5. Bites by domestic and per idomestic mammals does not cause rabies like Rat Squirrel Rabbits Genie pig
  6. 6. 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 by-by- Oxidizing agent Quaternary ammonium compound, soap and detergent.
  7. 7. 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.
  8. 8. Viruses can also enter motor axon in peripheral nerve directly during a penetrating injury. In Bat variant – viral propagation may also occur via sensory nerve due skin tropism.occur via sensory nerve due skin tropism.
  9. 9. 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.
  10. 10. 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
  11. 11. There are two distinct clinical forms 1. Furious Rabies or encephalitis type. It is about 80% 2. Dumb Rabies or Paralytic type. It is about 20%.20%.
  12. 12. 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.
  13. 13. 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
  14. 14. Suspected- It is compantable with clinical case definition. Probable –reliable history with exposure to rabid animal. Confirmed-suspected or probable case that isConfirmed-suspected or probable case that is laboratory confirmed.
  15. 15. Malaise Headache Fever NumbnessNumbness And tingling sensation at site of bite. Thease symptoms are common in both type of rabies
  16. 16. Symptoms are mainlly related with spasm due to stimulation of olfactory system Hydrobhobia Aerobhobia Dysphagia
  17. 17. Myoedema (in chest, deltoid muscle , thigh) Ascending paralysis Tingling at site of bite
  18. 18. Diagnosis of rabies mainly clinical Laboratory test may be required in atypical cases. 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 PCR.
  19. 19. To detect antibodies to rabies virus Post mortem diagnosis Demonstration of negries body in brain tissue
  20. 20. CATEGORY I Licks on intact skin, fall down on animal, touching, feeding of animal. No prophylaxis if history is reliable. CATEGORY II Minor scratches or abrasion without bleeding or licks on Wound management ant anti rabies vaccine.bleeding or licks on broken skin and nibbling of uncovered skin vaccine. CATEGORY III Single or multiple transdermal bites or scratches, or contamination of mucous membrane with saliva. Wound management with rabies immmunoglobin plus anti-rabies vaccine
  21. 21. 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.
  22. 22. 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 India.India. Exposure to Bat bite does not warrant treatment. Tretment must be started as soon as possible Person who exposure is months before, must be treated like recent exposure.
  23. 23. Management of wound Passive immunization – rabies immunoglobin Active immunization- anti-rabiesActive immunization- anti-rabies vaccine
  24. 24. Immediate washing and flushing the wound with soap and water. Followed by disinfection with ethanol or iodine. 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.
  25. 25. Two types of RIG(Rabies immunoglobin) ERIG(Equine RIG) HRIG(Human RIG) ERIG Require sensitivity testing as perERIG Require sensitivity testing as per manufactured instruction. 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.
  26. 26. 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 Injection.
  27. 27. RIG can be given up to 7th day of first dose of ARV. 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.
  28. 28. Anti rabies vaccine There are different types of ARV available in market like Human diploid cell vaccine(HDCV) Purified chick embryo cell vaccine(PCEC) Purified vero cell vaccine(PVRV)
  29. 29. All cell culture vaccine are in dried –freezed form and should be stored at 2-8 degre centigrate. Reconstited vaccine must be used within 6-8 hours.hours. Inter switching between different cell culture vaccine is not recommended. All vaccines should must have potency above2.5IU per dose.
  30. 30. INTRAMUSCULAR REGIMEN 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.
  31. 31. 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 and 90. Vaccine are approved by DCGI should be used.
  32. 32. Two booster doses either by intradermal or IM will be given on day 0 and 3. No Rabies immunoglobin is required.
  33. 33. Immunocompromised with category II exposure should receive rabies immunoglobin in addition to full post exposure vaccination.
  34. 34. Children constitute special risk group of exposure. High risk children will be vaccinated after 3 yrs. IM schedule- On day 0, 3, 28.IM schedule- On day 0, 3, 28. ID schedule – On day 0, 7, 28.